Vicarious Improvement Among Parents Participating in Child-Focused Cognitive-Behavioral Therapy for Anxiety

Parental variables likely have important and bidirectional influences on the etiology of child anxiety. Although some child-focused cognitive-behavioral therapy (CCBT) anxiety trials have found vicarious improvements among parents who participated in their children’s treatment, this is an understudied area. We hypothesized that parental variables (psychopathology, stress, and burden) will significantly decrease from pre- to post-CCBT and will be associated with child treatment response. We explored whether intervention delivery method—in-person CCBT versus parent-mediated bibliotherapy—influenced vicarious parental improvements. Parental variables decreased from pre- to post-CCBT and were associated with child treatment response. Effects did not interact with delivery method. Parent participation in anxiety CCBT may result in vicarious improvements for parents.     

Feasibility and Preliminary Efficacy of an Internet Support Group for Parents of a Child with Neurofibromatosis Type 1: a Pilot Study

This pilot study investigated the feasibility and preliminary efficacy of an Internet Support Group (ISG) for parents of children with NF1. Eligible parents were recruited by email and completed baseline questionnaires assessing social support, self-efficacy, depression, and anxiety. The ISG involved eight weekly 90-min chat sessions and a discussion forum open 24 h/day for 8 weeks. Follow-up measures were completed immediately post-intervention and 3 months later. Parents from 33 families (29 mothers, 4 fathers) completed baseline measures. Over half of parents (52 %) rated their child’s disease severity as mild, 33 % moderate, and 15 % severe. Among 21 parents who completed post-intervention measures, ratings of perceived emotional (p = .0008) and informational (p = .0003) support increased. There were no significant changes in self-efficacy, depression, or anxiety (ps > .05). The mean satisfaction rating was moderately high (7.6/10; range 4–10). Some parents commented that the chat sessions were at inconvenient times, which may have limited participation. Preliminary evidence in this small sample of parents suggests that ISGs may be a feasible and potentially efficacious method of providing support to parents of children with NF1. Having multiple weekly chat sessions held at various days and times may improve accessibility and participation. Clinicians are encouraged to help parents access online support resources.     

Parent-directed cognitive behavioral therapy for young anxious children: a pilot study

Anxiety in children age 8 years and above has been successfully treated with cognitive behavioral therapy (CBT). However, the efficacy of CBT for anxious children ages 4-7 years has not, to date, been fully investigated. This paper piloted a CBT intervention targeting child anxiety that was delivered exclusively to parents of 26 children with anxiety symptoms ages 4-7 years. The intervention consisted of four 2-hour group sessions of four to six parents (couples). These group sessions were followed by four individual telephone sessions, once per week across a 4-week period. The pre- and postintervention assessment involved measures of multiple constructs of child anxiety (anxiety symptoms, children's fears, behavioral inhibition, and internalizing symptoms) from multiple informants (parents, children, and teachers). Parents also reported parenting strategies they were likely to use to manage their children's anxiety pre- and postintervention. Results indicated a significant decrease in child anxiety and behavioral inhibition as reported by parents and teachers. Furthermore, mothers reported significant increases in their use of positive reinforcement, and modeling and reassurance, and a significant decrease in their use of reinforcement of dependency directly after treatment. Taken together, parent-directed CBT appears to be an effective approach for treating children ages 4-7 years with anxiety symptoms. Limitations of the current research are discussed.     

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

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

Parent Training for Childhood Anxiety Disorders: The SPACE Program

Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in children’s therapy, training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment manual are included with the hope of “bringing the treatment to life” and conveying a rich sense of the therapeutic process. Parents participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the child’s motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may be effective in improving childhood anxiety.     

Application of a Quality Improvement Process to Evaluate Self-Directed Therapy for Patients on a Waitlist in an Outpatient Anxiety Disorders Specialty Clinic

The demand for psychological services in the United States is higher than the available supply of qualified mental health professionals. As a result, there is a substantial need for low-cost interventions that are more accessible and amenable to scale-up independent of the availability of clinicians. Previous studies have found that self-directed bibliotherapy can be an effective intervention with minimal therapist contact. Using the Plan-Do-Study-Act (PDSA) improvement process framework, we implemented self-directed therapy in our outpatient anxiety disorders specialty clinic. We identified four self-directed therapy resources (two books and two smartphone apps) based on cognitive behavioral or acceptance and mindfulness principles. We conducted initial 30-minute billable bibliotherapy consultations with six patients on our waitlist, where we provided the rationale for self-guided treatment, introduced the four resources, helped the patient identify one resource to use, and answered any questions. Eight weeks later, we met with five of these patients for a second billable 30-minute consultation (one had already started individual therapy) and gathered information regarding feasibility and acceptability of these resources as well as helped the patient make continued or better use of the resource until beginning therapy. This case series suggests that self-directed interventions can be effectively implemented in this manner, though with mixed outcomes and effects on patients and their course of care. We describe improvements we intend to implement in future iterations of self-directed therapy.     

The effect of affective bibliotherapy on clients' functioning in group therapy

Abstract The effect of affective group bibliotherapy (GB) was compared to affective group therapy (GT) on patients' functioning in therapy and their session impression. Three small groups totaling twenty-five in-patients in a hospital in Israel participated in the study. Clients concurrently participated in both group types, undergoing three sessions in each condition. In-therapy behaviors were assessed through the Client Behavior System (CBS; Hill & O'Brien, 1999). Results indicated that in the GB condition compared to the GT condition, clients showed less resistance, used simple responses less frequently, and expressed greater affective exploration. The Session Evaluation Questionnaire (SEQ; Stiles et al., 1994) was used to measure clients' impressions of the sessions. Results indicated that patients evaluated the two treatment conditions equally. Overall, the results support earlier findings, suggesting that affective bibliotherapy can be an effective method of treatment.     

Single Session Psychology Clinic for Parents of Children with Autism Spectrum Disorder: A Feasibility Study

Children are being diagnosed with autism spectrum disorder at much higher rates than in the past, with the increasing rates arising primarily from the broadened diagnostic criteria and increased public and professional awareness of the disorder. In turn, this has resulted in increased demands for psychological services, which many service providers struggle to meet. Single session clinics are an innovative form of intervention which can facilitate quick access to psychological services, without the burden of lengthy waiting times. This feasibility study examined the nature of presenting problems, attendance rates and parental satisfaction with a single session clinic for parents of children with autism spectrum disorder. The service offers short one-to-one consultation with a psychologist and sessions can be booked up to one month in advance. The single session clinic was developed to provide individual intervention to families within the constraints of an overwhelmed service. Good attendance rates and relatively high satisfaction suggest the single-session consultation for parents of children with autism spectrum disorder is an acceptable form of service. Limitations include the a need for more detailed evaluation of the impact of the sessions on both parental anxiety and child outcomes, and to identify more clearly who may benefit most from this model.     

A Comparison of Interactions Among Children,Parents, and Therapists in Cognitive Behavior Therapy for Anxiety Disorders in Australia and Japan

Despite growing attention to the efficacy of culturally adapted cognitive-behavioral treatment (CBT) programs for children and adolescents, there is still little empirical and practical information available to therapists who adapt original treatment protocols to suit clients of a specific culture. The current study aimed to compare therapeutic interactions across CBT treatment delivered with two different cultural groups. We developed an observational coding system to examine behaviors exhibited by child, parent, and therapist during CBT sessions conducted in Australia and Japan for children with anxiety disorders. Our results demonstrated significant differences between the two countries with respect to the treatment readiness of children, the proportion of talking during the sessions by parents and children, therapists’ laughter, length of silence during the first session, and parent indices of accommodation. In terms of transitions over time (i.e., first to last CBT session), parents in both countries tended to talk more during the last CBT session, whereas only Australian therapists talked less over time. The proportion of silence decreased over time during the Japanese sessions, and the amount of interruptions by parents increased over time for Australian sessions. Finally, our exploratory analyses demonstrated that a number of behavioral observations were correlated with anxiety treatment outcome at posttreatment. This study suggests that interactions between a child, parent, and therapist during CBT sessions may be affected by the culture in which the CBT session occurs, which could have implications for culturally adapted CBT programs.     

Targeted Prevention of Childhood Anxiety: Engaging Parents in an Underserved Community

Selective prevention programs hold the promise of alleviating child anxiety symptoms, decreasing the risk for emotional problems across the lifespan. Such programs have particular public health import for young children of poor, underserved communities. Identifying factors related to parent engagement, and methods to improve engagement, are paramount in the effort to develop anxiety‐focused, community prevention programs. This feasibility study investigated the effect of an enhanced recruitment strategy to maximize parent engagement, as well as factors related to attendance in a single session focused on anxiety prevention. Participants were poor, ethnic minority parents of children aged 11–71 months (n = 256) who completed a survey that assessed anxiety risk according to trauma exposure, child anxiety, or parent anxiety, as well as preferences for preventive services (phase 1). Those meeting risk criteria (n = 101) were invited to a preventive group session (phase 2). Half of parents received enhanced recruitment (ER), which included personalized outreach, matching parent preferences, and community endorsement. Other parents were invited by mail. Chi square analyses indicated that ER was associated with planning to attend (49 vs. 6 % of control). Parents receiving ER were 3.5 times more likely to attend. Higher sociodemographic risk was correlated with higher child anxiety symptoms but not attendance. Results highlight the need for improved strategies for engaging parents in preventive, community‐based interventions.     

Cognitive-behavioural therapy for young children with anxiety disorders: Comparison of a Child + Parent condition versus a Parent Only condition

The present study compared the efficacy of a group-based cognitive-behavioural treatment (GCBT) delivered exclusively to parents of young anxious children (between 4 and 8 years of age) with the same intervention delivered to both children and parents, relative to a Wait-list Control condition. Parents of children in the Parent Only condition (N = 25) received 10 weekly sessions of GCBT whereas children and parents in the Parent + Child condition (N = 24) each received 10 weekly sessions of GCBT. Intent-to-treat analyses indicated that both active treatment conditions were superior to the Wait-list condition (N = 11), with 55.3% of children in the Parent Only condition and 54.8% of children in the Parent + Child condition no longer meeting criteria for their principal diagnosis at post-treatment. These treatment gains were maintained in both treatment conditions at six-month and 12-month follow-up assessments. There were no significant differences between the two active conditions on other outcome measures including parental psychopathology and parenting style. However, an unexpected finding was that parenting satisfaction and to some extent parenting competence reduced significantly from pre- to post-treatment regardless of the active treatment condition. The present results suggest that GCBT delivered exclusively to parents of young anxious children may be a viable treatment alternative for improving accessibility to efficacious treatments for children with anxiety disorders and for reducing costs associated with mental health care delivery.     

Therapist-Led,Internet-Delivered Treatment for Early Child Social Anxiety: A Waitlist-Controlled Evaluation of the iCALM Telehealth Program

Despite recent advances in the treatment of early child social anxiety, the broad accessibility of brick-and-mortar services has been limited by traditional barriers to care, and more recently by new obstacles related to efforts to slow the spread of COVID-19. The present waitlist-controlled trial examined the preliminary efficacy of a family-based behavioral parenting intervention (i.e., the iCALM Telehealth Program) that draws on Parent-Child Interaction Therapy and videoconferencing to remotely deliver clinician-led care for anxiety in early childhood. Young children (3–8 years) with a diagnosis of social anxiety disorder (N = 40; 65% from ethnic/racial minority backgrounds) were randomly assigned to iCALM or waitlist. Intent-to-treat analyses found that at post, independent evaluators classified roughly half of the iCALM-treated children, but only 6% of waitlist children, as “Responders” (Wald test = 4.51; p = .03). By Post, iCALM led to significantly greater reductions than waitlist in child anxiety symptoms, fear, discomfort, and anxiety-related social impairment, and also led to greater improvements in child soothability. By 6-month follow-up, the percentage of iCALM-treated children classified as “Responders” rose to roughly 60%. Exploratory moderation tests found iCALM was particularly effective in reducing life impairments and parental distress among families presenting with higher, relative to lower, levels of baseline parental accommodation. The present findings add to a growing body of research supporting the promise of technology-based strategies for broadening the portfolio of options for delivering clinician-led mental health services.     

The Psychoanalytic Study of the Child,Volume VI Edited by Ruth S. Eissler,Anna Freud,Heinz Hartmann,Ernst Kris

Abstract

The effect of affective group bibliotherapy (GB) was compared to affective group therapy (GT) on patients’ functioning in therapy and their session impression. Three small groups totaling twenty–five in–patients in a hospital in Israel participated in the study. Clients concurrently participated in both group types, undergoing three sessions in each condition. In–therapy behaviors were assessed through the Client Behavior System (CBS; Hill &; O’Brien, 1999). Results indicated that in the GB condition compared to the GT condition, clients showed less resistance, used simple responses less frequently, and expressed greater affective exploration. The Session Evaluation Questionnaire (SEQ; Stiles et al., 1994) was used to measure clients’ impressions of the sessions. Results indicated that patients evaluated the two treatment conditions equally. Overall, the results support earlier findings, suggesting that affective bibliotherapy can be an effective method of treatment.     

Enhancing recovery rates: Lessons from year one of IAPT

BackgroundThe English Improving Access to Psychological Therapies (IAPT) initiative aims to make evidence-based psychological therapies for depression and anxiety disorder more widely available in the National Health Service (NHS). 32 IAPT services based on a stepped care model were established in the first year of the programme. We report on the reliable recovery rates achieved by patients treated in the services and identify predictors of recovery at patient level, service level, and as a function of compliance with National Institute of Health and Care Excellence (NICE) Treatment Guidelines.MethodData from 19,395 patients who were clinical cases at intake, attended at least two sessions, had at least two outcomes scores and had completed their treatment during the period were analysed. Outcome was assessed with the patient health questionnaire depression scale (PHQ-9) and the anxiety scale (GAD-7).ResultsData completeness was high for a routine cohort study. Over 91% of treated patients had paired (pre-post) outcome scores. Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration. Most patients received treatments that were recommended by NICE. When a treatment not recommended by NICE was provided, recovery rates were reduced. Service characteristics that predicted higher reliable recovery rates were: high average number of therapy sessions; higher step-up rates among individuals who started with low intensity treatment; larger services; and a larger proportion of experienced staff.ConclusionsCompliance with the IAPT clinical model is associated with enhanced rates of reliable recovery.     

Coaching Approach Behavior and Leading by Modeling: Rationale,Principles, and a Session-by-Session Description of the CALM Program for Early Childhood Anxiety

Whereas the cognitive-behavioral treatment of childhood anxiety has been well-researched and empirically supported over the last 20 years, interventions for anxiety in young children (ages 7 and below) have garnered little attention. Because young children generally lack the required developmental skills to effectively engage in cognitive-behavioral treatment, a simple downward extension of treatments used for older children is inappropriate. The CALM program (Coaching Approach behavior and Leading by Modeling) was developed as a developmentally compatible intervention to treat anxiety disorders in young children ages 3 to 7. The CALM program is an adaptation of Parent-Child Interaction Therapy (PCIT), and an extension of Pincus, Eyberg, and Choate's (2000) adaptation of PCIT for young children with separation anxiety disorder. It is a parent-focused treatment that teaches parents skills to effectively reinforce their children's brave behavior and coaches the use of these skills during in-session parent-child interactions. The treatment emphasizes live, bug-in-the-ear coaching of parents during in vivo exposure sessions. This article describes the CALM program in detail.     

Predictors of Treatment Engagement for Young Children Exposed to Violence

This study examined factors associated with treatment engagement and child outcomes in 1,365 children receiving community-based services for exposure to violence. Data were collected on children and families who completed an intake interview. Children were categorized into groups based on whether they attended any therapy sessions after the intake, terminated prematurely from therapy, or completed treatment. Results demonstrated that child emotional and behavioral problems at intake, general parent stress, and income did not differ by treatment engagement. Type of violence exposure, parent–child stress, and race differed by category of treatment engagement. Strategies from Safe From the Start service providers to increase treatment engagement are included in the discussion.     

A Unified,Transdiagnostic Treatment for Adolescents With Chronic Pain and Comorbid Anxiety and Depression

Chronic pain disorders represent a significant public health concern, particularly for children and adolescents. High rates of comorbid anxiety and unipolar mood disorders often complicate psychological interventions for chronic pain. Unified treatment approaches, based on emotion regulation skills, are applicable to a broad range of emotional disorders and suggest the possibility of extending these interventions to chronic pain and pain-related dysfunction. This case report describes the use of a unified protocol for treatment of an adolescent boy with chronic daily headache and social anxiety and an adolescent girl with whole body pain and depression. Following weekly, 50-minute individual treatment sessions, the boy demonstrated notable improvement in emotional symptoms, emotion regulation skills, somatization, and functional disability. The girl showed some improvement on measures of anxiety and depression, although there appeared to be a worsening of pain symptoms and somatization. However, both patients demonstrated improvement over follow-up. This case study illustrates the potential utility of a unified treatment approach targeting pain and emotional symptoms from an emotion regulation perspective in an adolescent population.     

Examining the Relation Between the Therapeutic Alliance, Treatment Adherence, and Outcome of Cognitive Behavioral Therapy for Children With Anxiety Disorders

Little is known about the contribution of technical and relational factors to child outcomes in cognitive behavioral therapy (CBT) for children with anxiety disorders. This study investigated the association between treatment adherence, the child-therapist alliance, and child clinical outcomes in manual-guided individual- and group-based CBT for youths diagnosed with anxiety disorders. Trained observers rated tapes of therapy sessions for treatment adherence and child-therapist alliance in a sample of 52 children (aged 8 to 12) with anxiety disorders. Self-reported child anxiety was assessed at pre-, mid-, and posttreatment; parent-reported child internalizing symptoms was assessed at pre- and posttreatment. The results showed high levels of treatment adherence and child-therapist alliance in both CBT programs. Neither treatment adherence nor child-therapist alliance predicted traditional measurements of child outcomes in the present study, but a relation between alliance and outcome was found using a more precise estimation of the true pre-post differences. Implications of these findings for expanding our understanding of how treatment processes relate to child outcome in CBT for children with anxiety disorders are discussed.     

An Investigation of the Rate and Predictors of Initiating and Attending Group Cognitive Behavioral Therapy for Insomnia After Referral

Although group Cognitive Behavioral Therapy for Insomnia (CBT-I) is an efficacious and well-studied treatment, relatively less is known about its clinical effectiveness in community outpatient settings. Prior research has suggested that dropout from CBT-I may be high in treatment settings vs. clinical trials. The current study therefore investigated the rates and predictors of initiating and attending CBT-I group within an outpatient psychiatry clinic. Participants were 75 consecutive outpatients presenting for treatment at a specialty sleep and anxiety clinic who completed an evaluation and were referred to CBT-I group. Participants completed self-report measures at initial evaluation, and their attendance throughout treatment was tracked. The majority of patients attended ≥1 session, with a mean of 3/5 sessions completed for initiators. Those with poorer global sleep quality and longer sleep onset latency were less likely to attend group and attended fewer sessions. Those with more severe anxiety and depression were less likely to initiate attendance and attended fewer sessions. The majority of patients referred to CBT-I initiated group and attended at least half of the sessions. Further, demographics do not seem to impact these rates. Unfortunately, those with the most severe symptoms, and thus in most need for treatment, are least likely to initiate and attend. This may be due to comorbid anxiety or depression symptoms. Future research should replicate these findings, as well as explore how to encourage those most in need of treatment to initiate and attend CBT-I.     

Sociodemographic, clinical and outcome differences among anxiety disorders

The aims of this paper are to analyze differences in sociodemographic and clinical characteristics among the various anxiety disorders treated in a Psychology Clinic, and the results of treatment in each anxiety disorder. Data from 282 patients of University Psychology Clinic at the Complutense University of Madrid, who had at least one diagnosis of anxiety according to DMS-IV-TR criteria, were analyzed. The most frequent anxiety disorders were nonspecific anxiety disorder (19.1%) and social phobia (18.8%). Significant differences were observed according to sex (in all disorders, the percentage of women was significantly higher than that of men, except for obsessive-compulsive disorder). Unspecific anxiety disorder required a smaller number of assessment and treatment sessions, whereas obsessive-compulsive disorder required a greater number of sessions. There were no significant differences between the percentage of patients who completed treatment and dropout rates in specific phobia, general anxiety disorder and obsessive-compulsive disorder. Differences between epidemiological and clinical data are discussed.