Brian C. Chu

Cognitive-Behavioral Therapy versus Usual Clinical Care for Youth Depression: An Initial Test of Transportability to Community Clinics and Clinicians

Community clinic therapists were randomized to (a) brief training and supervision in cognitive-behavioral therapy (CBT) for youth depression or (b) usual care (UC). The therapists treated 57 youths (56% girls), ages 8-15, of whom 33% were Caucasian, 26% were African American, and 26% were Latino/Latina. Most youths were from low-income families and all had Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) depressive disorders (plus multiple comorbidities). All youths were randomized to CBT or UC and treated until normal termination. Session coding showed more use of CBT by CBT therapists and more psychodynamic and family approaches by UC therapists. At posttreatment, depression symptom measures were at subclinical levels, and 75% of youths had no remaining depressive disorder, but CBT and UC groups did not differ on these outcomes. However, compared with UC, CBT was (a) briefer (24 vs. 39 weeks), (b) superior in parent-rated therapeutic alliance, (c) less likely to require additional services (including all psychotropics combined and depression medication in particular), and (d) less costly. The findings showed advantages for CBT in parent engagement, reduced use of medication and other services, overall cost, and possibly speed of improvement--a hypothesis that warrants testing in future research.

Does Cognitive Behavioral Therapy for Youth Anxiety Outperform Usual Care in Community Clinics? An Initial Effectiveness Test.

OBJECTIVE Most tests of cognitive behavioral therapy (CBT) for youth anxiety disorders have shown beneficial effects, but these have been efficacy trials with recruited youths treated by researcher-employed therapists. One previous (nonrandomized) trial in community clinics found that CBT did not outperform usual care (UC). The present study used a more stringent effectiveness design to test CBT versus UC in youths referred to community clinics, with all treatment provided by therapists employed in the clinics. METHOD A randomized controlled trial methodology was used. Therapists were randomized to training and supervision in the Coping Cat CBT program or UC. Forty-eight youths (56% girls, 8 to 15 years of age, 38% Caucasian, 33% Latino, 15% African-American) diagnosed with DSM-IV anxiety disorders were randomized to CBT or UC. RESULTS At the end of treatment more than half the youths no longer met criteria for their primary anxiety disorder, but the groups did not differ significantly on symptom (e.g., parent report, eta-square = 0.0001; child report, eta-square = 0.09; both differences favoring UC) or diagnostic (CBT, 66.7% without primary diagnosis; UC, 73.7%; odds ratio 0.71) outcomes. No differences were found with regard to outcomes of comorbid conditions, treatment duration, or costs. However, youths receiving CBT used fewer additional services than UC youths (χ(2)(1) = 8.82, p = .006). CONCLUSIONS CBT did not produce better clinical outcomes than usual community clinic care. This initial test involved a relatively modest sample size; more research is needed to clarify whether there are conditions under which CBT can produce better clinical outcomes than usual clinical care. CLINICAL TRIAL REGISTRY INFORMATION: Community Clinic Test of Youth Anxiety and Depression Study, URL: http://clinicaltrials.gov, unique identifier: NCT01005836.

Retrospective self-reports of therapist flexibility in a manual-based treatment for youths with anxiety disorders.

Evaluated retrospective therapist ratings of the flexibility used when applying the procedures and strategies prescribed in the treatment manual. Flexibility ratings were collected from 18 therapists who had treated 148 children with anxiety disorders (ages 9 through 13). Analyses revealed strong reliabilities for a flexibility questionnaire and that flexibility was used by therapists; however, significant relations between therapist-rated flexibility and treatment outcome were not found. Discussion focuses on the role of flexibility in manual-based psychological treatments and future directions for study.

What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice

Across 5 decades, hundreds of randomized trials have tested psychological therapies for youth internalizing (anxiety, depression) and externalizing (misconduct, attention deficit and hyperactivity disorder) disorders and problems. Since the last broad-based youth meta-analysis in 1995, the number of trials has almost tripled and data-analytic methods have been refined. We applied these methods to the expanded study pool (447 studies; 30,431 youths), synthesizing 50 years of findings and identifying implications for research and practice. We assessed overall effect size (ES) and moderator effects using multilevel modeling to address ES dependency that is common, but typically not modeled, in meta-analyses. Mean posttreatment ES was 0.46; the probability that a youth in the treatment condition would fare better than a youth in the control condition was 63%. Effects varied according to multiple moderators, including the problem targeted in treatment: Mean ES at posttreatment was strongest for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiproblem treatment (0.15). ESs differed across control conditions, with “usual care” emerging as a potent comparison condition, and across informants, highlighting the need to obtain and integrate multiple perspectives on outcome. Effects of therapy type varied by informant; only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports. Effects did not differ for Caucasian versus minority samples, but more diverse samples are needed. The findings underscore the benefits of psychological treatments as well as the need for improved therapies and more representative, informative, and rigorous intervention science.

Therapist responsiveness to child engagement: flexibility within manual-based CBT for anxious youth.

Therapy process research helps delineate common and specific elements essential to positive outcomes as well as develop best practice training protocols. Child involvement and therapist flexibility were rated in 63 anxious youth (ages 8-14) who received cognitive-behavioral therapy. Therapist flexibility, defined as therapist attempts to adapt treatment to a childs needs, was hypothesized to act as an engagement strategy that serves to increase child involvement during therapy. Flexibility was significantly related to increases in later child engagement, which subsequently predicted improvement in posttreatment diagnosis and impairment. Therapist flexibility was not associated with earlier measures of child engagement, so a mediation model could not be supported. It was also hypothesized that the impact of flexibility would be greatest for cases who began treatment highly disengaged (i.e., early involvement would moderate the effect of flexibility). Basic descriptive data supported this model, but formal analyses failed to confirm. Further descriptive analyses suggest therapists employ a range of adaptations and a profile of flexible applications within a manual-based treatment is provided. Treatment, measurement, and dissemination issues are discussed.

Trajectory and Predictors of Alliance in Cognitive Behavioral Therapy for Youth Anxiety

Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7–17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel “alliance rupture” model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.

Attention Mechanisms in Children with Anxiety Disorders and in Children with Attention Deficit Hyperactivity Disorder: Implications for Research and Practice.

Inattention is among the most commonly referred problems for school-aged youth. Research suggests distinct mechanisms may contribute to attention problems in youth with anxiety disorders versus youth with attention deficit hyperactivity disorder (ADHD). This study compared children (8–17 years) with anxiety disorders (n = 24) and children (8–16 years) with ADHD (n = 23) on neurocognitive tests of both general and emotion-based attention processes. As hypothesized, children with ADHD demonstrated poorer selective and sustained attention, whereas youth with anxiety disorders demonstrated greater attentional bias toward threatening faces on a visual probe task. Findings suggest the neuropsychological differentiation of attention problems in anxious and ADHD children, despite potentially similar phenotypes.

Cross-ethnic measurement invariance of the SCARED and CES-D in a youth sample.

This study evaluated the cross-ethnic measurement invariance of 2 common screening measures of anxiety and depressive symptoms in youth. The measurement invariance of the Screen for Childhood Anxiety and Related Emotional Disorders (SCARED) and the Center for Epidemiologic Studies Depression Scale (CES-D) was tested across 881 African American (Black; n = 396), Hispanic (n = 185), non-Hispanic White (White; n = 166), and Asian/Indian (n = 134) youth in the 7th grade. The measures were administered as part of a grade-wide screening to identify youth with elevated anxiety and depressive symptoms. The 5-factor model of the SCARED and the 4-factor model of the CES-D best represented the data for all ethnic groups. Results provided support for strong invariance of the SCARED across all 4 ethnic groups. Results provided support for strong invariance of the CES-D across Black, White, and Asian/Indian youth, and partial strong invariance for Hispanic youth. Overall, results suggest that factor means and total scores can be compared across groups. Factor mean differences across groups were identified for both measures. In particular, Hispanic youth reported greater levels of anxiety and depression in certain domains than White, Black, and Asian youth. Our findings support the use of the SCARED and CES-D as tools for measuring anxiety and depressive symptoms in ethnically diverse youth in the United States. Results are discussed with respect to the importance of establishing measurement invariance for screening measures of anxiety and depressive symptoms prior to comparing symptom levels across ethnic groups.

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

BACKGROUND Studies exploring the association between alliance and outcome in youth cognitive-behavioral therapy (CBT) have yielded inconsistent results based upon whose perspective is measured. OBJECTIVE 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. METHOD 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. RESULTS 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. CONCLUSIONS 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.

The Relationship Between Alliance and Client Involvement in CBT for Child Anxiety Disorders

Little is known about the nature of the relationship between the alliance and client involvement in child psychotherapy. To address this gap, we examined the relationship between these therapy processes over the course of cognitive-behavioral therapy (CBT) for child anxiety disorders. The sample was 31 child participants (M age = 9.58 years, SD = 2.17, range = 6–13 years, 67.7% boys; 67.7% Caucasian, 6.5% Latino, 3.2% Asian/Pacific Islander, and 22.6% mixed/other) diagnosed with a primary anxiety disorder. The participants received a manual-based individual CBT program for child anxiety or a manual-based family CBT program for child anxiety. Ratings of alliance and client involvement were collected on early (Session 2) and late (Session 8) treatment phases. Two independent coding teams rated alliance and client involvement. Change in alliance positively predicted late client involvement after controlling for initial levels of client involvement. In addition, change in client involvement positively predicted late alliance after controlling for initial levels of the alliance. The findings were robust after controlling for potentially confounding variables. In CBT for child anxiety disorders, change in the alliance appears to predict client involvement; however, client involvement also appears to predict the quality of the alliance. Our findings suggest that the nature of the relationship between alliance and client involvement may be more complex than previously hypothesized. In clinical practice, tracking alliance and level of client involvement could help optimize the impact and delivery of CBT for child anxiety.