Brief Cognitive-Behavioral Therapy for Anxious Youth: Feasibility and Initial Outcomes

Parent-coached exposure therapy versus cognitive behavior therapy for childhood anxiety disorders

Cognitive-behavioral therapy (CBT) is the strongest evidenced-based therapy for childhood anxiety disorders (CADs). However, CBT's impact is limited by its lack of clear superiority over treatment as usual, excessive length, and greater than 50% of patients remaining symptomatic. Parent-coached exposure therapy (PCET) is designed to treat CADs more effectively and efficiently through a focus on exposure and working with parents and youth together. In a randomized controlled trial, 78 patients (78% female) aged 7 to 17 with CADs were assigned to PCET or the gold-standard CBT. The primary outcome was independent evaluator ratings of anxiety severity at mid- and post-treatment. Secondary outcomes were parent- and child-reported symptoms. Patients receiving PCET had significantly lower mean scores than those receiving CBT on the primary outcome measure at mid-treatment (3.03 ± 0.14, 95% CI, 2.75-3.32 vs. 3.77 ± 0.16 95% CI, 3.45-4.08, p = 0.0010) and post-treatment (2.79 ± 0.14, 95% CI, 2.50-3.07 vs. 3.33 ± 0.16, 95% CI, 2.02-3.64, p = 0.0153). Similar significant results were found with the secondary parent- and child-reported outcomes. These superior results were achieved in PCET with fewer sessions (6.62, SD = 2.8) than those in CBT (8.00, SD = 3.1), p = 0.041. The superior effectiveness and efficiency of PCET likely results from the greater focus on implementing exposure exercises compared to traditional CBT.

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Using session recordings to understand the content of community-based treatment for childhood anxiety disorders and response to technology-based training

OBJECTIVE

The goal of the current study is to advance efforts to increase the quality of care for childhood anxiety disorder (CADs) through (1) detailing the content of community-based treatment sessions, (2) exploring the validity of therapist surveys, (3) examining the influence of setting differences, and (4) testing the effects of a technology-based training on use of nonexposure strategies.

METHODS

Thirteen therapists were randomly assigned to technology-based training in the use of exposure therapy or treatment as usual (TAU) for CADs. Therapeutic techniques were coded from 125 community-based treatment sessions.

RESULTS

Consistent with survey responses community therapists spent the majority of session time reviewing symptoms (34% of session time), implementing nonexposure cognitive behavioral therapy (CBT; 36%), and rarely engaged in exposure (3%). An integrated behavioral health setting was associated with greater endorsement of exposure on survey, p < 0.05, although this difference was not significant in session recordings, p = 0.14. Multilevel models indicated that technology-based training that has been shown to increase exposure, also decreased use of nonexposure CBT techniques (2% vs. 29%, p < 0.001).

CONCLUSION

The study supports the validity of survey-based findings that community-based care for CADs consists of non-exposure CBT techniques. Efforts should be invested in dissemination of within-session exposure.

Effectiveness of school-based brief cognitive behavioral therapy with mindfulness in improving the mental health of adolescents in a Japanese school setting: A preliminary study

Background

Emotional regulation is important for adolescents’ adaptive development. Preventive interventions for anxiety and depression are necessary for reducing the development of disorders later in life, and emotional regulation is a potentially relevant factor.

Objective

We investigated the effects of a mindfulness-based psychological education and prevention program [the Mindfulness and Awareness Program (MAP)] on the mental health of junior high school students in Japan.

Methods

Our MAP primarily focused on mindfulness meditation to improve emotional regulation, thereby reducing depression and anxiety. The MAP comprised eight sessions (20 min each) administered by a school counselor in a school setting. All participants (N = 349) were 12–13-year-old adolescents from nine classes in two Japanese schools. The program was provided to the intervention group, wherein students were educated on emotional expression, emotional cognition, and emotional regulation. The control group received regular school counseling services.

Results

Compared with the control group, the intervention group showed significant improvement in emotional regulation and a decrease in depression and generalized anxiety. The effect was greater at the follow-up assessment than at the immediate post-intervention assessment, and greater in female students.

Conclusion

Our mental health prevention program exhibited efficacy in reducing depression and anxiety and enhancing emotional regulation in early adolescence. Further, it appeared to be more effective for female adolescents.

The efficacy of transdiagnostic cognitive behavioral therapy on migraine headache: a pilot, feasibility study

Introduction

Psychological interventions are shown to be effective in migraine, but not utilized routinely yet. We aimed to evaluate the efficacy of transdiagnostic cognitive behavioral therapy (TCBT) on people with migraine (PwM).

Method

This study was conducted on 40 PwM aged 20–50 years. We randomly assigned participants to two groups of intervention, receiving 10 sessions of TCBT, and control, attending one session on relaxation and stress-management techniques. Days with headache, headache severity, migraine-related disability and effects on daily life, number of pain-relivers taken for headache, depression, and anxiety were assessed pre-intervention, post-intervention (three-month follow-up), and one-month after TCBT termination (four-month follow-up).

Results

Thirty-five participants suffering moderate to severe migraine completed the study (16 and 19 in TCBT and control groups, respectively). TCBT improved all measured items between study time-points (p < 0.05) in the intervention group, while such an improvement was not observed in the control group. Between group comparisons revealed superiority of TCBT group compared to the control group in most measured items at three- and four-month follow-ups (p < 0.05).

Conclusion

Ten sessions of TCBT improved migraine severity, associated disability, anxiety, and depression in PwM, with persistent effects after one month of therapy termination. However, the generalizability of these findings is limited due to the placebo effect in the intervention arm, given the more time each participant has spent with the therapist. TCBT could be an affordable, practical, and feasible intervention to be utilized for PwM and larger studies with equal number of sham therapy sessions are needed to further explore this.

Trial registration number: The study protocol was registered in clinicaltrial.gov (NCT03701477) prior to enrollment.

Interpretation Bias and Anticipated Distress in the Face of Ambiguity: Predictors of Change in Cognitive Behavioral Therapy for Youth Anxiety

This study examined associations among children's anxiety, interpretation bias, and anticipated distress before and after cognitive behavioral therapy (CBT) and investigated baseline levels of interpretation bias and anticipated distress as well as changes in these cognitive biases following treatment as predictors of treatment outcome. Clinically anxious youth (N = 39) were treated with brief CBT augmented with a smartphone app. Children completed measures assessing their anxiety, interpretation bias, and anticipated distress at baseline, post-treatment, and 2-month follow-up. Children's anxiety, interpretation bias, and anticipated distress significantly decreased following treatment. Anticipated distress was associated with higher anxiety at all time points; however, interpretation bias was not significantly associated with anxiety before or after treatment. Reductions in anticipated distress following treatment predicted concurrent and prospective reductions in anxiety. Reduced anticipated distress following treatment may contribute to enhanced treatment outcomes and may be more strongly related to the maintenance of youth anxiety than interpretation bias.

Internet-based psychotherapy in children with obsessive-compulsive disorder (OCD): protocol of a randomized controlled trial

Background

Obsessive-compulsive disorder (OCD) in children can lead to a huge burden on the concerned patients and their family members. While successful state-of-the art cognitive behavioral interventions exist, there is still a lack of available experts for treatment at home, where most symptoms manifest. Internet-based cognitive behavioral therapy (iCBT) could overcome these restrictions; however, studies about iCBT in children with OCD are rare and mostly target computerized self-help resources and only email contact with the therapist. Therefore, we intended to build up and to evaluate an iCBT approach for children with OCD, replacing successful elements of traditional in-office face-to-face CBT, with face-to-face teleconferences, online materials, and apps.

Methods

With the help of a pilot feasibility study, we developed the iCBT consisting of 14 teleconference sessions with the child and parents. The sessions are supported by an app assessing daily and weekly symptoms and treatment course completed by children and parents. Additionally, we obtain heart rate and activity scores from the child via wristbands during several days and exposure sessions. Using a waiting list randomized control trial design, we aim to treat and analyze 20 children with OCD immediately after a diagnostic session whereas the control group of another set of 20 OCD patients will be treated after waiting period of 16 weeks. We will recruit 30 patients in each group to take account for potential dropouts. Outcomes for the treatment group are evaluated before randomization (baseline, t0), 16 weeks (end of treatment, t1), 32 weeks (follow-up 1, t2), and 48 weeks after randomization (follow-up 2, t3). For the waiting list group, outcomes are measured before the first randomization (baseline), at 16 weeks (waiting list period), 32 weeks (end of treatment), 48 weeks after the first randomization (follow-up I), and 64 weeks after the first randomization (follow-up II).

Discussion

Based on our experience of feasibility during the pilot study, we were able to develop the iCBT approach and the current study will investigate treatment effectiveness. Building up an iCBT approach, resembling traditional in-office face-to-face therapy, may ensure the achievement of well-known therapy effect factors, the acceptance in both patients and clinicians, and the wide distribution within the health system.

Trial registration

ClinicalTrials.govNCT05037344. Registered May 2019, last release August 13th, 2021.

Barriers to Increasing Access to Brief Pediatric Mental Health Treatment From Primary Care

A quality improvement process targeted mental health care uptake and system capacity in an underserved region. The pediatric program created pathways for rapid referral from primary care and schools to four sessions of evidence-based treatments for disruptive behavior and depression with community clinicians. Of 250 referrals, 46 families enrolled in treatments for disruptive behavior and 21 for depression. Many families did not respond or required more intensive treatment. Acceptability of the program was high for participating families, referrers, and clinicians. Brief treatment met most participating families' needs. The process demonstrated barriers to mental health care access and delivery and the need for integrated and multitiered care delivery.

Internet-based cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder: A randomized controlled trial

OBJECTIVES

Obsessive-compulsive disorder (OCD) in childhood and adolescence often leads to significant impairment in various areas of life and has a high risk of becoming chronic. Cognitive behavioral therapy (CBT) is the recommended first-line treatment, but it is too rarely implemented in accordance with guidelines and is often not available close to the patient's home. Importantly, internet-based CBT could help to reduce this gap in care. Having previously successfully demonstrated the feasibility of an internet-based CBT approach, we aimed to assess its effectiveness in a waiting list controlled randomized trial.

METHODS

Children and adolescents aged 6-18 years with a principal diagnosis of OCD received 14 sessions of therapist-delivered CBT via videoconference distributed over 16 weeks. After inclusion, participants were randomly assigned to either the treatment or waiting list group. Participants in the treatment group began treatment immediately after baseline diagnostics, and participants in the waiting list group began treatment after a 16-week waiting period. The primary outcome was a pre-post comparison of OCD symptoms as measured with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Additionally, remission was an important outcome measure. Follow-up assessments were conducted for all measures 16 and 32 weeks after completion of treatment.

RESULTS

A total of 60 children and adolescents were included into the analyses. Over the course of the treatment, OCD symptoms according to the CY-BOCS significantly decreased in the treatment group compared to the waiting-list control group. Cohen's d between groups was 1.63. After the patients in the waiting list group also received the treatment, the OCD symptoms decreased significantly in this group as well. This improvement of symptoms increased over the course of the follow-up assessments. Remission rate peaked at the 32-week follow-up, with 68% in the treatment group and 79% in the waiting list group. Importantly, patient satisfaction with treatment was high to very high.

CONCLUSION

In our study, OCD symptoms decreased significantly and remission rate was high after internet-based CBT. Those effects were comparable to those found in studies of face-to-face treatment. Although further evidence is needed, these are early indications that our approach may be a viable way to provide access to adequate treatment for children and adolescents affected by OCD.

CLINICAL TRIAL REGISTRATION

[www.ClinicalTrials.gov], identifier [NCT05037344].

Pediatrician-friendly perspectives on cognitive behavioral therapy for anxious youth: Current status and clinical implications for the next normal

Pediatric anxiety disorders are common and often debilitating conditions. Cognitive is a psychosocial intervention that represents a potentially powerful antidote to these disorders. This article reviews data from treatment outcome studies, meta-analyses, and systematic reviews as well as from moderation/mediational investigations. The literature supports the efficacy, effectiveness, and durability of positive treatment outcomes for pediatric anxiety disorders. Recommendations for clinical applications are suggested.

A Close Look Into Coping Cat: Strategies Within an Empirically Supported Treatment for Anxiety in Youth

The Coping Cat protocol has shown both efficacy and effectiveness in the treatment of youth anxiety across numerous randomized controlled trials (RCTs), leading to its designation as an empirically supported treatment. The treatment is completed in two phases. In the first phase, children are taught a series of coping skills outlined using the FEAR plan acronym. The FEAR plan is then practiced in exposure tasks during the second phase of treatment. To illustrate implementation of both phases, and highlight core treatment components (i.e., exposure, flexibility within fidelity), a case description is presented. Directions for future research are discussed.

A Systematic Review of Prevention and Intervention Strategies for Smartphone Addiction in Students: Applicability During the COVID-19 Pandemic

"During this coronavirus (COVID-19) pandemic, smartphones play an important role in online classes, study, and entertainment. However, excessive use may lead to smartphone addiction (SPA). The incidence of SPA among students has increased with the spread of COVID-19 and threatens to impair home-based students’ learning efficiency and physical and mental health. This study aimed to provide a comprehensive overview of the latest achievements in SPA prevention and treatment, and a theoretical basis for future experimental research and clinical treatment, while considering their applicability during the current pandemic. We researched the core literature in Chinese, English, and Korean databases from 2000 to 2021; 3208 articles were identified. After reading the titles, abstracts, and full texts, 53 articles were selected. Research on SPA interventions was relatively limited; we identified six types of prevention and treatment measures: psychotherapies, cognitive training, behavioral intervention, application restriction, social intervention, and complementary and alternative medicine. They can be implemented by students, parents, or online experts. Future research should focus on developing early measures to identify and prevent SPA and enhance students’ change motivation."

Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study

Cognitive behavioral therapy (CBT) is the first choice of treatment of obsessive–compulsive disorder (OCD) in children and adolescents. However, there is often a lack of access to appropriate treatment close to the home of the patients. An internet-based CBT via videoconferencing could facilitate access to state-of-the-art treatment even in remote areas. The aim of this study was to investigate feasibility and acceptability of this telemedical approach. A total of nine children received 14 sessions of CBT. The first session took place face-to-face, the remaining 13 sessions via videoconference. OCD symptoms were recorded with a smartphone app and therapy materials were made accessible in a data cloud. We assessed diagnostic data before and after treatment and obtained measures to feasibility, treatment satisfaction and acceptability. Outcomes showed high acceptance and satisfaction on the part of patients with online treatment (89%) and that face-to-face therapy was not preferred over an internet-based approach (67%). The majority of patients and their parents classified the quality of treatment as high. They emphasized the usefulness of exposures with response prevention (E/RP) in triggering situations at home. The app itself was rated as easy to operate and useful. In addition to feasibility, a significant decrease in obsessive–compulsive symptoms was also achieved. Internet-based CBT for pediatric OCD is feasible and well received by the patients and their parents. Furthermore, obsessive–compulsive symptomatology decreased in all patients. The results of this study are encouraging and suggest the significance of further research regarding this technology-supported approach, with a specific focus on efficacy.

Trial registration number: Clinical trials AZ53-5400.1-004/44.

A Meta-analysis to Guide the Enhancement of CBT for Childhood Anxiety: Exposure Over Anxiety Management

Cognitive behavior therapy (CBT) is the most empirically supported therapy for childhood anxiety disorders (CADs) but has not reliably outperformed other credible interventions. The current study used meta-analysis to examine the frequency with which the most common treatment components are included in outcome studies and the relation of these components to symptom improvement. Seventy-five studies were identified that included youth with an anxiety disorder treated with CBT or a comparison condition. The protocols for the 111 CBT conditions generally consisted of 12, 1-h sessions delivered to the child with minimal parent inclusion. A greater amount of in-session exposure was related to significantly larger effect sizes between CBT and waitlist control across reporters (- 0.12 to - 0.15; P's < .05) and from pre- to post-treatment for child report (- .06; P < .01). Compared to treatments that omitted relaxation, treatments that included relaxation strategies were associated with significantly smaller pre- to post-treatment effect sizes across reporters (0.38 to 0.80; P's < .05). The current study suggests that CBT protocols for CADs that emphasize in-session exposure and do not include relaxation have the potential to improve the efficacy and effectiveness of therapy. Dismantling studies directly testing these hypotheses are needed.

Anxiety Gremlins: mixed methods sequential explanatory evaluation of a CBT group intervention for children

Although research evidence supports the efficacy of cognitive behavioural therapy (CBT) for anxiety in children, it is important to examine practice-based evidence of effectiveness in typical clinical contexts. This study evaluated a CBT group intervention – ‘Anxiety Gremlins’ – for childhood anxiety. Participants were 36 children (19 boys, 17 girls) aged 8–13, referred for anxiety symptoms at a UK NHS service. The 8-session intervention included six child sessions (2 h) and two parent sessions (1 h). Self-report outcome measures of anxiety symptoms, life functioning and therapeutic relationships were used to measure change pre- and post-intervention. Semi-structured interviews were conducted with group facilitators and analysed through deductive content analysis to identify barriers and facilitators to change. No substantive differences were found between aggregated scores on pre- versus post-intervention outcome measures. Reliable change in anxiety symptoms was identified in 10 children (31%), with five improvers and five deteriorators. Interviews with facilitators identified disruption in group flow, lack of facilitator time to prepare and reflect, and the complexity of clients as hindering factors. Children meeting like-minded peers to share their stories and high engagement in the therapeutic process were helpful factors. Anxiety Gremlins did not demonstrate effectiveness on outcome measures, and this contrasted with clinical opinion. Recommendations were made for the service to revisit the intervention content and the method for recruiting children to the group – as complexity/co-morbidity was linked to poorer outcomes. Future research could explore fidelity to an adapted intervention and include interviews with children and their parents.

Key learning aims

After reading this paper the reader should be able to: (1)

How anxious is too anxious? State and trait physiological arousal predict anxious youth's treatment response to brief cognitive behavioral therapy

BACKGROUND

Exposure therapy is the gold standard for treating childhood anxiety, yet not all youth improve. Children do not always have insight on their distress, which can limit the utility of self-reported units of distress (SUDS) during exposures. Physiological assessment provides an objective means of monitoring emotional arousal. Electrodermal activity (EDA) in particular indexes sympathetic nervous system arousal which is heavily linked to anxiety. The aim of the current study was to examine the feasibility and utility of incorporating EDA assessment in an in-session exposure. We examined concordance between EDA and SUDS, and whether either predicted treatment response.

METHODS

Thirty-four youth who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder completed brief CBT (8 sessions) and completed a survey on trait physiological arousal. EDA and SUDS were collected from 18 youth (9 female, ages 9-14) during a mid-treatment exposure. Changes in anxiety severity were examined post-treatment.

RESULTS

SUDS were not correlated with trait or state physiological arousal. There was a large association between heightened sympathetic arousal and poorer post-treatment response. Similarly, SUDS indices of greater fear activation and habituation were associated with poorer post-treatment response with a small to moderate effect size. Supplemental analyses among the full sample aligned: trait physiological arousal predicted poorer treatment response.

CONCLUSIONS

The lack of concordance between sympathetic arousal and SUDS indices highlights the limitations of relying solely on SUDS with pediatric populations. EDA provided unique data on youth's distress during exposures. Thus, results indicate that physiological assessment may exhibit clinical utility for aiding clinicians in monitoring youth's progress in exposure therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02259036.

Using a Smartphone App and Clinician Portal to Enhance Brief Cognitive Behavioral Therapy for Childhood Anxiety Disorders

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40%-50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9-14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At posttreatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at 2-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to posttreatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders.

Effect of the combination of Benson's relaxation technique and brief psychoeducational intervention on multidimensional pain and negative psychological symptoms of pregnant women: A randomized controlled trial

BACKGROUND

Pregnancy is associated with negative psychological symptoms (NPS) and multidimensional pain. Therefore, the present study was conducted to determine the effect of the combination of Benson's relaxation technique (BRT) and brief psychoeducational intervention (BPI) on multidimensional pain and NPS of pregnant women.

MATERIALS AND METHODS

The present randomized clinical trial was conducted on pregnant women referred to Imam Reza and Motazedi Hospitals in Kermanshah, Iran. In this regard, 60 pregnant women were randomly allocated to intervention (n = 30) and control (n = 30) groups. The groups attended BRT and BPI educational sessions for 4 weeks, but the control group received no intervention. Subsequently, both groups completed Depression Anxiety Stress Scale-21 and multidimensional pain inventory.

RESULTS

The mean NPS (stress, anxiety, and depression) was significantly decreased in the intervention group (P < 0.001), while no statistically significant differences were observed in the control group (P > 0.05). The independent t-test revealed a significant difference between the mean scores of intervention and control groups (P < 0.001). The mean multidimensional pain was significantly decreased in mothers after the completion of educational sessions (P < 0.001), and the independent t-test results indicated a significant difference between the scores of the intervention and control groups (P < 0.001).

CONCLUSION

The results of this study suggested that the combination of BRT and BPI can lead to a reduction in the NPS and multidimensional pain in the pregnant women. This intervention is recommended to be considered as part of a healthcare program in pregnant mothers.

A Longitudinal Follow-up Study Examining Adolescent Depressive Symptoms as a Function of Prior Anxiety Treatment

OBJECTIVE

Children who are fearful and anxious are at heightened risk for developing depression in adolescence. Treating anxiety disorders in pre-/early adolescence may be one mechanism through which depressive symptoms later in adolescence can be prevented. We hypothesized that anxious youth who responded positively to cognitive-behavioral therapy (CBT) for anxiety would show reduced onset of depressive symptoms 2 years later compared to treatment nonresponders, and that this effect would be specific to youth treated with CBT compared to an active supportive comparison treatment.

METHOD

Participants were 80 adolescents ages 11 to 17 years who had previously completed a randomized trial comparing predictors of treatment response to CBT and child-centered therapy (CCT). Youth met DSM-IV criteria for generalized, separation, and/or social anxiety disorder at the time of treatment. The present study was a prospective naturalistic 2-year follow-up examining trajectories toward depression, in which participants were reassessed for depressive symptoms 2 years after anxiety treatment. Treatment response was defined as a 35% reduction in independent evaluator-rated anxiety severity on the Pediatric Anxiety Rating Scale after treatment.

RESULTS

As hypothesized, lower levels of depressive symptoms were observed in anxious youth who responded to CBT for anxiety (β = -0.807, p = .004) but not CCT (β = 0.254, p = .505). Sensitivity analyses showed that the effects were driven by girls.

CONCLUSION

Findings suggest that CBT for anxiety is a promising approach to preventing adolescent depressive symptomatology, especially among girls. The results highlight the need for better early screening for anxiety and better dissemination of CBT programs targeting anxiety in youth.

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.

The Long-Term Effects of Group-Based Psychological Interventions for Children With Tourette Syndrome: A Randomized Controlled Trial

This randomized controlled trial examined the long-term effects of group-based psychological interventions on measures of tic severity, self-reported quality of life (QOL), and school attendance. Children (n = 28) with Tourette syndrome (TS) were assessed 12 months after completing a course of either group-based Habit Reversal Training (HRT) or Education. Both groups demonstrated long-term improvement in tic severity and QOL, which included significant continued improvement during the follow-up (FU) period. Both groups also showed significant posttreatment improvement in school attendance. Further research is required to explore potential therapeutic mechanisms, independent or mutual, which may underlie long-term symptom improvements.

Child social and emotion functioning as predictors of therapeutic alliance in cognitive-behavioral therapy for anxiety

OBJECTIVE

This study examined baseline child social and emotional functioning as predictors of therapeutic alliance during a cognitive-behavioral therapy (CBT) program for children with anxiety disorders. It was hypothesized that better social and emotional functioning at baseline would be related to stronger alliance initially and over the course of treatment.

METHOD

Ninety-two anxious youth, ages 7-11 years (M age = 8.93 years, SD = 1.64; 42% female) participated. Children, caregivers, and teachers completed measures of child social and emotional functioning. Therapeutic alliance was measured using therapist-rated and observer-coded reports.

RESULTS

Receiving prosocial support from peers and emotion regulation (ER) were both related to initial rating and slope of alliance.

CONCLUSIONS

Child social and emotional functioning enhances our understanding of how the alliance is formed and in identifying children who might be at risk for difficulties in developing a strong therapeutic relationship.

A Successful Model for Clinical Training in Child/Adolescent Cognitive Behavior Therapy for Graduate Psychiatric Advanced Practice Nursing Students

BACKGROUND

Graduate faculty in advanced practice nursing programs seek to provide clinical training in psychotherapy for psychiatric mental health nurse practitioner (PMHNP) students and prepare them for practice with patients across the lifespan, including children and adolescents.

OBJECTIVE

To develop a clinical training model for child/adolescent cognitive behavior therapy (CBT) that is adaptable to all graduate nursing programs including online, classroom, and blended programs.

DESIGN

Clinical training included a didactic 4-hour workshop and 7 small group practice sessions utilizing Creating Opportunities for Personal Empowerment (COPE), a manualized CBT program for teens. Students completed post-clinical training evaluations. Using qualitative design, responses to the open-ended questions were analyzed and common themes identified.

RESULTS

One hundred seven PMHNP students completed evaluations. Four themes emerged from the data: (a) therapeutic understanding of adapting CBT for children and adolescents, (b) therapeutic skills and techniques for use with children/adolescents, (c) improved level of confidence through participation in the CBT program, and (d) therapeutic benefits of being in a group.

CONCLUSIONS

Positive PMHNP student evaluations indicated that this clinical training model is feasible both online and face-to-face and acceptable for providing clinical training in CBT for children and adolescents.

Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders

The present article uses meta-analysis to examine treatment components related to outcome within 35 randomized controlled trials (RCTs) for childhood anxiety disorders (CADs) and eight RCTs for childhood obsessive compulsive disorder (OCD). Examination of the RCTs of cognitive behavioral therapy (CBT) for CADs suggested that adding relaxation and delaying exposures until after the introduction of other anxiety management strategies does not increase the efficacy of exposure-based treatment. In addition, compared to the large effect size (ES) associated with exposure and response prevention (ERP) for OCD (k = 9, mean ES = 1.93), the effect size associated with CBT for CADs (k = 44, mean ES = 0.89) did not differentiate from attention placebo (k = 11, mean ES = 0.55), although it was more effective than waitlist control (k = 24, mean ES = 0.22). Instructively, ERP for OCD involved more exposure initiated earlier and less relaxation than CBT for CADs. In addition, RCTs of ERP were more likely to use clinician-administered measures as opposed to self-report and to be conducted in clinical versus recruited samples. These results suggest that dismantling studies using a gold-standard clinician-rated outcome measure to compare the value of adding anxiety management strategies to exposure will be necessary to increase the efficacy of CBT for CADs to levels achieved by ERP for OCD.

A Randomized Clinical Trial Comparing Individual Cognitive Behavioral Therapy and Child-Centered Therapy for Child Anxiety Disorders

This study compared individual cognitive behavioral therapy (CBT) and a supportive child-centered therapy (CCT) for child anxiety disorders on rates of treatment response and recovery at posttreatment and 1-year follow-up, as well as on real-world measures of emotional functioning. Youth (N = 133; ages 9-14) with anxiety disorders (generalized, separation, and/or social anxiety) were randomized using a 2:1 ratio to CBT (n = 90) or CCT (n = 43), which served as an active comparison. Treatment response and recovery at posttreatment and 1-year follow-up were assessed by Independent Evaluators, and youth completed ecological momentary assessment of daily emotions throughout treatment. The majority of youth in both CBT and CCT were classified as treatment responders (71.1% for CBT, 55.8% for CCT), but youth treated with CBT were significantly more likely to fully recover, no longer meeting diagnostic criteria for any of the targeted anxiety disorders and no longer showing residual symptoms (66.7% for CBT vs. 46.5% for CCT). Youth treated with CBT also reported significantly lower negative emotions associated with recent negative events experienced in daily life during the latter stages of treatment relative to youth treated with CCT. Furthermore, a significantly higher percentage of youth treated with CBT compared to CCT were in recovery at 1-year follow-up (82.2% for CBT vs. 65.1% for CCT). These findings indicate potential benefits of CBT above and beyond supportive therapy on the breadth, generalizability, and durability of treatment-related gains.

Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis

BACKGROUND

Cognitive-behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder.

OBJECTIVES

This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated.

DESIGN

Participants were randomised to receive (i) child cognitive-behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT + maternal cognitive-behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother-child interactions (MCIs) (CCBT + MCI).

SETTING

A NHS university clinic in Berkshire, UK.

PARTICIPANTS

Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder.

INTERVENTIONS

All families received eight sessions of individual CCBT. Mothers in the CCBT + MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact.

MAIN OUTCOME MEASURES

Primary clinical outcomes were the child's primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost-utility analysis framework with associated uncertainty.

RESULTS

MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBT + MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBT + MCBT nor CCBT + MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, p = 0.29; adjusted RR CCBT + MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, p = 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, p = 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, p = 0.13). CCBT + MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBT + MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%.

CONCLUSIONS

Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19762288.

FUNDING

This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership (09/800/17) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

The feasibility of improving CBT for childhood anxiety disorders through a dismantling study

This preliminary randomized controlled trial (RCT) examines the feasibility of dismantling cognitive behavioral therapy (CBT) for childhood anxiety disorders. Fourteen children (10 girls) ages 7 to 14 (m = 10.2) with social phobia, generalized anxiety disorder, separation anxiety disorder, or panic disorder were randomized to receive 6 sessions of either a) the pre-exposure anxiety management strategies presented in traditional CBT, or b) parent-coached exposure therapy. The sample was selected from a treatment seeking population and is representative of children in clinical settings. Examination of fidelity ratings, dropouts, and satisfaction ratings indicated that the interventions were distinguishable, safe, and tolerable. The overall sample improved significantly with pre-post effect sizes generally in the large range for both conditions. Between-group effect sizes indicating greater improvement with parent-coached exposure therapy were moderate or large for ten of 12 variables (i.e., 0.53 to 1.52). Re-evaluation after three months of open treatment suggested that the intervention emphasizing exposure early maintained its superiority while requiring fewer appointments.

Parental involvement in youth anxiety treatment: conceptual bases, controversies, and recommendations for intervention

Parents are often perceived as a contributing or maintaining source of youth anxiety disorders, making them natural targets for either intervention or involvement in treatment protocols. Efforts to increase the efficacy and durability of standard treatments by incorporating parents have been successful, yet they often do not outperform child-focused treatment. Breinholst et al. (2012) review and discuss several overlooked parental research variables (anxiety, overcontrol, beliefs and assumptions, global family dysfunction) found to promote and maintain child anxiety. However, it remains unclear how these proposed variables interfere with active therapeutic ingredients (e.g., exposure) or how the identified problems might be addressed. We propose that insufficient attention to exposure-based treatment and family behavioral responses explain the comparatively low added value for parental involvement in child anxiety treatment and outline directions for research to address them. With meaningful attention being given to exposure and its accompanying variables in the treatment of childhood anxiety, we believe that treatment outcomes and intervention acceptability can be improved.

The integration of behavioral health interventions in children's health care: services, science, and suggestions

Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.

The integration of behavioral health interventions in children's health care: services, science, and suggestions

Because the integration of mental or behavioral health services in pediatric primary care is a national priority, a description and evaluation of the interventions applied in the healthcare setting is warranted. This article examines several intervention research studies based on alternative models for delivering behavioral health care in conjunction with comprehensive pediatric care. This review describes the diverse methods applied to different clinical problems, such as brief mental health skills, clinical guidelines, and evidence-based practices, and the empirical outcomes of this research literature. Next, several key treatment considerations are discussed to maximize the efficiency and effectiveness of these interventions. Some practical suggestions for overcoming key service barriers are provided to enhance the capacity of the practice to deliver behavioral health care. There is moderate empirical support for the feasibility, acceptability, and clinical utility of these interventions for treating internalizing and externalizing behavior problems. Practical strategies to extend this work and address methodological limitations are provided that draw upon recent frameworks designed to simplify the treatment enterprise (e.g., common elements). Pediatric primary care has become an important venue for providing mental health services to children and adolescents due, in part, to its many desirable features (e.g., no stigma, local setting, familiar providers). Further adaptation of existing delivery models may promote the delivery of effective integrated interventions with primary care providers as partners designed to address mental health problems in pediatric healthcare.

The SmartCAT: an m-health platform for ecological momentary intervention in child anxiety treatment

INTRODUCTION

Cognitive behavioral therapy (CBT) for child anxiety, although efficacious, typically requires 16-20 weekly sessions with a therapist. Brief CBT (BCBT; eight sessions) for child anxiety is promising but may have less favorable outcomes owing to reduced session time. Mobile health (m-health) has the potential to improve BCBT efficacy by delivering ecological momentary intervention to engage youth in learning and practicing CBT skills in their everyday lives (in vivo).

MATERIALS AND METHODS

We developed an m-health platform entitled SmartCAT (Smartphone-enhanced Child Anxiety Treatment). SmartCAT consists of (1) a smartphone application (app) that cues youth to use the CBT skills taught in sessions, (2) an online portal that allows therapists to monitor skill use, to send cues and treatment-related materials, to engage youth in real-time via secure messages, and to manage rewards, and (3) a communication protocol that allows real-time bidirectional exchange between the app and the portal. A pilot study with nine youth (9-14 years old) examined the platform's feasibility as an adjunct to BCBT.

RESULTS

SmartCAT was found to be capable of supporting BCBT for child anxiety and received positive feedback from both therapists and youth patients. Patients rated the app as highly usable (mean=1.7 on a 1-7 scale, with 1="easy"). Patients completed 5.36 skills coach entries per session (standard deviation=1.95) and took an average of 3.14 min (standard deviation=0.98 min) to complete the entries.

CONCLUSIONS

A smartphone app is feasible within CBT for child anxiety. Users found SmartCAT both acceptable and easy to use. Integrating an m-health platform within BCBT for anxious children may facilitate involvement in treatment and dissemination of effective procedures.

Brief Cognitive-Behavioral Therapy for Anxious Youth: The Inner Workings

We provide a detailed description of the clinical application of brief cognitive-behavioral therapy (BCBT) for anxious youth. A rationale for the development of BCBT is presented, followed by a description and discussion of the 8 sessions of the treatment. Mike, a 7-year-old youth with anxiety disorders, is used to illustrate the inner workings of implementing BCBT. Case conceptualization, session details, and pre-, post- and follow-up-treatment information are provided. Conclusions regarding clinical advantages and future directions are made.