Michael A. Southam-Gerow

Emotion regulation and understanding: implications for child psychopathology and therapy

This paper considers the role of emotion regulation (i.e., extrinsic and intrinsic monitoring and adjusting of emotion) and emotion understanding (i.e., comprehension of the signs of, causes of, and ways to regulate emotion) in childhood adjustment. Developmental and clinical research focused on emotion regulation and emotion understanding are reviewed with an emphasis on studies including psychopathological samples. The implications of emotion research for the study of child psychopathology and child therapy are examined.

Toward the Effective and Efficient Measurement of Implementation Fidelity

Implementation science in mental health is informed by other academic disciplines and industries. Conceptual and methodological territory charted in psychotherapy research is pertinent to two elements of the conceptual model of implementation posited by Aarons and colleagues (2010)—implementation fidelity and innovation feedback systems. Key characteristics of scientifically validated fidelity instruments, and of the feasibility of their use in routine care, are presented. The challenges of ensuring fidelity measurement methods are both effective (scientifically validated) and efficient (feasible and useful in routine care) are identified as are examples of implementation research attempting to balance these attributes of fidelity measurement.

Examining Outcome Variability: Correlates of Treatment Response in a Child and Adolescent Anxiety Clinic

Examined correlates of treatment response in a clinic providing cognitive-behavioral therapy for children with anxiety disorders. Youth (ages 7 to 15) with a primary Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., or 4th ed.; American Psychiatric Association, 1987, 1994) anxiety-disorder diagnosis (overanxious disorder, generalized anxiety disorder, separation anxiety disorder, social phobia, or avoidant disorder) participated. After completing a full course of treatment and posttreatment (n = 135) and 1-year follow-up (n = 107) assessments, participants were classified into 1 of 2 groups-poor treatment response and good treatment response-using parent diagnostic reports. Discriminant function analyses indicated that higher levels of maternal- and teacher-reported child-internalizing psychopathology at pretreatment, higher levels of maternal self-reported depressive symptoms, and older-child age were all associated with less favorable treatment response. Other factors, such as child ethnicity, child sex, family income, family composition (i.e., dual parent vs. single parent), child-reported symptomatology, and maternal-reported level of child-externalizing behavior problems did not predict treatment response. Both practical and conceptual implications of the findings are discussed.

Cognitive-Behavioral Therapy versus Usual Clinical Care for Youth Depression: An Initial Test of Transportability to Community Clinics and Clinicians

Community clinic therapists were randomized to (a) brief training and supervision in cognitive-behavioral therapy (CBT) for youth depression or (b) usual care (UC). The therapists treated 57 youths (56% girls), ages 8-15, of whom 33% were Caucasian, 26% were African American, and 26% were Latino/Latina. Most youths were from low-income families and all had Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) depressive disorders (plus multiple comorbidities). All youths were randomized to CBT or UC and treated until normal termination. Session coding showed more use of CBT by CBT therapists and more psychodynamic and family approaches by UC therapists. At posttreatment, depression symptom measures were at subclinical levels, and 75% of youths had no remaining depressive disorder, but CBT and UC groups did not differ on these outcomes. However, compared with UC, CBT was (a) briefer (24 vs. 39 weeks), (b) superior in parent-rated therapeutic alliance, (c) less likely to require additional services (including all psychotropics combined and depression medication in particular), and (d) less costly. The findings showed advantages for CBT in parent engagement, reduced use of medication and other services, overall cost, and possibly speed of improvement--a hypothesis that warrants testing in future research.

Does Cognitive Behavioral Therapy for Youth Anxiety Outperform Usual Care in Community Clinics? An Initial Effectiveness Test.

OBJECTIVE Most tests of cognitive behavioral therapy (CBT) for youth anxiety disorders have shown beneficial effects, but these have been efficacy trials with recruited youths treated by researcher-employed therapists. One previous (nonrandomized) trial in community clinics found that CBT did not outperform usual care (UC). The present study used a more stringent effectiveness design to test CBT versus UC in youths referred to community clinics, with all treatment provided by therapists employed in the clinics. METHOD A randomized controlled trial methodology was used. Therapists were randomized to training and supervision in the Coping Cat CBT program or UC. Forty-eight youths (56% girls, 8 to 15 years of age, 38% Caucasian, 33% Latino, 15% African-American) diagnosed with DSM-IV anxiety disorders were randomized to CBT or UC. RESULTS At the end of treatment more than half the youths no longer met criteria for their primary anxiety disorder, but the groups did not differ significantly on symptom (e.g., parent report, eta-square = 0.0001; child report, eta-square = 0.09; both differences favoring UC) or diagnostic (CBT, 66.7% without primary diagnosis; UC, 73.7%; odds ratio 0.71) outcomes. No differences were found with regard to outcomes of comorbid conditions, treatment duration, or costs. However, youths receiving CBT used fewer additional services than UC youths (χ(2)(1) = 8.82, p = .006). CONCLUSIONS CBT did not produce better clinical outcomes than usual community clinic care. This initial test involved a relatively modest sample size; more research is needed to clarify whether there are conditions under which CBT can produce better clinical outcomes than usual clinical care. CLINICAL TRIAL REGISTRY INFORMATION: Community Clinic Test of Youth Anxiety and Depression Study, URL: http://clinicaltrials.gov, unique identifier: NCT01005836.

Youth With Anxiety Disorders in Research and Service Clinics: Examining Client Differences and Similarities

Compared 2 groups of children with anxiety disorders: those treated in a university-based research clinic (RC) and those treated in community-based service clinics (SCs). A widely endorsed goal in intervention research is to disseminate evidence- based treatments from RCs to SCs. Attaining this goal requires an understanding of the similarities and differences between clients in these 2 settings. Youth from SCs showed more comorbid externalizing diagnoses and externalizing problems and were more likely to come from low-income and single-parent families. On measures of internalizing symptomatology and diagnoses, youth from RCs were very similar to SC youth. To facilitate development of treatments with real-world applicability, we describe a model involving the testing of treatments in real-world settings. We also discuss limitations to this project.

A Preliminary Study of the Emotion Understanding of Youths Referred for Treatment of Anxiety Disorders

Examined the emotion understanding of children and adolescents referred for treatment of Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) anxiety disorders (separation anxiety disorder, generalized anxiety disorder, or social phobia). Referred youths (n = 17) and nonreferred youths (n = 21) and their parents participated by completing self-report and parent-report questionnaires and structured diagnostic interviews. We interviewed all youths by using an emotion understanding interview. Referred youths demonstrated poorer understanding of hiding emotions and changing emotions compared with nonreferred youth. The 2 groups were not significantly different regarding their understanding of emotion cues and multiple emotions, however. No statistically significant relation emerged between general intelligence and emotion understanding. Future research directions are discussed.

Control-Related Beliefs and Depressive Symptoms in Clinic-Referred Children and Adolescents: Developmental Differences and Model Specificity

The contingency-competence-control (CCC) model links contingency and competence beliefs to perceived control and, in turn, to depression. However, a developmental perspective suggests that noncontingency may be too abstract a concept to be directly tied to depression before adolescence. We tested the CCC model and this developmental notion, using structural equation modeling, with 360 clinic-referred 8- to 17-year-olds. The CCC model fit the data well for the full sample accounting for 46% of the variance in depression. Separate analyses by age group placed perceived contingency in the best-fit model for adolescents (ages 12-17 years) but not for children (8-11 years). This suggests that abstract cause-effect concepts may have more direct affective impact after the cognitive changes of adolescence (e.g., formal operations) than before. Finally, the CCC model accounted for much more variance in depression than conduct problems, suggesting diagnostic specificity.

Evidence Base Updates: The Evolution of the Evaluation of Psychological Treatments for Children and Adolescents

This article introduces a new feature in the journal: Evidence Base Updates. Starting with this issue of the journal, there will be one such update in each issue. The updates will focus on reviewing the treatments studies focused on a specific child/adolescent problem area and identifying those treatments with the strongest evidence base. Updates will use a revised set of criteria for evaluating the evidence, based on past work, but modified to emphasize methodological rigor of studies and designed to identify those treatments with questionable efficacy. The article also places the evaluation of psychological treatments in historical context. As well, the changes made in the criteria are discussed.

Are children with anxiety disorders privately referred to a university clinic like those referred from the public mental health system

Compared two groups of children with anxiety disorders served at a single mental health clinic whose referral source differed: private referrals (i.e., parent/legal guardian initiated) and public referrals (e.g., via state contracts—Departments of Health and Education, juvenile justice system). Comparisons were made across three domains of variables: (a) symptoms/diagnoses, (b) functioning, and (c) environments. Few symptom differences emerged. However, large differences were evident for contextual variables like family income and life stressors. Overall, the pattern of differences point to possible directions for adaptation of treatments for use with children with anxiety disorders served in public mental health systems.