Calibrating for Comorbidity: Clinical Decision-Making in Youth Depression and Anxiety

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.

Moderators of response to child-based and parent-based child anxiety treatment: a machine learning-based analysis

BACKGROUND

Identifying moderators of response to treatment for childhood anxiety can inform clinical decision-making and improve overall treatment efficacy. We examined moderators of response to child-based cognitive-behavioral therapy (CBT) and parent-based SPACE (Supportive Parenting for Anxious Childhood Emotions) in a recent randomized clinical trial.

METHODS

We applied a machine learning approach to identify moderators of treatment response to CBT versus SPACE, in a clinical trial of 124 children with primary anxiety disorders. We tested the clinical benefit of prescribing treatment based on the identified moderators by comparing outcomes for children randomly assigned to their optimal and nonoptimal treatment conditions. We further applied machine learning to explore relations between moderators and shed light on how they interact to predict outcomes. Potential moderators included demographic, socioemotional, parenting, and biological variables. We examined moderation separately for child-reported, parent-reported, and independent-evaluator-reported outcomes.

RESULTS

Parent-reported outcomes were moderated by parent negativity and child oxytocin levels. Child-reported outcomes were moderated by baseline anxiety, parent negativity, and parent oxytocin levels. Independent-evaluator-reported outcomes were moderated by baseline anxiety. Children assigned to their optimal treatment condition had significantly greater reduction in anxiety symptoms, compared with children assigned to their nonoptimal treatment. Significant interactions emerged between the identified moderators.

CONCLUSIONS

Our findings represent an important step toward optimizing treatment selection and increasing treatment efficacy.

A randomized trial of an integrated cognitive behavioral treatment protocol for adolescents receiving home-based services for co-occurring disorders

The current study conducted a preliminary test of whether community mental health clinic staff could implement a multicomponent cognitive behavioral treatment, developed for adolescents with substance misuse (alcohol and/or marijuana) and comorbid psychiatric symptoms. We randomized a total of 111 families, with an adolescent 12-18 years old, referred to a home-based services program for youth with co-occurring substance use and mental health problems, to receive treatment from either masters-level therapists who received intensive cognitive behavioral therapy (I-CBT) training or from masters-level therapists who took part in a typical brief continuing education-style CBT workshop (treatment as usual, or TAU). Each family's therapist and insurance company determined the frequency and intensity of treatment. We administered follow-up assessments at 3, 6, and 12 months. There was a small, but not statistically significant, reduction in the percent days of heavy drinking and marijuana use over time for both conditions, with the overall effect across the three follow-up points favoring the I-CBT condition. There were no differences on alcohol use days or other drug use. There was also a small, but nonsignificant, positive effect over time on externalizing symptoms, depressed mood, and anxiety, favoring the I-CBT condition. Youth in the I-CBT condition relative to TAU had significantly fewer juvenile justice contacts, while the pattern of costly service use varied, with higher rates at 6-month and lower rates at 12-month follow-ups. If therapists pay greater attention to parent training and provide more parent-adolescent communication sessions, outcomes may improve above standard community care. Training enhancements, to better meet the needs of community therapists and their clinic settings, may also produce better overall results for parents and adolescents.

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.

Predictors and Outcomes of Sudden Gains and Sudden Regressions in Cognitive Behavioral Therapy for Youth Anxiety

Sudden gains (SGs), referring to large, stable symptom improvement occurring between consecutive treatment sessions, have been associated with improved outcomes among adults with various psychological disorders. Little research exists on SGs or sudden symptom worsening (i.e., sudden regressions [SRs]) during treatment for youth disorders. The current study examined predictors and outcomes of SGs/SRs via multiple informants in youth anxiety treatment. Participants were 118 youth (age M = 11.6, SD = 2.5; 53.8% female) and their caregivers receiving a cognitive-behavioral therapy protocol for a principal anxiety disorder. Anxiety symptom severity was assessed weekly via the State-Trait Anxiety Inventory for Children-Trait-Child/Parent versions. SGs and SRs occurred in 45.8 and 31.3% of youth, respectively. SRs were more common among youth with comorbid mood or externalizing disorders, while SGs occurred more often among youth with greater pretreatment anxiety symptom severity. SGs were not associated with posttreatment outcomes, but SRs predicted significantly higher posttreatment internalizing symptoms based on child report (β = .23, p = .03) and externalizing symptoms based on child (β = .15, p = .04) and parent report (β = .16, p = .03), controlling for overall magnitude of symptom change. SRs among youth receiving cognitive-behavioral therapy for anxiety are associated with pretreatment clinical complexity and poorer posttreatment outcomes and may serve as a warning sign to clinicians of possible treatment failure.

Review: Comprehensive treatments for youth comorbidity - evidence-guided approaches to a complicated problem

BACKGROUND

Evidence-based treatments (EBTs) with a single-disorder focus have improved the potential for youth mental health care, yet may be an imperfect fit to clinical care settings where diagnostic comorbidity and co-occurring problems are commonplace. Most EBTs were developed to treat one diagnosis or problem (or a small homogenous cluster), but most clinically referred youths present with multiple disorders and problems.

FINDINGS

Three emerging approaches may help address the comorbidity that is so common in treated youths. Conceptually unified treatments target presumed causal and maintaining factors that are shared among more than one disorder or problem area; preliminary open trials and case studies show promising results. Modular protocols combine the 'practice elements' that commonly appear in separate single-disorder EBTs and repackage them into coordinated delivery systems; one modular protocol, MATCH, has produced positive findings in a randomized effectiveness trial. Monitoring and Feedback Systems (MFSs) provide real-time data on client progress to inform clinical decision-making, encompassing comorbid and co-occurring problems; one study shows beneficial effects in everyday practice with diverse youth problems.

CONCLUSIONS

All three approaches - conceptually unified, modular, and MFS - can be strengthened by increased research attention to treatment integrity, clinician user-appeal, design simplicity, and the infrastructure necessary for successful implementation.

Prevention of depression and anxiety symptoms in adolescents: 42 and 54 months follow-up of the Aussie Optimism Program-Positive Thinking Skills

Anxiety and depression are the most commonly reported mental health problems amongst Australian children and adolescents. The Aussie Optimism: Program-Positive Thinking Skills (AOP-PTS) is a universal intervention program based on cognitive and behavioral strategies and aimed to prevent anxiety and depression in the middle primary school children aged 9–10 years old. 370 students randomly assigned to the intervention and control condition participated in the 42 and 54 months follow-up study. The intervention group received the AOP-PTS 10-week program and the control group received the regular health education curriculum. Students were assessed on anxiety, depression and attribution style at school whilst parents reported on their child’s externalizing and internalizing problems at home. Results showed there were no significant reductions across groups in the depressive and anxiety symptoms, and attribution style at either 42 or 54 months follow-up. These findings suggest that AOP-PTS has short and medium term effects but were not sustained in longer term period. Future strategies to achieve the desirable outcomes in a longitudinal study are discussed.