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.     

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.     

Clinical Experiences in Conducting Empirically Supported Treatments for Generalized Anxiety Disorder

Knowledge of the efficacy of cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) predominantly derives from randomized controlled trials (RCTs). However, there may be unique or complex issues encountered in practice, but not necessarily in the context of a controlled clinical trial. Therefore, launching a systematic dialogue between researcher and practicing clinician can be instrumental in augmenting evidence-based therapies through identification of variables that promote and interfere with clinical effectiveness. Through an initiative sponsored by the American Psychological Association’s Divisions 12 (Society for Clinical Psychology) and 29 (Psychotherapy), this study aimed to examine clinical experiences conducting CBT for GAD. The participants were 260 psychotherapists who completed an online survey on assessment and therapeutic intervention utilization and their experience of factors that limit successful GAD treatment and symptom reduction. The majority of respondents reported 20 years or less experience using ESTs for GAD, typically treating clients in outpatient clinics, treatment centers, and private practice. Some of the most commonly used interventions address clients’ maladaptive cognitions and elevated anxiety and muscle tension typical of GAD. Approximately one half of respondents reported incorporating integrative techniques into treatment. Factors perceived as limiting effective GAD treatment included severity and chronicity of GAD, presence of comorbid conditions, stressful home and work environments, client motivation and resistance to treatment, and issues encountered when executing therapy techniques. This study provides researchers with clinically derived directions for future empirical investigation into enhancing efficacy of GAD treatment.     

Harnessing Home-School Partnerships and School Consultation to Support Youth With Anxiety

Youth with anxiety often experience significant impairment in the school setting. Despite the relevance and promise of addressing anxiety in schools, traditional treatment approaches to school-based anxiety often do not adequately address generalization to the school setting, or they require removing the student from the classroom to deliver time- and staff-intensive programs. Such programs often leave teachers and caregivers feeling ill-equipped to support the student with anxiety throughout the natural course of the school day. Given the heavy demands placed on teachers and documented burnout among school professionals, providing effective school supports requires collaborative partnerships among outpatient therapists/specialists, school personnel, and caregivers. Drawing from literature on collaborative models for externalizing problems, we offer recommendations for outpatient therapists and specialists working to implement evidence-based supports and promote home-school partnerships to benefit youth with anxiety in the school setting. Our recommendations touch upon several components of such school consultation, including (a) identification of key parties involved, (b) conducting a needs assessment, (c) collaborative goal setting and development of a fear hierarchy, (d) plan development and implementation (e.g., facilitating a school-based exposure mindset, promoting home-school communication, enhancing school relationships), and (e) progress monitoring and ongoing support. We conclude with a case example to bring these recommendations to life.     

The Relation Between Anxiety Sensitivity and Attachment Style in Adolescence and Early Adulthood

Given the accumulating evidence for a role of anxiety sensitivity in the etiology of panic, it is important to understand the developmental origins of anxiety sensitivity. To this end, this study examined the relation between attachment beliefs and anxiety sensitivity in a sample of high school students (n = 203; mean age 15.7 years) and university students (n = 324; mean age 21.7 years). The Experiences in Close Relationships (ECR; K. Brennan, C. Clark, &; P. Shaver, 1998) was used to assess attachment beliefs and to classify participants into attachment groups. The Anxiety Sensitivity Index (ASI; R. A. Peterson &; S. Reiss, 1987) was used to assess participants' levels of anxiety sensitivity. Results supported the hypothesis that individuals with insecure attachment, specifically those classified as preoccupied and fearful (i.e., those with a negative model of self), had significantly higher anxiety sensitivity scores than securely attached individuals in both the high school and college samples.     

Treating Speech Anxiety in Youth: A Randomized Controlled Microtrial Testing the Efficacy of Exposure Only Versus Exposure Combined With Anxiety Management Strategies

CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (N = 65; age 12–15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.     

Cognitive Indicators of Social Anxiety in Youth: A Structural Equation Analysis

Previous studies have demonstrated significant relationships among various cognitive variables such as negative cognition, self-efficacy, and social anxiety. Unfortunately, few studies focus on the role of cognition among youth, and researchers often fail to use domain-specific measures when examining cognitive variables. Therefore, the purpose of the present study was to examine domain-specific cognitive variables (i.e., socially oriented negative self-referent cognition and social self-efficacy) and their relationships to social anxiety in children and adolescents using structural equation modeling techniques. A community sample of children and adolescents (n = 245; 55.9% female; 83.3% Caucasian, 9.4% African American, 2% Asian, 2% Hispanic, 2% “other,” and 1.2% not reported) completed questionnaires assessing social cognition and social anxiety symptomology. Three latent variables were created to examine the constructs of socially oriented negative self-referent cognition (as measured by the SONAS scale), social self-efficacy (as measured by the SEQSS-C), and social anxiety (as measured by the SPAI-C and the Brief SA). The resulting measurement model of latent variables fit the data well. Additionally, consistent with the study hypothesis, results indicated that social self-efficacy likely mediates the relationship between socially oriented negative self-referent cognition and social anxiety, and socially oriented negative self-referent cognition yields significant direct and indirect effects on social anxiety. These findings indicate that socially oriented negative cognitions are associated with youth's beliefs about social abilities and the experience of social anxiety. Future directions for research and study limitations, including use of cross-sectional data, are discussed.     

Treating Social Anxiety in an Era of Social Distancing: Adapting Exposure Therapy for Youth During COVID-19

The novel coronavirus (COVID-19) pandemic has caused widespread disruption to our traditional way of life and mental health therapy has not been spared. A combination of increased anxiety, diminished social opportunities, and the shift to telehealth service provision presents particular challenges for the treatment of social anxiety in youth, which relies heavily on exposures to social situations with peers, adults, or other feared social stimuli. The objective of this commentary is to provide guidance to clinicians working with youth with social anxiety on how to maintain ethical, evidence-informed provision of exposure therapy in light of these unusual circumstances. We first present an overview of how COVID-19 may uniquely impact youth with social anxiety and highlight the importance of continuing to provide exposure-based treatments during this time. We then discuss guiding principles for delivering exposure therapy during COVID-19. We focus on providing practical examples of how common social anxiety exposures can be adapted and delivered successfully through telehealth while abiding by COVID-19 social distancing guidelines. Finally, we discuss key recommendations to assist clinicians in moving treatment forward while considering changing safety guidelines pertaining to COVID-19.     

Examining the Relationship Between Mathematics Anxiety and Mathematics Performance: An Instructional Hierarchy Perspective

This study investigated the relationship between mathematics anxiety, fluency, and error rates in basic mathematical operations among college students. College students were assigned to one of two groups (high anxiety or low anxiety) based on results from the Fennema-Sherman Mathematics Anxiety Scale (FSMAS). Both groups were then presented with timed tests in basic mathematical operations (addition, subtraction, multiplication, division, and linear equations). Results suggested that the higher mathematics anxiety group had significantly lower fluency levels across all mathematical operations tests. However, there were no significant differences in error rates between the two groups across any of the probes suggesting that mathematics anxiety is more related to higher levels of learning than to the initial acquisition stage of learning. Discussion focuses on a) stages of learning and their potential relationship to mathematics anxiety, b) the relationship between mathematics anxiety and mathematics performance, and c) directions for future research.     

Examining the Potential of Community-Based After-School Programs for Latino Youth

Results are presented from two pilot studies examining the potential influence of community-based after-school programs (ASPs) on regionally diverse Latino youth of varying ages. Study 1 examined relations between dimensions of ASP attendance and content, and ethnic identity development, and self-worth in urban Latino adolescents. In this study, higher ratings of the ASP’s emphasis on ethnic socialization were associated with a more developed ethnic identity, while greater intensity of ASP participation and perceptions of ASP quality were associated with higher levels of self-worth. Study 2 examined relations between ASP participation and development of concentration and emotion regulation skills in rural Latino grade-school youth. In this study, youth who regularly attended the ASP demonstrated significantly better concentration and regulation skills than those who did not regularly attend, if they exhibited preexisting concentration and regulation problems. Findings illustrate how ASPs with varying strategies, activities, and assessment tools can be evaluated in the interest of designing future large-scale investigations into ASPs and Latino positive youth development.     

Emotion Beliefs and Cognitive Behavioural Therapy for Social Anxiety Disorder

Despite strong support for the efficacy of cognitive behavioural therapy (CBT) for social anxiety disorder (SAD), little is known about mechanisms of change in treatment. Within the context of a randomized controlled trial of CBT, this study examined patients' beliefs about the fixed versus malleable nature of anxiety—their ‘implicit theories’—as a key variable in CBT for SAD. Compared to waitlist (n = 29; 58% female), CBT (n = 24; 52% female) led to significantly lower levels of fixed beliefs about anxiety (M_baseline = 11.70 vs. M_Post = 7.08, d = 1.27). These implicit beliefs indirectly explained CBT-related changes in social anxiety symptoms (κ² = .28, [95% CI = 0.12, 0.46]). Implicit beliefs also uniquely predicted treatment outcomes when controlling for baseline social anxiety and other kinds of maladaptive beliefs (perceived social costs, perceived social self-efficacy, and maladaptive interpersonal beliefs). Finally, implicit beliefs continued to predict social anxiety symptoms at 12 months post-treatment. These findings suggest that changes in patients' beliefs about their emotions may play an important role in CBT for SAD.     

Digital Mental Health Interventions for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health conditions in children, with approximately 13% of kids struggling with excessive anxiety. The vast majority do not have access to effective treatments and there continues to be a disjunction between treatments that are empirically supported and those that are available in the community. Digital mental health interventions (DMHI) can increase efficiency, reach, and standardization as well as reduce costs of providing of mental health care. Here we review the extant research on DMHI, including web- or cloud-based programs, mobile applications (apps), virtual reality (VR), and digital assessment methods such as ecological momentary assessment (EMA) for the delivery and/or support of evidence-based care in child anxiety. Preliminary research is promising for these tools to improve access and efficiency of evidence-based practice. However, ethics and practice guidelines are needed and questions remain regarding what level and quality of therapeutic involvement is needed to maximize treatment completion and outcomes in youth and whether DMHIs are contraindicated for certain populations or whether they are similarly effective with those with comorbid conditions is unclear.     

Therapist Awareness of Client Resistance in Cognitive-Behavioral Therapy for Generalized Anxiety Disorder

Clients' resistance relates negatively to their retention and outcomes in psychotherapy; thus, it has been increasingly identified as a key process marker in both research and practice. This study compared therapists' postsession ratings of resistance with those of trained observers in the context of 40 therapist–client dyads receiving 15 sessions of cognitive-behavioral therapy for generalized anxiety disorder. Therapist and observer ratings were then examined as correlates of proximal (therapeutic alliance quality and homework compliance) and distal (posttreatment worry severity) outcomes. Although there was reasonable concordance between rater perspectives, observer ratings were highly and consistently related to both proximal and distal outcomes, while therapist ratings were not. These findings underscore the need to enhance therapists' proficiency in identifying important and often covert in-session clinical phenomena such as the cues reflecting resistance and noncollaboration.     

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.     

Social Anxiety in Children with Anxiety Disorders: Relation with Social and Emotional Functioning

Investigated the psychometric properties of the Social Anxiety Scale for children-Revised (SASC-R) as well as relations between social anxiety and children's social and emotional functioning. Participants were a clinic sample of children, ages 6–11 with anxiety disorders (N = 154) who completed the SASC-R. For a subset of these children, parent ratings of social skills, and self-ratings of perceived competence and peer interactions were also obtained. Factor analysis of the SASC-R supported the original three-factor solution and internal consistencies were in the acceptable range. Among children with simple phobia, scores on the SASC-R differentiated those with and without a comorbid social-based anxiety disorder. Social anxiety was also associated with impairments in social and emotional functioning. Specifically, highly socially anxious children reported low levels of social acceptance and global self-esteem and more negative peer interactions. Girls with high levels of social anxiety were also rated by parents as having poor social skills, particularly in the areas of assertive and responsible social behavior.     

Intolerance of Uncertainty Mediates the Relation Between Generalized Anxiety Disorder Symptoms and Anger

Previous research has shown that individuals with generalized anxiety disorder (GAD) report elevated anger compared with nonanxious individuals; however, the pathways linking GAD and anger are currently unknown. We hypothesized that negative beliefs about uncertainty, negative beliefs about worry and perfectionism dimensions mediate the relationship between GAD symptoms and anger variables. We employed multiple mediation with bootstrapping on cross-sectional data from a student sample (N = 233) to test four models assessing potential mediators of the association of GAD symptoms to inward anger expression, outward anger expression, trait anger and hostility, respectively. The belief that uncertainty has negative personal and behavioural implications uniquely mediated the association of GAD symptoms to inward anger expression (confidence interval [CI] = .0034, .1845, P_M = .5444), and the belief that uncertainty is unfair and spoils everything uniquely mediated the association of GAD symptoms to outward anger expression (CI = .0052, .1936, P_M = .4861) and hostility (CI = .0269, .2427, P_M = .3487). Neither negative beliefs about worry nor perfectionism dimensions uniquely mediated the relation of GAD symptoms to anger constructs. We conclude that intolerance of uncertainty may help to explain the positive connection between GAD symptoms and anger, and these findings give impetus to future longitudinal investigations of the role of anger in GAD.     

Examining the Panic Attack Specifier in Social Anxiety Disorder

Panic attacks (PAs) are characterized by overwhelming surges of fear and discomfort and are one of the most frequently occurring symptoms in psychiatric populations. The most recent version of the Diagnostic and Statistical Manual of Mental Disorders (i.e. DSM-5) allows for a panic attack (PA) specifier for all disorders, including social anxiety disorder (SAD). However, there is little research examining differences between individuals diagnosed with SAD with the PA specifier versus individuals diagnosed with SAD without the PA specifier. The current study examined social anxiety, mood, anxiety, and anxiety sensitivity social concerns, a risk factor for social anxiety in SAD-diagnosed individuals without (N = 52) and with (N = 14) the PA specifier. The groups differed only in somatic symptoms of anxiety. Result of the current study provides preliminary evidence that the presence of the PA specifier in social anxiety does not result in elevated levels of comorbidity or a more severe presentation of social anxiety.     

Durability of Cognitive Behavioral Therapy Effects for Youth and Adolescents With Anxiety,Depression, or Traumatic Stress:A Meta-Analysis on Long-Term Follow-Ups

Cognitive behavioral therapies (CBT) for youth with anxiety, traumatic stress, and depression have demonstrated strong effects in individual studies and meta-analyses. Relatively more attention has been given to posttreatment effects, though, and assessment of follow-up effects has been limited at the meta-analytic level. The current meta-analysis aimed to (a) examine the effects of youth CBT at posttreatment, 1-month, 3-month, 6-month, 1-year, and long-term (2 + years) follow-up as well as (b) identify research-related variables (e.g., measure respondent type) that relate to effects. Using a random effects model across 110 child and adolescent CBT groups, within-group effect sizes were large at posttreatment (g = 1.24) and from 1-month through long-term follow-up (g = 1.23–1.82), and effect sizes did not significantly differ by treatment target (i.e., anxiety, traumatic stress, depression). However, availability of outcome data for effect sizes diminished across later follow-up assessments. Moreover, effect sizes were significantly associated with outcome respondent type across assessment timing, with outcome measures from caregiver and youth respondents associated with smaller effect sizes (B = -0.97, p < 0.001) relative to outcome measures that were evaluator-reported. Results provide initial support for the durability of treatment effects for youth CBTs and highlight the importance of some confounding variables. Implications for improving treatment research standards and prioritizing assessment of long-term follow-up assessment are discussed.     

The Links Between Social Anxiety Disorder,Insomnia Symptoms,and Alcohol Use Disorders: Findings From a Large Sample of Adolescents in the United States

Social anxiety disorder (SAD) is associated with increased risk of developing an alcohol use disorder (AUD). Most of the current literature has focused on the role of acute stress responding in this relation; however, both SAD and AUDs also are linked to insomnia symptoms (i.e., difficulty falling or staying asleep). As adolescence is a sensitive period for the onset of these disorders, the present study examined if insomnia symptoms might partially account for the SAD-AUD link in a large sample of adolescents. Data from the National Comorbidity Survey–Adolescent Supplement were examined. Participants (N = 10,140) completed interviews to assess past 12-month SAD and AUD diagnostic status as well as insomnia symptoms. Analyses tested whether insomnia symptoms accounted for a significant proportion of the SAD-AUD relation. Results indicated that insomnia symptoms were positively related to both SAD and AUD status, and the relation between SAD and AUD status was significantly reduced when insomnia symptoms were included in the model. Findings remained significant after controlling for the effects of age, gender, posttraumatic stress disorder, major depressive disorder, and other drug dependence status. Experimental examination and intensive longitudinal assessment of these relationships are needed before strong conclusions can be inferred about causality and temporal relationships. The current findings do indicate insomnia may be an important indirect and stigma-free treatment target to address in prevention and treatment efforts for SAD, AUDs, and their co-occurrence.     

Maternal Control Behavior and Locus of Control: Examining Mechanisms in the Relation Between Maternal Anxiety Disorders and Anxiety Symptomatology in Children

This study tested components of a proposed model of child anxiety and examined the mediational roles of (1) maternal control behavior, (2) maternal external locus of control, and (3) child external locus of control in the association between maternal and child anxiety. Thirty-eight clinically anxious mothers and 37 nonanxious mothers participated along with one of their children aged 6 to 14 (52.0% female; 78.7% Caucasian). Path analysis indicated that the overall model fit the data very well. Analyses also indicated that child external locus of control mediated the associations between (1) maternal and child anxiety and (2) maternal control behavior and child anxiety. Maternal anxiety was not related to maternal control behavior and maternal external locus of control was not associated with child anxiety. Findings are discussed in the context of theoretical models (e.g., Chorpita and Barlow 1998) regarding the transmission of maternal anxiety to their children and the specific roles of maternal behavior and child locus of control.