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Skumsnes T, Fjermestad KW, Wergeland GJ, Aalberg M, Heiervang ER, Kodal A, Ingul JM. Behavioral Inhibition and Social Anxiety Disorder as Predictors of Long-Term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders. Res Child Adolesc Psychopathol 2024:10.1007/s10802-024-01215-8. [PMID: 38869750 DOI: 10.1007/s10802-024-01215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/14/2024]
Abstract
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.
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Affiliation(s)
- Toril Skumsnes
- Tynset Child and Adolescents Mental Health Service, Innlandet Hospital Trust, Tynset, Norway.
- Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway.
| | | | - Gro Janne Wergeland
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Marianne Aalberg
- Department for Research and Development, Division of Mental Health and Substance Use, Akershus University Hospital, Oslo, Norway
| | - Einar R Heiervang
- Tynset Child and Adolescents Mental Health Service, Innlandet Hospital Trust, Tynset, Norway
| | - Arne Kodal
- Regional Centre for Child and Youth Mental Health and Child Welfare, NORCE Norwegian Research Centre, Bergen, Norway
| | - Jo Magne Ingul
- Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
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2
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Lei J, Leigh E, Charman T, Russell A, Hollocks MJ. Understanding the relationship between social camouflaging in autism and safety behaviours in social anxiety in autistic and non-autistic adolescents. J Child Psychol Psychiatry 2024; 65:285-297. [PMID: 37632264 DOI: 10.1111/jcpp.13884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Social camouflaging (hereafter camouflaging) in autism includes factors such as masking and compensating for one's neurodevelopmental differences, and to assimilate or 'fit in' with non-autistic peers. Efforts to hide one's authentic self and autism traits (masking) resemble impression management (IM) in safety behaviours identified in Clark and Wells' (1995) cognitive model of social anxiety (SA). This study explores the relationship between camouflaging in autism and safety behaviours in SA among autistic and non-autistic adolescents. METHODS One hundred fifteen adolescents (14-19 years) with (n = 61; 36 female) and without (n = 54; 37 female) a clinical diagnosis of autism matched on age and SA symptom severity were recruited from clinics, schools and online. Adolescents completed online measures including autism traits, SA symptoms, camouflaging behaviours, SA-related safety behaviours and SA-related negative cognitions. Partial and bivariate Pearson's correlations and structural equation modelling were used to understand the relationship between camouflaging, safety behaviours, autism traits and SA in both groups. Exploratory factor analysis assessed item-level factor cross-loadings between camouflaging and safety behaviours. RESULTS Across both groups, masking and IM were significantly associated with SA symptom severity, not autism traits, via SA-related social cognitions. Exploratory factor analysis indicated construct overlap across masking, assimilation, IM and avoidance behaviours and identified factors analogous to self-focused attention, social avoidance and mental rehearsal identified in the Clark and Wells' (1995) model of SA. CONCLUSIONS This is the first study using group-matched design to identify that masking (factor in social camouflaging) and IM both relate to SA in autistic and non-autistic adolescents. Assessment and formulation of construct overlap between masking and IM may inform psychoeducation and adaptation of SA treatment for autistic adolescents.
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Affiliation(s)
- Jiedi Lei
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Trust, London, UK
| | - Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Tony Charman
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Trust, London, UK
| | - Ailsa Russell
- Department of Psychology, Centre for Applied Autism Research, University of Bath, Bath, UK
| | - Matthew J Hollocks
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London and Maudsley NHS Trust, London, UK
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3
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Leigh LH, Doyle FL, Hudson JL. Increasing the Efficacy of Treatment for Socially Anxious Youth Through Theoretically Derived Improvements: A Pilot Study. Child Psychiatry Hum Dev 2023; 54:1653-1665. [PMID: 35507090 PMCID: PMC10582123 DOI: 10.1007/s10578-022-01351-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Lynda H Leigh
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, Australia
| | - Frances L Doyle
- MARCS Institute for Brain, Behaviour and Development, School of Psychology, Western Sydney University, Penrith, Australia
| | - Jennifer L Hudson
- Black Dog Institute, University of New South Wales, Sydney, Australia.
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Leigh E, Nicol-Harper R, Travlou M, Clark DM. Adolescents' experience of receiving internet-delivered cognitive therapy for social anxiety disorder. Internet Interv 2023; 34:100664. [PMID: 37720914 PMCID: PMC10502334 DOI: 10.1016/j.invent.2023.100664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023] Open
Abstract
Background Social anxiety disorder (SAD) is a debilitating condition that usually begins in adolescence. We recently demonstrated preliminary efficacy of an internet-delivered therapist-assisted version of Cognitive Therapy for Social Anxiety Disorder (SAD) for adolescents called Online Social anxiety Cognitive therapy for Adolescents (OSCA). Here we report on the helpfulness, support, and overall acceptability of OSCA from the perspective of trial participants. Methods Participants were 17 young people aged 15-18 years who had participated in a trial of OSCA. Post-treatment, participants completed an online treatment acceptability questionnaire and took part in a semi-structured interview to gain an understanding of their experience of OSCA. Results Overall, there was a very high rate of treatment satisfaction. Core aspects of the treatment were viewed as most helpful, including behavioural experiments even though participants found them challenging. Participants found the online nature of the treatment helpful, allowing for easier communication with the therapist, regular encouragement from the therapist, and the ability to go back to their treatment and view their progress. Challenges were, for some, the quantity of content and practical issues around scheduling the short weekly calls with their therapist. Conclusions This study suggests that young people felt helped and supported by OSCA.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford Health NHS Foundation Trust, UK
| | | | - Mariana Travlou
- Department of Experimental Psychology, University of Oxford, UK
| | - David M. Clark
- Department of Experimental Psychology, University of Oxford, UK
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5
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Biagianti B, Conelea C, Dabit S, Ross D, Beard KL, Harris E, Shen E, Jordan J, Bernstein GA. A Mobile Application Adjunct to Augment Cognitive-Behavioral Group Therapy for Adolescents with Social Anxiety: Feasibility and Acceptability Results from the Wiring Adolescents with Social Anxiety via Behavioral Interventions Pilot Trial. J Child Adolesc Psychopharmacol 2023; 33:212-224. [PMID: 37471177 PMCID: PMC10458379 DOI: 10.1089/cap.2023.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Objective: Cognitive-Behavioral Group Therapy (CBGT) is an established treatment for Social Anxiety (SA). However, diagnostic recovery rate is only 20.5% in CBGT, and up to 50% of patients remain symptomatic posttreatment. Using videocalls to deliver digital CBGT (dCBGT) is feasible, cost-effective, and efficacious. Yet, the impact of dCBGT on social functioning remains limited, as dCBGT does not offer opportunities for monitoring cognition and behavior in social situations. Wiring Adolescents with Social Anxiety via Behavioral Interventions (WASABI), a clinician-assisted application that uses ecological momentary assessments (EMAs), cognitive bias tests, and clinical self-reports, was investigated as an adjunct to dCBGT. Methods: A prospective, parallel arm, double-blind randomized controlled trial was employed in 24 SA adolescents randomly assigned to dCBGT versus dCBGT plus WASABI. Results: Study completion rates (83%) and exit survey data indicated that WASABI is feasible and acceptable. Engagement with EMAs varied from four to 244 EMAs completed per person. Cognitive bias tests and clinical self-reports were completed at least weekly by 53% and 69% of participants, respectively. While standard tests did not reveal statistically significant differences between dCBGT plus WASABI and dCBGT alone, effect sizes were greater for dCBGT plus WASABI on symptom severity, social skills, and functioning. Conclusions: Despite the small sample, preliminary results suggest that WASABI is feasible, acceptable, and may be an effective augmentation tool for treating SA in teenagers.
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Affiliation(s)
- Bruno Biagianti
- Department of Psychology, University of Milano-Bicocca, Milan, Italy
| | - Christine Conelea
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Sawsan Dabit
- Department of R&D, Posit Science Corporation, San Francisco, California, USA
| | - Daniel Ross
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Katie L. Beard
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Elizabeth Harris
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Erin Shen
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
| | - Josh Jordan
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
| | - Gail A. Bernstein
- Department of Psychiatry & Behavioral Sciences, University of Minnesota Medical School, Masonic Institute for the Developing Brain, Minneapolis, Minnesota, USA
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Clark DM, Wild J, Warnock-Parkes E, Stott R, Grey N, Thew G, Ehlers A. More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder. Psychol Med 2023; 53:5022-5032. [PMID: 35835726 PMCID: PMC10476054 DOI: 10.1017/s0033291722002008] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/01/2022] [Accepted: 06/13/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Cognitive therapy for social anxiety disorder (CT-SAD) is recommended by NICE (2013) as a first-line intervention. Take up in routine services is limited by the need for up to 14 ninety-min face-to-face sessions, some of which are out of the office. An internet-based version of the treatment (iCT-SAD) with remote therapist support may achieve similar outcomes with less therapist time. METHODS 102 patients with social anxiety disorder were randomised to iCT-SAD, CT-SAD, or waitlist (WAIT) control, each for 14 weeks. WAIT patients were randomised to the treatments after wait. Assessments were at pre-treatment/wait, midtreatment/wait, posttreatment/wait, and follow-ups 3 & 12 months after treatment. The pre-registered (ISRCTN 95 458 747) primary outcome was the social anxiety disorder composite, which combines 6 independent assessor and patient self-report scales of social anxiety. Secondary outcomes included disability, general anxiety, depression and a behaviour test. RESULTS CT-SAD and iCT-SAD were both superior to WAIT on all measures. iCT-SAD did not differ from CT-SAD on the primary outcome at post-treatment or follow-up. Total therapist time in iCT-SAD was 6.45 h. CT-SAD required 15.8 h for the same reduction in social anxiety. Mediation analysis indicated that change in process variables specified in cognitive models accounted for 60% of the improvements associated with either treatment. Unlike the primary outcome, there was a significant but small difference in favour of CT-SAD on the behaviour test. CONCLUSIONS When compared to conventional face-to-face therapy, iCT-SAD can more than double the amount of symptom change associated with each therapist hour.
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Affiliation(s)
- David M. Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Jennifer Wild
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Emma Warnock-Parkes
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK
| | - Richard Stott
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK
| | - Nick Grey
- Sussex Partnership NHS Foundation Trust, Worthing, West Sussex, UK
| | - Graham Thew
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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7
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Thew GR, Ehlers A, Clark DM. Sudden gains in face-to-face and internet-based cognitive therapy for social anxiety disorder. Behav Res Ther 2023; 166:104334. [PMID: 37210886 PMCID: PMC10933765 DOI: 10.1016/j.brat.2023.104334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 12/10/2022] [Accepted: 05/10/2023] [Indexed: 05/23/2023]
Abstract
Sudden gains are large and stable decreases in clinical symptoms between consecutive therapy sessions. This work examined the frequency and possible determinants of sudden gains in Cognitive Therapy for Social Anxiety Disorder, comparing face-to-face (CT) and internet-based (iCT) formats of treatment delivery. Data from 99 participants from a randomised controlled trial were analysed. The frequency of sudden gains was high: 64% and 51% of participants experienced a sudden gain in CT and iCT respectively. Having a sudden gain was associated with lower social anxiety symptoms at posttreatment and follow-up. There was evidence of reductions in negative social cognitions and self-focused attention immediately prior to the sudden gain, contrasting with no prior reductions in depression symptoms. Ratings of session videotapes in CT showed that clients' statements indicated greater generalised learning in sessions immediately prior to gains, compared to control sessions. This may suggest a role for generalised learning in facilitating these large symptom reductions. There were no significant differences in results between the CT and iCT treatment formats, suggesting that the therapy content appears to play a more important role in determining participants' large symptom improvements than the medium of treatment delivery.
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Affiliation(s)
- Graham R Thew
- Department of Experimental Psychology, University of Oxford, UK; Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK.
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, UK; Oxford Health NHS Foundation Trust, Oxford, UK
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8
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Walder N, Berger T, Schmidt SJ. Prevention and Treatment of Social Anxiety Disorder in Adolescents: Protocol for a Randomized Controlled Trial of the Online Guided Self-Help Intervention SOPHIE. JMIR Res Protoc 2023; 12:e44346. [PMID: 37342086 DOI: 10.2196/44346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/18/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Social anxiety symptoms are highly prevalent among adolescents and are associated with poor quality of life and low psychosocial functioning. If untreated, social anxiety often persists into adulthood and increases the risk for comorbid disorders. Therefore, early interventions for social anxiety to prevent negative long-term consequences are critical. However, adolescents rarely seek help and often avoid face-to-face psychotherapeutic interventions due to the perceived lack of autonomy and anonymity. Thus, online interventions represent a promising opportunity to reach adolescents who have social anxiety but do not seek help yet. OBJECTIVE This study aims to evaluate the efficacy, moderators, and mediators of an online intervention developed to reduce social anxiety in adolescents. METHODS A total of 222 adolescents aged 11-17 years with subclinical social anxiety (N=166) or with a diagnosis of social anxiety disorder (N=56) are randomly assigned to the online intervention or a care-as-usual control group. The 8-week guided online intervention is based on the Cognitive Model of Social Phobia and evidence-based online interventions for social anxiety adapted to the specific needs of adolescents. The care-as-usual group will be given access to the online intervention after the follow-up assessment. Participants are assessed at baseline, at 4 and 8 weeks post intervention, and at 3-month follow-up assessment on the primary outcome, that is, social anxiety, on secondary outcomes (eg, level of functioning, fear and avoidance, general anxiety, depression, quality of life, self-esteem, and negative effects of the intervention), on potential moderators (eg, therapy motivation, therapy expectancy, and satisfaction with the intervention), and potential mediators (eg, therapeutic alliance and adherence to the intervention). Data will be analyzed based on an intention-to-treat approach and both groups (intervention and care-as-usual) will be compared at each assessment time point. Furthermore, potential mechanisms of change and generalization of intervention effects on daily life are assessed using an ecological momentary assessment procedure that includes items on maintaining mechanisms of social anxiety, social context, and affect. Participants are prompted 3 times a day during the first 8 weeks of the study and again for 2 weeks following the follow-up assessment. RESULTS Recruitment is ongoing; initial results are expected in 2024. CONCLUSIONS Results are discussed considering the potential of online interventions as a low-threshold prevention and treatment option for adolescents with social anxiety and in light of current advances in dynamic modeling of change processes and mechanisms in early intervention and psychotherapy in adolescents. TRIAL REGISTRATION ClinicalTrials.gov NCT04782102; https://clinicaltrials.gov/ct2/show/NCT04782102. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44346.
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Affiliation(s)
- Noemi Walder
- Division of Clinical Child and Adolescent Psychology, Institute of Psychology, University of Bern, Bern, Switzerland
| | - Thomas Berger
- Division of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Bern, Bern, Switzerland
| | - Stefanie J Schmidt
- Division of Clinical Child and Adolescent Psychology, Institute of Psychology, University of Bern, Bern, Switzerland
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9
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Leigh E. Editorial: Treating Social Anxiety Disorder in Children and Young People: Challenges and Opportunities. J Am Acad Child Adolesc Psychiatry 2023; 62:621-623. [PMID: 36526159 DOI: 10.1016/j.jaac.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
In this issue of the Journal, Rapee et al.1 report a rigorous randomized controlled trial (RCT) comparing transdiagnostic treatment and specialized social anxiety treatment for children and young people with social anxiety disorder (SAD). The study is a welcome addition to the literature that highlights the need to renew our efforts to improve understanding and treatment of SAD in childhood.
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Affiliation(s)
- Eleanor Leigh
- Oxford Health NHS Foundation Trust, University of Oxford, United Kingdom.
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10
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Leigh E, Chiu K, Ballard ED. Social Anxiety and Suicidality in Youth: A Systematic Review and Meta-analysis. Res Child Adolesc Psychopathol 2023; 51:441-454. [PMID: 36525228 PMCID: PMC10017648 DOI: 10.1007/s10802-022-00996-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Abstract
Suicide is a leading cause of death among young people every year. Identifying risk factors provides opportunities to intervene, and social anxiety may represent one such factor. This systematic review and meta-analysis aimed to review the evidence of associations between social anxiety and suicidality in youth (10-25 years). Embase, PsycInfo, and Medline were searched to identify relevant articles. Meta-analysis was conducted to examine the mean effect sizes of concurrent and prospective associations between social anxiety and three indices of suicidality in adolescents aged 10-25 years. Meta-analyses of 16 studies showed that social anxiety was associated cross-sectionally with suicide attempt (r = 0.10, 95% CI: 0.04, 0.15), suicidal ideation (r = 0.22, 95% CI: 0.02, 0.41), and suicide risk (r = 0.24, 95% CI: 0.05, 0.41), and prospectively at trend level with suicidal ideation (r = 0.62, 95% CI: -0.03, 0.90). An examination of the prospective associations with suicide attempt and risk was not possible due to a lack of studies. Several studies suggested that results could not be solely attributed to depressive symptoms. A high level of heterogeneity was observed in each meta-analysis. Moderation analysis was possible for gender and publication year only; neither was significant. Findings provide further evidence of a link between social anxiety and suicidal thoughts and behaviors in youth but are limited by the small number of studies of mixed quality. This review supports future research into social anxiety symptoms as potential risk factors and treatment targets for suicidal youth.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, UK.
| | - Kenny Chiu
- Department of Clinical Psychology and Psychological Therapies, University of East Anglia, Norwich, Norfolk, UK
| | - Elizabeth D Ballard
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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11
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Mobach L, Rapee RM, Klein AM. The Role of Distorted Cognitions in Mediating Treatment Outcome in Children with Social Anxiety Disorder: A Preliminary Study. Child Psychiatry Hum Dev 2023; 54:558-569. [PMID: 34674074 PMCID: PMC9977708 DOI: 10.1007/s10578-021-01268-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
This study examined whether distorted cognition changes during cognitive behavioural therapy (CBT) in children (N = 61; aged 7-12) with social anxiety disorder (SAD) and whether changes in distorted cognition from pre- to post-treatment predict SAD at 6-month follow-up. Baseline distorted cognition was also examined as a predictor of post-treatment outcome. Multiple informant SAD-measures were obtained pre-treatment, post-treatment and at 6-month follow-up. Children reported on interpretation bias and dysfunctional beliefs. A decrease in interpretation bias and dysfunctional beliefs was prospectively related to greater SAD change between post-treatment and 6-month follow-up. Child-reported SAD-change at post-treatment predicted greater change in dysfunctional beliefs at 6-month follow-up. Higher baseline interpretation bias predicted greater change in SAD-severity at post-treatment. Children with greater distorted cognition reductions during treatment, showed greater treatment gains at 6-month follow-up. Children who do not show this reduction may require additional efforts focused on distorted cognition to maximally benefit from treatment.
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Affiliation(s)
- Lynn Mobach
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, 2109, Australia.
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Montessorilaan 3, 6525 HR, Nijmegen, the Netherlands.
| | - Ronald M Rapee
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, NSW, 2109, Australia
| | - Anke M Klein
- Department of Clinical Psychology, Behavioural Science Institute, Radboud University, Montessorilaan 3, 6525 HR, Nijmegen, the Netherlands
- Unit Developmental and Educational Psychology, Institute of Psychology, Leiden University, Leiden, the Netherlands
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12
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Leigh E, Clark DM. Internet-delivered therapist-assisted cognitive therapy for adolescent social anxiety disorder (OSCA): a randomised controlled trial addressing preliminary efficacy and mechanisms of action. J Child Psychol Psychiatry 2023; 64:145-155. [PMID: 35943064 PMCID: PMC10087225 DOI: 10.1111/jcpp.13680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cognitive therapy for SAD (CT-SAD) is a first-line recommended treatment for adult social anxiety disorder (SAD) and shows considerable promise for youth. However, the high prevalence of adolescent SAD and limited number of therapists presents an implementation challenge. Delivery of CT-SAD via the Internet may offer part of the solution. METHOD Forty-three youth (14-18 years) with SAD recruited through schools were randomly allocated to therapist-assisted Internet-delivered CT-SAD (called OSCA) or waitlist for 14 weeks (ISRCTN15079139). RESULTS OSCA outperformed waitlist on all measures and was associated with large effects that were maintained at 6-month follow-up. In the OSCA arm, 77% of adolescents lost their SAD diagnosis at post (vs. 14% in the waitlist arm), increasing to 91% at 6-months. Beneficial effects of OSCA were mediated through changes in cognitions and safety behaviours as predicted by cognitive models of SAD. OSCA was associated with high credibility and therapeutic alliance. CONCLUSIONS This preliminary trial suggests OSCA holds promise as an effective, accessible treatment for adolescent SAD. Future definitive trials could compare OSCA to active comparators to examine specificity of effects.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford Health NHS Foundation Trust, Oxford, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Oxford Health NHS Foundation Trust, Oxford, UK
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Michelson D, Hodgson E, Bernstein A, Chorpita BF, Patel V. Problem Solving as an Active Ingredient in Indicated Prevention and Treatment of Youth Depression and Anxiety: An Integrative Review. J Adolesc Health 2022; 71:390-405. [PMID: 35803863 DOI: 10.1016/j.jadohealth.2022.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/09/2022] [Accepted: 05/05/2022] [Indexed: 10/17/2022]
Abstract
Problem solving is a common focus of psychological interventions for young people. However, existing evidence syntheses are relatively limited in their scope and conclusions. Taking a transdiagnostic approach and incorporating diverse sources of evidence, we examined the role of problem solving as an active ingredient for the indicated prevention and treatment of depression and anxiety in 14-24-year-olds. Three information sources were integrated using framework synthesis: (1) a systematic review of randomized controlled trials of problem solving; (2) a metasynthesis of qualitative evidence on the therapeutic experience of problem solving; and (3) consultations with a Youth Advisory Group. Intervention protocols that included problem solving and no more than one other specific component appeared to be effective for depression but not anxiety. Larger multicomponent interventions with a problem-solving element achieved moderate effect sizes for both conditions. There was no clear evidence that effectiveness varied by population characteristics, intervention formats, or contextual factors. Qualitative evidence and youth consultations highlighted positive views about the practicality, simplicity, and flexibility of problem solving. Converging sources also suggested changes in problem orientation as a key transdiagnostic process contributing to positive outcomes. Problem solving is a widely applicable therapeutic approach that can help young people with emotional problems to resolve specific stressors and lead to a more hopeful mindset about managing future challenges. Implications for practice are discussed.
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Affiliation(s)
- Daniel Michelson
- School of Psychology, University of Sussex, Brighton, United Kingdom.
| | - Eleanor Hodgson
- School of Psychology, University of Sussex, Brighton, United Kingdom
| | | | - Bruce F Chorpita
- Department of Psychology, University of California, Los Angeles, California
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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14
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Diagnosis-Specific Group CBT Treating Social Anxiety in Adolescents: A Feasibility Study. Scand J Child Adolesc Psychiatr Psychol 2022; 10:89-101. [PMID: 36133734 PMCID: PMC9454321 DOI: 10.2478/sjcapp-2022-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Social anxiety disorder (SAD) is one of the most common anxiety disorders among adolescents. It is associated with extensive distress and negative long-term consequences. Generic cognitive behavioral therapy (CBT) is one of the preferred treatments for anxiety disorders, but it has shown poorer outcome for adolescents with SAD than for other anxiety disorders. Aim As preparation for a randomized controlled trial the aim of the present study was to examine the feasibility of an adjusted diagnosis-specific CBT group intervention for adolescents with SAD, and provide preliminary information on adolescent and family outcomes. Method Thirteen adolescents (age 12-17 years) diagnosed with SAD received a group therapy version of the Cool Kids Anxiety Program, Social Enhanced (CK-E), a program developed at Macquarie University, Sydney, Australia. The treatment is a diagnosis-specific manualized CBT treatment for adolescents with SAD. Semi-diagnostic interviews and questionnaires were completed at baseline, post, 3-month follow-up and 1-year follow-up. Results Thirteen adolescents participated with no drop-outs. Most families attended all 10 intervention sessions. The families were generally satisfied with the treatment and would recommend it to others in need. Preliminary outcomes showed that participants had marked improvements in their anxiety symptoms and life interference, with significant medium to large baseline-post effect sizes durable at 1-year follow-up. Two of the adolescents were free of their SAD diagnosis at 3-month follow-up. Conclusion Results from this feasibility study indicate that the Danish-translated and revised version of Cool Kids Anxiety Program - Social Enhanced could be a feasible intervention for Danish adolescents with SAD. The intervention will be investigated further in a randomized controlled trial.
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15
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Rapee RM, McLellan LF, Carl T, Trompeter N, Hudson JL, Jones MP, Wuthrich VM. Comparison of Transdiagnostic Treatment and Specialized Social Anxiety Treatment for Children and Adolescents With Social Anxiety Disorder: A Randomized Controlled Trial. J Am Acad Child Adolesc Psychiatry 2022; 62:646-655. [PMID: 35987298 DOI: 10.1016/j.jaac.2022.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 08/03/2022] [Accepted: 08/10/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Pediatric social anxiety disorder consistently shows the poorest treatment response of all anxiety disorders. The current study compared a generic cognitive-behavioral therapy (CBT) treatment for pediatric anxiety against a modified (social anxiety) treatment that incorporated specific components to target theoretically important maintaining processes. METHOD A total of 200 children and adolescents (mean age = 9.5 years, SD = 2.2 years; 47% boys) diagnosed with social anxiety disorder as either their principal or additional disorder were randomly allocated to either the generic or the modified treatment. Both treatments were based on a manualized, empirically validated program (Cool Kids) and comprised 10 sessions over 12 weeks. Assessments comprised structured diagnostic interview and parent and youth reports, and covered diagnoses, symptoms, life impairment, and assessment of maintaining processes at post-treatment and 6-month follow-up. RESULTS The treatments did not differ significantly on the primary outcome (remission of social anxiety disorder) at either post-treatment (remission in generic = 41%; modified = 44%) or follow-up (remission in generic = 51%; modified = 69%), although the latter approached significance (p = .08). They also did not differ at either time point on most secondary measures of outcome. The only maintaining process that changed more under modified treatment was attention to the current task. CONCLUSION Despite some positive hints in the data, there was little evidence that the modified intervention significantly improved treatment of pediatric social anxiety disorder, despite incorporating strategies to address putative maintaining mechanisms. The similar improvement between treatments on most maintaining processes suggests that new and innovative strategies may be needed to better target these processes. CLINICAL TRIAL REGISTRATION INFORMATION Efficacy of Cognitive Behavioural Treatment for Socially Anxious Youth; https://www.anzctr.org.au/; 12616001065482.
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Affiliation(s)
- Ronald M Rapee
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia.
| | - Lauren F McLellan
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia
| | - Talia Carl
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia
| | - Nora Trompeter
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia
| | - Jennifer L Hudson
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia; Black Dog Institute, University of New South Wales, Sydney, Australia
| | - Michael P Jones
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia
| | - Viviana M Wuthrich
- Centre for Emotional Health, School of Psychological Sciences, Macquarie University, Sydney, Australia
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16
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Baartmans JMD, van Steensel FJA, Klein AM, Wiers RWHJ, Bögels SM. The role of parental anxiety symptoms in the treatment of childhood social anxiety disorder. Behav Res Ther 2022; 156:104157. [PMID: 35863242 DOI: 10.1016/j.brat.2022.104157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 06/17/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022]
Abstract
The study investigated the role of parental anxiety symptoms in treatment outcomes for children with a primary social anxiety disorder compared to children with other primary anxiety disorders. Participants were 152 children between 7 and 18 years and their parents (146 mothers, 123 fathers). Anxiety was assessed pretreatment, posttreatment, and at three months and one year follow ups. There were no baseline differences in parental anxiety symptoms between the two groups. In both groups parental anxiety symptoms decreased from pretreatment to posttreatment, and only mothers' anxiety symptoms decreased further from posttreatment to the one year follow up. Parental anxiety symptoms before the treatment were not related to the being free of all anxiety diagnoses in the children at posttreatment. However, some indications were found for greater improvements during treatment when parents had higher anxiety symptoms before treatment. Changes in parental anxiety symptoms were found to be related to changes in child anxiety symptoms. This was not found for the total clinical severity of all inclusion anxiety disorders. This relation was visible independently in fathers or mothers, or in groups of children with a primary social anxiety disorder or with another primary anxiety disorder. In conclusion, we did not find clear indications that parental anxiety symptoms explain the differences in treatment outcomes for children with a primary social anxiety disorder compared to children with other primary anxiety disorders. More research with larger samples is needed to draw stronger conclusions.
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Affiliation(s)
- J M D Baartmans
- UvA Minds, Academic Treatment Centre, the Netherlands; Developmental Psychology, University of Amsterdam, the Netherlands.
| | - F J A van Steensel
- Child Development and Education, University of Amsterdam, the Netherlands
| | - A M Klein
- UvA Minds, Academic Treatment Centre, the Netherlands
| | - R W H J Wiers
- Developmental Psychology, University of Amsterdam, the Netherlands
| | - S M Bögels
- Child Development and Education, University of Amsterdam, the Netherlands
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17
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Ganho-Ávila A, Vieira Figueiredo D, Vagos P. Online Cognitive Therapy for Social Anxiety Disorder in Adolescence: A Clinical Case Study Using the CT@TeenSAD. Clin Case Stud 2022. [DOI: 10.1177/15346501221091519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
SAD is an intense fear or anxiety associated with past, current, or future social situations. The Clark and Wells (1995) cognitive model for SAD has been proved to be clinically effective in adults, and its developmentally sensitive adaptations for adolescents have recently shown promising results. Given this evidence and considering that adolescence is typically the age of onset for the first SAD symptoms and a critical developmental period for the delivery of evidence-based interventions, we adapted CT for adolescents for online intervention (CT@TeenSAD) encompassing 10 weekly, 90 min sessions, extended by two booster sessions. This work presents the first case study of that intervention as applied to Merida (M.; pseudonym; 17-year-old, girl). The estimated Reliable Change Index shows M.’s progress for most of her symptoms, from pre-to post-treatment (RCI-1 range: −.53 to −8.03), and the maintenance of benefits at 3 months follow-up (RCI-2 range: .00 to −2.25). A relapse in the adoption of safety behaviors was seen between post-treatment and follow-up, which might be explained by the life-changing challenges experienced by M. between session 10 and follow-up, concerning her transition from high school to college. M.’s case study offers a first glance on the promising results of CT@TeenSAD related to its efficacy and feasibility. Likewise, it offers the opportunity to critically appraise the limitations of the intervention as well as practical challenges and suggestions thought to be useful for therapists willing to implement CT@TeenSAD in the future.
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Affiliation(s)
- Ana Ganho-Ávila
- Center for Research in Neuropsychology and Cognitive Behavioral Intervention–CINEICC, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
| | - Diana Vieira Figueiredo
- Center for Research in Neuropsychology and Cognitive Behavioral Intervention–CINEICC, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
| | - Paula Vagos
- Center for Research in Neuropsychology and Cognitive Behavioral Intervention–CINEICC, Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal
- Institute of Human Development, Portucalense Infante D. Henrique University, Porto, Portugal
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18
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Aune T, Nordahl HM, Beidel DC. Social anxiety disorder in adolescents: Prevalence and subtypes in the Young-HUNT3 study. J Anxiety Disord 2022; 87:102546. [PMID: 35248811 DOI: 10.1016/j.janxdis.2022.102546] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 02/03/2022] [Accepted: 02/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few studies have examined the prevalence of social anxiety disorder (SAD) among adolescents and the associated sex-specific fears. No previous studies have reported variance in SAD prevalence among adolescents based on a stepwise diagnostic approach. METHODS Using various diagnostic thresholds from the Anxiety Disorders Interview Schedule child version, and the diagnostic criteria from both the 4th and 5th editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), we explored the point prevalence of SAD among a population-based sample of 8216 adolescents aged 13-19 years. RESULTS Overall, 2.6% of adolescents met the SAD diagnostic criteria. The prevalence varied from 2.0% to 5.7% depending on the criteria-set. Twice as many females met the overall SAD criteria. The DSM-IV generalized SAD subtype was assigned to 86.5% of the sample, while 3.5% met the DSM-5 performance-only subtype. Compared with males aged 16-19 years, significantly more of those aged 13-15 years met the SAD criteria; no significant age group differences were found among females. CONCLUSIONS This is the first study to demonstrate variance in SAD prevalence among adolescents based on the diagnostic threshold method. Depending on the threshold applied, SAD prevalence among adolescents varied from 2.0% to 5.7%. Age and sex differences in social fear experiences highlight the importance of considering developmental heterogeneity in SAD, especially for adapting prevention and treatment interventions.
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Affiliation(s)
- Tore Aune
- Norwegian Directorate for Children, Youth and Family Affaires, Bomvegen 3, 7725 Steinkjer, Norway; Faculty of Nursing and Health Sciences, Nord University, Norway.
| | - Hans M Nordahl
- Department of Mental Health, NTNU, Trondheim, Norway; St. Olavs Hospital, Division of Psychiatry, Nidaros DPS, Trondheim, Norway
| | - Deborah C Beidel
- UCF RESTORES, University of Central Florida, 4111 Pictor Lane, Orlando, FL 32816, USA
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19
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Leigh E, Clark DM. Development and Preliminary Validation of the Child & Adolescent Social Cognitions Questionnaire. Child Psychiatry Hum Dev 2022; 53:715-724. [PMID: 33811562 PMCID: PMC9287209 DOI: 10.1007/s10578-021-01163-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 12/02/2022]
Abstract
Negative cognitions play a central role in adolescent social anxiety, and yet there is a lack of empirically validated measures assessing these in detail. This study describes the adaptation of the Child & Adolescent Social Cognitions Questionnaire (CASCQ) from the adult version of the scale and its preliminary validation in a general adolescent school sample (N = 671). Exploratory and confirmatory factor analysis on split halves of the data indicated two factors, labelled 'negative self-concept' and 'anxious appearance', provided the best fit. Totals and subscales possessed good internal consistency and convergent validity. Findings suggest that the CASCQ is a reliable and valid measure of social anxiety-related cognitions in youth and may be useful for research and clinical purposes. Further examination of the scale with pre-adolescents and clinical samples is warranted.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, UK. .,OxCADAT, The Old Rectory, Paradise Square, Oxford, OX1 1TW, UK.
| | - David M. Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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20
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Kemper AR, Letostak TB, Hostutler CA, Stephenson KG, Butter EM. Screening for Anxiety in Pediatric Primary Care: A Systematic Review. Pediatrics 2021; 148:peds.2021-052633. [PMID: 34475269 DOI: 10.1542/peds.2021-052633] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2021] [Indexed: 12/19/2022] Open
Abstract
CONTEXT Anxiety is common, screening tools are available, and treatment can be effective. Recently, anxiety screening has been recommended for adolescent girls beginning at 13 years of age. OBJECTIVE To evaluate the evidence regarding anxiety screening test accuracy in primary care for children and adolescents and assess the effectiveness of treatment of individuals identified through screening. DATA SOURCES We searched PubMed, the Cochrane library, and references to potentially eligible studies cited in other articles. STUDY SELECTION Screening studies were included if they were conducted in primary care or a similar population and employed a reference standard based on DSM criteria. Treatment studies were included if subjects were identified through screening and there was at least 1 comparator intervention or a placebo arm. DATA EXTRACTION At least 2 reviewers evaluated each identified reference. RESULTS Two screening studies (1 with low risk of bias and 1 with high risk of bias) and 1 treatment study with a low risk of bias were included. The screening study with a low risk of bias reported a sensitivity of 56% and specificity of 80%. The treatment study found individual cognitive behavioral therapy to be effective for screen-detected adolescents with social phobia. LIMITATIONS This review only included screening or treatment studies with clear evidence that the study populations were derived from an unselected population reflective of typical primary care. Relevant studies not indexed in PubMed or the Cochrane library could have been missed. CONCLUSIONS There are significant gaps in evidence related to anxiety screening in the primary care setting.
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Affiliation(s)
| | | | | | | | - Eric M Butter
- Psychology, Nationwide Children's Hospital, Columbus, Ohio
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21
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Baker HJ, Lawrence PJ, Karalus J, Creswell C, Waite P. The Effectiveness of Psychological Therapies for Anxiety Disorders in Adolescents: A Meta-Analysis. Clin Child Fam Psychol Rev 2021; 24:765-782. [PMID: 34471966 PMCID: PMC8541960 DOI: 10.1007/s10567-021-00364-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 12/23/2022]
Abstract
Anxiety disorders are common in adolescence but outcomes for adolescents are unclear and we do not know what factors moderate treatment outcome for this age group. We conducted meta-analyses to establish the effectiveness of psychological therapies for adolescent anxiety disorders in (i) reducing anxiety disorder symptoms, and (ii) remission from the primary anxiety disorder, compared with controls, and examine potential moderators of treatment effects. The protocol was registered with PROSPERO (CRD42018091744). Electronic databases (Web of Science, MEDLINE, Psycinfo, EMBASE) were searched from January 1990 to December 2019. 2511 articles were reviewed, those meeting strict criteria were included. Random effects meta-analyses were conducted. Analyses of symptom severity outcomes comprised sixteen studies (CBT k = 15, non-CBT k = 1; n = 766 adolescents), and analyses of diagnostic remission outcomes comprised nine (CBT k = 9; n = 563 adolescents). Post-treatment, those receiving treatment were significantly more likely to experience reduced symptom severity (SMD = 0.454, 95% CI 0.22–0.69) and remission from the primary anxiety disorder than controls (RR = 7.94, 95% CI 3.19–12.7) (36% treatment vs. 9% controls in remission). None of the moderators analysed were statistically significant. Psychological therapies targeting anxiety disorders in adolescents are more effective than controls. However, with only just over a third in remission post-treatment, there is a clear need to develop more effective treatments for adolescents, evaluated through high-quality randomised controlled trials incorporating active controls and follow-up data.
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Affiliation(s)
- Holly J. Baker
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, RG6 6AL UK
| | - Peter J. Lawrence
- Centre for Innovation in Mental Health, School of Psychology, University of Southampton, Southampton, SO17 1BJ UK
| | - Jessica Karalus
- Central North West London NHS Foundation Trust, Grenfell Health and Wellbeing Service, St Charles Hospital, Exmoor Street, London, W10 6DZ UK
| | - Cathy Creswell
- Radcliffe Observatory, University of Oxford, Anna Watts Building, Woodstock Rd, Oxford, OX2 6GG UK
| | - Polly Waite
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, RG6 6AL UK
- Radcliffe Observatory, University of Oxford, Anna Watts Building, Woodstock Rd, Oxford, OX2 6GG UK
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22
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Gårdvik KS, Rygg M, Torgersen T, Wallander JL, Lydersen S, Indredavik MS. Association of treatment procedures and resilience to symptom load three-years later in a clinical sample of adolescent psychiatric patients. BMC Psychiatry 2021; 21:411. [PMID: 34412609 PMCID: PMC8377856 DOI: 10.1186/s12888-021-03417-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to examine symptom load in a clinical adolescent population at three-year follow-up and explore associations with standard care treatment procedures and resilience factors upon first presenting at Child and Adolescent Mental Health Services. METHODS This study is part of a prospective longitudinal cohort study: The Health Survey in Department of Children and Youth, St. Olavs hospital, Norway. A clinical population of 717 (43.5% of eligible) adolescents aged 13-18 years participated in the first study visit (T1, 2009-2011). Of these, 447 adolescents with psychiatric disorders, with treatment history from medical records and self-reported resilience factors (Resilience Scale for Adolescents; READ) at T1, reported symptom load (Achenbach System of Empirically Based Assessment - Youth Self Report; YSR) three years later aged 16-21 years (T2). RESULT At T1, 93.0% received individual treatment. The frequency of psychotherapy and medication varied by disorder group and between genders. Overall, psychotherapy was more frequent among girls, whereas medication was more common among boys. Total READ mean value (overall 3.5, SD 0.8), ranged from patients with mood disorders (3.0, SD 0.7) to patients with Attention Deficit Hyperactivity disorder (3.7, SD 0.7), and was lower for girls than boys in all diagnostic groups. At T2, the YSR Total Problem mean T-score ranged across the diagnostic groups (48.7, SD 24.0 to 62.7, SD 30.2), with highest symptom scores for those with mood disorders at T1, of whom 48.6% had T-scores in the borderline/clinical range (≥60) three years later. Number of psychotherapy sessions was positively associated and Total READ score was negatively associated with the YSR Total Problems T-score (regression coefficient β = 0.5, CI (0.3 to 0.7), p < 0.001 and β = - 15.7, CI (- 19.2 to - 12.1), p < 0.001, respectively). The subscale Personal Competence was associated with the lowest Total Problem score for both genders. CONCLUSIONS Self-reported symptom load was substantial after three years, despite comprehensive treatment procedures. Higher self-reported resilience characteristics were associated with lower symptom load after three years. These results highlight the burden of adolescent psychiatric disorders, the need for extensive interventions and the importance of resilience factors for a positive outcome.
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Affiliation(s)
- Kari Skulstad Gårdvik
- Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway. .,Department of Children and Youth, Clinic of Mental Health Care, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Marite Rygg
- grid.5947.f0000 0001 1516 2393Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway ,grid.52522.320000 0004 0627 3560Department of Pediatrics, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Terje Torgersen
- grid.52522.320000 0004 0627 3560Orkdal District Psychiatric Centre, Clinic of Mental Health Care, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway ,grid.5947.f0000 0001 1516 2393Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Lance Wallander
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway ,grid.266096.d0000 0001 0049 1282Psychological Sciences and Health Sciences Research Institute, University of California, Merced, USA
| | - Stian Lydersen
- grid.5947.f0000 0001 1516 2393Regional Centre for Child and Youth Mental Health and Child Welfare, Department of Mental Health, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marit Sæbø Indredavik
- grid.5947.f0000 0001 1516 2393Department of Clinical and Molecular Medicine (IKOM), Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
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23
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Whiteside SPH, Sim LA, Morrow AS, Farah WH, Hilliker DR, Murad MH, Wang Z. A Meta-analysis to Guide the Enhancement of CBT for Childhood Anxiety: Exposure Over Anxiety Management. Clin Child Fam Psychol Rev 2021; 23:102-121. [PMID: 31628568 DOI: 10.1007/s10567-019-00303-2] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cognitive behavior therapy (CBT) is the most empirically supported therapy for childhood anxiety disorders (CADs) but has not reliably outperformed other credible interventions. The current study used meta-analysis to examine the frequency with which the most common treatment components are included in outcome studies and the relation of these components to symptom improvement. Seventy-five studies were identified that included youth with an anxiety disorder treated with CBT or a comparison condition. The protocols for the 111 CBT conditions generally consisted of 12, 1-h sessions delivered to the child with minimal parent inclusion. A greater amount of in-session exposure was related to significantly larger effect sizes between CBT and waitlist control across reporters (- 0.12 to - 0.15; P's < .05) and from pre- to post-treatment for child report (- .06; P < .01). Compared to treatments that omitted relaxation, treatments that included relaxation strategies were associated with significantly smaller pre- to post-treatment effect sizes across reporters (0.38 to 0.80; P's < .05). The current study suggests that CBT protocols for CADs that emphasize in-session exposure and do not include relaxation have the potential to improve the efficacy and effectiveness of therapy. Dismantling studies directly testing these hypotheses are needed.
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Affiliation(s)
- Stephen P H Whiteside
- Department of Psychiatry and Psychology, Mayo Clinic, Mayo Bldg West 11, 200 First St., SW, Rochester, MN, 55905, USA.
| | - Leslie A Sim
- Department of Psychiatry and Psychology, Mayo Clinic, Mayo Bldg West 11, 200 First St., SW, Rochester, MN, 55905, USA
| | - Allison S Morrow
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Wigdan H Farah
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Daniel R Hilliker
- Department of Psychiatry and Psychology, Mayo Clinic, Mayo Bldg West 11, 200 First St., SW, Rochester, MN, 55905, USA
| | - M Hassan Murad
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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24
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Taylor L, Creswell C, Pearcey S, Brooks E, Leigh E, Stallard P, Waite P, Clark DM, Stephens G, Larkin M. Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a qualitative analysis of the experiences of young people, their parents and clinicians-in-training. Behav Cogn Psychother 2021; 49:1-15. [PMID: 33645496 DOI: 10.1017/s1352465821000047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Social anxiety disorder (SAD) is common. It usually starts in adolescence, and without treatment can disrupt key developmental milestones. Existing generic treatments are less effective for young people with SAD than with other anxiety disorders, but an adaptation of an effective adult therapy (CT-SAD-A) has shown promising results for adolescents. AIMS The aim of this study was to conduct a qualitative exploration to contribute towards the evaluation of CT-SAD-A for adoption into Child and Adolescent Mental Health Services (CAMHS). METHOD We used interpretative phenomenological analysis (IPA) to analyse the transcripts of interviews with a sample of six young people, six parents and seven clinicians who were learning the treatment. RESULTS Three cross-cutting themes were identified: (i) endorsing the treatment; (ii) finding therapy to be collaborative and active; challenging but helpful; and (iii) navigating change in a complex setting. Young people and parents found the treatment to be useful and acceptable, although simultaneously challenging. This was echoed by the clinicians, with particular reference to integrating CT-SAD-A within community CAMHS settings. CONCLUSIONS The acceptability of the treatment with young people, their parents and clinicians suggests further work is warranted in order to support its development and implementation within CAMHS settings.
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Affiliation(s)
- Lucy Taylor
- Department of Psychiatry, University of Oxford, Warneford Hospital, OxfordOX3 7JX, UK
| | - Cathy Creswell
- Department of Experimental Psychology and Department of Psychiatry, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, OxfordOX2 6GG, UK
| | - Samantha Pearcey
- Department of Experimental Psychology and Department of Psychiatry, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, OxfordOX2 6GG, UK
| | - Emma Brooks
- School of Psychology and Clinical Language Sciences, University of Reading, Earley Gate, Whiteknights, ReadingRG6 6AL, UK
| | - Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, OxfordOX1 1TW, UK
| | - Paul Stallard
- Child and Adolescent Mental Health Service, Oxford Health NHS Trust, Temple House, Temple Street, Keynsham, Bristol, BS31 1HA, UK
| | - Polly Waite
- Department of Experimental Psychology and Department of Psychiatry, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, OxfordOX2 6GG, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, OxfordOX1 1TW, UK
| | | | - Michael Larkin
- Department of Psychology, Aston Triangle, BirminghamB4 7ET, UK
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Creswell C, Leigh E, Larkin M, Stephens G, Violato M, Brooks E, Pearcey S, Taylor L, Stallard P, Waite P, Reynolds S, Taylor G, Warnock-Parkes E, Clark DM. Cognitive therapy compared with CBT for social anxiety disorder in adolescents: a feasibility study. Health Technol Assess 2021; 25:1-94. [PMID: 33759742 PMCID: PMC8020199 DOI: 10.3310/hta25200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Social anxiety disorder (SAD) is common, typically starts in adolescence and has a low natural recovery rate. Existing psychological treatments for adolescent SAD are only moderately effective. It is possible that recovery rates for adolescents could be substantially improved by adapting a psychological therapy that is highly effective among adults with SAD. OBJECTIVES To train child and adolescent mental health services (CAMHS) therapists to deliver cognitive therapy for SAD in adolescents (CT-SAD-A) and assess therapist competence. To estimate the costs to the NHS of training therapists to deliver CT-SAD-A and the mean cost per adolescent treated. To examine the feasibility of a randomised controlled trial (RCT) to compare CT-SAD-A with the general form of cognitive-behavioural therapy that is more commonly used. DESIGN During the training phase of the study, it became clear that the RCT would not be feasible because of high staff turnover and unfilled posts within CAMHS and changes in the nature of referrals, which meant that few young people with primary SAD were accessing some of the participating services. The study design was altered to comprise the following: a training case series of CT-SAD-A delivered in routine CAMHS, an estimate of the cost to the NHS of training therapists to deliver CT-SAD-A and of the mean cost per adolescent treated, and qualitative interviews with participating young people, parents, therapists and service managers/leads. SETTING Five CAMHS teams within Berkshire Healthcare and Oxford Health NHS Foundation Trusts. PARTICIPANTS Eight therapists received training in CT-SAD-A. Twelve young people received CT-SAD-A, delivered by six therapists. Six young people, six parents, seven therapists and three managers participated in qualitative interviews. INTERVENTIONS Cognitive therapy for social anxiety disorder in adolescents (CT-SAD-A). MAIN OUTCOME MEASURES Measured outcomes included social anxiety symptoms and diagnostic status, comorbid symptoms of anxiety and depression, social and general functioning, concentration in class and treatment acceptability. Patient level utilisation of the intervention was collected using clinicians' logs. RESULTS Nine out of 12 participants achieved good outcomes across measures (r ≥ 0.60 across social anxiety measures). The estimated cost of delivering CT-SAD-A was £1861 (standard deviation £358) per person. Qualitative interviews indicated that the treatment was acceptable to young people, parents and therapists, but therapists and managers experienced challenges when implementing the training and treatment within the current CAMHS context. LIMITATIONS Findings were based on a small, homogeneous sample and there was no comparison arm. CONCLUSIONS CT-SAD-A is a promising treatment for young people with SAD, but the current CAMHS context presents challenges for its implementation. FUTURE WORK Further work is needed to ensure that CAMHS can incorporate and test CT-SAD-A. Alternatively, CT-SAD-A should be delivered and tested in other settings that are better configured to treat young people whose lives are held back by SAD. The new schools Mental Health Support Teams envisaged in the 2017 Children's Mental Health Green Paper may provide such an opportunity. FUNDING The National Institute for Health Research (NIHR) Health Technology Assessment programme. Individual funding was also provided for Cathy Creswell, David M Clark and Eleanor Leigh as follows: NIHR Research Professorship (Cathy Creswell); Wellcome Senior Investigator Award (Anke Ehlers and David M Clark); and the Wellcome Clinical Research Training Fellowship (Eleanor Leigh).
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Affiliation(s)
- Cathy Creswell
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Michael Larkin
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | | | - Mara Violato
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Emma Brooks
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Samantha Pearcey
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Lucy Taylor
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Paul Stallard
- Child and Adolescent Mental Health Service, Oxford Health NHS Trust, Bristol, UK
| | - Polly Waite
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | | | - Gordon Taylor
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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Leigh E, Creswell C, Stallard P, Waite P, Violato M, Pearcey S, Brooks E, Taylor L, Warnock-Parkes E, Clark DM. Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a clinical and cost analysis. Behav Cogn Psychother 2021; 49:1-13. [PMID: 33645498 DOI: 10.1017/s1352465821000035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed. AIMS Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment? METHOD CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training. RESULTS Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment. CONCLUSIONS This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, OxfordOX1 1TW, UK
| | - Cathy Creswell
- Department of Experimental Psychology and Department of Psychiatry, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, OxfordOX2 6GG, UK
| | - Paul Stallard
- Child and Adolescent Mental Health Service, Oxford Health NHS Trust, Temple House, Temple Street, Keynsham, BristolBS31 1HA, UK
| | - Polly Waite
- Department of Experimental Psychology and Department of Psychiatry, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, OxfordOX2 6GG, UK
| | - Mara Violato
- Health Economics Research Centre, Nuffield Department of Population Health, NIHR Oxford Biomedical Research Centre, University of Oxford, Richard Doll Building, Old Road Campus, OxfordOX3 7LF, UK
| | - Samantha Pearcey
- Department of Experimental Psychology and Department of Psychiatry, University of Oxford, Anna Watts Building, Radcliffe Observatory Quarter, Woodstock Road, OxfordOX2 6GG, UK
| | - Emma Brooks
- School of Psychology and Clinical Language Sciences, University of Reading, Earley Gate, Whiteknights, ReadingRG6 6AL, UK
| | - Lucy Taylor
- Department of Psychiatry, University of Oxford, Warneford Hospital, OxfordOX3 7JX, UK
| | - Emma Warnock-Parkes
- Department of Experimental Psychology, University of Oxford, Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, OxfordOX1 1TW, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, OxfordOX1 1TW, UK
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Self-focused attention and safety behaviours maintain social anxiety in adolescents: An experimental study. PLoS One 2021; 16:e0247703. [PMID: 33635891 PMCID: PMC7909699 DOI: 10.1371/journal.pone.0247703] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 02/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Self-focused attention and safety behaviours are both associated with adolescent social anxiety. In adults, experimental studies have indicated that the processes are causally implicated in social anxiety, but this hypothesis has not yet been tested in a youth sample. METHODS This experiment explored this possibility by asking high and low socially anxious adolescents (N = 57) to undertake conversations under different conditions. During one conversation they were instructed to focus on themselves and use safety behaviours, and in the other they focused externally and did not use safety behaviours. Self-report, conversation partner report and independent assessor ratings were taken. RESULTS Self-focus and safety behaviours increased feelings and appearance of anxiety and undermined performance for all participants, but only high socially anxious participants reported habitually using self-focus and safety behaviours. CONCLUSIONS The findings provide support for the causal role of self-focus and safety behaviours in adolescent social anxiety and point to the potential clinical value of techniques reversing them to treat the disorder.
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Luo A, McAloon J. Potential mechanisms of change in cognitive behavioral therapy for childhood anxiety: A meta-analysis. Depress Anxiety 2021; 38:220-232. [PMID: 33225527 DOI: 10.1002/da.23116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/24/2020] [Accepted: 11/01/2020] [Indexed: 11/06/2022] Open
Abstract
Cognitive-behavioral therapy (CBT) is regarded as an effective treatment for anxiety disorders in childhood. Researchers have begun to investigate potential mechanisms of change that drive these positive outcomes, including shifts in cognitions, behavior, and affect. However, few studies have established the mediational effects of these factors as a proxy for establishing mechanistic change. This meta-analysis attempts to synthesize the literature on potential mechanisms of change in CBT for childhood anxiety and investigates the mediational effects of these factors on treatment outcomes. Seventeen studies met the inclusion criteria. Across studies, five potential mediators were identified: externalizing difficulties, negative self-talk, coping, fear, and depression. Results indicated that CBT was effective in improving outcomes on all potential mediators, except for fear. Mediational analyses showed that externalizing difficulties, negative self-talk, coping, and depression mediated anxiety following treatment. Fear did not mediate the relationship. Implications for future mechanisms of change research are proposed.
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Affiliation(s)
- Aileen Luo
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, NSW, Australia.,Department of Psychology, Macquarie University, NSW, Australia
| | - John McAloon
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, NSW, Australia
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29
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Chiu K, Clark DM, Leigh E. Cognitive predictors of adolescent social anxiety. Behav Res Ther 2021; 137:103801. [PMID: 33421893 PMCID: PMC7846721 DOI: 10.1016/j.brat.2020.103801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 12/10/2020] [Accepted: 12/28/2020] [Indexed: 11/25/2022]
Abstract
Background Identifying psychological processes that maintain social anxiety holds promise for improving treatment outcomes for young people. Experimental and prospective studies in adults suggest negative social cognitions, safety behaviours, self-focused attention, and pre- and post-event processing are all implicated in the maintenance of social anxiety. Despite social anxiety typically starting in adolescence, prospective studies examining these cognitive processes in youth are lacking. The current study examined prospective associations between these five cognitive processes and social anxiety in a sample of 614 participants (53% girls; aged 11–14 years). Methods Psychological processes, social anxiety symptoms, and depressive symptoms were assessed using self-report questionnaires at two time points. Results Negative social cognitions, safety behaviours, self-focused attention, and post-event processing predicted prospective levels of social anxiety over and above the effect of baseline levels of social anxiety. When these process variables were entered together in a regression model, three of them were independently associated with prospective social anxiety. Neither pre- nor post-event processing independently predicted later social anxiety over and above the effects of other psychological process variables. Conclusions The findings indicate that these psychological processes are promising targets for treatment in adolescent social anxiety. The applicability of the cognitive model of Clark & Wells was tested in a sample of 614 adolescents. Negative social cognitions independently predicted increases in social anxiety. Safety behaviours independently predicted increases in social anxiety. Self-focused attention independently predicted increases in social anxiety. Unexpectedly, neither pre- or post-event processing was an independent predictor of social anxiety.
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Affiliation(s)
- Kenny Chiu
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King'sCollege London, London, UK
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK
| | - Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, UK.
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30
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Guo T, Su J, Hu J, Aalberg M, Zhu Y, Teng T, Zhou X. Individual vs. Group Cognitive Behavior Therapy for Anxiety Disorder in Children and Adolescents: A Meta-Analysis of Randomized Controlled Trials. Front Psychiatry 2021; 12:674267. [PMID: 34744809 PMCID: PMC8564073 DOI: 10.3389/fpsyt.2021.674267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 09/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Anxiety disorder is the most prevalent mental disorder in children and adolescents. However, evidence for efficacy and acceptability between individual cognitive behavior therapy (I-CBT) and group cognitive behavior therapy (G-CBT) in anxiety disorders in children and adolescents remains unclear. Methods: Eight electronic databases (PubMed, Embase, Cochrane, Web of Science, CINAHL, PsycINFO, ProQuest, and LILACS) were searched from inception to October 2019. Randomized controlled trials comparing I-CBT with G-CBT for anxiety disorders in children and adolescents were included. The primary outcomes were efficacy (mean change in anxiety symptom scores) at post-treatment and acceptability (all-cause discontinuation). The secondary outcome was remission at post-treatment. Subgroup analyses were also conducted to examine whether the result would be influenced by age, number of treatment sessions, parental involvement, male/female sex, and number of participants. Results: Nine studies were selected in this meta-analysis. The pooled analyses indicated no significant difference between I-CBT and G-CBT for efficacy at post-treatment [standardized mean difference (SMD), -0.14; 95% confidence interval (CI), -0.37 to 0.09], acceptability [odds ratio (OR), 1.30; 95% CI, 0.61-2.77], and remission at post-treatment (OR, 1.15; 95% CI, 0.79-1.66). In the subgroup analysis of age, I-CBT was significantly more effective than G-CBT in adolescents at post-treatment (SMD, -0.77; 95% CI, -1.51 to -0.02), but not in children (SMD, 0.00; 95% CI, -0.02 to 0.20). However, the findings were not materially different from those of the efficacy subgroup analysis of number of treatment sessions, parental involvement, male/female sex, and number of participants. Conclusions: Based on those current evidence, I-CBT was shown to be more beneficial than G-CBT for anxiety disorders in adolescents, but not in children. However, further well-designed clinical studies should be performed to confirm these findings. Systematic Review Registration:http://osf.io/xrjkp, identifier: 10.17605/OSF.IO/XRJKP.
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Affiliation(s)
- Tingting Guo
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,The First Clinical College of Chongqing Medical University, Chongqing, China
| | - Jing Su
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,The Second Clinical College of Chongqing Medical University, Chongqing, China
| | - Jiayi Hu
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,The Second Clinical College of Chongqing Medical University, Chongqing, China
| | - Marianne Aalberg
- Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Yinglin Zhu
- School of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Joplin, MO, United States
| | - Teng Teng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xinyu Zhou
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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31
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Aune T, Juul EML, Beidel DC, Nordahl HM, Dvorak RD. Mitigating adolescent social anxiety symptoms: the effects of social support and social self-efficacy in findings from the Young-HUNT 3 study. Eur Child Adolesc Psychiatry 2021; 30:441-449. [PMID: 32300894 PMCID: PMC8019414 DOI: 10.1007/s00787-020-01529-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 04/06/2020] [Indexed: 12/24/2022]
Abstract
Adolescents' exposure to negative life events (NLEs) and potentially traumatic events is highly prevalent and increases their risk of developing psychological disorders considerably. NLE exposure has also been linked to the development of social anxiety disorder (SAD) among older children and young adolescents. Despite the relatively low treatment efficacy reported for children and adolescents suffering from SAD, few studies have addressed the extent to which resilience factors, such as social support and social self-efficacy, are associated with SAD symptoms. This study examined whether social support and social self-efficacy predict, and buffer against SAD symptoms using a large, population-based sample of adolescents, among whom a large proportion have experienced NLEs. The results reveal that NLEs are significantly associated with SAD symptoms, while social support and social self-efficacy are both negatively associated with SAD symptoms. Only the NLEs × social support interaction significantly predicted SAD symptoms, with social support attenuating the association between NLEs and SAD symptoms. Moreover, increases in both social self-efficacy and social support were associated with reduced SAD symptoms, over and above variance explained by social support alone. Our cumulative results suggest that interventions that can modify both social support and social self-efficacy may help reduce SAD symptoms in at-risk adolescents.
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Affiliation(s)
- Tore Aune
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway.
| | | | - Deborah C Beidel
- UCF RESTORES, University of Central Florida, 4111 Pictor Lane, Orlando, FL, 32816, USA
| | - Hans M Nordahl
- Department of Mental Health, NTNU, Trondheim, Norway
- Division of Psychiatry, St.Olavs Hospital, Nidaros DPS, Trondheim, Norway
| | - Robert D Dvorak
- Department of Psychology, College of Science, University of Central Florida, 4111 Pictor Lane, Orlando, FL, 32816, USA
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32
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Etkin RG, Shimshoni Y, Lebowitz ER, Silverman WK. Using Evaluative Criteria to Review Youth Anxiety Measures, Part I: Self-Report. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2021; 50:58-76. [PMID: 32915074 PMCID: PMC7914129 DOI: 10.1080/15374416.2020.1802736] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Evidence-based assessment serves several critical functions in clinical child psychological science, including being a foundation for evidence-based treatment delivery. In this Evidence Base Update, we provide an evaluative review of the most widely used youth self-report measures assessing anxiety and its disorders. Guided by a set of evaluative criteria (De Los Reyes & Langer, 2018), we rate the measures as Excellent, Good, or Adequate across their psychometric properties (e.g., construct validity). For the eight measures evaluated, most ratings assigned were Good followed by Excellent, and the minority of ratings were Adequate. We view these results overall as positive and encouraging, as they show that these youth anxiety self-report measures can be used with relatively high confidence to accomplish key assessment functions. Recommendations and future directions for further advancements to the evidence base are discussed.
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Are young people with primary social anxiety disorder less likely to recover following generic CBT compared to young people with other primary anxiety disorders? A systematic review and meta-analysis. Behav Cogn Psychother 2020; 49:352-369. [PMID: 33298222 PMCID: PMC8293629 DOI: 10.1017/s135246582000079x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Social anxiety disorder (SoAD) in youth is often treated with a generic form of cognitive behavioural therapy (CBT). Some studies have suggested that primary SoAD is associated with lower recovery rates following generic CBT compared with other anxiety disorders. Aims: This systematic review and meta-analysis investigated recovery rates following generic CBT for youth with primary SoAD versus other primary anxiety disorders. Method: Five databases (PsycINFO, Web of Science, PubMed, Embase, Medline) were searched for randomised controlled trials of generic CBT for child and/or adolescent anxiety. Results: Ten trials met criteria for inclusion in the systematic review, six of which presented sufficient data for inclusion in the meta-analysis. Sixty-seven did not report data on recovery rates relative to primary diagnosis. While most individual studies included in the systematic review were not sufficiently powered to detect a difference in recovery rates between diagnoses, there was a pattern of lower recovery rates for youth with primary SoAD. Across the trials included in the meta-analysis, the post-CBT recovery rate from primary SoAD (35%) was significantly lower than the recovery rate from other primary anxiety disorders (54%). Conclusions: Recovery from primary SoAD is significantly less likely than recovery from any other primary anxiety disorder following generic CBT in youth. This suggests a need for research to enhance the efficacy of CBT for youth SoAD.
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34
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James AC, Reardon T, Soler A, James G, Creswell C. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev 2020; 11:CD013162. [PMID: 33196111 PMCID: PMC8092480 DOI: 10.1002/14651858.cd013162.pub2] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments. OBJECTIVES To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches. SELECTION CRITERIA We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence. MAIN RESULTS We included 87 studies and 5964 participants in quantitative analyses. Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality). Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies). Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality). There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies) Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies). No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored. Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text. We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments. AUTHORS' CONCLUSIONS CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.
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Affiliation(s)
- Anthony C James
- Department of Psychiatry, University of Oxford, Oxford, UK
- Highfield Unit, Warneford Hospital, Oxford, UK
| | - Tessa Reardon
- Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- School of Psychology & Clinical Language Sciences, University of Reading, Reading, UK
| | | | | | - Cathy Creswell
- Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Experimental Psychology, University of Oxford, Oxford, UK
- School of Psychology & Clinical Language Sciences, University of Reading, Reading, UK
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35
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Waters AM, Groth TA, Purkis H, Alston‐knox C. Predicting outcomes for anxious children receiving group cognitive‐behavioural therapy: Does the type of anxiety diagnosis make a difference? CLIN PSYCHOL-UK 2020. [DOI: 10.1111/cp.12128] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Allison M. Waters
- School of Applied Psychology, Griffith University, Brisbane, Queensland, Australia,
| | - Trisha A. Groth
- School of Applied Psychology, Griffith University, Brisbane, Queensland, Australia,
| | - Helena Purkis
- School of Applied Psychology, Griffith University, Brisbane, Queensland, Australia,
| | - Clair Alston‐knox
- College of Griffith Social and Behavioural Research College, Griffith University, Brisbane, Queensland, Australia,
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Abstract
Remote delivery of evidence-based psychological therapies via video conference has become particularly relevant following the COVID-19 pandemic, and is likely to be an on-going method of treatment delivery post-COVID. Remotely delivered therapy could be of particular benefit for people with social anxiety disorder (SAD), who tend to avoid or delay seeking face-to-face therapy, often due to anxiety about travelling to appointments and meeting mental health professionals in person. Individual cognitive therapy for SAD (CT-SAD), based on the Clark and Wells (1995) model, is a highly effective treatment that is recommended as a first-line intervention in NICE guidance (NICE, 2013). All of the key features of face-to-face CT-SAD (including video feedback, attention training, behavioural experiments and memory-focused techniques) can be adapted for remote delivery. In this paper, we provide guidance for clinicians on how to deliver CT-SAD remotely, and suggest novel ways for therapists and patients to overcome the challenges of carrying out a range of behavioural experiments during remote treatment delivery.
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Creswell C, Waite P, Hudson J. Practitioner Review: Anxiety disorders in children and young people - assessment and treatment. J Child Psychol Psychiatry 2020; 61:628-643. [PMID: 31960440 DOI: 10.1111/jcpp.13186] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/18/2019] [Accepted: 12/02/2019] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Cathy Creswell
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Department of Psychiatry, University of Oxford, Oxford, UK
| | - Polly Waite
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Department of Psychiatry, University of Oxford, Oxford, UK.,School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Jennie Hudson
- Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia
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Asbrand J, Heinrichs N, Schmidtendorf S, Nitschke K, Tuschen-Caffier B. Experience Versus Report: Where Are Changes Seen After Exposure-Based Cognitive-Behavioral Therapy? A Randomized Controlled Group Treatment of Childhood Social Anxiety Disorder. Child Psychiatry Hum Dev 2020; 51:427-441. [PMID: 31960175 PMCID: PMC7235054 DOI: 10.1007/s10578-019-00954-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
A considerable number of children and adolescents with social anxiety disorder (SAD) do not benefit from treatment as much as expected. However, treatment success should not be measured with social anxiety reports alone; the cognitive, behavioral, and physiological components of social stress should also be assessed. The authors examined an exposure-based SAD-specific group cognitive behavioral therapy (CBT) in a randomized controlled trial (N = 67, age 9-13 years, blind randomized allocation to treatment [CBT; n = 31] and waitlist control [WLC; n = 36] groups). Success was operationalized as a clinically significant reduction of symptoms measured with SAD-specific questionnaires, structured interviews, and changes in response to the Trier Social Stress Test (TSST). In the CBT group, there was a trend toward a significant increase in positive cognitions in the TSST after treatment (d = 0.37), whereas these positive cognitions decreased in the WLC group (d = 0.40). No significant results involving group appeared for negative cognitions, behavior and physiology. Children in the CBT group, but not parents, further reported less social anxiety in one questionnaire from pre- to post-treatment (d = 0.89). A structured interview confirmed a decrease in severity of SAD in the CBT group. While the gold standard of a blind interview showed efficacy of treatment, not all trait and state measures demonstrated similar success patterns.Trial registration Eligibility criteria and some of the dependent variables (cognitions, physiology) for treatment success were registered with the German Research Foundation (TU 78/5-2, HE 3342/4-2) prior to recruitment. Clinical assessment of diagnosis and behavioral data were not a priori planned as outcome measures for this trial and therefore analyzed in a post-hoc approach.
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Affiliation(s)
- Julia Asbrand
- Department of Psychology, University of Freiburg, Freiburg im Breisgau, Germany.
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Nina Heinrichs
- Department of Psychology, University of Bremen, Bremen, Germany
- Department of Psychology, University of Braunschweig, Braunschweig, Germany
| | | | - Kai Nitschke
- Department of Psychology, University of Freiburg, Freiburg im Breisgau, Germany
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Leigh E, Chiu K, Clark DM. The effects of modifying mental imagery in adolescent social anxiety. PLoS One 2020; 15:e0230826. [PMID: 32251465 PMCID: PMC7135232 DOI: 10.1371/journal.pone.0230826] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/09/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The identification of negative self-imagery as a maintenance factor in adult social anxiety has led to enhanced treatments for this population. Whilst intrusive negative imagery is commonly reported by socially anxious adolescents, no studies have demonstrated that it plays a causal role in maintaining symptoms. To assess this possibility, we undertook an experimental study manipulating social self-imagery in high socially anxious adolescents. METHODS High socially anxious adolescents undertook two conversations under different conditions. During one conversation they held a negative social self-image in mind, and in the other they held a benign social self-image in mind. Self-report, conversation partner report and independent assessor ratings were taken. RESULTS When participants held a negative self-image in mind, they reported feeling more anxious, and believed they looked more anxious and performed more poorly. Furthermore, they overestimated how anxious they looked compared to conversation partner ratings. As well as distorting participants' perception of their anxious appearance, holding a negative image in mind also had observable effects on the interaction. Participants were rated as looking more anxious and performing less well by their conversation partner when they held such images in mind, and the conversation was rated more critically by conversation partners and independent observers. Finally, a preliminary mediation analysis suggested that the detrimental effect of negative imagery on the social interaction may be partly due to the spontaneous use of avoidant safety behaviours. CONCLUSIONS The findings provide support for a causal role of negative self-imagery in adolescent social anxiety and point to the potential clinical value of techniques targeting imagery to treat the disorder.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Kenny Chiu
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - David M. Clark
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
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40
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Sigurvinsdóttir AL, Jensínudóttir KB, Baldvinsdóttir KD, Smárason O, Skarphedinsson G. Effectiveness of cognitive behavioral therapy (CBT) for child and adolescent anxiety disorders across different CBT modalities and comparisons: a systematic review and meta-analysis. Nord J Psychiatry 2020; 74:168-180. [PMID: 31738631 DOI: 10.1080/08039488.2019.1686653] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Aim: Pediatric Anxiety Disorders (AD) are common. Cognitive behavioral therapy (CBT) is one of two first-line treatments of youth AD and it has previously been shown to be superior to wait-list but not placebo therapy. This study consists of a systematic review and meta-analysis of the literature to assess the efficacy of CBT modalities in comparison to control contingencies for pediatric anxiety disorders.Methods: Studies were included if they were randomized controlled trials, and if CBT was manualized or modular, alone or in combination with medication. CBT was required to include behavioral treatment, exposure treatment, or cognitive elements. Eligible studies included participants aged 18 years or younger.Results: Eighty-one studies were included, with 3386 CBT participants and 2527 control participants. The overall results indicated that CBT is an effective treatment for childhood AD. The results showed that individual-based CBT is superior to wait-list and attention control. Group-based CBT is superior to wait-list control and treatment as usual. Remote-based CBT was superior to attention control and wait-list control. Family-based CBT was superior to treatment as usual, wait-list control, and attention control. Selective serotonin reuptake inhibitors were no more effective than individual-based CBT. Combination treatment was, however, more effective than individual-based CBT.Conclusion: To the best of our knowledge, no meta-analysis has thus far disentangled the effects of CBT modalities across various comparisons. This meta-analysis hence provides an important update to the literature on the efficacy of CBT for treating anxiety disorders in young people.
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Affiliation(s)
| | | | | | - Orri Smárason
- Faculty of Psychology, University of Iceland, Reykjavik, Iceland.,Landspitali - the National University Hospital of Iceland, Reykjavik, Iceland
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41
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Mobach L, Klein AM, Schniering CA, Hudson JL. Specificity of Dysfunctional Beliefs in Children with Social Anxiety Disorder: Effects of Comorbidity. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2020; 51:389-396. [DOI: 10.1080/15374416.2019.1697930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Lynn Mobach
- Centre for Emotional Health, Department of Psychology, Macquarie University
- Behavioural Science Institute, Radboud University
| | - Anke M. Klein
- Behavioural Science Institute, Radboud University
- Developmental Psychology, University of Amsterdam
| | | | - Jennifer L. Hudson
- Centre for Emotional Health, Department of Psychology, Macquarie University
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42
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Lassen NF, Hougaard E, Arendt KB, Thastum M. A disorder-specific group cognitive behavior therapy for social anxiety disorder in adolescents: study protocol for a randomized controlled study. Trials 2019; 20:757. [PMID: 31864383 PMCID: PMC6925436 DOI: 10.1186/s13063-019-3885-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/05/2019] [Indexed: 11/16/2022] Open
Abstract
Background Social anxiety disorder (SAD) is a common disorder in adolescence associated with extensive distress and long-term impairment. Generic cognitive behavior therapy (CBT) programs for anxiety disorders have shown poorer outcomes for adolescents with SAD than for other anxiety disorders. Aim The aim of the present study is to investigate the efficacy of a disorder-specific group cognitive behavior therapy (G-CBT) program for youth SAD, the Cool Kids Anxiety Program - Social Enhanced (CK-E), developed at Macquarie University, Sidney, Australia. Methods The study is a randomized controlled trial comparing CK-E to a generic G-CBT program for anxiety disorders. Approximately 96 adolescents aged 12 to 17 years are included with data points at pre- and post-treatment, and at 3 months and 1 year follow-ups. Discussion The current study will provide more information about the efficacy of diagnosis-specific G-CBT treatment for youth SAD. Trial registration ClinicalTrials.gov, NCT03986827. Registered on 14 June 2019.
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Affiliation(s)
- Nanna Fensman Lassen
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Esben Hougaard
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Kristian Bech Arendt
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark
| | - Mikael Thastum
- Department of Psychology and Behavioural Sciences, Aarhus University, Aarhus, Denmark.
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43
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Leigh E, Clark DM. Online Social anxiety Cognitive therapy for Adolescents (OSCA): protocol for a randomised controlled trial. Trials 2019; 20:574. [PMID: 31590681 PMCID: PMC6781376 DOI: 10.1186/s13063-019-3651-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 08/12/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Adolescent social anxiety disorder (SAD) is common, impairing and persistent. There is a need to intervene early to avert its long-term consequences. Cognitive Therapy for SAD is the leading treatment for adults and shows promise for adolescents. However, given the scale of the problem of adolescent SAD and the limited availability of psychological therapists in child and adolescent mental health services, there is a substantial gap in service provision. Delivering therapy via the Internet may provide part of the solution to this problem. An Internet version of adult Cognitive Therapy for SAD has been developed, with outcomes similar to face-to-face therapy. We have recently adapted this treatment for use with adolescents with SAD. Here, we describe a randomised controlled trial designed to test the efficacy of Internet Cognitive Therapy for adolescent SAD compared to waitlist. METHODS/DESIGN Forty adolescents aged 14-18 years with a diagnosis of SAD will be recruited via schools. Participants will be randomly allocated to Internet Cognitive Therapy or to waitlist. All participants will be assessed three times during the study-at baseline (pretreatment/wait), midtreatment/wait (week 8) and posttreatment/wait (week 15). Participants in the experimental arm will also complete weekly measures as part of the online program and they will be assessed at 3 and 6 months. Postwait, participants in the waitlist arm will be offered Internet Cognitive Therapy, and weekly and posttreatment data will also be collected for them. The trial aims to test whether Internet Cognitive Therapy is superior to waitlist in reducing social anxiety symptoms and in reducing the proportion of adolescents meeting criteria for SAD. Other outcomes of interest include depression and general anxiety symptoms. Acceptability of the online treatment will also be evaluated. DISCUSSION This randomised controlled trial will provide preliminary evidence on whether this intervention, requiring relatively low levels of therapist input, is safe and clinically effective. If this is shown to be the case, Internet Cognitive Therapy for adolescents has the potential to provide a service to the large population of adolescents with untreated SAD. TRIAL REGISTRATION ISRCTN Registry, ISRCTN15079139 . Version 1 registered on 06/02/2019.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, OxCADAT, The Old Rectory, Paradise Square, Oxford, OX1 1TW UK
| | - David M. Clark
- Department of Experimental Psychology, University of Oxford, OxCADAT, The Old Rectory, Paradise Square, Oxford, OX1 1TW UK
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44
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Mobach L, Rinck M, Becker ES, Hudson JL, Klein AM. Content-Specific Interpretation Bias in Children with Varying Levels of Anxiety: The Role of Gender and Age. Child Psychiatry Hum Dev 2019; 50:803-814. [PMID: 30879167 PMCID: PMC6737177 DOI: 10.1007/s10578-019-00883-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The current study examined whether children varying in their levels of social anxiety, separation anxiety and spider fear exhibit a negative interpretation bias specific for their fears. Furthermore, age and gender were assessed as moderators of this relation. Children (N = 603) of the age of 7-12 years were asked to solve ambiguous scenarios reflecting social threat, separation threat or spider threat. Children's levels of anxiety were assessed with self-report questionnaires. Results indicated that children scoring higher on self-reported social anxiety, separation anxiety or spider fear, displayed a negative interpretation bias for the threat-scenarios pertaining to their specific anxiety or fear, even after controlling for comorbidity with other anxiety subtypes. Contrary to our hypotheses, we did not find moderating effects of age or gender. These results indicate that even in a community sample, content-specificity of negative interpretation biases is present.
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Affiliation(s)
- Lynn Mobach
- Department of Psychology, Behavioural Science Institute, Radboud University, Montessorilaan, 6525 HR, Nijmegen, The Netherlands.
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, Australia.
| | - Mike Rinck
- Department of Psychology, Behavioural Science Institute, Radboud University, Montessorilaan, 6525 HR, Nijmegen, The Netherlands
| | - Eni S Becker
- Department of Psychology, Behavioural Science Institute, Radboud University, Montessorilaan, 6525 HR, Nijmegen, The Netherlands
| | - Jennifer L Hudson
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, Australia
| | - Anke M Klein
- Department of Psychology, Behavioural Science Institute, Radboud University, Montessorilaan, 6525 HR, Nijmegen, The Netherlands
- Developmental Psychology, University of Amsterdam, Amsterdam, The Netherlands
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45
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Yang L, Zhou X, Pu J, Liu L, Cuijpers P, Zhang Y, Zhang H, Yuan S, Teng T, Tian L, Xie P. Efficacy and acceptability of psychological interventions for social anxiety disorder in children and adolescents: a meta-analysis of randomized controlled trials. Eur Child Adolesc Psychiatry 2019; 28:79-89. [PMID: 30006672 DOI: 10.1007/s00787-018-1189-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/28/2018] [Indexed: 11/26/2022]
Abstract
Social anxiety disorder (SAD) is highly prevalent and persistent in children and adolescents. However, evidence for the efficacy and acceptability of psychological interventions for SAD in children and adolescents remains unclear. Seven electronic databases (PubMed, CENTRAL, Embase, Web of Science, PsycINFO, CINAHL, and ProQuest) were searched. Randomized controlled trials (RCTs) that compared psychological interventions for SAD with control conditions in children and adolescents were included. Primary outcomes were the efficacy (mean change in anxiety symptom scores) and acceptability (dropouts for all reasons). Secondary outcomes were remission, quality of life/functional improvement, and depressive symptoms measures. Seventeen RCTs were included in this meta-analysis. Psychological interventions (including cognitive behavioral therapy and behavioral therapy) were significantly more effective than control conditions, with a standardized mean difference (SMD) of - 1.13, and remission with a risk ratio (RR) of 8.99, the number needed to treat was 3.3. There was no statistically significant difference between psychological interventions and control conditions for all-cause dropouts (RR = 1.00). Psychological interventions were superior to control conditions in improving quality of life/functioning (SMD = 0.79) and reducing depressive symptoms (SMD = - 0.39). Given considerable heterogeneity of primary efficacy outcome, a series of subgroup analyses of different variables were conducted. Psychological interventions are probably efficacious in the treatment of SAD among children and adolescents, and may markedly improve quality of life and functioning in this population. However, this finding should be interpreted with caution because of the high heterogeneity of trials and low literature quality.
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Affiliation(s)
- Lining Yang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Xinyu Zhou
- Department of Psychiatry, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Juncai Pu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Lanxiang Liu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.
| | - Yuqing Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Hanping Zhang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Shuai Yuan
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Teng Teng
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Lu Tian
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China
| | - Peng Xie
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People's Republic of China.
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Fuentes-Rodriguez G, Garcia-Lopez LJ, Garcia-Trujillo V. Exploring the role of the DSM-5 performance-only specifier in adolescents with social anxiety disorder. Psychiatry Res 2018; 270:1033-1038. [PMID: 29609991 DOI: 10.1016/j.psychres.2018.03.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 11/18/2022]
Abstract
The DSM-5 social anxiety disorder section has recently added the performance-only specifier for individuals whose anxiety is limited to speaking or performing in public. The impact of the DSM-5 performance-only specifier remains a neglected area. The sample comprised 44 healthy controls and 50 adolescents with a clinical diagnosis of SAD (20% met criteria for the performance-only specifier). Findings revealed that adolescents with the specifier had a later age of onset; lower levels of depression, social anxiety symptomatology and clinical severity; and a lesser degree of comorbidity relative to adolescents with SAD but excluding the performance-only specifier. Specifiers only evidenced higher (cognitive) social anxiety symptomatology compared to healthy controls. Results of this study also suggested that the performance-only specifier may correspond to a mild form of social anxiety disorder. Data also revealed that SAD exists on a continuum of severity among healthy controls, specifier participants, and those with both interactional and performance fears, which is consistent with a dimensional structure for SAD. Finally, findings suggested a unique comorbid pattern for specifiers and those adolescents with SAD but excluding the performance-only specifier. The implications of these findings for the etiology, assessment, classification, and treatment of social anxiety in youth are discussed.
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Affiliation(s)
- Gema Fuentes-Rodriguez
- Department of Psychology, Division of Clinical Psychology, Universidad de Jaen, Jaen, Spain
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47
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Salzer S, Stefini A, Kronmüller KT, Leibing E, Leichsenring F, Henningsen P, Peseschkian H, Reich G, Rosner R, Ruhl U, Schopf Y, Steinert C, Vonderlin E, Steil R. Cognitive-Behavioral and Psychodynamic Therapy in Adolescents with Social Anxiety Disorder: A Multicenter Randomized Controlled Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2018; 87:223-233. [PMID: 29895001 DOI: 10.1159/000488990] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 04/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although social anxiety disorder (SAD) has an early onset and is frequently found in adolescence, evidence for psychotherapeutic treatments of SAD in adolescents is rather scarce. Within the Social Phobia Psychotherapy Research Network (SOPHO-NET), we examined the efficacy of cognitive-behavioral (CBT) and psychodynamic therapy (PDT) compared to a waiting list (WL) in these patients. METHODS In a multicenter randomized controlled superiority trial, 107 patients, aged 14-20 years, were randomized to CBT (n = 34), PDT (n = 34), or WL (n = 39). Assessments were made at baseline, at the end of treatment, and 6 and 12 months after termination. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA) applied by raters masked to the treatment condition was used as the primary outcome. As secondary outcomes, rates of response and remission and the Social Phobia Anxiety Inventory (SPAI) were used. RESULTS Both treatments were superior to WL in the LSAS-CA (CBT: p = 0.0112, d = 0.61, 95% CI 0.14-1.08; PDT: p = 0.0261, d = 0.53, 95% CI 0.06-1.00). At the end of treatment, response rates were 66, 54, and 20% for CBT, PDT, and WL. The corresponding remission rates were 47, 34, and 6%, respectively. CBT and PDT were significantly superior to WL regarding remission (CBT: p = 0.0009, h = 1.0; PDT: p = 0.0135, h = 0.74), response (CBT: p = 0.0004, h = 0.97; PDT: p = 0.0056, h = 0.72), and the SPAI (CBT: p = 0.0021, d = 0.75, 95% CI 0.27-1.22; PDT: p = 0.0060, d = 0.66, 95% CI 0.19-1.13). Treatment effects were stable at 6- and 12-month follow-ups. CONCLUSIONS These results are comparable to the large SOPHO-NET trial in adults (n = 495). Early treatments for social anxiety are needed in order to prevent chronic manifestation of SAD.
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Affiliation(s)
- Simone Salzer
- Clinic of Psychosomatic Medicine and Psychotherapy, Georg August University Göttingen, Göttingen, Germany.,International Psychoanalytic University (IPU) Berlin, Berlin, Germany
| | - Annette Stefini
- Department of General Psychiatry, University of Heidelberg, Heidelberg, Germany
| | | | - Eric Leibing
- Clinic of Psychosomatic Medicine and Psychotherapy, Georg August University Göttingen, Göttingen, Germany
| | - Falk Leichsenring
- Clinic of Psychosomatics and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
| | - Peter Henningsen
- Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich, Munich, Germany
| | | | - Günter Reich
- Clinic of Psychosomatic Medicine and Psychotherapy, Georg August University Göttingen, Göttingen, Germany
| | - Rita Rosner
- Katholische Universität Eichstätt-Ingolstadt, Eichstätt, Germany
| | - Uwe Ruhl
- Department of Clinical Psychology and Psychotherapy, Georg August University Göttingen, Göttingen, Germany
| | - Yvonne Schopf
- Department of Clinical Psychology and Psychotherapy, Goethe University Frankfurt, Frankfurt, Germany
| | - Christiane Steinert
- Clinic of Psychosomatics and Psychotherapy, Justus Liebig University Giessen, Giessen, Germany
| | - Eva Vonderlin
- Department of Psychology, University of Heidelberg, Heidelberg, Germany
| | - Regina Steil
- Department of Clinical Psychology and Psychotherapy, Goethe University Frankfurt, Frankfurt, Germany
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48
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Leigh E, Clark DM. Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995). Clin Child Fam Psychol Rev 2018; 21:388-414. [PMID: 29654442 PMCID: PMC6447508 DOI: 10.1007/s10567-018-0258-5] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Social anxiety disorder is a condition characterised by a marked and persistent fear of being humiliated or scrutinised by others. Age-of-onset data point to adolescence as a developmentally sensitive period for the emergence of the condition, at a time when the peer group becomes increasingly important. Social anxiety in adolescence is associated with considerable impairment that persists through to adulthood. There are clear potential benefits to delivering effective interventions during adolescence. However, there is limited evidence on the specific efficacy of available therapies. This is in contrast to adults, for whom we have interventions with very specific treatment effects. One such treatment is individual cognitive therapy. Cognitive therapy is based on the cognitive model of social anxiety proposed by Clark and Wells (in: Heimberg, Leibowitz, Hope, Scheiber (eds) Social phobia: diagnosis, assessment and treatment, The Guilford Press, New York, 1995). The present review examines the potential application of this adult cognitive model to the understanding of adolescent social anxiety and considers additional adolescent-specific factors that need to be accommodated. It is suggested that a developmentally sensitive adoption of the cognitive model of social anxiety disorder (Clark and Wells 1995) for adolescents may lead to better treatment outcomes.
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Affiliation(s)
- Eleanor Leigh
- Department of Experimental Psychology, University of Oxford, Oxford, UK.
- Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, Oxford, OX1 1TW, UK.
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, UK
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McKinnon A, Keers R, Coleman JR, Lester KJ, Roberts S, Arendt K, Bögels SM, Cooper P, Creswell C, Hartman CA, Fjermestad KW, In‐Albon T, Lavallee K, Lyneham HJ, Smith P, Meiser‐Stedman R, Nauta MH, Rapee RM, Rey Y, Schneider S, Silverman WK, Thastum M, Thirlwall K, Wergeland GJ, Eley TC, Hudson JL. The impact of treatment delivery format on response to cognitive behaviour therapy for preadolescent children with anxiety disorders. J Child Psychol Psychiatry 2018; 59. [PMID: 29520926 PMCID: PMC6055633 DOI: 10.1111/jcpp.12872] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Several delivery formats of cognitive behaviour therapy (CBT) for child anxiety have been proposed, however, there is little consensus on the optimal delivery format. The primary goal of this study was to investigate the impact of the child's primary anxiety diagnosis on changes in clinical severity (of the primary problem) during individual CBT, group CBT and guided parent-led CBT. The secondary goal was to investigate the impact of the child's primary anxiety diagnosis on rates of remission for the three treatment formats. METHODS A sample of 1,253 children (5-12 years; Mage = 9.3, SD = 1.7) was pooled from CBT trials carried out at 10 sites. Children had a primary diagnosis of generalised anxiety disorder (GAD), social anxiety disorder (SoAD), specific phobia (SP) or separation anxiety disorder (SAD). Children and parents completed a semistructured clinical interview to assess the presence and severity of DSM-IV psychiatric disorders at preintervention, postintervention and follow-up. Linear mixture modelling was used to evaluate the primary research question and logistic modelling was used to investigate the secondary research question. RESULTS In children with primary GAD, SAD or SoAD, there were no significant differences between delivery formats. However, children with primary SP showed significantly larger reductions in clinical severity following individual CBT compared to group CBT and guided parent-led CBT. The results were mirrored in the analysis of remission responses with the exception that individual CBT was no longer superior to group CBT for children with a primary SP. The difference between individual and group was not significant when follow-up data were examined separately. CONCLUSIONS Data show there may be greater clinical benefit by allocating children with a primary SP to individual CBT, although future research on cost-effectiveness is needed to determine whether the additional clinical benefits justify the additional resources required.
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Affiliation(s)
- Anna McKinnon
- Department of PsychologyCentre for Emotional HealthMacquarie UniversitySydneyNSWAustralia
| | - Robert Keers
- Department of Biological and Experimental PsychologySchool of Biological and Chemical SciencesQueen Mary University of LondonLondonUK
| | - Jonathan R.I. Coleman
- Social, Genetic and Developmental Psychiatry CentreInstitute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,NIHR Biomedical Research Centre for Mental HealthSouth London and Maudsley NHS TrustLondonUK
| | | | - Susanna Roberts
- Social, Genetic and Developmental Psychiatry CentreInstitute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | - Kristian Arendt
- Department of Psychology and Behavioural SciencesAarhus UniversityAarhusDenmark
| | - Susan M. Bögels
- Research Institute Child Development and EducationUniversity of AmsterdamAmsterdamThe Netherlands
| | - Peter Cooper
- School of Psychology and Clinical Language SciencesUniversity of ReadingReadingUK,Department of PsychologyStellenbosch UniversityStellenboschSouth Africa,Department of PsychologyThe University of Cape TownCape TownSouth Africa
| | - Cathy Creswell
- School of Psychology and Clinical Language SciencesUniversity of ReadingReadingUK
| | - Catharina A. Hartman
- Department of PsychiatryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Krister W. Fjermestad
- Department of Clinical PsychologyFaculty of PsychologyUniversity of BergenBergenNorway,Department of Child and Adolescent PsychiatryAnxiety Disorders Research NetworkHaukeland University HospitalBergenNorway
| | - Tina In‐Albon
- Department of PsychologyUniversity Landau KoblenzLandauGermany
| | | | - Heidi J. Lyneham
- Department of PsychologyCentre for Emotional HealthMacquarie UniversitySydneyNSWAustralia
| | - Patrick Smith
- Department of PsychologyInstitute of PsychiatryKing's College LondonLondonUK
| | | | - Maaike H. Nauta
- Department of Clinical Psychology and Experimental PsychopathologyUniversity of GroningenGroningenThe Netherlands
| | - Ronald M. Rapee
- Department of PsychologyCentre for Emotional HealthMacquarie UniversitySydneyNSWAustralia
| | - Yasmin Rey
- Department of PsychologyChild Anxiety and Phobia ProgramFlorida International UniversityMiamiFLUSA
| | | | | | - Mikael Thastum
- Department of Psychology and Behavioural SciencesAarhus UniversityAarhusDenmark
| | - Kerstin Thirlwall
- School of Psychology and Clinical Language SciencesUniversity of ReadingReadingUK
| | - Gro Janne Wergeland
- Department of Child and Adolescent PsychiatryAnxiety Disorders Research NetworkHaukeland University HospitalBergenNorway
| | - Thalia C. Eley
- Social, Genetic and Developmental Psychiatry CentreInstitute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK,NIHR Biomedical Research Centre for Mental HealthSouth London and Maudsley NHS TrustLondonUK
| | - Jennifer L. Hudson
- Department of PsychologyCentre for Emotional HealthMacquarie UniversitySydneyNSWAustralia
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50
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Nordahl HM, Vogel PA, Morken G, Stiles TC, Sandvik P, Wells A. Paroxetine, Cognitive Therapy or Their Combination in the Treatment of Social Anxiety Disorder with and without Avoidant Personality Disorder: A Randomized Clinical Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2017; 85:346-356. [PMID: 27744447 DOI: 10.1159/000447013] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 05/23/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments. METHODS A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments. RESULTS CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group. CONCLUSIONS CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone.
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Affiliation(s)
- Hans M Nordahl
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
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