Treating child and adolescent anxiety effectively: Overview of systematic reviews

Do Parents Enhance Cognitive Behavior Therapy for Youth Anxiety? An Overview of Systematic Reviews Over Time

The last 20 years has seen debate regarding the merits of involving parents in cognitive behavior therapy (CBT) for youth anxiety played out across systematic reviews which have high impact. These reviews examined varying treatment formats in relation to parent involvement, including youth only CBT (Y-CBT), parent only CBT (P-CBT) and family CBT (youth and parent; F-CBT). This is a novel overview of systematic reviews examining evidence for parental involvement in CBT for youth anxiety over the period this was studied. Two independent coders systematically searched for studies in medical and psychological databases using the categories "Review", "Youth", "Anxiety", "Cognitive Behavior Therapy" and "Parent/Family". Of the 2,189 unique articles identified, there were 25 systematic reviews since 2005 which compared the effects of CBT for youth anxiety with varying parent involvement. Despite systematically studying the same phenomenon, the reviews were heterogeneous in outcome, design, inclusion criteria and often had methodological limitations. Of the 25 reviews, 21 found no difference between formats and 22 reviews were considered inconclusive. Yet while there were typically no statistical differences, consistent patterns in the direction of effects were detected over time. P-CBT was less effective than other formats, suggesting the importance of directly treating anxious youths. Early reviews favored F-CBT over Y-CBT, however, later reviews did not show this trend. We consider the effects of moderators including exposure therapy, long-term outcomes and the child's age. We consider how to manage heterogeneity in primary studies and reviews to better detect treatment differences where they exist.Trial registration This protocol is registered with the Open Science Framework: osf.io/2u58t.

Self-Compassion and Anxiety in Adolescents with and without Anxiety Disorder

Previous studies have linked self-compassion to mental health, specifically anxiety, in non-clinical adolescents, suggesting that self-compassion can be a protective factor against anxiety. This study compared the overall level of self-compassion and (un)compassionate self-responding in adolescents with and without an anxiety disorder and assessed the association between self-compassion and anxiety. This cross-sectional study included adolescents (12-19 years) with an anxiety disorder (N = 23) and a reference group (N = 28). Participants completed the Self-Compassion Scale (SCS) and State Trait Anxiety Inventory (STAI). Results showed that overall self-compassion and uncompassionate self-responding were significantly lower and higher in the clinical than the reference group, respectively, while compassionate self-responding did not differ between groups. In the clinical group, only uncompassionate self-responding was significantly associated with higher anxiety. In the reference group, uncompassionate self-responding showed a significant positive association with anxiety, and compassionate self-responding showed a significant negative association with anxiety. Although the results suggest that low uncompassionate self-responding may buffer against anxiety, the role of compassionate and uncompassionate self-responding remains unclear. An alternative explanation is that the uncompassionate self-responding items measure the presence of psychopathology in adolescents with an anxiety disorder. More research on the construct validity of the SCS uncompassionate self-responding scale is needed.

Parent Versus Individual Cognitive Behavioral Therapy for Youth Anxiety: Protocol for an Overview of Systematic Reviews Over Time

BACKGROUND

Cognitive behavioral therapy (CBT) has shown to be highly effective for treating youth anxiety; yet, there is ongoing debate as to whether involving parents improves outcomes. For example, parents who attend may learn CBT skills to help their child in an ongoing way; yet, they could also distract their child from treatment depending on how they interact. As evidence has accumulated, reviews and meta-analyses have attempted to examine the most effective treatment format. These reviews often have high impact in the field; however, they use varied methodologies and draw on different primary studies. Different formats of CBT for youth anxiety have been developed in relation to parental involvement, including youth-only CBT (Y-CBT; where the youth alone attends treatment), youth and parent or family CBT (F-CBT; where youths and their parents attend together), and, most recently, parent-only CBT (P-CBT; where the parent alone attends).

OBJECTIVE

This protocol describes an overview of systematic reviews comparing the relative efficacy of different formats of CBT for youth anxiety (Y-CBT, F-CBT, and P-CBT) over the study period. The protocol will also examine the moderating effects of variables on the efficacy of different formats; for example, youths' age and long-term outcomes.

METHODS

We will analyze the results of systematic reviews that compare different levels and types of parental involvement in CBT for youth anxiety over the study period. A systematic review of medical and psychological databases (PsycINFO, PubMed, SCOPUS, Web of Science, Cochrane Library, and Embase) will identify reviews comparing the efficacy of different formats of parent involvement in CBT for youth anxiety. Data extraction will include (1) author names (and year of publication), (2) review design, (3) age range, (4) analysis type, (5) conclusions, and (6) moderators. This overview will present the relative efficacy of formats chronologically in a table and then describe the main results longitudinally in a narrative summary. A Measurement Tool to Assess Systematic Reviews, 2nd Edition (AMSTAR 2), quality rating will be given to each review, and the amount of primary study overlap across reviews will be quantified.

RESULTS

The last search was conducted on July 1, 2022. The reviews were published between 2005 and 2022. We found a total of 3529 articles, of which we identified 25 for the final analysis.

CONCLUSIONS

This overview will compare and report the relative efficacy of Y-CBT, P-CBT, and F-CBT for youth anxiety over the study period, describe the heterogeneity across reviews and primary studies, and consider the moderating effect of relevant variables. It will describe the limitations of an overview, including the potential for nuance in the data to be lost, and provide conclusions and recommendations for conducting systematic reviews regarding parental involvement for CBT for youth anxiety.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/48077.

Effectiveness of Social Inclusion Interventions for Anxiety and Depression among Adolescents: A Systematic Review

BACKGROUND

Adolescents who are socially excluded are at increased risk of mental health problems such as depression and anxiety. Promoting social inclusion could be an effective strategy for preventing and treating adolescent depression and anxiety.

METHODS

We conducted a systematic review of intervention studies which aimed to prevent or treat adolescent depression and/or anxiety by promoting social inclusion. Throughout the review we engaged a youth advisory group of 13 young people (aged 21-24) from Uganda, Turkey, Syria, South Africa, and Egypt.

RESULTS

We identified 12 studies relevant to our review. The interventions tested use a range of different strategies to increase social inclusion and reduce depression and anxiety, including social skills training, psychoeducation, teaching life skills training, and cash transfers. Pooled standardised mean differences (SMDs) based on random-effects models showed medium-to-large benefits of interventions on improving depression and anxiety symptoms (n = 8; SMD = -0.62; 95% CI, -1.23 to -0.01, p < 0.05).

CONCLUSION

Although there are not many studies, those which have been done show promising results that strongly suggest that social inclusion could be an important component of programmes to promote adolescent mental health.

Internet-based emotion-regulation training added to CBT in adolescents with depressive and anxiety disorders: A pilot randomized controlled trial to examine feasibility, acceptability, and preliminary effectiveness

BACKGROUND

Dysfunctional emotion regulation (ER) is associated with symptoms of depression and anxiety in adolescents. This pilot study aimed to examine the acceptability and feasibility of a guided internet-based emotion regulation training (ERT) added to cognitive behavioral therapy (CBT). Furthermore, we aimed to examine the feasibility of the randomized study design and to provide a first estimate of the effectiveness of CBT + ERT compared with CBT alone in adolescents with depressive or anxiety disorders.

METHODS

In a pilot randomized controlled trial (RCT) with a parallel group design, 39 patients (13-18 years) with depressive or anxiety disorder were assigned to CBT + ERT (n = 21) or CBT (n = 18). Assessments at baseline, three-months and six-months follow-up included treatment adherence, satisfaction, depressive symptoms, anxiety symptoms, and ER strategies.

RESULTS

Adherence to ERT was 66.5 %, and treatment satisfaction was adequate. 76.5 % of eligible patients participated in the study. Linear mixed-model analyses showed significantly reduced anxiety symptoms (p = .003), depressive symptoms (p = .017), and maladaptive ER (p = .014), and enhanced adaptive ER (p = .008) at six months follow-up in the CBT + ERT group compared to controls.

LIMITATIONS

The sample size was small, and results regarding effectiveness remain preliminary. Data-collection took place during COVID-19, which may have influenced the results.

CONCLUSIONS

Both the intervention and the study design were found to be feasible. In a larger RCT, however, improvement of recruitment strategy is necessary. Preliminary results indicate potential effectiveness in decreasing anxiety, depression, and emotion dysregulation in adolescents. The next step should be the development of an improved internet-based ERT and its evaluation in a larger RCT.

TRIAL REGISTRATION

Registered on January 14th, 2020 in The Netherlands Trial Register (NL8304).

Evidence-based practice in cognitive-behavioural therapy

Cognitive-behavioural therapy (CBT) is a practical, goal-focused approach that helps children understand the relationship between their thoughts, feelings and behaviours. The aim is to identify the dysfunctional and distorted cognitions associated with their psychological problems and to create more functional and balanced cognitive patterns that create less emotional distress and more helpful behaviours. CBT has strong evidence as an effective intervention for children and adolescents with emotional problems. The benefits for children with physical health and chronic conditions appear promising, although further research is required to substantiate these gains.

Brain Stimulation for Emotion Regulation in Adolescents With Psychiatric Disorders: Study Protocol for a Clinical-Transdiagnostical, Randomized, Triple-Blinded and Sham-Controlled Neurotherapeutic Trial

BACKGROUND

Anxiety, conduct and depressive disorders represent three highly prevalent psychiatric conditions in adolescents. A shared underpinning of these disorders is a shortcoming in emotion regulation, connected to the functioning of the ventromedial prefrontal cortex. Thus, an intervention able to target the suggested neural correlate seems to be highly desirable, aiming to hinder a maladaptive development of emotion regulation abilities and chronification of associated psychiatric disorders. As transcranial direct current stimulation (tDCS) was repeatedly demonstrated as a safe and non-invasive method to modulate specific brain activity, research is in demand to evaluate neurotherapeutic applications in adolescents with psychiatric disorders.

METHOD

This transdiagnostic, randomized, triple-blind and sham-controlled clinical neurostimulation trial primary aims to investigate if emotion regulation abilities are increased after tDCS in adolescents with psychiatric disorders. Secondly, disorder-specific changes in the anxiety, depression or conduct disorder will be investigated, as well as changes in quality of life, and cognitive and emotional functioning after tDCS intervention. We will include 108 adolescents with psychiatric disorders, displaying a substantial deficit in emotion regulation. Of these, one third each has to be primarily diagnosed with a depressive, anxiety or conduct disorder, respectively. Participants will be randomized to the experimental group (n = 54) receiving real anodal tDCS, or to the control group (n = 54) receiving sham tDCS. Brain stimulation will be applied for 20 min on five consecutive days twice targeting the ventromedial prefrontal cortex (vmPFC). Changes in emotion regulation, together with changes in disorder-specific clinical symptoms will be recorded by multi-informant psychological ratings. To inspect changes in behavior and gaze, computerized tasks and an eye tracker system will be used. Changes in brain responses to emotional and cognitive stimuli will be examined with three functional magnetic resonance imaging (fMRI) paradigms. In addition, a resting state MRI will be acquired to investigate possible changes in brain connectivity.

DISCUSSION

By investigating "emotion regulation" as transdiagnostic treatment target, this project is oriented toward the Research Domain Criteria framework with a dimensional view on mental illness. The study aims at investigating the potential of tDCS as non-invasive intervention for depressive, anxiety and conduct disorders in adolescents and broadening the scientific foundation for its clinical application.

CLINICAL TRIAL REGISTRATION

The study is ongoing and has been registered in the German Registry of Clinical Trials (DRKS-ID: DRKS00025601X) on the 28.06.2021.

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.

Editorial: The Cognitive Neuropsychological Hypothesis in Pediatric Anxiety and the Advantage of Revealing Early Changes in Brain Mechanisms Associated With Therapeutic Effects

There is a pressing need to improve treatment, and clinical trials should not only focus on efficacy, but also on identifying the underlying mechanisms through which treatments operate.¹ Treatment with a serotonergic antidepressant is commonly used to treat pediatric anxiety disorders, including generalized anxiety disorder (GAD). Serotonergic antidepressants require considerable time to induce clinically observed responses, and tolerability and efficacy are difficult to predict. Risk and precautions have been widely discussed and are weighed against urgent needs for interventions early in life that may prevent recurrent mental health complaints. Drug-induced molecular, cellular, and chemical effects result in neurocognitive changes, which are believed to occur before behavioral changes. Assessments of early neurocognitive changes may therefore be a powerful tool to reveal key mechanisms through which antidepressants work. When the neurofunctional mechanisms believed to cause the symptoms are restored, the clinical manifestation of symptom improvement is expected. The degree of symptom improvement should also follow the degree of positive changes in neurocognitive function. Many patients do not respond early enough in the course of symptom evolution,^2,3 and thus assessments of early neurocognitive mechanisms may guide treatment individualization during titration of doses and effects.

Gender differences in the associations of multiple psychiatric and chronic conditions with major depressive disorder among patients with opioid use disorder

PURPOSE

The study examined the associations of multiple psychiatric and chronic conditions with the self-reported history of major depressive disorder (MDD) among patients with opioid use disorder (OUD) and tested whether the associations differed by gender.

METHODS

We conducted a secondary data analysis of baseline data from a clinical trial including 1,646 participants with OUD, of which 465 had MDD. A variable cluster analysis was used to classify chronic medical and psychiatric conditions. Multivariable logistic regression analyses were used to estimate their associations with MDD in subjects with OUD.

RESULTS

Nine variables were divided into three clusters: cluster 1 included heart condition, hypertension, and liver problems; cluster 2 included gastrointestinal (GI) problems and head injury, and cluster 3 included anxiety disorder, bipolar disorder, and schizophrenia. The overall prevalence of MDD in participants with OUD was 28.3% (22.8% for males and 39.5% for females). Gender, anxiety disorder, schizophrenia, liver problems, heart condition, GI problems, and head injury were significantly associated with MDD. Gender-stratified analyses showed that bipolar disorder, liver problems and individuals with one chronic condition were associated with MDD only in males, whereas heart condition, hypertension, and GI problems were associated with MDD only in females. In addition, anxiety disorder, head injury, individuals with one or more than two psychiatric conditions, and individuals with more than two chronic conditions were associated with MDD regardless of gender.

CONCLUSIONS

Treatment plans in patients with OUD should not only address MDD but also co-morbid psychiatric and chronic medical conditions that occur with MDD.

Cognitive-behavioral therapy training for multidisciplinary inpatient psychiatric teams: A novel curriculum using animated simulations

PROBLEM

Nurses assume primary responsibility teaching children self-management skills, yet few of them have formal training in evidence-based treatments such as cognitive-behavioral therapy (CBT).

METHODS

We developed a novel CBT training curriculum specifically tailored for nurses and other child psychiatric inpatient team members. The curriculum was anchored in three components: (1) a structured manual; (2) instructional videos of common clinical scenarios using animated simulations; and (3) interactive role-play exercises. The CBT curriculum was implemented through small group training sessions. We then conducted focus group sessions with the 20 participants to assess change in self-reported knowledge of, and utilization of CBT skills in clinical practice.

FINDINGS

The curriculum was well received by staff members, who found its content relevant and applicable to their daily inpatient work. Staff reported four main themes: (1) routine clinical care (feelings, challenges, and approaches); (2) CBT utility in practice; (3) CBT training components that facilitated learning of the discrete skills; and (4) professional development needs.

CONCLUSIONS

We were able to implement the curriculum within the time and staffing constraints of a clinically active inpatient setting. Future refinements of the model will include videotaped interactions between expert clinicians and simulated patients in high acuity situations.

The impact of COVID-19 on the mental health of Canadian children and youth

Children and youth flourish in environments that are predictable, safe, and structured. The COVID-19 pandemic has disrupted these protective factors making it difficult for children and youth to adapt and thrive. Pandemic-related school closures, family stress, and trauma have led to increases in mental health problems in some children and youth, an area of health that was already in crisis well before COVID-19 was declared a global pandemic. Because mental health problems early in life are associated with significant impairment across family, social, and academic domains, immediate measures are needed to mitigate the potential for long-term sequalae. Now more than ever, Canada needs a national mental health strategy that is delivered in the context in which children and youth are most easily accessible—schools. This strategy should provide coordinated care across sectors in a stepped care framework and across a full continuum of mental health supports spanning promotion, prevention, early intervention, and treatment. In parallel, we must invest in a comprehensive population-based follow-up of Statistics Canada’s Canadian Health Survey on Children and Youth so that accurate information about how the pandemic is affecting all Canadian children and youth can be obtained. It is time the Canadian government prioritizes the mental health of children and youth in its management of the pandemic and beyond.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

OBJECTIVES

To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches.

SELECTION CRITERIA

We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 87 studies and 5964 participants in quantitative analyses. Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality). Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies). Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality). There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies) Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies). No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored. Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text. We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments.

AUTHORS' CONCLUSIONS

CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders

Anxiety disorders are among the most common psychiatric disorders in children and adolescents. As reviewed in this guideline, both cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRI) medication have considerable empirical support as safe and effective short-term treatments for anxiety in children and adolescents. Serotonin norepinephrine reuptake inhibitor (SNRI) medication has some empirical support as an additional treatment option. In the context of a protracted severe shortage of child and adolescent-trained behavioral health specialists, research demonstrating convenient, efficient, cost-effective, and user-friendly delivery mechanisms for safe and effective treatments for child and adolescent anxiety disorders is an urgent priority. The comparative effectiveness of anxiety treatments, delineation of mediators and moderators of effective anxiety treatments, long-term effects of SSRI and SNRI use in children and adolescents, and additional evaluation of the degree of suicide risk associated with SSRIs and SNRIs remain other key research needs.

Internet and Computer-Based Cognitive Behavioral Therapy for Anxiety and Depression in Adolescents and Young Adults: Systematic Review and Meta-Analysis

BACKGROUND

Anxiety and depressive disorders are prevalent in adolescents and young adults. However, most young people with mental health problems do not receive treatment. Computerized cognitive behavior therapy (cCBT) may provide an accessible alternative to face-to-face treatment, but the evidence base in young people is limited.

OBJECTIVE

The objective was to perform an up-to-date comprehensive systematic review and meta-analysis of the effectiveness of cCBT in treating anxiety and depression in adolescents and young adults compared with active treatment and passive controls. We aimed to examine posttreatment and follow-up effects and explore the moderators of treatment effects.

METHODS

We conducted systematic searches in the following six electronic databases: PubMed, EMBASE, PsycINFO, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials. We included randomized controlled trials comparing cCBT with any control group in adolescents or young adults (age 12-25 years) with anxiety or depressive symptoms. The quality of included studies was assessed using the Cochrane risk-of-bias tool for randomized trials, version 2.0. Overall quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Posttreatment means and SDs were compared between intervention and control groups, and pooled effect sizes (Hedges g) were calculated. Random-effects meta-analyses were conducted using Comprehensive Meta-Analysis software. Subgroup analyses and meta-regression analyses were conducted to explore whether age, guidance level, and adherence rate were associated with treatment outcome.

RESULTS

The search identified 7670 papers, of which 24 studies met the inclusion criteria. Most included studies (22/24) had a high risk of bias owing to self-report measures and/or inappropriate handling of missing data. Compared with passive controls, cCBT yielded small to medium posttreatment pooled effect sizes regarding depressive symptoms (g=0.51, 95% CI 0.30-0.72, number needed to treat [NNT]=3.55) and anxiety symptoms (g=0.44, 95% CI 0.23-0.65, NNT=4.10). cCBT yielded effects similar to those of active treatment controls regarding anxiety symptoms (g=0.04, 95% CI -0.23 to 0.31). For depressive symptoms, the nonsignificant pooled effect size favored active treatment controls (g=-0.70, 95% CI -1.51 to 0.11, P=.09), but heterogeneity was very high (I²=90.63%). No moderators of treatment effects were identified. At long-term follow-up, cCBT yielded a small pooled effect size regarding depressive symptoms compared with passive controls (g=0.27, 95% CI 0.09-0.45, NNT=6.58). No other follow-up effects were found; however, power was limited owing to the small number of studies.

CONCLUSIONS

cCBT is beneficial for reducing posttreatment anxiety and depressive symptoms in adolescents and young adults compared with passive controls. Compared with active treatment controls, cCBT yielded similar effects regarding anxiety symptoms. Regarding depressive symptoms, however, the results remain unclear. More high-quality research involving active controls and long-term follow-up assessments is needed in this population.

TRIAL REGISTRATION

PROSPERO CRD42019119725; https://tinyurl.com/y5acfgd9.

Leveraging Technology to Improve Health in Adolescence: A Developmental Science Perspective

As technologies continue to evolve at exponential rates, online platforms are becoming an increasingly salient social context for adolescents. Adolescents are often early adopters, savvy users, and innovators of technology use. This not only creates new vulnerabilities but also presents new opportunities for positive impact-particularly, the use of technology to promote healthy learning and adaptation during developmental windows of opportunity. For example, early adolescence appears to represent a developmental inflection point in health trajectories and in technology use in ways that may be strategically targeted for prevention and intervention. The field of adolescent health can capitalize on technology use during developmental windows of opportunity to promote well-being and behavior change in the following ways: (1) through a deeper understanding of the specific ways that developmental changes create new opportunities for motivation and engagement with technologies; (2) by leveraging these insights for more effective use of technology in intervention and prevention efforts; and (3) by combining developmental science-informed targeting with broader-reach technologic approaches to health behavior change at the population level (e.g., leveraging and changing social norms). Collaboration across disciplines-including developmental science, medicine, psychology, public health, and computer science-can create compelling innovations to use digital technology to promote health in adolescents.

Empowering Children with ASD and Their Parents: Design of a Serious Game for Anxiety and Stress Reduction

Autism Spectrum Disorder (ASD) is characterized by social interaction difficulties and communication difficulties. Moreover, children with ASD often suffer from other co-morbidities, such as anxiety and depression. Finding appropriate treatment can be difficult as symptoms of ASD and co-morbidities often overlap. Due to these challenges, parents of children with ASD often suffer from higher levels of stress. This research aims to investigate the feasibility of empowering children with ASD and their parents through the use of a serious game to reduce stress and anxiety and a supporting parent application. The New Horizon game and the SpaceControl application were developed together with therapists and according to guidelines for e-health patient empowerment. The game incorporates two mini-games with relaxation techniques. The performance of the game was analyzed and usability studies with three families were conducted. Parents and children were asked to fill in the Spence’s Children Anxiety Scale (SCAS) and Spence Children Anxiety Scale-Parents (SCAS-P) anxiety scale. The game shows potential for stress and anxiety reduction in children with ASD.

Psychotropic medication use trends in a large pediatric and young adult solid organ transplant population

INTRODUCTION

This study describes psychotropic medication use in a pediatric and young adult solid organ transplant population.

METHODS

We conducted a retrospective review of the lifetime incidence of psychotropic medication use and associated characteristics in patients seen over a 6-year period at a large pediatric transplant center utilizing univariate and multivariate statistical analyses.

RESULTS

The lifetime incidence of psychotropic medication use was 36.5% in 393 patients. Transplant psychiatry provided psychopharmacological consultation to 21.9% of patients. Controlling for age and sex, there were significant associations between psychotropic use and thoracic organ disease (heart/lung) (AOR = 2.14; 95% CI: 1.2-3.8; P = 0.01), White race (P = 0.0002), histories of depressive/mood disorders (AOR = 3.68; 95% CI: 1.8-7.7; P = 0.0005), attention/learning disorders (AOR = 3.30; 95% CI: 1.6-6.9; P = 0.001), acute and post-traumatic stress disorders (AOR = 10.54; 95% CI: 2.6-42.8; P = 0.001), and experiencing bullying (AOR = 2.16; 95% CI: 1.03-4.55; P = 0.04). In unadjusted tests, significant associations were found between lifetime psychotropic usage and patient anxiety history (OR = 2.26; 95% CI: 1.5-3.5; P = 0.0002), end-of-life disease progression (OR = 3.04; 95% CI: 1.7-5.4; P = 0.0002), family psychiatric history (OR = 2.17; 95% CI: 1.4-3.4; P = 0.0007), and adherence concerns (OR = 2.67; 95% CI: 1.7-4.1; P < 0.0001).

DISCUSSION

The lifetime incidence of psychotropic medication use among pediatric and young adult transplant patients is substantial. Patients with thoracic organ disease, end-of-life illness, individual/family psychiatric histories, trauma, and bullying histories have particularly high rates. Integrating child psychiatry as part of pediatric transplant teams should be an important consideration for the care of these patients.

Durability of Cognitive Behavioral Therapy Effects for Youth and Adolescents With Anxiety, Depression, or Traumatic Stress:A Meta-Analysis on Long-Term Follow-Ups

Cognitive behavioral therapies (CBT) for youth with anxiety, traumatic stress, and depression have demonstrated strong effects in individual studies and meta-analyses. Relatively more attention has been given to posttreatment effects, though, and assessment of follow-up effects has been limited at the meta-analytic level. The current meta-analysis aimed to (a) examine the effects of youth CBT at posttreatment, 1-month, 3-month, 6-month, 1-year, and long-term (2+ years) follow-up as well as (b) identify research-related variables (e.g., measure respondent type) that relate to effects. Using a random effects model across 110 child and adolescent CBT groups, within-group effect sizes were large at posttreatment (g = 1.24) and from 1-month through long-term follow-up (g = 1.23-1.82), and effect sizes did not significantly differ by treatment target (i.e., anxiety, traumatic stress, depression). However, availability of outcome data for effect sizes diminished across later follow-up assessments. Moreover, effect sizes were significantly associated with outcome respondent type across assessment timing, with outcome measures from caregiver and youth respondents associated with smaller effect sizes (B = -0.97, p < 0.001) relative to outcome measures that were evaluator-reported. Results provide initial support for the durability of treatment effects for youth CBTs and highlight the importance of some confounding variables. Implications for improving treatment research standards and prioritizing assessment of long-term follow-up assessment are discussed.

Psychopharmacology Utilization Among Children with Anxiety and Obsessive-Compulsive and Related Disorders Following Hurricane Katrina

This study aimed to examine the impact of Hurricane Katrina exposure on medication utilization among children with pre-existing anxiety and obsessive-compulsive and related disorders (OCRDs). Medicaid claims data from 2004 to 2006 were analyzed. Children with pre-existing anxiety/OCRDs were compared as a function of those living in a Louisiana disaster area, Louisiana non-disaster area, or Texas in terms of filled prescriptions and average days medication supply. This was further examined as a function of disorder/medication type. Prescriptions filled and average days medication supply were lower for those who resided in the disaster area of Louisiana relative to non-disaster zones in Texas (but not Louisiana). Children with OCD who lived in a disaster zone in Louisiana had 16.6 fewer days supply of antidepressants relative to youth in Texas. Similarly, children with PTSD who lived in a disaster zone in Louisiana had approximately 7 fewer days supply of stimulant medication relative to those who lived in Texas. Medication utilization was reduced for those youth directly exposed to Katrina relative to children in Texas, suggesting potential service disruption. Children with OCD and PTSD may be more likely to experience treatment disruption. Following disasters, particular attention should be given to ensuring continued treatment access for youth with pre-existing anxiety and OCRDs (as well as other conditions).

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

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

An appraisal of the trustworthiness of practice guidelines for depression and anxiety in children and youth

OBJECTIVE

Little is known about the trustworthiness of clinical practice guidelines (PGs) relevant to child and youth depression or anxiety. To address this gap, we used systematic review methods to identify all available relevant PGs, quality appraise them, and make recommendations regarding which PGs are trustworthy and should be used by clinicians.

METHODS

Prespecified inclusion criteria identified eligible PGs. Two independent trained reviewers applied the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Using three AGREE II domain scores (stakeholder involvement, rigor of development [clinical validity/trustworthiness], and editorial independence), PG quality was designated as (1) minimum (≥50%) and (2) high (≥70%).

RESULTS

Of 25 eligible PGs, five met minimum quality criteria (depression, n = 4; anxiety, n = 1); three out of five met high-quality criteria (depression, n = 2; anxiety, n = 1). Among the five minimum quality PGs, developers included government (n = 2), independent expert groups (n = 2), and other (n = 1). No PGs developed by specialty societies achieved minimum or high-quality ratings; eight of 25 PGs were up-to-date.

CONCLUSIONS

Trustworthy PGs are available to support clinical decisions about depression and anxiety in children and youth, but are few in number. Many existing PGs (up to 80%) may not be clinically valid. Clinicians who implement the high-quality PGs identified here can increase the number of children and youth who receive effective interventions for depression and anxiety, minimize harm, and avoid wasted resources. Clinicians, service planners, youth, and their families should encourage PG developers to increase the pool of high-quality PGs using internationally recognized PG development standards.