Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents

Treatment engagement and response to CBT among Latinos with anxiety disorders in primary care

OBJECTIVE

In the current study, we compared measures of treatment outcome and engagement for Latino and non-Latino White patients receiving a cognitive behavioral therapy (CBT) program delivered in primary care.

METHOD

Participants were 18-65 years old and recruited from 17 clinics at 4 different sites to participate in a randomized controlled trial for anxiety disorders, which compared the Coordinated Anxiety Learning and Management (CALM) intervention (consisting of CBT, medication, or both) with usual care. Of those participants who were randomized to the intervention arm and selected CBT (either alone or in combination with medication), 85 were Latino and 251 were non-Latino White; the majority of the Latino participants received the CBT intervention in English (n = 77). Blinded assessments of clinical improvement and functioning were administered at baseline and at 6, 12, and 18 months after baseline. Measures of engagement, including attendance, homework adherence, understanding of CBT principles, and commitment to treatment, were assessed weekly during the CBT intervention.

RESULTS

Findings from propensity-weighted linear and logistic regression models revealed no statistically significant differences between Latinos and non-Latino Whites on symptom measures of clinical improvement and functioning at almost all time points. There were significant differences on 2 of 7 engagement outcomes, namely, number of sessions attended and patients' understanding of CBT principles.

CONCLUSIONS

These findings suggest that CBT can be an effective treatment approach for Latinos who are primarily English speaking and likely more acculturated, although continued attention should be directed toward engaging Latinos in such interventions.

A personalized and control systems engineering conceptual approach to target childhood anxiety in the contexts of cultural diversity

In the child and adolescent anxiety area, some progress has been made to develop evidence-based prevention protocols, but less is known about how to best target these problems in children and families of color. In general, data show differential program effects with some minority children benefiting significantly less. Our preliminary data, however, show promise and suggest cultural parameters to consider in the tailoring process beyond language and cultural symbols. It appears that a more focused approach to culture might help activate intervention components and its intended effects by focusing, for example, on the various facets of familismo when working with some Mexican parents. However, testing the effects and nuances of cultural adaption vis-à-vis a focused personalized approach is methodologically challenging. For this reason, we identify control systems engineering design methods and provide example scenarios relevant to our data and recent intervention work.

Childhood anxiety and psychophysiological reactivity: hypnosis to build discrimination and self-regulation skills

Clinically anxious, worried, and fearful children and teens need clinicians' assistance in reducing their exaggerated psychophysiological stress reactivity. Affective neuroscience finds that chronic activation of the body's emergency response system inhibits neurogenesis, disrupts neuronal plasticity, and is detrimental to physical and mental health. Patterns of faulty discrimination skills, for example, over-estimation of threat and danger and under-estimation of their coping capacity, fuel this over-arousal. Similarly, contributory patterns of reduced self-regulation skills are shown by "stuck" attention to and poor control of their exaggerated psychophysiological reactivity and somatization. This article considers the literature and focuses on cognitive hypnotherapy to enhance these under-developed capacities. A case illustration highlights various hypnotic phenomena and techniques, psychoeducation, and relaxation training that address the goals of interrupting these unproductive, interconnected patterns and fostering new patterns of more realistic and accurate discrimination capacities and sturdier psychophysiological self-regulation skills.

Targeted Behavioral Therapy for childhood generalized anxiety disorder: a time-series analysis of changes in anxiety and sleep

This study examined the efficacy of Targeted Behavioral Therapy (TBT), a newly developed intervention targeting features of childhood generalized anxiety disorder (GAD). Using a time-series design, 4 children (7-12 years) with primary GAD were treated with TBT, which includes sleep improvement strategies, systematic desensitization for reducing intolerance of uncertainty, and in vivo exposures for anxiety. Diagnostic interviews and questionnaires were administered at baseline, post-treatment and 3 months follow-up. Anxiety symptoms and sleep characteristics/problems were rated weekly during a 4-week baseline and 14-weeks of treatment. Two children remitted at post-treatment and no child had a GAD diagnosis at follow-up. Child but not parent report revealed improvements in both worry and sleep. Despite improvements from pre- to post-assessment, considerable symptom fluctuation observed during the baseline period preclude conclusion that symptom changes are specifically attributable to the course of treatment. Overall, preliminary support is provided for the efficacy of TBT for childhood GAD.

Attention Bias Modification Treatment for children with anxiety disorders who do not respond to cognitive behavioral therapy: a case series

Evidence is emerging to support the promise of Attention Bias Modification Treatment (ABMT), a computer-based attention training program, in reducing anxiety in children. ABMT has not been tested as an adjuvant for children with anxiety disorders who do not respond to Cognitive-Behavioral Therapy (CBT). This case series presents findings from an open trial of ABMT among six children (four girls; M age = 11.2 years) who completed a CBT protocol and continued to meet diagnostic criteria for an anxiety disorder. All children completed the ABMT protocol with no canceled or missed sessions. Child self-ratings on anxiety symptoms and depressive symptoms significantly decreased from pretreatment to posttreatment, as did parent ratings on child anxiety-related impairment. Parent ratings on child anxiety and internalizing symptoms displayed non-significant decreases from pretreatment to posttreatment. These findings support the potential promise of ABMT as a feasible adjuvant treatment that reduces anxiety and impairment among child anxiety CBT nonresponders.

Treatment of pediatric anxiety disorders

This article provides a brief review of the current available data concerning present treatment and potential new treatment advances for pediatric anxiety disorders, such as generalized anxiety disorder, separation anxiety disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Disorder-specific treatment methods and innovations, particularly computer-assisted methods of delivery for cognitive behavioral therapy (CBT) will be reviewed. Additionally, the paper will discuss novel psychopharmacological compounds (e.g., D-cycloserine, riluzole, memantine, and anticonvulsant medications). Available evidence for the efficacy of novel medication strategies in adult studies and implications for their use in pediatrics will be discussed.

Show Me, Don't Tell Me: Behavioral Rehearsal as a Training and Analogue Fidelity Tool

Behavioral rehearsal, when a trainee engages in a simulated interaction with another individual, is an underutilized but potentially cost-effective and feasible solution for two difficult questions in implementation science: how to improve training, a commonly used implementation strategy, and how to feasibly measure fidelity using analogue methods in community settings. This paper provides practical information on how to develop and use behavioral rehearsal for both of these purposes to implementation researchers. Therefore, we focus on development and use of behavioral rehearsal as a training and analogue fidelity tool in the context of three illustrative studies.

Childhood maltreatment and personality disorders in the USA: specificity of effects and the impact of gender

Childhood maltreatment increases the risk for adult personality disorders (PDs), but several PDs or maltreatment types co-occur. Specificity of maltreatment-personality associations is poorly understood. Using a representative US population sample, we identified specific associations between maltreatment types (sexual, physical and emotional abuse and physical and emotional neglect) and PDs after controlling for basic demographics, parental psychopathology, co-occurring maltreatment types and comorbid PD. We then examined interactions of gender and maltreatment in predicting PDs. Each maltreatment type significantly predicted three-four PDs. Borderline and schizotypal PDs were most strongly predicted by sexual abuse, antisocial by physical abuse and avoidant and schizoid by emotional neglect. Specific vulnerabilities differ by gender; maltreated boys may respond with attention seeking and girls with social withdrawal. Findings highlight the importance of evaluating all forms of maltreatment even when they co-occur and can inform development of interventions to prevent personality pathology in at-risk children.

Cognitive-behavioral therapy for anxious children: from evidence to practice

BACKGROUND

Anxiety is the most common mental health problem in children, yet less than one third of children with anxiety disorders seek treatment. Cognitive-behavioral therapy (CBT) is recommended as a first-line treatment for childhood anxiety. However, current practice generally does not include CBT due to issues of feasibility, affordability, and transportability.

AIMS

The primary purpose of this review was to appraise current literature regarding the effectiveness of individual CBT for childhood anxiety. Secondary purposes were to identify reasons for the discrepancy between current evidence and practice as well as to offer suggestions to overcome this dilemma.

METHODS

A systematic review of the literature published between 2007 and 2012 was conducted, searching four databases--Cochrane, PubMed, CINAHL, and PsycINFO.

FINDINGS

In all 10 studies reviewed, individual CBT significantly reduced rates of anxiety diagnoses when compared with controls, and was equally effective or superior to comparison therapies. The only exception was when CBT was compared to a combination of CBT and pharmacological management, in which case the latter was more effective.

LINKING EVIDENCE TO ACTION

Each study included in this review employed hour-long sessions over a minimum of 12 visits. In order to meet clinical demands and patient preferences, affordability, and feasibility of CBT interventions must be addressed. A brief, manualized CBT program that can be supported to be clinically effective is proposed as an evidence-based solution for anxious children in outpatient mental health and primary care settings.

Effectiveness of modular CBT for child anxiety in elementary schools

Most randomized controlled trials of cognitive-behavioral therapy (CBT) for children with anxiety disorders have evaluated treatment efficacy using recruited samples treated in research settings. Clinical trials in school settings are needed to determine if CBT can be effective when delivered in real world settings. This study evaluated a modular CBT program for childhood anxiety disorders in two elementary schools. Forty children (5-12 years old) with anxiety disorders, referred by teachers and school staff, were randomly assigned to modular CBT or a 3-month waitlist. Clinicians worked with individual families as well as teachers and school staff. Evaluators blind to treatment condition conducted structured diagnostic interviews and caregivers and children completed symptom checklists at pre- and posttreatment. The primary study outcome, the Clinical Global Impressions-Improvement scale, yielded a positive treatment response at posttreatment for 95.0% of CBT participants, as compared with only 16.7% of the waitlist participants. CBT also outperformed the waitlist on diagnostic outcomes and caregiver-report measures of anxiety. Treatment effects did not extend beyond anxiety diagnoses and symptoms. Results suggest that modular CBT delivered within the elementary school setting may be effective for the treatment of child anxiety disorders. A replication of the study results with a larger sample is indicated.

Improving transportability of a cognitive-behavioral treatment intervention for anxiety in youth with autism spectrum disorders: results from a US-Canada collaboration

Anxiety disorders frequently co-occur in youth with autism spectrum disorders. In addition to developing efficacious treatments for anxiety in children with autism spectrum disorders, it is important to examine the transportability of these treatments to real-world settings. Study aims were to (a) train clinicians to deliver Facing Your Fears: Group Therapy for Managing Anxiety in Children with High-Functioning Autism Spectrum Disorders to fidelity and (b) examine feasibility of the program for novel settings. A secondary aim was to examine preliminary youth treatment outcome. Results indicated that clinicians obtained excellent fidelity following a workshop and ongoing consultation. Acceptability ratings indicated that Facing Your Fears Therapy was viewed favorably, and critiques were incorporated into program revisions. Meaningful reductions in anxiety were reported posttreatment for 53% of children. Results support the initial effectiveness and transportability of Facing Your Fears Therapy in new clinical settings.

Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial

OBJECTIVE

We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS).

METHOD

Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures.

RESULTS

Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I).

DISCUSSION

Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.

Reactive/proactive aggression and the development of internalizing problems in males: the moderating effect of parent and peer relationships

The current study examined whether reactive and/or proactive aggression in adolescent males prospectively predicted increased levels of internalizing symptoms (depression and anxiety) in late adolescence. It was postulated that reactive aggression would be robustly related to later internalizing problems, but only among adolescent males who had problematic family or peer social relationships. Participants were a racially diverse group of 289 adolescent males (Mean age = 16). Measures of reactive and proactive aggression, peer rejection, and poor parent-adolescent communication were examined as predictors of both depression and anxiety symptoms assessed approximately 3 years later. The interactive effects between the two facets of aggression and measures of peer rejection and poor parent-adolescent communication in predicting internalizing problems was also examined. Adolescents with high levels of reactive aggression were more likely to exhibit elevated internalizing problems during late adolescence, even when controlling for pre-existing levels of anxiety/depression. However, this association only emerged for adolescents who had high levels of peer rejection and/or poor communication with their parent. Consistent with expectations, proactive aggression was unrelated to internalizing symptoms regardless of social relationship quality. Adolescent reactive, but not proactive, aggression is a risk factor for the development of internalizing problems. However, the findings suggest that interventions designed to foster positive social relationships among reactively aggressive youth may help protect them from developing significant internalizing problems over time.

Statewide implementation of the 4 Rs and 2 Ss for strengthening families

Embedding evidence-informed practices for children with mental health needs into "real-world" community settings has proven challenging. In this article, we discuss how the Practical, Robust, Implementation, and Sustainability Model (PRISM) guided statewide (New York) implementation of an evidence-informed intervention targeting families and youth with oppositional defiant and conduct disorders, collectively referred to as disruptive behavior disorders. Additionally, we present qualitative findings based on provider reports of integrating a novel, evidence-informed intervention within their respective community mental health settings. Finally, we discuss a process of modifying the intervention to address agency-level factors, as well as inform more widespread implementation efforts.

Cognitive indicators of social anxiety in youth: a structural equation analysis

Previous studies have demonstrated significant relationships among various cognitive variables such as negative cognition, self-efficacy, and social anxiety. Unfortunately, few studies focus on the role of cognition among youth, and researchers often fail to use domain-specific measures when examining cognitive variables. Therefore, the purpose of the present study was to examine domain-specific cognitive variables (i.e., socially oriented negative self-referent cognition and social self-efficacy) and their relationships to social anxiety in children and adolescents using structural equation modeling techniques. A community sample of children and adolescents (n=245; 55.9% female; 83.3% Caucasian, 9.4% African American, 2% Asian, 2% Hispanic, 2% "other," and 1.2% not reported) completed questionnaires assessing social cognition and social anxiety symptomology. Three latent variables were created to examine the constructs of socially oriented negative self-referent cognition (as measured by the SONAS scale), social self-efficacy (as measured by the SEQSS-C), and social anxiety (as measured by the SPAI-C and the Brief SA). The resulting measurement model of latent variables fit the data well. Additionally, consistent with the study hypothesis, results indicated that social self-efficacy likely mediates the relationship between socially oriented negative self-referent cognition and social anxiety, and socially oriented negative self-referent cognition yields significant direct and indirect effects on social anxiety. These findings indicate that socially oriented negative cognitions are associated with youth's beliefs about social abilities and the experience of social anxiety. Future directions for research and study limitations, including use of cross-sectional data, are discussed.

Direct-to-consumer marketing of psychological treatments for anxiety disorders

Progress disseminating and implementing evidence-based psychological treatments (EBPTs) for the anxiety disorders has been gradual. To date, the dominant approach for promoting the uptake of EBPTs in clinical settings has been to target the education and training of mental health providers, with many consumers remaining unaware of the potential benefits of EBPTs for anxiety disorders. Direct-to-consumer (DTC) marketing may be a promising vehicle for increasing EBPT utilization rates in the treatment of anxiety disorders. This paper provides an overview of the rationale and important considerations for applying DTC efforts to promote evidence-based care in the treatment of anxiety disorders, and reviews current DTC efforts in this area, including resources on the Internet and other media and in-person events. We conclude with recommendations for future efforts in the DTC marketing of EBPTs for the anxiety disorders, including the need for increased funding and grassroots efforts to inform consumers about anxiety disorders and their most effective treatments.

Cognitive-behavioral therapy for anxiety in children with high-functioning autism: a meta-analysis

BACKGROUND

Anxiety is a common and impairing problem in children and adolescents with autism spectrum disorder (ASD). There is emerging evidence that cognitive-behavioral therapy (CBT) could reduce anxiety in children with high-functioning ASD.

OBJECTIVE

To systematically review the evidence of using CBT to treat anxiety in children and adolescents with ASD. Methods for this review were registered with PROSPERO (CRD42012002722).

METHODS

We included randomized controlled trials published in English in peer-reviewed journals comparing CBT with another treatment, no treatment control, or waitlist control. Two authors independently screened 396 records obtained from database searches and hand searched relevant journals. Two authors independently extracted and reconciled all data used in analyses from study reports.

RESULTS

Eight studies involving 469 participants (252 treatment, 217 comparison) met our inclusion criteria and were included in meta-analyses. Overall effect sizes for clinician- and parent-rated outcome measures of anxiety across all studies were d = 1.19 and d = 1.21, respectively. Five studies that included child self-report yielded an average d = 0.68 across self-reported anxiety.

CONCLUSIONS

Parent ratings and clinician ratings of anxiety are sensitive to detecting treatment change with CBT for anxiety relative to waitlist and treatment-as-usual control conditions in children with high-functioning ASD. Clinical studies are needed to evaluate CBT for anxiety against attention control conditions in samples of children with ASD that are well characterized with regard to ASD diagnosis and co-occurring anxiety symptoms.

The feasibility and acceptability of virtual environments in the treatment of childhood social anxiety disorder

Two significant challenges for the dissemination of social skills training programs are the need to assure generalizability and provide sufficient practice opportunities. In the case of social anxiety disorder, virtual environments may provide one strategy to address these issues. This study evaluated the utility of an interactive virtual school environment for the treatment of social anxiety disorder in preadolescent children. Eleven children with a primary diagnosis of social anxiety disorder between 8 to 12 years old participated in this initial feasibility trial. All children were treated with Social Effectiveness Therapy for Children, an empirically supported treatment for children with social anxiety disorder. However, the in vivo peer generalization sessions and standard parent-assisted homework assignments were substituted by practice in a virtual environment. Overall, the virtual environment programs were acceptable, feasible, and credible treatment components. Both children and clinicians were satisfied with using the virtual environment technology, and children believed it was a high-quality program overall. In addition, parents were satisfied with the virtual environment augmented treatment and indicated that they would recommend the program to family and friends. Findings indicate that the virtual environments are viewed as acceptable and credible by potential recipients. Furthermore, they are easy to implement by even novice users and appear to be useful adjunctive elements for the treatment of childhood social anxiety disorder.

A systematic review of interventions for children with cerebral palsy: state of the evidence

AIM

The aim of this study was to describe systematically the best available intervention evidence for children with cerebral palsy (CP).

METHOD

This study was a systematic review of systematic reviews. The following databases were searched: CINAHL, Cochrane Library, DARE, EMBASE, Google Scholar MEDLINE, OTSeeker, PEDro, PsycBITE, PsycINFO, and speechBITE. Two independent reviewers determined whether studies met the inclusion criteria. These were that (1) the study was a systematic review or the next best available; (2) it was a medical/allied health intervention; and (3) that more than 25% of participants were children with CP. Interventions were coded using the Oxford Levels of Evidence; GRADE; Evidence Alert Traffic Light; and the International Classification of Function, Disability and Health.

RESULTS

Overall, 166 articles met the inclusion criteria (74% systematic reviews) across 64 discrete interventions seeking 131 outcomes. Of the outcomes assessed, 16% (21 out of 131) were graded 'do it' (green go); 58% (76 out of 131) 'probably do it' (yellow measure); 20% (26 out of 131) 'probably do not do it' (yellow measure); and 6% (8 out of 131) 'do not do it' (red stop). Green interventions included anticonvulsants, bimanual training, botulinum toxin, bisphosphonates, casting, constraint-induced movement therapy, context-focused therapy, diazepam, fitness training, goal-directed training, hip surveillance, home programmes, occupational therapy after botulinum toxin, pressure care, and selective dorsal rhizotomy. Most (70%) evidence for intervention was lower level (yellow) while 6% was ineffective (red).

INTERPRETATION

Evidence supports 15 green light interventions. All yellow light interventions should be accompanied by a sensitive outcome measure to monitor progress and red light interventions should be discontinued since alternatives exist.

Psychometric properties of the Child Anxiety Life Interference Scale (CALIS)

This paper describes the development and psychometric evaluation of a parent and child report measure of life interference and impairment associated with childhood anxiety, the Child Anxiety Life Interference Scale (CALIS). The CALIS is designed to measure life interference and impairment experienced by the child from the child (9 items) and parent (16 items) point of view and also the interference experienced by the parent in their own life. A total of 622 children between 6 and 17 years of age, and their parents, completed the CALIS. Results indicated that the CALIS has good internal consistency, moderate-to-high test re-test reliability, significant inter rater reliability, good convergent and divergent validity and is sensitive to treatment change. The CALIS is a reliable and valid tool for the assessment of life interference and impairment associated with anxiety disorders in childhood.

Cognitive behavioral therapy age effects in child and adolescent anxiety: an individual patient data metaanalysis

BACKGROUND

Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap.

QUESTION

Does age moderate CBT effect size, measured by a clinically and statistically significant interaction between age and CBT exposure?

METHODS

All English language RCTs of CBT for anxiety in 6-19 year olds were identified using systematic review methods. Investigators of eligible trials were invited to submit their individual patient data. The anxiety disorder interview schedule (ADIS) primary diagnosis severity score was the primary outcome. Age effects were investigated using multilevel modeling to account for study level data clustering and random effects.

RESULTS

Data from 17 of 23 eligible trials were obtained (74%); 16 studies and 1,171 (78%) cases were available for the analysis. No interaction between age and CBT exposure was found in a model containing age, sex, ADIS baseline severity score, and comorbid depression diagnosis (power ≥ 80%). Sensitivity analyses, including modeling age as both a categorical and continuous variable, revealed this result was robust.

CONCLUSIONS

Adolescents who receive CBT in efficacy research studies show benefits comparable to younger children. However, CBT protocol modifications routinely carried out by expert trial therapists may explain these findings. Adolescent CBT protocols are needed to facilitate the transportability of efficacy research effects to usual care settings where therapists may have less opportunity for CBT training and expertise development.

Psychiatric outcomes at age seven for very preterm children: rates and predictors

BACKGROUND

  Uncertainty remains about the rate of specific psychiatric disorders and associated predictive factors for very preterm (VPT) children. The aims of this study were to document rates of psychiatric disorders in VPT children aged 7 years compared with term born children, and to examine potential predictive factors for psychiatric diagnoses in VPT children.

METHODS

  Participants were 177 VPT and 65 term born children. Perinatal medical data were collected, which included brain abnormalities detected using magnetic resonance imaging. The Infant-Toddler Social-Emotional Assessment (ITSEA) and Strengths and Difficulties Questionnaire (SDQ) were administered at 2 and 5 years respectively. At 7 years of age, the Developmental and Well-being Assessment (DAWBA) was used to indicate psychiatric diagnoses.

RESULTS

  Compared with term born children, VPT children had three times the odds of meeting criteria for any psychiatric diagnosis at age 7 years (odds ratio 3.03; 95% confidence interval 1.23, 7.47, p = .02). The most common diagnoses were anxiety disorders (11% VPT, 8% term), attention-deficit/hyperactivity disorder (10% VPT, 3% term) and autism spectrum disorder (4.5% VPT, 0% term). For VPT children, those with severe global brain abnormalities (p = .02), those who displayed social-emotional problems at age 5 (p = .000) and those with higher social risk at age 7 (p = .001) were more likely to meet criteria for a psychiatric illness at age 7.

CONCLUSIONS

Compared with term born children, VPT children have higher rates of psychiatric diagnoses at early school age, predicted by neonatal brain abnormalities, prior social-emotional problems and social factors.

Anxiety and related outcomes in young adults 7 to 19 years after receiving treatment for child anxiety

OBJECTIVE

This study evaluated follow-up outcomes associated with cognitive behavioral therapy (CBT) for childhood anxiety by comparing successfully and unsuccessfully treated participants 6.72 to 19.17 years after treatment.

METHOD

Participants were a sample of 66 youths (ages 7-14 years at time of treatment, ages 18-32 years at present follow-up) who had been diagnosed with an anxiety disorder and randomized to treatment in a randomized clinical trial on average 16.24 (SD = 3.56, range = 6.72-19.17) years prior. The present follow-up included self-report measures and a diagnostic interview to assess anxiety, depression, and substance misuse.

RESULTS

Compared with those who responded successfully to CBT for an anxiety disorder in childhood, those who were less responsive had higher rates of panic disorder, alcohol dependence, and drug abuse in adulthood. Relative to a normative comparison group, those who were less responsive to CBT in childhood had higher rates of several anxiety disorders and substance misuse problems in adulthood. Participants remained at particularly increased risk, relative to the normative group, for generalized anxiety disorder and nicotine dependence regardless of initial treatment outcome.

CONCLUSIONS

The present study is the first to assess the long-term follow-up effects of CBT treatment for an anxiety disorder in youth on anxiety, depression, and substance abuse through the period of young adulthood when these disorders are often seen. Results support the presence of important long-term benefits of successful early CBT for anxiety.

Distinguishing primary and secondary variants of callous-unemotional traits among adolescents in a clinic-referred sample

The current study used model-based cluster analyses to determine if there are 2 distinct variants of adolescents (ages 11-18) high on callous-unemotional (CU) traits that differ on their level of anxiety and history of trauma. The sample (n = 272) consisted of clinic-referred youths who were primarily African American (90%) and who came from low-income families. Consistent with hypotheses, 3 clusters emerged, including a group low on CU traits, as well as 2 groups high on CU traits that differed in their level of anxiety and past trauma. Consistent with past research on incarcerated adults and adolescents, the group high on anxiety (i.e., secondary variant) was more likely to have histories of abuse and had higher levels of impulsivity, externalizing behaviors, aggression, and behavioral activation. In contrast, the group low on anxiety (i.e., primary variant) scored lower on a measure of behavioral inhibition. On measures of impulsivity and externalizing behavior, the higher scores for the secondary cluster were found only for self-report measures, not on parent-report measures. Youths in the primary cluster also were perceived as less credible reporters than youths in the secondary cluster (i.e., secondary variant) or cluster low on CU traits. These reporter and credibility differences suggest that adolescents within the primary variant may underreport their level of behavioral disturbance, which has important assessment implications.

Brief Cognitive-Behavioral Therapy for Anxious Youth: The Inner Workings

We provide a detailed description of the clinical application of brief cognitive-behavioral therapy (BCBT) for anxious youth. A rationale for the development of BCBT is presented, followed by a description and discussion of the 8 sessions of the treatment. Mike, a 7-year-old youth with anxiety disorders, is used to illustrate the inner workings of implementing BCBT. Case conceptualization, session details, and pre-, post- and follow-up-treatment information are provided. Conclusions regarding clinical advantages and future directions are made.

Brief Cognitive-Behavioral Therapy for Anxious Youth: Feasibility and Initial Outcomes

We developed and evaluated a brief (8-session) version of cognitive-behavioral therapy (BCBT) for anxiety disorders in youth ages 6 to 13. This report describes the design and development of the BCBT program and intervention materials (therapist treatment manual and child treatment workbook) and an initial evaluation of child treatment outcomes. Twenty-six children who met diagnostic criteria for a principal anxiety diagnosis of separation anxiety disorder, generalized anxiety disorder, and/or social phobia were enrolled. Results suggest that BCBT is a feasible, acceptable, and beneficial treatment for anxious youth. Future research is needed to examine the relative efficacy of BCBT and CBT for child anxiety in a randomized controlled trial.

Trajectory and predictors of alliance in cognitive behavioral therapy for youth anxiety

Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7-17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel "alliance rupture" model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.

Therapist Factors and Outcomes in CBT for Anxiety in Youth

This study examined the relationship between therapist factors and child outcomes in anxious youth who received cognitive-behavioral therapy (CBT) as part of the Child-Adolescent Anxiety Multimodal Study (CAMS). Of the 488 youth who participated in the CAMS project, 279 were randomly assigned to one of the CBT conditions (CBT only or CBT plus sertraline). Participants included youth (ages 7-17; M = 10.76) who met criteria for a principal anxiety disorder. Therapists included 38 cognitive-behavioral therapists. Therapist style, treatment integrity, and therapist experience were examined in relation to child outcome. Child outcome was measured via child, parent, and independent evaluator report. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way had youth with better treatment outcomes. Therapist "coach" style was a significant predictor of child-reported outcome, with the collaborative "coach" style predicting fewer child-reported symptoms. Higher levels of therapist prior clinical experience and lower levels of prior anxiety-specific experience were significant predictors of better treatment outcome. Findings suggest that although all therapists used the same manual-guided treatment, therapist style, experience, and clinical skills were related to differences in child outcome. Clinical implications and recommendations for future research are discussed.

Temperament and parenting predicting anxiety change in cognitive behavioral therapy: the role of mothers, fathers, and children

OBJECTIVE

A considerable amount of children with anxiety disorders do not benefit sufficiently from cognitive behavioral treatment. The present study examines the predictive role of child temperament, parent temperament and parenting style in the context of treatment outcome.

METHOD

Participants were 145 children and adolescents (ages 8-18) with DSM-IV-TR anxiety disorders who received a 12-session CBT program and were assessed at pretreatment, posttreatment and three months follow-up. Multiple-regression analyses were used to evaluate the following pretreatment and posttreatment variables as potential predictors of treatment response at follow-up: baseline level of anxiety symptoms, child reported maternal and paternal rearing style (emotional warmth, rejection, and overprotection), parent reported child temperament traits (negative affect, effortful control, and extraversion), and mothers' and fathers' self-report temperament traits.

RESULTS

More maternal negative affect and less emotional warmth as perceived by the child before treatment were related to less favorable treatment outcome (accounting for 29% of the variance in anxiety at follow-up). Furthermore, maternal negative affect and children's extraversion measured after treatment also predicted anxiety at follow-up (together accounting for 19% of the variance). Paternal temperament and parenting style were unrelated to treatment outcome, as were children's pretreatment temperament traits.

CONCLUSION

The results suggest that tailoring intervention to include strategies to reduce maternal negative affect and promote an emotional warm rearing style may improve treatment outcome.

Internalizing problems as a predictor of change in externalizing problems in at-risk youth

Intervention and prevention programs for children with externalizing problems frequently involve children with co-occurring internalizing problems. Little is known about how these co-occurring internalizing problems predict outcomes, particularly for programs involving cognitive-behavioral strategies. The current study examined how a set of child-related risk factors (including anxiety and depressive symptoms) predicted change in parent- and teacher-reported externalizing problems following a school-based preventative intervention for children at risk for externalizing problems. Participants included 112 preadolescent children (ages 9-12) who participated in a study designed to evaluate the efficacy of the Coping Power Program (Lochman & Wells, 2004 ). Participants included 81 boys (68%) who were primarily African American (69%) or Caucasian (30%). Regression analyses were conducted to examine predictors of change in parent- and teacher-reported externalizing problems on the Behavior Assessment System for Children (Reynolds & Kamphaus, 1992 ). Results indicated that greater child depression symptoms (as reported by parent or teacher) were associated with a larger reduction in externalizing behavior problems based on parent or teacher report. This effect was found in both the parent and teacher models and held after controlling for a number of child-oriented baseline variables including baseline aggression. Future research studies should examine whether co-occurring symptoms of depression relate to enhanced changes in externalizing problems following intervention for externalizing problems, particularly when cognitive-behavioral interventions are utilized. In addition, it will be important for studies to examine such effects relative to a control group and/or alternative treatment conditions and to further explore possible mechanisms of change.

Behavioral parenting interventions for child disruptive behaviors and anxiety: what's different and what's the same

This paper reviews the role of parents in behavioral interventions with children's disruptive and anxiety problems. The evolution of interventions for these two types of problems differs, as has the role of parents in these interventions. In contrast to the central role of parents in the conceptualization and treatment of disruptive behaviors, parents have played a more varied and less prominent role in the conceptualization and treatment of children's anxiety. Furthermore, the literature involving parents in the treatment of children's anxiety indicates these interventions are more efficacious than control groups but not more efficacious than intervening with the child alone. Some limited evidence emerges for parenting as a mediator in the treatment of disruptive behaviors, but not of anxiety, where the role of parenting has rarely been measured. Implications for conceptualizing the role of parents in intervention programs for youth are discussed and directions for future research are delineated (e.g., collecting long term follow-up data, examine moderators of treatment response, develop programs for comorbid diagnoses).

Anxiety disorders

With the adoption of a developmental psychopathology perspective, the DSM-5 translates empirical evidence on the continuity of childhood anxiety disorders into diagnostic practice, thereby completing a process that started with the exclusion of the former childhood anxiety disorders overanxious disorder and avoidant disorder from DSM-III to DSM-IV. This change in perspective, however, leads to a low level of concordance between the DSM-5 and ICD-10. To reliably identify anxiety disorders at different points in development, and to take into account their developmental pathways, assessment instruments need to be sensitive to age-related manifestations and age-related subtypes of a disorder. This may best be achieved by a multi-informant, multi-method assessment approach. With regard to treatment, only cognitive-behavioral therapy (CBT) fulfills the criteria of an evidence-based treatment approach in youth. Disorder-specific treatments can lead to larger treatment effects and slightly higher remission rates as compared to more general treatment programs for childhood anxiety disorders (e.g., Coping Cat). Parental involvement seems not to add to treatment success. In conclusion, the evidence-based diagnostic approach of the DSM-5 needs to be complemented by the development and evaluation of child-friendly, developmentally sensitive assessment tools and evidence-based treatments for anxiety disorders in children. With regard to diagnostic concordance, the gap between the DSM-5 and ICD-10 needs to be bridged by more closely aligning the two nosological systems.

Quality of attachment relationships and peer relationship dysfunction among late adolescents with and without anxiety disorders

Little is known about the links between anxiety disorders and parent-child attachment disorganization and quality of peer relationships in late adolescence. This study examined the quality of attachment and peer relationships among adolescents with and without anxiety disorders in a sample of 109 low- to moderate-income families. Psychopathology was assessed with the SCID-I. Attachment disorganization and dysfunction in peer relationships were measured using semi-structured interviews and behavioral observations. Adolescents with anxiety disorders and comorbid conditions showed higher levels of attachment disorganization across three measurement approaches, as well as higher levels of dysfunction in peer relationships than those with no Axis I diagnosis. Adolescents without anxiety disorders but with other Axis I disorders differed only in the quality of school relationships from those with no diagnoses. The pattern of results suggests that pathological anxiety, in the context of other comorbidities, may be a marker for more pervasive levels of social impairment.

Defining treatment response and remission in child anxiety: signal detection analysis using the pediatric anxiety rating scale

OBJECTIVE

To determine optimal Pediatric Anxiety Rating Scale (PARS) percent reduction and raw score cut-offs for predicting treatment response and remission among children and adolescents with anxiety disorders.

METHOD

Data were from a subset of youth (N = 438; 7-17 years of age) who participated in the Child/Adolescent Anxiety Multimodal Study (CAMS), a multi-site, randomized controlled trial that examined the relative efficacy of cognitive-behavioral therapy (CBT; Coping Cat), medication (sertraline [SRT]), their combination, and pill placebo for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. The clinician-rated PARS was administered pre- and posttreatment (delivered over 12 weeks). Quality receiver operating characteristic methods assessed the performance of various PARS percent reductions and absolute cut-off scores in predicting treatment response and remission, as determined by posttreatment ratings on the Clinical Global Impression scales and the Anxiety Disorders Interview Schedule for DSM-IV. Corresponding change in impairment was evaluated using the Child Anxiety Impact Scale.

RESULTS

Reductions of 35% and 50% on the six-item PARS optimally predicted treatment response and remission, respectively. Post-treatment PARS raw scores of 8 to 10 optimally predicted remission. Anxiety improved as a function of PARS-defined treatment response and remission.

CONCLUSIONS

Results serve as guidelines for operationalizing treatment response and remission in future research and in making cross-study comparisons. These guidelines can facilitate translation of research findings into clinical practice.

Anxious youth in research and service clinics

With the current focus on increasing utilization of empirically supported treatments, knowledge of sample differences and similarities has increasing importance. The present study compared anxiety-disordered youth (age 7-13) from (a) five Norwegian service clinics (SC, N = 111) to (b) a university research clinic (RC) in Philadelphia, USA (N = 144) on pre-treatment characteristics measured by the Multidimensional Anxiety Scale for Children, Child Behavior Checklist, Teacher Report Form, Anxiety Disorders Interview Schedule, and Children's Global Assessment Scale (CGAS). SC youth demonstrated higher levels of anxiety based on child- (d = 0.42-1.04) and parent-report (d = 0.53) and conduct problems based on parent-report (d = 0.43) compared to RC youth. SC youth was more functionally impaired on the CGAS (d = 0.97), whereas RC youth evidenced a greater number of diagnoses (d = 0.63). The two samples were equivalent regarding parent-reported symptoms of affective, somatic, attention-deficit/hyperactivity, and oppositional problems. Future directions and clinical implications are discussed.

Training School Mental Health Providers to Deliver Cognitive-Behavioral Therapy

Anxiety disorders are among the most prevalent mental health difficulties experienced by youth. A well-established literature has identified cognitive-behavior therapy (CBT) as the gold-standard psychosocial treatment for youth anxiety disorders. Access to CBT in community clinics is limited, but a potential venue for the provision of CBT for child anxiety disorders is the school setting. The present study examined a subset of data from a larger study in which therapists from a variety of settings, including schools, were trained in CBT for child anxiety (N = 17). The study investigated the relationship between provider- and organizational-level variables associated with training and implementation among school mental health providers. The present findings indicate a positive relationship between provider attitudes and adherence to CBT. Self-reported barriers to implementation were also identified. Integrating CBT into school mental health providers' repertoires through training and consultation is a critical step for dissemination and implementation of empirically supported psychosocial treatments.

Pediatric social anxiety disorder: predictors of response to pharmacological treatment

OBJECTIVE

Pediatric social anxiety disorder (SAD) is associated with an increased risk of comorbid mental disorders, with implications for prognosis and treatment strategy. The aim of this study is to explore predictors of treatment response, and the role of comorbidity in affecting refractoriness.

METHODS

One hundred and forty consecutive youths (81 males, 57.9%), ages 7-18 years (mean age 13.7 ± 2.5 years, mean age at onset of SAD 10.6 ± 2.7 years) met American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for SAD as primary diagnosis, according to a structured clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version [K-SADS-PL]). All received a pharmacological treatment with serotonin reuptake inhibitors (SSRIs) targeted to SAD, associated with additional medications for comorbidities (mood stabilizers in 27.1%, antipsychotics in 12.8%) and 57.9% received an additional psychotherapy.

RESULTS

Eighty-nine patients (63.6%) responded to treatments after 3 months, namely 72.8% with psychotherapy plus medication and 50.8% with medication only. Nonresponders had more severe symptoms at baseline in terms of both clinical severity and functional impairment, and had more comorbid disruptive behavior disorders. The backward logistic regression indicated that clinical severity and functional impairment at baseline, comorbid disruptive behavior disorders, and bipolar disorders were predictors of nonresponse.

CONCLUSION

Our data suggest that SSRIs can be effective in pediatric SAD, but that the more severe forms of the disorder and those with heavier comorbidity are associated with poorer prognosis.

An Adaptation of the Coping Cat Program

Generalized anxiety disorder (GAD) during childhood is a common condition with negative implications. This case study describes the successful cognitive-behavioral treatment of a 6-year-old boy with excessive worry and sleep disturbances. Because of the patient’s age, treatment methods were adapted for an early reader. The frequency and intensity of his symptoms (e.g., physiologic arousal, apprehensive expectations, sleep disturbances) were measured over the course of treatment and at 3 and 7 years after treatment. Recommendations are provided for clinicians and students who aim to treat young children with GAD. The results of this intervention suggest a durable and meaningful reduction in GAD-related symptoms.

Facing your fears in adolescence: cognitive-behavioral therapy for high-functioning autism spectrum disorders and anxiety

Adolescents with high-functioning autism spectrum disorders (ASDs) are at high risk for developing psychiatric symptoms, with anxiety disorders among the most commonly cooccurring. Cognitive behavior therapies (CBTs) are considered the best practice for treating anxiety in the general population. Modified CBT approaches for youth with high-functioning ASD and anxiety have resulted in significant reductions in anxiety following intervention. The purpose of the present study was to develop an intervention for treating anxiety in adolescents with ASD based on a CBT program designed for school-aged children. The Facing Your Fears-Adolescent Version (FYF-A) program was developed; feasibility and acceptability data were obtained, along with initial efficacy of the intervention. Twenty-four adolescents, aged 13–18, completed the FYF-A intervention. Results indicated significant reductions in anxiety severity and interference posttreatment, with low rates of anxiety maintained at 3-month follow-up. In addition, nearly 46% of teen participants met criteria for a positive treatment response on primary diagnosis following the intervention. Initial findings from the current study are encouraging and suggest that modified group CBT for adolescents with high-functioning ASD may be effective in reducing anxiety symptoms. Limitations include small sample size and lack of control group. Future directions are discussed.