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Lord KA, Tolin DF. Symptom distress and psychosocial functioning improve bidirectionally during cognitive-behavioral therapy for anxiety disorders. J Anxiety Disord 2024; 103:102843. [PMID: 38310753 DOI: 10.1016/j.janxdis.2024.102843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 06/30/2023] [Accepted: 01/29/2024] [Indexed: 02/06/2024]
Abstract
The efficacy of cognitive-behavioral therapy (CBT) for reducing anxiety disorder symptoms is well documented. However, limited research has investigated how symptom amelioration is temporally associated with changes in psychosocial functioning, such as interpersonal and social role functioning, during CBT. Participants were 288 (M age = 37.00 [SD = 14.41]; 59.0% female; 69.0% White; 6.6% Hispanic/Latino) outpatients diagnosed with an anxiety disorder who received CBT at a specialized hospital-based clinic. Participants completed the Outcome Questionnaire-45, a measure of symptom distress, social role performance, and interpersonal problems, at initial assessment and prior to each treatment session. Symptom distress and indicators of psychosocial functioning were robustly related during 25 sessions of CBT. Cross-lagged analyses revealed that reductions in symptom distress predicted subsequent improvements in psychosocial functioning during treatment, and vice versa. Associations from symptom distress to subsequent psychosocial functioning evidenced larger effect sizes than the reverse. Lower levels of severity at intake and presence of comorbid depression attenuated the association between symptom reduction and subsequent social role performance improvement. In sum, anxiety symptoms and psychosocial functioning bidirectionally improve during CBT for anxiety disorders. Maximally effective treatments may be those that simultaneously ameliorate symptoms and focus on improving functioning in key domains.
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Affiliation(s)
- Kayla A Lord
- Anxiety Disorders Center, Institute of Living, Hartford, USA.
| | - David F Tolin
- Anxiety Disorders Center, Institute of Living, Hartford, USA; Department of Psychiatry, Yale School of Medicine, New Haven, USA
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Viswanathan M, Wallace IF, Cook Middleton J, Kennedy SM, McKeeman J, Hudson K, Rains C, Vander Schaaf EB, Kahwati L. Screening for Anxiety in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2022; 328:1445-1455. [PMID: 36219404 DOI: 10.1001/jama.2022.16303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions. Objective To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force. Data Sources PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022. Study Selection English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration-approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms. Data Extraction and Synthesis Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events. Results Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement-mean difference (Pediatric Anxiety Rating Scale mean difference, -4.0 [95% CI, -5.5 to -2.5]; n = 726; 5 studies; and Clinical Global Impression-Severity scale mean difference, -0.84 [95% CI, -1.13 to -0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)-but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different. Conclusions and Relevance Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.
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Affiliation(s)
- Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Ina F Wallace
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Jennifer Cook Middleton
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Sara M Kennedy
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Joni McKeeman
- Department of Psychiatry, University of North Carolina at Chapel Hill
| | - Kesha Hudson
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Caroline Rains
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Emily B Vander Schaaf
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill
| | - Leila Kahwati
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
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Dickson SJ, Kuhnert RL, Lavell CH, Rapee RM. Impact of Psychotherapy for Children and Adolescents with Anxiety Disorders on Global and Domain-Specific Functioning: A Systematic Review and Meta-analysis. Clin Child Fam Psychol Rev 2022; 25:720-736. [PMID: 35794304 PMCID: PMC9622529 DOI: 10.1007/s10567-022-00402-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 12/01/2022]
Abstract
A substantial empirical base supports the use of psychotherapy to alleviate anxiety symptoms and diagnoses in children and adolescents. However, focusing only on symptom or diagnostic reduction provides an incomplete picture of clinically meaningful efficacy given that anxiety disorders in this age group are integrally associated with problems in functioning. A systematic review and meta-analysis (N studies = 40, N participants = 3094) evaluating the impacts of psychotherapy for anxiety was conducted on the following outcomes: global functioning, social functioning, academic functioning, and school attendance. Randomised controlled trials with a passive control condition, a child and/or adolescent sample (7–17 years) with a primary anxiety diagnosis, and receiving anxiety-focused psychotherapy were eligible for inclusion if they reported suitable outcome data. Results from the meta-analysis indicated that from pre- to post-treatment, psychotherapy led to significant improvements in global functioning according to clinician (d = 1.55), parent (d = 0.67), and child (d = 0.31) reports and on social functioning according to parent (d = 0.51), but not child (d = 0.31) reports. The qualitative review provided preliminary support psychotherapy’s efficacy in increasing family functioning and school attendance, but not so much in enhancing academic performance. These results indicate that psychotherapy improves daily functioning in anxious children and adolescents. The study also highlighted the limited attention paid to measures of functioning in the empirical literature on treatment of childhood anxiety. Trial Registry: This study is registered with PROSPERO under the identification number CRD42021246565.
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Affiliation(s)
- Sophie J Dickson
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Rebecca-Lee Kuhnert
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Cassie H Lavell
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, NSW, 2109, Australia
| | - Ronald M Rapee
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, NSW, 2109, Australia.
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Conroy K, Hong N, Poznanski B, Hart KC, Ginsburg GS, Fabiano GA, Comer JS. Harnessing Home-School Partnerships and School Consultation to Support Youth With Anxiety. COGNITIVE AND BEHAVIORAL PRACTICE 2021; 29:381-399. [PMID: 35812004 PMCID: PMC9267952 DOI: 10.1016/j.cbpra.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Youth with anxiety often experience significant impairment in the school setting. Despite the relevance and promise of addressing anxiety in schools, traditional treatment approaches to school-based anxiety often do not adequately address generalization to the school setting, or they require removing the student from the classroom to deliver time- and staff-intensive programs. Such programs often leave teachers and caregivers feeling ill-equipped to support the student with anxiety throughout the natural course of the school day. Given the heavy demands placed on teachers and documented burnout among school professionals, providing effective school supports requires collaborative partnerships among outpatient therapists/specialists, school personnel, and caregivers. Drawing from literature on collaborative models for externalizing problems, we offer recommendations for outpatient therapists and specialists working to implement evidence-based supports in school settings and promote home-school partnerships to benefit youth with anxiety in the school setting. Our recommendations touch upon several components of such school consultation, including (a) identification of key parties involved, (b) conducting a needs assessment, (c) collaborative goal setting and development of a fear hierarchy, (d) plan development and implementation (e.g., facilitating a school-based exposure mindset, promoting home-school communication, enhancing school relationships), and (e) progress monitoring and ongoing support. We conclude with a case example to bring these recommendations to life.
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Norris LA, Kendall PC. Moderators of Outcome for Youth Anxiety Treatments: Current Findings and Future Directions. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2020; 50:450-463. [PMID: 33140992 DOI: 10.1080/15374416.2020.1833337] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: To improve outcomes and create more personalized interventions, the field has sought to identify moderators of treatment response (variables that specify which treatments work for whom and under what conditions).Method: The current review examines moderators of youth anxiety treatments.Results: The majority of studies to date have examined variables of convenience, including demographics (age, sex, race, ethnicity, socioeconomic status), pretreatment youth clinical characteristics (anxiety severity, principal diagnosis, comorbidity) and pretreatment parent variables (parent psychopathology, parenting). Findings indicate few consistent moderators.Conclusions: Future directions are discussed, including (a) group to individual generalizability, (b) power considerations, and (c) updates to study design and measure selection.
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Thurman AJ, Potter LA, Kim K, Tassone F, Banasik A, Potter SN, Bullard L, Nguyen V, McDuffie A, Hagerman R, Abbeduto L. Controlled trial of lovastatin combined with an open-label treatment of a parent-implemented language intervention in youth with fragile X syndrome. J Neurodev Disord 2020; 12:12. [PMID: 32316911 PMCID: PMC7175541 DOI: 10.1186/s11689-020-09315-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/27/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The purpose of this study was to conduct a 20-week controlled trial of lovastatin (10 to 40 mg/day) in youth with fragile X syndrome (FXS) ages 10 to 17 years, combined with an open-label treatment of a parent-implemented language intervention (PILI), delivered via distance video teleconferencing to both treatment groups, lovastatin and placebo. METHOD A randomized, double-blind trial was conducted at one site in the Sacramento, California, metropolitan area. Fourteen participants were assigned to the lovastatin group; two participants terminated early from the study. Sixteen participants were assigned to the placebo group. Lovastatin or placebo was administered orally in a capsule form, starting at 10 mg and increasing weekly or as tolerated by 10 mg increments, up to a maximum dose of 40 mg daily. A PILI was delivered to both groups for 12 weeks, with 4 activities per week, through video teleconferencing by an American Speech-Language Association-certified Speech-Language Pathologist, in collaboration with a Board-Certified Behavior Analyst. Parents were taught to use a set of language facilitation strategies while interacting with their children during a shared storytelling activity. The main outcome measures included absolute change from baseline to final visit in the means for youth total number of story-related utterances, youth number of different word roots, and parent total number of story-related utterances. RESULTS Significant increases in all primary outcome measures were observed in both treatment groups. Significant improvements were also observed in parent reports of the severity of spoken language and social impairments in both treatment groups. In all cases, the amount of change observed did not differ across the two treatment groups. Although gains in parental use of the PILI-targeted intervention strategies were observed in both treatment groups, parental use of the PILI strategies was correlated with youth gains in the placebo group and not in the lovastatin group. CONCLUSION Participants in both groups demonstrated significant changes in the primary outcome measures. The magnitude of change observed across the two groups was comparable, providing additional support for the efficacy of the use of PILI in youth with FXS. TRIAL REGISTRATION US National Institutes of Health (ClinicalTrials.gov), NCT02642653. Registered 12/30/2015.
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Affiliation(s)
- Angela John Thurman
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA. .,Department of Psychiatry and Behavioral Sciences, University of California Davis Health, Sacramento, USA.
| | - Laura A Potter
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Pediatrics, University of California Davis Health, Sacramento, USA
| | - Kyoungmi Kim
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Public Health Sciences, University of California Davis Health, Sacramento, USA
| | - Flora Tassone
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Biochemistry and Molecular Medicine, University of California Davis Health, Sacramento, USA
| | - Amy Banasik
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Psychiatry and Behavioral Sciences, University of California Davis Health, Sacramento, USA
| | - Sarah Nelson Potter
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Human Ecology, University of California Davis, Davis, USA
| | - Lauren Bullard
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Human Ecology, University of California Davis, Davis, USA
| | - Vivian Nguyen
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Psychiatry and Behavioral Sciences, University of California Davis Health, Sacramento, USA
| | - Andrea McDuffie
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Psychiatry and Behavioral Sciences, University of California Davis Health, Sacramento, USA
| | - Randi Hagerman
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Pediatrics, University of California Davis Health, Sacramento, USA
| | - Leonard Abbeduto
- MIND Institute, University of California Davis Health, 2825 50th Street, Room 2335, Sacramento, CA, 95817, USA.,Department of Psychiatry and Behavioral Sciences, University of California Davis Health, Sacramento, USA
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