Culturally Informed and Flexible Family-Based Treatment for Adolescents: A Tailored and Integrative Treatment for Hispanic Youth

The increasing utilization of evidence-based treatments has highlighted the need for treatment development efforts that can craft interventions that are effective with Hispanic substance abusing youth and their families. The list of evidence-based treatments is extremely limited in its inclusion of interventions that are explicitly responsive to the unique characteristics and treatment needs of young Hispanics and that have been rigorously tested with this population. Some treatments that have been tested with Hispanics do not articulate the manner in which cultural characteristics and therapy processes interact. Other treatments have emphasized the important role of culture but have not been tested rigorously. The value of well designed interventions built upon an appreciation for unique patient characteristics was highlighted by Beutler et al. (1996) when they argued that "psychotherapy is comprised of a set of complex tasks, and practitioners need comprehensive knowledge of how different processes used in psychotherapy interact with patient characteristics in order to make treatment decisions that will maximize and optimize therapeutic power" (p. 30). A focus on how treatment processes interact with patient characteristics is particularly relevant in the Hispanic population because of the considerable heterogeneity beneath the Hispanic umbrella. Our new program of clinical research focuses on articulating how the varied profiles with regard to immigration stressors, acculturation processes, values clashes, sense of belonging to the community, discrimination, and knowledge about issues important to adolescent health can be more effectively addressed by a culturally informed treatment.     

Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders: Protocol Development and Initial Outcome Data

The Unified Protocol (UP) is a transdiagnostic, emotion-focused cognitive-behavioral treatment developed to be applicable across the emotional disorders. The UP consists of 4 core modules: increasing emotional awareness, facilitating flexibility in appraisals, identifying and preventing behavioral and emotional avoidance, and situational and interoceptive exposure to emotion cues. Here we present data from 2 open clinical trials. In the first trial, an initial version of the UP was administered to a heterogeneous clinical sample, yielding significant pre- to posttreatment effects across disorders on a variety of measures. Analyses of clinical significance demonstrated modest results, with 56% of participants achieving responder status and 33% achieving high end-state functioning. Further manual development ensued, resulting in specific modifications and enhancements to core treatment components, and a second trial presents data from an additional pilot study of this revised version of the UP. Results from this trial demonstrated more robust treatment effects, with 73% achieving responder status and 60% achieving high end-state functioning. Results improved further at 6-month follow-up, with 85% classified as treatment responders and 69% achieving high end-state functioning. Implications for the treatment of emotional disorders as well as dimensional conceptualizations of psychopathology are discussed.     

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

Attention Problems and Restlessness as Transdiagnostic Markers of Severity and Treatment Response in Youth with Internalizing Problems

Research on Child and Adolescent Psychopathology - Transdiagnostic models of psychopathology suggest that disorders may share common features that could influence their severity. Attention problems...     

Development and Application of an Innovative Transdiagnostic Treatment Approach for Pediatric Irritability

Recent work has drawn attention to the previously underrecognized role that irritability plays in childhood psychopathology. Despite increased recognition of the clinical importance of pediatric irritability as a transdiagnostic symptom dimension, there is a lack of evidence-based treatments for this population that simultaneously and equitably addresses both child and contextual (e.g., parental) factors implicated in the development and maintenance of associated emotional and behavioral difficulties. In the current pilot study, we adapted the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C) for the treatment of pediatric irritability in a sample of 19 children (ages 8 to 12) with primary presenting concerns of irritability and/or disruptive behaviors. Results supported the feasibility and acceptability of this treatment and provided preliminary evidence that such an approach may yield improved outcomes for symptoms of pediatric irritability and disruptive behaviors. Implications of these findings for future research and clinical interventions for pediatric irritability are discussed.     

Using Student Paraprofessionals in the Treatment of Eating Disorders

A rationale for adjunctive treatment in responding to eating disorder clients at a university counseling center is presented. The program described provides a highly structured internship experience for paraprofessional psychology trainees who serve as therapeutic aides and peer counselors to eating disorder clients. This collaborative Counseling Center and Psychology Department model emphasizes intern training, close supervision, and professional-paraprofessional cotreatment of anorexic and bulimic clients. Program evaluation methods and therapy outcome data are presented. Advantages of this treatment-training program for all participants are discussed.     

Changes in Risk Factors During the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents

This study aimed to assess whether changes in potentially modifiable risk factors associated with the construct of neuroticism and common to emotional disorders (i.e., poor distress tolerance and heightened avoidance) occur in concordance with the administration of different treatment components of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) and with reductions in emotional disorder symptoms (i.e., anxiety and depressive symptoms) overall. Using single-case analytic strategies, including multiple-baseline design and modeling techniques, the authors treated 8 adolescents with emotional disorder diagnoses and evaluated trajectories of change in distress tolerance and experiential avoidance as well as in the sequencing of such change in regard to change in anxiety and depressive symptoms. Clinical outcomes were favorable based on parent, adolescent, and clinician-rated measures. Treatment-based change was demonstrated, at both group and individual levels, and at expected points in treatment, in regard to facets of neuroticism. Overall, self-reported change in experiential avoidance and distress tolerance tended to occur simultaneously to reductions in emotional disorder symptoms. This study helps to clarify the course of expected change in variables believed to be common among a range of emotional disorders during a transdiagnostic treatment and provides initial information regarding tailoring the UP-A for individuals with different clinical profiles.     

Methodological Issues in Treatment Research for Anxiety Disorders in Youth

This article identifies and addresses three methodological domains relevant to the treatment of anxiety disorders in youth: (a) procedural matters, (b) the assessment of anxious distress, and (c) the analysis of treatment-produced change. Procedural topics include the need to manualize treatment, have diversity among participants and comparability of the duration of treatment and control conditions, and control for medication status. Multiple-method measurement issues include child and parent reports, observations, and structured interviewing. Our examination of change issues considers comorbidity, analyzing the intent-to-treat sample, treatment spillover, and clinical as well as statistical significance. Problems are identified and potential ameliorative strategies are offered.     

Examining Hope as a Transdiagnostic Mechanism of Change Across Anxiety Disorders and CBT Treatment Protocols

Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.     

The Children of Mothers with Eating Disorders

There is good evidence that children of parents with psychological disorders are themselves at increased risk of disturbances in their development. Although there has been considerable research on a variety of disorders such as depression and alcohol, research on the children of parents with eating disorders has been relatively recent. This paper aims to review the evidence and covers a number of areas, including genetic factors, pregnancy, the perinatal and postpartum period, infancy, and the early years of life, focusing on feeding and mealtimes, general parenting functions, and growth. This is followed by a consideration of psychopathology in the children, parental attitudes to children's weight and shape, and adolescence. What is clear is that although there are numerous case reports and case series, the number of systematic controlled studies is relatively small, and almost nothing has been written about the children of fathers with eating disorders. What is evident from the available evidence is that children of mothers with eating disorders are at increased risk of disturbance, but that the risk depends on a variety of factors, and that difficulties in the children are far from invariable. The paper concludes by summarizing five broad categories of putative mechanisms, based on the evidence to date, by which eating disturbance in parents can influence child development.     

Enhanced Cognitive Behavior Therapy: A Single Treatment for All Eating Disorders

Eating disorders are serious mental illnesses affecting a significant proportion of women and a smaller number of men. Approximately half of those with an eating disorder (ED) will not meet the criteria for anorexia or bulimia nervosa, and will be diagnosed with an eating disorder not otherwise specified (EDNOS). Until recently, there were no recommended treatments for EDNOS. This article provides an overview of enhanced cognitive behavior therapy, a validated treatment for all forms of EDs.     

Outcomes of a Day Treatment Program for Eating Disorders Using Clinical and Statistical Significance

The present study was designed to evaluate the outcomes of a day treatment program for 55 eating disordered (ED) patients using clinical and statistical significance testing. Results indicated a statistically significant reduction on all eating disordered outcomes. With respect to clinical significance testing, analysis of these data indicated that the majority of the individuals in the day treatment program made clinically significant and reliable change by the termination of treatment on all eating disorder measures. However, considerably less patients improved to such a point that they were asymptomatic. The importance of combining clinical significance testing with traditional significance testing is discussed.     

College Atmosphere and Eating Disorders

The authors investigated whether different campus environment factors were related to eating disorder symptomatology at two distinctly different colleges. The first campus was conservative, placing an emphasis on appearance and dress, whereas the second campus was liberal, placing an emphasis on political activism and intellectual talent. As hypothesized, the two schools did not differ in regard to overall levels of eating disorders, yet different factors were associated with eating disorder symptomatology at each school. Implications for eating disorder interventions on college campuses are discussed.     

Emotion Regulation in Youth with Emotional Disorders: Implications for a Unified Treatment Approach

Given the relationship between internalizing disorders and deficits in emotion regulation in youth, the emotion science literature has suggested several avenues for increasing the efficacy of interventions for youth presenting with anxiety and depression. These possibilities include the identification and addition of emotion-regulation skills to existing treatment packages and broadening the scope of those emotions addressed in cognitive-behavioral treatments. Current emotion-focused interventions designed to meet one or both of these goals are discussed, and the developmental influences relevant to the selection of emotion-focused treatment goals are explored using the framework of a modal model of emotion regulation. These various lines of evidence are woven together to support the utility of a novel emotion-focused, cognitive-behavioral intervention, the Unified Protocol for the Treatment of Emotional Disorders in Youth, a transdiagnostic treatment protocol that aims to treat the range of emotional disorders (i.e., anxiety and depression) simultaneously. Avenues for future directions in treatment outcome and assessment of emotion regulation are also discussed.     

Secret Agent Society: A Randomized Controlled Trial of a Transdiagnostic Youth Social Skills Group Treatment

Group programs are key for targeting social skills (SS) for children with developmental disorders and/or mental illness. Despite promising evidence regarding efficacy of group treatments, there are several limitations to current research regarding generalizability and effectiveness across diagnoses. This randomized control trial assessed whether the Secret Agent Society (SAS) group program was superior to treatment as usual (TAU) in improving social-emotional functioning for children with Attention Deficit-Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), and/or anxiety. Eighty-nine youth (8–12) with ADHD, ASD, and/or an anxiety disorder receiving treatment at hospital-based outpatient clinics were randomized to receive SAS (n?=?47) or TAU (n?=?42) over a three-month period, at which point TAU participants were offered the SAS intervention. Parent report showed significant improvement in Emotion Regulation (ER) and Social Skills (SS) for youth in SAS vs. TAU (Fs?≥?6.79, ps?≤?01). Gains for the SAS condition were maintained at 6-months. Intent-to-treat analysis of teacher report indicated youth in SAS had positive gains in SS (F?=?0.41, p?=?0.475) and ER (F?=?0.99, p?=?0.322), though not significantly better than youth in TAU. Clinically reliable improvement rates were significantly higher for SAS participants than TAU for parent and teacher reported SS and ER. Improvements were significant for youth with single and comorbid diagnoses. Results suggest that SAS was superior to TAU in improving SS and ER for youth aged 8–12 with ADHD, ASD, and/or anxiety. Gains maintained in the medium-term. Trial registration number NCT02574273, registered 10/12/2015.

     

Emotion Regulation Difficulties During and After Partial Hospitalization Treatment Across Eating Disorders

Emotion regulation deficits are associated with eating disorder (ED) symptoms, regardless of eating disorder diagnosis. Thus, recent treatment approaches for EDs, such as dialectical behavior therapy (DBT), have focused on teaching patients skills to better regulate emotions. The present study examined changes in emotion regulation among adult patients with EDs during DBT-oriented partial hospital treatment, and at follow-up (M[SD] = 309.58[144.59] days from discharge). Exploratory analyses examined associations between changes in emotion regulation and ED symptoms. Patients with anorexia nervosa, restricting (AN-R, n = 77), and binge-eating/purging subtype (AN-BP, n = 46), or bulimia nervosa (BN, n = 118) completed the Difficulties in Emotion Regulation Scale (DERS) at admission, discharge, and follow-up. Patients with BN demonstrated significant improvements across all facets of emotion dysregulation from admission to discharge and maintained improvements at follow-up. Although patients with AN-BP demonstrated statistically significant improvements on overall emotion regulation, impulsivity, and acceptance, awareness, and clarity of emotions, from admission to discharge, these improvements were not significant at follow-up. Patients with AN-R demonstrated statistically significant improvements on overall emotion dysregulation from treatment admission to discharge. Changes in emotion regulation were moderately correlated with changes in ED symptoms over time. Results support different trajectories of emotion regulation symptom change in DBT-oriented partial hospital treatment across ED diagnoses, with patients with BN demonstrating the most consistent significant improvements.