The impact of treatment delivery format on response to cognitive behaviour therapy for preadolescent children with anxiety disorders

Patterns of sub-optimal change following CBT for childhood anxiety

BACKGROUND

Children and adolescents demonstrate diverse patterns of symptom change and disorder remission following cognitive behavioural therapy (CBT) for anxiety disorders. To better understand children who respond sub-optimally to CBT, this study investigated youths (N = 1,483) who continued to meet criteria for one or more clinical anxiety diagnosis immediately following treatment or at any point during the 12 months following treatment.

METHODS

Data were collected from 10 clinical sites with assessments at pre-and post-treatment and at least once more at 3, 6 or 12-month follow-up. Participants were assigned to one of three groups based on diagnostic status for youths who: (a) retained an anxiety diagnosis from post to end point (minimal responders); (b) remitted anxiety diagnoses at post but relapsed by end point (relapsed responders); and (c) retained a diagnosis at post but remitted to be diagnosis free at end point (delayed responders). Growth curve models assessed patterns of change over time for the three groups and examined predictors associated with these patterns including demographic, clinical and parental factors, as well as treatment factors.

RESULTS

Higher primary disorder severity, being older, having a greater number of anxiety disorders, having social anxiety disorder, as well as higher maternal psychopathology differentiated the minimal responders from the delayed and relapsed responders at the baseline. Results from the growth curve models showed that severity of the primary disorder and treatment modality differentiated patterns of linear change only. Higher severity was associated with significantly less improvement over time for the minimal and relapsed response groups, as was receiving group CBT, when compared to the delayed response group.

CONCLUSIONS

Sub-optimal response patterns can be partially differentiated using variables assessed at pre-treatment. Increased understanding of different patterns of change following treatment may provide direction for clinical decision-making and for tailoring treatments to specific groups of clinically anxious youth. Future research may benefit from assessing progress during treatment to detect emerging response patterns earlier.

Parent-Led Cognitive Behavioral Teletherapy for Anxiety in Autistic Youth: A Randomized Trial Comparing Two Levels of Therapist Support

Parent-led cognitive behavioral therapy (CBT) is an efficient, promising form of therapy that may be well suited for autistic youth with anxiety disorders, though to date it has been minimally tested. In this study, 87 autistic youth (7 to 13 years old) with anxiety disorders and their parents were randomized to two forms of parent-led CBT in which parents led their child through a guided CBT workbook across 12 weeks: one with low therapist contact (four 30-minute telehealth calls), and one with standard therapist contact (ten 60-minute telehealth calls). Anxiety, functional impairment, and autism features significantly declined across therapy, without differences between groups. High satisfaction was reported in both groups, though significantly higher satisfaction ratings were reported in standard-contact CBT. Responder rates were 69% of completers at posttreatment (70% in standard contact, 68% in low contact) and 86% at 3-month follow-up (86% in standard contact, 87% in low contact). Low-contact CBT was estimated to incur an average cost of $755.70 per family compared with $1,978.34 in standard-contact CBT. Parent-led CBT with minimal or standard therapist contact both appear to be effective CBT delivery formats for autistic youth with anxiety disorders, with significant cost savings for low-contact CBT.

Randomized trial comparing standard versus light intensity parent training for anxious youth

OBJECTIVE

To examine the efficacy of the parent-led intervention Supportive Parenting for Anxious Childhood Emotions (SPACE) relative to a low-dose version of the protocol among children and adolescents with clinically significant anxiety and/or obsessive-compulsive disorder (OCD).

METHOD

68 youth (7-17) with anxiety/OCD and their parents were randomized to receive 12 weekly telehealth SPACE sessions (SPACE-Standard) or bibliotherapy plus 4 telehealth sessions over 12 weeks (SPACE-light). After screening, assessments were conducted via videoconferencing at baseline, post-treatment, and one-month follow-up. Independent evaluators were blind to treatment condition.

RESULTS

Treatment condition did not predict whether a participant responded to the intervention (SPACE-Standard = 70%; SPACE-Light = 68%), nor was treatment condition a predictor of anxiety severity, parent-reported anxiety, or parent-/child-reported functional impairment at post-treatment or one-month follow-up. Youth in SPACE-Light self-reported higher post-treatment anxiety than youth in SPACE-standard, though this was no longer significant at one-month follow-up. Parent-reported family accommodation total change scores were associated with anxiety severity at post-treatment across both arms.

CONCLUSION

This is the second randomized controlled trial (RCT) evaluating SPACE and provides further support for the efficacy of this intervention both in standard and low-dose formats. This study provides support for parent-led anxiety treatment targeting family accommodation as a primary mechanism of change and extends evidence of efficacy to a more clinically diverse sample.

TRIAL REGISTRATION

ClinicalTrials.gov Registry: NCT04922502.https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04922502.

Parent-led cognitive behaviour therapy for child anxiety problems: overcoming challenges to increase access to effective treatment

BACKGROUND

Anxiety problems have a particularly early age of onset and are common among children. As we celebrate the anniversary of the BABCP, it is important to recognise the huge contribution that cognitive behavioural therapy (CBT) has made to the treatment of anxiety problems in children. CBT remains the only psychological intervention for child anxiety problems with a robust evidence base, but despite this, very few children with anxiety problems access CBT. Creative solutions are urgently needed to ensure that effective treatments can be delivered at scale. Here we focus on parent-led CBT as this offers a potential solution that is brief and can be delivered by clinicians without highly specialised training. Over the last decade there has been a substantial increase in randomised controlled trials evaluating this approach with consistent evidence of effectiveness. Nonetheless clinicians, and parents, often have concerns about trying the approach and can face challenges in its delivery.

METHOD

We draw on empirical evidence and our clinical experience to address some of these common concerns and challenges, with particular emphasis on the key principles of empowering parents and working with them to provide opportunities for new learning for their children.

CONCLUSIONS

We conclude by highlighting some important directions for future research and practice, including further evaluation of who does and does not currently benefit from the approach, determining how it should be adapted to optimise outcomes among groups that may not currently get maximum benefits and across cultures, and capitalising on recent technological developments to increase engagement and widen access.

Cool Kids: Cognitive Behavioral Therapy in a Spanish Sample of Children and Adolescents with Anxiety Disorders

Anxiety disorders (ADs) negatively impact functioning and life quality. Studies on cognitive behavioral therapy (CBT) have demonstrated its short- and long-term efficacy. Cool Kids (CK) is a 10-session CBT-based group program administered to participants with ADs aged 7-17 years and their parents, and it has demonstrated efficacy compared with control groups. This study analyzes the effectiveness of CK in a clinical cohort of Spanish children and adolescents with ADs. CK was offered to 57 patients with AD and their caregivers at the Hospital Clínic, Barcelona. In all global registered measures, the results demonstrated a reduction of symptoms and their interference in daily functioning. Moreover, a significant improvement was observed in participants who completed more sessions. Thus, CK reduced the severity of anxiety and its interference over individual and family functioning.

Parent-Led Cognitive Behavioural Therapy for Children with Autism Spectrum Conditions. A Pilot Study

This article reports on a pilot study of a parent-only cognitive behavioural therapy (CBT) programme for parents of children with autism spectrum disorders (ASD) and anxiety difficulties. Twenty-one parents of anxious children with ASD (5-11 of age) completed the From Timid to Tiger intervention. Parent outcome measures were assessed at post-intervention and at 3-month follow-up. Analysis indicated significant reductions in both parent and clinician reports of child anxiety symptoms. Specifically, 38% of children were free of their primary diagnosis at treatment end and this increased to 57% when measured at 3-month follow-up. Positive gains were evidenced regarding parents' ability to manage their child's anxiety without accommodating to it. The results provide preliminary evidence of parent-only CBT programs for children with ASD.

Receipt of evidence-based care for children and adolescents with anxiety in Australia

OBJECTIVE

Cognitive-behavioural therapy is recommended as the first-line treatment for children and adolescents with anxiety. Despite its efficacy, a recent United Kingdom study indicated that few children with anxiety disorders receive cognitive-behavioural therapy. The primary aim of this study was to examine the receipt of cognitive-behavioural therapy for children and adolescents with elevated anxiety symptoms in Australia. Second, this study also examined whether there was a difference in the type of treatment received based on socioeconomic status and geographical location.

METHOD

Using self-reported questionnaires, parents of children aged 4-18 years and children aged 12-18 years (N = 784; elevated anxiety symptom sample n = 169) were recruited from four samples: community (n = 164), school (n = 177), clinic (n = 16) and online panel provider (n = 427). Participants reported on the child's anxiety symptoms and the type of treatment (if any) the child received for their anxiety symptoms.

RESULTS

Results indicated that 19.5% of children and adolescents with elevated anxiety symptoms received evidence-based treatment (e.g. cognitive-behavioural therapy). Of those families who did seek help for anxiety in Australia, the majority (66.3%) did not receive cognitive-behavioural therapy. In addition, neither socioeconomic status (which was based on the Australian Index of Community Socio-Educational Advantage [ICSEA]) nor location (metropolitan vs regional/remote) affected whether individuals received evidence-based care or non-evidence-based care.

CONCLUSION

Overall, children and adolescents in this study seeking support for their anxiety symptoms were not receiving adequate evidence-based care, regardless of socioeconomic status and location. These findings indicate there is a need to increase the receipt of cognitive-behavioural therapy for children and adolescents with anxiety symptoms. The findings should tentatively be interpreted, given data were collected during the COVID-19 pandemic.

The impact of parent-only interventions on child anxiety: A systematic review and meta-analysis

BACKGROUND

Parent-only interventions for childhood anxiety may be an important alternative to resource and time intensive child-focused cognitive behavioural therapy (CBT). This systematic review and meta-analysis aimed to investigate the efficacy of parent-only interventions in reducing symptoms of anxiety disorders in school-aged children.

METHODS

A systematic search of five databases (inception to March 2021) identified 29 eligible studies. A range of study designs were captured, including randomised controlled trials (RCTs) and case series. A narrative synthesis was conducted. Random effects meta-analyses were performed on parent- and child-reported outcomes and pre-test post-test effect sizes were calculated for uncontrolled studies.

RESULTS

Findings indicated a significant treatment effect for parent-only interventions compared to waitlist controls. No significant differences were found when comparing parent-only interventions with other active interventions; anxiety symptoms reduced in both conditions. No significant treatment effects were found for child-rated outcomes. Calculated effect sizes for uncontrolled studies were typically large, although sample sizes were small. No clear evidence was found for a superior type, duration or format of intervention.

LIMITATIONS

The methodological quality of many studies in this review (19/29) was rated 'weak'. Only English language papers were included.

CONCLUSIONS

To date, this is the first systematic review and meta-analysis of the efficacy of parent-only interventions for reducing symptoms of child anxiety disorders. Our results suggest that parent-only interventions may be effective in reducing child anxiety. These findings are important for clinical practice because they suggest that efficient, low intensity interventions delivered to parents may lead to positive outcomes for children.

BDNF gene polymorphisms predicting treatment response to CBT-based rehabilitation of depression: to be submitted to: European Neuropsychopharmacology

Genetic factors were shown to play a major role in both variation of treatment response and incidence of adverse effects to medication in affective disorders. Nevertheless, there is still a lack of therapygenetic studies, investigating the prediction of psychological therapy outcomes from genetic markers. Neuroplasticity and one of its mediators, brain-derived neurotrophic factor (BDNF), are potential research targets in this field. We aimed to investigate Tag SNP polymorphisms of the BDNF gene in depressed patients treated with cognitive behavioral therapy (CBT) in the context of a standardized 6-weeks outpatient rehabilitation program. Treatment response was assessed calculating the mean differences in BDI-II (Beck Depression Inventory) scores from admission to discharge. Six BDNF SNPs, including the Val66Met polymorphism (rs6265), were genotyped. Both genotypic data and BDI-II-scores at admission and discharge were available for 277 patients. Three SNPs, rs10501087 (p = 0.005, FDRp=0.015), rs11030104 (p = 0.006, FDRp=0.012), and the Val66Met polymorphism (rs6265, p<0.001, FDRp=0.006), were significantly associated with treatment response in depressed patients, even after multiple testing correction using the false discovery rate method (FDRp). We conclude that BDNF might serve as promising genetic marker for treatment response to psychological treatment in depression. However, due to our limited sample size, further studies are needed to disentangle the role of BDNF as potential therapygenetic marker.

Brief, parent-led, transdiagnostic cognitive-behavioral teletherapy for youth with emotional problems related to the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has led to increased stress, anxiety, and depression in children. A six-session, parent-led, transdiagnostic, cognitive-behavioral teletherapy program was adapted from an established protocol to help youth aged between 5 and 13 years manage emotional problems during the pandemic.

METHODS

One-hundred twenty-nine parents of youth struggling with emotional problems during the COVID-19 pandemic participated in the program. Parents reported on their children's psychosocial functioning before and after treatment using validated assessments. They also reported on treatment satisfaction. Clinician-rated global improvement was assessed at each session to determine clinically significant treatment response.

RESULTS

Significant improvements in parent proxy-reported anxiety (d = 0.56), depression (d = 0.69), stress (d = 0.61), anger (d = 0.69), family relationships (d = 0.32), and COVID-19-related distress (d = 1.08) were found, with 62% of participants who completed the program being classified as treatment responders. Parents reported high levels of satisfaction with the program.

LIMITATIONS

This study was limited by use of primarily parent-report assessments and a lack of a control group.

CONCLUSIONS

Brief, parent-led, transdiagnostic cognitive-behavioral teletherapy appeared to be an effective way to help youth cope with the pandemic and may be a scalable framework in response to large-scale mental health crises.

Evaluation of a parent-led cognitive behaviour therapy programme in routine clinical practice: A controlled trial

Parent-led cognitive behavioural therapy for child anxiety disorders have garnered a growing evidence base. However, it is unclear how such approaches translate into routine clinical practice. The current study aims to evaluate the effectiveness of an 8-session treatment (From Timid to Tiger) in reducing child anxiety and behavioural difficulties, as well as family accommodation. The parents of 71 children (aged 4-11) were assigned to the treatment or a waitlist control. Parent report measures were completed pre-treatment, at treatment-end, and at 3-month follow-up. Parents assigned to the waitlist were assessed 8 weeks after the initial assessment. Findings indicated that parents who attended the group reported significant reductions in child anxiety and behavioural difficulties. In addition, the parents in the treatment group reported a reduction in family accommodation compared to those in the waitlist. The current control trial provides tentative evidence of the use and effectiveness of such parent-led approaches in addressing child anxiety difficulties commonly seen in routine clinical practice. PRACTITIONER POINTS: Parent-led approaches are effective treatments in managing child anxiety difficulties. Very little research to date has assessed the effectiveness of such approaches in routine clinical practice. The From Timid to Tiger program is a brief parent-led CBT intervention. The programme was effective in reducing child anxiety and behavioural difficulties. Parents also reported a reduction in behaviours related to family accommodation. Such programmes show promise and can be used in routine clinical practice.

A systematic review of the use of acceptance and commitment therapy in supporting parents

OBJECTIVES

Acceptance and commitment therapy (ACT) has accrued a growing evidence-base for a wide variety of psychological difficulties. Given that ACT promotes broad and flexible repertoires of behaviour as well as neutralizing the ubiquitous psychological processes theorized to be responsible for much human suffering, such an approach may hold promise. The use of ACT-informed parenting interventions offers another alternative to solely behavioural approaches but it remains relatively understudied and in need of further exploration.

DESIGN

The current systematic review, which searched four databases, aimed to collate all ACT interventions that included parental therapeutic components in the treatment of various child presenting difficulties. The review also rated the methodological rigour of the ACT evidence-base for this type of treatment format.

RESULTS

Twenty-seven individual studies covering a broad spectrum of presenting problems were included, comprising of 1,155 participants. A large proportion of studies were within-group designs with a smaller number using randomized controlled trials. The majority of studies reported improvements on either parent report symptoms regarding child physical or psychological functioning as well as parent-reported measures of stress, depression, and anxiety. Similar improvements were noted on a number of ACT mechanisms of change outcomes, including mindfulness, acceptance, and cognitive fusing. These gains were evident for parents of children with neurodevelopmental disorders, chronic pain, and significant physical health difficulties. Maintenance or further treatment gains were often reported at follow-up. These positive findings are tempered by low levels of methodological rigour common in some of the studies included.

CONCLUSIONS

Despite these limitations, ACT holds promise as a transdiagnostic intervention that can help with the parenting of children with a range of psychological and physical difficulties.

PRACTITIONER POINTS

ACT has accrued a relatively strong evidence base for a range of psychological difficulties. Despite some methodological shortcomings, ACT shows promise as an intervention to help parents manage stress and difficulties especially in relation to children with autism, chronic pain, and physical health needs. Further research is required in comparing ACT to more established treatments and helping consolidate initial positive findings.

The use of acceptance and commitment therapy (ACT) in addressing family accommodation (FA) for child anxiety

Many parents of children with anxiety tend to engage in varying levels of family accommodation (FA) in order to alleviate anxiety symptoms. This can exacerbate anxiety symptoms and have adverse effects for psychological treatments. A small number of general and specific interventions have been developed for FA but treatment research is at a nascent stage. Acceptance and commitment therapy (ACT) may be an effective treatment for FA. This article reviews the potential advantages and uses of ACT and how ACT’s six core processes can help target particular features of FA. The theoretical support for ACT is reviewed relevant to FA. The article concludes by conjecturing how ACT may be a useful and adaptive treatment in targeting FA.

Key learning aims

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Parent-led, stepped-care cognitive-behavioral therapy for youth with autism and co-occurring anxiety: study rationale and method

Anxiety disorders affect up to 50% of individuals with autism spectrum disorder (ASD) and are significantly impairing to the person affected, as well as to their loved ones. Cognitive-behavioral therapy (CBT) has been established as the gold-standard treatment for anxiety disorders among typically developing youth and adults, and demonstrates similar efficacy among youth with high-functioning autism (HFA). Many CBT interventions utilize a "full-package" treatment approach to treat co-occurring anxiety in youth with ASD. However, these service delivery systems are often therapist-intensive, costly, and impractical, thereby compromising full engagement and treatment adherence. This paper describes the design, rationale, and methodology of a study examining stepped-care CBT for youth with HFA and co-occurring anxiety - a clinical trial examining the efficacy of low-intensity, parent-led CBT as the first line of treatment and utilizing a more intensive, therapist-led intervention for nonresponders. The study will evaluate the potential benefits of stepped-care and parent-led therapist-assisted interventions, predictors of treatment response, and the economic value of using a stepped-care model. Implications for practice will be discussed.

Anxiety Gremlins: mixed methods sequential explanatory evaluation of a CBT group intervention for children

Although research evidence supports the efficacy of cognitive behavioural therapy (CBT) for anxiety in children, it is important to examine practice-based evidence of effectiveness in typical clinical contexts. This study evaluated a CBT group intervention – ‘Anxiety Gremlins’ – for childhood anxiety. Participants were 36 children (19 boys, 17 girls) aged 8–13, referred for anxiety symptoms at a UK NHS service. The 8-session intervention included six child sessions (2 h) and two parent sessions (1 h). Self-report outcome measures of anxiety symptoms, life functioning and therapeutic relationships were used to measure change pre- and post-intervention. Semi-structured interviews were conducted with group facilitators and analysed through deductive content analysis to identify barriers and facilitators to change. No substantive differences were found between aggregated scores on pre- versus post-intervention outcome measures. Reliable change in anxiety symptoms was identified in 10 children (31%), with five improvers and five deteriorators. Interviews with facilitators identified disruption in group flow, lack of facilitator time to prepare and reflect, and the complexity of clients as hindering factors. Children meeting like-minded peers to share their stories and high engagement in the therapeutic process were helpful factors. Anxiety Gremlins did not demonstrate effectiveness on outcome measures, and this contrasted with clinical opinion. Recommendations were made for the service to revisit the intervention content and the method for recruiting children to the group – as complexity/co-morbidity was linked to poorer outcomes. Future research could explore fidelity to an adapted intervention and include interviews with children and their parents.

Key learning aims

After reading this paper the reader should be able to: (1)

Cognitive-behavioural interventions for prevention and treatment of anxiety in young children: A systematic review and meta-analysis

BACKGROUND

Anxiety disorders are common and impairing throughout the life course. Propensity to anxiety disorders manifests as distress and avoidance of novel stimuli (called behavioural inhibition) as early as in infancy. Already in preschool children, anxiety disorders impact emotional development and school readiness. Anxiety disorders and behavioural inhibition are prospectively associated with increased risk of mood disorders, substance use, and suicide. Therefore, early targeted prevention and treatment need to be considered. Cognitive-behavioural interventions are effective for anxiety in older age group but their efficacy for preschool children remains to be established.

METHODS

We searched PsycINFO, PubMed, and Embase until September 19th, 2019 using terms describing anxiety, behavioural inhibition, intervention, and young children. We included studies with young children participating in a cognitive-behavioural intervention for anxiety disorders, anxiety symptoms, or behavioural inhibition. We completed random-effects robust meta-analyses to (1) compare anxiety measures before and after intervention and to (2) compare intervention and control groups.

RESULTS

We identified 43 samples including 2656 participants with a mean age of 5.45 (SD = 1.00) years. Anxiety decreased after cognitive-behavioural intervention (standardized mean difference [SMD] = -1.34, 95%CI -1.59 to -1.09, p < 0.0001). Anxiety decreased more in children who received intervention than in children in control conditions (SMD = -0.81, 95%CI -1.00 to -0.63, p < 0.0001). The difference remained significant after correcting for potential publication bias and outliers (SMD = -0.89, 95% CI -1.13 to -0.66, p < 0.0001). The improvement was maintained over follow-up.

CONCLUSIONS

Cognitive-behavioural interventions are effective for prevention and treatment of anxiety in young children.

What are the recovery and attrition outcomes for group CBT and individual CBT for generalised anxiety disorder in an IAPT service? An exploratory study

Group cognitive behavioural therapy (gCBT) is commonly used in Increasing Access to Psychological Therapies (IAPT) services. However, there is limited knowledge of the efficacy of gCBT as a delivery format for generalised anxiety disorder (GAD). To address gaps in literature, this study aims to explore the efficacy and attrition of individual and group CBT interventions, respectively, at Step 3 for GAD using data from a routine IAPT service over a 24-month period. Data were retrospectively derived from a routine serviceʼs IAPTus database, separating those eligible for comparison into group (n = 44) and individual (n = 55) CBT for GAD. Outcomes were differences in pre–post self-reported anxiety (GAD-7) and depression (PHQ-9) scores, clinical recovery and attrition for gCBT and individual CBT. Both gCBT and individual CBT yielded significant reductions in self-reported anxiety and depression scores over time. Results indicate that 53% of patients attending individual CBT achieved clinical recovery, with similar but less competitive rates of 41% in gCBT. Attrition rates were similar between gCBT (29.5%) and individual CBT (27.3%), respectively. Preliminary results suggest that both individual and gCBT are effective interventions for GAD patients in IAPT, offering symptom alleviation and comparable recovery and attrition rates post-intervention. This observational design offers credibility and insight into a pragmatic evaluative and explorative comparison. gCBT may offer an acceptable and potentially economical alternative.

Key learning aims

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