Matthew M. Carper

The effects of cognitive-behavioral therapy for youth anxiety on sleep problems

The present study examined (a) whether sleep related problems (SRPs) improved following cognitive-behavioral therapy (CBT) for youth with anxiety disorders, (b) whether variables that may link anxiety and SRPs (e.g., pre-sleep arousal, family accommodation, sleep hygiene) changed during treatment, and (c) whether such changes predicted SRPs at posttreatment. Youth were diagnosed with anxiety at pretreatment and received weekly CBT that targeted their principal anxiety diagnosis at one of two specialty clinics (N=69 completers, Mage=10.86). Results indicated that parent-reported SRPs improved from pre- to post-treatment and that treatment responders with regard to anxiety yielded greater SRP improvements than nonresponders. Parent report of bedtime resistance and sleep anxiety showed significant improvements. Youth reported lower rates of SRPs compared to their parents and did not demonstrate pre- to post-treatment changes in SRPs. Pre-sleep arousal and family accommodation decreased over treatment but did not predict lower SRPs at posttreatment. Higher accommodation was correlated with greater SRPs. Sleep hygiene evidenced no change and did not mediate links between accommodation and posttreatment SRPs.

A probabilistic and individualized approach for predicting treatment gains: an extension and application to anxiety disordered youth.

The objective of this study was to extend the probability of treatment benefit method by adding treatment condition as a stratifying variable, and illustrate this extension of the methodology using the Child and Adolescent Anxiety Multimodal Study data. The probability of treatment benefit method produces a simple and practical way to predict individualized treatment benefit based on pretreatment patient characteristics. Two pretreatment patient characteristics were selected in the production of the probability of treatment benefit charts: baseline anxiety severity, measured by the Pediatric Anxiety Rating Scale, and treatment condition (cognitive-behavioral therapy, sertraline, their combination, and placebo). We produced two charts as exemplars which provide individualized and probabilistic information for treatment response and outcome to treatments for child anxiety. We discuss the implications of the use of the probability of treatment benefit method, particularly with regard to patient-centered outcomes and individualized decision-making in psychology and psychiatry.

ACCOMMODATION AND TREATMENT OF ANXIOUS YOUTH

Parental accommodation refers to the ways in which a parent modifies their behavior to avoid or reduce the distress their child experiences. Parents of youth with anxiety disorders have been found to accommodate their childs anxiety in a variety of ways that contribute to the maintenance of the disorder. The current study evaluated the relationship between parental accommodation and the outcome of treatment for youth with anxiety.

Pathways to anxiety–depression comorbidity: A longitudinal examination of childhood anxiety disorders

Anxiety disorders are prevalent in youth and associated with later depressive disorders. A recent model posits three distinct anxiety–depression pathways. Pathway 1 represents youth with a diathesis to anxiety that increases risk for depressive disorders; Pathway 2 describes youth with a shared anxiety‐depression diathesis; and Pathway 3 consists of youth with a diathesis for depression who develop anxiety as a consequence of depression impairment. This is the first partial test of this model following cognitive‐behavioral treatment (CBT) for child anxiety.

In Pursuit of Generalization: An Updated Review

Stokes and Osnes (1989) outlined three principles to facilitate the generalization and maintenance of therapeutic gains. Use of functional contingencies, training diversely, and incorporating functional mediators were recommended. Our review, with most illustrations from studies of youth, updates Stokes and Osness original paper with a focus on evidence-based strategies to increase generalization of therapeutic gains across settings, stimuli, and time. Research since 1989 indicates that training for generalization by increasing the frequency of naturally occurring reinforcers for positive behaviors, and altering maladaptive contingencies that inadvertently reinforce problem behaviors, are associated with favorable treatment outcomes. Training diversely by practicing therapy skills across contexts and in response to varying stimuli is also implicated in clinical outcomes for internalizing, externalizing, and neurodevelopmental disorders. Preliminary research recommends the use of internal (e.g., emotion identification) and external (e.g., coping cards) functional mediators to prompt effective coping in session and at home. Strategies for increasing generalization, including the use of technology, are examined and future research directions are identified.

Web-Based Parent-Training for Parents of Youth With Impairment From Anxiety

ABSTRACT Child Anxiety Tales (CAT), an online, web-based cognitive-behavioral parent-training program for parents of youth with anxiety, was developed and evaluated. Parents (N = 73; 59 female; 52.1% Caucasian, 42.5% African American, 4.1% Hispanic) who reported concerns about anxiety in their child (7–14 years; M = 10.1 ± 1.6) were randomly assigned to (a) parent-training provided through CAT, (b) parent-training provided via bibliotherapy, or (c) a waitlist control. Measures of parent knowledge, the acceptability of training, and child symptomatology were completed at pre- and post-parent-training and at 3-month follow-up. Findings support the feasibility, acceptability, and beneficial effects on knowledge of CAT for parents of youth with impairment from anxiety.

Testing the Habituation-Based Model of Exposures for Child and Adolescent Anxiety.

Exposure has been identified as key to effective treatment of youth anxiety. However, the precise theoretical mechanisms of exposure are a matter of debate. Emotional processing theory emphasizes the need for fear activation during exposure and its habituation both within and across exposures. Despite the popularity of the theory to explain exposure, it has not been tested with anxious youth. To determine whether emotional processing theory parameters predict anxiety severity, coping abilities, and global functioning after cognitive-behavioral treatment. The present study examined 72 youth (Mage = 10.50 years; 45% female; 87.5% non-Hispanic Caucasian) diagnosed with an anxiety disorder and who received family or individual CBT. Three exposure habituation variables—initial fear activation (peak anxiety), within-session habituation, and between-session habituation—were assessed using Subjective Units of Distress and examined as predictors of outcome at posttreatment and at 1-year follow-up. Outcomes were measured using the Coping Questionnaire, Multidimensional Anxiety Scale for Children, Revised Children’s Manifest Anxiety Scale, Children’s Global Assessment Scale, and clinician severity ratings on the Anxiety Disorder Interview Schedule. Emotional processing theory variables did not predict any anxiety outcomes at posttreatment or follow-up with one exception: Initial fear activation predicted less anxiety at follow-up among youth without GAD. In addition, within- and between-session habituation were not associated with one another. Between-session habituation was not associated with initial fear activation. These findings suggest a limited role of habituation within cognitive-behavioral therapy for anxiety in youth. An alternative to emotional processing theory, inhibitory learning theory, is discussed.

Future Directions for the Examination of Mediators of Treatment Outcomes in Youth

How do psychological therapies work? How can we enhance treatment to improve outcomes? Questions of mediation lie at the heart of these inquiries. However, within the child and adolescent treatment literature, studies of mediation often rely on methodological and statistical approaches that limit the inferences that can be drawn from study findings. This future directions review delineates some of these issues and suggests improvements through two interrelated paths. We propose that mediation studies in the youth treatment literature will be enhanced (a) by adopting best practices in nomothetic (group-based) methodologies for assessing putative mediating variables and conducting appropriate statistical analyses and (b) by increasing the use of idiographic (individual-focused) approaches to youth outcome research through mediation studies that use innovative designs, data collection techniques, and analytic methods. We discuss the applicability of findings using these approaches to the treatment of youth in particular.

On the importance of temporal precedence in mediational analyses.

This response to the commentary by Gaynor (in press) (a) underscores the importance of defining terms (predictor, moderator, and mediator variables) used in psychological treatment outcome research, (b) notes the improvements in mediation analyses using treatment of youth anxiety as the illustration, and (c) encourages continued advancement in the methodology for mediation analyses. We agree with Gaynor (in press) both on the importance of temporal precedence and on the use of cautious language with regard to interpreting mediational analyses. (PsycINFO Database Record

Addressing Comorbidities When Treating Anxious Youth

ABSTRACT Anxiety disorders are highly prevalent among youth, with comorbid diagnoses being the norm, not the exception. Few guidelines exist regarding the best approach to treating anxious youth with comorbid mental health conditions. The present article presents a framework to guide clinicians treating anxious youth who present with comorbid (a) depressive disorders, (b) attention deficit/hyperactivity disorder, (c) oppositional defiant disorder, (d) autism spectrum disorder, or (e) other anxiety disorders. We propose three paths for clinicians to consider when treating youth with anxiety and a comorbid disorder: (a) treating the comorbid condition first, (b) treating only the anxiety and referring the youth out for comorbidity-specific treatment, or (c) treating both disorders simultaneously by integrating components of other evidence-based treatments. We conclude with practical implications and a call for future research on the treatment of comorbid diagnoses in youth.