Maaike Nauta

A parent-report measure of children's anxiety: psychometric properties and comparison with child-report in a clinic and normal sample

This study examined the psychometric properties of the parent version of the Spence Childrens Anxiety Scale (SCAS-P); 484 parents of anxiety disordered children and 261 parents in a normal control group participated in the study. Results of confirmatory factor analysis provided support for six intercorrelated factors, that corresponded with the child self-report as well as with the classification of anxiety disorders by DSM-IV (namely separation anxiety, generalized anxiety, social phobia, panic/agoraphobia, obsessive-compulsive disorder, and fear of physical injuries). A post-hoc model in which generalized anxiety functioned as the higher order factor for the other five factors described the data equally well. The reliability of the subscales was satisfactory to excellent. Evidence was found for both convergent and divergent validity: the measure correlated well with the parent report for internalizing symptoms, and lower with externalizing symptoms. Parent-child agreement ranged from 0.41 to 0.66 in the anxiety-disordered group, and from 0.23 to 0.60 in the control group. The measure differentiated significantly between anxiety-disordered children versus controls, and also between the different anxiety disorders except GAD. The SCAS-P is recommended as a screening instrument for normal children and as a diagnostic instrument in clinical settings.

Breathing life into a manual: Flexibility and creativity with manual-based treatments

Manuals (a) provide an overall framework that outlines treatment and session goals, (b) supply strategies that aid the therapist in achieving the goals, and (c) guide the therapist as he or she navigates each challenge that arises over the course of treatment. Following a brief description of our model of treatment, treatment strategies are described and illustrated. Specifically, the discussion and illustrations focus on somatic cues, relaxation, self-talk, the FEAR plan, exposure tasks, and the closing video (commercial). The examples demonstrate how to individualize treatment, and the discussion includes the perspectives of two visiting scholars and considers the merits of flexible and creative use of manual-based treatments. This article addresses the use of a manual as a guide for the treatment of children, particularly children with anxiety disorders.

Child versus family cognitive-behavioral therapy in clinically anxious youth: An efficacy and partial effectiveness study

OBJECTIVE The efficacy and partial effectiveness of child-focused versus family-focused cognitive-behavioral therapy (CBT) for clinically anxious youths was evaluated, in particular in relation to parental anxiety disorders and childs age. METHOD Clinically referred children with anxiety disorders (N = 128) and their parents were randomly assigned to child or family CBT and evaluated at pretreatment, posttreatment, and 3-month follow-up. Twenty-five families were measured before and after a 2- to 3-month waitlist period. RESULTS None of the waitlisted children recovered from their anxiety disorders. In contrast, 41% of the treated children no longer met criteria for any anxiety disorder after CBT, and 52% demonstrated continued improvement at the 3-month follow-up. Significantly more children were free of anxiety disorders (53%) in the child CBT condition compared with family CBT condition (28%) at posttreatment, whereas at 3-month follow-up, the superior effect of child CBT was no longer significant. Similar results were obtained from the questionnaire measures. Both child and family CBT were less effective if parents had an anxiety disorder themselves. On some of the measures, child CBT was superior if parents had anxiety disorders themselves, whereas family CBT was superior if parents had no anxiety disorders. Finally, younger children had better outcomes than older children, regardless of the treatment condition. CONCLUSIONS Overall, child CBT seems slightly more beneficial than family CBT. Because this study was conducted in a clinical setting with clinically referred children, results indicate partial effectiveness for child CBT.

Effectiveness of an emotion regulation group training for adolescents: a randomized controlled pilot study

Emotion Regulation Training (ERT) was developed for adolescents with symptoms of borderline personality disorder (BPD) and emotion dysregulation. ERT is an adaptation of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) programme. This paper describes the background of the programme, and gives an outline of the treatment programme. The effectiveness of ERT was examined in a randomized controlled pilot study with 43 youth (aged 14-19 years) in five mental health centres in the Netherlands. Subjects were assessed before and after random assignment to ERT plus treatment as usual (TAU) (n = 23) or to TAU alone (n = 20). Outcome measures included assessment of BPD symptoms, locus of control, and internalizing and externalizing behaviour. Both groups showed equal reductions in BPD symptoms over time. The group receiving ERT plus TAU (and not the TAU-only group) had a significant increase in internal locus of control: ERT participants reported more sense of control over their own mood swings, and attributed changes in mood swings not only to external factors. The study was complicated by a high attrition. The implications of the findings are discussed, including the difficulties inherent in treating and researching an adolescent population, and the need for researchers to develop age-appropriate assessments.

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.

Behavioral Parent Training as an Adjunct to Routine Care in Children with Attention-Deficit/Hyperactivity Disorder: Moderators of Treatment Response

OBJECTIVE To investigate predictors and moderators of outcome of behavioral parent training (BPT) as adjunct to ongoing routine clinical care (RCC), versus RCC alone. METHODS We randomly assigned 94 referred children (4-12 years) with attention-deficit/hyperactivity disorder (ADHD) to BPT plus RCC or RCC alone. Outcome was based on parent-reported behavioral problems and ADHD symptoms. Predictor/moderator variables included childrens IQ, age, and comorbidity profile, and maternal ADHD, depression, and parenting self-efficacy. RESULTS Superior BPT treatment effects on behavioral problems and ADHD symptoms were present in children with no or single-type comorbidity-anxiety/depression or oppositional defiant disorder (ODD)/conduct disorder (CD)-and when mothers had high parenting self-efficacy, but absent in children with broad comorbidity (anxiety/depression and ODD/CD) and when mothers had low parenting self-efficacy. In older children ADHD symptoms tended to decrease more through BPT than in younger children. CONCLUSIONS Adjunctive BPT is most useful when mothers have high parenting self-efficacy and in children with no or single-type comorbidity.

Clinical Predictors of Response to Cognitive-Behavioral Therapy in Pediatric Anxiety Disorders: The Genes for Treatment (GxT) Study

Objective The Genes for Treatment study is an international, multisite collaboration exploring the role of genetic, demographic, and clinical predictors in response to cognitive-behavioral therapy (CBT) in pediatric anxiety disorders. The current article, the first from the study, examined demographic and clinical predictors of response to CBT. We hypothesized that the child’s gender, type of anxiety disorder, initial severity and comorbidity, and parents’ psychopathology would significantly predict outcome. Method A sample of 1,519 children 5 to 18 years of age with a primary anxiety diagnosis received CBT across 11 sites. Outcome was defined as response (change in diagnostic severity) and remission (absence of the primary diagnosis) at each time point (posttreatment, 3-, 6-, and/or 12-month follow-up) and analyzed using linear and logistic mixed models. Separate analyses were conducted using data from posttreatment and follow-up assessments to explore the relative importance of predictors at these time points. Results Individuals with social anxiety disorder (SoAD) had significantly poorer outcomes (poorer response and lower rates of remission) than those with generalized anxiety disorder (GAD). Although individuals with specific phobia (SP) also had poorer outcomes than those with GAD at posttreatment, these differences were not maintained at follow-up. Both comorbid mood and externalizing disorders significantly predicted poorer outcomes at posttreatment and follow-up, whereas self-reported parental psychopathology had little effect on posttreatment outcomes but significantly predicted response (although not remission) at follow-up. Conclusion SoAD, nonanxiety comorbidity, and parental psychopathology were associated with poorer outcomes after CBT. The results highlight the need for enhanced treatments for children at risk for poorer outcomes.

Cognitive Bias Modification versus CBT in Reducing Adolescent Social Anxiety: A Randomized Controlled Trial

Social anxiety is a common mental disorder among adolescents and is associated with detrimental long term outcomes. Therefore, this study investigated the efficacy of two possible early interventions for adolescent social anxiety and test anxiety. An internet-based cognitive bias modification (CBM; n = 86) was compared to a school-based cognitive behavioral group training (CBT; n = 84) and a control group (n = 70) in reducing symptoms of social and test anxiety in high socially and/or test anxious adolescents aged 13–15 years. Participants (n = 240) were randomized at school level over the three conditions. CBM consisted of a 20-session at home internet-delivered training; CBT was a 10-session at school group training with homework assignments; the control group received no training. Participants were assessed before and after the intervention and at 6 and 12 month follow-up. At 6 month follow-up CBT resulted in lower social anxiety than the control condition, while for CBM, this effect was only trend-significant. At 12 month follow-up this initial benefit was no longer present. Test anxiety decreased more in the CBT condition relative to the control condition in both short and long term. Interestingly, in the long term, participants in the CBM condition improved more with regard to automatic threat-related associations than both other conditions. The results indicate that the interventions resulted in a faster decline of social anxiety symptoms, whereas the eventual end point of social anxiety was not affected. Test anxiety was influenced in the long term by the CBT intervention, and CBM lead to increased positive automatic threat-related associations. Trial Registration TrialRegister.nl NTR965

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.

Implicit and explicit self-esteem and their reciprocal relationship with symptoms of depression and social anxiety: A longitudinal study in adolescents

BACKGROUND AND OBJECTIVES A negative self-view is a prominent factor in most cognitive vulnerability models of depression and anxiety. Recently, there has been increased attention to differentiate between the implicit (automatic) and the explicit (reflective) processing of self-related evaluations. This longitudinal study aimed to test the association between implicit and explicit self-esteem and symptoms of adolescent depression and social anxiety disorder. Two complementary models were tested: the vulnerability model and the scarring effect model. METHOD Participants were 1641 first and second year pupils of secondary schools in the Netherlands. The Rosenberg Self-Esteem Scale, self-esteem Implicit Association Test and Revised Child Anxiety and Depression Scale were completed to measure explicit self-esteem, implicit self-esteem and symptoms of social anxiety disorder (SAD) and major depressive disorder (MDD), respectively, at baseline and two-year follow-up. RESULTS Explicit self-esteem at baseline was associated with symptoms of MDD and SAD at follow-up. Symptomatology at baseline was not associated with explicit self-esteem at follow-up. Implicit self-esteem was not associated with symptoms of MDD or SAD in either direction. LIMITATIONS We relied on self-report measures of MDD and SAD symptomatology. Also, findings are based on a non-clinical sample. CONCLUSIONS Our findings support the vulnerability model, and not the scarring effect model. The implications of these findings suggest support of an explicit self-esteem intervention to prevent increases in MDD and SAD symptomatology in non-clinical adolescents.