Transdiagnostic group behavioral activation and exposure therapy for youth anxiety and depression: Initial randomized controlled trial

Two universal school-based prevention programs for depression and anxiety: 24-Month follow-up of an RCT

BACKGROUND AND OBJECTIVES

Transdiagnostic approaches have been promoted as a means of maximising preventative effects across multiple problems with depression and anxiety suitable targets as they appear to have highly interconnected systems in pathology development and maintenance. This study investigated long-term effects of two universal school-based programs, Emotion Regulation (ER) and Behavioral Activation (BA), that sought to prevent depression and anxiety by targeting worry (a transdiagnostic feature) to promote resilience.

METHODS

This follow-up study captured data from 162 of 316 initial students (aged 8-13; 52.2% female), from six Australian schools. The original study design cluster randomised students by school into BA, ER, or a usual class control. Intervention conditions consisted of 8 × 50-min weekly sessions. This study measured the effects of these interventions after 24 months on resilience, worry, depression, and anxiety. Resilience was also examined as a potential mediator.

RESULTS

At 24-month follow-up, there was no significant effect of either intervention on depression, anxiety, worry, or resilience levels. Significantly fewer participants in ER and BA met clinical thresholds for separation anxiety disorder (SAD) and obsessive-compulsive disorder (OCD) in the 24-month follow-up compared with baseline. No mediation effects were found.

LIMITATIONS

Although self-report measures are common in universal, school-based research, this represents a study limitation.

CONCLUSIONS

Both interventions may provide limited long-term protective effects on SAD and OCD symptoms, which appear to have a shelf-life shorter than 24 months. To maintain program effects, refresher sessions at shorter intervals may be a consideration for future research.

Family Support Protocol for Adolescent Internalizing Disorders: Protocol for a Pre-Post Quantitative Treatment Development Study

BACKGROUND

Internalizing disorders (IDs), primarily depression and anxiety, are highly prevalent among adolescents receiving community-based treatment for substance use disorders (SUDs). For such clients, interventions that do not holistically address both SUDs and IDs are less effective.

OBJECTIVE

This pilot treatment development study aims to develop and test a modular treatment protocol for addressing cooccurring IDs among adolescents (aged 13 to 18 years) enrolled in routine care for substance use problems: Family Support Protocol for Adolescent Internalizing Disorders (Fam-AID). As an adjunctive protocol, Fam-AID will not require clinicians to markedly alter existing base practices for SUD. It will be anchored by 3 evidence-based foundations for treating cooccurring adolescent IDs: family engagement techniques, transdiagnostic individual cognitive behavioral therapy techniques, and family psychoeducation and safety planning.

METHODS

This quasi-experimental study will proceed in 2 stages. The pilot stage will use rapid-cycle prototyping methods in collaboration with end-user stakeholders to draft protocol delivery and fidelity guidelines adapted from existing resources, solicit provider and client input on protocol content and delivery via cognitive interviewing, and pilot prototype components on 4 to 6 cases. The second stage will be an interrupted time series study for 60 comorbid SUD+ID cases across 2 sites serving diverse adolescents: 30 will receive treatment as usual (TAU); following clinician training in the protocol, 30 new cases will receive TAU enhanced by Fam-AID. For aim 1, the focus is on evaluating the acceptability of the Fam-AID protocol through therapist and client interviews as well as assessing fidelity benchmarks using therapist- and observer-reported protocol fidelity data. For aim 2, the plan is to compare the effects of TAU only cases versus TAU+Fam-AID cases on family treatment attendance and on adolescent ID and substance use symptoms, with measurements taken at baseline and at 3-month and 6-month follow-ups.

RESULTS

Study recruitment will begin in April 2025.

CONCLUSIONS

We anticipate that Fam-AID will contain 5 treatment modules that can be delivered in any sequence to meet client needs: family engagement of primary supports in treatment planning and services; relational reframing of family constraints, resiliencies, and social capital connected to the adolescent's ID symptoms; functional analysis of the adolescent's ID symptoms and related behaviors; cognitive behavioral therapy to address the adolescent's ID symptoms and functional needs, featuring 3 core techniques (emotion acceptance, emotional exposure, and behavioral activation) to address negative affect and emotional dysregulation; and family psychoeducation and safety planning focused on education about comorbid SUD+ID and prevention of adolescent self-harm. If the abovementioned modules are found to be feasible and effective, Fam-AID will offer a set of pragmatic interventions to SUD clinicians for treating cooccurring IDs in adolescent clients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06413979; https://www.clinicaltrials.gov/study/NCT06413979.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/64332.

Mental Health Interventions in Middle Schools: A 10-Year Review of Research

Schools can play an important role in addressing growing concerns about adolescent mental health. Mental health of high school students has predominantly been the focus in literature with less emphasis on younger adolescents. This review identified articles published in the last decade that described evaluations of middle school-based mental health interventions and randomized participants to an intervention or control condition. Fourteen interventions met the inclusion criteria. About two-thirds of interventions were based on mindfulness or cognitive behavioral therapy. Many trials utilized racially diverse, low-income samples. All interventions were delivered to groups, and three contained a parent component. Five trials increased rigor by using an active control condition. Almost two-thirds of the interventions were effective (p < .10) in reducing at least one depression, anxiety, affect, or internalizing symptom outcome compared to a control group. This article provides information about intervention characteristics, efficacy, theoretical framework, and acceptability/feasibility.

The utility of behavioral activation therapy in addressing emotional problems of two depressed students with borderline intellectual disability: A case study

PURPOSE

Intellectual disability is one of the neurodevelopmental disorders. Studies indicated that depression and anxiety are the most prevalent emotional problems among the people with intellectual disability. The aim of this study was to investigate the utility of behavioral activation therapy in addressing emotional problems of two depressed students with borderline intellectual disability.

METHOD

This study is a single-subject design with multiple baseline and one month follow-up. Two students with borderline intelligence underwent behavioral activation therapy for 12 sessions. Beck Depression Inventory-Second Edition, Beck Anxiety Inventory, Oxford Happiness Inventory and Rosenberg Self-Esteem Scale were used. Data were analyzed using visual inspection of graphed data, changes in trends, improvement percentage and effect size.

FINDINGS

The findings of this study support the utility of behavioral activation therapy in addressing the emotional problems of two depressed students with borderline intellectual disability.

CONCLUSION

Behavioral activation therapy has had favorable outcomes in reducing depression and anxiety in depressed students with borderline intellectual disabilities.

Compare the effectiveness of two treatments, behavioral activation and acceptance and commitment therapy, on depression and mental rumination in mothers of children with cerebral palsy in Ilam city

BACKGROUND

Since in most families, mothers are more responsible for taking care of children and have more responsibility than fathers for monitoring the child, taking care of a disabled child can have a more negative effect on the psychological state of mothers. This study aimed to investigate the effectiveness of behavioral activation (BA) and acceptance and commitment therapy (ACT) in depression and rumination in mothers with children with cerebral palsy.

MATERIALS AND METHODS

This research was quasi-experimental field research with a pre-posttest and control group. The study population comprised 237 mothers with children who had cerebral palsy and were referred to occupational therapy centers in Ilam, Iran. The sample consisted of 60 participants selected by convenience sampling, who were randomly divided into two experimental groups (BA and ACT) and a control group (n = 20 per group). Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 27.0 with descriptive and inferential statistics, such as mean, standard deviation, and multivariate analysis of covariance (MANCOVA).

RESULTS

The results of both BA and ACT were effective in reducing depression (P < 0.01) and rumination (P < 0.01) in the two experimental groups compared with the control group in the posttest phase. Furthermore, the effectiveness of the ACT in reducing depression and rumination was found to be more significant than the effectiveness of BA (P ≤ 0.05).

CONCLUSION

The findings of the study suggest that both BA and ACT are effective in reducing depression and rumination in the research participants. However, the study also found that ACT was more effective than BA in reducing depression and rumination. Thus, both approaches can be used to strengthen treatment interventions to lessen depression and rumination in the research participants.

[Formula: see text] Cognitive disengagement syndrome in pediatric patients with long COVID: associations with mood, anxiety, and functional impairment

Children with long COVID often report symptoms that overlap with cognitive disengagement syndrome (CDS, previously sluggish cognitive tempo (SCT)), a set of behaviors distinct from attention-deficit/hyperactivity disorder (ADHD) including excessive daydreaming, mental fogginess, and slowed behavior and thinking. Those with long COVID also frequently report low mood and anxiety, which are linked to CDS. The relationships between cognitive difficulties, mood, and functional impairment have yet to be explored in pediatric long COVID. Specifically, it is unclear how much cognitive difficulties (CDS, inattention) contribute to functional impairment, when accounting for mood/anxiety symptoms in this population. Retrospective parent-reported data was collected from 34 patients with long COVID (22 females, Mage = 14.06 years, SD = 2.85, range 7-19) referred for neuropsychological consultation through a multidisciplinary Post-COVID-19 clinic. Compared to community and clinically referred samples, on average, long COVID patients showed elevated CDS symptoms, including Sluggish/sleepy (e.g., fatigue) and Low Initiation subscales (e.g., difficulty performing goal directed behaviors). Low Initiation, mood, anxiety, and inattention were associated with functional impairment. In multiple hierarchical regression models, after controlling for mood and anxiety, Low Initiation and inattention were no longer predictive of functional impairment. Instead, anxiety remained the sole predictor of functional impairment. Our results demonstrate that children with long COVID have high levels of CDS symptoms. The association between cognitive difficulties and functional impairment dissipated with the inclusion of mood and anxiety, suggesting behavioral health interventions targeting anxiety may help improve daily functioning and quality of life in pediatric long COVID patients.

Is behavioural activation an effective treatment for depression in children and adolescents? An updated systematic review and meta-analysis

Behavioural Activation (BA)-a brief therapy based on the scheduling of enjoyable, purposeful and rewarding activities-is an effective and cost-effective treatment for depression in adults that shows promise for children and adolescents. We provide an update on a previous systematic review of evidence on BA-delivered in-person, telephone, or online-for depression and comorbid anxiety in children and adolescents. We conducted systematic literature searches in 6 databases up to February 2024. We included all study designs evaluating BA with participants up to 18 years old with diagnosable depression, as established by a validated screening tool or diagnostic manual. We used the Moncrieff Scale and the Cochrane Risk of Bias tool to assess study quality. We summarised the findings of all study types with a narrative synthesis and of randomised controlled trials (RCTs) with a meta-analysis. Overall, 24 studies (6 RCTs, 18 pre-post evaluations, n = 2,758) met our inclusion criteria. A meta-analysis of 4 RCTs (n = 156) showed that BA has a small effect of 0.24 (Hedge's adjusted g) in reducing depression symptoms compared to a waiting-list control, usual care and other therapies. Online and telephone-facilitated BA was shown to be feasible in 3 studies and effective in 1. Outcomes on comorbid anxiety were mixed. No economic evaluations met our inclusion criteria. BA shows sufficient promise as an intervention for reducing depression symptoms in children and adolescents to justify the need for further RCTs, providing that five conditions are met: studies are powered to detect a minimal clinically important difference; BA materials are fit-for-purpose to produce clinically meaningful change; follow-ups are longer than 6 months; primary outcomes are child-reported; and intervention costs, resource use and adverse events are reported.

Hypnosis with depressed children and teens: Building skills, creating connection

Depression in children and teens has been on the rise for several years. Recent increases in anxiety and loneliness, both contributors to the development of depression, are putting more young people at risk for chronic and comorbid mental health struggles. The use of hypnosis with depressed children offers the opportunity to target the identified skills depressed and anxious children need and is a modality clinicians should embrace. This article describes how to create hypnotic interventions focusing on improved emotional and cognitive management, better sleep, and the ability to make positive social connections. Such interventions serve to not only build the resources depressed children need for recovery, but also support a paradigm shift toward prevention in children and families.

A comparison of the effectiveness of cognitive behavioural interventions based on delivery features for elevated symptoms of depression in adolescents: A systematic review

Background

Depression is a public health problem and common amongst adolescents. Cognitive behavioural therapy (CBT) is widely used to treat adolescent depression but existing research does not provide clear conclusions regarding the relative effectiveness of different delivery modalities.

Objectives

The primary aim is to estimate the relative efficacy of different modes of CBT delivery compared with each other and control conditions for reducing depressive symptoms in adolescents. The secondary aim is to compare the different modes of delivery with regard to intervention completion/attrition (a proxy for intervention acceptability).

Search Methods

The Cochrane Depression, Anxiety and Neurosis Clinical Trials Register was searched in April 2020. MEDLINE, PsycInfo, EMBASE, four other electronic databases, the CENTRAL trial registry, Google Scholar and Google were searched in November 2020, together with reference checking, citation searching and hand-searching of two databases.

Selection Criteria

Randomised controlled trials (RCTs) of CBT interventions (irrespective of delivery mode) to reduce symptoms of depression in young people aged 10-19 years with clinically relevant symptoms or diagnosis of depression were included.

Data Collection and Analysis

Screening and data extraction were completed by two authors independently, with discrepancies addressed by a third author. CBT interventions were categorised as follows: group CBT, individual CBT, remote CBT, guided self-help, and unguided self-help. Effect on depressive symptom score was estimated across validated self-report measures using Hedges' g standardised mean difference. Acceptability was estimated based on loss to follow-up as an odds ratio. Treatment rankings were developed using the surface under the cumulative ranking curve (SUCRA). Pairwise meta-analyses were conducted using random effects models where there were two or more head-to-head trials. Network analyses were conducted using random effects models.

Main Results

Sixty-eight studies were included in the review. The mean age of participants ranged from 10 to 19.5 years, and on average 60% of participants were female. The majority of studies were conducted in schools (28) or universities (6); other settings included primary care, clinical settings and the home. The number of CBT sessions ranged from 1 to 16, the frequency of delivery from once every 2 weeks to twice a week and the duration of each session from 20 min to 2 h. The risk of bias was low across all domains for 23 studies, 24 studies had some concerns and the remaining 21 were assessed to be at high risk of bias. Sixty-two RCTs (representing 6435 participants) were included in the pairwise and network meta-analyses for post-intervention depressive symptom score at post-intervention. All pre-specified treatment and control categories were represented by at least one RCT. Although most CBT approaches, except remote CBT, demonstrated superiority over no intervention, no approaches performed clearly better than or equivalent to another. The highest and lowest ranking interventions were guided self-help (SUCRA 83%) and unguided self-help (SUCRA 51%), respectively (very low certainty in treatment ranking). Nineteen RCTs (3260 participants) were included in the pairwise and network meta-analyses for 6 to 12 month follow-up depressive symptom score. Neither guided self-help nor remote CBT were evaluated in the RCTs for this time point. Effects were generally attenuated for 6- to 12-month outcomes compared to posttest. No interventions demonstrated superiority to no intervention, although unguided self-help and group CBT both demonstrated superiority compared to TAU. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking approaches were unguided self-help and individual CBT, respectively. Sixty-two RCTs (7347 participants) were included in the pairwise and network meta-analyses for intervention acceptability. All pre-specified treatment and control categories were represented by at least one RCT. Although point estimates tended to favour no intervention, no active treatments were clearly inferior. No CBT approach demonstrated clear superiority over another. The highest and lowest ranking active interventions were individual CBT and group CBT respectively. Pairwise meta-analytic findings were similar to those of the network meta-analysis for all analyses. There may be age-based subgroup effects on post-intervention depressive symptoms. Using the no intervention control group as the reference, the magnitudes of effects appear to be larger for the oldest age categories compared to the other subgroups for each given comparison. However, they were generally less precise and formal testing only indicated a significant difference for group CBT. Findings were robust to pre-specified sensitivity analyses separating out the type of placebo and excluding cluster-RCTs, as well as an additional analysis excluding studies where we had imputed standard deviations.

Authors' Conclusions

At posttreatment, all active treatments (group CBT, individual CBT, guided self-help, and unguided self-help) except for remote CBT were more effective than no treatment. Guided self-help was the most highly ranked intervention but only evaluated in trials with the oldest adolescents (16-19 years). Moreover, the studies of guided self-help vary in the type and amount of therapist support provided and longer-term results are needed to determine whether effects persist. The magnitude of effects was generally attenuated for 6- to 12-month outcomes. Although unguided self-help was the lowest-ranked active intervention at post-intervention, it was the highest ranked at follow-up. This suggests the need for further research into whether interventions with self-directed elements enable young people to maintain effects by continuing or revisiting the intervention independently, and whether therapist support would improve long-term outcomes. There was no clear evidence that any active treatments were more acceptable to participants than any others. The relative effectiveness of intervention delivery modes must be taken into account in the context of the needs and preferences of individual young people, particularly as the differences between effect sizes were relatively small. Further research into the type and amount of therapist support that is most acceptable to young people and most cost-effective would be particularly useful.

Impact of trauma exposure and depression comorbidity on response to transdiagnostic behavioral therapy for pediatric anxiety and depression

By adolescence, two-thirds of youth report exposure to at least one traumatic event, yet the impact of trauma history is not routinely considered when evaluating the effect of psychotherapeutic interventions. Trauma may be a particularly important moderator of the effects of transdiagnostic therapies for emotional disorders, as trauma exposure is associated with risk for the development of comorbid depression and anxiety. The current study examined the history of trauma exposure and the presence of clinically significant depression as moderators of treatment outcomes in the Brief Behavioral Therapy (BBT) trial, the largest study of transdiagnostic psychotherapy for youth. Youths (age 8-16 years) were randomized to BBT (n = 89) based in pediatric primary care or assisted referral to outpatient community care (ARC; n = 86). Clinical response, functioning, anxiety symptoms, and depression symptoms were assessed at post-treatment (Week 16) and at follow-up (Week 32). A significant three-way interaction emerged between the treatment group, comorbid depression, and trauma exposure. BBT was broadly effective for 3/4 of the sample, but, for anxious-depressed youth with trauma exposure, BBT never significantly separated from ARC. Differences in outcome were not accounted for by other participant characteristics or by therapist-rated measures of alliance, youth engagement, or homework completion. Implications for models of learning and for intervention theory and development are discussed.

Impact of the Integrated Program of Transdiagnostic Treatment and Parent Education on the Social Anxiety of Female Students

OBJECTIVE

The objective of this study was to assess the efficacy of the combined program of transdiagnostic treatment and parent education in reducing social anxiety among female students.

METHODOLOGY

 This descriptive cross-sectional study was conducted among all female elementary school students in Bandar Abbas, Iran, during the academic year 2022-2023. The social phobia questionnaire was given to all female students in grades three to six to assess individuals in terms of the social anxiety disorder (SAD) variable. We used the social anxiety scale developed by Leibovitz as the questionnaire in this investigation. This self-assessment questionnaire was designed for individuals aged 18 and above. It consists of 24 statements, divided into two subscales: performance anxiety (13 statements) and social settings (11 statements). Each item is individually assessed for fear intensity on a scale of 0 to 3, ranging from no to extreme. Similarly, avoidance behavior is evaluated on a scale of 0 to 3, representing the frequency ranging from never to always.

RESULTS

 The mean general anxiety levels among both groups (students vs. parents) during the pre-test were similar (48.06 ± 4.39 vs. 48.06± 4.1). However, in the post-test, the mean of the experimental groups was lower than that of the pre-test (32.13 ± 3.77 vs. 47.2 ± 3.6). The normality assumption for the pre-test and post-test variables of generalized anxiety was verified with a significance level over 0.05 (p ≥ 0.05).

CONCLUSION

The findings demonstrated that the integrated meta-diagnostic treatment program for parents had a more pronounced effect on alleviating their social anxiety in comparison to students. These findings imply that if parents possess a comprehensive understanding of the factors contributing to their children's anxiety, it will significantly enhance their ability to mitigate their child's social anxiety.

Early indicators of response to transdiagnostic treatment of pediatric anxiety and depression

BACKGROUND

Pediatric anxiety and depression are prevalent, impairing, and highly comorbid. Available evidence-based treatments have an average response rate of 60%. One path to increasing response may be to identify likely non-responders midway through treatment to adjust course prior to completing an episode of care. The aims of this study, thus, were to identify predictors of post-intervention response assessing (a) mid-treatment symptom severity, (b) session-by-session treatment process factors, and (c) a model optimizing the combination of these.

METHOD

Data were drawn from the treatment arm (N = 95, ages 8-16) of a randomized transdiagnostic intervention trial (Msessions  = 11.2). Mid-point measures of youth- and parent-reported anxiety and depression were collected, and therapists rated homework completion, youth and parent engagement, and youth therapeutic alliance at each session. Logistic regression was used to predict response on the Clinical Global Impression Improvement Scale (CGI-I ≤2) rated by independent evaluators masked to treatment condition.

RESULTS

Mid-point symptom measures were significant predictors of treatment response, as were therapist-ratings of youth and parent engagement, therapeutic alliance, and homework completion. Therapist ratings were significant when tested as mean ratings summing across the first eight sessions of treatment (all ps < .004) and at individual session points (all ps <0.05). A combined prediction model included youth-reported anxiety, parent-reported depression, youth engagement at Session 2, and parent engagement at Session 8. This model correctly classified 76.5% of youth as non-responders and 91.3% as responders at post-treatment (Nagelkerke R2  = .59, χ2 (4, 80) = 46.54, p < .001).

CONCLUSION

This study provides initial evidence that response to transdiagnostic intervention for pediatric anxiety and depression may be reliably predicted by mid-point. These data may serve as foundational evidence to develop adaptive treatment strategies to personalize intervention, correct treatment course, and optimize outcomes for youth with anxiety and depression.

Mechanisms of change in Behavioral Activation: Adapting depression treatment for autistic people

Despite high rates of co-occurring depression, few studies have developed or adapted treatments targeting depressive symptoms for autistic adults. Behavioral activation is widely accepted as an empirically-supported approach for treating depression in other populations. Careful attention to the mechanisms targeted by behavioral activation is an essential step toward adapting behavioral activation protocols for use with autistic adults. We consider the mechanisms targeted by behavioral activation and provide a framework for research to explore the facilitators and barriers to the use of behavioral activation to treat depression in autistic adults. Drawing upon clinical experience and extant literature, the suggestions presented are aimed at highlighting considerations for clinicians wanting to use behavioral activation programs in their clinical practices with autistic adults and to promote the research needed to establish behavioral activation as an evidence-based practice for treating depression in adults on the autism spectrum.

Longitudinal associations between academic competence-building and depression symptoms in early adolescence

The longitudinal associations between academic competence-building and depression symptoms were investigated among 741 early adolescents in Singapore. Extending from past studies on academic achievement and depression, the current research tested two competing hypotheses - the academic incompetence hypothesis versus the adjustment erosion hypothesis using a 3-wave longitudinal study over an academic year. The former hypothesis suggests that prior deficits in academic competence-building lead to subsequent depression symptoms, whereas the latter posits that previous depression leads to subsequent deficits in competence-building. Longitudinal associations between a higher-order competence-building factor (operationalized using multiple constituent motivational variables) and depression were examined using a random intercept cross-lagged panel model. Results indicated that within-individual decreases in competence-building prospectively predicted subsequent within-individual increases in depression symptoms, but the opposite effect was not observed. Within-individual fluctuations in competence-building also predicted end-of-year grades and teacher-reported adjustment problems. Overall, the current findings were consistent with the academic incompetence hypothesis, suggesting that interventions aimed at sustaining academic competence-building could offer protection against the worsening of depression. These results clarified the within-individual developmental dynamics between academic competence-building and depression symptoms in adolescents over time.

Effectiveness of behavioral activation therapy and acceptance and commitment therapy on depression and rumination as a tool for health promotion on mothers with cerebral palsy children

BACKGROUND

Since in most families, mothers are more responsible for taking care of children and they have more responsibility than fathers for monitoring the child; taking care of a disabled child can have a more negative effect on the psychological state of mothers. The purpose of the present study is to investigate the effectiveness of behavioral activation therapy (BAT) and acceptance and commitment therapy (ACT) on depression and rumination on mothers with children with cerebral palsy in the city of Ilam.

MATERIALS AND METHODS

The design of this research was pretest and post-test quasi-experimental with a control group. The research sample was 60 mothers who referred to occupational therapy centers in the city of Ilam in 2022, who were randomly divided into two experimental groups (N = 40 for each) and a control group (N = 20). One of the experimental groups, received behavioral activation group therapy method; and the other received the group therapy method based on acceptance and commitment for eight sessions lasted for 90 minutes in week. Data were collected using the Beck depression questionnaire (BDI-II) and the rumination questionnaire in two stages before the intervention and after the intervention. In this research, covariance analysis was used for data analysis.

RESULTS

The results of covariance analysis showed that behavioral activation therapy and acceptance and commitment-based therapy reduced depression (P < 0.01) and rumination (P < 0.01), and the two experimental groups were compared with the control group in the post-test phase.

CONCLUSION

It seems that behavioral activation therapy and acceptance and commitment therapy are effective in reducing depression and rumination in the subjects of the present study. Therefore, these treatments are suggested as complementary treatments along with drug treatments to improve psychological symptoms.

Emotion regulation in children (ERiC): A protocol for a randomised clinical trial to evaluate the clinical and cost effectiveness of Mentalization Based Treatment (MBT) vs Treatment as Usual for school-age children with mixed emotional and behavioural difficulties

BACKGROUND

The majority of children referred to Child and Adolescent Mental Health Services (CAMHS) in the UK will present with mixed emotional and behavioural difficulties, but most mental health treatments are developed for single disorders. There is a need for research on treatments that are helpful for these mixed difficulties, especially for school-age children. Emotion Regulation (ER) difficulties present across a wide range of mental health disorders and mentalizing may help with regulation. The ability to mentalize one's own experiences and those of others plays a key role in coping with stress, regulation of emotions, and the formation of stable relationships. Mentalization Based Therapy (MBT) is a well-evidenced therapy that aims to promote mentalization, which in turn increases ER capacities, leading to decreased emotional and behavioural difficulties. The aim of this study is to test the clinical- and cost-effectiveness of MBT compared to treatment as usual for school age children with emotional and behavioural difficulties. If effective, we hope this approach can become available to the growing number of children presenting to mental health services with a mix of emotional and behavioural difficulties.

MATERIALS AND METHODS

Children referred to CAMHS aged 6-12 with mixed mental health problems (emotional and behavioural) as primary problem can take part with their parent/carers. Children will be randomly allocated to receive either MBT or treatment as usual (TAU) within the CAMHS clinic they have been referred to. MBT will be 6-8 sessions offered fortnightly and can flexibly include different family members. TAU is likely to include CBT, parenting groups, and/or children's social skills groups. Parent/carers and children will be asked to complete outcome assessments (questionnaires and tasks) online at the start of treatment, mid treatment (8 weeks), end of treatment (16 weeks) and at follow up (40 weeks).

TRIAL REGISTRATION

Clinical trial registration: ISRCTN 11620914.

Reduction in avoidance mediates effects of brief behavioral therapy for pediatric anxiety and depression

Brief behavioral therapy (BBT) is an efficacious transdiagnostic intervention for pediatric anxiety and depression that targets behavioral avoidance as a key mechanism. It is unknown if change in avoidance mediates treatment effects, as theorized. Data on avoidance at baseline and Week 16 were available on 52 youth (ages 8-16 years) from a randomized controlled trial (Weersing, Jeffreys, et al., 2017) comparing BBT and assisted referral to community care (ARC). BBT had significant effects on youth-reported behavioral avoidance, and significant indirect effects on functioning and anxiety, statistically mediated through changes in youth-reported behavioral avoidance. Change in youth-reported avoidance was not a significant mediator of depression. Parent-report of avoidance was not impacted by treatment and was not a significant mediator. Overall, BBT appears to be an effective treatment for targeting behavioral avoidance, which in turn, may improve functioning and lessen anxiety. CLINICAL TRIAL REGISTRATION INFORMATION: https://clinicaltrials.gov; NCT01147614.

Do youth anxiety measures assess the same construct consistently throughout treatment? Results are...complicated

Interventionists interpret changes in symptoms as reflecting response to treatment. However, changes in symptom functioning and the measurement of the underlying constructs may be reflected in reported change. Longitudinal measurement invariance (LMI) is a statistical approach that assesses the degree to which measures consistently capture the same construct over time. We examined LMI in measures of anxiety severity/symptoms [i.e., Pediatric Anxiety Rating Scale (PARS), Multidimensional Anxiety Scale for Children (MASC), Screen for Child Anxiety and Related Disorders (SCARED)] in anxious youth at baseline and posttreatment. Initial fit was inadequate for 27 of 38 baseline and posttreatment models, but model modifications resulted in acceptable fit. Tests of LMI supported scalar invariance for the PARS and many, but not all, MASC and SCARED subscales. Findings suggest that the PARS, and many MASC and SCARED subscales can accurately be used to measure change over time, however, others may reflect changes in measurement properties.

Brief Behavioral Therapy for Anxiety and Depression in Pediatric Primary Care: Breadth of Intervention Impact

OBJECTIVE

To report on broad-based outcomes of the Brief Behavioral Therapy (BBT) trial for pediatric anxiety and depression. Secondary data analyses expand on previous reports by assessing diagnostic remission and independent functioning, impact on targeted psychopathology, and spillover effects on non-targeted outcomes.

METHOD

Youth (N = 185; 8-16.9 years; 58% female; 78% White; 21% Hispanic) with anxiety and/or depression were eligible for this multi-site trial. Enrolled youth were randomly assigned to receive 8 to 12 sessions of BBT in primary care or assisted referral to outpatient care (ARC). Assessments were conducted 16 and 32 weeks post randomization.

RESULTS

BBT was superior to ARC on remission of all targeted diagnoses (week 16: 56.8% vs 28.2%, p < .001; week 32: 62.5% vs 38.9%, p = .004), clinician-rated independent functioning (week 16: 75.0% vs 45.7%, p < .001; week 32: 81.2% vs 55.7%, p < .001), and on measures of anxiety, depression, suicide items, total comorbid behavioral and emotional problems, and hyperactivity (d = 0.21-0.49). Moderation analyses revealed superior outcomes for Hispanic youth in BBT vs ARC for diagnostic remission, anxiety, emotional problems, and parent-child conflict. Youth depression at baseline moderated effects on peer problems and parent-child conflict, with effects favoring BBT. Significant main and moderated effects of BBT on change in non-targeted outcomes were largely mediated by change in anxiety (24.2%-49.3% of total effects mediated).

CONCLUSION

BBT has positive effects on youth, mediated by the strong impact of the intervention on anxiety. Analyses continue to support positive outcomes for Hispanic youth, suggesting that BBT is a broadly effective transdiagnostic treatment option for diverse populations.

CLINICAL TRIAL REGISTRATION INFORMATION

Brief Cognitive Behavioral Therapy (CBT) for Pediatric Anxiety and Depression in Primary Care; https://clinicaltrials.gov; NCT01147614.

High Rates of Anxiety Among Adolescents in a Partial Hospitalization Program

Background

Anxiety disorders are garnering increasing attention for their contribution to high-risk issues and functional impairment. Adolescents are typically admitted to partial hospitalization programs (PHPs) due to high-risk presentations. However, the frequency of anxiety disorders in PHPs is not well-established, in part because anxiety can be overlooked in acute settings due to limited lengths of stay and focus on stabilization.

Objective

This study aims to evaluate the frequency and severity of anxiety disorders among a sample of adolescent PHP patients to assess the need for anxiety-specific assessment and interventions in higher acuity settings.

Methods

Participants were 158 youths ages 13 to 19 years old (M = 15.49 years, SD = 1.50) who were admitted to an adolescent PHP and their caregivers. Clinician-reported diagnostic information was collected from the youth's electronic medical record, and self- and caregiver-rated severity of anxiety was collected using the Screen for Child Anxiety Related Emotions Disorders (SCARED-C/P). Frequency of anxiety and related disorder diagnoses and self- and caregiver-reported severity were assessed using descriptive statistical methods.

Results

75% of participants were diagnosed with an anxiety disorder (n = 118). On average, participants with anxiety disorders had elevated SCARED-C scores. Youths with depressive disorders had elevated SCARED-C scores even when they did not carry anxiety disorder diagnoses. Caregiver ratings of the youth's anxiety symptoms on the SCARED-P were elevated when youths had anxiety disorders.

Conclusions

These findings suggest that anxiety is common in an adolescent PHP setting and support investing in evidence-based assessment and treatment of anxiety in high-acuity settings.

Online treatment of adolescents with comorbid anxiety and depression: A randomized controlled trial

OBJECTIVE

Adolescents experiencing both anxiety and mood disorders show greater life impairment than those with either disorder alone. The aim of this study was to evaluate the efficacy of an online cognitive behavior therapy (CBT) program for these comorbid youth.

METHODS

Ninety-one adolescents aged 12 to 17 years (M = 14.29, S.D. = 1.62; 66% female) participated if they met DSM-5 criteria for both an anxiety and depressive disorder. Diagnoses were assessed by structured interview and participants also completed measures of symptoms, negative thoughts, and life interference. Participants were randomly allocated to either active treatment (n = 45) or wait (n = 46). Treatment comprised access to an 8-module, online program and was supported by 8, 30-minute telephone sessions with a therapist and the youth, of which the caregiver participated in four.

RESULTS

Treated participants showed significantly greater reduction than waiting participants on the primary outcome: total number of disorders and were more likely to remit from all anxiety and mood disorders (43.8% vs 20.9%). Secondary outcomes covering symptoms of anxiety and depression showed similar group by time differences, but there was no significant group by time interaction on life interference.

CONCLUSIONS

This brief, easily accessible, online intervention that requires relatively low levels of therapist time showed promising impact for a very impaired population.

REGISTRATION

This trial was registered on the ANZ clinical trials registry-ACTRN12616000139471.

Long-term effectiveness and trajectories of change after treatment with SMART, a transdiagnostic CBT for adolescents with emotional problems

Background

There is a need for long-term effectiveness trials of transdiagnostic treatments. This study investigates the effectiveness and diagnosis-specific trajectories of change in adolescent patients attending SMART, a 6-week transdiagnostic CBT for anxiety and depression, with 6-month follow-up.

Methods

A randomized controlled trial with waiting list control (WLC) was performed at three child and adolescent mental health outpatient services (CAMHS) in Norway. Referred adolescents (N = 163, age = 15.72, 90.3% females) scoring 6 or more on the emotional disorders subscale of the Strengths and Difficulties Questionnaire (SDQ) were randomly assigned to treatment or to WLC. Long-term follow-up (N = 83, baseline age = 15.57, 94% females) was performed 6 months after treatment completion (Mean = 7.1 months, SD = 2.5). Linear mixed model analysis was used to assess time by group effects in patients with no diagnosis, probable anxiety, depressive disorder, and combined anxiety and depressive disorder.

Results

Almost one third (31%) obtained full recovery according to the inclusion criterium (SDQ emotional). There was highly significant change in all outcome variables. Effect sizes (ES) were largest for general functioning, measured with CGAS (ES: d = 2.19), and on emotional problems measured with SDQ (ES: d = 2.10), while CORE-17, BDI-II and CGAS all obtained ES’s close to 1. There were no significant time by diagnostic group interactions for any outcomes, indicating similar trajectories of change, regardless of diagnostic group. Waiting 6 weeks for treatment had no significant impact on long-term treatment effects.

Limitations

Possible regression to the mean. Attrition from baseline to follow-up.

Conclusions

Six weeks of transdiagnostic treatment for adolescents with emotional problems showed highly significant change in emotional symptoms and functioning at 6-month follow-up. Patients with anxiety, depression, combined anxiety and depression, and emotional problems with no specific diagnoses, all had similar trajectories of change. Hence this transdiagnostic SMART treatment can be recommended for adolescent patients with symptoms within the broad spectrum of emotional problems.

Trial registration: ClinicalTrials.gov Identifier: NCT02150265. First registered May 29, 2014.

Is Activation the Active Ingredient of Transdiagnostic Therapies? A Randomized Clinical Trial of Behavioral Activation, Acceptance and Commitment Therapy, and Transdiagnostic Cognitive-Behavioral Therapy for Emotional Disorders

Studying the usefulness of contextual and cognitive transdiagnostic therapies calls for an analysis of both their differential efficacy and their specificity when acting on the transdiagnostic conditions on which they focus. This controlled trial compares the post-treatment and 3- and 6-month follow-up effects of Behavioral Activation (BA), Acceptance and Commitment Therapy (ACT) and Cognitive-Behavioral Transdiagnostic Therapy (TD-CBT) on emotional symptomatology, and analyses the role played by Experiential Avoidance, Cognitive Fusion, Activation and Emotion Regulation in the clinical change. One hundred twenty-eight patients who fulfilled diagnostic criteria for anxiety and/or depression (intention-to-treat sample) were randomly assigned to three experimental group-treatment conditions (BA, n = 34; ACT, n = 27; TD-CBT n = 33) and one control group (WL, n = 34). Ninety-nine (77.34%) completed the treatment (per-protocol sample). In the post-treatment, all therapies reduced anxiety and depression symptomatology. In the follow-ups, the reduction in emotional symptomatology was greater in the condition which produced greater and more prolonged effects on Activation. Activation appears to be the principal condition in modifying all the transdiagnostic patterns and BA was the most efficacious and specific treatment. The trial was registered at ClinicalTrials.gov NCT04117464. Raw data are available online http://dx.doi.org/10.17632/krj3w2hfsj.1 .

A randomised controlled trial evaluating two universal prevention programs for children: Building resilience to manage worry

BACKGROUND

Childhood anxiety and depression lead to great distress and impairment. Preventing them simultaneously in early life is critically important. We evaluated the long-term efficacy of an emotion regulation-based (ER) and a behavioural activation-based (BA) program. Both aimed to build resilience to prevent worry, a transdiagnostic feature across anxiety and depression.

METHODS

Participants were 316 students (52.2% female; 8-13 years) from six South Australian primary schools. Schools were randomised to the ER, BA or a control condition. Measures of resilience, worry, anxiety, and depression were taken at pre- and post- program, and at 6- and 12-month follow-up. In addition, levels of emotion regulation, behavioural activation and resilience were measured as potential mediators of changes in anxiety and depression.

RESULTS

No significant condition × time interactions were observed. However, the percentage of children who met the clinical cut-offs for generalised anxiety disorder and major depressive disorder decreased significantly in the BA condition at 12-month follow-up, as well as the percentage of children who met the clinical cut-off for obsessive compulsive disorder in the ER condition. Furthermore, emotion regulation mediated the relationship between condition and worry at post-program in the ER condition.

LIMITATIONS

The sample size is relatively small. Reliance on child self-report may have resulted in inaccurate responses.

CONCLUSION

The ER and BA transdiagnostic prevention programs for childhood anxiety and depression showed promising results for certain anxiety disorders not otherwise observed in universal school-based studies. Future research should consider evaluating the programs with a larger sample using alternative outcome measures.

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders Among Japanese Children: A Pilot Study

At present, there is no established cognitive behavioral therapy (CBT) for treating emotional disorders in Japanese children. Therefore, we introduced the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C) in Japan and adapted it to the Japanese context. We then examined its feasibility and preliminary efficacy using a single-arm pretest, posttest, follow-up design. Seventeen Japanese children aged between 8 and 12 years (female n = 11; male n = 6; M = 10.06 ± 0.97 years) with a principal diagnosis of anxiety, obsessive-compulsive, or depressive disorders, and their parents were enrolled in the study. The primary outcome was the overall severity of emotional disorders as assessed by psychiatrists using the Clinical Global Impression-Severity Scale. Secondary outcomes included child- and parent-reported anxiety symptoms, depressive symptoms, and functional status. No severe adverse events were observed. The feasibility was confirmed by the low dropout proportion (11.76%), high attendance proportion (children: 95.6%; parents: 94.6%), and sufficient participant satisfaction. Linear mixed models (LMMs) showed that the overall severity of emotional disorders and child- and parent-reported anxiety symptoms improved from pre-treatment to post-treatment, and that these treatment effects were maintained during the 3-month follow-up period. Additionally, child- and parent-reported functional status improved from pre-treatment to the 3-month follow-up. In contrast, child-reported depressive symptoms improved from pre-treatment to follow-up, but there was no significant change in parent-reported depressive symptoms between pre-treatment and other time points. These findings demonstrate the feasibility and preliminary efficacy of the Japanese version of the UP-C, suggesting that future randomized controlled trials (RCTs) are warranted (Clinical trial registration: UMIN000026911).

Transdiagnostic Behavioural Intervention for Children with Anxiety and Depressive Disorders: A Feasibility Study

There is increasing support for the efficacy of transdiagnostic cognitive behavioural interventions for anxiety and depression. However, little is known about the applicability of transdiagnostic behavioural interventions for children younger than 12 years old. This study was conducted to examine the feasibility and potential efficacy of Streamlined Transdiagnostic Intervention for Anxiety and Depression (STREAM) for children with anxiety and/or depressive disorders using a randomised controlled design with a wait-list control (WLC) condition and blind-assessments. Of the 22 potential participants, 16 Japanese children (M = 9.81; SD = 0.75; range 9–12 years) with principal anxiety or depressive disorder were eligible and enrolled. Then, the participants were randomly assigned to the STREAM or WLC condition. The dropout rates were 0% for both the conditions at post-assessment. Mixed model analyses showed that, although there were no significant interactions at post-assessment between both the conditions, both anxiety and depressive disorders significantly improved at 3 months compared with pre-assessment for the combined condition (the STREAM and WLC conditions). Therefore, this study demonstrated the feasibility of the STREAM in the Japanese clinical setting and potentially supported its efficacy for children with anxiety and depressive disorders at the follow-up assessment.

Behavioral Activation as an 'active ingredient' of interventions addressing depression and anxiety among young people: a systematic review and evidence synthesis

BACKGROUND

Psychological interventions such as behavioral activation (BA) that focus on overt behaviors rather than complex cognitive skills may be developmentally well-suited to address youth mental health problems. The current systematic review synthesized evidence on the characteristics, effectiveness and acceptability of behavioral activation (BA) to examine its role as a potential 'active ingredient' for alleviating depression and anxiety among young people aged 14 to 24 years.

METHODS

Evidence across the following sources were synthesized: (i) randomized control trials (RCT) evaluating interventions where BA has been used as a standalone intervention or as part of a multicomponent intervention, (ii) qualitative studies examining the acceptability of BA as an intervention or as a coping strategy among young people with lived experiences. Consultations with a youth advisory group (YAG) from India were used to draw inferences from existing evidence and identify future research priorities.

RESULTS

As part of the review, 23 RCTs were identified; three studies examined BA as a standalone intervention, and the remaining studies examined multicomponent intervention where BA was a constituent element. The intervention protocols varied in composition, with the number of intervention elements ranging between 5 to 18. There was promising but limited evidence in standalone interventions for thse effectiveness of BA for depression. The impact of BA in multicomponent interventions was difficult to evaluate in the absence of focal assessment of activation outcomes. Evidence from 37 additional qualitative studies of youth lived experience literature, corroborated by the YAG inputs, indicated that young people preferred using behavioral strategies similar to BA to cope with depression in their own life. Themes indicated that the activities that are important to an individual and their socio-contextual factors need to be considered in the planning and implementing BA intervention. Evidence for the use of BA in anxiety was limited across data sources.

CONCLUSIONS

Overall, there was preliminary empirical evidence for the effectiveness and acceptability of BA for youth depression. Further research is needed to examine the components and mechanisms that contribute to its effectiveness as an active intervention ingredient for depression and anxiety.

Psychological Treatments for Depression in Adolescents: More Than Three Decades Later

Depression is a common and impairing disorder which is a serious public health problem. For some individuals, depression has a chronic course and is recurrent, particularly when its onset is during adolescence. The purpose of the current paper was to review the clinical trials conducted between 1980 and 2020 in adolescents with a primary diagnosis of a depressive disorder, excluding indicated prevention trials for depressive symptomatology. Cognitive behavioral therapy (CBT) is the pre-eminent treatment and is well established from an evidence-based treatment perspective. The body of research on the remaining treatments is smaller and the status of these treatments is varied: interpersonal therapy (IPT) is well established; family therapy (FT) is possibly effective; and short-term psychoanalytic therapy (PT) is experimental treatment. Implementation of the two treatments that work well-CBT and IPT-has more support when provided individually as compared to in groups. Research on depression treatments has been expanding through using transdiagnostic and modular protocols, implementation through information and communication technologies, and indicated prevention programs. Despite significant progress, however, questions remain regarding the rate of non-response to treatment, the fading of specific treatment effects over time, and the contribution of parental involvement in therapy.

Review: Delivering mental health support within schools and colleges - a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents

BACKGROUND

Increasing the role of schools and colleges in the provision of mental health services for young people has the potential to improve early intervention and access to treatment. We aimed to understand what factors influence the successful implementation of indicated psychological interventions within schools and colleges to help guide increased provision of mental health support within education settings.

METHODS

Systematic search for studies that have reported barriers or facilitators to the implementation of indicated interventions for adolescent emotional disorders delivered within schools and further education/sixth form colleges (CRD42018102830). Databases searched were EMBASE, MEDLINE, PsycINFO, CINAHL, British Nursing Index, ASSIA, ERIC and British Education Index. A thematic synthesis of factors reported to impact implementation was conducted.

RESULTS

Two thousand five hundred and sixty-nine records and 177 full texts were screened. Fifty studies were identified for inclusion, all of which were of school-based interventions. Eleven analytic themes were developed encompassing intervention characteristics, organisational capacity, training and technical assistance, provider characteristics and community-level factors. Findings indicate the need to select appropriate interventions, consider logistical challenges of the school context and provide training and supervision to enable staff to deliver interventions with fidelity. However, structural and environmental support is required for these facilitators to have the greatest impact on successful implementation.

CONCLUSIONS

Implementing indicated school-based mental health interventions is challenging. Those involved in planning school-based mental health initiatives must be alert to the impact of factors on multiple interacting levels. There is a lack of research on implementing mental health support within further education and sixth form colleges.

KEY PRACTITIONER MESSAGE

Increased utilisation of schools and colleges as a setting for early intervention has been proposed as a means of improving access to mental health treatment, but successful implementation of mental health interventions within educational settings is challenging. Based on a synthesis of current evidence, we recommend that young people and education professionals should be involved in the selection of school-based interventions to ensure they are acceptable and practical to deliver within the logistical constraints of the school environment. Those delivering interventions within schools, as well as staff involved in identifying young people who might benefit from these interventions, must receive high-quality ongoing training and support. Senior school leaders play an important role in championing mental health interventions and developing a school culture that prioritises mental well-being. Health and education policy should be designed to promote a cross-sector focus on the emotional health of young people. There is a lack of evidence on the implementation of indicated psychological interventions within sixth form and further education colleges.

Effectiveness of the Super Skills for Life programme in enhancing the emotional wellbeing of children and adolescents in residential care institutions in a low- and middle-income country: A randomised waitlist-controlled trial

BACKGROUND

The present study examined the effectiveness of a transdiagnostic prevention programme, Super Skills for Life (SSL), among children and adolescents with emotional problems in residential care institutions (RCIs) in the low- and middle-income country of Mauritius using a randomised waitlist-controlled trial (RCT). SSL is based on the principles of cognitive behavioural therapy, behavioural activation, social skills training, and uses video-feedback and cognitive preparation as part of the treatment.

METHODS

The RCT involved 100 children and adolescents aged 9 to 14 years, from six RCIs, randomly allocated to either an SSL intervention group (IG) or a waitlist-control (WLC) group. A set of questionnaires measuring internalising and externalising problems, emotion regulation and self-esteem, and experimental tasks measuring attentional bias and inhibitory control, were completed at baseline, post-intervention and 3-month follow-up. Participants also completed a 2-min video speech task during the first and final sessions of the SSL intervention.

RESULTS

Children and adolescents in the IG showed significant improvements in internalising symptoms (e.g. anxiety and depression), externalising symptoms (e.g. conduct problems and hyperactivity), and inhibitory control, and an increase in adaptive (except putting into perspective strategy) and decrease in maladaptive emotion regulation strategies, at both post-intervention and follow-up. These findings were not replicated among children in the WLC.

LIMITATIONS

The small sample size and lack of an active control group were the major limitations of this study.

CONCLUSIONS

This study provides evidence for the effectiveness of a transdiagnostic prevention programme for emotional problems in RCIs in a low- and middle-income country.

Preliminary Findings for Group Transdiagnostic Behavior Therapy for Affective Disorders Among Youths

OBJECTIVE

The literature on transdiagnostic psychotherapy among youths is limited. Group transdiagnostic behavior therapy (TBT) has been shown to be effective for adults with affective disorders and may contain beneficial features for youths (e.g., behavioral focus, group format, ease of dissemination, and diversity of targeted diagnoses). This study aimed to investigate group TBT among youths in Canada to determine its feasibility and efficacy.

METHODS

Twenty participants (ages 16-19) diagnosed as having a principal anxiety disorder completed 12 sessions of group TBT. Symptoms of anxiety, depression, and transdiagnostic impairment were assessed pre- and posttreatment.

RESULTS

Participants demonstrated significant improvements on measures of anxiety (general, cognitive, and somatic) and stress, with moderate effect sizes. Findings for symptoms of depression and transdiagnostic impairment were unreliable, with small effect sizes.

CONCLUSIONS

These findings provide preliminary support for the use of group TBT among youths with anxiety disorders. Future research should incorporate comparison groups and larger samples.

Practitioner Review: Effectiveness of indicated school-based interventions for adolescent depression and anxiety - a meta-analytic review

BACKGROUND

Interest in delivering psychological interventions within schools to facilitate early intervention is increasing. However, most reviews have focused on universal or preventative programmes rather than interventions designed to decrease existing symptoms of depression or anxiety. This paper aims to provide a meta-analytic review of randomised controlled trials of indicated psychological interventions for young people aged 10-19 with elevated symptoms of depression and/or anxiety.

METHODS

Eight electronic databases were systematically searched from inception to April 2019 for eligible trials. Study quality was assessed using two scales designed to evaluate psychotherapy intervention trials. Random effects meta-analyses were conducted separately for trials that recruited participants based on symptoms of depression and based on symptoms of anxiety.

RESULTS

Data from 45 trials were analysed. Most interventions studied used cognitive and behavioural strategies. Few studies met methodological quality criteria, but effect size was not associated with study quality. Indicated school-based interventions had a small effect on reducing depression symptoms (SMD = .34, 95% CI -0.48, -0.21) and a medium effect on reducing anxiety symptoms (SMD = -.49, 95% CI -0.79, -0.19) immediately postintervention. Subgroup analyses indicated that interventions delivered by internal school staff did not have significant effects on symptoms. Reductions in depression were maintained at short-term (≤6 months) but not medium (>6 months ≤ 12) or long-term (>12-month) follow-up. Reductions in anxiety symptoms were not maintained at any follow-up.

CONCLUSIONS

Indicated school-based interventions are effective at reducing symptoms of depression and anxiety in adolescents immediately postintervention but there is little evidence that these reductions are maintained. Interventions delivered by school staff are not supported by the current evidence base. Further high-quality randomised controlled trials incorporating assessment of longer-term outcomes are needed to justify increased investment in school-based interventions for adolescent depression and anxiety.

New directions in behavioral activation: Using findings from basic science and translational neuroscience to inform the exploration of potential mechanisms of change

Interest in behavioral activation treatments for depression has increased over the past two decades. Behavioral activation treatments have been shown to be effective in treating depression across a variety of populations and settings. However, little is known about the mechanisms of change that may bring about symptom improvement in behavioral activation treatments. Recent developments in the theoretical and empirical literature on behavioral activation treatments have coincided with advances in basic science and translational neuroscience regarding the mechanisms underlying individual differences in responsiveness to reward. Attenuated reward responsiveness has been associated with depression and related clinical outcomes at the self-report, behavioral, and neural levels of analysis. Given that behavioral activation treatments are focused on increasing individuals' contact and engagement with sustainable sources of reward in their environment, it is plausible that behavioral activation treatments bring about improvements in depression symptoms by targeting (low) reward responsiveness directly. This paper integrates findings from the clinical research literature on behavioral activation treatments with insights drawn from basic science and translational neuroscience in order to propose hypotheses about potential mechanisms of change in behavioral activation. Conceptual issues and recommendations for future research on behavioral activation treatments are discussed.

A 12-month follow-up of a transdiagnostic indicated prevention of internalizing symptoms in school-aged children: the results from the EMOTION study

BACKGROUND

Anxious and depressive symptoms in youth are highly prevalent, are often comorbid and have a high rate of relapse. Preventive interventions are promising, but follow-up results are lacking. The transdiagnostic EMOTION program is an indicated preventive cognitive behavioral therapy (CBT) intervention targeting children aged 8-12 years.

METHODS

The present study investigates the 12 months follow-up effects of the EMOTION intervention in a cluster randomized controlled trial (RCT) with 795 children that included both child self-reports and parental reports.

RESULTS

Mixed model analyses showed a larger decrease of symptoms in the intervention group than in the control group for child self-reported anxious symptoms (The Multidimensional Anxiety Scale for Children (MASC) difference 4.56, CI 1.83 to 7.29, p = .001). Parental reports for both anxious (MASC difference 2.50, CI .26 to 4.74, p = .029) and depressive (The Mood and Feelings Questionnaire-short form (SMFQ) difference 1.55, CI .83 to 2.26, p ≤ .001) symptoms in children also showed a reduction. No statistically significant difference was found for child self-reported depressive symptoms (SMFQ difference .69, CI - .22 to 1.60, p = .139).

CONCLUSION

The transdiagnostic EMOTION program has shown the potential for long-term reductions in symptoms of both anxiety and depression in school-aged children. However, results regarding depressive symptoms must be considered preliminary as only parental report indicated effect.Trial registration The regional ethics committee (REC) of Norway approved the study. Registration number: 2013/1909; Project title: Coping Kids: a randomized controlled study of a new indicated preventive intervention for children with symptoms of anxiety and depression. ClinicalTrials.gov Identifier; NCT02340637.

Social and Non-social Reward: A Preliminary Examination of Clinical Improvement and Neural Reactivity in Adolescents Treated With Behavioral Therapy for Anxiety and Depression

Background

Pediatric anxiety and depression are highly prevalent and debilitating disorders that often co-occur. Neural circuitry of reward processing has been shown to be implicated in both, and there is an emerging evidence base linking treatment response to brain patterns of reward processing. The current study aimed to add to this literature by investigating the association between clinical improvement and social and non-social reward in youth previously treated for anxiety and depression.

Methods

The current study leveraged clinical improvement data from a successful randomized controlled trial testing the efficacy of a transdiagnostic, brief behavioral treatment for youth diagnosed with anxiety or depression. Participants (N = 15) interested in engaging in a neuroimaging follow-up underwent an fMRI scan, during which they completed social (i.e., Face Task) and non-social (i.e., Piñata Task, a youth-friendly monetary incentive delay task) reward tasks. Whole-brain activation and functional connectivity analyses identified neural responses to the tasks separately; a third set of analyses directly compared clinical improvement-related findings to understand the impact of task context on neural reactivity to reward.

Results

Activation-based findings were sparse; however, connectivity as a function of degree of treatment response was apparent and robust. Within the context of social reward, significant clusters within frontal and temporal regions driven by happy face contrasts, the social reward stimulus, were observed. This supports connectivity between these regions and both amygdala and ventral striatum seeds as a function of degree of clinical improvement. Connectivity within the context of non-social reward also yielded significant clusters in temporal and parietal regions. Here too, the magnitude and direction of region coupling depended on the degree of clinical improvement and the task conditions. No differences in connectivity by task type as a function of clinical improvement were found.

Conclusion

Findings serve as preliminary evidence that neural regions found to be related to clinical improvement within the context of social and non-social reward are similar to regions that have been shown to support reward processing in normative samples. Implications for treatment and future work are discussed.

Relation between cognitive and behavioral strategies and future change in common mental health problems across 18 years

Major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder (PD), constitute common mental disorders that may have chronic and disabling courses. Cognitive and behavioral theories posit that lack of engagement in certain strategies (goal persistence, self-mastery, positive reappraisal) increases vulnerability toward these disorders. Further, scar effect theories assert that experiencing more of these disorders may diminish engagement in such strategies within individuals across time. However, dynamic longitudinal associations between cognitive-behavioral strategies (CBS) and disorder counts across adulthood are not well understood. Using bivariate latent difference score models, this study aimed to test the dynamic trajectories between disorder counts and each CBS across 18 years. Participants were 3,294 community-dwelling adults ages 45.62 years (SD = 11.41, range = 20-74; 54.61% female) who took part in 3 waves of measurement spaced 9 years apart. Self-mastery, disorder counts, and their change were not significantly related. However, higher within-subject increase in goal persistence (but not self-mastery or positive reappraisal) led to greater future decline in disorder counts, but not vice versa. Last, within individuals, greater prior levels of goal persistence and positive reappraisal predicted larger subsequent reduction in disorder counts, and vice versa. The reciprocal, bidirectional associations between specific CBS (goal persistence, positive reappraisal) and disorder counts support both vulnerability and scar models of depression and anxiety. Treatments for MDD, GAD, and PD should attempt to enhance perseverance and optimism. Theoretical and clinical implications are further discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Back2School modular cognitive behavioral intervention for youths with problematic school absenteeism: study protocol for a randomized controlled trial

BACKGROUND

School absenteeism (SA) is associated with anxiety, depression, and disruptive behavior. It is a risk factor for academic difficulties and school dropout, which predict problems in adulthood such as social, work-related, and health problems. The main goal of this study is to examine the initial effectiveness of a modular transdiagnostic cognitive behavioral therapy (CBT) intervention (Back2School) for increasing school attendance and decreasing psychological problems, relative to a comparator control arm (treatment as usual [TAU]).

METHODS/DESIGN

One hundred sixty children, aged 7 to 16 years, will be randomly assigned to either Back2School or TAU. The design is a two (Back2School and TAU) by four (preassessment [T1], postassessment [T2], and 3-month [T3] and 1-year [T4] assessments) mixed between-within design. The primary outcome is school attendance based on daily registration. Secondary outcomes pertain to youth psychosocial functioning, quality of life, bullying, self-efficacy, and teacher-parent collaboration. These secondary outcomes are measured via youth, parent, and teacher reports.

DISCUSSION

This study will provide critically needed empirical evidence on the initial effectiveness of a manualized treatment program for youth with SA. If the intervention is found to be effective, the program can be further implemented and tested in a larger school health effectiveness trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03459677 . Retrospectively registered on 9 March 2018.

Different Types and Acceptability of Psychotherapies for Acute Anxiety Disorders in Children and Adolescents: A Network Meta-analysis

IMPORTANCE

Anxiety disorders are common in children and adolescents, and uncertainty remains regarding the optimal strategy of psychotherapies in this population.

OBJECTIVE

To compare and rank the different types of psychotherapies and the different ways of delivering psychological treatments for anxiety disorders in children and adolescents.

DATA SOURCES

PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ProQuest Dissertations, LILACS (Literatura Latino Americana em Ciências da Saúde), international trial registers, and US Food and Drug Administration reports were searched from inception to November 30, 2017.

STUDY SELECTION

Randomized clinical trials that compared any structured psychotherapy with another psychotherapy or a control condition for anxiety disorders in children and adolescents were selected.

DATA EXTRACTION AND SYNTHESIS

Four researchers independently performed data extraction and quality assessment. Pairwise meta-analyses and Bayesian network meta-analysis within the random-effects model were used to synthesize data.

MAIN OUTCOMES AND MEASURES

Efficacy (change in anxiety symptoms) posttreatment and at follow-up, acceptability (all-cause discontinuation), and quality of life and functional improvement were measured. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

A total of 101 unique trials including 6625 unique participants compared 11 different psychotherapies with 4 specific control conditions. The certainty of evidence was rated as low or very low for most comparisons. For efficacy, most psychotherapies were significantly more effective than the wait list condition posttreatment (standardized mean difference [SMD], -1.43 to -0.61) and at the longest follow-up (SMD, -1.84 to -1.64). However, only group cognitive behavioral therapy (CBT) was significantly more effective than the other psychotherapies and all control conditions posttreatment. For acceptability, bibliotherapy CBT had significantly more all-cause discontinuations than some psychotherapies and control conditions (range of odds ratios, 2.48-9.32). In terms of quality of life and functional improvement, CBT (delivered in different ways) was significantly beneficial compared with psychological placebo and the wait list condition (SMDs, 0.73 to 1.99).

CONCLUSIONS AND RELEVANCE

Group CBT would be the more appropriate choice of psychotherapy for anxiety disorders in children and adolescents, based on these findings. Other types of psychotherapies and different ways of delivering psychological treatment can be alternative options. Further research is needed to explore specific anxiety disorders, disorder-specific psychotherapy, and moderators of treatment effect.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42015016283.

Behavioral activation for children and adolescents: a systematic review of progress and promise

Behavioral activation (BA) effectively treats depression in adults, and shows promise in treating anxiety. Research into its application to children and adolescents is emerging. This review aimed to explore the scope of studies, current evidence of effectiveness and how the intervention has been delivered and adapted, to inform future research. A systematic review was undertaken searching PsycInfo, PubMed including Medline, EMBASE, and Scopus for terms relating to BA and children and adolescents. Two researchers scored abstracts for inclusion. Data extraction was completed by one researcher and checked by another. 19 studies were identified, across 21 published articles. 12 were case studies, with three pre-post pilot designs and four randomized-controlled trials. Case studies found early support for the feasibility and potential effectiveness of BA to address both anxiety and depression. The RCTs reported largely positive outcomes. Meta-analysis of depression scores indicated that BA may be effective; however, high heterogeneity was observed. Sample sizes to date have been small. BA has been delivered by trained therapists, doctoral trainee psychologists, social workers, or psychology graduates. Studies are uniquely in high-income settings. Adaptations include flexibility in content delivery, youth friendly materials, and parental involvement. There is some limited evidence to support BA as effective for young people. Feasibility and acceptability are supported. Fully powered trials are now required, with expansion to delivery in low- and middle-income settings, and detailed consideration of implementation issues that consider culture and environment.

Does Exposure and Response Prevention Behaviorally Activate Patients With Obsessive-Compulsive Disorder? A Preliminary Test

Exposure and response prevention (ERP) and behavioral activation (BA) are effective treatments for obsessive-compulsive disorder (OCD) and depression, respectively. Patients with OCD often exhibit depression; furthermore, ERP for OCD is associated with reduced depressive symptoms. To our knowledge, no study has examined whether ERP itself functions to behaviorally activate patients with concurrent OCD and depressive symptoms. This prospective study was designed to test the hypotheses that (a) OCD exposure hierarchy completion, increased BA, and depressive symptom reduction would all be related, and (b) pre- to posttreatment changes in BA would mediate the direct effect of OCD hierarchy completion on posttreatment depressive symptoms, even after controlling for pretreatment depressive symptoms, pretreatment BA, pre- to posttreatment reductions in OCD symptoms, treatment duration, and antidepressant medication use. Patients (N = 90) with a primary diagnosis of OCD who received residential ERP for OCD completed a self-report battery at pre- and posttreatment. Exposure hierarchy completion, increases in BA, and decreases in depression were all significantly correlated (rs ranged .33 to .44). The effect of hierarchy completion on posttreatment depressive symptoms was fully mediated by pre- to posttreatment changes in BA. Findings highlight the potential for ERP to exert antidepressant effects by behaviorally activating patients. Limitations, clinical implications, and future directions are discussed.

A randomized waitlist-controlled trial of cognitive behavior therapy to improve emotion regulation in children with autism

BACKGROUND

Mental health problems are common among individuals with autism spectrum disorder (ASD), and difficulties with emotion regulation processes may underlie these issues. Cognitive behavior therapy (CBT) is considered an efficacious treatment for anxiety in children with ASD. Additional research is needed to examine the efficacy of a transdiagnostic treatment approach, whereby the same treatment can be applied to multiple emotional problems, beyond solely anxiety. The purpose of the present study was to examine the efficacy of a manualized and individually delivered 10-session, transdiagnostic CBT intervention, aimed at improving emotion regulation and mental health difficulties in children with ASD.

METHODS

Sixty-eight children (M age = 9.75, SD = 1.27) and their parents participated in the study, randomly allocated to either a treatment immediate (n = 35) or waitlist control condition (n = 33) (ISRCTN #67079741). Parent-, child-, and clinician-reported measures of emotion regulation and mental health were administered at baseline, postintervention/postwaitlist, and at 10-week follow-up.

RESULTS

Children in the treatment immediate condition demonstrated significant improvements on measures of emotion regulation (i.e., emotionality, emotion regulation abilities with social skills) and aspects of psychopathology (i.e., a composite measure of internalizing and externalizing symptoms, adaptive behaviors) compared to those in the waitlist control condition. Treatment gains were maintained at follow-up.

CONCLUSIONS

This study is the first transdiagnostic CBT efficacy trial for children with ASD. Additional investigations are needed to further establish its relative efficacy compared to more traditional models of CBT for children with ASD and other neurodevelopmental conditions.

Statewide Implementation of Parenting with Love and Limits Among Youth with Co-Existing Internalizing and Externalizing Functional Impairments Reduces Return to Service Rates and Treatment Costs

Many community mental health (CMH) systems contain inefficiencies, contributing to unmet need for services among youth. Using a quasi-experimental research design, we examined the implementation of an adapted structural-strategic family intervention, Parenting with Love and Limits, in a state CMH system to increase efficiency of services to youth with co-existing internalizing and externalizing functional impairments (PLL n = 296; Treatment-As-Usual n = 296; 54% male; 81% Caucasian). Youth receiving PLL experienced shorter treatment durations and returned to CMH services at significantly lower rates than youth receiving treatment-as-usual. They also demonstrated significant decreases in internalizing and externalizing symptoms over time. Findings lay the foundation for further examination of the role of an adapted structural-strategic family treatment in increasing the efficiency of CMH systems.

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.