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de Jong R, Lommen MJJ, de Jong PJ, van Hout WJPJ, Duin-van der Marel ACE, Nauta MH. Effectiveness of exposure-based treatment for childhood anxiety disorders: An open clinical trial to test its relation with indices of emotional processing and inhibitory learning. J Behav Ther Exp Psychiatry 2024; 83:101942. [PMID: 38309121 DOI: 10.1016/j.jbtep.2024.101942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND AND OBJECTIVES The current study examined how effectiveness of exposure-based CBT was related to indices of emotional processing and inhibitory learning during exposure exercises. METHODS Adolescents with anxiety disorder(s) (N = 72; age 11-19; 85% girls) received a group-based, intensive two-week treatment of which effectiveness was indexed by the SCARED and by ratings of anxiety and approach towards individualized goal situations. To index emotional processing, subjective units of distress (SUDs) were used to indicate both initial and final fear level, and absolute, relative, and total dose of fear reduction. To index inhibitory learning, subjective threat expectancies (STEs) were used to indicate initial and final threat expectancy, and absolute, relative, and total dose of expectancy change. RESULTS From pre-treatment to follow-up, there was a large-sized reduction of anxiety symptoms, small-sized decrease of subjective anxiety and a large-sized increase in subjective approach towards individual treatment goals. Higher fear levels prior to exposure were related to a larger decrease of symptoms. Higher threat expectancies after exposure exercises were independently associated with less decrease of anxiety and increase of approach towards treatment goals. Total dose of experienced fear reduction and total dose of experienced expectancy change were (partly) independently related to more increase in approach towards individualized goal situations. LIMITATIONS As patients also received other treatment elements, the results cannot be interpreted unequivocally. CONCLUSIONS The pattern of findings seems to indicate that emotional processing (as indexed by fear reduction) and inhibitory learning (as indexed by expectancy change) are both relevant in exposure-based CBT.
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Affiliation(s)
- Rachel de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Miriam J J Lommen
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Peter J de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Wiljo J P J van Hout
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | | | - Maaike H Nauta
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
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de Jong R, Lommen MJJ, van Hout WJPJ, Kuijpers RCWM, Stone L, de Jong P, Nauta MH. Better together? A randomized controlled microtrial comparing different levels of therapist and parental involvement in exposure-based treatment of childhood specific phobia. J Anxiety Disord 2023; 100:102785. [PMID: 37832323 DOI: 10.1016/j.janxdis.2023.102785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 09/19/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE). METHODS Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up. RESULTS TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up. CONCLUSIONS These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.
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Affiliation(s)
- Rachel de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Miriam J J Lommen
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Wiljo J P J van Hout
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | | | - Lisanne Stone
- Karakter Child and Youth Psychiatry, Nijmegen, the Netherlands
| | - Peter de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands; Radboud University Nijmegen, Department of Pedagogical Sciences, the Netherlands; Karakter Child and Youth Psychiatry, Nijmegen, the Netherlands
| | - Maaike H Nauta
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
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Jong RD, Hofs A, Lommen MJJ, van Hout WJPJ, Jong PJD, Nauta MH. Treating specific phobia in youth: A randomized controlled microtrial comparing gradual exposure in large steps to exposure in small steps. J Anxiety Disord 2023; 96:102712. [PMID: 37043895 DOI: 10.1016/j.janxdis.2023.102712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 02/17/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023]
Abstract
INTRODUCTION Exposure may be especially effective when within exercises, there is a strong violation of threat expectancies and much opportunity for fear reduction. Outcomes of exposure may therefore improve when exposure is conducted in large steps (LargeSE) relative to small steps (SmallSE). METHODS Children and young people with a specific phobia (SP) (N = 50, age 8-17, 64 % girls) participated in a preregistered single-blind, randomized controlled microtrial comparing LargeSE and SmallSE in a four-week baseline-treatment design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up. RESULTS Within exercises, LargeSE resulted in higher initial fear levels and more within-session expectancy violation. Nevertheless, SmallSE resulted in a larger decline of SP severity from baseline to post-treatment and follow-up, and a larger decline of anxiety and avoidance towards one's individual goal from baseline to follow-up. There were no differences between LargeSE and SmallSE regarding changes in general self-efficacy or behavioral avoidance. Although session duration was standardized and similar for both conditions, participants in SmallSE received more (shorter) exercises. DISCUSSION SmallSE might be more effective in reducing SP severity because children in SmallSE were exposed to a larger number and variety of exercises than children in LargeSE.
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Affiliation(s)
- Rachel de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Annemieke Hofs
- Accare Child Study Center, University Center for Child and Adolescent Psychiatry, Groningen, the Netherlands
| | - Miriam J J Lommen
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Wiljo J P J van Hout
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Peter J De Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Maaike H Nauta
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands; Accare Child Study Center, University Center for Child and Adolescent Psychiatry, Groningen, the Netherlands.
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Creswell C, Nauta MH, Hudson JL, March S, Reardon T, Arendt K, Bodden D, Cobham VE, Donovan C, Halldorsson B, In-Albon T, Ishikawa SI, Johnsen DB, Jolstedt M, de Jong R, Kreuze L, Mobach L, Rapee RM, Spence SH, Thastum M, Utens E, Vigerland S, Wergeland GJ, Essau CA, Albano AM, Chu B, Khanna M, Silverman WK, Kendall PC. Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders - an international consensus statement. J Child Psychol Psychiatry 2021; 62:255-269. [PMID: 32683742 DOI: 10.1111/jcpp.13283] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/03/2020] [Accepted: 05/12/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anxiety disorders in children and young people are common and bring significant personal and societal costs. Over the last two decades, there has been a substantial increase in research evaluating psychological and pharmacological treatments for anxiety disorders in children and young people and exciting and novel research has continued as the field strives to improve efficacy and effectiveness, and accessibility of interventions. This increase in research brings potential to draw together data across studies to compare treatment approaches and advance understanding of what works, how, and for whom. There are challenges to these efforts due largely to variation in studies' outcome measures and variation in the way study characteristics are reported, making it difficult to compare and/or combine studies, and this is likely to lead to faulty conclusions. Studies particularly vary in their reliance on child, parent, and/or assessor-based ratings across a range of outcomes, including remission of anxiety diagnosis, symptom reduction, and other domains of functioning (e.g., family relationships, peer relationships). METHODS To address these challenges, we convened a series of international activities that brought together the views of key stakeholders (i.e., researchers, mental health professionals, young people, parents/caregivers) to develop recommendations for outcome measurement to be used in treatment trials for anxiety disorders in children and young people. RESULTS AND CONCLUSIONS This article reports the results of these activities and offers recommendations for selection and reporting of outcome measures to (a) guide future research and (b) improve communication of what has been measured and reported. We offer these recommendations to promote international consistency in trial reporting and to enable the field to take full advantage of the great opportunities that come from data sharing going forward.
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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
| | - Maaike H Nauta
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands
| | - Jennifer L Hudson
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia
| | - Sonja March
- School of Psychology and Counselling, University of Southern Queensland, Springfield, QLD, Australia
| | - Tessa Reardon
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Department of Psychiatry, University of Oxford, Oxford, UK
| | | | - Denise Bodden
- Department of Child and Adolescent Studies, Utrecht University, Utrecht, The Netherlands
| | - Vanessa E Cobham
- Children's Health QLD Child and Youth Mental Health Service, Brisbane, QLD, Australia.,School of Psychology, The University of Queensland, Brisbane, QLD, Australia
| | - Caroline Donovan
- School of Applied Psychology, Griffith University, Brisbane, QLD, Australia
| | - Brynjar Halldorsson
- Department of Experimental Psychology, University of Oxford, Oxford, UK.,Department of Psychiatry, University of Oxford, Oxford, UK.,Department of Psychology, Reykjavik University, Reykjavik, Iceland
| | - Tina In-Albon
- Clinical Child and Adolescent Psychology and Psychotherapy Unit, University of Koblenz and Landau, Landau, Germany
| | | | | | - Maral Jolstedt
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden.,Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Rachel de Jong
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands
| | - Leonie Kreuze
- Department of Clinical Psychology and Experimental Psychopathology, University of Groningen, Groningen, The Netherlands
| | - Lynn Mobach
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia.,Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Ronald M Rapee
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, NSW, Australia
| | - Susan H Spence
- School of Applied Psychology, Griffith University, Brisbane, QLD, Australia.,Australian Institute for Suicide Research and Prevention, Griffith University, Brisbane, QLD, Australia
| | | | - Elisabeth Utens
- Research Institute of Child Development and Education, University of Amsterdam / The Bascule / Amsterdam UMC, Amsterdam, The Netherlands.,Sophia Children's Hospital, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Sarah Vigerland
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, Stockholm, Sweden.,Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Gro Janne Wergeland
- Division of Psychiatry, Department of Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Cecilia A Essau
- Department of Psychology, University of Roehampton, London, UK
| | - Anne Marie Albano
- Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Brian Chu
- Department of Clinical Psychology, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Muniya Khanna
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Wendy K Silverman
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA
| | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, PA, USA
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de Jong R, Lommen MJJ, van Hout WJPJ, de Jong PJ, Nauta MH. Therapists' characteristics associated with the (non-)use of exposure in the treatment of anxiety disorders in youth: A survey among Dutch-speaking mental health practitioners. J Anxiety Disord 2020; 73:102230. [PMID: 32428821 DOI: 10.1016/j.janxdis.2020.102230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 03/27/2020] [Accepted: 04/20/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Although there is consensus that exposure is the key ingredient in treating childhood anxiety disorders, several studies in the USA suggest exposure to be underused in clinical practice. Previous research pointed to therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety as important factors in the underusage of exposure in the treatment of adult anxiety disorders. This study examined what therapist characteristics may be involved in the (non-)use of exposure in treating childhood anxiety disorders. METHODS An internet-based survey among 207 youth mental health care professionals in the Netherlands and Belgium was conducted to assess therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety, depression and stress. RESULTS The current survey showed that therapists used exposure in about half of their cases of childhood anxiety and that the non-use was independently associated with the relatively strong negative beliefs about exposure, therapists' age, and non-CBT orientation. DISCUSSION Findings point to the importance of addressing negative beliefs about exposure in therapists' training and supervision to resolve therapy drift away from exposure, and consequently improve utilization and delivery of exposure-based therapy for childhood anxiety disorders.
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Affiliation(s)
- Rachel de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Miriam J J Lommen
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Wiljo J P J van Hout
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Peter J de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Maaike H Nauta
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
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Lommen MJJ, Duta M, Vanbrabant K, de Jong R, Juechems K, Ehlers A. Training discrimination diminishes maladaptive avoidance of innocuous stimuli in a fear conditioning paradigm. PLoS One 2017; 12:e0184485. [PMID: 29023466 PMCID: PMC5638232 DOI: 10.1371/journal.pone.0184485] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 08/24/2017] [Indexed: 01/20/2023] Open
Abstract
Anxiety disorders are the most common mental disorder worldwide. Although anxiety disorders differ in the nature of feared objects or situations, they share a common mechanism by which fear generalizes to related but innocuous objects, eliciting avoidance of objects and situations that pose no objective risk. This overgeneralization appears to be a crucial mechanism in the persistence of anxiety psychopathology. In this study we test whether an intervention that promotes discrimination learning reduces generalization of fear, in particular, harm expectancy and avoidance compared to an irrelevant (control) training. Healthy participants (N = 80) were randomly allocated to a training condition. Using a fear conditioning paradigm, participants first learned visual danger and safety signals (set 1). Baseline level of stimulus generalization was tested with ambiguous stimuli on a spectrum between the danger and safety signals. There were no differences between the training groups. Participants then received the stimulus discrimination training or a control training. After training, participants learned a new set of danger and safety signals (set 2), and the level of harm expectancy generalization and behavioural avoidance of ambiguous stimuli was tested. Although the training groups did not differ in fear generalization on a cognitive level (harm expectancy), the results showed a different pattern of avoidance of ambiguous stimuli, with the discrimination training group showing less avoidance of stimuli that resembled the safety signals. These results support the potential of interventions that promote discrimination learning in the treatment of anxiety disorders.
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Affiliation(s)
- Miriam J. J. Lommen
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
- Oxford Cognitive Health NIHR Clinical Research Facility, University of Oxford, Oxford, United Kingdom
| | - Mihaela Duta
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Koen Vanbrabant
- Center for the Psychology of Learning and Experimental Psychopathology, University of Leuven, Leuven, Belgium
| | - Rachel de Jong
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
- Oxford Cognitive Health NIHR Clinical Research Facility, University of Oxford, Oxford, United Kingdom
| | - Keno Juechems
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
- Oxford Cognitive Health NIHR Clinical Research Facility, University of Oxford, Oxford, United Kingdom
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