Araceli Gonzalez

Predictors of Treatment Attrition Among an Outpatient Clinic Sample of Youths With Clinically Significant Anxiety

Predictors of treatment attrition were examined in a sample of 197 youths (ages 5–18) with clinically-significant symptoms of anxiety seeking psychotherapy services at a community-based outpatient mental health clinic (OMHC). Two related definitions of attrition were considered: (a) clinician-rated dropout (CR), and (b) CR dropout qualified by phase of treatment (pre, early, or late phases) (PT). Across both definitions, rates of attrition in the OMHC sample were higher than those for anxious youths treated in randomized controlled trials, and comorbid depression symptoms predicted dropout, with a higher rate of depressed youths dropping out later in treatment (after 6 sessions). Using the PT definition, minority status also predicted attrition, with more African-American youths lost pre-treatment. Other demographic (age, gender, single parent status) and clinical (externalizing symptoms, anxiety severity) characteristics were not significantly associated with attrition using either definition. Implications for services for anxious youths in public service settings are discussed. Results highlight the important role of comorbid depression in the treatment of anxious youth and the potential value of targeted retention efforts for ethnic minority families early in the treatment process.

Bounce Back: Effectiveness of an Elementary School-Based Intervention for Multicultural Children Exposed to Traumatic Events

OBJECTIVE To evaluate the feasibility and acceptability of a school-based intervention for diverse children exposed to a range of traumatic events, and to examine its effectiveness in improving symptoms of posttraumatic stress, depression, and anxiety. METHOD Participants were 74 schoolchildren (Grades 1-5) and their primary caregivers. All participating students endorsed clinically significant posttraumatic stress symptoms. School clinicians were trained to deliver Bounce Back, a 10-session cognitive-behavioral group intervention. Children were randomized to immediate or delayed (3-month waitlist) intervention. Parent- and child-report of posttraumatic stress and depression, and child report of anxiety symptoms, were assessed at baseline, 3 months, and 6 months. RESULTS Bounce Back was implemented with excellent clinician fidelity. Compared with children in the delayed condition, children who received Bounce Back immediately demonstrated significantly greater improvements in parent- and child-reported posttraumatic stress and child-reported anxiety symptoms over the 3-month intervention. Upon receipt of the intervention, the delayed intervention group demonstrated significant improvements in parent- and child-reported posttraumatic stress, depression, and anxiety symptoms. The immediate treatment group maintained or showed continued gains in all symptom domains over the 3-month follow-up period (6-month assessment). CONCLUSIONS Findings support the feasibility, acceptability, and effectiveness of the Bounce Back intervention as delivered by school-based clinicians for children with traumatic stress. Implications are discussed.

Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care: A Randomized Clinical Trial

Importance Anxiety and depression affect 30% of youth but are markedly undertreated compared with other mental disorders, especially in Hispanic populations. Objective To examine whether a pediatrics-based behavioral intervention targeting anxiety and depression improves clinical outcome compared with referral to outpatient community mental health care. Design, Setting, and Participants This 2-center randomized clinical trial with masked outcome assessment conducted between brief behavioral therapy (BBT) and assisted referral to care (ARC) studied 185 youths (aged 8.0-16.9 years) from 9 pediatric clinics in San Diego, California, and Pittsburgh, Pennsylvania, recruited from October 6, 2010, through December 5, 2014. Youths who met DSM-IV criteria for full or probable diagnoses of separation anxiety disorder, generalized anxiety disorder, social phobia, major depression, dysthymic disorder, and/or minor depression; lived with a consenting legal guardian for at least 6 months; and spoke English were included in the study. Exclusions included receipt of alternate treatment for anxiety or depression, presence of a suicidal plan, bipolar disorder, psychosis, posttraumatic stress disorder, substance dependence, current abuse, intellectual disability, or unstable serious physical illness. Interventions The BBT consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in pediatric clinics by master’s-level clinicians. The ARC families received personalized referrals to mental health care and check-in calls to support accessing care from master’s-level coordinators. Main Outcomes and Measures The primary outcome was clinically significant improvement on the Clinical Global Impression–Improvement scale (score ⩽2). Secondary outcomes included the Pediatric Anxiety Rating Scale, Childrens Depression Rating Scale–Revised, and functioning. Results A total of 185 patients were enrolled in the study (mean [SD] age, 11.3 [2.6] years; 107 [57.8%] female; 144 [77.8%] white; and 38 [20.7%] Hispanic). Youths in the BBT group (n = 95), compared with those in the ARC group (n = 90), had significantly higher rates of clinical improvement (56.8% vs 28.2%; &khgr;21 = 13.09, P < .001; number needed to treat, 4), greater reductions in symptoms (F2,146 = 5.72; P = .004; Cohen f = 0.28), and better functioning (mean [SD], 68.5 [10.7] vs 61.9 [11.9]; t156 = 3.64; P < .001; Cohen d = 0.58). Ethnicity moderated outcomes, with Hispanic youth having substantially stronger response to BBT (76.5%) than ARC (7.1%) (&khgr;21 = 14.90; P < .001; number needed to treat, 2). Effects were robust across sites. Conclusions and Relevance A pediatric-based brief behavioral intervention for anxiety and depression is associated with benefits superior to those of assisted referral to outpatient mental health care. Effects were especially strong for Hispanic participants, suggesting that the protocol may be a useful tool in addressing ethnic disparities in care. Trial Registration clinicaltrials.gov Identifier: NCT01147614

Preparing and Partnering with Families to Support the Adoption of Children from Foster Care

ABSTRACT This investigation evaluated the effectiveness of a pre-placement education and preparation curriculum (PREP) for prospective foster/adoptive parents in improving attitudes toward children with prenatal substance exposure and their substance-using birth parent and increasing willingness to adopt these children. Participants included 1,836 prospective parents seeking adoption through foster care who received three 3-hour sessions of PREP. Prospective parents completed questionnaires assessing their knowledge about important issues involved in adopting a child from foster care, attitudes, and willingness to adopt children with a variety of characteristics. Changes from pre- to post-intervention were examined. Results indicated significant increases in self-reported knowledge; significantly more positive attitudes toward substance-abusing parents and children with prenatal substance exposure; and significantly increased willingness to adopt children with a variety of potential difficulties, including children with serious behavior problems, attention deficit hyperactivity disorder, and a biological history of mental illness. In sum, findings suggest that prospective adoptive parents who attended the PREP sessions felt better prepared by the end of training with regard to issues related to adoption of high-risk foster children with special needs, particularly those with prenatal substance exposure.

The Interplay of Familial and Individual Risk in Predicting Clinical Improvements in Pediatric Anxiety Disorders

Bioecological models of developmental psychopathology underscore the role of familial experiences of adversity and children’s individual-level characteristics in heightening risk for pediatric anxiety through direct, combined, and interactive effects. To date, much of the existing research dedicated to pediatric anxiety disorders has largely been examined in bioecological models of diathesis-stress using community samples. This study extends our understanding of children’s differential responsiveness to familial adversity by examining the diathesis-stress interaction of cumulative risk and children’s individual-level vulnerabilities (negative affectivity and coping efficacy) within a clinic-referred treatment study for pediatric anxiety disorders. A cumulative risk index assessing exposure to familial adversity (e.g., socioeconomic status [SES], parent psychiatric illness) and self-reported measures of children’s negative affectivity and coping efficacy were each measured at the intake of a randomized controlled clinical trial for the treatment of pediatric anxiety disorders (N = 488; 7–17 years of age). Trajectories of interviewer-rated anxiety symptoms were assessed across 12 weeks of treatment at baseline, 4 weeks, 8 weeks, and 12 weeks. Consistent with models of temperamental risk for mental health problems, negative affectivity predicted higher anxiety symptoms at intake. A significant diathesis-stress interaction between cumulative risk and coping efficacy emerged, as high risk and perceptions of lower coping efficacy attenuated declines in anxiety across 12 weeks. These patterns did not differ across treatment conditions. The results indicate that for youth experiencing high levels of stress, additional treatment efforts targeting familial stressors and coping efficacy may be important in maximizing treatment outcomes.