Therapy For Anxious Youth Research Articles

Development of \u2018learn to dare!\u2019: An online assessment and intervention platform for anxious children

BackgroundMany children and adolescents suffer from problematic levels of anxiety, but the multitude of these children do not receive an intervention. It is of importance to increase the accessibility and availability of child anxiety interventions, as to identify and treat anxious children early and successfully. Online platforms that include information, assessments and intervention can contribute to this goal. Interventions for child anxiety are frequently based on Cognitive Behavioral Therapy, because of its strong theoretical and empirical basis. However, the working mechanisms of Cognitive Behavioral Therapy in children are poorly studied. To our knowledge, mediation studies on child anxiety are non-existent regarding online Cognitive Behavioral Therapy.MethodsWe will aim at children aged 8–13 years with problematic anxiety. We recruit these children via the community setting, and refer them to our online platform ‘Learn to Dare!’ (in Dutch: ‘Leer te Durven!’), https://leertedurven.ou.nl, where information about child anxiety and our research is freely accessible. After an active informed consent procedure, the participants can access the screening procedure, which will select the children with problematic anxiety levels. Thereafter, these children will be randomized to an online intervention based on Cognitive Behavioral Therapy (n = 120) or to a waitlist control (WL, n = 120). The intervention consists of 8 sessions with minimal therapist support and contains psycho-education, exposure (based on inhibitory learning), cognitive restructuring and relapse prevention. Child anxiety symptoms and diagnoses, cognitions, avoidance behavior and level of abstract reasoning are measured. Assessments are the same for both groups and are performed before and after the proposed working mechanisms are offered during the intervention. A follow-up assessment takes place 3 months after the final session, after which children in the waitlist control group are offered to take part in the intervention.DiscussionThis protocol paper describes the development of the online platform ‘Learn to Dare!’, which includes information about child anxiety, the screening procedure, anxiety assessments, and the online intervention. We describe the development of the online intervention. Offering easy accessible interventions and providing insight into the working mechanisms of Cognitive Behavioral Therapy contributes to optimizing Cognitive Behavioral Therapy for anxious youth.

Generalizability and Decision Studies of a Treatment Adherence Instrument

Observational measurement of treatment adherence has long been considered the gold standard. However, little is known about either the generalizability of the scores from extant observational instruments or the sampling needed. We conducted generalizability (G) and decision (D) studies on two samples of recordings from two randomized controlled trials testing cognitive-behavioral therapy for youth anxiety in two different contexts: research versus community. Two doctoral students independently coded 543 session recordings from 52 patients treated by 13 therapists. The initial G-study demonstrated that context accounted for a disproportionately large share of variance, so we conducted G- and D-studies for the two contexts separately. Results suggested that reliable cognitive-behavioral therapy adherence studies require at least 10 sessions per patient, assuming 12 patients per therapists and two coders-a challenging threshold even in well-funded research. Implications, including the importance of evaluating alternatives to observational measurement, are discussed.

Testing the Habituation-Based Model of Exposures for Child and Adolescent Anxiety

Exposure has been identified as key to effective treatment of youth anxiety. However, the precise theoretical mechanisms of exposure are a matter of debate. Emotional processing theory emphasizes the need for fear activation during exposure and its habituation both within and across exposures. Despite the popularity of the theory to explain exposure, it has not been tested with anxious youth. To determine whether emotional processing theory parameters predict anxiety severity, coping abilities, and global functioning after cognitive-behavioral treatment. The present study examined 72 youth (Mage = 10.50 years; 45% female; 87.5% non-Hispanic Caucasian) diagnosed with an anxiety disorder and who received family or individual CBT. Three exposure habituation variables—initial fear activation (peak anxiety), within-session habituation, and between-session habituation—were assessed using Subjective Units of Distress and examined as predictors of outcome at posttreatment and at 1-year follow-up. Outcomes were measured using the Coping Questionnaire, Multidimensional Anxiety Scale for Children, Revised Children’s Manifest Anxiety Scale, Children’s Global Assessment Scale, and clinician severity ratings on the Anxiety Disorder Interview Schedule. Emotional processing theory variables did not predict any anxiety outcomes at posttreatment or follow-up with one exception: Initial fear activation predicted less anxiety at follow-up among youth without GAD. In addition, within- and between-session habituation were not associated with one another. Between-session habituation was not associated with initial fear activation. These findings suggest a limited role of habituation within cognitive-behavioral therapy for anxiety in youth. An alternative to emotional processing theory, inhibitory learning theory, is discussed.

Scalable Options for Extended Skill Building Following Didactic Training in Cognitive-Behavioral Therapy for Anxious Youth: A Pilot Randomized Trial

A sizable gap exists between the availability of evidence-based psychological treatments and the number of community therapists capable of delivering such treatments. Limited time, resources, and access to experts prompt the need for easily disseminable, lower cost options for therapist training and continued support beyond initial training. A pilot randomized trial tested scalable extended support models for therapists following initial training. Thirty-five postdegree professionals (43%) or graduate trainees (57%) from diverse disciplines viewed an initial web-based training in cognitive-behavioral therapy (CBT) for youth anxiety and then were randomly assigned to 10 weeks of expert streaming (ES; viewing weekly online supervision sessions of an expert providing consultation), peer consultation (PC; non-expert-led group discussions of CBT), or fact sheet self-study (FS; weekly review of instructional fact sheets). In initial expectations, trainees rated PC as more appropriate and useful to meet its goals than either ES or FS. At post, all support programs were rated as equally satisfactory and useful for therapists’ work, and comparable in increasing self-reported use of CBT strategies (b = .19, p = .02). In contrast, negative linear trends were found on a knowledge quiz (b = −1.23, p = .01) and self-reported beliefs about knowledge (b = −1.50, p < .001) and skill (b = −1.15, p < .001). Attrition and poor attendance presented a moderate concern for PC, and ES was rated as having the lowest implementation potential. Preliminary findings encourage further development of low-cost, scalable options for continued support of evidence-based training.

Translating Cognitive Behavioral Therapy for Anxious Youth to Rural-Community Settings via Tele-Psychiatry.

This study aimed to determine the feasibility of translating cognitive behavioral therapy for anxious youth to rural-community settings via tele-psychiatry training. A 20-week group-supervision training program was delivered to ten different groups from different agencies within Northern Ontario. Each group consisted of four to nine clinicians with child therapy background not specific to CBT (n = 78, 51% social workers, 49% other mental health disciplines). Clinicians were each required to treat an anxious youth under supervision. Changes in clinician knowledge and youth internalizing symptoms were measured. Northern Ontario clinicians showed significant gains on a child CBT-related knowledge test (t (1, 52) = -4.6, p < .001). Although youth treated by these clinicians showed a significant decrease in anxiety symptoms, possible response bias and the lack of a comparison group mandate further studies before generalizing our findings. Nevertheless, training local therapists in anxiety-focused CBT for children via a group supervision based tele-psychiatry model appears to be a feasible and well-received approach to knowledge translation to rural settings.

Client-therapist alliance discrepancies and outcome in cognitive-behavioral therapy for youth anxiety.

Studies exploring the association between alliance and outcome in youth cognitive-behavioral therapy (CBT) have yielded inconsistent results based upon whose perspective is measured. The current study explored the degree to which youth with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, anxiety disorders and their therapists agree in their ratings of the alliance at multiple assessment points and evaluated whether inter-rater discrepancies predicted treatment outcome. Youth (N = 62; Mage = 12.43, SD = .76) received empirically supported CBT. Paired samples t tests assessed for significant disagreement between youth- and therapist-rated alliance at sessions 4, 8, and 12. Regression analyses were conducted to evaluate whether discrepancies between raters at each time point predicted posttreatment anxiety symptom scores. Overall, alliance was positive for both child (aged 7-12 years) and adolescent (aged 13-16 years) clients. Discrepancies between youth and therapist ratings of alliance were statistically significant at session 4 for children and session 8 for adolescents, with youth rating the relationship more favorably than therapists. However, rating discrepancies did not predict youth- or parent-reported treatment outcome. Considerable variability may exist between youth and therapist perspectives on the therapeutic alliance, indicating potential attunement problems, particularly during earlier phases of treatment. However, these discrepancies did not negatively affect treatment response. Implications for alliance research and clinical practice are discussed.

Facilitating the Dissemination and Application of Cognitive-Behavioral Therapy for Anxiety in Youth

Facilitating the Dissemination and Application of Cognitive-Behavioral Therapy for Anxiety in Youth

Facilitating the Dissemination and Application of Cognitive-Behavioral Therapy for Anxiety in Youth

Much work has been done to develop and evaluate approaches to the treatment of behavioral and emotional disorders in children and adolescents, in general (e.g., Hibbs & Jensen, 2005; Kazdin & Weisz, 2003) and of anxiety disorders in youth, specifically (see Velting, Setzer, & Albano, 2004). One such approach, typically labeled "cognitive-behavioral therapy" (CBT), represents an integration of strategies that have a research basis. For example, exposure tasks in CBT address behavioral avoidance, a primary feature of anxiety, whereas cognitive training targets the cognitive misinterpretations and attentional biases found in anxious youth. Thus, CBT can be considered an empirically based approach: The components of the treatment target data-based aspects of the disorder. In addition, CBT has been subjected to randomized clinical trials (RCTs) to rigorously evaluate treatment outcome. The literature now contains a sufficient number of RCTs, conducted with clinical cases, in several countries, and with reasonably consistent and positive outcomes reported by multiple teams of investigators. Given the body of empirical support that has been reported, and in sync with the evaluative reviews of others (e.g., Kazdin & Weisz, 1998; Ollendick, King, & Chorpita, 2006), CBT has been included among those treatments referred to as an empirically supported treatment (EST), and more specifically can be considered a "probably efficacious" treatment (see also Albano & Kendall, 2002). Achieving the status of an EST is an accomplishment, but the set of necessary treatment outcome evaluations for CBT have not yet been completed. The data to date are sufficiently encouraging, but the distance to be traveled is further than the distance traveled thus far. What is needed, and hence the motivation for this special issue, is a scholarly yet applied consideration of how to facilitate the further development and deployment of CBT for anxiety in youth. Toward this goal, we briefly mention issues in and ideas for dissemination, opportunities for the proper individualization of treatment, and features of the multicomponent nature of the treatment. The broader discussions appear in the articles that follow. It is worth noting that the authors are associated with the Child/Adolescent Anxiety Multimodal Study (CAMS), a multisite study comparing the relative efficacy of CBT, medication (sertraline), the combination of these approaches (combined treatment), and a pill placebo condition.1 Participants ages 7 to 17 must meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for generalized anxiety disorder (GAD), social phobia (SP), and/or separation anxiety disorder (SAD), with relatively few exclusionary criteria. Across 12 weeks, CBT therapists in CAMS provide 14 sessions of CBT. FLEXIBILITY WITHIN FIDELITY: AN IDEAL DISSEMINATION When critics of manualized treatments assume that adherence to a manual requires rigid and inflexible applications, they may be legitimately resistant to using a manualized approach. However, the truth is that manuals are not rigid and there is indeed a desired place for "flexibility within fidelity" (Kendall, 2001; Kendall & Beidas, in press). Authors of the set of articles in this special issue will mention treatment manuals and discuss clinical experiences with the intent of communicating the common clinical features of implementing a manual-based EST. Flexibility has a place, but it is worthwhile to consider how and where to be flexible. For example, the exact application of therapy procedures may vary from client to client, but the underlying principles (see Gosch, Flannery-Schroeder, Mauro, & Compton, this issue) remain largely the same. Understanding the underlying principles that are consistent across cases facilitates the flexible application of manualized treatments. Age is often used as the easy marker for maturation. …

Mechanisms of Change in Cognitive Behavioral Therapy for Anxious Youth

Mechanisms of Change in Cognitive Behavioral Therapy for Anxious Youth

Mechanisms of Change in Cognitive Behavioral Therapy for Anxious Youth.

Davis and Ollendick (this issue) challenge CBT therapists to move beyond the measurement of subjective fear and diagnostic status in the treatment of phobic youth and urge that cognitive, behavioral, and physiological measurements of the emotional response be included. In this paper I highlight the ways in which current measures of child and adolescent anxiety assess the emotional response and discuss the need for reliable and valid measures of these three components. Next, I review some of the current evidence for the mechanisms of change in CBT for anxious youth and highlight the need for future research in this area.

Equine Facilitated CBT Group Therapy for Youth Anxiety

Equine Facilitated CBT Group Therapy for Youth Anxiety