Effectiveness of exposure-based treatment for childhood anxiety disorders: An open clinical trial to test its relation with indices of emotional processing and inhibitory learning

BACKGROUND AND OBJECTIVES

The current study examined how effectiveness of exposure-based CBT was related to indices of emotional processing and inhibitory learning during exposure exercises.

METHODS

Adolescents with anxiety disorder(s) (N = 72; age 11-19; 85% girls) received a group-based, intensive two-week treatment of which effectiveness was indexed by the SCARED and by ratings of anxiety and approach towards individualized goal situations. To index emotional processing, subjective units of distress (SUDs) were used to indicate both initial and final fear level, and absolute, relative, and total dose of fear reduction. To index inhibitory learning, subjective threat expectancies (STEs) were used to indicate initial and final threat expectancy, and absolute, relative, and total dose of expectancy change.

RESULTS

From pre-treatment to follow-up, there was a large-sized reduction of anxiety symptoms, small-sized decrease of subjective anxiety and a large-sized increase in subjective approach towards individual treatment goals. Higher fear levels prior to exposure were related to a larger decrease of symptoms. Higher threat expectancies after exposure exercises were independently associated with less decrease of anxiety and increase of approach towards treatment goals. Total dose of experienced fear reduction and total dose of experienced expectancy change were (partly) independently related to more increase in approach towards individualized goal situations.

LIMITATIONS

As patients also received other treatment elements, the results cannot be interpreted unequivocally.

CONCLUSIONS

The pattern of findings seems to indicate that emotional processing (as indexed by fear reduction) and inhibitory learning (as indexed by expectancy change) are both relevant in exposure-based CBT.

Long-Term Effectiveness of Cognitive Behavioral Therapy in Routine Outpatient Care for Youth with Anxiety Disorders

INTRODUCTION

This study examined the long-term effectiveness of cognitive behavioral therapy (CBT) (≥ 2 years after the end of therapy) in the routine care of youth (mean 11.95 years; SD = 3.04 years) with primary anxiety disorder (AD).

METHODS

Two hundred and ten children with any AD as a primary diagnosis and with any comorbidity were included in the "Kids Beating Anxiety (KibA)" clinical trial and received evidence-based CBT. Diagnoses, severity of diagnoses, and further dimensional outcome variables of symptoms and functioning were assessed before (baseline), after the last treatment session (POST), and at two follow-up (FU) assessments in the child and caregiver report: 6 months (6MONTHS-FU) and >2 years (mean 4.31; SD = 1.07 years) after the last treatment session (long-term FU).

RESULTS

At POST, 61.38% showed total remission of all and any ADs. At long-term FU, the remission rate was 63.64%. Compared to baseline, ratings of severity, anxiety, impairment/burden, and life quality improved significantly after CBT in child and caregiver report. All pre-post/FU improvements and global success ratings were stable in child (Pre-Post: Hedges' g = 3.57; Pre-6MONTHS-FU: Hedges' g = 3.43; Pre-LT-FU: Hedges' g = 2.34) and caregiver report (Pre-Post: Hedges' g = 2.00; Pre-6MONTHS-FU: Hedges' g = 2.31; Pre-LT-FU: Hedges' g = 2.31) across all POST- and FU-assessment points. Some outcomes showed further significant improvement, and no deterioration was found over the course of time. Effect sizes calculated in the present study correspond to, or even exceed, effect sizes reported in previous meta-analysis.

CONCLUSIONS

Stable long-term effects of "KibA" CBT for youth with ADs, comparable to those results from efficacy studies, were achieved in a routine practice setting by applying treatment manuals tested in randomized controlled trials. These findings are remarkable, as the patient group studied here consisted of an age group within the main risk phase of developing further mental disorders, and therefore an increase in new-onset anxiety and further mental disorders would be expected over the long time span studied here.

Better together? A randomized controlled microtrial comparing different levels of therapist and parental involvement in exposure-based treatment of childhood specific phobia

INTRODUCTION

Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE).

METHODS

Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up.

RESULTS

TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up.

CONCLUSIONS

These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.

The perinatal origins of childhood anxiety disorders and the role of early-life maternal predictors

BACKGROUND

The development of childhood anxiety disorders (CADs) is likely to depend on pathways that can be programmed by early-life risk factors. We test the hypothesis that early-life maternal factors can predict this programming effect on CAD.

METHODS

Data were obtained from 198 women and children from the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS), a cohort study with data collected across pregnancy, postpartum and until 4 years of age. Maternal antenatal depression was measured using the Structured Clinical Interview for DSM-IV (SCID-IV), together with antenatal hair cortisol concentrations, maternal childhood trauma and parenting stress at 6 months postpartum. CAD was assessed with the Preschool Age Psychiatric Assessment and the Child Behaviour Checklist.

RESULTS

Antenatal depression, a history of maternal childhood trauma and lower gestational age at birth were each associated with anxiety disorders at 4 years of age in their children. A multivariate binary logistic model with these early predictors explained approximately 9% of variance in CAD outcome at 4 years of age; however, only maternal trauma and gestational age were significant predictors in the model. The effect of early parenting stress on CAD was found to vary by the concentration of maternal antenatal hair cortisol, whereby postpartum parenting stress was associated with CAD only when there were higher maternal antenatal cortisol levels.

CONCLUSIONS

This study suggests the importance of maternal factors pre-conception, pregnancy and in the postnatal period, which predict CADs and this is consistent with a developmental programming hypothesis for CAD.

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.

Mediators of youth anxiety outcomes 3 to 12 years after treatment

OBJECTIVE

Test changes in perceived coping efficacy, negative self-statements, and interpretive biases to threat during treatment as potential mediators of the relationship between randomly assigned treatment conditions and long-term anxiety follow-ups. Age at randomization was also tested as a moderator of mediational relationships.

METHOD

Participants included 319 youth (ages 7-17) from the Child/Adolescent Multimodal Study (CAMS) who participated in a naturalistic follow-up beginning an average of 6.5 years after the end of the CAMS intervention. The intervention conditions included cognitive behavioral therapy (CBT; Coping Cat), pharmacotherapy (sertraline), combined CBT and sertraline, and pill placebo. Putative mediators were measured four times during the intervention phase. Follow-up consisted of four annual assessments of current anxiety.

RESULTS

Reductions on a measure of interpretive bias to threat over the course of the combined condition intervention, as compared to the placebo condition, mediated anxiety outcomes at the first follow-up visit. This mediated effect was not significant for the CBT-only or sertraline-only conditions when compared to the placebo condition. No other significant mediated effects were found for putative mediators. Age did not significantly moderate any mediated effects.

CONCLUSION

Changes in youth-reported interpretive biases to threat over the course of combined youth anxiety interventions, as compared to a placebo intervention, may be associated with lower anxiety an average of 6.5 years following treatment.

Do Youth with Separation Anxiety Disorder Differ in Anxiety Sensitivity From Youth with Other Anxiety Disorders?

Studies on the relationship between separation anxiety disorder (SAD) in childhood and panic disorder (PD) in adolescence and adulthood have yielded results which suggest a common underlying vulnerability for both disorders. In this study, we examined whether one such possible vulnerability-anxiety sensitivity-differed for youth diagnosed with SAD versus other anxiety disorders. Anxiety sensitivity was assessed using the Childhood Anxiety Sensitivity Index (CASI) in 315 clinic-referred youth (ages 6-17, 113 girls). 145 children (46%) were diagnosed with one or more primary anxiety disorder, including SAD (n = 22), generalized anxiety (GAD) (n = 79), social anxiety (SocA) (n = 55), and specific phobia (SP) (n = 45). Children with SAD reported higher levels of anxiety sensitivity and fears of physical symptoms than children with SP and SocA, but not children with GAD. We speculate that children who have SAD and GAD and high anxiety sensitivity may be more vulnerable to develop PD.

Maternal immune and affiliative biomarkers and sensitive parenting mediate the effects of chronic early trauma on child anxiety

BACKGROUND

Chronic early trauma alters children's stress reactivity and increases the prevalence of anxiety disorders; yet the neuroendocrine and immune mechanisms underpinning this effect are not fully clear. Animal studies indicate that the mother's physiology and behavior mediate offspring stress in a system-specific manner, but few studies tested this external-regulatory maternal role in human children exposed to chronic stress.

METHODS

We followed a unique cohort of children exposed to continuous wartime trauma (N = 177; exposed; N = 101, controls; N = 76). At 10 years, maternal and child's salivary immunoglobulin A (s-IgA) and oxytocin (OT), biomarkers of the immune and affiliation systems, were assayed, maternal and child relational behaviors observed, mother and child underwent psychiatric diagnosis, and child anxiety symptoms assessed.

RESULTS

War-exposed mothers had higher s-IgA, lower OT, more anxiety symptoms, and their parenting was characterized by reduced sensitivity. Exposed children showed higher s-IgA, more anxiety disorders and post traumatic stress disorder, and more anxiety symptoms. Path analysis model defined three pathways by which maternal physiology and behavior impacted child anxiety; (a) increasing maternal s-IgA, which led to increased child s-IgA, augmenting child anxiety; (b) reducing maternal OT, which linked with diminished child OT and social repertoire; and (c) increasing maternal anxiety, which directly impacted child anxiety.

CONCLUSIONS

Our findings, the first to measure immune and affiliation biomarkers in mothers and children, detail their unique and joint effects on children's anxiety in response to stress; highlight the relations between chronic stress, immune activation, and anxiety in children; and describe how processes of biobehavioral synchrony shape children's long-term adaptation.

Parents' Perceptions of Novel Treatments for Child and Adolescent Specific Phobia and Anxiety Disorders

This study aimed to examine parents' perceptions of established treatments, including cognitive behaviour therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), relative to novel treatments of D-cycloserine (DCS) and attention bias modification (ABM) augmented CBT to determine if novel treatments are perceived as more or less favorable than established treatments. Participants included parents of children with a specific phobia, enrolled in one of two randomized controlled trials of either one-session augmented DCS (n = 38, Gold Coast) or ABM augmented one-session treatment (n = 34, Brisbane), as well as parents from a community sample (n = 38). Parents of children with a specific phobia perceived CBT most favorably. There was no difference between the sites on perceptions of ABM. However, parents of children enrolled in the DCS trial perceived DCS more favorably than parents of children enrolled in the ABM trial and the community sample. These results demonstrate parents' greater acceptance of psychological treatments over pharmacological treatments for the treatment of childhood phobias, highlighting the importance of educating parents to novel treatments.

Non-obsessive-compulsive anxiety disorders in child and adolescent mental health services--Are they underdiagnosed, and how accurate is referral information?

BACKGROUND

Previous studies have reported low prevalence of non-obsessive-compulsive (OCD) anxiety disorders in child and adolescent mental health services (CAMHSs), suggesting that these disorders may go unrecognized. Possible reasons may be lack of routinely used standardized diagnostic instruments, and/or an under-reporting of anxiety symptoms in the referral information.

AIMS

To examine the frequency of non-OCD anxiety disorders in referred children based on a standardized diagnostic interview, to compare the results with data from the Norwegian Patient Register (NPR), and to explore the correspondence between anxiety as a referral symptom and anxiety as a diagnosis, and the influence of heterotypic co-morbidity on this correspondence.

METHODS

Parents of 407 consecutive referrals to CAMHS aged 7-13 years were interviewed with the semi-structured diagnostic interview Kiddie-SADS-PL at the time of admittance. Referral symptoms were collected from national referral forms.

RESULTS

A total of 133 referred children (32.7%) met the criteria for a non-OCD anxiety disorder compared with about 5% in the NPR. Half of those who met diagnostic criteria for an anxiety disorder did not have anxiety as a referral symptom. Co-morbid ADHD or disruptive disorder was significantly associated with a lower probability of having anxiety as a referral symptom.

CONCLUSIONS

The use of a standardized diagnostic interview in consecutively referred children yielded significantly higher rates of anxiety disorders than the NPR prevalence rates. Co-morbid ADHD or disruptive disorder may contribute to the underdiagnosing of anxiety disorders. Diagnostic instruments covering the whole range of child psychiatric symptoms should be implemented routinely in CAMHS.

Autonomic arousal in childhood anxiety disorders: associations with state anxiety and social anxiety disorder

BACKGROUND

Psychophysiological theories suggest that individuals with anxiety disorders may evidence inflexibility in their autonomic activity at rest and when responding to stressors. In addition, theories of social anxiety disorder, in particular, highlight the importance of physical symptoms. Research on autonomic activity in childhood (social) anxiety disorders, however, is scarce and has produced inconsistent findings, possibly because of methodological limitations.

METHOD

The present study aimed to account for limitations of previous studies and measured respiratory sinus arrhythmia (RSA) and heart rate (HR) using Actiheart heart rate monitors and software (Version 4) during rest and in response to a social and a non-social stressor in 60 anxious (30 socially anxious and 30 'other' anxious), and 30 nonanxious sex-and age-matched 7-12 year olds. In addition, the effect of state anxiety during the tasks was explored.

RESULTS

No group differences at rest or in response to stress were found. Importantly, however, with increases in state anxiety, all children, regardless of their anxiety diagnoses showed less autonomic responding (i.e., less change in HR and RSA from baseline in response to task) and took longer to recover once the stressor had passed.

LIMITATIONS

This study focused primarily on parasympathetic arousal and lacked measures of sympathetic arousal.

CONCLUSION

The findings suggest that childhood anxiety disorders may not be characterized by inflexible autonomic responding, and that previous findings to the contrary may have been the result of differences in subjective anxiety between anxious and nonanxious groups during the tasks, rather than a function of chronic autonomic dysregulation.