Applicability of the intolerance of uncertainty model to Generalized Anxiety Disorder symptoms in young people / Watts, Cossar & Ferreira (2021)
In UK services, intolerance of uncertainty (IU) is most often conceptualised and treated within high-intensity CBT for Generalised Anxiety Disorder (GAD), typically drawing on adult-derived models and protocols. At a low-intensity level, interventions for children and young people more commonly focus on psychoeducation, worry management, problem solving, and general cognitive change, with IU addressed implicitly, if at all.
However, emerging evidence suggests that intolerance of uncertainty may play a more central role in the maintenance of anxiety in young people than is sometimes reflected in stepped-care decisions. This research spotlight explores a 2021 UK-based study examining the applicability of the IU model to GAD symptoms in adolescents, and considers what this may mean for formulation and intervention planning across CBT pathways.
The Study at a Glance
Watts, Cossar and Ferreira (2021) investigated whether core components of the intolerance of uncertainty model predict GAD symptoms in young people aged 11–15 years. The IU model proposes that excessive worry is maintained by four interacting cognitive processes:
- Intolerance of uncertainty (IU)
- Negative problem orientation (NPO)
- Positive beliefs about worry (PBW)
- Cognitive avoidance (CA)
The study recruited 326 adolescents from secondary schools in West Scotland and used validated child- and adolescent-appropriate self-report measures to assess worry, physical symptoms of anxiety, and each IU model component.
Importantly, the authors also examined whether age or gender moderated these relationships — a key consideration when translating adult models into developmentally appropriate practice.
Key Findings
Two findings are particularly relevant for clinical work with children and young people:
1. Intolerance of uncertainty and negative problem orientation were robust predictors of GAD symptoms
Across analyses, IU and NPO consistently explained unique variance in both:
- Worry severity, and
- Physical symptoms associated with GAD.
In contrast, positive beliefs about worry and cognitive avoidance played a more limited role, particularly once IU and NPO were accounted for.
This mirrors findings from adult samples, where IU and problem orientation are understood as core maintaining processes in GAD, suggesting greater continuity between adolescent and adult presentations than is sometimes assumed.
2. Age did not moderate these relationships within early-to-mid adolescence
Within the 11–15 age range, the relationship between IU, NPO and anxiety symptoms remained stable. This suggests that by early adolescence, intolerance of uncertainty may already be functioning as a meaningful cognitive vulnerability factor, rather than something that only becomes clinically relevant later.
Gender differences were observed in symptom severity and endorsement of some cognitive variables, but these did not substantially alter the central role of IU and NPO in predicting worry.
Why This Matters for CBT Pathways
In UK stepped-care models, intolerance of uncertainty is often conceptualised as a higher-order cognitive process, requiring more complex formulation and intervention, and therefore positioned within high-intensity CBT.
However, this study raises an important question: If IU is already a key maintaining factor in adolescent anxiety, what are the implications of not addressing it until later stages of treatment?
This does not necessarily suggest that all low-intensity work should explicitly target IU in the same way as specialist GAD protocols. But it does highlight the potential value of:
- Noticing uncertainty-related distress early,
- Incorporating formulation-led conversations about uncertainty,
- And being mindful of how interventions are experienced when uncertainty remains unaddressed.
For some young people, difficulties engaging with worry management, exposure tasks, or behavioural change may reflect an underlying intolerance of uncertainty rather than poor motivation or limited skill acquisition.
Clinical Reflections
From a formulation-led perspective, this research invites several considerations:
IU as a transdiagnostic process: Although examined here in relation to GAD symptoms, intolerance of uncertainty is relevant across anxiety presentations commonly seen in CYP services, including social anxiety, health anxiety, and obsessive–compulsive difficulties.
Low-intensity does not mean low-complexity: Even within brief or guided self-help interventions, clinicians may find it helpful to listen for themes of uncertainty intolerance — for example, an urgent need for reassurance, difficulty tolerating “not knowing,” or rigid attempts to control outcomes.
Problem orientation as a developmental target: The strong role of negative problem orientation may reflect young people’s limited autonomy and perceived lack of control. Supporting realistic problem-solving and flexibility may therefore be as important as targeting worry content itself.
Stepped care as responsive, not rigid: For some young people, limited progress in low-intensity CBT may reflect a mismatch between intervention focus and maintaining processes, rather than readiness or engagement.
Concluding Thoughts
This study does not argue for a redefinition of CBT pathways, but it does offer a useful reminder: developmentally informed CBT still requires careful attention to cognitive maintenance processes, even early in treatment.
Intolerance of uncertainty appears to be meaningful for young people well before adulthood. Holding this in mind — particularly when progress stalls or anxiety feels resistant to standard approaches — may support more responsive formulation, clearer decision-making, and ultimately better outcomes.
As the evidence base continues to grow, research like this helps bridge the gap between adult-derived models and the lived experience of young people in therapy.
References & Further Reading
Watts, R., Cossar, J., & Ferreira, N. (2021). Applicability of the intolerance of uncertainty model to Generalized Anxiety Disorder symptoms in young people. Mediterranean Journal of Clinical Psychology, 9(2). https://doi.org/10.13129/2282-1619/mjcp-2978
Dugas, M. J., & Robichaud, M. (2007). Cognitive-behavioral treatment for generalized anxiety disorder: From science to practice. Routledge.
Dugas, M. J., Laugesen, N., & Bukowski, W. M. (2012). Intolerance of uncertainty, fear of anxiety, and adolescent worry. Journal of Abnormal Child Psychology, 40(6), 863–870.
Esbjørn, B. H., et al. (2015). Meta-cognitive beliefs and anxiety in children and adolescents. Journal of Anxiety Disorders, 33, 9–18.
Kitchen, C. E. W., et al. (2023). Barriers and enablers for young people undertaking psychological therapy for depression. Psychology and Psychotherapy, 96(3), 730–748.