The effect of parent involvement in the treatment of anxiety disorders in children: a meta-analysis

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.

Optimizing indicated cognitive behavioral therapy to prevent child anxiety and depression: A cluster-randomized factorial trial

Identifying effective components can lead to interventions that are less resource-intensive and better suited for real-world needs. In this 2×2×2 cluster-randomized factorial trial (clinicaltrials.gov NCT04263558), we investigated the effects of three components of an indicated, transdiagnostic CBT intervention for children: 1) Intervention Delivery Format (child group format versus a blended format with group sessions and automated web-based sessions), 2) Parental Involvement in the intervention (group-based versus psychoeducational brochure), and 3) a Measurement Feedback System (MFS; on versus off). The intervention was delivered at schools in a group-based format. The participants (N = 701 children) were school children (age 8-12 years) with elevated symptoms of anxiety or depression, and their parents. The main outcomes were self-reported (N = 633) and parent-reported (N = 725) symptoms of child anxiety and depression post-intervention. The secondary outcome was children's user satisfaction with the intervention. We did not find significant main or interaction effects of Delivery Format, Parental Involvement, or MFS on children's symptom levels. There were no significant effects on children's user satisfaction. Results were compatible with retaining the least resource intensive combination (i.e., blended format, parental brochure, no MFS) in an optimized intervention.

Abbreviated Dialectical Behavior Therapy Virtual Skills Group for Caregivers of Adolescents: An Exploratory Study of Service User and Clinical Outcomes

Prior work emphasizes involving caregivers in youth mental health services. To support youth with emotion dysregulation, dialectical behavior therapy for adolescents (DBT-A) includes a multi-family skills group, wherein adolescents and caregivers learn skills together. However, limited work has examined the impact of caregiver involvement within DBT-A. The current study examines outcomes of two caregiver-only DBT-A skills groups adapted for abbreviated telehealth delivery. We report on caregivers' (N = 11, 100% mothers, 55% Hispanic) service user outcomes (e.g. self-efficacy at skill usage, group cohesion, therapeutic alliance) and clinical outcomes (i.e. their own emotion functioning, criticism, responses to their adolescent's negative emotions). Results indicate caregiver-only groups were feasible and acceptable, and suggest preliminary efficacy, including improvements in caregiver emotion functioning, distress during interactions with their adolescents, and adolescent-reported criticism. Caregivers also reported reductions in unsupportive responses with their adolescents. Overall, while we caution interpretation due to a small sample size, findings support the preliminary feasibility and efficacy of modifying caregiver participation in DBT-A to be less time-consuming and administered via telehealth.

Research Review: The internalizing paradox - youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice

BACKGROUND

Youth anxiety and depression have long been combined within the empirically derived internalizing syndrome. The two conditions show substantial comorbidity, symptom co-occurrence, and overlap in treatment procedures, but paradoxically diverge in psychotherapy outcomes: strong, positive effects for anxiety and weak effects for depression.

METHODS

Drawing on recent research, we examine candidate explanations for this paradox to help identify strategies for addressing it by improving outcomes for youth depression.

RESULTS

Candidate explanations include that youth depression, compared with youth anxiety, has more varied comorbidities and more heterogeneous symptom combinations, has greater uncertainty regarding mediators and mechanisms of change, is treated with more complex and potentially confusing protocols, and has characteristics that may impede client engagement. Candidate strategies for shrinking the psychotherapy effectiveness gap include personalizing through transdiagnostic modular treatment, simplifying therapy by focusing on empirically supported principles of change, developing effective strategies for engaging family members as intervention allies, using shared decision-making to inform clinical decisions and boost client engagement, capitalizing on youth-friendly technological advances, and shortening and digitizing treatments to enhance their accessibility and appeal.

CONCLUSIONS

Recent advances suggest explanations for the internalizing paradox, which in turn suggest strategies for shrinking the youth anxiety-depression psychotherapy outcome gap; these form an agenda for a promising new era of research.

Involving Parents in Child Mental Health Treatments: Survey of Clinician Practices and Variables in Decision Making

OBJECTIVE

Child therapy outcomes research has indicated that involving parents in child mental health treatments is generally beneficial. This study aimed to explore clinicians' decisions to involve parents in treatment for childhood disorders and child-, parent-, and clinician-related variables influencing these decisions.

METHODS

Data on decision making and reported use of parent involvement by 40 therapists with patients ages 6-12 were obtained from a self-report survey. Most clinicians were psychologists, White, and female and worked in community-based clinics. They reported using cognitive-behavioral and family system interventions considerably more than psychodynamic therapy.

RESULTS

Clinician-reported use of parent involvement was significantly greater for children with oppositional defiant or conduct disorder than for those with attention-deficit hyperactivity disorder, depression, anxiety, or posttraumatic stress disorder or trauma. A child's age and diagnosis (100% of clinicians), parental level of stress (85%), and parent interest in working with the clinician (60%) were frequently reported as being important to clinicians' decisions. Ninety percent of clinicians reported that they believed working with parents was effective, whereas only 25% reported their own training to be influential in decision making.

CONCLUSIONS

Findings regarding use of parent involvement stratified by common childhood disorder were not surprising, given the behavioral and treatment complexities of oppositional defiant or conduct disorder. Clinicians often reported parents' stress level and interest in working with the clinician as influencing decision making, reflecting the importance of lesser researched decision variables. The relatively limited influence of training on decision making suggests the need for better parent involvement education for clinicians treating children.

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.

Interventions Involving Caregivers for Children and Adolescents Following Traumatic Events: A Systematic Review and Meta-Analysis

Although treatment guidelines recommend interventions entailing caregiver involvement for children and adolescents following traumatic experiences, evidence on their effectiveness is inconsistent. The present systematic review and meta-analysis considered possible moderators of their effectiveness.

METHOD

Eligible studies were (quasi-)randomized controlled trials and efficacy trials published in English or German with participants up to the age of 21 years presenting symptoms of mental disorders due to traumatic experiences. The effectiveness of interventions entailing any kind and extent of caregiver involvement had to be investigated by applying evaluated instruments. PubMed, PsycINFO, ERIC, COCHRANE and PSYNDEX were searched.

RESULTS

A total of 33 studies with 36 independent samples were retrieved. Child- and parent-reports on PTSD, depression, anxiety, ADHD, internalizing, externalizing symptoms and behavior problems were analyzed where available. The pooled effect size is significant and robust at post-treatment for child-reported PTSD, g = - 0.34 (95% CI = - 0.53; - 0.14), parent-reported PTSD, g = - 0.41 (95% CI = - 0.71; - 0.11), child-reported depression, g = - 0.29 (95% CI = - 0.46; - 0.11), child-reported anxiety, g = - 0.25 (95% CI = - 0.42; - 0.08), and parent-reported internalizing symptoms, g = - 0.27 (95% CI = - 0.47; - 0.07). Female sex and fulfilling diagnostic criteria appeared as potential moderators. The only significant effect size at follow-up is found for child-reported PTSD symptoms 12 months post-treatment, g = - 0.37 (95% CI = - 0.67; - 0.07).

CONCLUSIONS

Interventions entailing caregiver involvement revealed greater symptom reductions than control conditions. Determinants of their effectiveness should be examined further.

Mindful Parenting Group Intervention for Parents of Children with Anxiety Disorders

Parenting behaviour and rearing style contribute to the intergenerational relationship between parental and child anxiety. Current psychological interventions for child anxiety typically do not adequately address parental mental health, parenting behaviours or the parent-child relationship. The current pilot study examines the effectiveness of a mindful parenting intervention (MPI) for parents of young children with clinical anxiety. It was hypothesised that the intervention would be associated with improvements in parental stress, mental health, and mindfulness, and a reduction in child clinical anxiety symptoms. Twenty-one parents of children aged 3-7 years diagnosed with anxiety disorders participated in an 8-week group MPI program that aimed to increase their intentional moment to moment awareness of the parent-child relationship. Parental (anxiety, depression, hostility, stress, burden, mindfulness, mindful parenting) and child (anxiety diagnoses, anxiety severity, comorbidities) outcomes were assessed at pre- and post-intervention, and at 3-month follow-up. Parents reported a significant increase in mindful parenting and a significant reduction in parent-child dysfunctional interaction, but no change in mental health symptoms. There was a significant reduction in parent-rated child anxiety symptoms, severity of child anxiety diagnosis and number of comorbid diagnoses at post and 3-month follow-up. Limitations include a lack of waitlist control, small sample size, and participants were largely mothers, from intact families and highly educated. There was attrition of 43% and outcomes were predominantly self-report. MPIs offer a novel and potentially effective method of increasing mindful parenting, decreasing dysfunctional parent-child interactions, reducing parenting stress and might also be an effective early intervention for indirectly decreasing young children's clinical anxiety symptoms. Larger-scale controlled trials of MPIs are needed.

Parent-Led Cognitive Behavioural Therapy for Children with Autism Spectrum Conditions. A Pilot Study

This article reports on a pilot study of a parent-only cognitive behavioural therapy (CBT) programme for parents of children with autism spectrum disorders (ASD) and anxiety difficulties. Twenty-one parents of anxious children with ASD (5-11 of age) completed the From Timid to Tiger intervention. Parent outcome measures were assessed at post-intervention and at 3-month follow-up. Analysis indicated significant reductions in both parent and clinician reports of child anxiety symptoms. Specifically, 38% of children were free of their primary diagnosis at treatment end and this increased to 57% when measured at 3-month follow-up. Positive gains were evidenced regarding parents' ability to manage their child's anxiety without accommodating to it. The results provide preliminary evidence of parent-only CBT programs for children with ASD.

The impact of parent-only interventions on child anxiety: A systematic review and meta-analysis

BACKGROUND

Parent-only interventions for childhood anxiety may be an important alternative to resource and time intensive child-focused cognitive behavioural therapy (CBT). This systematic review and meta-analysis aimed to investigate the efficacy of parent-only interventions in reducing symptoms of anxiety disorders in school-aged children.

METHODS

A systematic search of five databases (inception to March 2021) identified 29 eligible studies. A range of study designs were captured, including randomised controlled trials (RCTs) and case series. A narrative synthesis was conducted. Random effects meta-analyses were performed on parent- and child-reported outcomes and pre-test post-test effect sizes were calculated for uncontrolled studies.

RESULTS

Findings indicated a significant treatment effect for parent-only interventions compared to waitlist controls. No significant differences were found when comparing parent-only interventions with other active interventions; anxiety symptoms reduced in both conditions. No significant treatment effects were found for child-rated outcomes. Calculated effect sizes for uncontrolled studies were typically large, although sample sizes were small. No clear evidence was found for a superior type, duration or format of intervention.

LIMITATIONS

The methodological quality of many studies in this review (19/29) was rated 'weak'. Only English language papers were included.

CONCLUSIONS

To date, this is the first systematic review and meta-analysis of the efficacy of parent-only interventions for reducing symptoms of child anxiety disorders. Our results suggest that parent-only interventions may be effective in reducing child anxiety. These findings are important for clinical practice because they suggest that efficient, low intensity interventions delivered to parents may lead to positive outcomes for children.

Does Training Parents in Reinforcement Skills or Relationship Skills Enhance Individual Youths' Cognitive Behavioral Therapy for Anxiety? Outcome, Specificity, and Mediation

We conducted a dismantling design treatment study comparing individual CBT, CBT targeting parents' reinforcement skills (CBT+Reinf), and CBT targeting parents' relationship skills (CBT+ Relat) in 341 youths with primary anxiety diagnoses. At posttreatment, youths in CBTs with parent involvement had lower anxiety than youths in CBT. At 12-month follow-up, youths in CBT+Relat maintained lower anxiety relative to CBT. At posttreatment, negative reinforcement was significantly lower in CBT+Reinf than CBT+Relat and CBT; negative reinforcement partially mediated youth anxiety reduction. Reducing parental negative reinforcement in CBT+Reinf was associated with lower parental psychological control which also partially mediated youth anxiety reduction. Some of these mediational dynamics continued through follow-up. Targeting concrete behavioral parenting skills, especially negative reinforcement, produced treatment specificity and partial mediation relative to less concrete targeting, and enhanced CBT. Findings highlight complexities in identifying mechanisms through which targeting of parenting skills produces youth anxiety reduction and suggest avenues for future research.

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.

Supporting the parents of children and young people with anxiety and depressive disorders is an opportunity not to be missed: a scoping review

Guidance is scarce on whether and how to involve parents in treatment for anxiety and depressive disorders in children and young people. We did a scoping review of randomised controlled trials of psychological interventions for anxiety and depressive disorders in children and young people, in which parents were involved in treatment, to identify how parents and carers have been involved in such treatments, how this relates to both child and broader outcomes, and where research should focus. We identified 73 trials: 62 focused on anxiety and 11 on depressive disorders. How parents were involved in treatments varied greatly, with at least 13 different combinations of ways of involving parents in the anxiety trials and seven different combinations in the depression trials. Including parents in treatment did not impair children's and young people's outcomes, but the wide variability in how they were involved prevents clarity about why some trials favoured parent involvement and others did not. Studies must consider the long-term and wider benefits beyond children's and young people's mental health, such as enhanced engagement, family wellbeing, and economic gains.

Evaluation of a parent-led cognitive behaviour therapy programme in routine clinical practice: A controlled trial

Parent-led cognitive behavioural therapy for child anxiety disorders have garnered a growing evidence base. However, it is unclear how such approaches translate into routine clinical practice. The current study aims to evaluate the effectiveness of an 8-session treatment (From Timid to Tiger) in reducing child anxiety and behavioural difficulties, as well as family accommodation. The parents of 71 children (aged 4-11) were assigned to the treatment or a waitlist control. Parent report measures were completed pre-treatment, at treatment-end, and at 3-month follow-up. Parents assigned to the waitlist were assessed 8 weeks after the initial assessment. Findings indicated that parents who attended the group reported significant reductions in child anxiety and behavioural difficulties. In addition, the parents in the treatment group reported a reduction in family accommodation compared to those in the waitlist. The current control trial provides tentative evidence of the use and effectiveness of such parent-led approaches in addressing child anxiety difficulties commonly seen in routine clinical practice. PRACTITIONER POINTS: Parent-led approaches are effective treatments in managing child anxiety difficulties. Very little research to date has assessed the effectiveness of such approaches in routine clinical practice. The From Timid to Tiger program is a brief parent-led CBT intervention. The programme was effective in reducing child anxiety and behavioural difficulties. Parents also reported a reduction in behaviours related to family accommodation. Such programmes show promise and can be used in routine clinical practice.

Better Together: A Review and Recommendations to Optimize Research on Family Involvement in CBT for Anxiety and Related Disorders

Anxiety and related disorders (ARDs) occur in an interpersonal context. Individuals with ARDs respond well to individual cognitive behavioral therapy (CBT); however, there is room for improvement. As such, family members may be included to "enhance" treatment outcomes, yet findings from studies examining family involvement in CBT for ARDs are equivocal. The present paper (a) identifies methodological considerations for explaining inconsistent outcomes among CBT for ARDs with family involvement, and (b) reviews factors that affect outcomes of CBT for ARDs with family involvement including levels of involvement in treatment (e.g., number, duration, and spacing of sessions) and characteristics of who is involved in treatment (e.g., family member cognitions and cultural factors). Limitations of the literature and recommendations for future research are discussed. Researchers should focus on conducting studies that can test not whether but for whom and how family involvement can contribute to improved outcomes above and beyond individual CBT for ARDs.

Family Intervention for Child and Adolescent Anxiety: A Meta-analytic Review of Therapy Targets, Techniques, and Outcomes

Parent- and family-level correlates of youth anxiety are well-documented, and they highlight potential targets for family-focused intervention. Although family-based approaches for treating youth anxiety generally are considered efficacious for achieving symptom reduction, they vary in format and approach and it remains unclear whether they offer an advantage over individual child treatment. To better understand the current state of the evidence, we used meta-analytic methods to examine the therapeutic approaches described in existing family interventions for child and adolescent anxiety, whether they mapped to the major mechanisms proposed in the literature, and the timeline along which relevant parent/family variables were measured. We examined how these mechanism-focused family interventions performed in RCTs relative to individual child CBT and whether they shifted symptoms and relevant parenting behaviors. A total of 11 randomized controlled trials (RCTs) compared individual cognitive behavior therapy (CBT) to CBT+ a family component (CBT + FAM) and included a youth anxiety measure at pre- and post-treatment; only half of these (n=6) also included a parent/family functioning measure at both pre- and post-treatment (across both primary and secondary outcome papers). Only a single study included anxiety measures at a mid-treatment time point, and none included parent measures at a mid-treatment time point. Findings are discussed in terms of design considerations and advancing the field of family intervention for youth anxiety.

Practitioner review: health anxiety in children and young people in the context of the COVID-19 pandemic

Health-related fear is a normal and common response in the face of the global pandemic of COVID-19. Children and young people are frequently being exposed to messages about the threat to health, including from the media and authorities. Whilst for most, their anxiety will be proportionate to the threat, for some, existing pre-occupation with physical symptoms and illness will become more problematic. There is a growing body of evidence that health anxiety may occur in childhood, however much of the literature is taken from research using adult samples. This practitioner review aims to give an overview of the assessment and treatment of health-related worries in children and young people in the context of the COVID-19 pandemic. This review is based on the limited existing evidence in this population and the more substantial evidence base for treating health anxiety in adults. We consider the adaptations needed to ensure such interventions are developmentally appropriate.

Learning About Safety: Conditioned Inhibition as a Novel Approach to Fear Reduction Targeting the Developing Brain

Adolescence is a peak time for the onset of psychiatric disorders, with anxiety disorders being the most common and affecting as many as 30% of youths. A core feature of anxiety disorders is difficulty regulating fear, with evidence suggesting deficits in extinction learning and corresponding alterations in frontolimbic circuitry. Despite marked changes in this neural circuitry and extinction learning throughout development, interventions for anxious youths are largely based on principles of extinction learning studied in adulthood. Safety signal learning, based on conditioned inhibition of fear in the presence of a cue that indicates safety, has been shown to effectively reduce anxiety-like behavior in animal models and attenuate fear responses in healthy adults. Cross-species evidence suggests that safety signal learning involves connections between the ventral hippocampus and the prelimbic cortex in rodents or the dorsal anterior cingulate cortex in humans. Particularly because this pathway follows a different developmental trajectory than fronto-amygdala circuitry involved in traditional extinction learning, safety cues may provide a novel approach to reducing fear in youths. In this review, the authors leverage a translational framework to bring together findings from studies in animal models and humans and to bridge the gap between research on basic neuroscience and clinical treatment. The authors consider the potential application of safety signal learning for optimizing interventions for anxious youths by targeting the biological state of the developing brain. Based on the existing cross-species literature on safety signal learning, they propose that the judicious use of safety cues may be an effective and neurodevelopmentally optimized approach to enhancing treatment outcomes for youths with anxiety disorders.

Experiences of online exposure-based treatment with parental support for teenagers with excessive worry

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable.

Key learning aims

(1)

Efficacy and acceptability of parent-only group cognitive behavioral intervention for treatment of anxiety disorder in children and adolescents: a meta-analysis of randomized controlled trials

BACKGROUND

Anxiety disorder is the most prevalent mental disorder among children and adolescents, causing significant psychosocial problems and physical health conditions. Cognitive behavioral therapy (CBT) is an effective treatment for anxiety disorder in children and adolescents. And parent-only CBT is an alternative treatment for childhood anxiety disorder, which includes psychologists and parents rather than children in the treatment. As a new type of CBT, parent-only CBT has some advantages. However, it remains unclear whether parent-only CBT interventions are effective for treating children and adolescents with anxiety disorder.

METHODS

In this study, we evaluated the efficacy (the mean change scores of the anxiety rating scale from baseline to post-treatment, standardized mean difference SMD) and acceptability (the proportion of patients in the treatment group who withdrew from treatment early for any reason, risk ratios RRs) of parent-only cognitive behavioral therapy (CBT) for children and adolescents with anxiety disorder. We searched electronic databases, including PubMed, Cochrane Library, Embase, Web of Science, ProQuest, and PsycINFO from inception to June 2019. We included randomized controlled trials (RCTs) comparing parent-only CBT either with waitlist (WL), or CBT with parents in children and adolescents with anxiety disorder.

RESULTS

Finally, six RCTs with 407 participants were included in the meta-analyses. In terms of efficacy, pooled analyses indicated that parent-only CBT was significantly more effective than WL for reducing anxiety symptoms with SMD of - 0.72 (95% CI - 1.41 to - 0.03, p = 0.04), and more remission rate with RR of 4.33 (37.96% vs. 6.85, 95% CI 1.82 to 10.27, p = 0.0009) at post-treatment. And our analyses showed no evidence that parent-only CBT had significantly greater efficacy than CBT with parents with SMD of 0.21 (95% CI - 0.09 to 0.50, p = 0.17). Acceptability in the parent-only CBT group was not significantly different to the WL group with RR of 0.92 (95% CI 0.52 to 1.62, p = 0.77), and was significantly worse than in the CBT with parents group with RR of 1.93 (95% CI 1.05 to 3.57, p = 0.03).

CONCLUSIONS

Current evidence indicates that parent-only CBT can be an alternative and acceptable intervention for treating children and adolescents with anxiety disorder.

Maternal Depression and Mother-Child Oxytocin Synchrony in Youth with Anxiety Disorders

The neuropeptide oxytocin (OT) plays a central role in the regulation of affiliative bonds and anxiety. However, the degree to which its levels are synchronized between interaction partners has not yet been assessed. Physiological synchrony assessed using other peripheral measures (e.g., heart rate, etc.) has been tied to positive outcomes for the individual and the dyad. The present study examined OT synchrony in the context of child anxiety and maternal depression by examining mother-child dyads. Mothers and their children with anxiety disorders participated in a behavioral interaction task. Changes in OT levels and mother-child OT synchrony before and after the interaction, as well as their moderation by maternal depression, were assessed. Ninety-eight youth with anxiety disorders (ages 10 to 17) and their mothers underwent psychiatric evaluation, and mothers rated their own depressive symptoms and their children's behavior problems. Salivary OT was assayed from mother and child before and after the task. Behavioral coding showed that interactions were characterized by high behavioral synchrony between mothers and their children, and both individuals displayed higher levels of positive vs. negative affect during the interactions. Mothers and their children also showed decreases in OT levels after the interaction. As hypothesized, OT synchrony increased following the task, but only dyads in which mothers showed high levels of depressive symptoms showed this increase. As hypothesized, lower levels of OT-synchrony were associated with higher levels of child internalizing symptoms. The findings suggest that positive interactions may be beneficial for youth with anxiety disorders with mothers with depression.

Therapieprozesse in der Kinder- und Jugendlichenpsychotherapie

Zusammenfassung. Theoretischer Hintergrund: Die Psychotherapieforschung zu therapeutischen Wirkfaktoren bei Kindern steckt in den Kinderschuhen. Mit dem Stundenbogen für Kinder und Jugendliche Patientenversion (SBKJ-P) wurde ein entsprechendes Messinstrument entwickelt. Die erfassten Wirkfaktoren sind Problemaktualisierung, Ressourcenaktivierung, Problembewältigung, motivationale Klärung als auch Rolle der Eltern und therapeutische Allianz. Fragestellung: Untersucht werden die Faktorstruktur, interne Konsistenz und konvergente Validität. Methode: Die Stichprobe umfasst 123 Kinder und Jugendliche (62 Mädchen) im Alter zwischen 7 und 18 Jahren ( MW = 13.1, SD = 3.03). Ergebnisse: Die Ergebnisse zeigen, dass der SBKJ-P ein verständliches, reliables und valides Instrument für die Prozess- und Verlaufsmessung von allgemeinen therapeutischen Wirkfaktoren darstellt. Diskussion und Schlussfolgerung: Der SBKJ-P erlaubt eine zuverlässige Einschätzung der Qualitätssicherung im psychotherapeutischen Prozess.

Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis

Various Cognitive Behavioral Therapy (CBT) programs for externalizing disorders in children and adolescents are supported by a substantial body of empirical evidence. Most of the research evidence comes from efficacy studies conducted in university settings, but there is less knowledge about the effect of these treatments in routine clinical care. The purpose of this meta-analysis was to investigate the effectiveness of CBT in non-university settings for Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Embase OVID, Ovid MEDLINE and PsycINFO were systematically searched for eligible studies published up to May 2020. In total, 51 treatment effectiveness studies involving 5295 patients were included. The average within-group effect size at post-treatment was significant (g = 0.91), and there were large effect sizes for both ADHD (g = 0.80) and CD/ODD (g = 0.98). At post treatment, remission rates were 38% for ADHD and 48% for CD/ODD, and the overall attrition rate was 14%. Benchmarking against efficacy studies showed that CBT in routine clinical care yields remission rates, within-group effect sizes and attrition rates that are very similar to those found in university settings. The findings support the transportability of CBT for externalizing disorders from university settings to routine clinical care. PROSPERO registration: CRD42020147524.

Cognitive behavior therapy for internalizing disorders in children and adolescents in routine clinical care: A systematic review and meta-analysis

Cognitive behavioral therapy (CBT) has received considerable empirical support for internalizing disorders including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder in children and adolescents. However, there is less knowledge regarding how CBT performs when delivered in routine clinical care. A systematic review and meta-analysis was conducted of CBT for internalizing disorders in children and adolescents in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for articles published until October 2019. The effectiveness of CBT, methodological quality, and moderators of treatment outcome were examined. The effects of CBT in routine clinical care were benchmarked by comparing with efficacy studies for the same disorders. Fifty-eight studies were included, comprising 4618 participants. Large effect sizes for outcome were detected at post-treatment (g = 1.28-2.54), and follow-up (g = 1.72-3.36). Remission rates across diagnoses ranged from 50.7% - 77.4% post-treatment, to 53.5% -83.3% at follow-up. Attrition rate across the disorders was 12.2%. Quality of the included studies was fair, and heterogeneity was high. Similarities between the effectiveness and efficacy studies were greater than the differences in outcome. CBT delivered in routine clinical care is efficacious in reducing internalizing disorders and symptoms. The outcomes are comparable with results obtained in efficacy studies. PROSPERO registration: ID CRD42019128709.

Feasibility of group-based acceptance and commitment therapy for adolescents (AHEAD) with multiple functional somatic syndromes: a pilot study

BACKGROUND

Recurrent and impairing functional somatic syndromes (FSS) are common in adolescents. Despite a high need for care, empirically supported treatments are lacking for youth. The aim of this uncontrolled pilot study was to assess feasibility and treatment potential of a new intervention with group-based Acceptance and Commitment Therapy (ACT) in a generic treatment approach for adolescents with multiple FSS.

METHODS

Twenty-one patients received 'ACT for Health in Adolescents' (AHEAD) (30 h), specifically developed for adolescents (aged 15-19 years) with moderate to severe FSS. Close relatives attended an information meeting to facilitate support of the patients throughout treatment. Treatment satisfaction was evaluated by means of self-report and relatives' impressions. Self-reported physical health at 3 months follow-up (FU) after end of treatment was the primary outcome whereas secondary outcomes included symptom burden, limitation due to symptoms, illness worry, emotional distress and physical and emotional symptoms. Treatment targets were assessed by measures on illness behaviour, illness perception and psychological inflexibility.

RESULTS

Nineteen patients (90.5%) completed the treatment with a high overall attendance rate of 93%. All would recommend the treatment to a friend with similar problems. Close relatives rated it valuable to participate in an information meeting. Patients' physical health improved significantly from assessment to FU with a clinically relevant mean change of 8.9 points (95% CI [5.4; 12.4]; SRM 0.91 [0.26;1.57]). Improvement was also seen on all secondary outcome measures, from assessment to FU. Maladaptive illness behaviours and perceptions as well as psychological inflexibility showed a significant decline from assessment to FU.

CONCLUSION

AHEAD was feasible and potentially efficacious and warrants testing in a larger clinical trial.

TRIAL REGISTRATION

Clinical Trials gov NCT04464447 , registration date July 9th, 2020. Retrospectively registered.

A Systematic Review of Parental Involvement in Cognitive Behavioural Therapy for Adolescent Anxiety Disorders

Anxiety disorders are common among adolescents and lead to poor long-term outcomes. Cognitive Behavioural Therapy (CBT) is an evidenced-based intervention for adolescent anxiety disorders, but little is known about whether and how parents should be involved. This systematic review evaluated how parents have been involved and associated treatment outcomes in studies of CBT for adolescent anxiety disorders. Electronic systematic searches were conducted in PsycINFO, Embase, CINAHL, Medline, AMED databases, to identify studies investigating CBT for adolescent anxiety disorder(s) that included parents in treatment. Twenty-three papers were identified. Parents were involved in treatment in a number of different ways: by attending separate parent sessions, joint parent–adolescent sessions, or both, or through provision of a workbook while attending some adolescent sessions. Content varied but was most typically aimed at the parent developing an understanding of core CBT components and skills to help them manage their adolescent’s anxiety and avoidance. Treatment outcomes indicate that CBT with parental involvement is an effective intervention for adolescent anxiety disorders; however, it is not possible to draw conclusions regarding whether parental involvement (generally or in any particular form) enhances treatment outcomes. Poor reporting and methodological issues also limit the conclusions. Further research is required to identify whether there are particular types of parental involvement in CBT that bring clinical benefits to adolescents with anxiety disorders generally, as well as in particular circumstances.

Separating From the Mothership: A Coordinated Individual and Parent-Based Approach to Severe Agoraphobia in a Young Adult

Families are invested in an older adolescent gradually separating from the family to live independently as an adult, but for many families, adolescent psychopathology makes this transition difficult. Addressing such psychopathology is critical in preventing "failure to launch," a breakdown in gaining age-appropriate independence from parents. This case study illustrates a promising approach directed at helping an 18-year-old female with agoraphobia and panic disorder who, upon intake, was at risk for long-lasting, prohibitive dependence on her parents. The clinical approach entails the convergence of two psychological treatments conducted in the same treatment center. One provider, working directly with the patient, delivered traditional cognitive-behavioral therapy (CBT) for anxiety. A second provider, working with the parents, delivered Supportive Parenting for Anxious Childhood Emotions (SPACE) a parent-based treatment focused on reducing family accommodation of the patient's anxiety. Behavioral indices and self-report scores indicated clinically significant improvement following the combined intervention. Attention is drawn to the convergence of those treatments and the utility and special considerations in taking this kind of approach. Overall, the combined treatment may have been more successful than the sum of its parts at preventing failure to launch. This case study, the first to describe the integration of CBT and SPACE, can provide useful guidance for clinicians helping families of adult children to transition to independence.

Practitioner Review: Anxiety disorders in children and young people - assessment and treatment

Despite significant advancements in our knowledge of anxiety disorders in children and adolescents, they continue to be underrecognised and undertreated. It is critical that these disorders are taken seriously in children and young people as they are highly prevalent, have a negative impact on educational, social and health functioning, create a risk of ongoing anxiety and other mental health disorders across the life span and are associated with substantial economic burden. Yet very few children with anxiety disorders access evidence-based treatments, and there is an urgent need for widespread implementation of effective interventions. This review aimed to provide an overview of recent research developments that will be relevant to clinicians and policymakers, particularly focusing on the development and maintenance of child anxiety disorders and considerations for assessment and treatment. Given the critical need to increase access to effective support, we hope this review will contribute to driving forward a step change in treatment delivery for children and young people with anxiety disorders and their families.

How to Optimise Cognitive Behaviour Therapy (CBT) for People with Autism Spectrum Disorders (ASD): A Delphi Study

Children and adults with autism spectrum disorders (ASD) can benefit from cognitive behaviour therapy (CBT), yet the prevailing opinion is that this requires adaptations to accommodate commonly experienced socio-communication and neuropsychological impairments. There are, however, no empirically-derived guidelines about how best to adapt standard practice. In a three round Delphi survey, we asked expert clinicians and clinical-researchers, based in England, about how to optimise the design, delivery and evaluation of CBT for people with ASD. Of 50 people approached, 18 consented to take part in Round 1, nine in Round 2 and eight in Round 3. Using a five-point scale, participants rated the degree to which 221 statements—pertaining to the referral process, assessment, engagement, formulation, goal setting, therapy structure, interventions and techniques, homework, outcome measurement, managing endings and therapist attributes—were integral to CBT. The consensus was that 155 statements represented essential or important components of CBT. Adaptations to the structure and process of therapy were consistently endorsed, and an individualised formulation-derived approach was favoured when deciding upon which interventions and techniques to offer. Further studies are needed to clarify if adapted CBT is associated with improved treatment outcomes and acceptability.

Group- versus Parent-Involvement CBT for Childhood Anxiety Disorders: Treatment Specificity and Long-term Recovery Mediation

Objective

Treatment specificity and long-term recovery mediation of peer-involvement group cognitive behavioral therapy (GCBT) and parent-involvement CBT (PCBT) were investigated for youth anxiety disorders.

Method

240 youths with primary anxiety diagnoses participated in a randomized controlled efficacy trial. Youth anxiety and peer variables/mediators (positive peer-youth relationships; social skills), and parent variables/mediators (psychological control; negative parent-youth relationships) were assessed.

Results

At posttreatment and 12-month follow up, positive peer-youth relationships were significantly higher in GCBT than PCBT (specificity). At posttreatment, not follow up, parental psychological control was significantly lower in PCBT than GCBT (specificity). Parental psychological control and positive peer-youth relationships were putative mediators. The two CBTs produced similar anxiety reductions through different mechanisms.

Conclusions

CBT targets show specificity and mediation, providing insight into specific mechanisms through which GCBT and PCBT bring about anxiety reduction and guidance for streamlining these CBTs in practice.

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

IMPORTANCE

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

OBJECTIVE

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION AND SYNTHESIS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

TRIAL REGISTRATION

PROSPERO Identifier: CRD42015016283.

Internet-delivered cognitive behavioural therapy for young children with obsessive-compulsive disorder: development and initial evaluation of the BIP OCD Junior programme

BACKGROUND

Internet-delivered cognitive behavioural therapy (ICBT) is a promising approach for increasing access to evidence-based treatments.

AIMS

To develop and evaluate the feasibility and preliminary efficacy of an ICBT programme for young children with obsessive-compulsive disorder (OCD), named BIP OCD Junior.

METHOD

Eleven children aged 7-11 years were enrolled in a 12-week open trial of parent- and therapist-guided ICBT for OCD. The primary outcome measure was the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS).

RESULTS

There was a significant improvement in OCD symptoms post-treatment, with a large within-group effect size on the CY-BOCS (Cohen's d = 1.86, 95% CI 0.83 to 2.86). Results were maintained at 3-month follow-up. Both children and parents rated the treatment as credible and were highly satisfied with the intervention.

CONCLUSIONS

BIP OCD Junior is a feasible and credible treatment option for young children with OCD. Randomised controlled trials are needed to further establish its efficacy and cost-effectiveness relative to gold standard face-to-face CBT.

DECLARATION OF INTEREST

None.

Treatment Features Associated with Youth Cognitive Behavioral Therapy Follow-Up Effects for Internalizing Disorders: A Meta-Analysis

Our aim was to investigate whether four treatment features (i.e., the inclusion of parental involvement, goal-setting strategies, maintenance/relapse prevention sessions, the addition of booster sessions) were associated with posttreatment and follow-up effect size of youth cognitive behavioral therapies (yCBTs) for anxiety, depression, posttraumatic stress disorder, and obsessive-compulsive disorder in age groups spanning young children to adolescents. We conducted a random-effects meta-analysis of 106 yCBTs tested in 76 randomized clinical trials from the PracticeWise Database to examine average effects of yCBTs posttreatment and at a later follow-up assessment. We coded the use of parental involvement, goal setting, booster sessions, and maintenance/relapse prevention in each yCBT and conducted random-effects meta-regression analyses to investigate whether these treatment features were associated with yCBT effects at posttreatment as well as at follow-up. Overall, yCBTs produced large pre- to posttreatment effects (d = 1.05), 95% confidence interval [0.94, 1.15], and larger pre- to follow-up effects (d = 1.29), 95% confidence interval [1.18, 1.40]. Metaregression results indicated that parental involvement was significantly associated with larger pre- to posttreatment effect sizes as well as pre- to follow-up effect sizes. Booster sessions, goal setting, and maintenance/relapse prevention were not significantly related to effect sizes at posttreatment or follow-up. Parental involvement may be helpful for maximizing long-term effectiveness of yCBT. Future studies should investigate for whom and under what conditions inclusion of yCBT treatment features is related to the durability of treatment gains.

Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis

Anxiety disorders are among the most common disorders affecting youths in the general population, with up to 10% of children and 20% of adolescents meeting criteria for an anxiety disorder at any one point in time. Cognitive-behavior therapies (CBT), varying between 9 and 18 weeks of treatment, are considered evidence-based for the treatment of anxiety disorders in youth. During the last two decades treatments that are brief, intensive, or concentrated (BIC) have been developed and this meta-analysis includes 23 RCTs of these new approaches across the anxiety disorders. BIC yielded a lower attrition (2.3%) than standard CBT (6.5%). The effect sizes (ES) for comparison of BIC with waiting-list (1.47) and placebo (0.91) were significant, whereas that with standard CBT (0.01) was not. Regarding remission at post/recovery at follow-up BIC (54%/64%) and standard CBT (57%/63%) were comparable and both were significantly higher than placebo (26%/35%), which was higher than WLC (7%/9%). Within-group ES at post and follow-up were 1.50 and 1.53 for BIC, and 0.98 and 1.05 for standard CBT, indicating maintenance of the effects up to 12 months after therapy. Advantages and disadvantages of BIC are discussed and we suggest that BIC-interventions represent a paradigm shift in the delivery of services for youth with anxiety disorders.

Parental acculturation level moderates outcome in peer-involved and parent-involved CBT for anxiety disorders in Latino youth

Cognitive behavioral therapies (CBTs) are efficacious treatments for anxiety disorders in Latino youth. However, there is a gap in knowledge about moderators of CBT outcomes in Latino youth. This study addresses this gap by examining parental acculturation as a moderator of youth anxiety outcomes in a randomized controlled trial of parent-involved CBT (CBT/P) and peer-involved group CBT (GCBT) in 139 Latino youth (ages 6 to 16 years; mean age = 9.68 years). Comparable youth anxiety reduction effects were found for CBT/P and GCBT. Parental acculturation to majority US culture, but not identification with country of origin, significantly moderated youth anxiety outcomes: at low levels of parental acculturation to majority US culture, youth posttreatment anxiety scores were lower in GCBT than CBT/P; at high levels of parental acculturation to majority US culture, youth posttreatment anxiety scores were lower in CBT/P than GCBT. These findings provide further evidence for the efficacy of CBTs for anxiety disorders in Latino youth and also provide guidance for moving toward personalization of CBTs' selection depending on parental acculturation levels.

Efficacy of cognitive-behavioral therapy for childhood anxiety and depression

A review of meta-analyses of cognitive-behavioral therapy (CBT) for childhood anxiety and depression was conducted. A total of 36 meta-analyses were identified that met inclusion criteria for this review. In most cases, medium-to-large effect sizes for treatment reduction were observed when CBT was compared to non-active control conditions. Small-to-medium effects were observed when CBT was compared to active control treatments. The available meta-analyses generally did not examine, or data were not sufficient to evaluate, potential moderators of outcome, differential effects for parental involvement, or changes in quality of life or functional outcomes associated with treatment. Accordingly, while CBT should be broadly considered an effective treatment approach for childhood anxiety and depression, additional research is warranted in order to establish guidelines for service delivery for complicating factors in client presentation.

Cognitive behavioral and pharmacological treatments of OCD in children: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) is ranked by the World Health Organization (WHO) among the 10 most debilitating disorders. The treatments which have been found effective are cognitive behavior therapy (CBT) and serotonin reuptake inhibitors (SRI). This meta-analysis includes all RCTs of CBT (25) and SRI (9) for OCD in youth using the Children's Yale-Brown Obsessive Compulsive Scale (C-YBOCS). CBT yielded significantly lower attrition (12.7%) than SRI (23.5%) and placebo (24.7%). The effect sizes for comparisons of CBT with waiting-list (1.53), placebo (0.93), and SRI with placebo (0.51) were significant, whereas CBT vs. SRI (0.22) and Combo (CBT+SRI) vs. CBT (0.14) were not. Regarding response rate CBT (70%) and Combo (66%) were significantly higher than SRI (49%), which was higher than placebo (29%) and WLC (13%). As for remission CBT (53%) and Combo (49%) were significantly higher than SRI (24%), placebo (15%), and WLC (10%), which did not differ from each other. Combo was not more effective than CBT alone irrespective of initial severity of the samples. The randomized controlled trials (RCTs) have a number of methodological problems and recommendations for improving research methodology are discussed as well as clinical implications of the findings.

Mütterliches Expressed Emotion und elterliche Angst vor negativer Bewertung bei Kindern mit sozialer Angststörung

Zusammenfassung. Theoretischer Hintergrund: Ziel dieser Studie ist die Untersuchung von Expressed Emotion (EE) als Faktor des familiären Klimas sowie elterlicher Angst vor negativer Bewertung des Kindes als potentieller Mediator für den Zusammenhang von sozialer Angst der Eltern und Kinder. Methode: Kinder mit Sozialer Angststörung (SAS; n = 64) und ohne SAS (healthy control, HC, n = 52) sowie deren Eltern (Mütter und Väter) berichteten über eigene soziale Ängste und ihre Angst vor negativer Bewertung des Kindes. Mütter nahmen zudem am Five Minute Speech Sample (FMSS) zur Erhebung von EE teil. Ergebnisse: Berichte von Müttern von Kindern mit einer SAS wurden häufiger als High Expressed Emotion (HEE) eingestuft als Berichte von Müttern von HC Kindern. Es zeigte sich ein Zusammenhang von EE und sozialer Angst der Mutter wie auch mütterlicher Angst vor negativer Bewertung des Kindes. Zudem wurde der Zusammenhang zwischen kindlicher und mütterlicher sozialer Angst partiell durch die Angst vor negativer Bewertung des Kindes mediiert. Schlussfolgerungen: Es konnte ein Zusammenhang von kindlicher SAS und gleichzeitig erhöhtem EE der Mütter gezeigt werden. Erhöhte Angst vor negativer Bewertung des Kindes stellt einen potenziellen Mechanismus dar, wie mütterliche, nicht aber väterliche, soziale Angst an das Kind vermittelt werden kann.

Psychological Inflexibility and Child Anxiety

Psychological flexibility is the main outcome of acceptance commitment therapy. Insight into the usefulness of measuring psychological flexibility is an important step to enable studies on the effectiveness of acceptance commitment therapy in middle-aged children (8-10 years). For this purpose, we examined the factor structure, the construct validity and the reliability of the Avoidance and Fusion Questionnaire for Youth. The Avoidance and Fusion Questionnaire for Youth taps psychological inflexibility (the opposite of psychological flexibility) in children and adolescents. Although the questionnaire has been extensively validated in older children, this is not the case for middle-aged children. The Avoidance and Fusion Questionnaire for Youth contains 17 items and is constituted of the subscales cognitive fusion, experiential avoidance and behavioral ineffectiveness. A shortened 8-item version also exists, the Avoidance and Fusion Questionnaire for Youth-8, which does not distinguish between these subscales. We performed a confirmatory factor analysis. Additionally, we assessed the relationship between psychological flexibility and child anxiety. Children, aged 8-10 years, were recruited via regular primary schools. Of the 459 approached children, 267 (58 %) parents signed informed consents for their children (Age: M = 9.18; SD = .79; Sex: n_boys = 137, 51 %). Children completed the questionnaires during regular classes. In this sample, the 17-item version of the Avoidance and Fusion Questionnaire for Youth was less appropriate for measuring psychological inflexibility than the 8-item version. Furthermore, we found a significant positive relationship between psychological inflexibility and child anxiety. We argue that acceptance commitment therapy would be an interesting candidate for intervening early on in dysfunctional child anxiety, as acceptance commitment therapy's cognitive elements require cognitive skills that children are likely to master early on.

Parents' difficulties as co-therapists in CBT among non-responding youths with anxiety disorders: Parent and therapist experiences

No increased effect has been associated with parent involvement in cognitive behavioral therapy (CBT) for youths with anxiety disorders. The purpose of this study was to explore parent and therapist experiences of CBT among non-responding youths with anxiety disorders, with a primary focus on parent involvement in therapy. Interpretative phenomenological analysis was applied to 24 sets of semi-structured interviews with families and therapists of anxiety-disordered youths who had not profited from CBT with parental inclusion. From the superordinate theme parents' difficulties acting as co-therapists, which emerged from the analyses, two master themes represented the perspectives of parents (difficulty working together with the youth and feeling unqualified, with limited resources), and two represented the perspectives of therapists (family dynamics stood in the way of progress and difficulty transferring control to parents). Parent and therapist experiences complemented each other, offering two different perspectives on parent difficulties as co-therapists. However, the two groups' views on their respective roles in therapy were in conflict. Parents wished to remain being "just the parents" and for the experts to take over, while therapists wished to act as facilitators transferring the control to parents. Clinical implications are drawn for parental involvement and enhancement of treatment outcomes for likely non-responders.

Efficacy of a Danish version of the Cool Kids program: a randomized wait-list controlled trial

OBJECTIVE

The purpose of the study was to evaluate the efficacy of a Danish version of the Cool Kids program, a generic manualized group cognitive-behavioural therapy (CBT) program for anxiety disorders among children and adolescents.

METHOD

Children and adolescents (age 7-16) with a primary anxiety disorder diagnosis (n = 109) were randomly allocated to group CBT or a wait-list (WL) control condition at a Danish university clinic.

RESULTS

Results showed that the Danish version of the Cool Kids program was efficacious with 48.2% free of all anxiety diagnoses at post-treatment, compared with 5.7% in the WL condition, and large effect sizes on self-report measures of child anxiety symptoms rated by child, mother, and father (ηp2 range = 0.18-0.24). Children and adolescents improved further from post-treatment to 3-month follow-up, and this improvement was maintained at 12-month follow-up. Participants with a primary diagnosis of social phobia (SoP) showed less improvement compared with other anxiety diagnoses.

CONCLUSION

The study contributes to the evidence base for the Cool Kids program, previously only evaluated by its developers in Australia. Generic group CBT programs may not be the most appropriate treatment for children and adolescents with primary SoP.

The Effect of Child Distress on Accommodation of Anxiety: Relations With Maternal Beliefs, Empathy, and Anxiety

Little is known about the influence of child behaviors on accommodation of anxiety and how accommodation relates to other parent factors. The present study examined the comparative effect of high and low levels of child distress on mother-reported accommodation, mother factors in relation to accommodation, and moderators of the relation between accommodation and child distress. Maternal perceptions of accommodation were measured by vignettes depicting youth exhibiting high or low levels of distress in anxiety-provoking situations that elicited social anxiety, generalized anxiety, or separation anxiety in a sample of 7- to 17-year-old youth with anxiety disorders (N = 70, M = 11.66, 47.1% male). Findings indicated an effect of child distress on mother-reported accommodation of youth anxiety, such that mothers reported more overall accommodation under conditions of high child distress; situation-level analyses revealed this effect for social and generalized anxiety situations. Furthermore, an association was found between greater mother-reported accommodation and more negative beliefs about their child's experience of anxiety, which held across situations. Maternal empathy moderated the relation between overall accommodation and child distress. Maternal anxiety also moderated the relation between accommodation and child distress, with results varying based on situation type. Findings, consistent with theory, indicate a relation between child distress and mother-reported accommodation and suggest that maternal beliefs about anxiety are an important treatment target. High maternal empathy may be related to a greater degree of adaptability in response to child behaviors, whereas maternal anxiety may be linked with less adaptive responses to child behaviors.