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EMOTIONAL REGULATION IN ADOLESCENTS WITH ANTICIPATORY

ANXIETY: A SYSTEMATIC REVIEW ON MECHANISMS, INTERVENTIONS

AND DEVELOPMENT OF SELF-REGULATION SKILLS

Ricardo José Ferretti1

Abstract: The objective of this study is to systematically analyze recent scientiﬁ c literature on the

neurobiological and psychological mechanisms underlying anticipatory anxiety in adolescents, as

well as to evaluate the effectiveness of brief psychotherapeutic interventions and emotional self-

regulation techniques, following the PRISMA (Preferred Reporting Items for Systematic Reviews

and Meta-Analyses) guidelines. The method adopted was a systematic literature review of the last

ﬁ ve years (2021–2026), covering epidemiological and neurobiological studies and clinical trials on

interventions such as cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT),

and mindfulness practices, identiﬁ ed in PubMed, PsycINFO, Web of Science, and Scopus databases.

After applying eligibility criteria, 20 studies were included in the qualitative synthesis. The results

demonstrate that anticipatory anxiety in adolescents shows an increasing prevalence — exceeding 20%

in American populations in 2023 — negatively impacting social and academic functioning, associated

with asymmetric maturation of the prefrontal cortex and amygdala hyperactivity. Mindfulness-based

interventions and cognitive reappraisal show signiﬁ cant effectiveness in reducing symptoms, promoting

greater psychological ﬂ exibility. Digital CBT-based interventions show moderate effect sizes and

constitute an accessible alternative to in-person treatment. The main conclusion indicates that brief

intervention protocols integrating rapid emotional regulation techniques — such as diaphragmatic

1 É graduado em Psicologia, desde 2014, pela UNESA - Universidade Estácio de Sá, RJ e atua

como pesquisador independente nas áreas de inteligência emocional, regulação emocional, ansiedade

e saúde mental preventiva. Seus interesses de pesquisa concentram-se no desenvolvimento de estra-

tégias de intervenção breve, educação emocional e tecnologias aplicadas ao cuidado psicológico. É

autor e coautor de livros voltados ao desenvolvimento humano, à saúde emocional e à integração entre

conhecimento cientí co e aplicação prática.

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breathing and self-compassion — are crucial to mitigate anticipatory anxiety effects, providing

essential support for the development of digital tools and school-based interventions. Limitations

include methodological heterogeneity among included studies and the scarcity of randomized clinical

trials with representative samples from low- and middle-income countries.

Keywords: Anticipatory Anxiety. Adolescent. Emotional Regulation. Mindfulness. Brief Intervention.

PRISMA. Cognitive-Behavioral Therapy.

Introduction

Adolescence constitutes a critical period of neurobiological and psychosocial development,

characterized by profound transformations in brain structure and emotional regulation. In this

context, anticipatory anxiety emerges as a clinically relevant manifestation, characterized by

excessive and persistent concern about potential future events that may or may not materialize. Recent

epidemiological data show a substantial increase in the prevalence of mental and behavioral disorders

in this age group.

According to the National Survey of Children’s Health, the prevalence of diagnosed mental

conditions among American adolescents aged 12 to 17 years increased signiﬁ cantly, reaching more

than 20% of the population in 2023, with anxiety being the most frequently reported condition

(SAPPENFIELD et al., 2024). In parallel, the meta-analytic review by Racine et al. (2021), published in

JAMA Pediatrics, identiﬁ ed a global 25.2% increase in anxiety symptoms in children and adolescents

during and after the COVID-19 pandemic, consolidating the perspective that this phenomenon

constitutes a public health emergency of global proportions.

Anticipatory thinking, in its adaptive form, is a fundamental cognitive process that allows

predicting future scenarios, planning actions, and regulating emotions (KAMARUDZAMAN et al.,

2026). However, when dysregulated, it transforms into pathological anticipatory anxiety. Adolescents

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with maladaptive anticipatory thinking frequently report elevated levels of stress and depression,

showing an inverse relationship between proﬁ ciency in future-oriented cognitive skills and mental

well-being (KAMARUDZAMAN et al., 2026). Anticipatory anxiety differs from acute fear by its

prospective orientation, keeping the individual in a state of prolonged hypervigilance with substantial

cognitive and emotional costs.

The impact on adolescents’ daily functioning is multifaceted. In the academic domain, a

direct correlation between high anxiety levels and school disengagement is observed: adolescents with

anxiety diagnoses are more likely to miss classes for health reasons, show concentration difﬁ culties,

and frequently experience drops in performance (SAPPENFIELD et al., 2024). Socially, these youth

face obstacles in forming and maintaining interpersonal relationships, as well as greater vulnerability

to bullying situations (SAPPENFIELD et al., 2024). Systematic screening for anxiety in children and

adolescents, as recommended by the US Preventive Services Task Force based on a review published in

JAMA (VISWANATHAN et al., 2022), reinforces the urgency of effective, accessible, and evidence-

based therapeutic approaches.

Given this need, the present article proposes a systematic literature review following

the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria.

The central objective is to synthesize current knowledge on the neurobiological mechanisms of

anticipatory anxiety, evaluate the impact on psychosocial functioning, and analyze the evidence on

brief psychotherapeutic interventions and rapid emotional self-regulation techniques, with a view to

supporting the development of digital and school-based intervention protocols.

Method

Protocol and Registration

This systematic review was conducted in accordance with the PRISMA guidelines (PAGE et

al., 2021) and followed a pre-deﬁ ned protocol. The study was not registered on a prospective platform

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(PROSPERO), which constitutes one of the recognized methodological limitations.

Eligibility Criteria

Inclusion and exclusion criteria were deﬁ ned according to the PICOS framework (Population,

Intervention, Comparison, Outcome, and Study Type), as presented in Table 1.

Table 1 – Eligibility criteria according to PICOS framework

PICOS Component Inclusion / Exclusion Criteria

Population (P) Adolescents (10–19 years), of both sexes, with anticipatory anxiety or

diagnosed or subclinical anxiety disorders. Excluded: adults (≥20 years) and

children (<10 years).

Intervention (I) Cognitive-Behavioral Therapy (CBT), Acceptance and Commitment Therapy

(ACT), mindfulness, emotional self-regulation techniques (diaphragmatic

breathing, self-compassion, cognitive reappraisal), digital interventions.

Comparison (C) Waitlist control groups, usual care, or alternative active conditions. Studies

without a comparator group were included when they were systematic

reviews.

Outcome (O) Reduction of anxiety symptoms, improvement in emotional regulation,

psychological ﬂ exibility, social and academic functioning.

Study Type (S) Randomized controlled trials (RCTs), systematic reviews and meta-analyses,

neurobiological and epidemiological studies. Excluded: case reports,

qualitative studies, publications in languages other than English, Portuguese,

or Spanish, and articles prior to January 2021.

Information Sources and Search Strategy

The systematic search was conducted in PubMed/MEDLINE, PsycINFO, Web of Science,

and Scopus databases, covering the period from January 2021 to April 2026. The search strategy

combined controlled terms (MeSH/Thesaurus) and free terms, using the following descriptors and

Boolean operators: (“anticipatory anxiety” OR “adolescent anxiety” OR “anxiety disorder” AND

“adolescent”) AND (“emotion regulation” OR “self-regulation” OR “cognitive reappraisal” OR

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“mindfulness” OR “acceptance and commitment therapy” OR “cognitive behavioral therapy”) AND

(“intervention” OR “treatment” OR “randomized controlled trial” OR “systematic review”)

The reference lists of included articles were additionally consulted to identify relevant studies

not captured by the electronic search (snowballing).

Selection Process — PRISMA Flowchart

Study selection followed the four phases of the PRISMA ﬂ owchart: (1) Identiﬁ cation, (2)

Screening, (3) Eligibility, and (4) Inclusion. Two independent reviewers conducted the screening of

titles and abstracts, with disagreements resolved by consensus or by a third reviewer. Figure 1 presents

the selection ﬂ owchart.

Figure 1 – PRISMA Study Selection Flowchart

IDENTIFICATION — Records identiﬁ ed in databases (n = 1,847): PubMed (n = 643) | PsycINFO

(n = 512) | Web of Science (n = 421) | Scopus (n = 271)

▼

SCREENING — Records after duplicate removal (n = 1,384). Screened by title and abstract →

Excluded (n = 1,198): outside age range (n = 412), outside period (n = 287), irrelevant outcome (n =

317), ineligible language (n = 182)

▼

ELIGIBILITY — Full-text articles assessed (n = 186). Excluded after full reading (n = 166): no

adequate control group (n = 48), exclusively adult clinical samples (n = 39), no emotional regulation

measures (n = 44), insufﬁ cient methodological quality (n = 35)

▼

INCLUSION — Studies included in qualitative synthesis: n = 20

Methodological Quality Assessment

The quality of randomized clinical trials was assessed using the RoB 2 tool (Revised Cochrane

Risk of Bias Tool for Randomized Trials). Systematic reviews were assessed with the AMSTAR-2

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instrument (A MeaSurement Tool to Assess systematic Reviews). Observational neurobiological

studies were assessed using the Newcastle-Ottawa scale. Risk of bias was classiﬁ ed as low, moderate,

or high, and high-risk studies were maintained in the synthesis with appropriate interpretive caveats.

Neurobiological and Psychological Mechanisms of Anticipatory Anxiety

Asymmetric Maturation of the Adolescent Brain

Understanding anticipatory anxiety in adolescence requires in-depth analysis of the

neurobiological transformations characteristic of this phase. The adolescent brain undergoes a process

of asymmetric maturation, in which limbic structures, particularly the amygdala, develop more

rapidly than prefrontal regions. The amygdala plays a central role in processing emotional stimuli and

detecting threats, being hyperactivated in individuals with anxiety disorders (OHI, 2025).

Kenwood et al. (2022), in a review published in Neuropsychopharmacology, demonstrated

that the prefrontal cortex, especially its ventromedial subdivision (vmPFC), is fundamental for fear

extinction and top-down emotional regulation, but remains functionally immature during adolescence.

This immaturity creates a window of neurobiological vulnerability to emotional dysregulation, in

which amygdalar hyperactivity is not adequately modulated by cortical inhibitory mechanisms. During

anticipatory anxiety episodes, the vmPFC frequently fails to modulate the amygdala’s hyperactive

response, perpetuating the cycle of chronic worry.

In a work published in Neuropsychopharmacology in 2025, Goodpaster et al. (2025) described

that the maturational development of the medial prefrontal cortex (mPFC) is regulated by both

genetic programs and activity-dependent processes, creating an extended window in which adverse

experiences — including repetitive anticipatory stress — can permanently alter the developmental

trajectory of prefrontal circuits, increasing the risk of anxiety disorders and depression in adult life.

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HPA Axis and Neurotoxicity of Chronic Stress

The relationship between cortisol and the adolescent hippocampus is considerably more

complex than a simple linear causal chain. Current literature critically distinguishes between acute

and chronic cortisol exposure: punctual and transient elevations in glucocorticoids — such as those

occurring in response to a delimited stressor — can, in fact, facilitate the consolidation of emotionally

salient memories, a well-documented adaptive function (ROMEO, 2013). It is chronic, prolonged, and

dysregulated cortisol exposure — typical of pathological anticipatory anxiety — that compromises

hippocampal neuroplasticity. In this scenario of sustained HPA axis hyperstimulation, persistent

activation of glucocorticoid receptors in the hippocampus suppresses neurogenesis in the dentate

gyrus region, reduces dendritic spine density in CA1 and CA3 regions, and compromises long-

term synaptic plasticity — negatively impacting the consolidation of new memories and learning.

Furthermore, the magnitude of these effects critically depends on moderating variables underexplored

in the adolescent population: the temporal window of exposure within the brain maturation period,

the presence of genetic factors that modulate the density and sensitivity of glucocorticoid receptors,

and the availability of social support and coping resources that buffer the HPA response. The study by

Ohi (2025) mapped some of these genetic substrates, identifying polymorphisms in the serotonergic

and dopaminergic systems that amplify amygdalar stress reactivity and increase susceptibility to

anticipatory anxiety, signaling that neurobiological vulnerability to these effects is not uniform in the

adolescent population.

Psychological Flexibility Deﬁ cits and Maladaptive Strategies

From a psychological perspective, anticipatory anxiety is closely linked to deﬁ cits in

psychological ﬂ exibility. Acceptance and Commitment Therapy (ACT) posits that psychological

inﬂ exibility — characterized by cognitive fusion with negative thoughts about the future and

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experiential avoidance of uncomfortable emotions — is a central mechanism in the maintenance

of anxiety (PETERSEN; PIMENTEL, 2024). Anxious adolescents tend to fuse with anticipated

catastrophic scenarios, treating them as imminent realities rather than passing mental events.

Maladaptive strategies, such as expressive suppression and rumination, are commonly used

by anxious adolescents. Nguyen et al. (2025) demonstrated, in an Australian sample of adolescents,

that self-compassion acts as a moderator of the relationship between emotional regulation strategies

and anxiety symptoms: adolescents with higher self-compassion scores showed less impact of

maladaptive strategies on mental well-being, suggesting that this dimension functions as a protective

factor of signiﬁ cant clinical relevance.

Muris et al. (2024), in a review published in the Clinical Child and Family Psychology

Review, identiﬁ ed strong associations between negative self-compassion (excessive self-criticism)

and symptoms of anxiety and depression in young people, consolidating self-compassion as a priority

therapeutic target in intervention protocols for adolescents.

Brief and Evidence-Based Psychotherapeutic Interventions

Cognitive-Behavioral Therapy (CBT)

Cognitive-Behavioral Therapy (CBT) remains the gold standard for treating juvenile anxiety.

Brief interventions based on this approach focus on identifying and restructuring cognitive distortions

related to future events, combined with gradual exposure techniques. Cognitive reappraisal, a core

skill taught in these interventions, involves reformulating anxiogenic thoughts to alter their emotional

impact, demonstrating signiﬁ cant negative prediction of anxiety and depression symptoms (NGUYEN

et al., 2025).

Hudson et al. (2023), in a double-blind randomized clinical trial published in Psychological

Medicine, investigated the combination of CBT with sertraline in anxious youth, demonstrating that

CBT alone presents robust efﬁ cacy and that pharmacological addition did not produce statistically

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signiﬁ cant incremental beneﬁ ts, endorsing the primacy of psychotherapeutic interventions.

Wickersham et al. (2022), in a meta-analysis published in the Journal of Medical Internet Research

(JMIR), demonstrated that computerized CBT (cCBT) signiﬁ cantly reduces anxiety and depression

symptoms in adolescents, with moderate to large effect sizes (d = 0.43–0.71), especially when some

level of human support is associated.

Acceptance and Commitment Therapy (ACT)

ACT has gained prominence as a transdiagnostic effective intervention for adolescents.

Unlike focusing on direct symptom reduction, it aims to increase psychological ﬂ exibility through six

core processes: acceptance, cognitive defusion, present-moment awareness, self as context, values,

and committed action (PETERSEN; PIMENTEL, 2024). Cognitive defusion is particularly useful in

anticipatory anxiety, as it teaches adolescents to observe their worrying thoughts without becoming

entangled in them.

Petersen and Pimentel (2024) documented that speciﬁ c adaptations for youth — such as

the DNAV model (Direction, Noticing, Opening Up, Values) — use accessible metaphors to teach

these skills, promoting acceptance of uncomfortable internal experiences while encouraging actions

based on personal values. Recent clinical trials indicate that ACT interventions of 8 to 12 sessions

produce signiﬁ cant reductions in anticipatory anxiety and avoidance behaviors in adolescents, with

maintenance of gains at 3 to 6 month follow-ups (PETERSEN; PIMENTEL, 2024).

Mindfulness-Based Interventions

Mindfulness-based interventions (MBIs) have demonstrated notable efﬁ cacy in managing

anxiety in adolescents and young adults. Hue et al. (2025) conducted a systematic review on the

application of Mindfulness-Based Stress Reduction (MBSR) in adolescents and young adults aged

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13 to 26 years, published in the Asian Journal of Psychiatry, documenting signiﬁ cant reductions in

anxiety levels, as well as improvements in emotional regulation and coping skills.

The practice of mindfulness acts directly on the mechanisms of anticipatory anxiety, training

the individual to anchor their attention in the present moment, interrupting the cycle of rumination

about the future. The proposed mechanisms of action include reduction of stress reactivity and increase

of metacognitive awareness, which allows the adolescent to identify worrying thoughts as passing

mental events without identifying with them (HUE et al., 2025). The review by Wright et al. (2023),

published in the Journal of Youth and Adolescence, conﬁ rmed that digital mindfulness interventions

show comparable effects to in-person interventions in adolescents aged 11 to 18, with the additional

advantage of accessibility.

Self-Compassion as a Therapeutic Component

Self-compassion has emerged as a vital component in adolescents’ emotional regulation.

Nguyen et al. (2025) demonstrated that the compassionate response to oneself acts as a protective

factor, negatively predicting anxiety, while the non-compassionate response acts as a risk factor. Tali

et al. (2023), in a study published in the journal Children, compared adolescents with and without

anxiety disorder, identifying signiﬁ cantly lower levels of self-compassion in the clinical group, with

self-compassion explaining a substantive proportion of variance in anxiety scores.

The integration of self-compassion in brief protocols represents a promising frontier in

adolescent clinical psychology: teaching youth to treat themselves with kindness and understanding

during moments of anticipatory distress can potentiate the effects of other therapeutic interventions

(MURIS et al., 2024).

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Rapid Emotional Self-Regulation Techniques and Digital Applications

Diaphragmatic Breathing and Parasympathetic Activation

Diaphragmatic breathing, characterized by a slow and controlled rhythm involving

diaphragm contraction, is a potent physiological technique. It stimulates the vagus nerve and activates

the parasympathetic nervous system, counterbalancing the ﬁ ght-or-ﬂ ight response mediated by the

sympathetic nervous system. Czub et al. (2024), in a study published in Stress & Health, investigated

how respiratory rate and inhalation/exhalation ratio inﬂ uence self-reported anxiety during a single

slow diaphragmatic breathing exercise, ﬁ nding that rates of 4–6 breaths per minute with prolonged

exhalation ratio (1:2) produce more expressive reductions in state anxiety.

The application of focused breathing exercises can rapidly reduce heart rate and muscle

tension, providing immediate somatic relief that facilitates subsequent cognitive regulation. These

physiological effects make diaphragmatic breathing a ﬁ rst-line technique in emergency intervention

protocols for adolescents in a state of anxious hyperactivation.

Cognitive and Sensory Anchoring Techniques

Rapid cognitive reframing, derived from cognitive reappraisal, is another crucial tool. It

involves training the adolescent to quickly identify the catastrophic thought and replace it with a more

balanced or realistic perspective. Sensory anchoring techniques, such as the ﬁ ve senses rule (5-4-3-2-

1), help redirect attention from the feared future to concrete stimuli in the present environment. These

adaptive distraction and anchoring strategies are highly effective for interrupting the escalation of

anticipatory anxiety before it culminates in a panic attack or severe behavioral avoidance.

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Digital Interventions: Access, Efﬁ cacy, and Personalization

The delivery of these techniques through digital platforms has revolutionized access to

mental health support. Csirmaz et al. (2024) conducted a systematic meta-analysis demonstrating that

digital CBT-based interventions are effective in reducing anxiety in children and adolescents, with

signiﬁ cant and consistent effect sizes regardless of geographic context.

Walder et al. (2025), in a meta-analysis published in JMIR, speciﬁ cally assessed digital

interventions for social anxiety disorder in youth, identifying a signiﬁ cant effect (Hedges g =

0.508; 95% CI: 0.308–0.707) in favor of digital interventions over control conditions, involving 22

randomized clinical trials. Reynard et al. (2022) demonstrated that digital games with emotional

regulation elements reduce negative emotional experience with a small but signiﬁ cant effect size in

youth at risk for anxiety.

Ji et al. (2024), in a comprehensive meta-analysis published in European Psychiatry, assessed

different modalities of digital interventions — including virtual reality, mobile apps, and internet-based

interventions — for anxiety disorders, identifying that the level of human therapeutic involvement

signiﬁ cantly moderates outcomes. Wright et al. (2023) corroborated that the most effective digital

interventions incorporate gamiﬁ cation elements to maintain engagement, provide guided mindfulness

and breathing exercises, and use algorithms to personalize coping strategies based on user-reported

emotional state.

Ethical and Structural Considerations for Digital Interventions with Adolescents

The efﬁ cacy of digital tools does not exhaust the relevant issues for their responsible

development. Four ethical and structural dimensions are especially critical when the target population

are adolescents in emotional distress, and are consistently underrepresented in the reviewed literature.

Data privacy and protection of minors. Mental health applications collect sensitive health

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data, behavioral patterns, and emotional information from users under 18 years of age, which

imposes speciﬁ c legal and ethical obligations beyond those applicable to adults. In Brazil, the General

Data Protection Law (LGPD, Law No. 13,709/2018) establishes, in Article 14, that the processing

of personal data of children and adolescents must be conducted with the speciﬁ c and highlighted

consent of at least one parent or legal guardian. At the international level, the European General Data

Protection Regulation (GDPR) and the Children’s Online Privacy Protection Act (COPPA) impose

similar safeguards. Any digital tool for adolescent mental health must therefore adopt privacy by

design architecture, minimize data collection to what is strictly necessary, clearly specify processing

purposes, and establish auditable parental consent mechanisms.

Safety in acute crisis situations. A critical gap in the literature on mental health apps for

adolescents concerns what happens when a user in acute emotional crisis — including suicidal

ideation — accesses the tool and ﬁ nds no human support available. The absence of robust crisis

escalation protocols in digital tools represents a serious clinical risk and an ethical failure that cannot

be minimized by scalability considerations. Responsible development of apps for this audience

requires the prior deﬁ nition of validated risk detection algorithms, immediate referral ﬂ ows to support

lines, and clear indications of the tool’s limits of action when the level of distress exceeds the scope

of self-sufﬁ cient digital support.

Risk of substituting professional care. The reviewed literature consistently frames digital

interventions as complements — not substitutes — to specialized clinical care. However, the way

these tools are positioned in the market and perceived by adolescents and families does not always

reﬂ ect this distinction. In scenarios of limited access to mental health services — which characterize

the reality of most Brazilian cities and low- and middle-income countries — there is a real risk that

the app will be used as the only form of support by youth who would require professional follow-up.

Equity of access and digital inequality. A central paradox of digital mental health interventions

is that the adolescents who would beneﬁ t most from the accessibility of digital tools are often those

with the least access to them. In Brazil, IBGE data (2023) indicate that approximately 17% of young

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people aged 10 to 17 do not have home internet access, with marked disparities by region, race,

and income. Dependence on high-performance smartphones, stable connectivity, and digital literacy

constitutes an equity barrier that must be considered in the design and efﬁ cacy assessment of these

tools.

Integrated Brief Digital Intervention Protocol

The development of a brief digital intervention protocol for anticipatory anxiety should

integrate a multifaceted approach: (1) physiological stabilization through diaphragmatic breathing

techniques; (2) promotion of mindfulness for present-moment anchoring; (3) cognitive defusion to alter

the young person’s relationship with anxiogenic thoughts; and (4) cultivation of self-compassion to

reframe the experience of suffering. This integrated model should be accompanied, from conception,

by the ethical and structural safeguards described in the previous section — data privacy, crisis

protocols, delimitation of scope of action, and equity of access — so that the scientiﬁ c robustness of

the protocol is inseparable from the ethical responsibility of its implementation.

Limitations of the Systematic Review

The present systematic review presents methodological limitations that should be considered

in the interpretation and generalization of results:

• Absence of prospective registration: The protocol of this review was not previously

registered in PROSPERO or equivalent platform, which limits transparency and the possibility of

identifying deviations from the original plan.

• Methodological heterogeneity: The included studies present considerable heterogeneity

regarding anxiety assessment instruments (GAD-7, SCARED, STAI, RCMAS), operational deﬁ nitions

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of anticipatory anxiety, and the number and duration of intervention sessions, which hampers direct

comparison between studies and formal quantitative meta-analysis.

• Publication bias: Studies with positive results are more likely to be published. Despite

efforts to include grey literature, publication bias risk cannot be excluded, which may inﬂ ate efﬁ cacy

estimates.

• Underrepresentation of low- and middle-income countries: The vast majority of included

studies come from high-income countries (USA, UK, Australia, European countries), which limits

the generalization of ﬁ ndings to contexts of lesser resource availability and different cultural settings,

including Brazil and other Latin American countries.

• Imprecise deﬁ nition of anticipatory anxiety: Anticipatory anxiety as a speciﬁ c construct

does not have standardized diagnostic criteria in the DSM-5-TR or ICD-11, being frequently

operationalized differently across studies.

• Limitation of long-term follow-ups: Most studies evaluate outcomes immediately after

interventions or at follow-ups of up to 6 months, with a scarcity of data on the maintenance of

therapeutic gains over the long term (12 months or more).

• Language exclusion: Restriction to articles published in English, Portuguese, and Spanish

may have excluded relevant studies published in other languages, particularly in the Asian literature.

• Variability in samples: Included studies show signiﬁ cant variations in sample size (from N

< 30 to N > 1,000), the exact age range within adolescence (10–19 years), and sex proportion.

• Self-report assessment: Most studies rely on self-report instruments for measuring anxiety

and emotional regulation outcomes, which may be affected by social desirability biases.

• Absence of cost-effectiveness assessment: None of the included studies conducted formal

cost-effectiveness analysis of the evaluated interventions.

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Conclusion

Anticipatory anxiety represents a signiﬁ cant challenge for adolescent mental health, with

profound impacts on neurobiological development, academic performance, and social functioning. The

interaction between the immaturity of the prefrontal cortex and amygdala hyperactivity — supported

by vast recent neurobiological literature (OHI, 2025; KENWOOD et al., 2022; GOODPASTER et al.,

2025) — creates a vulnerability that is frequently exacerbated by deﬁ cits in psychological ﬂ exibility

and the use of maladaptive emotional regulation strategies.

The present systematic review, conducted according to PRISMA criteria with analysis

of 20 studies selected after a rigorous screening and eligibility process, demonstrates that brief

psychotherapeutic interventions — grounded in CBT (WICKERSHAM et al., 2022; HUDSON et al.,

2023), ACT (PETERSEN; PIMENTEL, 2024), and mindfulness practices (HUE et al., 2025; WRIGHT

et al., 2023) — are highly effective in mitigating these symptoms. Digital interventions based on these

approaches demonstrate moderate to large effect sizes and constitute an accessible alternative that

overcomes traditional barriers of cost, stigma, and geographic availability of specialized services

(CSIRMAZ et al., 2024; WALDER et al., 2025; REYNARD et al., 2022; JI et al., 2024).

The integration of rapid emotional self-regulation techniques — diaphragmatic breathing

(CZUB et al., 2024), cognitive defusion (PETERSEN; PIMENTEL, 2024), cognitive reappraisal

(NGUYEN et al., 2025), and self-compassion (TALI et al., 2023; MURIS et al., 2024) — constitutes

an essential therapeutic framework for the immediate management of anticipatory anxiety.

The development of evidence-based intervention protocols that combine the scientiﬁ c rigor of

neurophysiology and cognitive psychology with the accessibility of mobile technology is fundamental

to equip the new generation with the necessary skills to navigate in a world characterized by

uncertainty, promoting resilience and long-term psychological well-being.

Future investigations should prioritize randomized clinical trials with representative samples

from low- and middle-income countries, long-term follow-up assessments, and cost-effectiveness

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studies that support the implementation of school-based mental health public policies on a global

scale.

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