Predictors of treatment outcome in an effectiveness trial of cognitive behavioral therapy for children with anxiety disorders

Modular CBT for Childhood Anxiety Disorders: Evaluating Clinical Outcomes and its Predictors

This study examined clinical outcomes of a modular individual CBT for children with anxiety disorders (AD), and predictors of outcomes, in usual clinical practice. Participants were 106 children with ADs (7-17 years), and parents. Assessments were pre-, mid-, post-test, and 10 weeks after CBT (follow-up). Predictors (measured pre-treatment) were child characteristics (gender, age, type of AD, comorbid disorders), fathers' and mothers' anxious/depressive symptoms, and parental involvement (based on parents' presence during treatment sessions and the use of a parent module in treatment). At follow-up, 59% (intent-to-treat analyses) to 70% (completer analysis) of the children were free from their primary anxiety disorder. A significant decrease in anxiety symptoms was found. Higher parental involvement was related to lower child anxiety at follow-up, but only for children with comorbid disorders. Findings suggest that it is beneficial to treat anxiety with modular CBT. Future steps involve comparisons of modularized CBT with control conditions.

Factors predicting depressive symptoms in parents of children with autism spectrum disorder in eastern China

BACKGROUND

Parents of children with autism spectrum disorder (ASD) are at a higher risk of depression than parents of typically developing children and those of children with other developmental disorders. Depression affects the well-being and quality of life of parents of children with ASD and has serious consequences for the long-term health outcomes of children with ASD. Therefore, this study explored the current status of depressive symptoms in parents of children with ASD in eastern China and further analyzed multiple aspects of the predictors of depressive symptoms.

METHODS

A multicenter cross-sectional survey was conducted among parents of children with ASD in the rehabilitation department of a large specialized hospital and 10 rehabilitation centers for children with special needs in Lianyungang, Jiangsu Province, Eastern China. A structured questionnaire that focused on child-related factors, parent-related factors, depressive symptoms, courtesy stigma, and social support was used to obtain data. Binary logistic regression was used to identify the independent predictors of depressive symptoms in parents of children with ASD.

RESULTS

A total of 409 parents of children with ASD were recruited, of whom 18.8% had depressive symptoms. Parents of children with ASD who raised a child who spoke few to no words (odds ratio [OR]: 2.747, 95% confidence interval [CI]: 1.026-7.357), claimed a high economic burden (OR: 3.215, 95% CI: 1.234-8.379), reported no change or increased severity of ASD in their children (OR: 2.518, 95% CI: 1.108-5.720), and those with a higher courtesy stigma score (OR: 1.189, 95% CI: 1.093-1.294) were more likely to have depressive symptoms. Conversely, parents of children with ASD who were employed (OR: 0.427, 95% CI: 0.201-0.907), satisfied with their current marital status (OR: 0.429, 95% CI: 0.221-0.834), and those with a higher social support score (OR: 0.973, 95% CI: 0.950-0.996) were less likely to have depressive symptoms.

CONCLUSIONS

Depressive symptoms are common in parents of children with ASD in eastern China. Therefore, screening and intervention for depressive symptoms in parents of children with ASD is necessary, especially for those with high-risk factors.

Assessing Anxiety-Related Impairment in Children and Adolescents

Anxiety disorders (ADs) frequently lead to significant impairment across important domains of youth functioning. Yet until recently, clinical research and assessment have largely neglected the measurement of anxiety-related impairment. In this article, we review the evidence for five extant rating scales of youth anxiety-related impairment, guided by widely used evaluative criteria. Emerging psychometric data show the potential utility of these rating scales for achieving different assessment functions. Of the five scales, the Child Anxiety Impact Scale, particularly the parent-report version, has been the most researched one. Promising psychometric data support its use for assessing anxiety-related impairment in school, social, and family/home domains of functioning. We conclude with recommendations for growing this research base and for incorporating these rating scales into the youth AD clinical and research assessment process.

The Role of Maternal Anxiety in Treatment Response for Youth with ASD and Co-occurring Anxiety

Anxiety disorders occur at higher rates in youth with ASD than in neurotypical youth. Although the efficacy of CBT for anxiety in children with ASD is widely supported, factors that influence treatment outcomes are not well understood. This study examined the role of maternal anxiety in treatment outcomes for youth with ASD. Youth with ASD and anxiety (ages 8 to 14), along with their mothers (n = 87), participated in a group CBT intervention. Results indicated that maternal anxiety did not improve over the course of treatment. However, findings suggest that high levels of maternal anxiety at pre-treatment predicted higher levels of youth anxiety post-treatment. Importantly, the relationship between parent anxiety and youth outcomes was moderated by child age. The findings of the present study may provide initial insight into the role that maternal anxiety plays in treatment outcomes for children with ASD and co-occurring anxiety, particularly when considering child age.

Integrated Behavior Therapy for Exclusively Anxious Selective Mutism: A Nonconcurrent Multiple-Baseline Design across Five Participants

Selective mutism (SM) is a rare childhood anxiety disorder which may be markedly detrimental to a child's academic and social functioning if left untreated. Cognitive-behavioral treatments for social anxiety disorders have been found to be effective for SM, yet a paucity of published studies have explored manualized treatment approaches carried out by novice clinicians. The purpose of the present study was to examine the adherence, effectiveness, and acceptability of a condensed, 16-session version of Integrated Behavior Therapy for Selective Mutism (IBTSM; Bergman, 2013), the first manualized treatment for SM. A nonconcurrent multiple-baseline single-case design was used across five children diagnosed with SM, exclusively anxious subtype. IBTSM was implemented with excellent adherence (M = 98%) over an average of 19 weeks (range = 16-22 weeks). Visual analyses of weekly caregiver ratings of social anxiety and speaking behaviors did not demonstrate a replicated intervention effect; however, Tau-U effect sizes and Reliable Change Index (RCI) calculations demonstrated significant individual improvements in social anxiety and speaking behaviors over time on several measures. Three children (60%) no longer met diagnostic criteria for SM following treatment. All caregivers rated IBTSM as acceptable, with specific endorsements of acceptability in the areas of time required and treatment quality.

Predictors of school-based cognitive behavior therapy outcome for youth with anxiety

Meta-analyses of school-based CBT have shown that prevention for anxiety symptoms typically report small but significant effects. There is limited knowledge regarding which youths may benefit most and least from such programs, and characteristics of youth who respond differentially to interventions of different intensity. The present study examined predictors of school-based CBT outcomes among 302 youths (mean age 14.0 years, SD 0.8, 84% female) who participated in a randomized waitlist-controlled trial comparing a 10-session and a 5-session group intervention. Potential predictors included youth and parental factors, and credibility and expectancy of the interventions. Pre-intervention anxiety and depression levels, and clinician rated severity were examined as moderators of intervention effects. Outcomes were youth-, and parent-reported youth anxiety and depressive symptoms at post-intervention and 1-year follow-up. Higher parent-reported impairment from youth anxiety predicted larger parent-reported anxiety and depressive symptom change, whereas higher caregiver strain was associated with less symptom change. Higher parent rated credibility and expectancy was associated with improved outcomes at post-intervention. At 1-year follow-up, no predictors of outcome were identified. No moderators were identified. Families with high levels of caregiver strain associated with youth anxiety may need extra support regardless of length of intervention program. Parents' credibility and expectancy of interventions should be targeted to optimize school-based CBT.

Evidence for distinct genetic and environmental influences on fear acquisition and extinction

BACKGROUND

Anxiety disorders are highly prevalent with an early age of onset. Understanding the aetiology of disorder emergence and recovery is important for establishing preventative measures and optimising treatment. Experimental approaches can serve as a useful model for disorder and recovery relevant processes. One such model is fear conditioning. We conducted a remote fear conditioning paradigm in monozygotic and dizygotic twins to determine the degree and extent of overlap between genetic and environmental influences on fear acquisition and extinction.

METHODS

In total, 1937 twins aged 22-25 years, including 538 complete pairs from the Twins Early Development Study took part in a fear conditioning experiment delivered remotely via the Fear Learning and Anxiety Response (FLARe) smartphone app. In the fear acquisition phase, participants were exposed to two neutral shape stimuli, one of which was repeatedly paired with a loud aversive noise, while the other was never paired with anything aversive. In the extinction phase, the shapes were repeatedly presented again, this time without the aversive noise. Outcomes were participant ratings of how much they expected the aversive noise to occur when they saw either shape, throughout each phase.

RESULTS

Twin analyses indicated a significant contribution of genetic effects to the initial acquisition and consolidation of fear, and the extinction of fear (15, 30 and 15%, respectively) with the remainder of variance due to the non-shared environment. Multivariate analyses revealed that the development of fear and fear extinction show moderate genetic overlap (genetic correlations 0.4-0.5).

CONCLUSIONS

Fear acquisition and extinction are heritable, and share some, but not all of the same genetic influences.

Health professionals' experience of nursing home residents' consumption of alcohol and use of psychotropic drugs

Background:

Nursing home (NH) residents are in most cases in older ages and use prescription drugs. As alcohol interacts with many commonly prescribed drugs, NH residents may be more vulnerable to the effects of alcohol.

Aim:

To investigate the experiences of health professionals in Norwegian NHs when it comes to residents' alcohol consumption and use of psychotropic drugs, and the facilitation of such use in the NH.

Method:

Focus-groups and individual interviews with NH health professionals were performed in 2017 and 2018. The data were analysed using content analysis.

Findings:

Two main themes emerged: (1) the balancing of alcohol consumption, and (2) the use of psychotropic drugs. Each of these themes involved reasoning, which revealed that the informants in general had little attention regarding alcohol consumption among residents, and few institutions had policies regarding serving and consumption of alcohol. The informants reported an increased attention regarding use of psychotropic drugs and a tendency towards less use of psychotropic drugs among the residents than before, but few informants reported use of standardised observations tools of symptoms related to prescribing and discontinuation of drugs.

Conclusion:

Alcohol policies or procedures related to alcohol consumption were uncommon at the NH that the interviewees of this study represented, and the professionals regarded infrequent serving and consumption of alcohol among the residents as a part of everyday life. In cases when residents frequently consumed alcohol, the professionals used dialogue to underpin the adherent risks and they also tried to control the consumption of the resident in different ways. The interviewees were aware of various side-effects of psychotropic drugs; they were also aware of their effects in combination with alcohol.

A Systematic Review Focusing on Psychotherapeutic Interventions that Impact Parental Psychopathology, Child Psychopathology and Parenting Behavior

Given the high rates of co-occurrence of psychopathology within families, it is important to identify and characterize interventions that simultaneously reduce both parent and child symptoms, and improve parenting quality. This is needed as intervention development is increasingly moving toward integrated interventions that target some combination of parent and child mental health, and parenting behavior. Even so, much remains unknown regarding which treatment components provide maximum benefit for parent symptoms, child symptoms, and parenting behavior. This systematic review identified and characterized psychotherapeutic interventions that report improvements in each of three outcomes: parent symptoms, child symptoms and parenting behavior. Fifty-six unique interventions were eligible for review, of which 25 reported improvements in all three outcomes. All 25 of these interventions directly intervened on parenting behavior, often as the sole target of the intervention. Few interventions improved all three outcomes in samples in which parents, children or both met clinical-level thresholds of psychopathology. Additional research is needed to better understand the bi-directional and transactional influences of treatment on family members, and to better inform the development of interventions for dually disordered parent-child dyads across a range of diagnostic profiles.

A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders

BACKGROUND

Treatment of a child who has an anxiety disorder usually begins with the question of which treatment to start first, medication or psychotherapy. Both have strong empirical support, but few studies have compared their effectiveness head-to-head, and none has investigated what to do if the treatment tried first isn't working well-whether to optimize the treatment already begun or to add the other treatment.

METHODS

This is a single-blind Sequential Multiple Assignment Randomized Trial (SMART) of 24 weeks duration with two levels of randomization, one in each of two 12-week stages. In Stage 1, children will be randomized to fluoxetine or Coping Cat Cognitive Behavioral Therapy (CBT). In Stage 2, remitters will continue maintenance-level therapy with the single-modality treatment received in Stage 1. Non-remitters during the first 12 weeks of treatment will be randomized to either [1] optimization of their Stage 1 treatment, or [2] optimization of Stage 1 treatment and addition of the other intervention. After the 24-week trial, we will follow participants during open, naturalistic treatment to assess the durability of study treatment effects. Patients, 8-17 years of age who are diagnosed with an anxiety disorder, will be recruited and treated within 9 large clinical sites throughout greater Los Angeles. They will be predominantly underserved, ethnic minorities. The primary outcome measure will be the self-report score on the 41-item youth SCARED (Screen for Child Anxiety Related Disorders). An intent-to-treat analysis will compare youth randomized to fluoxetine first versus those randomized to CBT first ("Main Effect 1"). Then, among Stage 1 non-remitters, we will compare non-remitters randomized to optimization of their Stage 1 monotherapy versus non-remitters randomized to combination treatment ("Main Effect 2"). The interaction of these main effects will assess whether one of the 4 treatment sequences (CBT➔CBT; CBT➔med; med➔med; med➔CBT) in non-remitters is significantly better or worse than predicted from main effects alone.

DISCUSSION

Findings from this SMART study will identify treatment sequences that optimize outcomes in ethnically diverse pediatric patients from underserved low- and middle-income households who have anxiety disorders.

TRIAL REGISTRATION

This protocol, version 1.0, was registered in ClinicalTrials.gov on February 17, 2021 with Identifier: NCT04760275 .

Interpretation biases and depressive symptoms among anxiety-disordered children: The role of individual differences in respiratory sinus arrhythmia

Individual differences in interpretation biases-the tendency to interpret ambiguous stimuli as threatening-partially explain the presence of comorbid depressive symptoms among anxious youth. Increasing efforts have examined physiological processes that influence the association between interpretation biases and depressive symptoms in this population, and potential gender differences in this relationship. This study examined the moderating role of respiratory sinus arrhythmia (RSA) suppression (i.e., decrease from baseline)-an index of parasympathetic nervous system reactivity-in the association between interpretation biases and depressive symptoms in clinically anxious youth. One-hundred-and-five clinically anxious children (Mage  = 10.09 years, SD = 1.22; 56.7% female; 61.9% racial/ethnic minority) completed measures of self-reported and behaviorally indexed interpretation biases, reported anxiety/depression symptom severity, and participated in a speech task. RSA suppression during the task moderated the association between interpretation biases and depressive symptom severity in the total sample. Separate exploratory moderation analyses were conducted among girls and boys. Among girls, RSA suppression moderated the association between behaviorally indexed interpretation biases and depressive symptoms, and marginally moderated (p = .067) the association between self-reported interpretation biases and depressive symptoms. Among boys, RSA suppression was not a significant moderator. These findings may help identify clinically anxious youth most at-risk for comorbid depressive symptoms.

Parental internalizing symptoms as predictors of anxiety symptoms in clinic-referred children

Background:

Mothers’ and fathers’ internalizing symptoms may influence children’s anxiety symptoms differently.

Objective:

To explore the relationship between parental internalizing symptoms and children’s anxiety symptoms in a clinical sample of children with anxiety disorders.

Method:

The sample was recruited through community mental health clinics for a randomized controlled anxiety treatment trial. At pre-intervention, children (n = 182), mothers (n = 165), and fathers (n = 72) reported children’s anxiety symptoms. Mothers and fathers also reported their own internalizing symptoms. The children were aged 8 to 15 years (M_age = 11.5 years, SD = 2.1, 52.2% girls) and all had a diagnosis of separation anxiety, social phobia, and/or generalized anxiety disorder. We examined parental internalizing symptoms as predictors of child anxiety symptoms in multiple regression models.

Results:

Both mother and father rated internalizing symptoms predicted children’s self-rated anxiety levels (adj. R² = 22.0%). Mother-rated internalizing symptoms predicted mother-rated anxiety symptoms in children (adj. R² = 7.0%). Father-rated internalizing symptoms did not predict father-rated anxiety in children.

Conclusions:

Clinicians should incorporate parental level of internalizing symptoms in their case conceptualizations.

Psychological Predictors of Cognitive-Behavioral Therapy Outcomes for Anxiety and Depressive Disorders in Children and Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

By understanding specific differences between responders to a treatment and non-responders, treatment modalities may be fitted to the individual in order to increase effectiveness, a concept known as "precision medicine". This systematic review and meta-analysis investigated which pretreatment patient and family characteristics may predict the outcome of cognitive-behavioral therapy (CBT) in clinically anxious and/or depressed youth. In particular, higher symptom severity, more severe co-occurring anxiety or depression and more severe parental psychopathology were hypothesized to predict a worse CBT outcome.

METHODS

The databases PubMed, PsycINFO and Cochrane Library were searched; 73 publications were included in the review from which 23 studies were used for the meta-analysis.

RESULTS

Higher symptom severity represented a clinically relevant predictor of a worse CBT outcome, with large effects estimated by meta-analysis. Further, parental psychopathology was significant and detrimental for CBT outcome in anxious but not depressed youth, while the effects for co-occurring anxiety and depression remained unclear. The additional results of the review show that only few characteristics seemed to be clearly associated with a worse CBT outcome, namely worse coping skills and, restricted to depressed patients, more non-suicidal self-injury.

LIMITATIONS

The available evidence was of only moderate quality in general, further high-quality research with more transparent reporting is needed.

CONCLUSIONS

The patient characteristics identified as being relevant for CBT outcome may represent important candidates for use in single patient prediction models for precision medicine in the field of child and adolescent psychotherapy. The review was preregistered on PROSPERO (ID: CRD42018116881).

Are young people with primary social anxiety disorder less likely to recover following generic CBT compared to young people with other primary anxiety disorders? A systematic review and meta-analysis

Background:

Social anxiety disorder (SoAD) in youth is often treated with a generic form of cognitive behavioural therapy (CBT). Some studies have suggested that primary SoAD is associated with lower recovery rates following generic CBT compared with other anxiety disorders.

Aims:

This systematic review and meta-analysis investigated recovery rates following generic CBT for youth with primary SoAD versus other primary anxiety disorders.

Method:

Five databases (PsycINFO, Web of Science, PubMed, Embase, Medline) were searched for randomised controlled trials of generic CBT for child and/or adolescent anxiety.

Results:

Ten trials met criteria for inclusion in the systematic review, six of which presented sufficient data for inclusion in the meta-analysis. Sixty-seven did not report data on recovery rates relative to primary diagnosis. While most individual studies included in the systematic review were not sufficiently powered to detect a difference in recovery rates between diagnoses, there was a pattern of lower recovery rates for youth with primary SoAD. Across the trials included in the meta-analysis, the post-CBT recovery rate from primary SoAD (35%) was significantly lower than the recovery rate from other primary anxiety disorders (54%).

Conclusions:

Recovery from primary SoAD is significantly less likely than recovery from any other primary anxiety disorder following generic CBT in youth. This suggests a need for research to enhance the efficacy of CBT for youth SoAD.

Which passengers are on your bus? A taxonomy of the barriers adolescents with chronic pain face in achieving functional recovery

BACKGROUND

Despite evidence that intensive interdisciplinary pain treatment (IIPT) is effective in facilitating functional recovery in adolescents with chronic pain, engagement with IIPT is suboptimal among adolescents. A key aspect of IIPT is to support functional recovery via (re)engagement with age-appropriate daily activities. The aim of this study was to gain a comprehensive insight into adolescents' perceptions of the barriers they need to overcome to engage with age-appropriate activities in order to achieve functional recovery.

METHODS

Forty-one adolescents who were starting an IIPT programme completed the 'passenger-on-the-bus metaphor', an exercise in which they identify and describe their perceived barriers (i.e. 'passengers' on their bus) that prevent them from engaging with age-appropriate activities. The responses were analysed using inductive thematic analyses to generate a taxonomy of perceived barriers to functional recovery.

RESULTS

We generated a taxonomy of seven different barriers that participants described facing on their road to functional recovery: physical constraints, being 'fed up', low self-confidence and self-esteem, perfectionism, avoidance of engagement with pain, feelings (such as sadness, anger, guilt, anxiety) and social barriers (received from a range of sources such as parents, friends, school and wider society).

CONCLUSION

The findings reveal a variety of barriers that were perceived to hinder functional recovery through reduced engagement with age-appropriate activities and thereby hamper progress within IIPT. The Passenger on the bus metaphor can be used to identify similar barriers faced by adolescents in an individualized treatment approach, thereby making it possible for clinicians to target their IIPT more precisely.

Parental Depressive Symptoms as a Predictor of Outcome in the Treatment of Child Internalizing and Externalizing Problems

Child internalizing and externalizing problems have been identified as high priority intervention targets by the World Health Organization. Parental depression is a risk factor for development of these childhood problems and may negatively influence intervention outcomes; however, studies have rarely assessed its influence on these outcomes. The present study assessed whether baseline parental depressive symptoms predicted psychotherapy outcomes among children treated for clinically significant internalizing and externalizing problems. The sample included 142 children (79 with primary internalizing problems, 63 with primary externalizing problems). Children were aged 7-13, 67.6% boys, and race included Caucasian (46.5%), African-American (9.9%), Latino (5.6%), Asian (1.4%), and multi-racial (32.4%). Analyses focused on child- and parent-reported weekly trajectories of change and post-treatment symptoms among children treated for internalizing and externalizing problems whose parents did (N = 28 and 25) and did not (N = 51 and 38) have elevated depressive symptoms. For children with internalizing problems, growth curve analyses showed markedly different trajectories, by child- and parent-report: children with less depressed parents showed significantly steeper symptom declines than did children with more depressed parents, who showed an increase in symptoms. ANCOVAs showed marginally lower post-treatment symptoms for children of less depressed versus more depressed parents (p = 0.064 by child-report). For children with externalizing problems, growth curve analyses showed trajectories in the opposite direction, by child- and parent-report; however, ANCOVAs showed no group differences at post-treatment. These findings suggest that it may be important to consider the impact of parental depressive symptoms when treating child internalizing and externalizing problems.

Associations between family factors, childhood adversity, negative life events and child anxiety disorders: an exploratory study of diagnostic specificity

BACKGROUND

Chronic childhood adversity, negative life events, and anxiogenic parenting behaviours have all been implicated in the development and maintenance of childhood anxiety disorders. However, few studies have addressed whether these factors are associated with particular types of childhood anxiety disorders.

AIMS

The aims of this study were to investigate whether specific associations were obtained between specific types of childhood anxiety disorder - namely, social anxiety disorder (SOC), separation anxiety disorder (SEP) and generalized anxiety disorder (GAD) - and the nature of particular forms of psycho-social risk - namely, chronic childhood adversity, negative life events, and particular forms of parenting behaviours.

METHOD

Two-hundred and ten children (aged 7-12 years) who met diagnostic criteria for SOC, SEP or GAD and their primary caregivers completed questionnaire measures on chronic childhood adversity and negative life events. In addition, dyads participated in two laboratory-based assessments of parent-child interactions.

RESULTS

We found little evidence for disorder specificity for chronic childhood adversity and negative life events, except in the case of separation anxiety disorder. Anxious children with separation anxiety were more likely than children with other forms of anxiety disorders to live with a single parent, experience more frequent parent arguments, and more negative life events. No group differences in observed parenting behaviours were found.

CONCLUSIONS

Childhood SEP may be particularly associated with family challenges which may need specific consideration to optimize prevention and/or treatment. Beyond this, there is limited evidence of specific associations between family and environmental factors and specific types of childhood anxiety disorders.

Challenges, Coping and Resources: A Thematic Analysis of Foreign Teachers' Experience of Cultural Adaptation in China

The aim of this study was to explore foreign teachers’ experience of cultural and life adaptation in China, including the difficulties, emotional stress, and challenges they confronted, as well as the useful coping strategies and resources that facilitated their cultural adaptation. Ten foreign professors who taught in China were recruited from three Chinese universities. Semi-structured interviews on the participants’ experience of cross-cultural adaptation in China were conducted. Thematic analysis of the transcribed dialogs was performed, and five core themes emerged: multiple challenges, mixed negative emotions, active coping and insulation, rich supportive resources, and personal traits. In the cross-cultural adaptation process in China, the main challenges for foreign teachers were language barriers; a lack of supportive relationships; and conflicts in perceptions related to teaching, privacy, and boundaries. Useful coping strategies included seeking interpersonal interactions that provided emotional and instrumental support, developing localized teaching models, and maintaining connections with the culture of origin. Under circumstances with convenient living facilities and supportive interpersonal relationships, these strategies promoted the adaptation of foreign teachers with functional personality traits. The potential correlations among these different themes and the influence of their interactions on foreign teachers’ adaptation experience were also discussed. The themes that emerged in our study can help clinicians and university administrators develop therapy methods and support systems for foreign teachers who work in Chinese universities.

Examining the Relationship Between Parental Symptomatology and Treatment Outcomes in Children with Autism Spectrum Disorder

This report examines the relationship between treatment response in children with ASD and parents' affective symptomatology. This study examined 29 children with ASD in a manualized group psychotherapy program, Resilience Builder Program^® (RBP), where emotional and social functioning of parent and child were measured through pre- and post-treatment questionnaires. Greater parental symptomatology was associated with children's reduced response to RBP in resilience-based emotion regulation skills. Greater parental interpersonal sensitivity (β = - .27, p = .024) predicted worse post-treatment scores in child communication skills, greater parental anxious symptoms (β = - .45, p = .005) predicted worse post-treatment scores in child emotional control, and greater parental depressive (β = .27, p = .041) and anxious symptoms (β = .36, p = .004) predicted worse post-treatment scores in child internalizing problems.

A genome-wide association meta-analysis of prognostic outcomes following cognitive behavioural therapy in individuals with anxiety and depressive disorders

Major depressive disorder and the anxiety disorders are highly prevalent, disabling and moderately heritable. Depression and anxiety are also highly comorbid and have a strong genetic correlation (rg ≈ 1). Cognitive behavioural therapy is a leading evidence-based treatment but has variable outcomes. Currently, there are no strong predictors of outcome. Therapygenetics research aims to identify genetic predictors of prognosis following therapy. We performed genome-wide association meta-analyses of symptoms following cognitive behavioural therapy in adults with anxiety disorders (n = 972), adults with major depressive disorder (n = 832) and children with anxiety disorders (n = 920; meta-analysis n = 2724). We estimated the variance in therapy outcomes that could be explained by common genetic variants (h2SNP) and polygenic scoring was used to examine genetic associations between therapy outcomes and psychopathology, personality and learning. No single nucleotide polymorphisms were strongly associated with treatment outcomes. No significant estimate of h2SNP could be obtained, suggesting the heritability of therapy outcome is smaller than our analysis was powered to detect. Polygenic scoring failed to detect genetic overlap between therapy outcome and psychopathology, personality or learning. This study is the largest therapygenetics study to date. Results are consistent with previous, similarly powered genome-wide association studies of complex traits.

Predictors of long-term outcome of CBT for youth with anxiety disorders treated in community clinics

Cognitive behavioral therapy (CBT) has proven long-term effects in youth with anxiety disorders. However, only a few studies have examined predictors of long-term outcomes of CBT treatment. The present study investigated possible predictors of long-term treatment outcomes in youth with mixed anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11-21 years) with a principal diagnosis of separation anxiety disorder, social anxiety disorder, and/or generalized anxiety disorder were evaluated a mean of 3.9 years post-treatment (range 2.2-5.9 years). Outcomes were loss of all inclusion anxiety diagnoses, loss of the principal inclusion anxiety diagnosis, and changes in youth- and parent-rated youth anxiety symptoms. Predictors encompassed youth, parent and demographic factors, and post-treatment recovery. The most consistent finding was that low family social class predicted poorer outcomes. Higher treatment motivation was associated with better outcome whereas a diagnosis of social anxiety was associated with poorer outcome. Identified predictors extend on previous findings from efficacy trials, and the results indicate a need for more specific treatment protocols.

Predictors of treatment outcome for the unified protocol for transdiagnostic treatment of emotional disorders in children (UP-C)

Various efficacious treatment packages exist for youth anxiety, and cognitive behavior therapy (CBT) is now considered to be a well-established treatment for child anxiety disorders (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). Improving outcomes for the significant proportion of anxious youth who demonstrate inadequate response to CBT is imperative, but our understanding of who does and does not benefit is incomplete. Further, there are no known empirical studies of predictors of treatment response for youth who receive a transdiagnostic intervention for anxiety or depression, and it is therefore unclear whether predictors of response to a transdiagnostic treatment for children are similar to those found in previous studies of anxiety-specific treatments. This study investigated potential predictors of outcome following administration of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2018). Participants were 60 children ages 6-13 (M = 9.47, SD = 1.68) with a primary anxiety diagnosis (with or without comorbid depression) who received a 15-week UP-C group treatment. Consistent with prior literature on CBT for anxiety, social anxiety emerged as a consistent predictor of poorer response to the UP-C. Inconsistent with prior literature, depression, symptom severity, parent psychopathology, and child age were not significant predictors of poor outcome. Results indicate some differences between predictors for transdiagnostic versus anxiety-focused treatments, but point to a need for both types of interventions to better target social anxiety in children.

Multimodal Residential Treatment for Adolescent Anxiety: Outcome and Associations with Pre-treatment Variables

This study aimed to determine the effect of a multimodal residential treatment program for severe adolescent anxiety, and examine whether treatment outcome was associated with pre-treatment anxiety, comorbid disorders, or participant age or gender. Participants were 70 adolescents (61.4% female, mean age = 15.4 years) with a primary anxiety disorder who received residential treatment involving cognitive behavioral therapy and medication management. Treatment outcome was assessed both as the change in adolescent-reported anxiety symptoms, and using treatment response criteria. Results indicated a strong effect of the intervention on symptoms of anxiety, depression, and anxiety-related life interference. Most pre-treatment variables were not associated with treatment outcome. However, higher adolescent-reported pre-treatment anxiety was associated with a greater reduction in anxiety at post-treatment, and the presence of a comorbid anxiety disorder was associated with poorer odds of treatment response. Findings indicate that residential treatment is a robust intervention for adolescent anxiety.

Advancing Personalized Medicine: Application of a Novel Statistical Method to Identify Treatment Moderators in the Coordinated Anxiety Learning and Management Study

There has been increasing recognition of the value of personalized medicine where the most effective treatment is selected based on individual characteristics. This study used a new method to identify a composite moderator of response to evidence-based anxiety treatment (CALM) compared to Usual Care. Eight hundred seventy-six patients diagnosed with one or multiple anxiety disorders were assigned to CALM or Usual Care. Using the method proposed by Kraemer (2013), 35 possible moderators were examined for individual effect sizes then entered into a forward-stepwise regression model predicting differential treatment response. K-fold cross validation was used to identify the number of variables to include in the final moderator. Ten variables were selected for a final composite moderator. The composite moderator effect size (r = .20) was twice as large as the strongest individual moderator effect size (r = .10). Although on average patients benefitted more from CALM, 19% of patients had equal or greater treatment response in Usual Care. The effect size for the CALM intervention increased from d = .34 to d = .54 when accounting for the moderator. Findings support the utility of composite moderators. Results were used to develop a program that allows mental health professionals to prescribe treatment for anxiety based on baseline characteristics (http://anxiety.psych.ucla.edu/treatmatch.html).

Social Interpretation Bias in Children and Adolescents with Anxiety Disorders: Psychometric Examination of the Self-report of Ambiguous Social Situations for Youth (SASSY) Scale

BACKGROUND

Anxiety disorders are among the most common mental health problems in youth, and faulty interpretation bias has been positively linked to anxiety severity, even within anxiety-disordered youth. Quick, reliable assessment of interpretation bias may be useful in identifying youth with certain types of anxiety or assessing changes on cognitive bias during intervention.

OBJECTIVE

This study examined the factor structure, reliability, and validity of the Self-report of Ambiguous Social Situations for Youth (SASSY) scale, a self-report measure developed to assess interpretation bias in youth.

METHODS

Participants (N=488, age 7 to 17) met diagnostic criteria for Social Phobia, Generalized Anxiety Disorder, and/or Separation Anxiety Disorder. An exploratory factor analysis was performed on baseline data from youth participating in a large randomized clinical trial.

RESULTS

Exploratory factor analysis yielded two factors (Accusation/Blame, Social Rejection). The SASSY full scale and Social Rejection factor demonstrated adequate internal consistency, convergent validity with social anxiety, and discriminant validity as evidenced by non-significant correlations with measures of non-social anxiety. Further, the SASSY Social Rejection factor accurately distinguished children and adolescents with Social Phobia from those with other anxiety disorders, supporting its criterion validity, and revealed sensitivity to changes with treatment. Given the relevance to youth with social phobia, pre- and post-intervention data were examined for youth social phobia to test sensitivity to treatment effects; results suggested that SASSY scores reduced for treatment responders.

CONCLUSIONS

Findings suggest the potential utility of the SASSY Social Rejection factor as a quick, reliable, and efficient way of assessing interpretation bias in anxious youth, particularly as related to social concerns, in research and clinical settings.

Subtyping social anxiety in youth

Few empirical studies have examined subtypes of social anxiety disorder (SAD) in youth, and limited consensus resides on the nature of potential subtypes. Identifying subtypes, based on both fear and avoidance patterns, can help improve assessment and treatment of SAD. Subtypes of fear and avoidance were examined in a sample comprising 131 youth (age 8-15 years) diagnosed with SAD using the Anxiety Disorders Interview Schedule for children and parents (ADIS-C/P). Exploratory factor analysis of fear responses revealed three factors, defining fear subtypes linked to: (1) performance, (2) observation, and (3) interaction situations, respectively. Exploratory factor analysis of avoidance responses showed these were best represented by one avoidance factor. Few youth qualified exclusively for either of the fear subtypes, thus calling into question the clinical utility of these subtypes. Nevertheless, the findings indicate distinct contributions of fear and avoidance in SAD presentation. This finding might help clinicians target and improve treatment of the disorder.