What steps to take? How to approach concerning anxiety in youth

Integrated psychological care in pediatric hospital settings for children with complex chronic illness and their families: a systematic review

OBJECTIVE

To synthesize and critically evaluate evidence on the effectiveness of integrated psychological care models for children with complex chronic illness within pediatric hospital settings and provide recommendations for successful implementation.

DESIGN

Six electronic databases (Medline, Cochrane, Embase, PsycINFO, Scopus, CINAHL) were systematically searched for English language studies including families of children aged 0-17 years with complex chronic illness. Eligible studies reported on psychology or neuropsychology screening, assessment, intervention, or services provided within a pediatric hospital setting.

RESULTS

Fifteen studies were identified for review; nine assessed a psychological service, five examined psychosocial screening, and one examined a neuropsychology service. Three studies demonstrated the effectiveness of integrated psychological services in improving child or parent physical, psychological, or behavioral health outcomes. Uptake of psychosocial screening was high (84-96%), but only 25-37% of children or families identified as 'at-risk' engaged with on-site psychology services. Integrated psychological services offering consultations at the same time and location as the child's medical visit reported the highest rates of uptake (77-100%).

CONCLUSIONS

The available evidence supports co-location of child medical and psychological services. A more consistent and comprehensive approach to the assessment of patient- and caregiver-reported outcomes and implementation effectiveness is recommended.

Practitioner Review: Signposts for Enhancing Cognitive-Behavioral Therapy for School Refusal in Adolescence

Factors associated with adolescent development influence the occurrence and presentation of school refusal (SR). Cognitive-behavioral therapy (CBT) manuals for the treatment of SR account for these developmental issues to varying degrees. Some multimodal treatments aim to address the complexity of adolescent SR by incorporating interventions alongside CBT, such as medication, inpatient treatment, and educational support in a special setting. However, CBT manuals and multimodal treatments appear to fail to help approximately one-third to two-thirds of adolescents, with respect to achieving regular school attendance. This paper provides an overview of suggestions in the literature for improving treatment for SR, with a focus on adolescent SR. Seven signposts emerge from the literature, namely, increased number or frequency of sessions, greater attention to social anxiety disorder and social functioning, greater attention to depression, greater attention to emotion regulation, careful consideration of the role of parents, greater attention to parent-adolescent communication and problem-solving, and the use of alternative educational settings. Professionals may find these signposts helpful when planning and delivering treatment for SR in adolescents. Research is needed to determine the benefit of including one or more of these adaptations alongside an existing SR treatment.

Attention Training as a Low-Intensity Treatment for Concerning Anxiety in Clinic-Referred Youth

Although youth anxiety treatment research has focused largely on severe and impairing anxiety levels, even milder anxiety levels, including levels that do not meet full criteria for a diagnosis, can be impairing and cause for concern. There is a need to develop and test viable treatments for these concerning anxiety levels to improve functioning and reduce distress. We present findings from a randomized controlled efficacy trial of attention bias modification treatment (ABMT) and attention control training (ACT) for youths with concerning anxiety levels. Fifty-three clinic-referred youths (29 boys, M age = 9.3 years, SD age = 2.6) were randomized to either ABMT or ACT. ABMT and ACT consisted of attention-training trials in a dot-probe task presenting angry and neutral faces; probes appeared in the location of neutral faces in 100% of ABMT trials and 50% of ACT trials. Independent evaluators provided youth anxiety severity ratings; youths and parents provided youth anxiety severity and global impairment ratings; and youths completed measures of attention bias to threat and attention control at pretreatment, posttreatment, and 2-month follow-up. In both arms, anxiety severity and global impairment were significantly reduced at posttreatment and follow-up. At follow-up, anxiety severity and global impairment were significantly lower in ACT compared with ABMT. Attention control, but not attention bias to threat, was significantly improved at follow-up in both arms. Changes in attention control and attention focusing were significantly associated with changes in anxiety severity. Findings support the viability of attention training as a low-intensity treatment for youths with concerning anxiety levels, including levels that do not meet full criteria for a diagnosis. Superior anxiety reduction effects in ACT highlight the critical need for mechanistic research on attention training in this population.

Systematic identification and stratification of help-seeking school-aged youth with mental health problems: a novel approach to stage-based stepped-care

We investigated whether a novel visitation model for school-aged youth with mental health problems based on a stage-based stepped-care approach facilitated a systematic identification and stratification process without problems with equity in access. The visitation model was developed within the context of evaluating a new transdiagnostic early treatment for youth with anxiety, depressive symptoms, and/or behavioural problems. The model aimed to identify youth with mental health problems requiring an intervention, and to stratify the youth into three groups with increasing severity of problems. This was accomplished using a two-phase stratification process involving a web-based assessment and a semi-structured psychopathological interview of the youth and parents. To assess problems with inequity in access, individual-level socioeconomic data were obtained from national registers with data on both the youth participating in the visitation and the background population. Altogether, 573 youth and their parents took part in the visitation process. Seventy-five (13%) youth had mental health problems below the intervention threshold, 396 (69%) were deemed eligible for the early treatment, and 52 (9%) had symptoms of severe mental health problems. Fifty (9%) youth were excluded for other reasons. Eighty percent of the 396 youth eligible for early treatment fulfilled criteria of a mental disorder. The severity of mental health problems highlights the urgent need for a systematic approach. Potential problems in reaching youth of less resourceful parents, and older youth were identified. These findings can help ensure that actions are taken to avoid equity problems in future mental health care implementations.

Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults

AIMS

Many young people with mental health and/or substance use concerns do not have access to timely, appropriate, and effective services. Within this context, stepped care models (SCMs) have emerged as a guiding framework for care delivery, inspiring service innovations across the globe. However, substantial gaps remain in the evidence for SCMs as a strategy to address the current systemic challenges in delivering services for young people. This scoping review aims to identify where these gaps in evidence exist, and the next steps for addressing them.

METHODS

A scoping review was conducted involving both peer-reviewed and grey literature. Eligible studies explored SCMs implemented in the various health care settings accessed by young people aged 12-24 seeking treatment for mental health and substance use challenges. After screening titles and abstracts, two reviewers examined full-text articles and extracted data to create a descriptive summary of the models.

RESULTS

Of the 656 studies that were retrieved, 51 studies were included and grouped by study team for a final yield of 43 studies. Almost half of the studies were focused on the adult population (i.e., 18 and over), and most did not specify interventions for young people. Among the SCMs, substantial variability was found in almost every aspect of the models.

CONCLUSIONS

Considering the current body of evidence, there is an urgent need for a consensus position on the definition, implementation, and outcome measures required for rigorously assessing the utility of SCMs for young people.

Smooth Sailing: A Pilot Study of an Online, School-Based, Mental Health Service for Depression and Anxiety

Background: Schools play an important role in supporting young people's mental health, but face challenges identifying and responding to students in need of care. To assist secondary schools, the Black Dog Institute has developed an online, school-based, mental health service (Smooth Sailing). Delivered in the classroom, Smooth Sailing uses a website to screen, assess, allocate, and deliver care for depression and anxiety. The service is based on the principles of stepped care, offering treatments with varied intensity and follow-up by a school counselor when necessary. The current study aimed to evaluate the feasibility, acceptability, and safety of this new type of service among secondary school students. Methods: Between February and June 2017, a single-arm, pre-post, pilot study was conducted among students from four NSW secondary schools. Schools were given access to the service for 6 weeks. Feasibility measures (consent rates and step allocations), acceptability measures (service use and satisfaction) and safety measures (deterioration in help-seeking intention scores and mental health symptoms) were assessed at baseline and completion of the 6-week trial period. Results: A total of 59 students took part in the service pilot (mean age, 14.57 years; SD, 0.89 years; range, 13-16 years). At baseline, 18.64% of students were found to require follow-up from the school counselor, and 80% of these were new cases. Although completion of the online modules was low, service satisfaction was high. At 6 weeks, the mean scores for help-seeking, depression, and anxiety remained relatively stable or improved. Conclusions: The current study presents important findings for the development and implementation of an online mental health service that screens students' mental health and allocates care accordingly, all within the school setting. Although the findings provide some support for the feasibility, acceptability, and safety, service improvements are needed. The modifications outlined are likely to improve the quality of the service and its effectiveness. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12617000977370.

A Cost Analysis of a Stepped Care Treatment Approach for Anxiety Disorders in Youth

To address the high demand for youth anxiety treatment, researchers have begun to evaluate stepped care approaches to use limited resources efficiently. Quantifying cost savings can inform policy decisions about optimal ways to use limited resources. This study presents a cost analysis of a stepped care treatment approach for anxiety disorders in youth. Youths (N = 112) completed an 8-session computer-administered attention bias modification treatment (Step 1), and families were given the option to "step up" to cognitive behavioral therapy (CBT; Step 2). Stepped care treatment cost estimates were based on (a) resources used in treatment (i.e., clinician/paraprofessional time, equipment/materials) and (b) Medicaid reimbursement rates for clinician and paraprofessional time. We compared these two cost estimates with a hypothetical standard treatment approach for youth anxiety disorders: CBT only. We also tested predictive models to determine whether they could guide decisions about which youths, based on baseline characteristics, should be assigned to stepped care or directly to CBT only to avoid the costs associated with Step 1. Compared to a hypothetical standard CBT approach, the stepped care treatment was associated with an overall cost savings of 44.4% for the Medicaid reimbursement model and 47.7% for the resource cost model. The predictive models indicated that assigning all youths to stepped care would be more cost-effective than assigning certain youths directly to CBT only. This study provides the first evidence that a stepped care treatment approach for youth anxiety is associated with substantial cost savings compared with a standard CBT.

Can less be more? Open trial of a stepped care approach for child and adolescent anxiety disorders

This open trial presents a stepped care treatment approach for youths with anxiety disorders. In Step 1, 124 youths (65 girls; M age=9.7years) participated in a low intensity computer administered attention bias modification (ABM) protocol. Statistically significant reductions in youth anxiety severity were found following Step 1. Youths and parents were then given the option to not continue with further treatment or step up to a higher intensity cognitive behavioral therapy (CBT) protocol (Step 2). Of 112 youths who completed Step 1, 67 (59.8%) discontinued treatment and 45 (40.2%) stepped up. Co-occurring ADHD and higher anxiety severity at baseline were significantly associated with the decision to step up. Of those youths who completed Step 2, additional statistically significant reductions in youth anxiety severity were found. Across the entire protocol, 68.6% of youths were rated as either very much improved or much improved on the Clinical Global Impressions-Improvement scale. In a hypothetical comparison in which all youths received CBT alone, the stepped care protocol resulted in approximately 50% less time in treatment sessions. These findings support the promise of initiating youth anxiety disorder treatment with low intensity treatment and then stepping up to higher intensity treatment as needed.

Anxiety and Atopic Disease: Comorbidity in a Youth Mental Health Setting

Anxiety frequently co-occurs with atopic diseases (e.g., allergies) in community samples, although data are limited to community and pediatric medical samples. Little work has examined atopy rates among mental health treatment seeking youth or whether youth with comorbid anxiety and atopy present similarly to non-comorbid youth. Using initial intake data from a University-based specialty youth clinic for anxiety and depressive disorders (n = 189), rates of atopic comorbidity were benchmarked against lifetime prevalence estimates in epidemiological samples. Anxiety severity and parental stress were compared between youth with and without atopy. Results indicated high rates of atopy in the clinical sample (51.3 %) relative to population atopy estimates (34.5 %). Anxious youth with atopy exhibited more overall and generalized anxiety symptoms relative to non-atopic youth (ps < .05); parental stress was comparable between atopic and non-atopic anxious youth. This suggests potentially heightened clinical severity for youth with co-occurring anxiety and atopy.