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

Computers and psychosocial treatment for child anxiety: recent advances and ongoing efforts

Building on the empirical data supporting the efficacy of cognitive-behavioral therapy (CBT) for child anxiety, researchers are working on the development and evaluation of cost-effective and transportable CBT approaches. Related to this, a widely endorsed goal is to disseminate evidence-based treatments from research settings to community settings. Computer-assisted treatments have emerged as a means to provide cost-effective and efficient service to an increased number of anxious youth for whom a CBT treatment would be otherwise unavailable. We offer a rationale for the development and evaluation of computer-assisted psychosocial treatments for anxiety in youth, offer illustrative advances made in this area, and describe our efforts in using computers to enhance dissemination of CBT for child anxiety. Specifically, our illustrations include a description of (a) Camp-Cope-A-Lot (CCAL), a computer-assisted CBT for the treatment of anxiety disorders in youth ages 7-12, and (b) CBT4CBT: Computer-based training in CBT for anxious youth. Findings from evaluations of these programs are summarized, and further advances are proposed and discussed.

Predicting nonresponse to juvenile drug court interventions

Using data from a recent randomized clinical trial involving juvenile drug court (JDC), youth marijuana use trajectories and the predictors of treatment nonresponse were examined. Participants were 118 juvenile offenders meeting diagnostic criteria for substance use disorders assigned to JDC and their families. Urine drug screen results were gathered from weekly court visits for 6 months, and youth reported their marijuana use over 12 months. Semiparametric mixture modeling jointly estimated and classified trajectories of both marijuana use indices. Youth were classified into responder versus nonresponder trajectory groups based on both outcomes. Regression analyses examined pretreatment individual, family, and extrafamilial predictors of nonresponse. Results indicated that youth whose caregivers reported illegal drug use pretreatment were almost 10 times as likely to be classified into the nonresponder trajectory group. No other variable significantly distinguished drug use trajectory groups. Findings have implications for the design of interventions to improve JDC outcomes.

Social Anxiety Scale for Adolescents: factorial invariance and latent mean differences across gender and age in Spanish adolescents

Little is known about the factorial invariance across gender and age for self-report measures of social anxiety in adolescence. This study examined the factorial invariance and latent mean differences of the Social Anxiety Scale for Adolescents (SAS-A) across gender and age groups in 1570 Spanish adolescents (54% girls), ranging in age from 14 to 17 years. Equality of factor structures was compared using multi-group confirmatory factor analyses. Measurement invariance for the correlated three-factor model of the SAS-A was found across gender and age samples. Analyses of latent mean differences revealed that girls exhibited higher means than boys on two SAS-A subscales, Fear of Negative Evaluation and Social Avoidance and Distress-New (SAD-New). In addition, on the SAD-New subscale, the structured means significantly diminished from 14-year olds to 16- and 17-year olds and from 15-year olds to 17-year olds. Findings are discussed in terms of the use of the SAS-A with Spanish adolescents.

Social information processing in children: specific relations to anxiety, depression, and affect

Two studies examined shared and unique relations of social information processing (SIP) to youth's anxious and depressive symptoms. Whether SIP added unique variance over and above trait affect in predicting internalizing symptoms was also examined. In Study 1, 215 youth (ages 8-13) completed symptom measures of anxiety and depression and a vignette-based interview measure of SIP. Anxiety and depression were each related to a more negative information-processing style. Only depression was uniquely related to a less positive information processing style. In Study 2, 127 youth (ages 10-13) completed measures of anxiety, depression, SIP, and trait affect. SIP's relations to internalizing symptoms were replicated. Over and above negative affect, negative SIP predicted both anxiety and depression. Low positive SIP added variance over and above positive affect in predicting only depression. Finally, SIP functioning partially mediated the relations of affect to internalizing symptoms.

Does cognitive behavioral therapy for youth anxiety outperform usual care in community clinics? An initial effectiveness test

OBJECTIVE

Most tests of cognitive behavioral therapy (CBT) for youth anxiety disorders have shown beneficial effects, but these have been efficacy trials with recruited youths treated by researcher-employed therapists. One previous (nonrandomized) trial in community clinics found that CBT did not outperform usual care (UC). The present study used a more stringent effectiveness design to test CBT versus UC in youths referred to community clinics, with all treatment provided by therapists employed in the clinics.

METHOD

A randomized controlled trial methodology was used. Therapists were randomized to training and supervision in the Coping Cat CBT program or UC. Forty-eight youths (56% girls, 8 to 15 years of age, 38% Caucasian, 33% Latino, 15% African-American) diagnosed with DSM-IV anxiety disorders were randomized to CBT or UC.

RESULTS

At the end of treatment more than half the youths no longer met criteria for their primary anxiety disorder, but the groups did not differ significantly on symptom (e.g., parent report, eta-square = 0.0001; child report, eta-square = 0.09; both differences favoring UC) or diagnostic (CBT, 66.7% without primary diagnosis; UC, 73.7%; odds ratio 0.71) outcomes. No differences were found with regard to outcomes of comorbid conditions, treatment duration, or costs. However, youths receiving CBT used fewer additional services than UC youths (χ(2)(1) = 8.82, p = .006).

CONCLUSIONS

CBT did not produce better clinical outcomes than usual community clinic care. This initial test involved a relatively modest sample size; more research is needed to clarify whether there are conditions under which CBT can produce better clinical outcomes than usual clinical care. CLINICAL TRIAL REGISTRY INFORMATION: Community Clinic Test of Youth Anxiety and Depression Study, URL: http://clinicaltrials.gov, unique identifier: NCT01005836.

Cognitive behavioral treatment for childhood anxiety disorders: long-term effects on anxiety and secondary disorders in young adulthood

BACKGROUND

The present study's aim was to examine the long-term effects (8 to 13 years post-treatment; M = 9.83 years; SD = 1.71) of the most widely used treatment approaches of exposure-based cognitive behavioral treatment for phobic and anxiety disorders in children and adolescents (i.e., group treatment and two variants of individual treatment). An additional aim was to compare the relative long-term efficacy of the treatment approaches.

METHOD

At long-term follow-up, participants (N = 67) were between 16 and 26 years of age (M = 19.43 years, SD = 3.02). Primary outcome was the targeted anxiety disorder and targeted symptoms. Secondary outcomes were other disorders and symptoms not directly targeted in the treatments including (1) other anxiety disorders and symptoms, (2) depressive disorders and symptoms, and (3) substance use disorders and symptoms.

RESULTS

Long-term remission for anxiety disorders and symptoms targeted in the treatments was evident 8 to 13 years post-treatment. Long-term remission also was found for the secondary outcomes. There were more similarities than differences in the long-term gains when comparing the treatment approaches.

CONCLUSIONS

Consistent with past research, the study's findings provide further evidence that the short-term benefits of exposure-based CBT for childhood phobic and anxiety disorders using both group and individual treatment may extend into the critical transition years of young adulthood.

Comorbidity in youth with specific phobias: Impact of comorbidity on treatment outcome and the impact of treatment on comorbid disorders

The purpose of the present study was twofold. In an analysis of data from an existing randomized control trial of brief cognitive behavioral treatment on specific phobias (One-Session Treatment, OST; Ollendick et al., 2009), we examined 1) the effect of comorbid specific phobias and other anxiety disorders on treatment outcomes, and 2) the effect of treatment of the specific phobia on these co-occurring disorders. These relations were explored in 100 youth presenting with animal, natural environment, situational, and "other" types of phobia. Youth were reliably diagnosed with the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (Silverman & Albano, 1996). Clinician severity ratings at post-treatment and 6-month follow-up were examined as were parent and child treatment outcome satisfaction measures. Results indicated that the presence of comorbid phobias or anxiety disorders did not affect treatment outcomes; moreover, treatment of the targeted specific phobias led to significant reductions in the clinical severity of other co-occurring specific phobias and related anxiety disorders. These findings speak to the generalization of the effects of this time-limited treatment approach. Implications for treatment of principal and comorbid disorders are discussed, and possible mechanisms for these effects are commented upon.

Flexible Applications of the Coping Cat Program for Anxious Youth

The current article offers suggestions for ways to adapt empirically supported treatments (ESTs). A specific manualized EST (Coping Cat; Kendall & Hedtke, 2006a) is used to illustrate the concept of "flexibility within fidelity" (Kendall & Beidas, 2007; Kendall, Gosch, Furr, & Sood, 2008). Flexibility within fidelity stresses the importance of using ESTs while considering and taking into account individual client presentations. In this discussion, recommendations are offered for the use of the Coping Cat with younger youth, adolescents, and youth with secondary comorbidities (i.e., social skills deficits, inattentive symptoms, and depressive symptoms).

Clinical characteristics of anxiety disordered youth

Reports the characteristics of a large, representative sample of treatment-seeking anxious youth (N=488). Participants, aged 7-17 years (mean 10.7 years), had a principal DSM-IV diagnosis of separation anxiety disorder (SAD), generalized anxiety disorder (GAD), or social phobia (SP). Although youth with a co-primary diagnosis for which a different disorder-specific treatment would be indicated (e.g., major depressive disorder, substance abuse) were not included, there were few other exclusion criteria. Participants and their parent/guardian underwent an extensive baseline assessment using a broad array of measures capturing diagnostic status, anxiety symptoms and severity, and areas of functional impairment. Means and standard deviations of the measures of psychopathology and data on diagnostic status are provided. The sample had moderate to severe anxiety disorder and was highly comorbid, with 55.3% of participants meeting criteria for at least one non-targeted DSM-IV disorder. Anxiety disorders in youth often do not present as a single/focused disorder: such disorders in youth overlap in symptoms and are highly comorbid among themselves.

Training Therapists in Evidence-Based Practice: A Critical Review of Studies From a Systems-Contextual Perspective

Evidence-based practice (EBP), a preferred psychological treatment approach, requires training of community providers. The systems-contextual (SC) perspective, a model for dissemination and implementation efforts, underscores the importance of the therapist, client, and organizational variables that influence training and consequent therapist uptake and adoption of EBP. This review critiques the extant research on training in EBP from an SC perspective. Findings suggest that therapist knowledge improves and attitudinal change occurs following training. However, change in therapist behaviors (e.g., adherence, competence, and skill) and client outcomes only occurs when training interventions address each level of the SC model and include active learning. Limitations as well as areas for future research are discussed.

Impact of childhood trauma on treatment outcome in the Treatment for Adolescents with Depression Study (TADS)

OBJECTIVE

The impact of childhood trauma was examined in 427 adolescents (54% girls, 74% Caucasian, mean = 14.6, SD = 1.5) with major depressive disorder participating in the Treatment for Adolescents with Depression Study (TADS).

METHOD

TADS compared the efficacy of cognitive behavioral therapy (CBT), fluoxetine (FLX), their combination (COMB), and placebo (PBO). Teens were separated into four trauma history groups: (1) no trauma; (2) trauma, no abuse; (3) physical abuse; (4), and sexual abuse. The effects of treatment and trauma history on depression severity across 12 weeks of acute treatment, as measured by the Children's Depression Rating Scale-Revised (CDRS-R), were examined.

RESULTS

A significant trauma-by-treatment-by-time interaction indicated that trauma history moderated treatment. The Week 12 primary efficacy findings previously reported by TADS were replicated in the no trauma group (n = 201): COMB = FLX > CBT = PBO. No significant differences in treatment arms were observed among the trauma, no abuse, or physical abuse group. Teens with a history of sexual abuse treated with COMB, FLX, and PBO showed significant and equivalent improvement on the CDRS-R (mean <45), whereas the mean CDRS-R for the CBT group tended to remain in the depressed range (mean >45). Baseline suicidality and self-reported depression were significantly related to a history of sexual abuse.

CONCLUSIONS

The study was limited by the level of detail regarding childhood traumatic experiences. Results are discussed in terms of the implications for treating depressed adolescents with traumatic backgrounds.Clinical Trials Registry Information: Treatment for Adolescents with Depression Study; http://www.clinicaltrials.gov, NCT00006286.

Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods

OBJECTIVE

To present the design, methods, and rationale of the Child/Adolescent Anxiety Multimodal Study (CAMS), a recently completed federally-funded, multi-site, randomized placebo-controlled trial that examined the relative efficacy of cognitive-behavior therapy (CBT), sertraline (SRT), and their combination (COMB) against pill placebo (PBO) for the treatment of separation anxiety disorder (SAD), generalized anxiety disorder (GAD) and social phobia (SoP) in children and adolescents.

METHODS

Following a brief review of the acute outcomes of the CAMS trial, as well as the psychosocial and pharmacologic treatment literature for pediatric anxiety disorders, the design and methods of the CAMS trial are described.

RESULTS

CAMS was a six-year, six-site, randomized controlled trial. Four hundred eighty-eight (N = 488) children and adolescents (ages 7-17 years) with DSM-IV-TR diagnoses of SAD, GAD, or SoP were randomly assigned to one of four treatment conditions: CBT, SRT, COMB, or PBO. Assessments of anxiety symptoms, safety, and functional outcomes, as well as putative mediators and moderators of treatment response were completed in a multi-measure, multi-informant fashion. Manual-based therapies, trained clinicians and independent evaluators were used to ensure treatment and assessment fidelity. A multi-layered administrative structure with representation from all sites facilitated cross-site coordination of the entire trial, study protocols and quality assurance.

CONCLUSIONS

CAMS offers a model for clinical trials methods applicable to psychosocial and psychopharmacological comparative treatment trials by using state-of-the-art methods and rigorous cross-site quality controls. CAMS also provided a large-scale examination of the relative and combined efficacy and safety of the best evidenced-based psychosocial (CBT) and pharmacologic (SSRI) treatments to date for the most commonly occurring pediatric anxiety disorders. Primary and secondary results of CAMS will hold important implications for informing practice-relevant decisions regarding the initial treatment of youth with anxiety disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00052078.

The impact of adolescent chronic pain on functioning: disentangling the complex role of anxiety

A number of adolescents with chronic pain have clinically significant disability across physical, social, and academic activities, and pain severity only explains a portion of the variance in functioning. Thus, it is important to identify therapeutic options to improve adolescents' functioning. In contrast to studies with adults with chronic pain, research in pediatric pain has not consistently found anxiety to be a good predictor of pain-related disability. The present study evaluated pain, anxiety, and functioning in 222 adolescents with chronic pain. Results indicated that pain was consistently and linearly related to disability across measures of physical and social functioning, school attendance, and physician visits. The relation between anxiety and functioning was complex; increased anxiety was related to poorer physical and social functioning and was related to fewer physician visits, although it was not associated with school attendance. Additional analyses revealed that anxiety serves to moderate the relation between pain and functioning. Specifically, at high anxiety, pain was not related to functioning, but at low anxiety, pain consistently predicted disability. In other words, highly anxious adolescents were functioning poorly regardless of the level of pain. The moderating role of anxiety highlights a number of research and clinical possibilities to explore with adolescents with chronic pain-related disability.

PERSPECTIVE

Data suggest that high anxiety is associated with poor functioning irrespective of pain intensity. At low anxiety, higher pain predicted greater disability. Anxiety is important to assess when investigating potential reasons for pain-related disability.

Cognitive behavior therapy for anxious adolescents: developmental influences on treatment design and delivery

Anxiety disorders in adolescence are common and disruptive, pointing to a need for effective treatments for this age group. Cognitive behavior therapy (CBT) is one of the most popular interventions for adolescent anxiety, and there is empirical support for its application. However, a significant proportion of adolescent clients continue to report anxiety symptoms post-treatment. This paper underscores the need to attend to the unique developmental characteristics of the adolescent period when designing and delivering treatment, in an effort to enhance treatment effectiveness. Informed by the literature from developmental psychology, developmental psychopathology, and clinical child and adolescent psychology, we review the 'why' and the 'how' of developmentally appropriate CBT for anxious adolescents. 'Why' it is important to consider developmental factors in designing and delivering CBT for anxious adolescents is addressed by examining the age-related findings of treatment outcome studies and exploring the influence of developmental factors, including cognitive capacities, on engagement in CBT. 'How' clinicians can developmentally tailor CBT for anxious adolescents in six key domains of treatment design and delivery is illustrated with suggestions drawn from both clinically and research-oriented literature. Finally, recommendations are made for research into developmentally appropriate CBT for anxious adolescents.

Treatments for common psychiatric conditions among children and adolescents during acute rehabilitation and reintegration phases of burn injury

Advances in critical care and surgical management during the last 20 years have decreased mortality rates among children with severe burn injuries. This improved survival rate has prompted researchers to study the psychological aspects of recovering from a burn injury. Initially research focused primarily on epidemiology, prevention and descriptions of the psychological phenomenon experienced by the children and adolescents. Whereas previously interventions were often utilized during the acute phases of burn injury without knowledge of the long-term effects, more recently, priorities have shifted to include long-term treatment outcome studies. The purpose of this paper is to review and discuss the current evidence-based techniques and their efficacy in the treatment of common psychological and psychiatric conditions among children and adolescents during the three major phases of burn injury.

Changes in emotion regulation following cognitive-behavioral therapy for anxious youth

This study examined emotion-related functioning following cognitive-behavioral therapy (CBT) with 37 youth with anxiety disorders (22 boys, 15 girls) ranging in age from 7 to 15 with a principal diagnosis of generalized anxiety disorder (n = 27), separation anxiety disorder (n = 12), and/or social phobia (n = 13). Treated youth exhibited a reduction in anxiety and increased anxiety self-efficacy and emotional awareness at posttreatment. Treated youth also demonstrated improved coping and less emotional dysregulation with worry but not with anger or sadness. The results suggest that the gains made in worry regulation do not generalize to other emotions that are not specifically targeted within the CBT protocol.

Mediators and moderators of outcome in the behavioral treatment of childhood social phobia

OBJECTIVE

The current study examined mediators and moderators of treatment response among children and adolescents (ages 7-17 years) with a primary diagnosis of social phobia.

METHOD

Participants were 88 youths participating in one of two randomized controlled treatment trials of Social Effectiveness Therapy for Children. Potential mediators included changes in observer-rated social skill and child-reported loneliness after 12 weeks of Social Effectiveness Therapy for Children. Age and depressive symptoms were examined as potential moderators.

RESULTS

Loneliness scores and social effectiveness during a role-play task predicted changes in social anxiety and overall functioning at posttreatment. Changes in social anxiety were mediated by child-reported loneliness. Outcomes were not moderated by age or depressive symptoms.

CONCLUSIONS

Findings support the role of loneliness as an important mechanism of change during treatment for childhood social phobia.

One-year follow-up of family versus child CBT for anxiety disorders: Exploring the roles of child age and parental intrusiveness

OBJECTIVE

To compare the relative long-term benefit of family-focused cognitive behavioral therapy (FCBT) and child-focused cognitive behavioral therapy (CCBT) for child anxiety disorders at a 1-year follow-up.

METHOD

Thirty-five children (6-13 years old) randomly assigned to 12-16 sessions of family-focused CBT (FCBT) or child-focused CBT (CCBT) participated in a 1-year follow-up assessment. Independent evaluators, parents, and children rated anxiety and parental intrusiveness. All were blind to treatment condition and study hypotheses.

RESULTS

Children assigned to FCBT had lower anxiety scores than children assigned to CCBT on follow-up diagnostician- and parent-report scores, but not child-report scores. Exploratory analyses suggested the advantage of FCBT over CCBT may have been evident more for early adolescents than for younger children and that reductions in parental intrusiveness may have mediated the treatment effect.

CONCLUSION

FCBT may yield a stronger treatment effect than CCBT that lasts for at least 1 year, although the lack of consistency across informants necessitates a circumspect view of the findings. The potential moderating and mediating effects considered in this study offer interesting avenues for further study.

Directionality of change in youth anxiety treatment involving parents: an initial examination

This randomized clinical trial compared cognitive behavioral therapy (CBT) with minimal parent involvement to CBT with active parent involvement in a sample of 119 youths (7-16 years old; 33.6% Caucasian, 61.3% Latino) with anxiety disorders. The dynamics of change between youth anxiety and parent variables (positive-negative behaviors toward the child, conflict in the parent-youth relationship, and parental anxiety) in both treatment conditions over pretreatment, posttreatment, and 12-month follow-up were also examined. Results indicated that youth anxiety was significantly reduced with both treatments and that the dynamics of change may not solely flow from parent to youth but also from youth to parent. Findings highlight the need for research on directionality and mechanisms of change to move from evidence-based treatments toward evidence-based explanations of treatment outcome.

Anxiety in children and adolescents with autism spectrum disorders

Anxiety and poor stress management are common concerns in clinical samples of children with autism spectrum disorders (ASD). Anxiety may worsen during adolescence, as young people face an increasingly complex social milieu and often become more aware of their differences and interpersonal difficulties. This review summarizes the state of research on the prevalence, phenomenology, and treatment of anxiety in youth with autism and related conditions such as Asperger's Disorder. Using search words autism, asperger(s), or pervasive developmental disorder and anxiety or anxious to find reports published between 1990 and 2008, this review identified 40 papers. The results of the review suggest that anxiety, whether measured categorically or dimensionally, is indeed common in children and adolescents with autism spectrum disorders and may be a source of additional morbidity. The assessment of anxiety disorders in ASD should be conducted using multiple informants and modalities, as children with ASD often do not display age-typical symptoms of anxiety. To date, relatively few controlled intervention studies using well-characterized samples have been conducted despite preliminary evidence for efficacy of select pharmacological and psychosocial approaches. Recommendations for future applied research are presented and clinical implications are explored.

Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety

BACKGROUND

Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy.

METHODS

In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12.

RESULTS

The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline.

CONCLUSIONS

Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)