School-Based Acceptance and Commitment Therapy for Adolescents With Anxiety: A Pilot Trial

Anxiety disorders are one of the most prevalent diagnoses in youth, often resulting in impaired social and school functioning. Research on treatments for youth anxiety is primarily based in traditional clinical settings. However, integrating youth psychotherapies into the school environment improves access to evidence-based care. The present study is a pilot, randomized waitlist-controlled trial of a school-based, group Acceptance and Commitment Therapy–based (ACT) intervention for adolescents with anxiety. Students at two separate schools (N = 26) with elevated anxiety were randomized to a 12-week waitlist or to immediate treatment. Participants in the immediate treatment condition reported statistically significant decreases in anxiety and class absences at posttreatment and follow-up compared to the waitlist group. No statistically significant differences were found between groups for depression, psychological flexibility, positive mental health, and student well-being. However, medium within-condition effect sizes were seen in the treatment group for all outcomes. Participants reported the treatment as favorable with good acceptance ratings. Overall, this study supports ACT as a viable intervention for schools and other clinical settings providing services to adolescents with anxiety.     

Parent Accommodation Contemporaneously Mediates the Association Between Youth Irritability and Youth Anxiety Treatment Outcome

Research documents that child and adolescent (youth) irritability and anxiety have high co-occurrence, and anxious-irritable presentations are associated with greater impairment than anxious nonirritable presentations. This study examines the association between irritability and youth anxiety treatment outcome and tests a conceptual model of the associations among youth irritability, parent accommodation, and youth anxiety severity following cognitive behavioral treatment (CBT). Participants were N = 128 clinic-referred youths ages 6 to 17 years (M = 9.76 years; 57% female) who met criteria for primary anxiety disorder diagnoses and completed a 12- to 14-week CBT anxiety protocol. Parent- and youth-report on youth irritability, parent accommodation of their child’s anxiety, and youth anxiety severity were assessed pretreatment and posttreatment. Using parent-report, youth irritability at pretreatment was associated with high parent accommodation of youth anxiety and high youth anxiety severity at posttreatment. The association between irritability and youth anxiety outcome was mediated contemporaneously by parent accommodation at posttreatment. These findings show that parent accommodation of their anxious-irritable children’s anxiety may account for high youth anxiety severity following treatment. Developing strategies to target irritability in anxious youth and/or reduce parent accommodation in the presence of youth irritability represent important directions for future research.     

The Role of Anxiety/Depression in the Development of Youth High Risk Behaviors: An Examination of Two Competing Hypotheses in a Sample of African-American,Single Mother Families

The role of anxiety/depression in the progression of youth externalizing problems to future high risk behaviors has been disputed in the literature. Mixed support exists for a multiple problem hypothesis (i.e., co-occurring anxiety/depression leads to more high risk behaviors) and a protective hypothesis (i.e., anxiety/depression buffers this progression). The present study compared these two hypotheses in a sample of 124 African-American single mother families by examining mother report of externalizing problems and anxiety/depression at an initial timepoint and youth report of high risk behaviors fifteen months later. Results support the multiple problem hypothesis: In the context of high levels of externalizing problems, high levels of anxiety/depression were associated with more youth engaging in high risk behavior across the 15 month follow-up than were low levels of anxiety/depression. The findings suggest it is important to consider multiple domains of youth problem behaviors to conceptualize and prevent high risk behaviors.     

School absenteeism and mental health among sexual minority youth and heterosexual youth

Adolescent school absenteeism is associated with negative outcomes such as conduct disorders, substance abuse, and dropping out of school. Mental health factors, such as depression and anxiety, have been found to be associated with increased absenteeism from school. Sexual minority youth (youth who are attracted to the same sex or endorse a gay, lesbian, or bisexual identity) are a group at risk for increased absenteeism due to fear, avoidance, and higher rates of depression and anxiety than their heterosexual peers. The present study used longitudinal data to compare sexual minority youth and heterosexual youth on excused and unexcused absences from school and to evaluate differences in the relations between depression and anxiety symptoms and school absences among sexual minority youth and heterosexual youth. A total of 108 14- to 19-years-old adolescents (71% female and 26% sexual minority) completed self-report measures of excused and unexcused absences and depression and anxiety symptoms. Compared to heterosexual youth, sexual minority youth reported more excused and unexcused absences and more depression and anxiety symptoms. Sexual minority status significantly moderated the effects of depression and anxiety symptoms on unexcused absences such that depression and anxiety symptoms were stronger predictors of unexcused absences for sexual minority youth than for heterosexual youth. The results demonstrate that sexual minority status and mental health are important factors to consider when assessing school absenteeism and when developing interventions to prevent or reduce school absenteeism among adolescents.     

Integrating Etiological Models of Social Anxiety and Depression in Youth: Evidence for a Cumulative Interpersonal Risk Model

Models of social anxiety and depression in youth have been developed separately, and they contain similar etiological influences. Given the high comorbidity of social anxiety and depression, we examine whether the posited etiological constructs are a correlate of, or a risk factor for, social anxiety and/or depression at the symptom level and the diagnostic level. We find core risk factors of temperament, genetics, and parent psychopathology (i.e., depression and anxiety) are neither necessary nor sufficient for the development of social anxiety and/or depression. Instead, aspects of children’s relationships with parents and/or peers either mediates (i.e., explains) or moderates (i.e., interacts with) these core risks being related to social anxiety and/or depression. We then examine various parent- and peer-related constructs contained in the separate models of social anxiety and depression (i.e., parent–child attachment, parenting, social skill deficits, peer acceptance and rejection, peer victimization, friendships, and loneliness). Throughout our review, we report evidence for a Cumulative Interpersonal Risk model that incorporates both core risk factors and specific interpersonal risk factors. Most studies fail to consider comorbidity, thus little is known about the specificity of these various constructs to depression and/or social anxiety. However, we identify shared, differential, and cumulative risks, correlates, consequences, and protective factors. We then put forth demonstrated pathways for the development of depression, social anxiety, and their comorbidity. Implications for understanding comorbidity are highlighted throughout, as are theoretical and research directions for developing and refining models of social anxiety, depression, and their comorbidity. Prevention and treatment implications are also noted.     

Anxiety sensitivity as a specific and unique marker of anxious symptoms in youth psychiatric inpatients

We addressed several questions regarding the relation of anxiety sensitivity to anxious symptoms among 47 youth psychiatric inpatients (18 boys, 29 girls), ages 9–17 (M = 14.23, SD = 1.89). Participants completed measures of anxiety sensitivity, anxious and depressive symptoms, trait anxiety, and positive and negative affect; chart diagnoses were available. Consistent with hypotheses, we found that (a) anxiety sensitivity was associated with anxious symptoms, even controlling for trait anxiety and depressive symptoms; and (b) anxiety sensitivity displayed symptom specificity to anxious versus depressive symptoms (i.e., was associated with anxiety controlling for depression but not with depression controlling for anxiety). Furthermore, regarding factors of anxiety sensitivity, we obtained mixed support for our prediction that phrenophobia would be associated with both depression and anxiety, whereas fear of physical arousal would be associated with anxiety but not depression. Implications for the construct validity of anxiety sensitivity were discussed.     

Working From Home: An Initial Pilot Examination of Videoconferencing-Based Cognitive Behavioral Therapy for Anxious Youth Delivered to the Home Setting

Progress in evidence-based treatments for child anxiety has been hampered by limited accessibility of quality care. This study utilized a multiple baseline design to evaluate the pilot feasibility, acceptability, and preliminary efficacy of real-time, Internet-delivered, family-based cognitive-behavioral therapy for child anxiety delivered to the home setting via videoconferencing. Participants included 13 anxious youth (mean age = 9.85) with a primary/co-primary anxiety disorder diagnosis. Eleven participants (84.6%) completed treatment and all study procedures. Consistent with hypotheses, the intervention was feasible and acceptable to families (i.e., high treatment retention, high client satisfaction, strong therapeutic alliance, and low barriers to participation). Moreover, the novel videoconferencing treatment format showed preliminary efficacy: 76.9% of the intention-to-treat (ITT) sample and 90.9% of treatment completers were treatment responders (i.e., Clinical Global Impressions-Improvement Scale = 1 or 2 at posttreatment), and 69.2% of the ITT sample and 81.8% of treatment completers were diagnostic responders (as per the Anxiety Disorders Interview for Children). Gains were largely maintained at 3-month follow-up evaluation. Outcome patterns within and across subjects are discussed, as well as limitations and the need for further controlled evaluations. With continued support, videoconferencing treatment formats may serve to meaningfully broaden the reach of quality care for youth anxiety disorders.     

Daily suppression of discrete emotions during the work of police service workers and criminal investigation officers

Abstract

This study provided an initial test of a theoretical model which emphasizes patterns of actual and perceived control. The model suggests that profiles of actual and perceived control are differentially related to emotional and behavioral problems. We examined whether anxiety and depression symptoms and aggressive behavior would differ among diverse patterns of actual (caregiver reported competencies) and perceived control (anxiety-related control beliefs) in youth (n=203). Results were consistent with the theoretical predictions in that reported levels of anxiety and depression symptoms and aggressive behavior varied depending upon youth's control profiles. For example, youth with high actual and low perceived control exhibited relatively more anxiety/depression symptoms than aggressive behavior, while those youth with low actual and high perceived control exhibited relatively more aggressive behavior. Furthermore, youth with both high actual and perceived control reported and were reported by caregivers as having the least anxiety/depression symptoms and aggressive behavior, respectively. The findings provide empirical support for the model and suggest the importance of considering the role of actual and perceived control in emotional and behavioral problems. Implications for future tests of the model are also discussed.     

Efficacy of Dialectical Behavior Therapy for Adolescents in a Partial Hospitalization Program

This study evaluated dialectical behavior therapy for adolescents (DBT‐A) vs. treatment as usual within a 6‐week partial hospitalization program. The 103 adolescent participants (mean age = 15.27 years) were predominantly girls (n = 63, 61%) with a variety of primary mental health diagnoses. Results indicated that DBT‐A was superior for decreasing symptoms of depression and interpersonal sensitivity, but no statistically significant difference was detected for anxiety or hostility. Implications for treating youth with transdiagnostic identities are discussed.     

An Examination of the Tripartite Model of Anxiety and Depression and Its Application to Youth

The ability to differentiate anxiety and depression has been a topic of discussion in the adult and youth literatures for several decades. The tripartite model of anxiety and depression proposed by L. A. Clark and D. Watson (1991) has helped focus the discussion. In the tripartite model, anxiety is characterized by elevated levels of physiological hyperarousal (PH), depression is characterized by low levels of positive affect (PA), and negative affect (NA) or generalized emotional distress is common to both. The advent of the model led to the development of measures of tripartite constructs and subsequent validity studies. The tripartite model and resultant activity concerning the model was largely devoted to adult samples. However, those interested in anxiety and depression among youth are now incorporating the tripartite model in their work. This paper examines the current influence of the tripartite model in the youth literature, especially with regard to measuring anxiety and depression.     

Differences in Internalizing Symptoms Across Specific Ethnic Minority Groups: An Analysis Across Chinese American,Filipino American,Japanese American,Native Hawaiian,and White Youth

Research to date on child and adolescent anxiety and depression have focused predominantly on major ethnic groups. Very few studies to date have been conducted on specific ethnic minority groups and the relatively few studies on these ethnic minority samples have produced mixed findings. The following question therefore still remains: Do specific ethnic subgroups differ with respect to their expression of anxiety and depression? And do these differences differ as a function of reporter type (i.e., youth versus parent)? If the expression of internalizing symptoms differs across specific ethnic subgroups, these differences could inform approaches to assessing and treating these populations. In the current study, we therefore examined ethnic differences in anxiety and depression symptoms in ethnic subgroups. A total of 629 children and adolescents from various public and private schools, aged 8–18 years (M = 12.37, SD = 2.8) and their caregivers completed anxiety and depression scales. Multiple indicators, multiple causes confirmatory factor analysis revealed that the following specific ethic subgroups were associated with significantly greater anxiety and depression relative to Caucasian youth: Chinese American, Filipino American, Japanese American, and Native Hawaiian. These results were found only among parent (but not youth) reports. Age and low SES status was also associated with more internalizing problems among Chinese, Filipino, and Japanese American youth. Implications related to ethnic minority subgroup differences and the role of multi-informant reports in understanding the relationship between anxiety, depression and ethnic minority subgroups are discussed.     

Treating Youth Depression and Anxiety: A Randomised Controlled Trial Examining the Efficacy of Computerised versus Face‐to‐face Cognitive Behaviour Therapy

Barriers to accessing psychologists for the treatment of depression and anxiety include a shortage of specialised therapists, long waiting lists, and the affordability of therapy. This study examined the efficacy of a computerised‐based self‐help program (MoodGYM) delivered in‐conjunction with face‐to‐face cognitive behavioural therapy (CBT) to expand the delivery avenues of psychological treatment for young adults (aged 18–25 years). Eighty‐nine participants suffering from depression and/or generalised anxiety were randomly allocated to a control intervention or to one of three experimental groups: receiving face‐to‐face CBT, receiving computerised CBT (cCBT), or receiving treatment in‐conjunction (face‐to‐face CBT and cCBT). While MoodGYM did not significantly decrease depression in comparison to the control group, significant decreases were found for anxiety. MoodGYM delivered in‐conjunction with face‐to‐face CBT is more effective in treating symptoms of depression and anxiety compared with standalone face‐to‐face or cCBT. This study suggests that for youth who are unable to access face‐to‐face therapy—such as those in rural or remote regions, or for communities in which there is stigma attached to seeking help—computerised therapy may be a viable option. This is an important finding, especially in light of the current capacity‐to‐treat and accessibility problems faced by youth when seeking treatment for depression and/or anxiety.     

Experiential Avoidance and Anxiety Sensitivity: Independent and Specific Associations with Children’s Depression,Anxiety, and Social Anxiety Symptoms

Experiential avoidance (EA) is a key component in acceptance and commitment therapy (ACT) theory and research. EA is associated with a wide range of psychopathology in adults including anxiety, in particular social anxiety, and depression, yet little research exists on EA in youth. Anxiety sensitivity (AS), like EA, has been viewed as a form of distress tolerance or emotion regulation. In a sample of 124 children (age 10 to 12), this study examined the independent and specific relations of EA and AS to children’s depression, anxiety, and social anxiety symptoms, both before and after controlling for comorbid symptoms. EA and AS had independent associations with each of children’s depression, anxiety, and social anxiety; and EA had significantly stronger relations than AS with each of children’s social anxiety and anxiety. After controlling for depression, only EA (and not AS) was uniquely related to both children’s anxiety and social anxiety. After controlling for anxiety and social anxiety, only AS (and not EA) was uniquely related to depression. After controlling for depression and social anxiety, neither EA nor AS was significantly related to anxiety. In contrast, after controlling for depression and anxiety, EA (and not AS) showed a significant and unique relation to children’s social anxiety. These findings indicate: 1) there are distinctions between EA and AS; 2) EA and AS are overlapping yet independent correlates for each of depression, anxiety and social and anxiety; and 3) EA and AS show some differential relations with children’s depression, anxiety, and social anxiety when comorbid symptoms are considered. Theoretical and treatment implications are highlighted.     

An Uncontrolled Clinical Trial of Guided Respiration Mindfulness Therapy (GRMT) in the Treatment of Depression and Anxiety

Guided respiration mindfulness therapy (GRMT) is a manualized intervention that synthesizes a sustained focus on self-regulation of respiration, mindfulness, and relaxation. In our previous publication (in Lalande et al. J Contemp Psychother 46(2):107–116, 2016) we reported an evaluation of a manual-based GRMT therapist training program for the treatment of depression and anxiety. Here we report the outcomes of the manualized treatment program for depression and anxiety with clients. Forty-two participants with a primary diagnosis of depression or anxiety disorder participated in an uncontrolled clinical trial evaluating treatment response using standardised outcome measures with data collected on a session-by-session basis. For the majority of participants, treatment led to statistically and clinically significant reduction in symptoms of depression, anxiety and stress, along with reduced anxiety sensitivity and increases in overall wellbeing. Results suggested GRMT shows promise as an effective brief treatment option that does not rely on cognitive or behavioural techniques.     

Exploring Relationships Between Negative Cognitions and Anxiety Symptoms in Youth With Autism Spectrum Disorder

Although cognitions are central to the conceptualization and treatment of anxiety in typically developing (TD) youth, there is scant research investigating automatic thoughts and their relationship with anxiety in youth with autism spectrum disorder (ASD). We sought to examine the types of automatic thoughts experienced by youth with ASD and co-occurring anxiety as well as the predictive relationship of anxiety to different types of automatic thoughts in 97 children, ages 8-14 years. We also explored the relationship of automatic thoughts and intolerance of uncertainty. Consistent with prior data, there was a strong relationship between anxiety and automatic thoughts pertaining to social and physical threat. Anxiety and IU were independently associated with thoughts pertaining to personal failure which raises the hypothesis that personal failure may serve as a common pathway between anxiety, IU, and depression in ASD youth. These findings highlight the importance of assessing and treating negative cognitions in youth with ASD and anxiety.     

Emotion-Focused Cognitive-Behavioral Therapy for Youth with Anxiety Disorders: A Randomized Trial

Difficulties with emotion regulation are a core feature of anxiety disorders (ADs) in children and adults. Interventions with a specific focus on emotion regulation are gaining empirical support. Yet, no studies to date have compared the relative efficacy of such interventions to existing evidence-based treatments. Such comparisons are necessary to determine whether emotion-focused treatments might be more effective for youth exhibiting broad emotion-regulation difficulties at pretreatment. This study examined an emotion-focused cognitive-behavioral therapy (ECBT) protocol in comparison to traditional cognitive-behavioral therapy (CBT) in a sample of children with a primary anxiety disorder diagnosis. Moderation analyses examined whether children with higher levels of emotion dysregulation at pretreatment would show greater levels of improvement in ECBT than CBT. Ninety-two youth ages 7 to 12 years (58% male) with a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia were included. Participants were randomly assigned to ECBT or CBT. Results showed that youth in both conditions demonstrated similar improvements in emotion regulation and that pretreatment levels of emotion dysregulation did not moderate treatment outcomes. Additional analyses showed that ECBT and CBT were similarly effective on diagnostic, severity, and improvement measures. Future work is needed to further explore the ways that emotion regulation is related to treatment outcome for anxious youth.     

Evaluating anxiety and depression symptoms in children and adolescents with prior mild traumatic brain injury: Agreement between methods and respondents

Psychological functioning can be adversely impacted after a mild traumatic brain injury (mTBI) and may be a potential target for intervention. Despite the use of symptom ratings or structured diagnostic interview to assess long-term anxiety and depression symptoms in children and adolescents post-injury, no known studies have considered the agreement between different assessment methods and between respondents. The objectives of this study were to investigate the agreement between symptom ratings and structured diagnostic interview and between children and parents’ symptom reporting. Participants (N = 33; 9–18 years old) were recruited from the Emergency Department and assessed on average 22.8 months (SD = 5.6) after their mTBI. Anxiety and depression symptoms were evaluated via subscales of a questionnaire (Behavior Assessment System for Children) and parts of a computerized structured diagnostic interview (generalized anxiety disorder and major depressive episode; Diagnostic Interview Schedule for Children – C-DISC-IV) administered individually to children and their parents. Results showed that the inter-method agreement to identify high levels of anxiety and depression was moderate to perfect in children while it was lower in parents. Although a similar percentage of participants with elevated anxiety or depression were identified by both children and parents, the agreement between youth and parents was variable, ranging from poor to good for anxiety and poor to moderate for depression. These results highlight the importance of collecting youth and parents’ reports of anxiety and depression symptoms and considering potential discrepancies between informants’ answers.     

Pragmatic Screening of Anxiety,Depression, Suicidal Ideation,and Substance Misuse in Older Adults

Older adults’ mental health needs are often unmet across care settings (e.g., primary or residential care) for a variety of reasons, such as mental health stigma and mental health care professionals’ lack of awareness of age-related changes in mental disorders. Screening, when coupled with access to evidence-based interventions, is effective at identifying and reducing anxiety, depression, suicidal ideation, and substance misuse in older adults across care settings. Unfortunately, due to lack of training many mental health care professionals may be unsure about what or how to screen, as well as which screening measures are available for use with older adults. Following professional guidelines recommended for older adults, we provide an overview of screening measures for anxiety, depression, suicidal ideation, and substance misuse that are evidence-based and meet pragmatic criteria identified by stakeholder research. Specific pragmatic criteria include screening measures developed with older adults (unless unavailable) as well as brief in length (items ≤30), time for administration (≤15 minutes), scoring (<5 minutes), and interpretation (<5 minutes). Other pragmatic criteria include screening measures readily available on the internet at no cost and usable across diverse settings (e.g., community, primary care, and/or residential care). For each measure, we also review relevant psychometric properties (e.g., reliability, cut-scores, sensitivity, specificity, and construct validity). Lastly, we discuss strategies to facilitate screening with older adults and direct mental health care providers to internet resources that can be used to learn more about assessment with older adults.     

Anxiety Disorders Among Older Primary Care Patients

Data from the 1997 National Ambulatory Medical Care Survey (NAMCS) were accessed to obtain information about naturalistic patterns of recognition, service utilization, and treatment for late-life anxiety in primary care. The NAMCS is a national probability sample survey of office visits to non-Federal, U.S. physicians engaged in patient care. The survey was conducted by the Division of Health Care Statistics, National Center for Health Statistics, and Centers for Disease Control and Prevention (CDC). Data are now in the public domain. For the current report, all cases indicating office visits for patients age 60 and older were selected (n = 7,687). Anxiety disorders were assigned for 1.3% (n = 99) of these visits, with anxiety disorder NOS the most frequent diagnosis. For 20.2% of these visits (n = 20), a coexistent depressive disorder also was diagnosed. Depression without coexistent anxiety was diagnosed for 2.3% of all visits (n = 176). These figures suggest that late-life anxiety may often go unrecognized and may be more difficult to detect than depression. Nevertheless, other data indicate that appropriate pharmacological treatment and mental health services or referrals are often provided when anxiety or depression is recognized. However, visits wherein these disorders are recognized require increased physician time, and significant proportions of patients in some groups may still not receive appropriate mental health care. Results are discussed in terms of the nature of usual care for late-life anxiety and the needs for future research.