The Role of Families and Care Givers as Risk and Protective Factors in Preventing Youth Violence

This paper reviews research which discusses the risk and protective functions that families and other caregivers provide in influencing the development of aggressive behavior in youth. Currently, there is an emphasis on providing violence prevention programs in the school environment, typically with little parental or caregiver involvement. By enhancing the role of families and caregivers in youth violence prevention programs, we assert that an unique opportunity exists to both address specific risk factors for violence while enhancing the protective features of the family. Relatedly, the risk literature on youth violence indicates that the most influential risk factors (i.e., the family, community, and peers) have their principle impact on youth aggression outside the school. We suggest a shift in the focus of violence prevention programming that is more inclusive of families as both a risk and protective agent. In support of this position, relevant theory and reviews of exemplary family-involved programs are offered. Challenges to involving youth caregivers are identified and recommendations for overcoming those challenges suggested. Last, recommendations for future research and public policy in the prevention of youth violence are offered.     

Have Phobias,Will Travel: Addressing One Barrier to the Delivery of an Evidence-Based Treatment

Although a host of evidence-based treatments exist for youth with anxiety disorders, less than 30% of youth and their families receive these treatments. One of the main barriers to receiving these treatments is the lack of access to care, due largely to the absence of mental health professionals who have expertise in the delivery of these treatments in certain geographic locales. The current study examined whether a brief intensive treatment for specific phobias (SPs), Augmented One-Session Treatment (OST-A), would result in comparable treatment gains for families who traveled a considerable distance to receive this treatment when compared to families who resided in our local community. Participants included 76 youth with a clinically confirmed diagnosis of SP (38 local families and an age- and sex-matched sample of 38 nonlocal families). Although SP severity at pretreatment was significantly greater for the nonlocal youth than the local youth, both nonlocal and local youth showed commensurate improvement and maintenance of treatment gains over a 6-month period across several clinical outcome measures. Findings from this study show that OST-A is effective when families choose to travel for treatment, addressing at least one of the barriers to use of this evidence-based treatment.     

Prevention of anxiety disorders: A model for intervention

Anxiety disorders are among the most prevalent of all psychological disorders and are potentially amenable to early intervention and prevention. In this article, we review the various costs associated with anxiety disorders that make early prevention a valuable endeavor. Also, we considered extant data regarding risk factors for anxiety disorders, as knowledge of risk factors permits the targeting of a select group of the population considered to be most likely to develop anxiety disorders. Existing efficacy research on prevention for anxiety disorders is promising, but an overarching model to guide further research and development is lacking. We propose such models to guide high-risk sample selection including the content and format of prevention efforts.     

Cigarette Smoking, Anxiety, and Depression

This review provides a detailed analysis of anxiety and depression as they relate to each stage of the cigarette smoking cycle: initiation, maintenance, and cessation with an emphasis on nicotine withdrawal. An analysis of the literature confirms that cigarette smoking is highly comorbid with anxiety disorders and clinical depression, and that this relationship appears to be moderated by factors such as age of the smoker, type of disorder, and level of nicotine dependence. Studies also offer evidence to suggest a relationship between smoking and both subclinical anxiety and depression. Research findings have not revealed whether common factors influence the development of anxiety, depression, and smoking, whether anxiety and depression lead to smoking, or whether the reverse is true. Nevertheless, a current understanding of the links among smoking, anxiety, and depression confirms current prevention and cessation techniques, as well as suggests new directions for research and clinical practice.     

Comorbidity of Anxiety and Depression in Children and Adolescents: An Integrative Review

Much evidence exists documenting the comorbidity of anxiety and affective disorders in youth. Furthermore, comorbidity appears to have serious implications both in terms of severity of impairment and course of disorder. Despite this, little is known about the meaning behind the high rate of co-occurrence of anxiety and depression in children and adolescents. Several conditions exist that may give rise to comorbidity. Specifically, two disorders may be comorbid when there is a high rate of symptom overlap between the disorders, when one underlying construct is split into two separate disorders, when the disorders share common risk or etiological factors, or because one disorder causes or increases the risk of developing the second disorder. The present paper examines each of these explanations as they relate to the comorbidity of anxiety and depression in youth.     

Parental Involvement: Contribution to Childhood Anxiety and Its Treatment

Anxiety disorders are prevalent in youth. Despite demonstrated efficacy of cognitive behavioral therapy (CBT), approximately 40 % of anxiety-disordered youth remain unresponsive to treatment. Because developmental and etiological models suggest that parental factors are relevant to the onset and maintenance of childhood anxiety, researchers have proposed and investigated family-based interventions with increased parent work in treatment, aiming to improve the efficacy of treatment for childhood anxiety. However, contrary to what theoretical models suggest, data to date did not indicate additive benefit of family-based CBT in comparison with child-centered modality. Is parent/family involvement unnecessary when treating childhood anxiety disorders? Or could there be the need for specificity (tailored family-based treatment) that is guided by a revised conceptualization that improves the implementation of a family-based intervention? The current review examines (1) relevant parental factors that have been found to be associated with the development and maintenance of childhood anxiety and (2) interventions that incorporate parental involvement. Relevant findings are integrated to formulate a “targeted” treatment approach for parental involvement in CBT for youth anxiety. Specifically, there is potential in the assessment of parent/family factors prior to treatment (for appropriateness) followed by a target-oriented implementation of parent training.     

Latino Family Participation in Youth Mental Health Services: Treatment Retention,Engagement, and Response

Although researchers have identified a multitude of factors that contribute to family participation in mental health services, few studies have examined them specifically for Latino youth and their families in the U.S., a population that continues to experience significant disparities related to the availability, accessibility, and quality of mental health services. Latino youth and their families are at greater risk of dropping out of treatment prematurely and demonstrating poor treatment engagement, both of which have subsequent negative effects on treatment response outcomes. In order to help to guide efforts to improve the accessibility and quality of mental health services for Latino youth and their families, the current paper integrates modern conceptualization of family participation in youth mental health services and provides a summary of contextual factors within an ecological framework (Bronfenbrenner in The ecology of human development: experiments by nature and design, Harvard University Press, Cambridge, 1979). The current review aims to integrate empirical research on the impact of various contextual factors across multiple levels (i.e., culture, community, mental health system, family, parent/caregiver, and child/adolescent) on Latino family participation in youth mental health services, including treatment retention, engagement, and response. Clinical implications will be discussed, and an integrated, conceptual model will be presented. Not only does this model help to demonstrate the way in which existing literature is conceptually linked, but it also helps to highlight factors and underlying processes that health care providers, administrators, and policy makers must consider in working to improve mental health services for Latino youth and their families living in the U.S.     

Family Factors in the Development and Management of Anxiety Disorders

Family variables are thought to play a key role in a wide variety of psychopathology according to many theories. Yet, specific models of the development of anxiety disorders place little emphasis on general family factors despite clear evidence that anxiety runs in families. The current review examines evidence for the involvement of a number of family-related variables in the development of anxiety disorders as well as the importance of families in their management. Evidence across most areas is shown to be weak and inconsistent, with the one exception being an extensive literature on the role of parenting in the development of anxiety. There is also currently little evidence that family factors have a strong role to play in the treatment of anxiety, aside from research demonstrating the value of parents and partners as non-critical supports in therapy. The promises and hints in the literature, combined with the currently inconsistent methods, suggest that considerably more research is needed to determine whether specific family factors may yet be shown to play a key role in the development and management of anxiety disorders.     

The Role of Stress Exposure and Family Functioning in Internalizing Outcomes of Urban Families

Although research suggests that stress exposure and family functioning are associated with internalizing problems in adolescents and caregivers, surprisingly few studies have investigated the mechanisms that underlie this association. To determine whether family functioning buffers the development of internalizing problems in stress-exposed families, we assessed the relation between stress exposure, family functioning, and internalizing symptoms among a large sample of inner-city male youth and their caregivers living in poverty across five waves of data collection. We hypothesized that stress exposure and family functioning would predict development of subsequent youth and caregiver internalizing problems and that family functioning would moderate this relation, with higher functioning families demonstrating greater resiliency to stress exposure. We used a longitudinal, prospective design to evaluate whether family functioning (assessed at waves one through four) activated or buffered the effects of stress exposure (assessed at wave one) on subsequent internalizing symptoms (assessed at waves four and five). Stress from Developmental Transitions and family functioning were significant predictors of depressive symptoms and anxiety in youth; however, family functioning did not moderate the relation. Family functioning mediated the relation between stress from Daily Hassles and internalizing outcomes suggesting that poor parenting practices, low structure, and low emotional cohesion activate depression and anxiety in youth exposed to chronic and frequent everyday stressors. Surprisingly, only family functioning predicted depressive symptoms in caregivers. Results validate the use of a comprehensive, multi-informant assessment of stress when investigating internalizing outcomes in youth and support using family-based interventions in the treatment and prevention of internalizing.     

Anxiety, anxiety disorders, tobacco use, and nicotine: a critical review of interrelationships

Smoking is highly prevalent across most anxiety disorders. Tobacco use increases risk for the later development of certain anxiety disorders, and smokers with anxiety disorders have more severe withdrawal symptoms during smoking cessation than smokers without anxiety disorders. The authors critically examined the relationships among anxiety, anxiety disorders, tobacco use, and nicotine dependence and reviewed the existing empirical literature. Future research is needed to better understand the interrelationships among these variables, including predictors, moderators, and mechanisms of action. Increased knowledge in these areas should inform prevention efforts as well as the development and improvement of smoking cessation programs for those with anxiety and other psychiatric disorders.     

An Innovative Treatment Approach for Children With Anxiety Disorders and Medically Unexplained Somatic Complaints

Anxiety disorders in children and adolescents are largely undetected and the majority of youth do not receive services. Given the deleterious consequences of anxiety disorders, early identification and intervention have public health implications. In order to increase identification and treatment of anxious youth, expansion to nonpsychiatric settings (i.e., pediatric medical settings, schools) is necessary. Pediatric medical offices represent ideal settings for detection and intervention for several reasons: (1) access to large numbers of children, (2) high prevalence of unrecognized anxiety disorders in medical settings, and (3) an association between anxiety disorders and medically unexplained somatic symptoms. This paper describes a cognitive-behavioral intervention for youth who present to pediatric medical settings with nonmedical somatic symptoms and undiagnosed anxiety disorders. We explain the rationale for and focus of our treatment approach, present two case studies illustrating the treatment process, and conclude with a discussion of implementation considerations.     

Brief Behavioral Therapy for Pediatric Anxiety and Depression: Piloting an Integrated Treatment Approach

Mood and anxiety disorders in youth are disabling, distressing, and prevalent. Furthermore, depression and anxiety frequently co-exist, may share several etiological factors, and respond to similar interventions. In this paper, we report preliminary results from a treatment adaptation project designed to condense existing cognitive behavioral therapy protocols for anxiety and depression to their core components and combine them into a brief, integrated treatment suitable for the broad population of internalizing youth seen in primary care. Specifically, we discuss: (a) the rationale for targeting anxiety and depression in pediatric primary care and the deployment-focused treatment development model; (b) the content of our behaviorally based treatment program; and (c) clinical outcomes of 2 sample cases with comorbid depression and anxiety.     

Comorbid ADHD: Implications for the Treatment of Anxiety Disorders in Children and Adolescents

Despite high comorbidity rates and potential clinical implications, the influence of co-occurring attention-deficit/hyperactivity disorder (ADHD) on outcomes of cognitive-behavioral treatment (CBT) for anxious youth remains poorly understood. In this qualitative review, the current literature on the influence of comorbid ADHD on CBT of youth with diverse anxiety disorders is explored. Peer-reviewed studies examining ADHD, at the diagnostic and symptom level, received highest priority. In addition, inasmuch as some studies did not isolate the effects of ADHD from other disruptive behavior disorders (DBDs: oppositional defiant disorder, conduct disorders), studies with the three DBDs were explored as well. Ten studies met our specified methodological criteria. Findings are discussed in relation to the following two factors: type of anxiety disorder and measurement of ADHD (diagnostic or symptom level) in these studies. There was evidence that youth with a variety of anxiety disorders and with co-occurring ADHD fared worse than their counterparts without ADHD. Additionally, grouping ADHD with other DBDs tended to obscure the negative impact of ADHD on treatment outcomes. Additional research is needed to delineate the influence of comorbid ADHD specifically on treatment outcomes for the various anxiety disorders. Clinical implications of treating anxious youth with comorbid ADHD are explored.     

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.     

Improving prevention of depression and anxiety disorders: Repetitive negative thinking as a promising target

Prevention of depression and anxiety disorders is widely acknowledged as an important health care investment. However, existing preventive interventions have only shown modest effects. In order to improve the efficacy of prevention of depression and anxiety disorders, a number of authors have suggested that it is promising to focus on selective prevention programs that are offered to individuals scoring high on clearly established risk factors, whereby the preventive intervention then specifically targets these risk variables. This review presents repetitive negative thinking (worry and rumination) as a promising target for the prevention of depression and anxiety disorders.     

Predicting internalizing symptoms over a two year period by BIS,FFFS and attentional control

Identifying risk factors for the development of internalizing disorders is of major importance. In this context, behavioral inhibition (BIS), the fight-flight-freeze-system (FFFS), and attentional control (AC) have been proposed as being possible risk factors for both anxiety disorders and depression. Even though related cross-sectionally, it is still unclear whether these factors are precursors for internalizing disorders. In this longitudinal study, 1811 participants (aged 12–15) completed questionnaires on BIS/FFFS, AC, and internalizing symptoms at pretest and at two year follow-up. Supporting the alleged importance of BIS/FFFS and AC in the development of internalizing symptoms, BIS/FFFS and AC showed predictive value for anxiety and depression symptoms at two year follow-up. For anxiety symptoms this predictive value was not independent of the level of symptoms at pretest. For depression symptoms, AC showed predictive value over and above pretest level of depression symptoms. In the context of early detection of at risk adolescents, results suggest that screening of current anxiety and depression symptoms is most relevant in addition to a focus on AC for the screening of depression. However, it cannot be ruled out that at a further extended follow-up also BIS/FFFS might show independent predictive value for symptoms of anxiety and/or depression.     

TO BE FEMALE, MIDDLE CLASS, ANXIOUS, AND BLACK

Women of color theorists have suggested that the double minority status of gender and ethnicity places African American women at higher risk for anxiety. However, little information is available about anxiety disorders among African American women. The existing literature subsumes Black women under the general category of African Americans and focuses on low-income samples. In this study, we examine the manifestation of panic disorder in a sample of 15 predominantly middle-class African American women. We then compare these women to a group of 35 predominantly middle-class African American women without panic disorder on several factors, including presence of isolated sleep paralysis, presence of other anxiety disorders, help-seeking behavior, and victimization. Results indicate that African American women with panic disorder experienced isolated sleep paralysis, and that both groups had high levels of sexual victimization. Help-seeking among women with panic and other anxiety disorders was limited to relationship difficulties, sexual assault, and bereavement.     

An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents

Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive–compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.     

Using a Smartphone App and Clinician Portal to Enhance Brief Cognitive Behavioral Therapy for Childhood Anxiety Disorders

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40%–50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9–14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At posttreatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at 2-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to posttreatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders.