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.     

A Probabilistic and Individualized Approach for Predicting Treatment Gains: An Extension and Application to Anxiety Disordered Youth

The objective of this study was to extend the probability of treatment benefit method by adding treatment condition as a stratifying variable, and illustrate this extension of the methodology using the Child and Adolescent Anxiety Multimodal Study data. The probability of treatment benefit method produces a simple and practical way to predict individualized treatment benefit based on pretreatment patient characteristics. Two pretreatment patient characteristics were selected in the production of the probability of treatment benefit charts: baseline anxiety severity, measured by the Pediatric Anxiety Rating Scale, and treatment condition (cognitive-behavioral therapy, sertraline, their combination, and placebo). We produced two charts as exemplars which provide individualized and probabilistic information for treatment response and outcome to treatments for child anxiety. We discuss the implications of the use of the probability of treatment benefit method, particularly with regard to patient-centered outcomes and individualized decision-making in psychology and psychiatry.     

Predictors and Outcomes of Sudden Gains and Sudden Regressions in Cognitive Behavioral Therapy for Youth Anxiety

Sudden gains (SGs), referring to large, stable symptom improvement occurring between consecutive treatment sessions, have been associated with improved outcomes among adults with various psychological disorders. Little research exists on SGs or sudden symptom worsening (i.e., sudden regressions [SRs]) during treatment for youth disorders. The current study examined predictors and outcomes of SGs/SRs via multiple informants in youth anxiety treatment. Participants were 118 youth (age M = 11.6, SD = 2.5; 53.8% female) and their caregivers receiving a cognitive-behavioral therapy protocol for a principal anxiety disorder. Anxiety symptom severity was assessed weekly via the State-Trait Anxiety Inventory for Children–Trait–Child/Parent versions. SGs and SRs occurred in 45.8 and 31.3% of youth, respectively. SRs were more common among youth with comorbid mood or externalizing disorders, while SGs occurred more often among youth with greater pretreatment anxiety symptom severity. SGs were not associated with posttreatment outcomes, but SRs predicted significantly higher posttreatment internalizing symptoms based on child report (β = .23, p = .03) and externalizing symptoms based on child (β = .15, p = .04) and parent report (β = .16, p = .03), controlling for overall magnitude of symptom change. SRs among youth receiving cognitive-behavioral therapy for anxiety are associated with pretreatment clinical complexity and poorer posttreatment outcomes and may serve as a warning sign to clinicians of possible treatment failure.     

Effective Treatment for Mental Disorders in Children and Adolescents

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.     

Anxiety Disorders in Late Life: Considerations for Assessment and Cognitive-Behavioral Treatment

Anxiety disorders are among the most frequently diagnosed mental disorders in late life. As older adults comprise a growing segment of the population, evidence-based treatments for anxiety disorders in late life have come into sharper focus. Cognitive-behavioral therapy (CBT) for anxiety disorders in late life has received less empirical attention and widespread dissemination relative to other age groups. Increasing older adults’ access to timely assessment and effective treatment can help reduce the personal and societal costs of anxiety disorders. The purpose of this review paper is to discuss important considerations for the assessment of anxiety disorders in older adults and offer adaptations to CBT treatment for this population. As part of assessment considerations, we discuss how physical health conditions, cognitive impairment, and functional limitations can impact anxiety disorder diagnoses with older adults. We also outline validated self-report measures of anxiety disorder symptoms for older adults and highlight the importance of assessing older adults’ suitability for CBT. Several recommendations for adapting CBT protocols for older adults with anxiety disorders are described, such as extending psychoeducation, altered treatment pacing, use of content aids, and medical contraindications for interoceptive exposure. A case study is included that illustrates helpful assessment and treatment adaptions for an older woman with panic disorder. We highlight the pressing need to increase research and dissemination of CBT for anxiety disorders for older adults to meet the needs of an increasing segment of the population worldwide.     

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.     

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.     

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

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

The Role of Emotion Regulation in the Treatment of Child Anxiety Disorders

In this review, we examine the role of emotion regulation in the treatment of children with anxiety disorders. Cognitive-behavioral therapy (CBT) has been shown to “work” for children with anxiety disorders and it has been categorized as an evidence-based treatment. However, most studies have shown that the treatment is effective for about 60–70% of children, leaving the remaining children symptomatic and oftentimes with persisting psychological disorders. Of importance, it has also been shown that many children with anxiety disorders demonstrate poor emotion regulation skills. Despite these findings, little attention has been directed toward incorporating emotion regulation strategies into these relatively effective cognitive-behavioral treatments. It is possible that CBT programs do not work as well for a portion of children because their emotion regulation deficits, if present, are not being targeted sufficiently. In this review, it is suggested that adding an emotion regulation component could increase treatment efficacy. In addition, strategies aimed at improving emotion regulation at the individual level and at the family level are introduced. Details of how improved emotion regulation skills could be beneficial in bringing about change are discussed. Finally, issues of measurement and the clinical implications for research and practice are considered.     

Changes in Anxiety Control Beliefs Following a Brief CBT Treatment and Their Association With Anxiety Symptom Reduction

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.     

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.     

Cognitive Mediators of Treatment for Social Anxiety Disorder: Comparing Acceptance and Commitment Therapy and Cognitive-Behavioral Therapy

Objective

To assess the relationship between session-by-session mediators and treatment outcomes in traditional cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT) for social anxiety disorder.

Method

Session-by-session changes in negative cognitions (a theorized mediator of CBT) and experiential avoidance (a theorized mediator of ACT) were assessed in 50 adult outpatients randomized to CBT (n = 25) or ACT (n = 25) for DSM-IV social anxiety disorder.

Results

Multilevel modeling analyses revealed significant nonlinear decreases in the proposed mediators in both treatments, with ACT showing steeper decline than CBT at the beginning of treatment and CBT showing steeper decline than ACT at the end of treatment. Curvature (or the nonlinear effect) of experiential avoidance during treatment significantly mediated posttreatment social anxiety symptoms and anhedonic depression in ACT, but not in CBT, with steeper decline of the Acceptance and Action Questionnaire at the beginning of treatment predicting fewer symptoms in ACT only. Curvature of negative cognitions during both treatments predicted outcome, with steeper decline of negative cognitions at the beginning of treatment predicting lower posttreatment social anxiety and depressive symptoms.

Conclusions

Rate of change in negative cognitions at the beginning of treatment is an important predictor of change across both ACT and CBT, whereas rate of change in experiential avoidance at the beginning of treatment is a mechanism specific to ACT.     

Attachment, Behavioral Inhibition, and Anxiety Disorders Symptoms in Normal Adolescents

The current study examined relationships between attachment style, behavioral inhibition, and anxiety disorders symptoms not only relying on youths' self-report but also including the parents' point of view. A large group of young adolescents aged 11–15 years and their parents (N = 280) completed measures of attachment style and behavioral inhibition and the Revised Children's Anxiety and Depression Scale, a questionnaire designed to measure symptoms of anxiety disorders in terms of the Diagnostic and Statistical Manual of Mental Disorders. Highly similar results were found for child and parent report. That is, attachment style and behavioral inhibition were found to be interrelated with insecure attachment being associated with higher levels of behavioral inhibition. Furthermore, adolescents who were classified as insecurely attached and/or high on behavioral inhibition displayed higher levels of anxiety disorders symptoms. Finally, attachment status and behavioral inhibition both accounted for a unique proportion of the variance of anxiety disorders symptomatology.     

Anxiety Disorders in Childhood: Casting a Nomological Net

Empirical research highlights the need for improving the childhood anxiety disorder diagnostic classification system. In particular, inconsistencies in the stability estimates of childhood anxiety disorders and high rates of comorbidity call into the question the utility of the current DSM criteria. This paper makes a case for utilizing a nomological net⁴ model for advancing the understanding of childhood anxiety disorders. In this article, we discuss measurement and assessment issues related to improving the childhood anxiety disorder diagnostic system and show how these issues can be addressed by employing the nomological net of childhood anxiety. Because employing the nomological net involves drawing from etiological process theories to facilitate classification and assessment, an integrative model of childhood anxiety disorders is presented as a tentative heuristic. Then evidence for the existing symptom sets is discussed in the context of how process theory mechanisms may be utilized to improve classification and assessment. Testable hypotheses are presented. Measurement, disorder definition, treatment, and policy implications are also discussed.A nomological net can be briefly defined as the theoretical structure of a construct.     

Adaptations for Youth

Aaron T. Beck exemplified the clinical scientist, willing to test his hypotheses, and willing to share his experiences and treatment features with others. Assessment and treatment of emotional disorders have been forever improved through the efforts of Aaron T. Beck. Using the psychological treatment of an emotional disorder in youth (i.e., anxiety), this commemorative reflects on how Aaron T. Beck’s clinical strategies have been impactful well beyond his initial focus. As a world-renowned clinical scientist, Beck’s work has influenced multiple fields addressing mental health. As a friend and colleague, Beck was a gentleman and a scholar.     

Sensitivity for Treatment Effects of the Screen for Child Anxiety Related Emotional Disorders

The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a relatively new self-report questionnaire that measures DSM-defined anxiety disorders symptoms in children. The present study examined the treatment sensitivity of the SCARED. Eleven anxiety-disordered children aged 10 to 13 years received cognitive-behavioral treatment, an intervention that is generally known to be effective. Children completed the SCARED on three occasions: (1) 3 months before treatment (i.e., baseline), (2) at pretreatment, and (3) at posttreatment. Before and after treatment, scores on traditional childhood anxiety measures (i.e., State-Trait Anxiety Inventory for Children, Revised Children's Manifest Anxiety Scale, and Fear Survey Schedule for Children) were also obtained. Results showed that children's SCARED scores remained relatively stable from baseline to pretreatment. However, from pre- to post-treatment, significant decreases were evident for the SCARED and for all traditional measures. These results suggest that the SCARED reliably taps treatment effects and, thus, provide further support for its utility as a self-report index of childhood anxiety in clinical and research settings.     

Usability of a Smartphone Application to Support the Prevention and Early Intervention of Anxiety in Youth

Mental, emotional, and behavioral disorders are common in youth with anxiety problems being among the most prevalent, typically failing to spontaneously remit, and placing some youth at risk for additional difficulties. Mobile health (mHealth) might be a novel avenue to strengthen prevention efforts for child anxiety, since program effects are generally small. However, although a significant number of mHealth tools have been developed, few have been evaluated in terms of usability (or even clinical effectiveness). Usability testing is the first level of evaluation in responsible mHealth efforts as it is one of the main barriers to usage and adoption. As such, the objective of this research was to evaluate the usability of a smartphone application (app) corresponding to an indicated prevention and early intervention targeting youth anxiety. To accomplish this, 132 children (M_age = 9.65, 63% girls) and 45 service providers (M_age = 29.13, 87% female) rated our app along five established dimensions of usability (ease of use, ease of learning, quality of support information, satisfaction, and stigma). Findings showed that the app was highly and positively rated by youth and providers, with some variations (lower ratings when errors occurred). Path analyses also showed that system understanding was significantly related to greater system satisfaction, but that such relation occurred through the quality of support information offered by the app. Together, this has research and clinical implications as it highlights avenues for advancing youth care via mHealth usability evaluation, including prior to establishing effectiveness.     

Using Technology to Promote Therapist Use of Exposure Therapy for Childhood Anxiety Disorders: A Randomized Pilot Study

Increasing the use of exposure by community therapists during the treatment of childhood anxiety disorders is critical to improving the quality of available treatment. The aim of the current study was to investigate whether a brief training in the delivery of an exposure-focused and technology-assisted treatment protocol increased community therapist openness to exposure therapy, use of exposure in treatment, and improvement in patient symptoms. Participants were 17 therapists recruited from a large health system to provide outpatient therapy to 32 youth ages 8–18 (M = 12.13, 78.1% girls) with treatment as usual or with the Anxiety Coach application (AC-app). Consistent with two of three hypotheses, therapists in the AC-app condition increased their openness to, and use of, exposure—however, these changes did not translate into improved therapeutic outcomes. Comparisons to benchmark studies suggest that the community therapists did not implement enough in vivo exposure of sufficient intensity or include parents enough to improve outcome. Results support the ability of exposure-focused treatment protocols to increase community therapists’ use of evidence-based treatment and suggest that future efforts should focus on improving the quality, in addition to quantity, of therapist-delivered exposure.     

Development of a Unified Protocol for the Treatment of Emotional Disorders in Youth

This study evaluated the efficacy of the Mind Reading interactive computer software to remediate emotion recognition deficits in children with autism spectrum disorders (ASD). Six unmedicated children with ASD and 11 unmedicated non-clinical control subjects participated in the study. The clinical sample used the software for five sessions. The control sample was evaluated only on pre- and post-test performance to assess practice effects. Results showed that participants with ASD scored significantly higher on the posttest than on the pretest. As level of emotion difficulty increased, mean scores on the pretest decreased, indicating that difficulty level had a valid effect. The Mind Reading computer software appears to significantly improve the emotion recognition abilities in children with ASD.