Treatment Concerns and Functional Impairment in Pediatric Anxiety

A Systematic Review and Meta-Analysis of Impairment and Quality of Life in Children and Adolescents with Anxiety Disorders

Anxiety disorders are common, emerge during childhood, and pose a significant burden to society and individuals. Research evaluating the impact of anxiety on functional impairment and quality of life (QoL) is increasing; however, there is yet to be a systematic review and meta-analysis of these relationships in pediatric samples. This systematic review and meta-analysis were conducted to determine the extent of impairments in functioning and QoL that young people with anxiety disorders experience relative to their healthy peers, as well as sociodemographic and clinical moderators of these relationships. Studies were included when they compared young people (mean age range within studies 7-17 years) with a primary clinical anxiety disorder to a healthy comparison group and measured impairment and/or QoL via a validated instrument. A total of 12 studies met criteria for this review (N = 3,129 participants). A majority of studies (K = 9) assessed impairment as an outcome measure, and three assessed QoL outcomes. Meta-analysis of nine studies (N = 1,457 children) showed large relationships between clinical anxiety and life impairment (g = 3.23) with the strongest effects seen for clinician report (g = 5.00), followed by caregiver (g = 2.15) and child (g = 1.58) report. The small number of studies and diversity in methodology prevented quantitative investigation of moderating factors. In the systematic review of QoL outcomes, all three studies reported significantly poorer QoL for youth with anxiety disorders relative to unaffected peers. Findings support the importance of measuring functioning and QoL as outcomes in clinical research and practice among anxious young people.This study is registered with PROSPERO under the identification number CRD42023439040.

Impact of youth and caregiver worries about treatment on therapeutic process factors and posttreatment outcomes

OBJECTIVE

To examine the impact of youth- and caregiver-reported pretreatment worries about treatment (i.e., concerns about the effect of, perceptions of, or aspects involved in treatment) before cognitive behavioral therapy for anxiety on (1) clinician-rated therapeutic process factors (i.e., client engagement, client-therapist alliance, content mastery, and homework completion) and symptom change (i.e., improvement, anxiety severity) assessed throughout treatment and (2) independent evaluator-rated posttreatment outcomes (i.e., response, remission, and functional impairment).

METHODS

Participants were 128 youth, aged 7-17 years, who sought treatment for a principal anxiety disorder, and their primary caregiver. Multilevel models were estimated to examine the relationship between worries about treatment and the set of therapeutic factors. Regression models examined the relationship between worries about treatment and posttreatment outcomes.

RESULTS

Results indicated that greater youth-reported worries about treatment flattened/lessened improvement trajectories throughout treatment and had a positive association with higher anxiety severity and lower content mastery. Greater caregiver-reported worries about treatment were associated with greater homework completion, client engagement, and content mastery throughout treatment. Youth- and caregiver-reports of worries about treatment did not impact independent evaluator-rated posttreatment outcomes.

CONCLUSIONS

Findings support the notion that worries about treatment do not prevent youth from achieving favorable posttreatment outcomes, but do impact various therapeutic factors differentially across youth and caregiver report (e.g., content mastery, client engagement, and homework completion). The value of addressing worries about treatment at the start of therapy is discussed.

Adolescent Perception of Mental Health: It's Not Only about Oneself, It's about Others Too

Adolescents are at an increased risk of mental health problems due to the natural processes of development and maturation. Given that their mental health is mainly assessed by adults and not by the adolescents themselves, the purpose of this study is to reveal adolescents' perceptions of mental health. Semi-structured, in-depth interviews were conducted, and an inductive qualitative approach with thematic analysis was used. The qualitative study consisted of 19 adolescents aged 11-17 years. Five themes were identified: (1) What does mental health mean to you? (subthemes: realm of emotions, customary behavior, and relationships with others); (2) needs (subthemes: communication and support, self-expression and freedom of decision-making, and a safe and personal environment); (3) risk factors (subthemes: un-healthy relationships and social media dangers); (4) red flags (subthemes: self-exclusion from social life and self-destructive behavior); and (5) role of mental health professionals (subthemes: attentiveness to and proper pace for adolescent and acceptance of adolescent's life in its entirety). This study revealed that adolescents view their mental health not only from their own emotional and behavioral perspectives but also through the prism of relationships with other people.

Understanding parental knowledge, attitudes and self-efficacy in professional help-seeking for child anxiety

BACKGROUND

Child anxiety disorders are highly prevalent yet undertreated. As parents are often 'gatekeepers' to children receiving treatment and support, this study aimed to investigate modifiable parental factors affecting professional help-seeking for their children from general practitioners (GPs), psychologists, and paediatricians.

METHODS

In this study, 257 Australian parents of children aged 5-12 years with elevated anxiety symptoms completed a cross-sectional online survey. The survey assessed help-seeking from a GP, psychologist, and paediatrician (General Help Seeking Questionnaire), as well as anxiety knowledge (Anxiety Literacy Scale), help-seeking attitudes (Attitudes Toward Seeking Professional Psychological Help), personal stigma (Generalised Anxiety Stigma Scale) and self-efficacy (Self-Efficacy in Seeking Mental Health Care).

RESULTS

66.9 % of participants had sought help from a GP, 61.1 % from a psychologist, and 33.9 % from a paediatrician. Help-seeking from a GP or psychologist was associated with lower personal stigma (p = .02 and p = .03 respectively). Participants who sought help from a psychologist also had more positive attitudes toward seeking professional support (p = .01). Conversely, knowledge of anxiety disorders and self-efficacy were not associated with help-seeking from any source.

LIMITATIONS

Limitations of the study include the representativeness of our sample (female gender, higher education level); unexplained variance potentially accounted for by other factors (e.g., structural barriers); lack of prior validation of measures in a parent sample.

CONCLUSIONS

This research will inform the development of public health policy and psychoeducation interventions for parents, to reduce personal stigma and increase positive attitudes toward professional help-seeking, in turn improving help-seeking for child anxiety.

The Impact of Treatment Expectations on Exposure Process and Treatment Outcome in Childhood Anxiety Disorders

This study examined the relationship between caregivers' and youths' treatment expectations and characteristics of exposure tasks (quantity, mastery, compliance) in cognitive-behavioral therapy (CBT) for childhood anxiety. Additionally, compliance with exposure tasks was tested as a mediator of the relationship between treatment expectations and symptom improvement. Data were from youth (N = 279; 7-17 years old) enrolled in the Child/Adolescent Anxiety Multimodal Study (CAMS) and randomized to cognitive-behavioral therapy (CBT) or the combination of CBT and sertraline for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. Caregivers and youth independently reported treatment expectations prior to randomization, anxiety was assessed pre- and post-treatment by independent evaluators blind to treatment condition, and exposure characteristics were recorded by the cognitive-behavioral therapists following each session. For both caregivers and youths, more positive expectations that anxiety would improve with treatment were associated with greater compliance with exposure tasks, and compliance mediated the relationship between treatment expectations and change in anxiety symptoms following treatment. Additionally, more positive parent treatment expectations were related to a greater number and percentage of sessions with exposure. More positive youth treatment expectations were associated with greater mastery during sessions focused on exposure. Findings underscore the importance of addressing parents' and youths' treatment expectations at the outset of therapy to facilitate engagement in exposure and maximize therapeutic gains.

Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies

Mental health disorders in children and adolescents are highly prevalent yet undertreated. A detailed understanding of the reasons for not seeking or accessing help as perceived by young people is crucial to address this gap. We conducted a systematic review (PROSPERO 42018088591) of quantitative and qualitative studies reporting barriers and facilitators to children and adolescents seeking and accessing professional help for mental health problems. We identified 53 eligible studies; 22 provided quantitative data, 30 provided qualitative data, and one provided both. Four main barrier/facilitator themes were identified. Almost all studies (96%) reported barriers related to young people's individual factors, such as limited mental health knowledge and broader perceptions of help-seeking. The second most commonly (92%) reported theme related to social factors, for example, perceived social stigma and embarrassment. The third theme captured young people's perceptions of the therapeutic relationship with professionals (68%) including perceived confidentiality and the ability to trust an unknown person. The fourth theme related to systemic and structural barriers and facilitators (58%), such as financial costs associated with mental health services, logistical barriers, and the availability of professional help. The findings highlight the complex array of internal and external factors that determine whether young people seek and access help for mental health difficulties. In addition to making effective support more available, targeted evidence-based interventions are required to reduce perceived public stigma and improve young people's knowledge of mental health problems and available support, including what to expect from professionals and services.