Kendra L. Read

Cognitive behavioral therapy for youth with social anxiety: differential short and long-term treatment outcomes.

This study examined social anxiety symptoms and/or diagnosis as a predictor of differential short- and long-term cognitive-behavioral treatment (CBT) outcomes. Ninety-one anxiety-disordered youth participated in a randomized clinical trial of CBT. Semi-structured interviews provided dimensional clinical severity ratings (CSRs) for childrens principal anxiety disorder at pretreatment, posttreatment, 1-year and 7.4-year follow-up assessments for youth with versus without pretreatment social anxiety. Thirty-nine youth presented with either principal (n=17), secondary (n=11), or tertiary social phobia diagnoses (n=7) or subclinical social anxiety symptoms (n=4). Hierarchal linear modeling (HLM) indicated that youth made similar gains from pretreatment to posttreatment and 1-year follow-up regardless of their social anxiety symptoms or diagnosis; however, youth with social anxiety symptoms or diagnosis were significantly less improved at 7.4-year follow-up. This pattern was distinct from that of youth with the most severe (CSR=4) principal anxiety disorders at pretreatment. Though initially responsive to CBT, children who present with social anxiety diagnoses or symptoms may require an enhanced or extended treatment to maintain their gains into young adulthood whether or not social anxiety is considered their principal childhood difficulty.

The Intolerance of Uncertainty Scale for Children (IUSC): discriminating principal anxiety diagnoses and severity.

The specific relationship of intolerance of uncertainty (IU) to generalized anxiety disorder (GAD) in youth was examined by evaluating the ability of the Intolerance of Uncertainty Scale for Children (IUSC) to discriminate among principal anxiety disorder diagnoses. Analyses examined parent, child, and composite reports of principal anxiety diagnoses in youth aged 7 to 17 years. Results indicate that higher IU scores are associated with GAD by the composite diagnostic. Additionally, the IUSC significantly predicted child-reported anxiety severity. This relationship was not moderated by diagnostic group. The results indicate that IUSC scores are particularly associated with GAD, as well as with more severe child-reported anxiety symptoms.

The Therapeutic Relationship in Cognitive-Behavioral Therapy and Pharmacotherapy for Anxious Youth

OBJECTIVE We examined the therapeutic relationship with cognitive-behavioral therapists and with pharmacotherapists for youth from the Child/Adolescent Anxiety Multimodal Study (Walkup et al., 2008). The therapeutic relationship was examined in relation to treatment outcomes. METHOD Participants were 488 youth (ages 7-17 years; 50% male) randomized to cognitive-behavioral therapy (CBT; Coping Cat), pharmacotherapy (sertraline), their combination, or placebo pill. Participants met criteria for generalized anxiety disorder, social phobia, and/or separation anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). The therapeutic relationship was assessed by youth report at Weeks 6 and 12 of treatment using the Childs Perception of Therapeutic Relationship scale (Kendall et al., 1997). Outcome measures (Pediatric Anxiety Rating Scale; Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002; and Clinical Global Impressions Scales; Guy, 1976) were completed by independent evaluators blind to condition. RESULTS For youth who received CBT only, a stronger therapeutic relationship predicted positive treatment outcome. In contrast, the therapeutic relationship did not predict outcome for youth receiving sertraline, combined treatment, or placebo. CONCLUSION A therapeutic relationship may be important for anxious youth who receive CBT alone.

Barriers to and Facilitators in the Implementation of Cognitive-Behavioral Therapy for Youth Anxiety in the Community

OBJECTIVE The study examined, from the perspective of therapists, the barriers to and facilitators in implementing cognitive-behavioral therapy (CBT) for anxious youths in community settings. METHODS Fifty therapists (43% of the original training sample of 115 providers) participated in a follow-up interview two years after training and consultation. They reported on barriers to and facilitators in implementation of CBT for youths with anxiety. RESULTS Qualitative analyses identified numerous barriers and facilitators, including client factors (for example, motivated clients facilitated the use of CBT, whereas clients with complex issues and numerous psychosocial stressors hindered its use), intervention factors (the structure of CBT helped facilitate its use for some providers, whereas others reported feeling constrained by such structure), and organizational factors (for example, the absence of support within ones institution served as a barrier, whereas supervision supporting the use of CBT facilitated implementation). CONCLUSIONS Findings of this implementation trial align with conceptual implementation frameworks and may guide the tailoring of future implementation efforts in order to overcome barriers and maximize facilitators.

Contextual factors and anxiety in minority and European American youth presenting for treatment across two urban university clinics

The current study compared ethnic minority and European American clinically-referred anxious youth (N=686; 2-19 years) on internalizing symptoms (i.e., primary anxiety and comorbid depression) and neighborhood context. Data were provided from multiple informants including youth, parents, and teachers. Internalizing symptoms were measured by the Multidimensional Anxiety Scale for Children, Child Depression Inventory, Child Behavior Checklist and Teacher Report Form. Diagnoses were based on the Anxiety Disorders Interview Schedule for Children. Neighborhood context was measured using Census tract data (i.e., owner-occupied housing, education level, poverty level, and median home value). Ethnic minority and European American youth showed differential patterns of diagnosis and severity of anxiety disorders. Further, ethnic minority youth lived in more disadvantaged neighborhoods. Ethnicity and neighborhood context appear to have an additive influence on internalizing symptoms in clinically-referred anxious youth. Implications for evidence-based treatments are discussed.

Sleep-Related Problems and the Effects of Anxiety Treatment in Children and Adolescents.

This study examined (a) demographic and clinical characteristics associated with sleep-related problems (SRPs) among youth with anxiety disorders, and (b) the impact of anxiety treatment: cognitive-behavioral therapy (CBT; Coping Cat), medication (sertraline), their combination, and pill placebo on SRPs. Youth (N = 488, ages 7–17, 50% female, 79% White) with a principal diagnosis of generalized anxiety disorder, separation anxiety disorder, or social phobia participated. SRPs were reported by parents and youth. Findings differed by informant and by type of SRP, with evidence that SRPs are associated with age, anxiety severity, externalizing problems, functional impairment, and family burden at pretreatment. Anxiety treatment reduced SRPs; effect sizes were small to medium. Reductions in parent-reported separation-related sleep difficulties were significantly greater in active treatment than in the placebo condition, with the greatest reductions reported by parents of youth whose active treatment was multimodal or included sertraline. Youth whose anxiety treatment involved CBT reported significantly greater decreases in dysregulated sleep (e.g., sleeplessness). Both CBT for anxiety and sertraline appear to be somewhat effective in reducing SRPs, and multimodal treatment may be preferable depending on the symptom presentation. To inform practice, future research should examine a broad range of SRPs, incorporate objective measures of sleep, and evaluate the impact of behavioral strategies that directly target SRPs in youth with anxiety disorders.

Sustaining clinician penetration, attitudes and knowledge in cognitive-behavioral therapy for youth anxiety

BackgroundQuestions remain regarding the sustainment of evidence-based practices following implementation. The present study examined the sustainment of community clinicians’ implementation (i.e., penetration) of cognitive-behavioral therapy, attitudes toward evidence-based practices, and knowledge of cognitive-behavioral therapy for youth anxiety two years following training and consultation in cognitive-behavioral therapy for youth anxiety.MethodsOf the original 115 participants, 50 individuals (43%) participated in the two-year follow-up. A t- test examined sustainment in penetration over time. Hierarchical linear modeling examined sustainment in knowledge and attitudes over time. Time spent in consultation sessions was examined as a potential moderator of the change in knowledge and attitudes.ResultsFindings indicated sustained self-reported penetration of cognitive-behavioral therapy for anxious youth, with low fidelity to some key CBT components (i.e., exposure tasks). Follow-up knowledge was higher than at baseline but lower than it had been immediately following the consultation phase of the study. Belief in the utility of evidence-based practices was sustained. Willingness to implement an evidence-based practice if required to do so, appeal of evidence-based practices, and openness toward evidence-based practices were not sustained. Participation in consultation positively moderated changes in knowledge and some attitudes.ConclusionsSustainment varied depending on the outcome examined. Generally, greater participation in consultation predicted greater sustainment. Implications for future training include higher dosages of consultation.

Examining adherence to components of cognitive-behavioral therapy for youth anxiety after training and consultation.

The present study examined 115 service providers’ adherence to components of cognitive-behavioral therapy (CBT) for youth anxiety before training, postworkshop training, and after 3 months of weekly consultation. Adherence was measured using a role play with a trained actor. We examined differences in individual adherence to CBT components across time and the relationship between number of consultation sessions attended and adherence ratings after consultation. Findings indicated that somatic arousal identification and relaxation were the most used treatment components before training. Adherence to all components of CBT increased after workshop training, except the usage of problem-solving. Adherence to problem-solving, positive reinforcement, the identification of anxious self-talk, and the creation of coping thoughts increased after consultation but usage of problem-solving remained low compared with other treatment components. Overall adherence remained less than optimal at the final measurement point. The number of consultation sessions attended predicted postconsultation adherence to identification of somatic arousal, identification of anxious self-talk, and positive reinforcement. Implications include tailoring future training based on baseline levels of adherence and spending more time during training and consultation on underutilized CBT components, such as problem-solving. Limitations of the present study, including how adherence was measured, are discussed. This study adds to the implementation science literature by providing more nuanced information on changes in adherence over the course of training and consultation of service providers.

Continuing to Advance Empirically Supported Treatments: Factors in Empirically Supported Practice for Anxiety Disorders

Empirically supported treatments, including cognitive-behavioral therapy, for anxiety disorders have been widely studied for both children and adults. This chapter discusses evidence in support of CBT for each anxiety disorder. The impact of comorbidity, family and cultural factors, and therapeutic variables on CBT effects is highlighted. Finally, future directions for the study of empirically supported treatments are provided.