Jill T. Ehrenreich

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

This article reviews the development and initial trial of a treatment for adolescents that targets negative emotionality and associated psychological difficulties—particularly anxiety and depressive disorders—as a more singular entity by utilizing an approach rooted in both emotion science and theory. The rationale for such an approach is based upon the perceived need for novel treatment approaches that target commonalities in emotional disorder symptom presentation and their intervention. Utilizing the Unified Protocol for the Treatment of Emotional Disorders originally developed for adults (Barlow, Allen, & Choate, 2004), we conducted a multiple-baseline design study of a slightly modified version of this protocol with three adolescents presenting an array of anxiety and depression symptoms. Adolescent participants in this preliminary investigation evidenced symptom reductions across disorders at posttreatment, with greater improvements noted at a 6-month follow-up. Based on these findings and research regarding the association between emotion science and developmental psychopathology, we detail a more extensive set of modifications to the protocol, undertaken in preparation for a subsequent open-trial investigation of the revised treatment.

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.

The metacognitions questionnaire for children: Development and validation in a clinical sample of children and adolescents with anxiety disorders

A self-report measure of metacognition for both children and adolescents (ages 7-17) (Metacognitions Questionnaire for Children; MCQ-C) was adapted from a previous measure, the MCQ-A (Metacognitions Questionnaire for Adolescents) and was administered to a sample of 78 children and adolescents with clinical anxiety disorders and 20 non-clinical youth. The metacognitive processes included were (1) positive beliefs about worry (positive meta-worry); (2) negative beliefs about worry (negative meta-worry); (3) superstitious, punishment and responsibility beliefs (SPR beliefs) and (4) cognitive monitoring (awareness of ones own thoughts). The MCQ-C demonstrated good internal-consistency reliability, as well as concurrent and criterion validity, and four valid factors. In line with predictions, negative meta-worry was significantly associated with self-reports of internalizing symptoms (excessive worry and depression). Age-based differences on the MCQ-C were found for only one subscale, with adolescents reporting greater awareness of their thoughts than children. Adolescent girls scored higher on the total index of metacognitive processes than adolescent boys. Overall, these results provide preliminary support for the use of the MCQ-C with a broader age range as well as an association between metacognitive processes and anxiety symptomatology in both children and adolescents, with implications for cognitive behavioral interventions with anxious youth.

An Exploratory Study of the Psychological Impact and Clinical Care of Perinatal Loss

Perinatal loss is a unique and potentially traumatizing experience that can leave bereaved parents struggling with a host of mental health difficulties. In this exploratory study of the predictors and mental health outcomes associated with perinatal loss, we examined a cohort of women who experienced a perinatal loss within the previous 5 years. Results suggest perinatal loss is associated with considerable distress and impairment for some women, with greater severity primarily predicted by maladaptive coping skills, low social support, and intense emotionality following the loss. The majority of women in this sample were satisfied with the care they received in the hospital after their loss, including their engagement in reportedly contentious bereavement rituals in the medical setting. Limitations of this research are noted, and suggestions for future research and clinical care are provided.

Identification of high-risk behaviors among victimized adolescents and implications for empirically supported psychosocial treatment

An adolescents possible response to being the victim of interpersonal violence is not limited to posttraumatic stress disorder and depression but may also involve a host of developmental effects, including the occurrence of high-risk behaviors that may have a significant and negative impact on the adolescents psychological and physical health. Identifying such high-risk behaviors, understanding their possible link to a previous victimization incident, and implementing interventions that have been demonstrated to reduce such behaviors may help decrease potential reciprocal interactions between these areas. Clinicians in psychiatric practice may be in a unique position to make these connections, since parents of adolescents may perceive a greater need for mental health services for youth engaging in problematic externalizing behaviors than for those displaying internalizing symptoms. In this article, the authors first describe high-risk behaviors, including substance use, delinquent behavior, risky sexual behaviors, and self-injurious behaviors, that have been linked with experiencing interpersonal violence. They then review empirically based treatments that have been indicated to treat these deleterious behaviors in order to help clinicians select appropriate psychosocial interventions for this population. Recommendations for future research on the treatment of high-risk behaviors in adolescents are also presented.

Assessment and Behavioral Treatment of Selective Mutism

Children with selective mutism present with a complicated set of symptoms, as they not only refuse to speak in particular social situations but are often shy, socially isolative, anxious, and may present as oppositional and negativistic in their behavior. Limited research on treatments for selective mutism suggests a need for additional research examining intervention possibilities. The following case description presents a 10-year-old male with selective mutism and concurrent anxiety symptoms. Treatment included the use of a significantly modified version of Social Effectiveness Therapy for Children (SET-C), a manualized behavioral treatment for social anxiety. In addition to SET-C, treatment also included concurrent parent training in the management of child anxiety. The rationale for the treatment selection and a description of treatment course are provided. Further, a discussion is presented concerning challenges to treatment progress, including cultural differences between the primary clinician and the client.

Integrating Acceptance and Mindfulness into Treatments for Child and Adolescent Anxiety Disorders

In cognitive-behavioral therapy (CBT) for child and adolescent anxiety disorders, negatively evaluated thoughts and emotions are viewed as problematic responses to be managed via control-oriented strategies such as distraction, systematic desensitization, self-instruction, or cognitive restructuring. Within this framework, anxiety is conceptualized as “the problem,” and symptom reduction is a standard index of treatment success. Acceptance- and mindfulness-based therapies such as acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) differ from standard CBT primarily in their treatment of private events (e.g., thoughts, emotions, physical-bodily sensations, memories).

Validity and Specificity of the Children’s Automatic Thoughts Scale in Clinically Anxious and Non-clinical Children

The present study is a preliminary examination of the internal, criterion, and convergent validity of the Children’s Automatic Thoughts Scale (CATS; Schniering and Rapee 2002), a developmentally sensitive measure of cognitions associated with childhood internalizing and externalizing disorders, among clinically anxious and non-clinical children. Participants included 40 children (ages 7–14) with a clinical anxiety disorder and 40 non-clinical children with no prior anxiety disorder diagnosis. Results supported the internal consistency and criterion validity of the measure. In addition, controlling for age, sex, and clinical status, convergent validity was largely supported, with the Physical Threat subscale correlating with self-report of generalized anxiety and separation anxiety, and the Social Threat and Personal Failure subscales correlating with self-report of social anxiety and major depression. Limitations and suggestions for further research on the utility of the CATS are discussed.

Assessment of relevant parenting factors in families of clinically anxious children: the Family Assessment Clinician-rated Interview (FACI).

Objective Research on child and adolescent anxiety disorders has seen a surge in investigations of parenting factors potentially associated with their etiology. However, many of the well-established parenting measures are limited by over-reliance on self-report or lengthy behavioral observation procedures. Such measures may not assess factors most salient to anxiety etiology, since most family functioning measures were not originally developed for this purpose. The Family Assessment Clinician Interview (FACI) was developed as a clinician-administered interview of parent and family factors associated with child and adolescent anxiety. The present study is the first to investigate the psychometric properties of the FACI. Method Using a clinical sample of 65 children with various anxiety disorders, and their parents, inter-rater reliability, convergent validity and associations with child-reported and clinician-evaluated anxiety severity were examined. Results suggest that the FACI has good to excellent inter-rater reliability with kappas ranging from 0.79 to 1.0 across FACI scales and subscales. Some evidence of convergent validity with relevant portions of the Family Environment Scale was observed, although the latter findings varied by respondent (mother versus father). The Family Warmth/Closeness subscale of the FACI was consistently associated with increased child anxiety symptoms. Contrary to expectations, higher levels of parental expectations were associated with lower levels of child anxiety. Conclusion Results suggest that the FACI is a promising measure of family anxiety constructs that may be useful in both research and clinical settings.

Identifying efficacious treatment components of panic control treatment for adolescents: A preliminary examination

ABSTRACT Panic Control Treatment for Adolescents (PCT-A) is a developmentally sensitive and efficacious treatment for adolescents with panic disorder. The present study is a preliminary examination of the relative efficacy of individual treatment components in PCT-A in a sample of treatment completers; the study identified when rapid improvements in panic symptoms occurred over the course of treatment and which treatment components preceded these gains. Twenty-one adolescents (ages 13–17) completed weekly measures of panic-relevant symptoms, which were examined for between-session gains. Results indicate that psychoeducation may precede notable decreases in panic attacks while cognitive restructuring may contribute to rapid declines in overall anxiety and cognitive errors. The authors discuss the importance of future controlled dismantling studies to examine the relative contribution of PCT-A treatment components.