Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial

Moderators of cognitive and behaviour therapies for prevention and treatment of anxiety disorders in children and adolescents: A systematic review and meta-analysis

Previous studies have indicated wide variation in the effectiveness of cognitive and behaviour therapies (CBTs) for preventing and treating anxiety disorders in children and adolescents, indicating the presence of moderators influencing outcomes. This meta-analysis investigated whether sample characteristics (child age, child baseline anxiety levels, parental baseline anxiety levels) and intervention characteristics (intervention duration, facilitator contact time, facilitator background, delivery formats, parental involvement) moderate the effectiveness of CBTs for universal prevention, targeted prevention, and treatment of anxiety disorders in children and adolescents. We identified 86 eligible randomized controlled trials (RCTs) assessing the effectiveness of 98 CBTs versus non-active controls. Effect sizes were the post-intervention standardized mean difference of children's broad anxiety symptoms between CBT and non-active controls. Moderation analyses were conducted separately on child- and parent-reported outcomes using meta-regression and subgroup analyses. We found some evidence for (1) a moderating role of child age, facilitator background, and parental involvement on the effectiveness of CBTs for universal prevention; (2) a moderating role of child age and intervention duration on the effectiveness of CBTs for targeted prevention; (3) a moderating role of child age, facilitator contact time, and delivery formats on the effectiveness of CBTs for treatment. There was no evidence for a moderating role of child baseline anxiety levels on the effectiveness of CBTs for universal/targeted prevention or treatment. The moderating role of parental baseline anxiety levels and its potential interaction with parental involvement was not tested given the limited available data. Although these findings provide insights into the question of what works for whom, they should be interpreted cautiously given the limited available data, wide variation in outcomes, potential confounders, and discrepancies between child- and parent-reported outcomes.

An Exploratory Analysis of Child Characteristics Predicting Clinical Outcomes in Parent-Led Cognitive Behavioral Teletherapy for Anxiety in Autistic Children

Parent-led cognitive behavioral therapy (CBT) is an efficient, promising form of therapy that may be well suited for autistic youth with anxiety disorders. A recent clinical trial found that parent-led CBT - in which parents led their child through a guided CBT workbook with varying degrees of therapist support - was efficacious for reducing anxiety and associated functional impairment. While such findings demonstrate promise for future intervention development and dissemination efforts with this population, more work is needed to elucidate clinical factors that impact response to treatment as well as drop-out. Using data from the aforementioned clinical trial (N = 87), the present exploratory study examined pre-treatment patient characteristics, including family accommodation (FA), anxiety severity, autism features, and externalizing psychopathology, and their relationship with relevant treatment outcomes (i.e., anxiety severity and functional impairment) at both post-treatment and three-month follow-up and drop-out/completer status. Our findings did not reveal any consistent relations between pre-treatment patient characteristics and clinical outcomes, with several isolated exceptions: (a) baseline autism features were associated with greater post-treatment functional impairment; (b) non-male (vs. male) gender was associated with greater functional impairment at 3-month follow-up; and (c) Hispanic ethnicity (vs. non-Hispanic) was associated with greater likelihood of premature treatment drop-out. Findings are discussed in the context of the importance of continuing to elucidate unique patient characteristics predictive of optimal clinical outcomes for autistic youth with anxiety disorders.

Electronically Monitored Antidepressant Adherence in Adolescents with Anxiety Disorders: A Pilot Study

Background: Antidepressant medication adherence patterns are inconsistent in adolescents with anxiety and related disorders, and the clinical and demographic features predicting adherence are poorly understood. Methods: In an ongoing single-site prospective trial involving adolescents (aged 12-17) with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition anxiety disorders treated with escitalopram, adherence was measured for 12 weeks using electronic monitoring caps. Adherence patterns were examined using qualitative and unsupervised clustering approaches, and predictors of adherence were evaluated using logistic regression, with demographic (age, sex, and race) and clinical variables (e.g., anxiety severity [Pediatric Anxiety Rating Scale], irritability [Affective Reactivity Index], depressive symptoms [Children's Depression Rating Scale]). Results: Among adolescents (N = 33) aged 14.5 ± 1.8 years (64% female), four adherence patterns were identified: persistent adherence, intermittent adherence, early adherence-late nonadherence, and nonadherence. In a logistic model of a 5-day moving average measure of adherence, social anxiety disorder (β = -0.68 ± 0.19, p = 0.002) and separation anxiety disorder (β = -0.61 ± 0.18, p < 0.001) were associated with lower adherence. In contrast, panic disorder, attention-deficit/hyperactivity disorder, generalized anxiety disorder, and depressive symptoms were not associated with adherence. Baseline anxiety severity was linked to lower adherence (β = -0.199 ± 0.05, p < 0.001). Older age also reduced adherence (β = -0.342 ± 0.05, p < 0.001), with each additional year of age increasing time spent nonadherent by 5% (p < 0.001). Being female (β = 0.451 ± 0.17, p = 0.011) and expecting treatment to be efficacious (β = 0.092 ± 0.04, p = 0.011) increased adherence, while greater irritability was associated with nonadherence (β = -0.075 ± 0.03, p = 0.006). Conclusions: Antidepressant adherence is variable, with distinct patterns, and those with social and separation anxiety disorders were less likely to be adherent. Factors such as older age, severe anxiety, and greater irritability predicted lower adherence, while being female and expecting treatment efficacy were associated with better adherence. Interventions that address specific symptoms or enhance treatment expectations may improve adherence.

Patterns of sub-optimal change following CBT for childhood anxiety

BACKGROUND

Children and adolescents demonstrate diverse patterns of symptom change and disorder remission following cognitive behavioural therapy (CBT) for anxiety disorders. To better understand children who respond sub-optimally to CBT, this study investigated youths (N = 1,483) who continued to meet criteria for one or more clinical anxiety diagnosis immediately following treatment or at any point during the 12 months following treatment.

METHODS

Data were collected from 10 clinical sites with assessments at pre-and post-treatment and at least once more at 3, 6 or 12-month follow-up. Participants were assigned to one of three groups based on diagnostic status for youths who: (a) retained an anxiety diagnosis from post to end point (minimal responders); (b) remitted anxiety diagnoses at post but relapsed by end point (relapsed responders); and (c) retained a diagnosis at post but remitted to be diagnosis free at end point (delayed responders). Growth curve models assessed patterns of change over time for the three groups and examined predictors associated with these patterns including demographic, clinical and parental factors, as well as treatment factors.

RESULTS

Higher primary disorder severity, being older, having a greater number of anxiety disorders, having social anxiety disorder, as well as higher maternal psychopathology differentiated the minimal responders from the delayed and relapsed responders at the baseline. Results from the growth curve models showed that severity of the primary disorder and treatment modality differentiated patterns of linear change only. Higher severity was associated with significantly less improvement over time for the minimal and relapsed response groups, as was receiving group CBT, when compared to the delayed response group.

CONCLUSIONS

Sub-optimal response patterns can be partially differentiated using variables assessed at pre-treatment. Increased understanding of different patterns of change following treatment may provide direction for clinical decision-making and for tailoring treatments to specific groups of clinically anxious youth. Future research may benefit from assessing progress during treatment to detect emerging response patterns earlier.

Behavioral Inhibition and Social Anxiety Disorder as Predictors of Long-Term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders

The temperamental trait behavioral inhibition (BI) is related to the development and maintenance of anxiety, particularly much so to social anxiety disorder. We investigated if BI and social anxiety disorder predicted cognitive behavioral therapy (CBT) outcomes for youth anxiety. Youth (N = 179; Mage = 11.6 years) were assessed 4 years following a randomized controlled CBT effectiveness trial. BI was measured by the parent-reported Behavioral Inhibition Questionnaire at baseline. The outcomes were diagnostic recovery, youth- and parent-reported anxiety symptoms, and clinical severity at post-treatment, 1-year, and 4-year follow-up. Having social anxiety disorder negatively predicted diagnostic recovery and predicted higher clinical severity at all assessment points and was the only significant predictor of outcomes at 4-year follow-up. Higher BI negatively predicted diagnostic recovery and predicted higher clinical severity and parent-reported symptom levels at post-treatment and 1-year follow-up, and predicted higher youth-reported anxiety levels at 1-year follow-up. Higher BI was the only predictor of youth- and parent-reported anxiety symptoms. BI and social anxiety disorder seem to be unique predictors of CBT outcomes among youth with anxiety disorders. CBT adaptations may be indicated for youth with high BI and social anxiety disorder.

Respiratory Sinus Arrhythmia, Effortful Control, and Child Social Anxiety Symptoms

Emotion dysregulation is implicated in child social anxiety and its etiology. Child emotion dysregulation has been studied via physiological indicators (e.g., respiratory sinus arrhythmia [RSA]) and behavioral indicators (e.g., effortful control). Previous work suggests that physiological indicators of regulation may predict outcomes in a non-linear manner and must be considered within the context of other intrapersonal factors, perhaps including effortful control. To this end, the current study tested effortful control as a moderator of the relation between RSA and child social anxiety, considering both linear and curvilinear patterns and controlling for inhibited temperament, an established predictor of child anxiety. Children (n = 119; 44% female) participated when they were 4 years old and entering school age (5 to 7 years). Mothers reported on children's effortful control (age 4) and social anxiety (school age). Children's RSA (age 4) was calculated from electrocardiogram data when they were at rest (i.e., baseline RSA) and when they were giving a speech. Results indicated that when children were high in effortful control, lower baseline RSA predicted higher social anxiety symptoms. Tentative evidence emerged for a relation between greater suppression of RSA during the speech compared to baseline and higher social anxiety symptoms when children were low in effortful control. Results support assessing the temperamental domain of effortful control as a contextualizing factor in the relation between psychophysiology and child anxiety outcomes.

Efficacy of a Cognitive‑Behavioral Anxiety Management Program Integrated Within a Reading Intervention

This study examined the efficacy of a 2-year anxiety management intervention integrated with a reading intervention for struggling readers in upper-elementary grades on anxiety outcomes. The study randomly assigned 128 struggling readers to one of three conditions: (a) reading intervention with anxiety management intervention (RANX), (b) reading intervention with math fact practice, an attention control, (RMATH), and (c) business-as-usual comparison (BaU). Findings demonstrated promising results for students in the RANX condition, particularly compared with the BaU condition. However, findings were not always statistically significant suggesting the need for additional adequately powered trials. Secondary analyses among students beginning with average anxiety showed significant reductions in physical symptoms of anxiety at year 1 posttest favoring RANX over RMATH and BAU, as well as between RANX and BAU on reading anxiety at year 2 posttest. Among students beginning with elevated anxiety, significant reductions in social anxiety were found at year 2 posttest favoring RANX over RMATH and BaU. The findings underscore the promise of integrating anxiety management and reading interventions.

Boundaries on Parent Involvement in Their Child's Anxiety Cognitive-Behavioral-Treatment Outcome: Parent Reinforcement and Relationship Behaviors Moderate Outcome

Extending a recent parent mediation efficacy trial, we identified parent reinforcement and relationship behaviors as setting boundary conditions, or moderators, of youth anxiety outcome in 254 youths and their parents, who were randomized to: (1) Cognitive Behavioral Treatment (CBT) with parent reinforcement behavior training (CBT + Reinf); (2) CBT with parent relationship behavior training (CBT + Relat); or (3) individual youth CBT - a comparator control arm. Findings revealed that parents with high baseline negative reinforcement levels and acceptance levels (i.e., above the mean) report their children as having lower anxiety at outcome, when assigned to CBT + Reinf, and CBT + Relat, respectively, versus CBT. No moderation effects were found for either parent positive reinforcement or parent psychological control. Implications for treating anxiety disorders and moving toward precision treatment approaches in youth are discussed, and the importance of research replication and extension.

A Comparison of Telehealth and In-Person Therapy for Youth Anxiety Disorders

OBJECTIVE

At the onset of the COVID-19 pandemic, telehealth service use increased. However, little research has compared the efficacy of individual cognitive behavioral therapy (CBT) for youth with anxiety administered via (a) telehealth and (b) in-person. The present study used non-inferiority analyses to examine outcomes for youth with anxiety disorders (diagnosed by an Independent Evaluator; IE) treated via telehealth during the COVID-19 pandemic and youth treated via in-person therapy prior to the COVID-19 pandemic.

METHOD

Participants (n = 92; Mage = 11.5 years; 60.1% female; 75.0% White) were 46 youth who completed telehealth treatment and 46 youth who completed services in-person, matched on age and principal anxiety diagnosis. One-sided t-tests for non-inferiority were first estimated. Next, ANOVAs and regression models were performed, examining treatment differences and candidate moderators (e.g. social anxiety disorder, comorbid attention problems).

RESULTS

Results support non-inferiority across multiple indices of outcomes (i.e. self- and caregiver-reported anxiety symptoms, IE-rated functional impairment, and IE-rated treatment response). Analyses indicate that both treatments were effective in reducing anxiety symptoms and functional impairment. Caregivers reported higher post-treatment levels of anxiety for youth treated via telehealth than youth treated in person. No variables moderated the differences in outcomes between treatment modalities.

CONCLUSIONS

Findings support that CBT administered via telehealth is similarly efficacious as CBT administered in-person for youth with anxiety. Implications regarding the availability and accessibility of evidence-based treatment for youth with anxiety are discussed.

Cognitive Behavioral Therapy for Anxiety and Depression in Children and Adolescents

Anxiety and depression are prevalent and impairing psychiatric problems for children and adolescents. In this review, the authors summarize information about their prevalence and impact, the most common assessment methods, the main components of cognitive behavioral therapy (CBT), and research on the effectiveness of CBT for these disorders. Future directions, including improving access to CBT through technology-based approaches and increasing personalization of treatment, are discussed.

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

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

CBT+ Training Initiative in Washington State Community Mental Health: An Evaluation of Child Clinical Outcomes

The Washington State CBT+  Initiative offers a flexible training and consultation approach for community mental health providers in evidence-based practices for four child mental health targets: cognitive behavioral therapy for depression, anxiety, trauma, and behavioral difficulties. As part of consultation, clinicians used an online system to track delivery of treatment components and clinical outcomes using standardized symptom measures. The current study used these clinician-input data to examine symptom change for children using paired sample t-tests. Additionally, we explored if time elapsed or number of sessions between measurements related to symptom change using simple linear regression. Children had significant symptom reduction across all four targets. For most measures, children did not show greater improvements with increased length of time or increased number of sessions between assessment measures. Findings suggest that children treated by a CBT+  trained clinician may demonstrate symptom reduction for their primary clinical problem. Findings add to support for flexible training approaches for community mental health clinicians.

Asthma and anxiety in children and adolescents: characteristics and treatment outcomes

OBJECTIVE

This study (a) examined anxious youth with and without asthma on measures of negative self-talk, parental psychopathology, worry content, physical symptoms, panic symptoms, generalized symptoms, and separation anxiety symptoms, and (b) tested if outpatient CBT or medication were differentially effective in reducing anxiety for youth with asthma and anxiety.

METHODS

This secondary analysis separated youth with an anxiety disorder into asthma and non-asthma groups. Youth were also compared on response to treatments (i.e. CBT, sertraline, combined, and placebo).

RESULTS

A total of 488 participants participated in the original study, with an average age of 10 years (SD 2.87). Youth with comorbid asthma and anxiety demonstrated higher rates of negative self-talk. Youth with comorbid asthma and anxiety did not differ from the non-asthma group on measures of physical symptoms, anxiety disorder specific symptoms, parental psychopathology, or worry content. Youth with asthma and anxiety responded similarly to the non-asthma group to treatment across treatment conditions.

CONCLUSIONS

Treatment was comparably effective for youth with comorbid asthma and anxiety and youth with anxiety. Future research could examine the effects of psychopharmaceuticals on asthma and anxiety comorbidity.

Normalization of Fronto-Parietal Activation by Cognitive-Behavioral Therapy in Unmedicated Pediatric Patients With Anxiety Disorders

OBJECTIVE

Anxiety disorders are prevalent among youths and are often highly impairing. Cognitive-behavioral therapy (CBT) is an effective first-line treatment. The authors investigated the brain mechanisms associated with symptom change following CBT.

METHODS

Unmedicated youths diagnosed with an anxiety disorder underwent 12 weeks of CBT as part of two randomized clinical trials testing the efficacy of adjunctive computerized cognitive training. Across both trials, participants completed a threat-processing task during functional MRI before and after treatment. Age-matched healthy comparison youths completed two scans over the same time span. The mean age of the samples was 13.20 years (SD=2.68); 41% were male (youths with anxiety disorders, N=69; healthy comparison youths, N=62). An additional sample including youths at temperamental risk for anxiety (N=87; mean age, 10.51 years [SD=0.43]; 41% male) was utilized to test the stability of anxiety-related neural differences in the absence of treatment. Whole-brain regional activation changes (thresholded at p<0.001) were examined using task-based blood-oxygen-level-dependent response.

RESULTS

Before treatment, patients with an anxiety disorder exhibited altered activation in fronto-parietal attention networks and limbic regions relative to healthy comparison children across all task conditions. Fronto-parietal hyperactivation normalized over the course of treatment, whereas limbic responses remained elevated after treatment. In the at-risk sample, overlapping clusters emerged between regions showing stable associations with anxiety over time and regions showing treatment-related changes.

CONCLUSIONS

Activation in fronto-parietal networks may normalize after CBT in unmedicated pediatric anxiety patients. Limbic regions may be less amenable to acute CBT effects. Findings from the at-risk sample suggest that treatment-related changes may not be attributed solely to the passage of time.

Selective mutism in immigrant families: An ecocultural perspective

Although the diagnosis of selective mutism (SM) is more prevalent among immigrant children, the link between the disorder and an immigration background has been elusive. Guided by ecocultural models of development, the current study aimed to construct a theory-based description of SM while considering individual, family, and contextual risk factors. Participants were 78 children with SM (38.4% with an immigration background), and 247 typically developed children (18.2% with an immigration background). Consistent with previous studies, our results suggest that anxiety was the most important predictor of SM symptoms, above and beyond immigration background. Immigration, especially if coupled with bilingual status and low family income, predicted increased levels of SM symptoms. Identifying multi-level predictors of SM may help researchers and clinicians to improve early identification and treatment of SM in culturally and linguistically diverse children.

Evaluating the development and well-being assessment (DAWBA) in pediatric anxiety and depression

Enhancing screening practices and developing scalable diagnostic tools are imperative in response to the increasing prevalence of youth mental health challenges. Structured lay psychiatric interviews have emerged as one such promising tool. However, there remains limited research evaluating structured psychiatric interviews, specifically their characterization of internalizing disorders in treatment-seeking youth. This study evaluates the relationship between the Development and Well-Being Assessment (DAWBA), a structured psychiatric interview, and established measures of pediatric anxiety and depression, including the Screen for Child Anxiety Related Disorders (SCARED), the Pediatric Anxiety Rating Scale (PARS), and the Mood and Feelings Questionnaire (MFQ). The study comprised two independent clinical samples of treatment-seeking youth: sample one included 55 youth with anxiety and 29 healthy volunteers (HV), while sample two included 127 youth with Major Depressive Disorder and 73 HVs. We examined the association between the DAWBA band scores, indicating predicted risk for diagnosis, the SCARED and PARS (sample one), and the MFQ (sample two). An exploratory analysis was conducted in a subset of participants to test whether DAWBA band scores predicted the change in anxiety symptoms (SCARED, PARS) across a 12-week course of cognitive behavioral therapy. The results revealed that the DAWBA significantly predicted the SCARED, PARS and MFQ measures at baseline; however, it did not predict changes in anxiety symptoms across treatment. These findings suggest that the DAWBA may be a helpful screening tool for indexing anxiety and depression in treatment-seeking youth but is not especially predictive of longitudinal trajectories in symptomatology across psychotherapy.

Assessing Anxiety-Related Impairment in Children and Adolescents

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

Increasing the Efficacy of Treatment for Socially Anxious Youth Through Theoretically Derived Improvements: A Pilot Study

Cognitive behavioural therapy is the first line of treatment for social anxiety disorder; however, children with social anxiety disorder do not respond as well to generic cognitive behavioural therapy programs, compared to children with other anxiety disorders. The aim of the study was to provide a preliminary examination of the efficacy and applicability of a new disorder specific intervention for children with social anxiety disorder. Five children aged 7-13 years, with a primary or secondary DSM-5 diagnosis of social anxiety disorder were provided with an adapted version of the Cool Kids anxiety program. Three out of the five children were in remission from social anxiety disorder at the end of the intervention and at 3-month follow-up. Statistically significant improvements were also noted in overall anxiety symptoms and functioning. Preliminary evidence was found for the efficacy of a social anxiety version of the Cool Kids program.

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

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

Predictors and Moderators of Treatment Outcomes for Anxious Children Randomized to Computer-Assisted Cognitive Behavioral Therapy or Standard Community Care

Introduction: Computer-assisted cognitive behavioral therapy (CCBT) for childhood anxiety disorders may aid the dissemination of CBT, while maintaining treatment fidelity. Although CCBT is an effective intervention, not everyone benefits equally from treatment. Identifying patient characteristics that predict who will benefit from treatment and to what extent can help with matching patients to suitable interventions, and allow researchers and clinicians to modify, and individualize, their treatment formats more effectively. Such predictors and moderators have not yet been examined for CCBT outcomes in anxious children and studies of more traditional treatment formats have yielded inconsistent results. Methods: Using data from a randomized clinical trial evaluating CCBT for children with anxiety disorders, this study examined predictors and moderators of treatment outcomes in a sample of 100 children (age: mean [M] = 9.82, standard deviation [SD] = 1.82), randomized to either CCBT (n = 49) or standard community care (n = 51). Potential predictors and moderators were identified from the literature and examined in stepwise multiple linear regression models, using posttreatment anxiety severity and global impairment as outcomes. Results: Parent-rated internalizing symptoms predicted posttreatment anxiety severity for both treatment groups. High pretreatment levels of anxiety severity predicted higher global impairment at posttreatment for the group receiving community care, but not for the CCBT group. Conclusion: Further research is needed to clarify which patient characteristics are associated with CCBT outcomes in a consistent way. ClinicalTrials.gov identifier: NCT01416805.

Cognitive Behavioral Therapy for Children and Adolescents with Anxiety Disorders

Anxiety disorders are the most common class of psychiatric conditions among children and adolescents. The cognitive behavioral model of childhood anxiety has a strong theoretic and empirical foundation that provides the basis for effective treatment. Cognitive behavioral therapy (CBT), with an emphasis on exposure therapy, is the gold standard treatment for childhood anxiety disorders, with strong empirical support. A case vignette demonstrating CBT for childhood anxiety disorders in practice, as well as recommendations for clinicians, are also provided.

The current state-of-the-art in pharmacotherapy for pediatric generalized anxiety disorder

INTRODUCTION

Anxiety disorders are the most prevalent psychiatric disorders among youth. Among the various anxiety disorders, generalized anxiety disorder is particularly prevalent. Youth with GAD appear at elevated risk of developing other anxiety disorders, mood disorder, and substance use disorders. Functional outcomes of youth with GAD can be improved through early recognition and treatment, thus promoting better longer-term outcomes.

AREAS COVERED

The current article summarizes evidence-based state-of-the-art pharmacotherapy for pediatric GAD based on open-label, randomized, and controlled trials. Two electronic databases (PubMed and Scopus) were systematically searched in April 2022 for relevant publications.

EXPERT OPINION

The literature supports a combination of psychotherapy and pharmacotherapy as being associated with better outcomes when compared to mono-therapies. While longer-term follow-ups are limited, one such study does challenge this notion. Both selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) have been found across studies to have moderate effect sizes in the treatment of pediatric anxiety disorders. SSRIs continue to be a first-line intervention, whereas SNRIs may be considered a second-line treatment. While more evidence is needed, there are emerging data indicating that SSRIs are associated with a more rapid and greater reduction in anxiety symptoms when compared to SNRIs.

A Multicenter Double-Blind, Placebo-Controlled Trial of Escitalopram in Children and Adolescents with Generalized Anxiety Disorder

Objective: Generalized anxiety disorder (GAD) in children and adolescents is associated with substantial morbidity and increases the risk of future psychopathology. However, relatively few psychopharmacologic studies have examined treatments for GAD in pediatric populations, especially in prepubertal youth. Methods: Children and adolescents aged 7-17 years of age with a primary diagnosis of GAD were treated with flexibly dosed escitalopram (10-20 mg daily, n = 138) or placebo (n = 137) for 8 weeks. Efficacy measures included the Pediatric Anxiety Rating Scale (PARS) for GAD, Clinical Global Impression of Severity (CGI-S) scale, Children's Global Assessment Scale (CGAS); safety measures included the Columbia-Suicide Severity Rating Scale (C-SSRS) as well as adverse events (AEs), vital signs, and electrocardiographic and laboratory monitoring. Results: Escitalopram was superior to placebo in reducing anxiety symptoms of GAD, as seen in the difference in mean change from baseline to week 8 on the PARS severity for GAD score (least squares mean difference = -1.42; p = 0.028). Functional improvement, as reflected by CGAS score, was numerically greater in escitalopram-treated patients compared with those receiving placebo (p = 0.286), and discontinuation owing to AEs did not differ between the two groups. Vital signs, weight, laboratory, and electrocardiographic results were consistent with previous pediatric studies of escitalopram. Conclusions: Escitalopram reduced anxiety symptoms and was well tolerated in pediatric patients with GAD. These findings confirm earlier reports of escitalopram efficacy in adolescents aged 12-17 years and extend the safety and tolerability data to children with GAD aged 7-11 years. ClinicalTrials.gov Identifier: NCT03924323.

Vitamin B12, Folate, Homocysteine, Inflammatory Mediators (Interleukin-6, Tumor Necrosis Factor-α and C-Reactive Protein) Levels in Adolescents with Anxiety or Depressive Symptoms

Purpose

To evaluate the prevalence of abnormal vitamin B12, folate, total homocysteine (tHcy), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), C-reactive protein (CRP) levels, to analyze the relationship between these parameters and the severity of anxiety or depressive symptoms, and to explore the possible factors associated with abnormal levels of these parameters in adolescents with anxiety or depressive symptoms.

Methods

Adolescent (aged 12-18 years) outpatients with anxiety or depressive symptoms were recruited. The patient health questionnaire-9 and generalized anxiety disorder scale-7 were used to measure the severity of depression and anxiety. Serum vitamin B12, folate, tHcy, IL-6, TNF-α, and CRP levels were determined.

Results

128 subjects were recruited. The prevalence of vitamin B12 and folate deficiency, tHcy, TNF-α, IL-6, and CRP elevation was 8.6%, 10.2%, 25.8%, 14.8%, 21.9%, and 10.2%, respectively, in adolescents with anxiety or depressive symptoms. Lower vitamin B12 levels were correlated with a higher risk of severe anxiety and depressive symptoms. The severity of some symptoms of anxiety or depression were weakly correlated with vitamin B12, folate, tHcy, IL-6, and CRP levels. Vitamin B12, folate, and tHcy levels were not associated with inflammatory mediators. Vitamin B12 deficiency was associated with older age and higher tHcy levels. Folate deficiency was associated with elevated tHcy. Elevated tHcy was associated with lower vitamin B12 and folate levels. IL-6 elevation was associated with elevated CRP and TNF-α. CRP elevation was associated with older age, higher BMI, and current drinking.

Conclusion

Lower vitamin B12 levels were correlated with a higher risk of severe anxiety or depressive symptoms. Weak correlations were observed between the severity of some symptoms of anxiety or depression and vitamin B12, folate, tHcy, IL-6, and CRP levels. Vitamin B12, folate, and tHcy levels were related to each other. IL-6 elevation was associated with elevated CRP and TNF-α. CRP elevation was associated with older age, higher BMI, and current drinking.

Effect of pharmacogenomic testing on pediatric mental health outcome: a 6-month follow-up

Aim: This retrospective, case-control study evaluated the effect of pharmacogenomic testing (PGT) on the management of pediatrics with anxiety, major depressive disorder (MDD) and attention-deficit/hyperactivity disorder (ADHD). Methods: The authors examined psychiatric diagnoses, medication histories, CYP450 profiles, SLC6A4, HTR2A, COMT and MTHFR. Results: The authors found no difference in clinical improvement between the two groups. However, the number of medication changes was significantly larger after PGT. The treatment response in MDD and anxiety was not different between the groups, while ADHD treatment response was substantially improved in PGT and correlated with COMT status. Conclusion: PGT had some value with ADHD with doubtful benefit for MDD or anxiety disorders. Accordingly, pediatric indications must be weighed against cost, utility and clinician experience. Limitations included sample size and selection bias.

Clinical, demographic and theory-derived maintaining factors as moderators of treatment outcome in internet-delivered cognitive behavioural therapy for children and adolescents with social anxiety disorder

Internet-delivered cognitive behavioural therapy (ICBT) is an efficacious treatment for social anxiety disorder (SAD) in youth. However, we have limited knowledge about patient characteristics that may be associated with better (or worse) treatment outcome. Particularly concerning factors suggested to be involved in the maintenance of SAD (e.g., anticipatory anxiety and post-event processing). The aim of the current study was to evaluate possible predictors and moderators of the effect of ICBT in a randomised controlled trial where children and adolescents (N = 103; 10-17 years) with SAD received either ICBT or internet-delivered supportive therapy, ISUPPORT. Examined variables were pre-treatment levels of social anxiety, depression symptoms, putative maintaining factors as well as demographic variables like age and gender. Latent growth curve models were used to examine predictors and moderators of changes in youth and clinician rated social anxiety symptoms, from pre-treatment to 3-month follow-up. Baseline depression symptoms moderated the outcome, with higher depression scores being associated with greater reduction of SAD symptoms in ICBT compared to ISUPPORT. More difficulties at baseline with anticipatory anxiety, post-event processing, focus of attention and safety behaviours predicted greater reduction of SAD symptoms, regardless of treatment condition. No other clinical or demographic variable predicted or moderated the outcome. In summary, baseline depression severity may be an important moderator of ICBT, but the preliminary finding needs replication in sufficiently powered trials.

Screening for Anxiety in Children and Adolescents: Evidence Report and Systematic Review for the US Preventive Services Task Force

Importance

Anxiety in children and adolescents is associated with impaired functioning, educational underachievement, and future mental health conditions.

Objective

To review the evidence on screening for anxiety in children and adolescents to inform the US Preventive Services Task Force.

Data Sources

PubMed, Cochrane Library, PsycINFO, CINAHL, and trial registries through July 19, 2021; references, experts, and surveillance through June 1, 2022.

Study Selection

English-language, randomized clinical trials (RCTs) of screening; diagnostic test accuracy studies; RCTs of cognitive behavioral therapy (CBT) or US Food and Drug Administration-approved pharmacotherapy; RCTs, observational studies, and systematic reviews reporting harms.

Data Extraction and Synthesis

Two reviewers assessed titles/abstracts, full-text articles, and study quality and extracted data; when at least 3 similar studies were available, meta-analyses were conducted.

Main Outcomes and Measures

Test accuracy, symptoms, response, remission, loss of diagnosis, all-cause mortality, functioning, suicide-related symptoms or events, adverse events.

Results

Thirty-nine studies (N = 6065) were included. No study reported on the direct benefits or harms of screening on health outcomes. Ten studies (n = 3260) reported the sensitivity of screening instruments, ranging from 0.34 to 1.00, with specificity ranging from 0.47 to 0.99. Twenty-nine RCTs (n = 2805) reported on treatment: 22 on CBT, 6 on pharmacotherapy, and 1 on CBT, sertraline, and CBT plus sertraline. CBT was associated with gains on several pooled measures of symptom improvement (magnitude of change varied by outcome measure), response (pooled relative risk [RR], 1.89 [95% CI, 1.17 to 3.05]; n = 606; 6 studies), remission (RR, 2.68 [95% CI, 1.48 to 4.88]; n = 321; 4 studies), and loss of diagnosis (RR range, 3.02-3.09) when compared with usual care or wait-list controls. The evidence on functioning for CBT was mixed. Pharmacotherapy, when compared with placebo, was associated with gains on 2 pooled measures of symptom improvement-mean difference (Pediatric Anxiety Rating Scale mean difference, -4.0 [95% CI, -5.5 to -2.5]; n = 726; 5 studies; and Clinical Global Impression-Severity scale mean difference, -0.84 [95% CI, -1.13 to -0.55]; n = 550; 4 studies) and response (RR, 2.11 [95% CI, 1.58 to 2.98]; n = 370; 5 studies)-but was mixed on measures of functioning. Eleven RCTs (n = 1293) reported harms of anxiety treatments. Suicide-related harms were rare, and the differences were not statistically significantly different.

Conclusions and Relevance

Indirect evidence suggested that some screening instruments were reasonably accurate. CBT and pharmacotherapy were associated with benefits; no statistically significant association with harms was reported.

The psychometric properties of the of the Persian version of the Screen for adult anxiety related disorders (SCAARED) in patients with anxiety disorders

BACKGROUND

The aim of this study was to investigate the psychometric properties of the Persian version of the Screen for adult anxiety related disorders (SCAARED) in Tehran.

METHOD

The present study was a descriptive-survey method and a cross-sectional method. The present research population consists of patients referring to hospitals and psychiatric clinics in Tehran, as well as male and female students in Tehran. The sample of the present study included 300 participants (150 patients with a diagnosis of anxiety disorders and 150 non-clinical samples), who were selected by random sampling method. Inclusion criteria included age 18 to 50, minimum diploma, lack of mental retardation, and lack of acute physical illnesses such as cancer or severe pain. The participants, after completing the demographic questionnaire and conducting a Structured Clinical Interview for DSM-5 Disorders-Clinical Version (SCID-5-CV), completed the SCAARED and the Personal Wellbeing Index-Adults (PWI-A). Finally, face and content validity and construct validity, test-retest reliability, Cronbach's alpha, and factor analysis were used.

RESULTS

The results of the present study confirmed the face validity and content of the present scale. A review of Cronbach's standardized alpha showed that SCAARED has a reliability of 0.966, and therefore, the Persian version of these questionnaires is a reliable tool. Also, the results showed a correlation between the two implementations of the questionnaire; in addition to the strong correlation at the level (p < .01) between the factors of the questionnaire and the factors with the total score, there was a strong correlation between the first and second implementation in four factors and the overall score. Therefore, it can be concluded that the SCAARED has good test-retest reliability. Also, there is a positive correlation between the factors and the overall score of the SCAARED with anxiety disorders based on Structured Clinical Interview for DSM-5 Disorders (p < .01), which indicates the favorable convergent validity of the SCAARED questionnaire. There is a negative correlation between the factors and the overall score of the SCAARED with the PWI-A at the level (p < .01), which indicates the favorable divergent validity of the SCAARED, and the results of exploratory factor analysis of the questionnaire were confirmed.

CONCLUSION

The Persian version of the SCAARED is a tool with appropriate validity and reliability.

Effectiveness of 'Tackle Your Tics', a brief, intensive group-based exposure therapy programme for children with tic disorders: study protocol of a randomised controlled trial

INTRODUCTION

This paper outlines the study protocol for the Dutch Tackle Your Tics study in youth with tic disorders. Tourette syndrome and chronic tic disorders are prevalent neurodevelopmental disorders, placing considerable burden on youth and their families. Behavioural treatment is the first-line, evidence-based intervention for tic disorders, but tic reduction and availability remain relatively low. Patient associations stress the need for more accessible high-quality treatments, also focusing on improving quality of life. Therefore, the brief, intensive group-based treatment Tackle Your Tics was developed.

METHODS AND ANALYSIS

Tackle Your Tics is a 4-day intensive and comprehensive group-based intervention for children and adolescents (9-17 years) with Tourette syndrome or a chronic tic disorder. The programme encompasses exposure and response prevention treatment and additional supporting components (coping strategies, relaxation exercises and parent support). To study the effectiveness of Tackle Your Tics and identify predictors/moderators at baseline, a single-blinded randomised controlled trial (n=104) is conducted, comparing Tackle Your Tics (n=52) with a waiting list condition lasting 3 months (n=52). Assessments are performed at similar time points for both groups: at baseline, after 4 weeks, and at 3 and 6 months of follow-up, on tic severity, quality of life and other psychosocial variables.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the medical ethical committee of the Amsterdam Medical Centre (METC nr NL66340.018.18, v3 June 2020). Findings will be presented on national and international conferences, peer-reviewed scientific journals, patient organisation meetings and public media. Patient representatives are fully integrated as part of the research team. If Tackle Your Tics proves to be effective, it can expand evidence-based treatment possibilities for children and adolescents with tic disorders. Identifying the psychosocial predictors/moderators for the effectiveness of this intervention can provide personalised treatment advice in the future.

TRIAL REGISTRATION NUMBER

NL8052.

The Role of Comorbid Mood Disorders in Cognitive Behavioral Therapy for Childhood Social Anxiety

Background

Children with a social anxiety disorder have worse treatment outcomes after Cognitive Behavior Therapy (CBT) than children with other anxiety disorders. Anxiety disorders and mood disorders are strongly related and especially social anxiety is related to high comorbidity rates with mood disorders. The aim of the study was to investigate how comorbid mood disorders are related to treatment outcomes after CBT and whether this can explain the worse outcomes for childhood social anxiety.

Methods

Participants were 152 referred clinically children (7–18 years) with either a social anxiety disorder (n = 52) or another anxiety disorder (n = 100) of whom 24.3% (n = 37) had a comorbid mood disorder. Child anxiety, internalizing symptoms, and quality of life were measured pre-treatment, post-treatment, 3 months and 1 year after treatment, using child and both parents’ report.

Results

Children with a primary social anxiety disorder more often had a comorbid mood disorder than children with another primary anxiety disorder. Children with a mood disorder had more severe anxiety problems before treatment. Comorbid mood disorders were related to greater anxiety reductions after treatment. The worse outcomes for children with a primary social anxiety disorder remained after controlling for comorbid mood disorders.

Conclusions

Findings stress the importance of future studies examining why the presence of a comorbid mood disorder is associated with greater anxiety reductions, and other factors that explain the worse treatment outcomes found for childhood social anxiety disorder.

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.

Combining selective serotonin reuptake inhibitors and cognitive behavioral therapy in youth with depression and anxiety

BACKGROUND

Treatment studies of children and adolescents with internalizing disorders suggest that the combination of a selective serotonin reuptake inhibitor (SSRI) and cognitive behavioral therapy (CBT) consistently produces greater improvement than either treatment alone. We sought to determine how response to combined treatment varies across disorders (anxiety versus depression), and by specific patient characteristics.

METHODS

Three large National Institutes of Health-funded trials of children and adolescents with major depression (n = 2) and anxiety disorders (n = 1) were evaluated, each comparing CBT + SSRI to SSRI only, Bayesian Hierarchical Models (BHMs) were used, for endpoint response, time course of response and predictors of response in participants who received SSRI or SSRI+CBT.

RESULTS

SSRI+CBT significantly decreased symptoms by week 4 (p<0.001) across disorders. This improvement continued at week 8 and 12 (p<0.001); however, the additive benefit of CBT over SSRI monotherapy was not statistically significant until week 12 (p<0.001). The fastest response to SSRI+CBT was for patients who were younger, with milder baseline anxiety/depression symptoms and depressive disorders. The slowest response for SSRI+CBT was for boys, adolescents, minoritized children, those with severe symptoms and externalizing disorders.

LIMITATIONS

Limitations included inconsistent moderators, variation in the number of observations over time and a lack of genetic or pharmacokinetic variables related to SSRI exposure across studies.

CONCLUSIONS

The superiority of SSRI+CBT for youth with depression and anxiety is further supported. For purposes of rapid and greater relief, combination treatment is the superior approach across anxiety and depression and is robust to a range of participant characteristics. However, the added value of CBT (with an SSRI) occurs late in treatment. These findings represent a step towards understanding heterogeneity of treatment response and raise the possibility that interventions could be better tailored or adapted based on patient characteristics.

Predictors of Symptom Trajectories After Cognitive-Behavioral Therapy in Adolescents With an Age-Adapted Diagnosis of Binge-Eating Disorder

Although evidence demonstrated efficacy of cognitive-behavioral therapy (CBT) in adolescents with binge-eating disorder (BED), treatment response is heterogeneous. This study uniquely examined baseline predictors of symptom trajectories in N = 73 adolescents (12-20 years) with an age-adapted diagnosis of BED (i.e., based on objective and subjective binge-eating episodes). Based on evidence from adult BED, dietary restraint, overvaluation of weight/shape, and depressive symptoms were used to predict changes in abstinence from binge eating and eating disorder psychopathology after 4 months of individual, face-to-face CBT using growth models. Longitudinal trajectories of abstinence from objective and subjective binge eating and global eating disorder psychopathology assessed via the Eating Disorder Examination were modeled for five time points (pre- and posttreatment, 6-, 12-, and 24-month follow-up). Beyond significant, positive effects for time, no significant predictors for abstinence from binge eating emerged. In addition to significant decreases in eating disorder psychopathology over time, higher pretreatment dietary restraint and overvaluation of weight/shape significantly predicted greater decreases in eating disorder psychopathology over time. Consistent with research in adult BED, adolescents with higher than lower eating disorder-specific psychopathology especially benefit from CBT indicating that restrained eating and overvaluation of weight/shape may be BED-specific prognostic characteristic across developmental stages. Future predictor studies with an additional focus on potential age-specific predictors, such as family factors, and within-treatment processes may be critical in further evaluating treatment-related symptom trajectories in adolescent BED.

Implementing Cognitive-Behavioral Therapy in Children and Adolescents with Anxiety Disorders

This article provides an introduction and overview of the cognitive-behavioral treatment approach to anxiety disorders in children and adolescents. We first provide an introduction to the cognitive-behavioral conceptualization of anxiety, emphasizing the tripartite model of emotions: cognitions, physiological arousal, and avoidance behaviors. We then provide an overview of the basic principles of cognitive behavioral treatment for anxiety disorders in children and adolescents, including generalized, social, and separation anxiety, and specific phobia. We follow this introduction and overview with a discussion of the structure and goals of treatment, including the three phases of treatment (psychoeducation, application, and relapse prevention). In the context of discussing application, we focus primarily on implementation strategies relating to behavioral exposures and cognitive restructuring. We conclude with a summary of different formats wherein cognitive-behavioral treatment can be implemented, including child-only, peer-group, parent-involved, and telehealth.

Complex PTSD and treatment outcomes in TF-CBT for youth: a naturalistic study

Background: Complex posttraumatic stress disorder (CPTSD) has recently been added to the ICD-11 diagnostic system for classification of diseases. The new disorder adds three symptom clusters to posttraumatic stress disorder (PTSD) related to disturbances in self-organization (affect dysregulation, negative self-concept, and disturbances in relationships). Little is known whether recommended evidence-based treatments for PTSD in youth are helpful for youth with CPTSD. Objectives: This study examined whether Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is useful in reducing PTSD and CPTSD in traumatized youth. Methods: Youth (n = 73, 89.0% girls, M age = 15.4 SD = 1.8) referred to one of 23 Norwegian child and adolescent mental health clinics that fulfilled the criteria for PTSD or CPTSD according to ICD-11 and received TF-CBT were included in the study. Assessments were conducted pre-treatment, and every fifth session. Linear mixed effects models were run to investigate whether youth with CPTSD and PTSD responded differently to TF-CBT. Results: Among the 73 youth, 61.6% (n = 45) fulfilled criteria for CPTSD and 38.4% (n = 28) fulfilled criteria for PTSD. There were no differences in sex, age, birth country, trauma type, number of trauma types or treatment length across groups. Youth with CPTSD had a steeper decline in PTSD and CPTSD compared to youth with PTSD. The groups reported similar levels of PTSD and CPTSD post-treatment. The percentage of youth who dropped out of treatment was not different across groups. Further, the groups did not differ significantly in number of received treatment sessions. Conclusions: This is the first study to examine whether TF-CBT is helpful for youth who have CPTSD using a validated instrument for measuring CPTSD. The results suggest that TF-CBT may be useful for treating CPTSD in youth. These are promising findings that should be replicated in studies with larger sample sizes.

CBT for Childhood Anxiety: Reviewing the State of Personalised Intervention Research

This article presents a mini-review of the state of personalised intervention research in the field of child and adolescent anxiety. We evaluated narrative, systematic and meta-analytic reviews of key research methodologies and how they relate to current approaches for personalising CBT, specifically. Preliminary evidence of predictors (severity of primary disorder, social anxiety disorder (SoAD), comorbid depression, parental psychopathology, parental involvement and duration of treatment), moderators (type of primary disorder) and mediators (self-talk, coping, problem-solving and comorbid symptoms) of CBT outcomes provides content for several personalised approaches to treatment. Finally, we present a novel conceptual model depicting the state of personalised intervention research in childhood anxiety and propose a research agenda for continued progress.

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.

Does Stigma Moderate the Efficacy of Mental- and Behavioral-Health Interventions? Examining Individual and Contextual Sources of Treatment-Effect Heterogeneity

In this article, we argue that stigma may be an important, but heretofore underrecognized, source of heterogeneity in treatment effects of mental- and behavioral-health interventions. To support this hypothesis, we review recent evidence from randomized controlled trials and spatial meta-analyses suggesting that stigma may predict not only who responds more favorably to these health interventions (i.e., individuals with more stigma experiences), but also the social contexts that are more likely to undermine intervention effects (i.e., communities with greater structural stigma). By highlighting the potential role of personal and contextual stigma in shaping response to interventions, our review paves the way for additional research.

Treating Childhood Social Anxiety Disorder With Virtual Environments and Serious Games: A Randomized Trial

Disseminating efficacious psychological treatments remains a challenge for researchers and clinicians. In the case of social anxiety disorder (SAD), Social Effectiveness Therapy for Children (SET-C) has been demonstrated as an efficacious intervention, but elements of the protocol, such as peer generalization sessions, remain challenging to conduct in typical clinical settings. To address this need, we developed an artificially intelligent, web-based application, Pegasys-VR™, designed to replace peer generalization sessions and enhance homework compliance. The feasibility of Pegasys-VR™ was tested in a randomized controlled trial in comparison to SET-C. The results indicated that both programs were equally efficacious in decreasing anxiety and improving social skill in social encounters. Sixty-three percent (63%) of children treated with SET-C and 60% treated with Pegasys-VR™ did not meet diagnostic criteria for SAD at posttreatment. Pegasys-VR™ is a feasible, efficacious, and dissemination-friendly element of a comprehensive treatment program for social anxiety disorder in children.

Acute Neurofunctional Effects of Escitalopram in Pediatric Anxiety: A Double-Blind, Placebo-Controlled Trial

OBJECTIVE

Amygdala-ventrolateral prefrontal cortex (VLPFC) circuitry is disrupted in pediatric anxiety disorders, yet how selective serotonin reuptake inhibitors (SSRIs) affect this circuitry is unknown. We examined the impact of the SSRI escitalopram on functional connectivity (FC) within this circuit, and whether early FC changes predicted treatment response in adolescents with generalized anxiety disorder (GAD).

METHOD

Resting-state functional magnetic resonance (MR) images were acquired before and after 2 weeks of treatment in 41 adolescents with GAD (12-17 years of age) who received double-blind escitalopram or placebo for 8 weeks. Change in amygdala-based whole-brain FC and anxiety severity were analyzed.

RESULTS

Controlling for age, sex, and pretreatment anxiety, escitalopram increased amygdala-VLPFC connectivity compared to placebo (F = 17.79, p = .002 FWE-corrected). This early FC change predicted 76.7% of the variability in improvement trajectory in patients who received escitalopram (p < .001) but not placebo (p = .169); the predictive power of early amygdala-VLPFC FC change significantly differed between placebo and escitalopram (p = .013). Furthermore, this FC change predicted improvement better than baseline FC or clinical/demographic characteristics. Exploratory analyses of amygdala subfields' FC revealed connectivity of left basolateral amygdala (BLA) -VLPFC (F = 19.64, p < .001 FWE-corrected) and superficial amygdala-posterior cingulate cortex (F = 22.92, p = .001 FWE-corrected) were also increased by escitalopram, but only BLA-VLPFC FC predicted improvement in anxiety over 8 weeks of treatment.

CONCLUSION

In adolescents with GAD, escitalopram increased amygdala-prefrontal connectivity within the first 2 weeks of treatment, and the magnitude of this change predicted subsequent clinical improvement. Early normalization of amygdala-VLPFC circuitry might represent a useful tool for identifying future treatment responders as well as a promising biomarker for drug development.

CLINICAL TRIAL REGISTRATION INFORMATION

Neurofunctional Predictors of Escitalopram Treatment Response in Adolescents With Anxiety; https://www.clinicaltrials.gov/; NCT02818751.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Cognitive Behavioral Therapy-, Biofeedback-, and Game-Based eHealth Intervention to Treat Anxiety in Children and Young People With Long-Term Physical Conditions (Starship Rescue): Co-design and Open Trial

Background

Approximately 10%-12% of New Zealand children and young people have long-term physical conditions (chronic illnesses) and are more likely to develop psychological problems, particularly anxiety and depression. Delayed treatment leads to worse health care and poorer long-term outcomes. Recently, eHealth interventions, especially those based on principles of cognitive behavioral therapy and biofeedback, have been shown to be moderately effective in reducing anxiety. However, these modalities have rarely been combined. Young people have expressed a preference for well-designed and technology-based support to deal with psychological issues.

Objective

This study aims to co-design and evaluate the acceptability and usability of a cognitive behavioral therapy and biofeedback-based, 5-module eHealth game called Starship Rescue and to provide preliminary evidence regarding its effectiveness in addressing anxiety and quality of life in young people with long-term physical conditions.

Methods

Starship Rescue was co-designed with 15 children and young people from a tertiary hospital in New Zealand. Following this, 24 others aged 10-17 years participated in an open trial of the game, accessing it over an 8-week period. The acceptability of the game to all participants was assessed using a brief, open-ended questionnaire. More detailed feedback was obtained from a subset of 10 participants via semistructured interviews. Usability was evaluated via device-recorded frequency and duration of access on completion of the game and the System Usability Scale. Anxiety levels were measured at baseline, completion, and 3 months after completion of the game using the Generalized Anxiety Disorder 7-item scale and Spence Child Anxiety Scale, and at the start of each module and on completion using an embedded Likert visual analog scale. Quality of life was measured at baseline, completion, and 3 months after completion using the Pediatric Quality of Life Inventory scale.

Results

Users gave Starship Rescue an overall rating of 5.9 out of 10 (range 3-10) and a mean score of 71 out of 100 (SD 11.7; minimum 47.5; maximum 90) on the System Usability Scale. The mean period for the use of the game was just over 11 weeks (78.8 days, 13.5 hours, 40 minutes). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder 7-item scale (−4.6; P<.001), Spence Child Anxiety Scale (−9.6; P=.005), and the Likert visual analog scales (−2.4; P=.001). Quality of life also improved on the Pediatric Quality of Life Inventory scale (+4.3; P=.04). All changes were sustained at the 3-month follow-up.

Conclusions

This study provides preliminary evidence for Starship Rescue as an acceptable, usable, and effective eHealth intervention for treating anxiety in young people with long-term physical conditions. Further evaluation is planned via a randomized controlled trial.

Trial Registration

Australian New Zealand Clinical Trials Network Registry (ANZCTR) ACTRN12616001253493; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371443

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.

The knowns and unknowns of SSRI treatment in young people with depression and anxiety: efficacy, predictors, and mechanisms of action

The use of SSRIs for the treatment of depression and anxiety in young people is increasing. However, the effects of SSRIs in adolescence, a time when there are substantial changes in neural, cognitive, and social functioning, are not well understood. Here, we review evidence from clinical trials about the benefits and risks of SSRIs in young people and consider their mechanisms of action, as shown through human experimental work and animal models. We emphasise key outstanding questions about the effects of SSRIs in youth, identified through gaps in the literature and in consultation with young people with lived experience. It is crucial to characterise the mechanisms underpinning risks and benefits of SSRIs in this age group to progress the field, and to narrow the chasm between the widespread use of SSRIs in youth and the science on which this use is based.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Caregiver Strain Questionnaire-Short Form 11 (CGSQ-SF11): A Validation Study

Caregiver strain is associated with caregiver and child well-being and clinical outcomes. The present study examined the psychometric properties of a revised 11-item measure of caregiver strain, the Caregiver Strain Questionnaire-Short Form 11 (CGSQ-SF11). In a sample of 962 caregivers, we found support for a three-factor model of the CGSQ-SF11, consisting of objective (e.g., financial impact), subjective internalized (e.g., sadness about the child's problems), and subjective externalized (e.g., anger directed toward the child) strain factors. Measurement invariance was supported across multiple demographic and clinical groups, and all three subscales displayed high internal consistency. Convergent validity was also supported through positive correlations with measures of child psychopathology symptoms and psychosocial impairment. Moreover, caregiver strain was associated with number of child disorders as well as breadth of child symptoms across both internalizing and externalizing domains. Findings provide initial validation of the CGSQ-SF11 as a comprehensive yet brief measure of caregiver strain.

Increased self-reported reward responsiveness predicts better response to cognitive behavioral therapy for youth with anxiety

Few consistent predictors of differential cognitive behavioral therapy (CBT) outcome for anxious youth have been identified, although emerging literature points to youth reward responsiveness as a potential predictor. In a sample of youth ages 7-17 with a primary anxiety disorder (N = 136; Mage = 12.18 years, SDage = 3.12; 70 females; Caucasian n = 108, Black n = 12, Asian n = 4, Hispanic n = 5, other n = 7), the current study examined whether youth reward responsiveness assessed via the Behavioral Inhibition and Behavioral Activation System Scales for children, reward responsiveness subscale, predicted post-treatment (a) anxiety symptom severity, (b) depressive symptom severity, (c) functioning, (d) responder status and (e) number of homework/exposure tasks completed following 16-weeks of CBT, controlling for pre-treatment age, sex, anxiety/depressive symptom severity, and functioning. Moderation analyses examined whether relationships differed by age. Increased reward responsiveness was associated with lower anxiety and depressive symptom severity, higher functioning, and increased likelihood of being a responder, but not homework or exposure completion. Moderation analyses showed that younger, but not older, youth who were more reward responsive completed more exposures. Findings indicate that increased reward responsiveness is a predictor of better CBT outcomes for anxious youth, particularly functional outcomes, and that reward responsiveness may play a different role in exposure completion across development.

Moderators of Response to Personalized and Standard Care Cognitive-Behavioral Therapy for Youth with Autism Spectrum Disorder and Comorbid Anxiety

Anxiety/obsessive-compulsive disorders are common among youth with autism spectrum disorder (ASD). Two versions of cognitive behavior therapy (CBT) are effective, with some advantage for a personalized, adapted version. This study evaluated predictors and moderators of standard CBT and adapted CBT. Youth (N = 167) ages 7-13 were randomized to standard or adapted CBT, or treatment-as-usual. Age, IQ, ASD severity, and emotional-behavioral symptom severity were examined. More severe internalizing and emotional-behavioral problems predicted poorer treatment outcomes especially in standard versus personalized CBT. Elevated repetitive behaviors and restricted interests predicted poorer treatment outcomes across treatments, though youth with "moderate" repetitive behaviors and restricted interested experienced poorer outcomes only in standard but not personalized CBT. Externalizing symptoms directly predicted treatment outcomes. Older age predicted improved outcomes in adapted but not standard CBT. Findings highlight the need for further treatment refinements and the value in adapting treatment for youth with more complex presentations. Trial Registration Clinicialtrials.gov: NCT02028247; https://clinicaltrials.gov/ct2/show/NCT02028247 .