School-Based Intervention for Adolescents with Social Anxiety Disorder: Results of a Controlled Study

A comparison of two group cognitive behavioral therapy protocols for anxiety in urban schools: appropriateness, child outcomes, and cost-effectiveness

Background

Cognitive behavioral therapy (CBT) for pediatric anxiety is efficacious for reducing anxiety symptoms and improving functioning, but many children are unable to access CBT for anxiety in community settings. Schools are an important setting in which children access mental health care, including therapy for anxiety. In this setting, therapy is usually delivered by Masters-level therapists.

Objectives

Friends for Life (FRIENDS), a 12-session, manualized, group CBT program for anxiety has demonstrated effectiveness when implemented in schools. However, prior research has also found challenges regarding feasibility and cultural fit when delivering FRIENDS in the urban school context. To address these challenges, we adapted FRIENDS for implementation in the school setting so that it might be more feasible and culturally appropriate for low-income, urban schools in the United States, while maintaining the core components of treatment. The current study uses a mixed-method approach to compare the effectiveness, cost-effectiveness, and perceived appropriateness of FRIENDS and CATS when delivered by Masters-level therapists with train-the-trainer support.

Materials and methods

First, we compared change scores for student outcomes (i.e., child-report MASC-2 total score, parent-report MASC-2 total score, teacher-report Engagement and Disaffection subscale scores) from pre- to post- treatment between students receiving FRIENDS and students receiving CATS to assess whether the two conditions resulted in equivalent outcomes. Second, we compared the cost and cost-effectiveness between the groups. Finally, we used an applied thematic analysis to compare appropriateness of the interventions as perceived by therapists and supervisors.

Results

The mean change score for the child-reported MASC-2 was 1.9 (SE = 1.72) points in the FRIENDS condition and 2.9 (SE = 1.73) points in the CATS condition; results indicated that the conditions were similar in their treatment effects, and symptom reductions were small in both groups. The modified protocol, CATS, was shown to cost significantly less to implement compared to FRIENDS and showed greater cost-effectiveness. Finally, compared to therapists and supervisors in the CATS condition, therapists and supervisors in the FRIENDS condition more strongly described aspects of the intervention that were not appropriate for their context and in need of more extensive adaptations.

Conclusion

Relatively brief, group CBT for anxiety, with adaptations to improve cultural fit, is a promising approach to treat youth anxiety symptom when delivered by school-based therapists with train-the-trainer implementation support.

School-based cognitive behavioural intervention programme for addressing anxiety in 10- to 11-year-olds using short classroom activities in Japan: a quasi-experimental study

BACKGROUND

Although several school-based cognitive behavioural intervention programmes have been developed in Japan to prevent and improve children's anxiety disorders, the substantial time required for their completion remains a problem.

METHODS

A brief version of the cognitive behavioural programme called 'Journey of the Brave', developed for Japanese children was conducted among 90 children aged 10‒11 years using 20-min short classroom activities, and its effectiveness was examined. The children were divided into two groups: the intervention (n = 31) and control groups (n = 59). The control group did not attend any programme sessions and followed regular school curriculum. We conducted 14 weekly programme sessions and assessed children at pre-intervention, post-intervention, and 2-month follow-up (6 months after the beginning). The primary and secondary outcome measures were the Spence Children's Anxiety Scale (SCAS) to assess children's anxiety symptoms and the Strengths and Difficulties Questionnaire (SDQ) to measure behaviour problems, respectively.

RESULTS

A statistically significant reduction in the SCAS score in the intervention group was found at 2-month follow-up compared with the control group. A significant reduction was also observed in the SDQ score.

CONCLUSIONS

Our findings suggested that the 'Journey of the Brave' programme, which requires only 5 h of short classroom activities, demonstrates promising results compared with previous programmes. A larger randomised control trial would be desirable.

TRIAL REGISTRATION

UMIN, UMIN000009021, Registered 10 March 2012.

The Prevalence of Adolescent Social Fears and Social Anxiety Disorder in School Contexts

Social fears arise when fearing to be judged in social events. When these fears are intense, persistent, and debilitating, the individual may suffer from social anxiety disorder (SAD), which has its most frequent onset during adolescence and tends to be chronic. Still, evidence on the prevalence of social fears and SAD in adolescence is scarce. This study analyzed the prevalence of social fears and of SAD in Portuguese adolescents. Of the initial sample (n = 1495), 26% presented with intense self-reported social fears. Of those, 53.9% accepted to be further assessed for diagnosis, resulting in a point-estimate prevalence of adolescent SAD of 9.4%; this is slightly higher than previously found. Social performance was the most feared social event. Of the adolescents with SAD, 12.9% were receiving psychological intervention, 12.1% refused intervention, and 92 (65.7%) accepted intervention. Findings confirm SAD as a highly prevalent mental disorder among adolescents, particularly girls, and additionally, that most of these adolescents did not seek treatment but are willing to receive help if made available. Hence, schools should be invested not only in identifying vulnerable adolescents but also in providing diverse intervention options, tailored to their needs, and directing them to successful developmental trajectories.

Loneliness as an active ingredient in preventing or alleviating youth anxiety and depression: a critical interpretative synthesis incorporating principles from rapid realist reviews

Loneliness is a relatively common problem in young people (14-24 years) and predicts the onset of depression and anxiety. Interventions to reduce loneliness thus have significant potential as active ingredients in strategies to prevent or alleviate anxiety and depression among young people. Previous reviews have focused on quantitative evidence and have not examined potential mechanisms that could be targets for intervention strategies. To build on this work, in this review we aimed to combine qualitative and quantitative evidence with stakeholder views to identify interventions that appear worth testing for their potential effectiveness in reducing loneliness, anxiety and depression in young people aged 14-24 years, and provide insights into the potential mechanisms of action. We conducted a Critical Interpretative Synthesis, a systematic review method that iteratively synthesises qualitative and quantitative evidence and is explicitly focused on building theory through a critical approach to the evidence that questions underlying assumptions. Literature searches were performed using nine databases, and eight additional databases were searched for theses and grey literature. Charity and policy websites were searched for content relevant to interventions for youth loneliness. We incorporated elements of Rapid Realistic Review approaches by consulting with young people and academic experts to feed into search strategies and the resulting conceptual framework, in which we aimed to set out which interventions appear potentially promising in terms of theoretical and empirical underpinnings and which fit with stakeholder views. We reviewed effectiveness data and quality ratings for the included randomised controlled trials only. Through synthesising 27 studies (total participants n = 105,649; range 1-102,072 in different studies) and grey literature, and iteratively consulting with stakeholders, a conceptual framework was developed. A range of 'Intrapersonal' (e.g. therapy that changes thinking and behaviour), 'Interpersonal' (e.g. improving social skills), and 'Social' Strategies (e.g. enhancing social support, and providing opportunities for social contact) seem worth testing further for their potential to help young people address loneliness, thereby preventing or alleviating depression and/or anxiety. Such strategies should be co-designed with young people and personalised to fit individual needs. Plausible mechanisms of action are facilitating sustained social support, providing opportunities for young people to socialise with peers who share similar experiences, and changing thinking and behaviour, for instance through building positive attitudes to themselves and others. The most convincing evidence of effectiveness was found in support of Intrapersonal Strategies: two randomised controlled studies quality-rated as 'good' found decreases in loneliness associated with different forms of therapy (Cognitive Behavioural Therapy or peer network counselling), although power calculations were not reported, and effect sizes were small or missing. Strategies to address loneliness and prevent or alleviate anxiety and depression need to be co-designed and personalised. Promising elements to incorporate into these strategies are social support, including from peers with similar experiences, and psychological therapy.

Treating Speech Anxiety in Youth: A Randomized Controlled Microtrial Testing the Efficacy of Exposure Only Versus Exposure Combined With Anxiety Management Strategies

CBT for anxious youth usually combines anxiety management strategies (AMS) with exposure, with exposure assumed to be critical for treatment success. To limit therapy time while retaining effectiveness, one might optimize CBT by restricting treatment to necessary components. This study tested whether devoting all sessions to exposure is more effective in reducing speech anxiety in youth than devoting half to AMS including cognitive or relaxation strategies and half to exposure. After a 6-week waitlist period, adolescents with speech anxiety (N = 65; age 12-15; 42 girls) were randomized to a 5-session in-school group-based CBT training consisting of either (1) exposure-only (EXP+EXP) or (2) cognitive strategies followed by exposure (COG+EXP) or (3) relaxation strategies followed by exposure (REL+EXP). Clinical interviews, speech tests, and self-report measures were assessed at pretest, posttest, and follow-up. For all conditions (a) the intervention period resulted in a stronger decline of speech anxiety than waitlist period; (b) there was a large sized reduction of speech anxiety that was maintained at six-week follow-up; (c) there was no meaningful difference in the efficacy of EXP+EXP versus COG+EXP or REL+EXP. These findings suggest that devoting all sessions to exposure is not more effective than combining exposure with AMS. AMS appeared neither necessary for CBT to be effective, nor necessary for youth to tolerate exposure. This indicates that CBT can be optimized by restricting treatment to exposure.

Supporting the parents of children and young people with anxiety and depressive disorders is an opportunity not to be missed: a scoping review

Guidance is scarce on whether and how to involve parents in treatment for anxiety and depressive disorders in children and young people. We did a scoping review of randomised controlled trials of psychological interventions for anxiety and depressive disorders in children and young people, in which parents were involved in treatment, to identify how parents and carers have been involved in such treatments, how this relates to both child and broader outcomes, and where research should focus. We identified 73 trials: 62 focused on anxiety and 11 on depressive disorders. How parents were involved in treatments varied greatly, with at least 13 different combinations of ways of involving parents in the anxiety trials and seven different combinations in the depression trials. Including parents in treatment did not impair children's and young people's outcomes, but the wide variability in how they were involved prevents clarity about why some trials favoured parent involvement and others did not. Studies must consider the long-term and wider benefits beyond children's and young people's mental health, such as enhanced engagement, family wellbeing, and economic gains.

The Effectiveness of Psychological Therapies for Anxiety Disorders in Adolescents: A Meta-Analysis

Anxiety disorders are common in adolescence but outcomes for adolescents are unclear and we do not know what factors moderate treatment outcome for this age group. We conducted meta-analyses to establish the effectiveness of psychological therapies for adolescent anxiety disorders in (i) reducing anxiety disorder symptoms, and (ii) remission from the primary anxiety disorder, compared with controls, and examine potential moderators of treatment effects. The protocol was registered with PROSPERO (CRD42018091744). Electronic databases (Web of Science, MEDLINE, Psycinfo, EMBASE) were searched from January 1990 to December 2019. 2511 articles were reviewed, those meeting strict criteria were included. Random effects meta-analyses were conducted. Analyses of symptom severity outcomes comprised sixteen studies (CBT k = 15, non-CBT k = 1; n = 766 adolescents), and analyses of diagnostic remission outcomes comprised nine (CBT k = 9; n = 563 adolescents). Post-treatment, those receiving treatment were significantly more likely to experience reduced symptom severity (SMD = 0.454, 95% CI 0.22–0.69) and remission from the primary anxiety disorder than controls (RR = 7.94, 95% CI 3.19–12.7) (36% treatment vs. 9% controls in remission). None of the moderators analysed were statistically significant. Psychological therapies targeting anxiety disorders in adolescents are more effective than controls. However, with only just over a third in remission post-treatment, there is a clear need to develop more effective treatments for adolescents, evaluated through high-quality randomised controlled trials incorporating active controls and follow-up data.

Single-Session Therapy by Appointment for the Treatment of Anxiety Disorders in Youth and Adults: A Systematic Review of the Literature

Purpose: This systematic review provides a summary of the available evidence of the efficacy of single-session therapy (SST) on anxiety disorders in both youth and adults. Methods: PubMed, Scopus, Medline, and Google Scholar databases were search for relevant articles, and the Cochrane Collaboration's tool for assessing the risk of bias in randomized trials was used for transparent reporting of the methodological quality of each selected study. Results: The search of electronic databases identified 18 reports based on rigorous inclusion criteria. Single-session therapy was found superior to no treatment in reducing anxiety symptoms, and similar results were observed while comparing SST to multi-treatment sessions. Discussion: The findings support the benefits of SST in enhancing cognitive, behavioral, and psychological outcomes in both youth and adults suffering from anxiety disorders across treatment conditions and approaches, SST thus appears to be a promising way of providing access to both private and public therapeutic services efficiently and cost-effectively. Conclusions: Single-session therapy is effective in treating anxiety disorders. Further research is required to quantify its cost-effectiveness and deepen the knowledge of effective treatment ingredients for both young people and the adult population suffering from diverse anxiety disorders. Systematic Review Registration: PROSPERO, identifier [CRD42021232024].

Therapist-Guided Internet-Delivered Cognitive Behavioral Therapy vs Internet-Delivered Supportive Therapy for Children and Adolescents With Social Anxiety Disorder: A Randomized Clinical Trial

IMPORTANCE

Social anxiety disorder (SAD) is a prevalent childhood-onset disorder associated with lifelong adversity and high costs for the individual and society at large. Cognitive behavioral therapy (CBT) is an established evidence-based treatment for SAD, but its availability is limited.

OBJECTIVE

To assess the efficacy and cost-effectiveness of therapist-guided internet-delivered cognitive behavioral therapy (ICBT) for SAD in youths vs an active comparator, internet-delivered supportive therapy (ISUPPORT).

DESIGN, SETTING, AND PARTICIPANTS

This single-masked, superiority randomized clinical trial enrolled participants at a clinical research unit integrated within the child and adolescent mental health services in Stockholm, Sweden, from September 1, 2017, to October 31, 2018. The final participant reached the 3-month follow-up (primary end point) in May 2019. Children and adolescents 10 to 17 years of age with a principal diagnosis of SAD and their parents were included in the study.

INTERVENTIONS

ICBT and ISUPPORT, both including 10 online modules, 5 separate parental modules, and 3 video call sessions with a therapist.

MAIN OUTCOMES AND MEASURES

The Clinician Severity Rating (CSR), derived from the Anxiety Disorder Interview Schedule, rated by masked assessors 3 months after the end of treatment. The CSR ranges from 0 to 8, with scores of 4 or higher indicating caseness. Secondary outcomes included masked assessor-rated diagnostic status of SAD and global functioning, child- and parent-reported social anxiety and depressive symptoms, and health-related costs.

RESULTS

Of the 307 youths assessed for eligibility, 103 were randomized to 10 weeks of therapist-guided ICBT (n = 51) or therapist-guided ISUPPORT (n = 52) for SAD. The sample consisted of 103 youths (mean [SD] age, 14.1 [2.1] years; 79 [77%] female). Internet-delivered cognitive behavioral therapy was significantly more efficacious than ISUPPORT in reducing the severity of SAD symptoms. Mean (SD) CSR scores for ICBT at baseline and at the 3-month follow-up were 5.06 (0.95) and 3.96 (1.46), respectively, compared with 4.94 (0.94) and 4.48 (1.30) for ISUPPORT. There was a significant between-group effect size of d = 0.67 (95% CI, 0.21-1.12) at the 3-month follow-up. Similarly, all of the secondary outcome measures demonstrated significant differences with small to large effect sizes, except for child-rated quality of life (nonsignificant). The cost-effectiveness analyses indicated cost savings associated with ICBT compared with ISUPPORT, with the main drivers of the savings being lower medication costs (z = 2.38, P = .02) and increased school productivity (z = 1.99, P = .047) in the ICBT group. There was 1 suicide attempt in the ISUPPORT group; no other serious adverse events occurred in either group.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, internet-delivered cognitive behavioral therapy was an efficacious and cost-effective intervention for children and adolescents with SAD. Implementation in clinical practice could markedly increase the availability of effective interventions for SAD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03247075.

A Meta-analysis to Guide the Enhancement of CBT for Childhood Anxiety: Exposure Over Anxiety Management

Cognitive behavior therapy (CBT) is the most empirically supported therapy for childhood anxiety disorders (CADs) but has not reliably outperformed other credible interventions. The current study used meta-analysis to examine the frequency with which the most common treatment components are included in outcome studies and the relation of these components to symptom improvement. Seventy-five studies were identified that included youth with an anxiety disorder treated with CBT or a comparison condition. The protocols for the 111 CBT conditions generally consisted of 12, 1-h sessions delivered to the child with minimal parent inclusion. A greater amount of in-session exposure was related to significantly larger effect sizes between CBT and waitlist control across reporters (- 0.12 to - 0.15; P's < .05) and from pre- to post-treatment for child report (- .06; P < .01). Compared to treatments that omitted relaxation, treatments that included relaxation strategies were associated with significantly smaller pre- to post-treatment effect sizes across reporters (0.38 to 0.80; P's < .05). The current study suggests that CBT protocols for CADs that emphasize in-session exposure and do not include relaxation have the potential to improve the efficacy and effectiveness of therapy. Dismantling studies directly testing these hypotheses are needed.

Much more than just shyness: the impact of social anxiety disorder on educational performance across the lifespan

BACKGROUND

Social anxiety disorder (SAD) has been linked to academic underachievement, but previous studies had methodological limitations. We investigated the association between SAD and objective indicators of educational performance, controlling for a number of covariates and unmeasured confounders shared between siblings.

METHODS

This population-based birth cohort study included 2 238 837 individuals born in Sweden between 1973 and 1997, followed-up until 2013. Within the cohort, 15 755 individuals had a recorded ICD-10 diagnosis of SAD in the Swedish National Patient Register. Logistic regression models tested the association between SAD and educational performance. We also identified 6488 families with full siblings discordant for SAD.

RESULTS

Compared to unexposed individuals, individuals diagnosed with SAD were less likely to pass all subjects in the last year of compulsory education [adjusted odds ratios (aOR) ranging from 0.19 to 0.44] and less likely to be eligible for a vocational or academic programme in upper secondary education [aOR = 0.31 (95% confidence interval [CI] 0.30-0.33) and aOR = 0.52 (95% CI 0.50-0.55), respectively], finish upper secondary education [aOR = 0.19 (95% CI 0.19-0.20)], start a university degree [aOR = 0.47 (95% CI 0.45-0.49)], obtain a university degree [aOR = 0.35 (95% CI 0.33-0.37)], and finish postgraduate education [aOR = 0.58 (95% CI 0.43-0.80)]. Results were attenuated but remained statistically significant in adjusted sibling comparison models. When psychiatric comorbidities were taken into account, the results were largely unchanged.

CONCLUSIONS

Treatment-seeking individuals with SAD have substantially impaired academic performance throughout the formative years. Early detection and intervention are warranted to minimise the long-term socioeconomic impact of the disorder.

Review: Alleviating loneliness in young people - a meta-analysis of interventions

BACKGROUND

Loneliness is common among youth and is associated with poor physical and mental health, and poor educational outcomes. To date, there have been no meta-analyses of interventions aimed at reducing loneliness among young people.

METHODS

We conducted meta-analyses of single group and randomised control trials (RCTs) of studies published between 1980 and 2019, which measured loneliness as an outcome in youth ages 25 years or younger. Moderators, including sample demographics and intervention characteristics, that might affect intervention success, were examined.

RESULTS

A total of 39 studies (14 single group and 25 RCTs) were included, and we found evidence that youth loneliness could be reduced via intervention. Moderator analysis - including intervention characteristics, study quality and sample demographics - was also examined.

CONCLUSIONS

While interventions were shown to reduce loneliness among youth, the interventions included in the meta-analyses often targeted youth viewed to be at risk - for example those with health concerns - and rarely did the interventions target youth who reported loneliness. There is also no indication of whether youth experienced chronic or transient loneliness. In future work, interventions should be designed specifically for loneliness, with universal programmes helping youth manage their transient feelings of loneliness, and targeted interventions for those suffering from chronic loneliness. There is also a need to look at socioeconomic and other risk factors outside the individual for targeted interventions.

KEY PRACTITIONER MESSAGE

There have been no meta-analyses that have evaluated the effect of interventions for reducing loneliness among children and adolescents. We found intervention programmes targeted at youth are successful at reducing loneliness. Future interventions should be designed specially with loneliness in mind, with (a) universal programmes to help youth manage their experiences of transient loneliness, and (b) targeted interventions for youth reporting chronic loneliness. They should also examine the longer-term outcomes of the interventions. Future interventions should be designed, evaluated and then documented using guidelines on how to write up an intervention evaluation.

Review: Delivering mental health support within schools and colleges - a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents

BACKGROUND

Increasing the role of schools and colleges in the provision of mental health services for young people has the potential to improve early intervention and access to treatment. We aimed to understand what factors influence the successful implementation of indicated psychological interventions within schools and colleges to help guide increased provision of mental health support within education settings.

METHODS

Systematic search for studies that have reported barriers or facilitators to the implementation of indicated interventions for adolescent emotional disorders delivered within schools and further education/sixth form colleges (CRD42018102830). Databases searched were EMBASE, MEDLINE, PsycINFO, CINAHL, British Nursing Index, ASSIA, ERIC and British Education Index. A thematic synthesis of factors reported to impact implementation was conducted.

RESULTS

Two thousand five hundred and sixty-nine records and 177 full texts were screened. Fifty studies were identified for inclusion, all of which were of school-based interventions. Eleven analytic themes were developed encompassing intervention characteristics, organisational capacity, training and technical assistance, provider characteristics and community-level factors. Findings indicate the need to select appropriate interventions, consider logistical challenges of the school context and provide training and supervision to enable staff to deliver interventions with fidelity. However, structural and environmental support is required for these facilitators to have the greatest impact on successful implementation.

CONCLUSIONS

Implementing indicated school-based mental health interventions is challenging. Those involved in planning school-based mental health initiatives must be alert to the impact of factors on multiple interacting levels. There is a lack of research on implementing mental health support within further education and sixth form colleges.

KEY PRACTITIONER MESSAGE

Increased utilisation of schools and colleges as a setting for early intervention has been proposed as a means of improving access to mental health treatment, but successful implementation of mental health interventions within educational settings is challenging. Based on a synthesis of current evidence, we recommend that young people and education professionals should be involved in the selection of school-based interventions to ensure they are acceptable and practical to deliver within the logistical constraints of the school environment. Those delivering interventions within schools, as well as staff involved in identifying young people who might benefit from these interventions, must receive high-quality ongoing training and support. Senior school leaders play an important role in championing mental health interventions and developing a school culture that prioritises mental well-being. Health and education policy should be designed to promote a cross-sector focus on the emotional health of young people. There is a lack of evidence on the implementation of indicated psychological interventions within sixth form and further education colleges.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

OBJECTIVES

To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches.

SELECTION CRITERIA

We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 87 studies and 5964 participants in quantitative analyses. Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality). Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies). Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality). There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies) Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies). No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored. Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text. We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments.

AUTHORS' CONCLUSIONS

CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

Reluctancy towards Help-Seeking for Mental Health Concerns at Secondary School among Students in the COMPASS Study

Youth populations represent a key population for addressing mental health, yet many youths express reluctance towards help seeking. Considering the volume of time that almost all youth spend at school during the school year, it is important to assess the role of the school environment in relation to students’ attitudes toward help-seeking. Data from 47,290 grade 9 to 12 students and 116 Canadian secondary schools that participated in the 2018-19 wave of the COMPASS (Cannabis, Obesity, Mental health, Physical activity, Alcohol, Smoking, Sedentary behaviour) study were analyzed using GEE models to assess the student and school characteristics associated with attitudes regarding seeking help for mental health concerns from an adult at school. Overall, 58% of students reported being reluctant to seek help for mental health concerns at school. Students who reported lower self-rated mental health (aOR = 1.76, 95% CI = 1.65, 1.87), emotion regulation (aOR = 1.08, 95% CI = 1.07, 1.09), family support (aOR = 2.31, 95% CI = 2.16, 2.47), peer support (aOR = 1.20, 95% CI = 1.13, 1.31), and school connectedness (aOR = 0.93, 95% CI = 0.92, 0.93) scores were more likely to be reluctant towards help-seeking at school than students with more favourable scores on these variables. Students with higher flourishing scores were less likely than students who were languishing to report reluctance to help-seeking at school (aOR = 0.96, 95% CI = 0.96, 0.97). Students attending schools in areas with lower population densities and median household incomes between $50,000–75,000 were less likely to be reluctant to help-seeking relative to students attending schools in areas with higher density (aOR = 0.85, 95% CI = 0.79, 0.93) and median household incomes (aOR = 1.20, 95% CI = 1.13, 1.31), respectively. The availability of school mental health services and specialists were not associated with student help-seeking reluctance. High levels of resistance towards help-seeking among youth remain a significant barrier, particularly among youth at highest risk (i.e., with lower support and poorer mental health). The student and school characteristics identified in the current study can help inform strategies to promote greater acceptance of help seeking among students in schools.

A Systematic Review of Parental Involvement in Cognitive Behavioural Therapy for Adolescent Anxiety Disorders

Anxiety disorders are common among adolescents and lead to poor long-term outcomes. Cognitive Behavioural Therapy (CBT) is an evidenced-based intervention for adolescent anxiety disorders, but little is known about whether and how parents should be involved. This systematic review evaluated how parents have been involved and associated treatment outcomes in studies of CBT for adolescent anxiety disorders. Electronic systematic searches were conducted in PsycINFO, Embase, CINAHL, Medline, AMED databases, to identify studies investigating CBT for adolescent anxiety disorder(s) that included parents in treatment. Twenty-three papers were identified. Parents were involved in treatment in a number of different ways: by attending separate parent sessions, joint parent–adolescent sessions, or both, or through provision of a workbook while attending some adolescent sessions. Content varied but was most typically aimed at the parent developing an understanding of core CBT components and skills to help them manage their adolescent’s anxiety and avoidance. Treatment outcomes indicate that CBT with parental involvement is an effective intervention for adolescent anxiety disorders; however, it is not possible to draw conclusions regarding whether parental involvement (generally or in any particular form) enhances treatment outcomes. Poor reporting and methodological issues also limit the conclusions. Further research is required to identify whether there are particular types of parental involvement in CBT that bring clinical benefits to adolescents with anxiety disorders generally, as well as in particular circumstances.

Practitioner Review: Effectiveness of indicated school-based interventions for adolescent depression and anxiety - a meta-analytic review

BACKGROUND

Interest in delivering psychological interventions within schools to facilitate early intervention is increasing. However, most reviews have focused on universal or preventative programmes rather than interventions designed to decrease existing symptoms of depression or anxiety. This paper aims to provide a meta-analytic review of randomised controlled trials of indicated psychological interventions for young people aged 10-19 with elevated symptoms of depression and/or anxiety.

METHODS

Eight electronic databases were systematically searched from inception to April 2019 for eligible trials. Study quality was assessed using two scales designed to evaluate psychotherapy intervention trials. Random effects meta-analyses were conducted separately for trials that recruited participants based on symptoms of depression and based on symptoms of anxiety.

RESULTS

Data from 45 trials were analysed. Most interventions studied used cognitive and behavioural strategies. Few studies met methodological quality criteria, but effect size was not associated with study quality. Indicated school-based interventions had a small effect on reducing depression symptoms (SMD = .34, 95% CI -0.48, -0.21) and a medium effect on reducing anxiety symptoms (SMD = -.49, 95% CI -0.79, -0.19) immediately postintervention. Subgroup analyses indicated that interventions delivered by internal school staff did not have significant effects on symptoms. Reductions in depression were maintained at short-term (≤6 months) but not medium (>6 months ≤ 12) or long-term (>12-month) follow-up. Reductions in anxiety symptoms were not maintained at any follow-up.

CONCLUSIONS

Indicated school-based interventions are effective at reducing symptoms of depression and anxiety in adolescents immediately postintervention but there is little evidence that these reductions are maintained. Interventions delivered by school staff are not supported by the current evidence base. Further high-quality randomised controlled trials incorporating assessment of longer-term outcomes are needed to justify increased investment in school-based interventions for adolescent depression and anxiety.

The effectiveness of interventions for reducing subjective and objective social isolation among people with mental health problems: a systematic review

PURPOSE

Subjective and objective social isolation are important factors contributing to both physical and mental health problems, including premature mortality and depression. This systematic review evaluated the current evidence for the effectiveness of interventions to improve subjective and/or objective social isolation for people with mental health problems. Primary outcomes of interest included loneliness, perceived social support, and objective social isolation.

METHODS

Three databases were searched for relevant randomised controlled trials (RCTs). Studies were included if they evaluated interventions for people with mental health problems and had objective and/or subjective social isolation (including loneliness) as their primary outcome, or as one of a number of outcomes with none identified as primary.

RESULTS

In total, 30 RCTs met the review's inclusion criteria: 15 included subjective social isolation as an outcome and 11 included objective social isolation. The remaining four evaluated both outcomes. There was considerable variability between trials in types of intervention and participants' characteristics. Significant results were reported in a minority of trials, but methodological limitations, such as small sample size, restricted conclusions from many studies.

CONCLUSION

The evidence is not yet strong enough to make specific recommendations for practice. Preliminary evidence suggests that promising interventions may include cognitive modification for subjective social isolation, and interventions with mixed strategies and supported socialisation for objective social isolation. We highlight the need for more thorough, theory-driven intervention development and for well-designed and adequately powered RCTs.

Practitioner Review: Anxiety disorders in children and young people - assessment and treatment

Despite significant advancements in our knowledge of anxiety disorders in children and adolescents, they continue to be underrecognised and undertreated. It is critical that these disorders are taken seriously in children and young people as they are highly prevalent, have a negative impact on educational, social and health functioning, create a risk of ongoing anxiety and other mental health disorders across the life span and are associated with substantial economic burden. Yet very few children with anxiety disorders access evidence-based treatments, and there is an urgent need for widespread implementation of effective interventions. This review aimed to provide an overview of recent research developments that will be relevant to clinicians and policymakers, particularly focusing on the development and maintenance of child anxiety disorders and considerations for assessment and treatment. Given the critical need to increase access to effective support, we hope this review will contribute to driving forward a step change in treatment delivery for children and young people with anxiety disorders and their families.

Experience Versus Report: Where Are Changes Seen After Exposure-Based Cognitive-Behavioral Therapy? A Randomized Controlled Group Treatment of Childhood Social Anxiety Disorder

A considerable number of children and adolescents with social anxiety disorder (SAD) do not benefit from treatment as much as expected. However, treatment success should not be measured with social anxiety reports alone; the cognitive, behavioral, and physiological components of social stress should also be assessed. The authors examined an exposure-based SAD-specific group cognitive behavioral therapy (CBT) in a randomized controlled trial (N = 67, age 9-13 years, blind randomized allocation to treatment [CBT; n = 31] and waitlist control [WLC; n = 36] groups). Success was operationalized as a clinically significant reduction of symptoms measured with SAD-specific questionnaires, structured interviews, and changes in response to the Trier Social Stress Test (TSST). In the CBT group, there was a trend toward a significant increase in positive cognitions in the TSST after treatment (d = 0.37), whereas these positive cognitions decreased in the WLC group (d = 0.40). No significant results involving group appeared for negative cognitions, behavior and physiology. Children in the CBT group, but not parents, further reported less social anxiety in one questionnaire from pre- to post-treatment (d = 0.89). A structured interview confirmed a decrease in severity of SAD in the CBT group. While the gold standard of a blind interview showed efficacy of treatment, not all trait and state measures demonstrated similar success patterns.Trial registration Eligibility criteria and some of the dependent variables (cognitions, physiology) for treatment success were registered with the German Research Foundation (TU 78/5-2, HE 3342/4-2) prior to recruitment. Clinical assessment of diagnosis and behavioral data were not a priori planned as outcome measures for this trial and therefore analyzed in a post-hoc approach.

Effectiveness of cognitive behavioral therapy (CBT) for child and adolescent anxiety disorders across different CBT modalities and comparisons: a systematic review and meta-analysis

Aim: Pediatric Anxiety Disorders (AD) are common. Cognitive behavioral therapy (CBT) is one of two first-line treatments of youth AD and it has previously been shown to be superior to wait-list but not placebo therapy. This study consists of a systematic review and meta-analysis of the literature to assess the efficacy of CBT modalities in comparison to control contingencies for pediatric anxiety disorders.Methods: Studies were included if they were randomized controlled trials, and if CBT was manualized or modular, alone or in combination with medication. CBT was required to include behavioral treatment, exposure treatment, or cognitive elements. Eligible studies included participants aged 18 years or younger.Results: Eighty-one studies were included, with 3386 CBT participants and 2527 control participants. The overall results indicated that CBT is an effective treatment for childhood AD. The results showed that individual-based CBT is superior to wait-list and attention control. Group-based CBT is superior to wait-list control and treatment as usual. Remote-based CBT was superior to attention control and wait-list control. Family-based CBT was superior to treatment as usual, wait-list control, and attention control. Selective serotonin reuptake inhibitors were no more effective than individual-based CBT. Combination treatment was, however, more effective than individual-based CBT.Conclusion: To the best of our knowledge, no meta-analysis has thus far disentangled the effects of CBT modalities across various comparisons. This meta-analysis hence provides an important update to the literature on the efficacy of CBT for treating anxiety disorders in young people.

School-Based Treatment for Anxiety Research Study (STARS): a Randomized Controlled Effectiveness Trial

The current study compared the effectiveness of a school-clinician administered cognitive behavioral treatment (CBT) to treatment as usual (TAU) at post-treatment (i.e., after 12 weeks) and at a 1 year follow-up. Sixty-two school-based clinicians (37 in CBT; 25 in TAU) and 216 students (148 students in CBT; 68 in TAU) participated. Students were ages 6-18 (mean age 10.87; 64% Caucasian & 29% African American; 48.6% female) and all met DSM-IV diagnostic criteria for a primary anxiety disorder. Independent evaluators (IEs) assessed clinical improvement, global functioning, and loss of anxiety diagnoses; children and parents completed measures of anxiety symptoms. At post-treatment, no significant treatment main effects emerged on the primary outcome; 42% and 37% of youth were classified as treatment responders in CBT and TAU respectively. However, parent-report of child anxiety showed greater improvements in CBT relative to TAU (d = .29). Moderation analyses at post-treatment indicated that older youth, those with social phobia and more severe anxiety at baseline were more likely to be treatment responders in CBT compared to TAU. At the 1 year follow-up, treatment gains were maintained but no treatment group differences or moderators emerged. CBT and TAU for pediatric anxiety disorders, when delivered by school clinicians were generally similar in effectiveness for lowering anxiety and improving functioning at both post-treatment (on all but the parent measure and for specific subgroups) and 1 year follow-up. Implications for disseminating CBT in the school setting are discussed.

Incorporating evidence-based behavioral teacher training into Head Start mental health consultation: Description and initial outcomes of a large-scale program

Development of a multicomponent mental health consultation program for a countywide Head Start program is described. The consultation program incorporates strategies from the evidence-based practice, Teacher-Child Interaction Training (TCIT). Through large group professional development trainings before the school year, comprehensive feedback reports based on observations, and in-class coaching via modeling and performance feedback on teachers' use of TCIT skills, the consultation program served 55 Head Start classrooms with 789 children. Outcome data are presented on teachers' improvement in TCIT skill use and the relative effectiveness of two coaching methods (i.e., modeling and performance feedback) used during consultation. Results from multilevel modeling analyses indicated that teachers improved in the use of multiple observed TCIT skills between the initial and midyear assessment (i.e., increased frequency of labeled praises, reflections, behavioral descriptions, and commands that were complied with; decreased frequency of commands that children did not have an opportunity to comply with). Additionally, teachers who received coaching in the form of performance feedback, in comparison to modeling, exhibited greater gains in the frequency of labeled praises and commands that resulted in compliance. Discussion focuses on implementation of evidence-based practice in large-scale preventative early interventions, study limitations, and directions for future research.

Therapeutic strategies for social anxiety disorder: where are we now?

Introduction: Classical well-established treatments of social anxiety disorder (SAD) are now complemented by more recent therapeutic strategies. This review aims to summarize available therapies for SAD and discuss recent evidence-based findings on the management of this disorder.Areas covered: Recent guidelines recommend psychotherapy, particularly cognitive-behavioral therapy (CBT), and pharmacotherapy, as first-line treatments of patients with SAD, without a clear superiority of one option over the other. CBT includes classical approaches such as in vivo exposure to social situations and cognitive therapy, but new modalities and techniques have been recently developed: third-wave approaches, internet-delivered therapy, virtual reality exposure, and cognitive bias modification. Selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors have been also extensively studied and shown to be effective in SAD. Two alternative strategies have been developed to treat SAD with disappointing results: cognitive bias modification, and pharmacological augmentation of psychotherapy using D-cycloserine during exposure sessions.Expert opinion: Personalized treatments for SAD patients are now available. Innovative strategies such as online psychotherapy and virtual reality exposure are useful alternatives to CBT and SSRIs. Future developments and optimization of attention bias modification and of pharmacological augmentation of psychotherapy can be promising.

The influence of a blended, theoretically-informed pre-implementation strategy on school-based clinician implementation of an evidence-based trauma intervention

BACKGROUND

Individual-level implementation determinants, such as clinician attitudes, commonly influence the successful adoption of evidence-based practices, but few explicit strategies have been tested with regard to their ability to impact these key mechanisms of change. This paper reports on an initial test of a blended, theoretically informed pre-implementation strategy designed to target malleable individual-level determinants of behavior change. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a brief and pragmatic pre-implementation strategy that uses strategic education, social influence techniques, and group-based motivational interviewing to target implementation attitudes, perceived social norms, perceived behavioral control, and behavioral intentions to implement among mental health clinicians working in the education sector.

METHODS

As part of a pilot trial, 25 school mental health clinicians were randomized to BASIS (n = 12) or an attention control placebo (n = 13), with both conditions receiving training and consultation in an evidence-based intervention for youth experiencing trauma (the Cognitive Behavioral Intervention for Trauma in Schools). Theorized mechanisms of change (attitudes, perceived social norms, perceived behavioral control, and behavioral intentions) were assessed at baseline, post-training, and 4-month follow-up. Clinician participation in post-training consultation and intervention adoption were also tracked.

RESULTS

A series of regression models and independent sample t tests indicated that BASIS had significant, medium to large effects on the majority of its proximal mechanisms from baseline to post-training. BASIS was also associated with a greater latency between initial training in the intervention and discontinuation of participation in post-training consultation, with clinicians in the BASIS condition persisting in consultation for an average of 134 days versus 32 days for controls, but this difference was not statistically significant. At 4-month follow-up, most differences in the theorized mechanisms had attenuated, and approximately the same small number of BASIS clinicians adopted the trauma intervention as controls.

CONCLUSION

Findings suggest that the brief BASIS pre-implementation strategy had a significant influence on its proximal mechanisms of change, but that these changes did not persist over time or translate into adoption of the trauma intervention. Implications for theory refinement, revisions to the BASIS protocol, and next steps for research surrounding individual-level implementation strategies are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03791281 . Registered 31 December 2018-Retrospectively registered.

Protocol for a randomised controlled feasibility study examining the efficacy of brief cognitive therapy for the Treatment of Anxiety Disorders in Adolescents (TAD-A)

Background

Anxiety disorders affect a quarter of the population during their lifetime, and typically emerge in childhood or adolescence. Anxiety disorders disrupt young people’s social, emotional and academic development and in the absence of treatment, often follow a chronic course. Although effective treatments, such as Cognitive Behaviour Therapy (CBT), exist, only a small proportion of adolescents with anxiety disorders who need treatment receive them. Barriers to treatment provision include the fact that CBT typically requires 14–16 sessions by a highly qualified therapist and services are stretched – resulting in lengthy waiting lists and limited access to treatment. This highlights the importance of developing new ways of providing effective treatments for adolescent anxiety disorders. This study aims to assess the feasibility of a future, large-scale trial. This will give a clear indication of the likely success of running a randomised controlled trial to compare a new, brief cognitive therapy treatment to an existing CBT group therapy for adolescents with anxiety disorders.

Methods/design

The study will examine whether a definitive trial can be conducted on the basis of a feasibility RCT using a number of well-defined criteria. The feasibility RCT is a single-centre, randomised control trial. Forty-eight Young people (age 11–17.5 years) attending a university research clinic, who meet the diagnostic criteria for a DSM-5 anxiety disorder, will be randomly allocated to receive either (1) Adolescent Cognitive Therapy for Anxiety (ACTA), which involves six 60–90-min sessions and a booster session or (2) group CBT, which involves eight 2-h sessions and a booster session. As part of the feasibility indicators, patient outcomes, expectations and experiences, as well as health economic factors, will be assessed before, at the end of treatment and at a 3-month follow-up.

Discussion

The successful delivery of a future, definitive trial has the potential to bring direct benefits to young people and their families, adolescent mental health service providers, as well as benefits to adult mental health services and society more broadly by disrupting the negative trajectory commonly associated with adolescent anxiety disorders.

Trial registration

ISRCTN, ID: ISRCTN86123204. Retrospectively registered on 23 November 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3295-6) contains supplementary material, which is available to authorized users.

Efficacy and acceptability of psychological interventions for social anxiety disorder in children and adolescents: a meta-analysis of randomized controlled trials

Social anxiety disorder (SAD) is highly prevalent and persistent in children and adolescents. However, evidence for the efficacy and acceptability of psychological interventions for SAD in children and adolescents remains unclear. Seven electronic databases (PubMed, CENTRAL, Embase, Web of Science, PsycINFO, CINAHL, and ProQuest) were searched. Randomized controlled trials (RCTs) that compared psychological interventions for SAD with control conditions in children and adolescents were included. Primary outcomes were the efficacy (mean change in anxiety symptom scores) and acceptability (dropouts for all reasons). Secondary outcomes were remission, quality of life/functional improvement, and depressive symptoms measures. Seventeen RCTs were included in this meta-analysis. Psychological interventions (including cognitive behavioral therapy and behavioral therapy) were significantly more effective than control conditions, with a standardized mean difference (SMD) of - 1.13, and remission with a risk ratio (RR) of 8.99, the number needed to treat was 3.3. There was no statistically significant difference between psychological interventions and control conditions for all-cause dropouts (RR = 1.00). Psychological interventions were superior to control conditions in improving quality of life/functioning (SMD = 0.79) and reducing depressive symptoms (SMD = - 0.39). Given considerable heterogeneity of primary efficacy outcome, a series of subgroup analyses of different variables were conducted. Psychological interventions are probably efficacious in the treatment of SAD among children and adolescents, and may markedly improve quality of life and functioning in this population. However, this finding should be interpreted with caution because of the high heterogeneity of trials and low literature quality.

Exploring the role of the DSM-5 performance-only specifier in adolescents with social anxiety disorder

The DSM-5 social anxiety disorder section has recently added the performance-only specifier for individuals whose anxiety is limited to speaking or performing in public. The impact of the DSM-5 performance-only specifier remains a neglected area. The sample comprised 44 healthy controls and 50 adolescents with a clinical diagnosis of SAD (20% met criteria for the performance-only specifier). Findings revealed that adolescents with the specifier had a later age of onset; lower levels of depression, social anxiety symptomatology and clinical severity; and a lesser degree of comorbidity relative to adolescents with SAD but excluding the performance-only specifier. Specifiers only evidenced higher (cognitive) social anxiety symptomatology compared to healthy controls. Results of this study also suggested that the performance-only specifier may correspond to a mild form of social anxiety disorder. Data also revealed that SAD exists on a continuum of severity among healthy controls, specifier participants, and those with both interactional and performance fears, which is consistent with a dimensional structure for SAD. Finally, findings suggested a unique comorbid pattern for specifiers and those adolescents with SAD but excluding the performance-only specifier. The implications of these findings for the etiology, assessment, classification, and treatment of social anxiety in youth are discussed.

Adaptive School-based Implementation of CBT (ASIC): clustered-SMART for building an optimized adaptive implementation intervention to improve uptake of mental health interventions in schools

Background

Depressive and anxiety disorders affect 20–30% of school-age youth, most of whom do not receive adequate services, contributing to poor developmental and academic outcomes. Evidence-based practices (EBPs) such as cognitive behavioral therapy (CBT) can improve outcomes, but numerous barriers limit access among affected youth. Many youth try to access mental health services in schools, but school professionals (SPs: counselors, psychologists, social workers) are rarely trained adequately in CBT methods. Further, SPs face organizational barriers to providing CBT, such as lack of administrative support. Three promising implementation strategies to address barriers to school-based CBT delivery include (1) Replicating Effective Programs (REP), which deploys customized CBT packaging, didactic training in CBT, and technical assistance; (2) coaching, which extends training via live supervision to improve SP competence in CBT delivery; and (3) facilitation, which employs an organizational expert who mentors SPs in strategic thinking to promote self-efficacy in garnering administrative support. REP is a relatively low-intensity/low-cost strategy, whereas coaching and facilitation require additional resources. However, not all schools will require all three strategies. The primary aim of this study is to compare the effectiveness of a school-level adaptive implementation intervention involving REP, coaching, and facilitation versus REP alone on the frequency of CBT delivered to students by SPs and student mental health outcomes. Secondary and exploratory aims examine cost-effectiveness, moderators, and mechanisms of implementation strategies.

Methods

Using a clustered, sequential multiple-assignment, randomized trial (SMART) design, ≥ 200 SPs from 100 schools across Michigan will be randomized initially to receive REP vs. REP+coaching. After 8 weeks, schools that do not meet a pre-specified implementation benchmark are re-randomized to continue with the initial strategy or to augment with facilitation.

Discussion

EBPs need to be implemented successfully and efficiently in settings where individuals are most likely to seek care in order to gain large-scale impact on public health. Adaptive implementation interventions hold the promise of providing cost-effective implementation support. This is the first study to test an adaptive implementation of CBT for school-age youth, at a statewide level, delivered by school staff, taking an EBP to large populations with limited mental health care access.

Trial registration

NCT03541317—Registered on 29 May 2018 on ClinicalTrials.gov PRS

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0808-8) contains supplementary material, which is available to authorized users.

Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995)

Social anxiety disorder is a condition characterised by a marked and persistent fear of being humiliated or scrutinised by others. Age-of-onset data point to adolescence as a developmentally sensitive period for the emergence of the condition, at a time when the peer group becomes increasingly important. Social anxiety in adolescence is associated with considerable impairment that persists through to adulthood. There are clear potential benefits to delivering effective interventions during adolescence. However, there is limited evidence on the specific efficacy of available therapies. This is in contrast to adults, for whom we have interventions with very specific treatment effects. One such treatment is individual cognitive therapy. Cognitive therapy is based on the cognitive model of social anxiety proposed by Clark and Wells (in: Heimberg, Leibowitz, Hope, Scheiber (eds) Social phobia: diagnosis, assessment and treatment, The Guilford Press, New York, 1995). The present review examines the potential application of this adult cognitive model to the understanding of adolescent social anxiety and considers additional adolescent-specific factors that need to be accommodated. It is suggested that a developmentally sensitive adoption of the cognitive model of social anxiety disorder (Clark and Wells 1995) for adolescents may lead to better treatment outcomes.

Group CBT for Externalizing Disorders in Urban Schools: Effect of Training Strategy on Treatment Fidelity and Child Outcomes

Public schools are an ideal setting for the delivery of mental health services to children. Unfortunately, services provided in schools, and more so in urban schools, have been found to lead to little or no significant clinical improvements. Studies with urban school children seldom report on the effects of clinician training on treatment fidelity and child outcomes. This study examines the differential effects of two levels of school-based counselor training: training workshop with basic consultation (C) vs. training workshop plus enhanced consultation (C+) on treatment fidelity and child outcomes. Fourteen school staff members (counselors) were randomly assigned to C or C+. Counselors implemented a group cognitive behavioral therapy protocol (Coping Power Program, CPP) for children with or at risk for externalizing behavior disorders. Independent coders coded each CPP session for content and process fidelity. Changes in outcomes from pre to post were assessed via a parent psychiatric interview and interviewer-rated severity of illness and global impairment. Counselors in C+ delivered CPP with significantly higher levels of content and process fidelity compared to counselors in C. Both C and C+ resulted in significant improvement in interviewer-rated impairment; the conditions did not differ from each other with regard to impairment. Groups did not differ with regard to pre- to- posttreatment changes in diagnostic severity level. School-based behavioral health staff in urban schools are able to implement interventions with fidelity and clinical effectiveness when provided with ongoing consultation. Enhanced consultation resulted in higher fidelity. Enhanced consultation did not result in better student outcomes compared to basic consultation. Implications for resource allocation decisions with staff training in EBP are discussed.

Social and academic functioning in adolescents with anxiety disorders: A systematic review

BACKGROUND

Anxiety disorders are highly prevalent during adolescence. Although literature points out that anxiety symptoms are related to problems in social and academic functioning, the extent of these problems among adolescents with clinical anxiety disorders has not been systematically reviewed before.

METHODS

Electronic databases were searched up to October 2017, with keywords representing anxiety disorders, adolescents, and social or academic functioning. The inclusion criteria were studies with a sample of adolescents (10-19 years) with anxiety disorders that provided data regarding their social or academic functioning. 3431 studies were examined, of which 19 met the inclusion criteria.

RESULTS

Adolescents with anxiety disorders had a lower social competence relative to their healthy peers. They reported more negativity within interpersonal relationships, higher levels of loneliness, and victimization. Most adolescents with anxiety disorders felt impaired at school, however, findings of their average school results, compared to peers, were mixed. In addition, they had a higher risk for school refusal and entered higher education less often. Impairments in social and academic functioning differed across type and the number of anxiety disorders.

LIMITATIONS

Most studies examined social phobia or anxiety disorders in general and methodological approaches varied widely between studies.

CONCLUSIONS

This systematic review indicates that adolescents with anxiety disorders experience a range of significant problems in both social and academic functioning. These findings suggest that the assessment and treatment of anxiety disorders in adolescence should focus on improving functioning across domains.

Assessing Clinical Improvement in School-Based Treatment for Social Anxiety Disorder: Agreement Between Adolescents, Parents, and Independent Evaluators

The Clinical Global Impressions of Improvement (CGI-I) scale is widely used in clinical trials to monitor clinically meaningful change during treatment. Although it is standard practice in research to have independent evaluators (IEs) complete the CGI-I, this approach is not practical in school and community settings. Few studies have explored the potential utility of other informants, such as youth and parents. Therefore, this study aimed to investigate agreement between IEs and both adolescents and parents in CGI-I improvement ratings in the context of a randomized controlled trial of cognitive-behavioral therapy for social anxiety disorder, as delivered by psychologists and school counselors. Multilevel growth models indicated that IEs were generally more conservative in their ratings of positive treatment response across time and treatment conditions, though greater agreement was observed between parents and IEs by post-intervention and 5-month follow-up. Possible explanations for these findings and suggestions for alternative approaches are discussed.

Applying new evidence standards to youth cognitive behavioral therapies - A review

This review included 136 published randomized controlled trials (RCTs) of youth cognitive behavioral therapy (CBT) treatments. We aimed to test the premise that evidence-based youth treatments can be better differentiated from each other by applying more nuanced standards of evidence. Accordingly, we applied three standards to this article sample to determine how many treatments produced significant results: (a) on multiple target symptom measures, (b) at follow-up, and/or (c) against an active comparison group. We identified how many trials met standards individually and in combination. Although 87 of the 136 articles produced at least one significant treatment result at post-assessment, the subsets of "passing" articles were smaller and varied for any one of our three standards, with only 11 articles (8%) meeting all three standards simultaneously. Implications are discussed regarding the definition of "evidence-based," the need for multi-parameter filtering in treatment selection and clinical decision making, and future directions for research. We ultimately argue the value in assessing youth treatments for different types of evidence, which is better achieved through dynamic sets of standards, rather than a single approach to assessing general strength of evidence.

Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders

The present article uses meta-analysis to examine treatment components related to outcome within 35 randomized controlled trials (RCTs) for childhood anxiety disorders (CADs) and eight RCTs for childhood obsessive compulsive disorder (OCD). Examination of the RCTs of cognitive behavioral therapy (CBT) for CADs suggested that adding relaxation and delaying exposures until after the introduction of other anxiety management strategies does not increase the efficacy of exposure-based treatment. In addition, compared to the large effect size (ES) associated with exposure and response prevention (ERP) for OCD (k = 9, mean ES = 1.93), the effect size associated with CBT for CADs (k = 44, mean ES = 0.89) did not differentiate from attention placebo (k = 11, mean ES = 0.55), although it was more effective than waitlist control (k = 24, mean ES = 0.22). Instructively, ERP for OCD involved more exposure initiated earlier and less relaxation than CBT for CADs. In addition, RCTs of ERP were more likely to use clinician-administered measures as opposed to self-report and to be conducted in clinical versus recruited samples. These results suggest that dismantling studies using a gold-standard clinician-rated outcome measure to compare the value of adding anxiety management strategies to exposure will be necessary to increase the efficacy of CBT for CADs to levels achieved by ERP for OCD.

Can school counselors deliver cognitive-behavioral treatment for social anxiety effectively? A randomized controlled trial

BACKGROUND

Social anxiety disorder (SAD) typically onsets in adolescence and is associated with multiple impairments. Despite promising clinical interventions, most socially anxious adolescents remain untreated. To address this clinical neglect, we developed a school-based, 12-week group intervention for youth with SAD, Skills for Academic and Social Success (SASS). When implemented by psychologists, SASS has been found effective. To promote dissemination and optimize treatment access, we tested whether school counselors could be effective treatment providers.

METHOD

We randomized 138, ninth through 11th graders with SAD to one of three conditions: (a) SASS delivered by school counselors (C-SASS), (b) SASS delivered by psychologists (P-SASS), or (c) a control condition, Skills for Life (SFL), a nonspecific counseling program. Blind, independent, evaluations were conducted with parents and adolescents at baseline, post-intervention, and 5 months beyond treatment completion. We hypothesized that C-SASS and P-SASS would be superior to the control, immediately after treatment and at follow-up. No prediction was made about the relative efficacy of C-SASS and P-SASS.

RESULTS

Compared to controls, adolescents treated with C-SASS or P-SASS experienced significantly greater improvement and reductions of anxiety at the end of treatment and follow-up. There were no significant differences between SASS delivered by school counselors and psychologists.

CONCLUSION

With training, school counselors are effective treatment providers to adolescents with social anxiety, yielding benefits comparable to those obtained by specialized psychologists. Questions remain regarding means to maintain counselors' practice standards without external support.

A comprehensive meta-analysis of cognitive-behavioral interventions for social anxiety disorder in children and adolescents

The effectiveness of different types of CBT for children and adolescents suffering from Social Anxiety Disorder (SAD) is generally supported. However, no systematic efforts have been made to quantitatively summarize and analyse the impact of specific variables on therapeutic outcome. Here, we assessed the magnitude and duration of CBT effectiveness in children and adolescents with SAD. The effectiveness of CBT was supported by the effect sizes of studies that had examined pre-post (g=0.99), between-group (g=0.71), and follow-up responses (follow-up vs. pre-test mean g=1.18, follow-up vs. post-test mean g=0.25). A significant moderating effect was found for the variable "number of treatment sessions". In addition, larger effect sizes were found in studies that included "Social Skills Training" sessions in the intervention package. Data support the effectiveness of CBT interventions and its durability for SAD in children and adolescents. Adding social skills training to the intervention package can further enhance the impact of treatment.

A hybrid effectiveness-implementation cluster randomized trial of group CBT for anxiety in urban schools: rationale, design, and methods

Background

Schools present a context with great potential for the implementation of psychosocial evidence-based practices. Cognitive behavioral therapy (CBT) is an evidence-based practice that has been found to be very effective in treating anxiety in various community settings, including schools. Friends for Life (FRIENDS) is an efficacious group CBT protocol for anxiety. Unfortunately, evidence-based practices for anxiety are seldom employed in under-resourced urban schools, because many treatment protocols are not a good fit for the urban school context or the population, existing behavioral health staff do not receive adequate training or support to allow them to implement the treatment with fidelity, or school districts do not have the resources to contract with external consultants. In our prior work, we adapted FRIENDS to create a more culturally sensitive, focused, and feasible CBT protocol for anxiety disorders (CBT for Anxiety Treatment in Schools (CATS)).

Methods/design

The aim of this 5-year study is to evaluate both the effectiveness of CATS for urban public schools compared to the original FRIENDS as well as compare the implementation strategies (train-the-trainer vs. train-the-trainer + ongoing consultation) by conducting a three-arm, parallel group, type 2 hybrid effectiveness-implementation trial in 18 K-8 urban public schools. We will also assess the cost-effectiveness and the mediators and moderators of fidelity. Ninety therapists, 18 agency supervisors, and 360 children will participate. The interactive systems framework for dissemination and implementation guides the training and support procedures for therapists and supervisors.

Discussion

This study has the potential to demonstrate that agency therapists and supervisors who have had little to no prior exposure to evidence-based practices (EBPs) can implement an anxiety disorder EBP with fidelity. Comparisons of the implementation strategies would provide large urban mental health systems with data to make decisions about the adoption of EBPs.

Trial registration

ClinicalTrials.gov, NCT02651402

School-Based Interventions for Anxious Children: Long-Term Follow-Up

This study examined the long-term outcomes of a nonclinical sample of anxious children (N = 61) who were randomized by school to 9 weeks of group cognitive-behavioral therapy (CBT) for children, group CBT for children plus parent training, or no-treatment control. Parents and children completed measures of anxiety symptoms at baseline, posttreatment, and at 3-, 6-, 12-month, 2-, and 3-year posttreatment follow-ups. Piecewise longitudinal growth curve analyses were applied to the data. When the two CBT groups were combined and compared with control, the combined treatment group showed significantly greater reduction in children's anxiety severity based on the parent ratings in the first longitudinal phase. However, on the parent Clinician Severity Rating, gains were maintained to 3 years. Child report revealed no significant differences between groups on anxiety reduction. This study maintained a small no-treatment control group during the entire follow-up period. From parental perspective only, school-based group CBT appeared to be beneficial in decreasing severity of anxiety symptoms and maintaining gains over time.

Examining Effectiveness of Group Cognitive-Behavioral Therapy for Externalizing and Internalizing Disorders in Urban Schools

This article presents outcome data of the implementation of three group cognitive-behavioral therapy (GCBT) interventions for children with externalizing behavior problems, anxiety, and depression. School counselors and graduate students co-led the groups in two low-income urban schools. Data were analyzed to assess pre-treatment to post-treatment changes in diagnostic severity level. Results of the exploratory study indicated that all three GCBT protocols were effective at reducing diagnostic severity level for children who had a primary diagnosis of an externalizing disorder, anxiety disorder, or depressive disorder at the clinical or intermediate (at-risk) level. All three GCBT protocols were implemented with relatively high levels of fidelity. Data on the effectiveness of the interventions for reducing diagnostic severity level for externalizing and internalizing spectrum disorders and for specific disorders are presented. A discussion of implementation of mental health evidence-based interventions in urban schools is provided.

Social Anxiety and Mental Health Service Use Among Asian American High School Students

Asian American adults endorse more symptoms of social anxiety (SA) on self-report measures than European Americans, but demonstrate lower prevalence rates of SA disorder in epidemiological studies. These divergent results create ambiguity concerning the mental health needs of Asian Americans. The present study is the first to investigate this issue in adolescents through assessment of self-reported SA in Asian American high school students. Parent and self-ratings of impairment related to SA and self-reported mental health service use for SA were also measured. Asian American students endorsed a greater number of SA symptoms and scored in the clinical range more frequently than other ethnic groups. Also, Asian American and Latino students endorsed more school impairment related to SA than other ethnic groups. No differences in parent-reported impairment or service utilization were identified. Implications for future research and treatment for SA among Asian American adolescents are discussed.