Recent developments in the treatment of anxiety disorders in children and adolescents

Emotion-focused skills training for parents with anxious children. A pilot study

Anxiety disorders are common among children and adolescents. Effective treatments exist, but meta-analyses indicate that 40% of children continue to have significant symptoms posttreatment. Alternative therapeutic interventions are needed. Emotion-focused parental interventions have been found to be effective in targeting children's internalizing difficulties, but no research has examined remission. In this pilot trial, we examined whether Emotion Focused Skills Training (EFST) was associated with remission of diagnosis in children with anxiety. Nine 8-14-year-olds diagnosed with anxiety were recruited at a mental health clinic in Norway. Both parents of each child attended a 2-day EFST program followed by five 1-hour weekly sessions. Pre- and posttreatment diagnosis and severity were evaluated using a multiinformant approach using the Spence Children's Anxiety Scale and the Anxiety Disorders Interview Schedule. After treatment, 33% no longer met criteria for any anxiety diagnosis, 66% obtained remission from their primary anxiety diagnosis, and 89% from at least one.

Reducing Anxiety and Stress among Youth in a CBT-Based Equine-Assisted Adaptive Riding Program

Simple Summary

Reining in Anxiety (RiA) is a therapeutic program for youth with mild-to-moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA is based on five foundational components of Cognitive Behavioral Therapy (CBT): in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. The intervention sought to support youth between the ages of 6–17 with self-identified anxiety. Due to global pandemic trauma, in the second iteration of the protocol, researchers also included two evidence-based trauma components: maintenance and personal safety skills. All instructors were trained in the RiA curriculum and delivered the same lessons. In addition to assessing the youth’s perception and changes over time, the researchers also assessed changes in the horses, both through saliva sampling. The authors learned that RiA may be a promising approach for reducing anxiety and stress among youth and that the intervention can be delivered by adaptive/therapeutic horseback riding instructors in a non-clinic setting.

Abstract

Reining in Anxiety (RiA) is a therapeutic program for youth with mild to moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA was developed after a review of the evidence base for youth anxiety, is manualized, and includes five core CBT components: in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. This study extended findings from a prior RCT that examined (1) the feasibility of collecting saliva samples from horses and children to measure stress (cortisol) and relaxation (oxytocin); (2) whether changes in stress and relaxation occurred both during each lesson and over the course of the 10-week intervention for horses and youth; (3) whether changes in anxiety symptoms, emotional regulation, and self-efficacy found in the first trial were comparable; and (4) if fidelity to the program was reliable. Youth participants (n = 39) ages 6–17 with caregiver-identified mild-to-moderate anxiety participated in a ten-week therapeutic intervention (RiA), which combined adaptive riding and components of CBT. Physiological data and self-report measures were taken at weeks one, four, seven, and ten for the youth and horses. Saliva assays assessed cortisol as a physiological marker of stress and anxiety, and oxytocin as a measure of relaxation. Fidelity data were recorded per session. Anxiety, as measured by caregiver self-reporting, significantly decreased from pre- to post-test, while emotional regulation scores increased. No significant changes in self-efficacy from pre- to post-test were observed. Saliva samples obtained from participants before and after riding sessions showed a consistent decrease in cortisol and a significant increase in oxytocin at two of the four timepoints (Week 1 and Week 7), but no overall pre- to post-test changes. Horse saliva data were collected using a modified bit; there were no significant changes in oxytocin or cortisol, suggesting that the horses did not have an increase in stress from the intervention. RiA may be a promising approach for reducing anxiety and stress among youth, as measured both by self-reported and by physiological measures. Collection of salivary assays for both youth and horses is feasible, and the intervention does not increase stress in the horses. Importantly, RiA can be delivered by adaptive/therapeutic horseback riding instructors in naturalistic (e.g., non-clinic-based) settings. As youth anxiety is a growing public health problem, novel interventions, such as RiA, that can be delivered naturalistically may have the potential to reach more youth and thus improve their quality of life. Further research is needed to examine the comparative value of RiA with other animal-assisted interventions and to assess its cost-effectiveness.

Linking Leeds: A Social Prescribing Service for Children and Young People

The use of social prescribing interventions for common mental health issues is expanding as clinicians seek to diverge from the traditional medical model of treatment. This intervention allows for the referral of patients to a nonclinical social activity via a link worker. Evidence for the benefits of social prescribing is growing. Most evidence is based on adults; however, a smaller number of studies involving children and young people have produced encouraging results. This evaluation reports on data routinely collected by the Linking Leeds service between 9 January 2019–11 January 2020. Linking Leeds provides Social Prescribing for people aged 16 years and above; however, the current paper focuses on service users aged between 16 and 25. Their aim is to connect people to services and activities in their community in order to benefit overall health and mental wellbeing. This evaluation of the Linking Leeds program supports the growing body of evidence to support the benefits social prescribing can have on young people’s mental health. Two main mechanisms were identified which underpin social prescribing in young people: social connectedness and behavioural activation.

Effectiveness, User Engagement and Experience, and Safety of a Mobile App (Lumi Nova) Delivering Exposure-Based Cognitive Behavioral Therapy Strategies to Manage Anxiety in Children via Immersive Gaming Technology: Preliminary Evaluation Study

BACKGROUND

Childhood anxiety disorders are a prevalent mental health problem that can be treated effectively with cognitive behavioral therapy, in which exposure is a key component; however, access to treatment is poor. Mobile-based apps on smartphones or tablets may facilitate the delivery of evidence-based therapy for child anxiety, thereby overcoming the access and engagement barriers of traditional treatment. Apps that deliver therapeutic content via immersive gaming technology could offer an effective, highly engaging, and flexible treatment proposition.

OBJECTIVE

In this paper, we aim to describe a preliminary multi-method evaluation of Lumi Nova, a mobile app intervention targeting mild to moderate anxiety problems in children aged 7-12 years using exposure therapy delivered via an immersive game. The primary objective is to evaluate the effectiveness, user engagement and experience, and safety of the beta version of Lumi Nova.

METHODS

Lumi Nova was co-designed with children, parents, teachers, clinicians, game industry experts, and academic partnerships. In total, 120 community-based children with mild to moderate anxiety and their guardians were enrolled to participate in an 8-week pilot study. The outcome measures captured the app's effectiveness (anxiety symptoms, child-identified goal-based outcomes, and functional impairment), user engagement (game play data and ease-of-use ratings), and safety (mood ratings and adverse events). The outcome measures before and after the intervention were available for 30 children (age: mean 9.8, SD 1.7 years; girls: 18/30, 60%; White: 24/30, 80%). Additional game play data were automatically generated for 67 children (age: mean 9.6, SD 1.53 years; girls: 35/67, 52%; White: 42/67, 63%). Postintervention open-response data from 53% (16/30) of guardians relating to the primary objectives were also examined.

RESULTS

Playing Lumi Nova was effective in reducing anxiety symptom severity over the 8-week period of game play (t₂₉=2.79; P=.009; Cohen d=0.35) and making progress toward treatment goals (z=2.43; P=.02), but there were no improvements in relation to functional impairment. Children found it easy to play the game and engaged safely with therapeutic content. However, the positive effects were small, and there were limitations to the game play data.

CONCLUSIONS

This preliminary study provides initial evidence that an immersive mobile game app may safely benefit children experiencing mild to moderate anxiety. It also demonstrates the value of the rigorous evaluation of digital interventions during the development process to rapidly improve readiness for full market launch.

Predicting patient engagement in IAPT services: a statistical analysis of electronic health records

Background

Across England, 12% of all improving access to psychological therapy (IAPT) appointments are missed, and on average around 40% of first appointments are not attended, varying significantly around the country. In order to intervene effectively, it is important to target the patients who are most likely to miss their appointments.

Objective

This research aims to develop and test a model to predict whether an IAPT patient will attend their first appointment.

Methods

Data from 19 adult IAPT services were analysed in this research. A multiple logistic regression was used at an individual service level to identify which patient, appointment and referral characteristics are associated with attendance. These variables were then used in a generalised linear mixed effects model (GLMM). We allow random effects in the GLMM for variables where we observe high service to service heterogeneity in the estimated effects from service specific logistic regressions.

Findings

We find that patients who self-refer are more likely to attend their appointments with an OR of 1.04. The older a patient is, the fewer the number of previous referrals and consenting to receiving a reminder short message service are also found to increase the likelihood of attendance with ORs of 1.02, 1.10, 1.04, respectively.

Conclusions

Our model is expected to help IAPT services identify which patients are not likely to attend their appointments by highlighting key characteristics that affect attendance.

Clinical implications

This analysis will help to identify methods IAPT services could use to increase their attendance rates.

Different Types and Acceptability of Psychotherapies for Acute Anxiety Disorders in Children and Adolescents: A Network Meta-analysis

IMPORTANCE

Anxiety disorders are common in children and adolescents, and uncertainty remains regarding the optimal strategy of psychotherapies in this population.

OBJECTIVE

To compare and rank the different types of psychotherapies and the different ways of delivering psychological treatments for anxiety disorders in children and adolescents.

DATA SOURCES

PubMed, Cochrane Central Register of Controlled Trials, EMBASE, PsycINFO, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ProQuest Dissertations, LILACS (Literatura Latino Americana em Ciências da Saúde), international trial registers, and US Food and Drug Administration reports were searched from inception to November 30, 2017.

STUDY SELECTION

Randomized clinical trials that compared any structured psychotherapy with another psychotherapy or a control condition for anxiety disorders in children and adolescents were selected.

DATA EXTRACTION AND SYNTHESIS

Four researchers independently performed data extraction and quality assessment. Pairwise meta-analyses and Bayesian network meta-analysis within the random-effects model were used to synthesize data.

MAIN OUTCOMES AND MEASURES

Efficacy (change in anxiety symptoms) posttreatment and at follow-up, acceptability (all-cause discontinuation), and quality of life and functional improvement were measured. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework.

RESULTS

A total of 101 unique trials including 6625 unique participants compared 11 different psychotherapies with 4 specific control conditions. The certainty of evidence was rated as low or very low for most comparisons. For efficacy, most psychotherapies were significantly more effective than the wait list condition posttreatment (standardized mean difference [SMD], -1.43 to -0.61) and at the longest follow-up (SMD, -1.84 to -1.64). However, only group cognitive behavioral therapy (CBT) was significantly more effective than the other psychotherapies and all control conditions posttreatment. For acceptability, bibliotherapy CBT had significantly more all-cause discontinuations than some psychotherapies and control conditions (range of odds ratios, 2.48-9.32). In terms of quality of life and functional improvement, CBT (delivered in different ways) was significantly beneficial compared with psychological placebo and the wait list condition (SMDs, 0.73 to 1.99).

CONCLUSIONS AND RELEVANCE

Group CBT would be the more appropriate choice of psychotherapy for anxiety disorders in children and adolescents, based on these findings. Other types of psychotherapies and different ways of delivering psychological treatment can be alternative options. Further research is needed to explore specific anxiety disorders, disorder-specific psychotherapy, and moderators of treatment effect.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42015016283.

Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners

Anxiety disorders are common in children and adolescents with reported prevalence rates between 10% and 30%. A combined approach to treatment has been found to be the most effective for optimal outcomes and is typically comprised of psychotherapy (especially exposure-based cognitive behavior therapy), family and patient education, and use of medication if indicated. In children and adolescents who might benefit from use of medications, selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice. The safety and efficacy of medications other than SSRIs in the treatment of children and adolescents with anxiety disorders are not fully established. Most children and adolescents respond well to treatment with long lasting resolution of symptoms, although, recurrence of the same, or development of a different type of anxiety disorder, is not uncommon. In most children and adolescents, anxiety disorders tend to persist into adulthood requiring long-term treatment planning. This paper reviews the pharmacological agents used in the treatment of anxiety disorders in children and adolescents.