J.M. Liber

Examining the relation between the therapeutic alliance, treatment adherence, and outcome of cognitive behavioral therapy for children with anxiety disorders.

Little is known about the contribution of technical and relational factors to child outcomes in cognitive behavioral therapy (CBT) for children with anxiety disorders. This study investigated the association between treatment adherence, the child-therapist alliance, and child clinical outcomes in manual-guided individual- and group-based CBT for youths diagnosed with anxiety disorders. Trained observers rated tapes of therapy sessions for treatment adherence and child-therapist alliance in a sample of 52 children (aged 8 to 12) with anxiety disorders. Self-reported child anxiety was assessed at pre-, mid-, and posttreatment; parent-reported child internalizing symptoms was assessed at pre- and posttreatment. The results showed high levels of treatment adherence and child-therapist alliance in both CBT programs. Neither treatment adherence nor child-therapist alliance predicted traditional measurements of child outcomes in the present study, but a relation between alliance and outcome was found using a more precise estimation of the true pre-post differences. Implications of these findings for expanding our understanding of how treatment processes relate to child outcome in CBT for children with anxiety disorders are discussed.

No differences between group versus individual treatment of childhood anxiety disorders in a randomised clinical trial

BACKGROUND The present study compares an individual versus a group format in the delivery of manualised cognitive-behavioural therapy (FRIENDS) for children with anxiety disorders. Clinically referred children (aged 8 to 12) diagnosed with Separation Anxiety Disorder (n = 52), Generalised Anxiety Disorder (n = 37), Social Phobia (n = 22) or Specific Phobia (n = 16) were randomly assigned to individual (n = 65) or group (n = 62) treatment. METHOD Analyses were conducted separately for the intent-to-treat sample and the sample of children who completed treatment. Analyses included chi-square comparisons and regression analyses with treatment format as a predictor. RESULTS Forty-eight percent of the children in the individual versus 41% in the group treatment were free of any anxiety disorder at post-treatment; 62% versus 54% were free of their primary anxiety disorder. Regression analyses showed no significant difference in outcome between individual and group treatment. CONCLUSIONS Children improved in both conditions. Choice between treatments could be based on pragmatic considerations such as therapeutic resources, referral rates, and the preference of the parents and the child.

Types of parental involvement in CBT with anxious youth: A preliminary meta-analysis

OBJECTIVE Meta-analytic studies have not confirmed that involving parents in cognitive behavior therapy (CBT) for anxious children is therapeutically beneficial. There is also great heterogeneity in the type of parental involvement included. We investigated parental involvement focused on contingency management (CM) and transfer of control (TC) as a potential outcome moderator using a meta-analysis with individual patient data. METHOD Investigators of randomized controlled trials (RCTs) of CBT for anxious children, identified systematically, were invited to submit their data. Conditions in each RCT were coded based on type of parental involvement in CBT (i.e., low involvement, active involvement without emphasis on CM or TC, active involvement with emphasis on CM or TC). Treatment outcomes were compared using a 1-stage meta-analysis. RESULTS All cases involved in active treatment (894 of 1,618) were included for subgroup analyses. Across all CBT groups, means of clinical severity, anxiety, and internalizing symptoms significantly decreased posttreatment and were comparable across groups. The group without emphasis on CM or TC showed a higher proportion with posttreatment anxiety diagnoses than the low-involvement group. Between posttreatment and 1-year follow-up, the proportion with anxiety diagnoses significantly decreased in CBT with active parental involvement with emphasis on CM or TC, whereas treatment gains were merely maintained in the other 2 groups. CONCLUSIONS CBT for anxious children is an effective treatment with or without active parental involvement. However, CBT with active parental involvement emphasizing CM or TC may support long-term maintenance of treatment gains. RESULTS should be replicated as additional RCTs are published.

Parenting and parental anxiety and depression as predictors of treatment outcome for childhood anxiety disorders: has the role of fathers been underestimated?

A substantial percentage of children with anxiety disorders do not respond adequately to Cognitive Behavioral Therapy (CBT). Examination of parental factors related to treatment outcome could contribute to a further understanding of treatment outcome responses. This study investigated the predictive value of paternal and maternal emotional warmth, rejection, overprotection, anxiety, and depression for CBT outcome in clinic-referred anxious children (ages 8–12). Levels of maternal emotional warmth, paternal rejection and anxiety, and depressive symptoms predicted treatment success and failure. A higher level of maternal emotional warmth was associated with a less favorable treatment outcome. Higher levels of paternal rejection, anxiety, and depressive symptoms were consistently associated with a less favorable treatment outcome.

Cognitive Behavioral Therapy Age Effects in Child and Adolescent Anxiety: An Individual Patient Data Metaanalysis

Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap.

The Relation of Severity and Comorbidity to Treatment Outcome with Cognitive Behavioral Therapy for Childhood Anxiety Disorders

The present study investigated the impact of comorbidity over and above the impact of symptom severity on treatment outcome of Cognitive Behavioral Therapy for children with anxiety disorders. Children (aged 8–12, n = 124) diagnosed with an anxiety disorder were treated with a short-term CBT protocol. Severity was assessed with a composite measure of parent-reported behavior problems. Two approaches to comorbidity were examined; “total comorbidity” which differentiated anxiety disordered children with (n = 69) or without (n = 55) a co-occurring disorder and “non-anxiety comorbidity’ which differentiated anxious children with (n = 22) or without a non-anxiety comorbid disorder (n = 102). Treatment outcome was assessed in terms of Recovery, represented by post-treatment diagnostic status, and Reliable Change, a score reflecting changes in pre- to post-treatment symptom levels. Severity contributed to the prediction of (no) Recovery and (more) Reliable Change in parent-reported internalizing and externalizing symptoms and self-reported depressive symptoms. Total and non-anxiety comorbidity added to the prediction of diagnostic recovery. Non-anxiety comorbidity added to the prediction of Reliable Change in parent reported measures by acting as a suppressor variable. Non-anxiety comorbidity operated as a strong predictor that explained all of the variance associated with severity for self-reported depressive symptoms. The results support the need for further research on mechanisms by which treatment gains in children with higher symptom severity and non-anxiety comorbidity can be achieved.

Maternal anxiety predicts favourable treatment outcomes in anxiety-disordered adolescents

Objective:  To determine the differential impact of maternal and paternal internalizing psychopathology on cognitive‐behavioural treatment (CBT) outcome of anxiety‐disordered children and adolescents.

Stepped Care Cognitive Behavioural Therapy for Children with Anxiety Disorders: A New Treatment Approach

BACKGROUND The current nonrandomized clinical trial explored changes over time in children with an anxiety disorder during stepped care, manual-based cognitive behaviour therapy (CBT). METHODS Clinically anxious children (8-12 years, n = 133) and their parents participated in child focused CBT (10 sessions). If assessments indicated additional treatment was necessary, participants could step up to a second and possibly third treatment phase (each 5 sessions) including more parental involvement. RESULTS After the first treatment phase 45% of the Intention-To-Treat sample was free of any anxiety disorder; after the second and third phase an additional 17% and 11% respectively. In total, 74% of the children no longer met criteria for any anxiety disorder following treatment. Child and parent reported anxiety and depression symptoms of children improved significantly during all treatment phases, as well as child reported anxiety sensitivity and negative affect. Children participating in more treatment showed significant improvements during additional treatment phases, indicating that late change occurred for the subgroup that had not changed during the first phase. CONCLUSIONS Stepped care offers a standardized, assessment based, yet tailored treatment approach for children with anxiety disorders. A more intensive treatment is offered when initial CBT is insufficient, providing children additional opportunities to reach the desired outcome.

School-based intervention for childhood disruptive behavior in disadvantaged settings: A randomized controlled trial with and without active teacher support

OBJECTIVE In this randomized controlled trial, we investigated the effectiveness of a school-based targeted intervention program for disruptive behavior. A child-focused cognitive behavioral therapy (CBT) program was introduced at schools in disadvantaged settings and with active teacher support (ATS) versus educational teacher support (ETS) (CBT + ATS vs. CBT + ETS). METHOD Screening (n = 1,929) and assessment (n = 224) led to the inclusion of 173 children ages 8-12 years from 17 elementary schools. Most of the children were boys (n = 136, 79%) of low or low-to-middle class socioeconomic status (87%); the sample was ethnically diverse (63% of non-Western origin). Children received CBT + ATS (n = 29) or CBT + ETS (n = 41) or were entered into a waitlist control condition (n = 103) to be treated afterward (CBT + ATS, n = 39, and CBT + ETS, n = 64). Effect sizes (ES), clinical significance (reliable change), and the results of multilevel modeling are reported. RESULTS Ninety-seven percent of children completed treatment. Teachers and parents reported positive posttreatment effects (mean ES = .31) for CBT compared with the waitlist control condition on disruptive behavior. Multilevel modeling showed similar results. Clinical significance was modest. Changes had remained stable or had increased at 3-months follow-up (mean ES = .39). No consistent effect of teacher condition was found at posttreatment; however, at follow-up, children who received ETS fared significantly better. CONCLUSIONS This study shows that a school-based CBT program is beneficial for difficult-to-reach children with disruptive behavior: The completion rate was remarkably high, ESs (mean ES = .31) matched those of previous studies with targeted intervention, and effects were maintained or had increased at follow-up.

Therapeutische alliantie: de tpocs-anl

De therapeutische alliantie bij kinderpsychotherapie is een belangrijke, niet-specifieke empirisch ondersteunde factor die consistent bijdraagt aan de therapie-uitkomst. Het doel van dit onderzoek is de psychometrische eigenschappen van de Nederlandse versie van de ‘Therapy Process Observational Coding System-Alliance Scale’ (tpocs-a) te bepalen. De psychometrische eigenschappen van de tpocs-anl zijn onderzocht bij 31 jeugdigen en 50 ouders van jeugdigen met angststoornissen die behandeld zijn door middel van cognitieve gedragstherapie. De intraclass correlatiecoefficienten en Cronbachs alfa laten zien dat de tpocs-anl een betrouwbaar instrument is om de therapeutische alliantie bij kinderpsychotherapie mee in kaart te brengen.SamenvattingDe therapeutische alliantie bij kinderpsychotherapie is een belangrijke, niet-specifieke empirisch ondersteunde factor die consistent bijdraagt aan de therapie-uitkomst. Het doel van dit onderzoek is de psychometrische eigenschappen van de Nederlandse versie van de ‘Therapy Process Observational Coding System-Alliance Scale’ (tpocs-a) te bepalen. De psychometrische eigenschappen van de tpocs-anl zijn onderzocht bij 31 jeugdigen en 50 ouders van jeugdigen met angststoornissen die behandeld zijn door middel van cognitieve gedragstherapie. De intraclass correlatiecoëfficiënten en Cronbachs alfa laten zien dat de tpocs-anl een betrouwbaar instrument is om de therapeutische alliantie bij kinderpsychotherapie mee in kaart te brengen.