Changes to sleep patterns and insomnia symptoms following cognitive behavioural therapy for anxiety disorders in adolescents

BACKGROUND

It is unclear whether treatment for an anxiety disorder improves sleep. This study examined baseline sleep characteristics of adolescents with an anxiety disorder, comparing weekdays and weekends, and whether there were significant improvements in sleep following cognitive behaviour therapy (CBT).

AIMS

To improve our understanding of sleep problems in adolescents with an anxiety disorder and examine whether CBT for the treatment of the anxiety disorder improves sleep.

METHOD

Data was gathered from 179 participants with an anxiety disorder (11-17 years old) who had previously engaged with the out-patient child and adolescent mental health service. Baseline self-report measures of anxiety and depression symptoms, sleep patterns and experiences of insomnia were examined. Of this group, 135 participants had baseline data. A subset (n=73) had outcome data, which was used to examine changes in sleep following CBT.

RESULTS

At baseline, adolescents reported significantly less total sleep and more night-time waking on weekdays than weekends. Following treatment for their anxiety disorder, adolescents' weekday sleep patterns significantly improved for sleep onset latency and total sleep time, whereas weekend sleep patterns only showed improvements for sleep onset latency. No significant improvements were reported for symptoms of insomnia.

CONCLUSIONS

The study relied upon subjective measurement of sleep and there was no control group; however, the findings provide promising results that CBT for adolescent anxiety disorders can improve some sleep problems. Further research is needed to understand discrepancies between subjective and objective sleep, and to explore avenues for the delivery of support for sleep problems.

Measuring dissociation across adolescence and adulthood: developing the short-form Černis Felt Sense of Anomaly scale (ČEFSA-14)

BACKGROUND

Dissociation may be important across many mental health disorders, but has been variously conceptualised and measured. We introduced a conceptualisation of a common type of dissociative experience, 'felt sense of anomaly' (FSA), and developed a corresponding measure, the Černis Felt Sense of Anomaly (ČEFSA) scale.

AIMS

We aimed to develop a short-form version of the ČEFSA that is valid for adolescent and adult respondents.

METHOD

Data were collected from 1031 adult NHS patients with psychosis and 932 adult and 1233 adolescent non-clinical online survey respondents. Local structural equation modelling (LSEM) was used to establish measurement invariance of items across the age range. Ant colony optimisation (ACO) was used to produce a 14-item short-form measure. Finally, the expected test score function derived from item response theory modelling guided the establishment of interpretive scoring ranges.

RESULTS

LSEM indicated 25 items of the original 35-item ČEFSA were age invariant. They were also invariant across gender and clinical status. ACO of these items produced a 14-item short-form (ČEFSA-14) with excellent psychometric properties (CFI=0.992; TLI=0.987; RMSEA=0.034; SRMR=0.017; Cronbach's alpha=0.92). Score ranges were established based on the expected test scores at approximately 0.7, 1.25 and 2.0 theta (equivalent to standard deviations above the mean). Scores of 29 and above may indicate elevated levels of FSA-dissociation.

CONCLUSIONS

The ČEFSA-14 is a psychometrically valid measure of FSA-dissociation for adolescents and adults. It can be used with clinical and non-clinical respondents. It could be used by clinicians as an initial tool to explore dissociation with their clients.

The relationship between dissociation and panic symptoms in adolescence and the exploration of potential mediators

Background

Dissociative experiences have been linked to panic symptoms in adolescents, yet the nature of the association remains unclear.

Methods

In the present study, we investigated the longitudinal relationship between dissociative experiences (focusing on the felt sense of anomaly subtype) and panic, as well as the potential mediating roles of emotion regulation strategies (expressive suppression and cognitive reappraisal), alexithymia, and cognitive appraisals of dissociation. Four thousand five hundred one adolescents aged 13-18 years were recruited via social media advertising to take part in an online survey at two timepoints, 1 month apart.

Results

Analysis of 421 datasets found a significant positive relationship between initial dissociative experiences and panic symptoms reported 1 month later. This was mediated by the emotion regulation strategy of cognitive reappraisal, and cognitive appraisals of dissociation. These two variables were no longer significant mediators when controlling for panic symptoms at the first time point, likely due to the stability of panic symptoms across both assessments. Neither alexithymia nor expressive suppression were significant mediators.

Conclusions

Thus, dissociative experiences that are persistently misinterpreted in a catastrophic manner may lead to escalating anxiety and panic symptoms, which could in turn heighten and maintain the feared dissociation sensation. These results indicate that dissociative experiences are associated with panic symptoms in adolescence, with cognitive appraisals of dissociation and cognitive reappraisal playing a role in this relationship.

Digitally augmented, parent-led CBT versus treatment as usual for child anxiety problems in child mental health services in England and Northern Ireland: a pragmatic, non-inferiority, clinical effectiveness and cost-effectiveness randomised controlled trial

BACKGROUND

Anxiety problems are common in children, yet few affected children access evidence-based treatment. Digitally augmented psychological therapies bring potential to increase availability of effective help for children with mental health problems. This study aimed to establish whether therapist-supported, digitally augmented, parent-led cognitive behavioural therapy (CBT) could increase the efficiency of treatment without compromising clinical effectiveness and acceptability.

METHODS

We conducted a pragmatic, unblinded, two-arm, multisite, randomised controlled non-inferiority trial to evaluate the clinical effectiveness and cost-effectiveness of therapist-supported, parent-led CBT using the Online Support and Intervention (OSI) for child anxiety platform compared with treatment as usual for child (aged 5-12 years) anxiety problems in 34 Child and Adolescent Mental Health Services in England and Northern Ireland. We examined acceptability of OSI plus therapist support via qualitative interviews. Participants were randomly assigned (1:1) to OSI plus therapist support or treatment as usual, minimised by child age, gender, service type, and baseline child anxiety interference. Outcomes were assessed at week 14 and week 26 after randomisation. The primary clinical outcome was parent-reported interference caused by child anxiety at week 26 assessment, using the Child Anxiety Impact Scale-parent report (CAIS-P). The primary measure of health economic effect was quality-adjusted life-years (QALYs). Outcome analyses were conducted blind in the intention-to-treat (ITT) population with a standardised non-inferiority margin of 0·33 for clinical analyses. The trial was registered with ISRCTN, 12890382.

FINDINGS

Between Dec 5, 2020, and Aug 3, 2022, 706 families (706 children and their parents or carers) were referred to the study information. 444 families were enrolled. Parents reported 255 (58%) child participants' gender to be female, 184 (41%) male, three (<1%) other, and one (<1%) preferred not to report their child's gender. 400 (90%) children were White and the mean age was 9·20 years (SD 1·79). 85% of families for whom clinicians provided information in the treatment as usual group received CBT. OSI plus therapist support was non-inferior for parent-reported anxiety interference on the CAIS-P (SMD 0·01, 95% CI -0·15 to 0·17; p<0·0001) and all secondary outcomes. The mean difference in QALYs across trial arms approximated to zero, and OSI plus therapist support was associated with lower costs than treatment as usual. OSI plus therapist support was likely to be cost effective under certain scenarios, but uncertainty was high. OSI plus therapist support acceptability was good. No serious adverse events were reported.

INTERPRETATION

Digitally augmented intervention brought promising savings without compromising outcomes and as such presents a valuable tool for increasing access to psychological therapies and meeting the demand for treatment of child anxiety problems.

FUNDING

Department for Health and Social Care and United Kingdom Research and Innovation Research Grant, National Institute for Health and Care (NIHR) Research Policy Research Programme, Oxford and Thames Valley NIHR Applied Research Collaboration, Oxford Health NIHR Biomedical Research Centre.

The Effectiveness and Cost-Effectiveness of a Universal Digital Parenting Intervention Designed and Implemented During the COVID-19 Pandemic: Evidence From a Rapid-Implementation Randomized Controlled Trial Within a Cohort

BACKGROUND

Children's conduct and emotional problems increased during the COVID-19 pandemic.

OBJECTIVE

We tested whether a smartphone parenting support app, Parent Positive, developed specifically for this purpose, reversed these effects in a cost-effective way. Parent Positive includes 3 zones. Parenting Boosters (zone 1) provided content adapted from standard face-to-face parent training programs to tackle 8 specific challenges identified by parents and parenting experts as particularly relevant for parents during the pandemic. The Parenting Exchange (zone 2) was a parent-to-parent and parent-to-expert communication forum. Parenting Resources (zone 3) provided access to existing high-quality web-based resources on a range of additional topics of value to parents (eg, neurodevelopmental problems, diet, and sleep).

METHODS

Supporting Parents And Kids Through Lockdown Experiences (SPARKLE), a randomized controlled trial, was embedded in the UK-wide COVID-19: Supporting Parents, Adolescents and Children during Epidemics (Co-SPACE) longitudinal study on families' mental health during the pandemic. Parents of children aged 4 to 10 years were randomized 1:1 to Parent Positive or follow-up as usual (FAU) between May 19, 2021, and July 26, 2021. Parent Positive provided advice on common parenting challenges and evidence-based web-based resources and facilitated parent-to-parent and expert-to-parent support. Child conduct and emotional problems and family well-being were measured before randomization (T1) and at 1 (T2) and 2 (T3) months after randomization. Service use, costs, and adverse events were measured, along with app use and satisfaction. The primary outcome was T2 parent-reported child conduct problems, which were analyzed using linear mixed regression models.

RESULTS

A total of 320 participants were randomized to Parent Positive, and 326 were randomized to FAU. The primary outcome analysis included 79.3% (512/646) of the participants (dropout: 84/320, 26% on Parent Positive and 50/326, 15% on FAU). There were no statistically significant intervention effects on conduct problems at either T2 (standardized effect=-0.01) or T3 (secondary outcome; standardized effect=-0.09) and no moderation by baseline conduct problems. Significant intervention-related reductions in emotional problems were observed at T2 and T3 (secondary outcomes; standardized effect=-0.13 in both cases). Parent Positive, relative to FAU, was associated with more parental worries at T3 (standardized effect=0.14). Few intervention-attributable adverse events were reported. Parent Positive was cost-effective once 4 outliers with extremely high health care costs were excluded.

CONCLUSIONS

Parent Positive reduced child emotional problems and was cost-effective compared with FAU once outliers were removed. Although small when considered against targeted therapeutic interventions, the size of these effects was in line with trials of nontargeted universal mental health interventions. This highlights the public health potential of Parent Positive if implemented at the community level. Nevertheless, caution is required before making such an interpretation, and the findings need to be replicated in large-scale, whole-community studies.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04786080; https://clinicaltrials.gov/ct2/show/NCT04786080.

Changes in UK pre-schooler's mental health symptoms over the first year of the COVID-19 pandemic: Data from Co-SPYCE study

Background

The COVID-19 pandemic caused significant disruption to the lives of children and their families. Pre-school children may have been particularly vulnerable to the effects of the pandemic, with the closure of childcare facilities, playgrounds, playcentres and parent and toddler groups limiting their opportunities for social interaction at a crucial stage of development. Additionally, for parents working from home, caring for pre-school aged children who require high levels of support and care, was likely challenging. We conducted an intensive longitudinal, but not nationally representative, study to examine trajectories of pre-schoolers' mental symptoms in the United Kingdom during the first year of the COVID-19 pandemic.

Methods

UK-based parents and carers (n = 1520) of pre-school-aged children (2-4 years) completed monthly online surveys about their pre-schoolers' mental health between April 2020 and March 2021. The survey examined changes in children's emotional symptoms, conduct problems and hyperactivity/inattention.

Results

In our final mixed-effects models, our predictors (fixed effects) accounted for 5% of the variance in each of conduct problems, emotional symptoms and hyperactivity/inattention symptoms scores, and the combined random and fixed effects accounted for between 64% and 73% of the variance. Pre-schoolers' emotional problems and hyperactivity/inattention symptoms declined from April through summer 2020 and then increased again during the autumn and winter 2020/2021 as lockdowns were re-introduced. Pre-schoolers who attended childcare showed greater decline in symptom severity than those who did not. Older children, compared to younger, showed greater lability of emotion symptom severity. Attending childcare predicted lower symptom severity across all three domains of conduct problems, emotional symptoms, and hyperactivity/inattention, while the opposite pattern was observed for children whose parent had a mental health problem.

Conclusions

Our findings reinforce the importance of examining pre-schoolers' mental health in the context of micro and macro-level factors. Interventions focussing on family factors such as parent mental health, as well as continued provision of childcare, may have most potential to mitigate the impact of COVID-19 on young children's mental health.

Changes in UK parental mental health symptoms over 10 months of the COVID-19 pandemic

Background

The threats to health, associated restrictions and economic consequences of the COVID-19 pandemic have been linked to increases in mental health difficulties for many. Parents, in particular, have experienced many challenges such as having to combine work with home-schooling their children and other caring responsibilities. Yet, it remains unclear how parental mental health has changed throughout the pandemic or what factors may have mitigated or compounded the impact of the pandemic on parents' mental health.

Methods

We examined monthly survey data from two linked UK-based longitudinal studies: COVID-19: Supporting Parents, Adolescents and Children during Epidemics' (Co-SPACE) and COVID-19: Supporting Parents and Young Children during Epidemics' (Co-SPYCE). Data from 5576 parents/carers of 2-17-year-old children collected between April 2020 and January 2021 was analysed using mixed-effect modelling and latent class growth (mixture) modelling.

Results

Parental stress and depression, but not anxiety, were higher during the periods of restrictions. This pattern was most pronounced for parents with primary-school-aged children, those that worked at home or had other adults in the household. Being younger, reporting secondary or below education, working out of home, having secondary-school-aged children or children with special education needs (SEN)/neurodevelopmental disorders (ND) further moderated whether, how and when parental mental health symptoms changed. Although around three quarters of parents reported consistently low mental health symptoms, a substantial minority reported consistently high or increasing symptoms of anxiety, stress and depression. The latter were more likely to be parents who were younger than average, were a single adult in the household, had a pre-existing mental health diagnosis or had a child with special educational needs or a ND.

Conclusions

These findings emphasise how different personal circumstances and pre-existing inequalities shaped how parents were affected by this unprecedented global pandemic and highlight the need for support and consideration to meet the needs of families in the future.

Examining Children and adolescent mental health trajectories during the COVID-19 pandemic: Findings from a year of the Co-SPACE study

Background

A major concern throughout the COVID-19 pandemic has been on young people's experiences with mental health. In this study we mapped children and adolescents' mental health trajectories over 13 months of the pandemic and examine whether family, peer, and individual-level factors were associated with trajectory membership.

Methods

This study focuses on a sub-sample from the Co-SPACE study of 3322 children and adolescents (aged 4-16 years) for whom parents completed a survey at Time 0 and at least one follow-up survey between March 2020 and May 2021. We used growth mixture models to examine trajectories in emotional, conduct, and hyperactivity/inattention difficulties using the Strengths and Difficulties Questionnaire and multinomial logistic regression models to estimate factors associated with individual trajectory membership.

Results

The average trend in young people's mental health appeared to follow changes in national guidelines regarding the pandemic. Distinct trends in GMM models highlighting individual differences showed that a 5-trajectory model best explained the changes in emotional problems whilst 4-trajectory models best explained variation in hyperactivity/inattention and conduct problems. While most young people followed low stable (62%-85%) or moderate stable (28%) symptom trajectories, 14%-31% experienced very high, high stable or increasing mental health difficulties. Young people following high stable trajectories were more likely to have special educational needs and/or neurodevelopmental disorders, parents reporting higher levels of distress and parent-child conflict, and were less likely to have at least one close friend.

Conclusions

Most young people adapted well and experienced low stable symptoms, but nearly one third experienced high stable or increasing mental health difficulties. Young people with complex needs and parents with higher psychological distress were particularly vulnerable to high stable problems while those with positive peer relationships were less vulnerable. This study offers insight into potential factors that can be addressed using targeted interventions to improve the wellbeing of parents and young people in the event of future lockdowns and school closures.

Developing an understanding of the relationship between anxiety and dissociation in adolescence

Anxiety is a common problem in adolescence which is hypothesised to be associated with dissociation, a range of distressing symptoms linked to reduced psychosocial functioning. Yet, to date, research into the mechanisms of dissociation in adolescents has been limited. The present study investigated the link between trait anxiety and dissociative experiences (depersonalisation and 'felt sense of anomaly') using an online survey. Cognitive appraisals of dissociation, perseverative thinking, and body vigilance were assessed as potential mediating factors of this relationship. 1211 adolescents aged 13-18 years were recruited via social media advertisements and local schools. Linear regression showed a moderate positive relationship between trait anxiety and both dissociation constructs. Hierarchical regression indicated that cognitive appraisals of dissociation and perseverative thinking mediated the relationship between trait anxiety and both dissociation constructs, but trait anxiety was a significant predictor for felt sense of anomaly but not depersonalisation after including the mediators. The final models accounted for 58.7% of variance in depersonalisation and 68.4% of variance in felt sense of anomaly. These results support the hypothesis that dissociation is associated with anxiety in adolescence. They also demonstrate that cognitive-behavioural conceptualisations may be valid for understanding dissociation in adolescence.

In the moment social experiences and perceptions of children with social anxiety disorder: A qualitative study

OBJECTIVES

Childhood social anxiety disorder (SAD) is a common and disabling condition. General forms of cognitive behavioural treatments have demonstrated poorer efficacy for childhood SAD when compared to other childhood anxiety disorders and further understanding of the psychological factors that contribute to the maintenance of childhood SAD is warranted. Examining the social experiences of children with SAD may help to identify relevant psychological factors and increase our understanding of what keeps childhood SAD going.

METHODS

The current study used reflexive thematic analysis to analyse the transcripts of interviews with 12 children aged 8-12 years with SAD who had been interviewed about their 'in the moment' social experiences during a social stress induction task. The interview topic guide included factors hypothesized to maintain SAD in adult cognitive models of the disorder.

RESULTS

The interviews revealed both variety and commonalities in the experiences and interpretations of social events in children with SAD, captured in three related main themes: (i) Discomfort being the centre of attention, (ii) (Lack of) awareness of cognitions and (iii) Managing social fears. Findings indicated likely developmental influences on which maintenance mechanisms apply at which point in time.

CONCLUSIONS

There is variation in the psychological mechanisms that children with SAD endorse and developmental factors are likely to influence when specific mechanisms are relevant. We now need further studies that take a developmentally informed approach to understand the nature of the association between the factors identified in this study and social anxiety in childhood to inform the development of more effective interventions for childhood SAD.

How the COVID-19 Pandemic Affected Young People’s Mental Health and Wellbeing in the UK: A Qualitative Study

There is emerging evidence of the detrimental impact of the pandemic and associated restrictions on young people’s mental health in the UK but to date, these data have been largely quantitative. The aim of the current study was to gain a deeper understanding of young people’s experiences in relation to their mental health and wellbeing during the pandemic. Seventeen young people, aged 11 to 16 years, sampled for diverse characteristics, and living in the UK, were interviewed virtually between December 2020 and February 2021. Reflexive thematic analysis was carried out by the research team, which included two young people, and five themes were developed: (1) positives; (2) worries and anxiety; (3) sadness and anger about losses; (4) mental exhaustion; and (5) support from others. Aspects of young people’s individual circumstances (e.g., pre-existing mental health difficulties; special educational needs and neurodevelopmental disorders) appeared to play a role in their experiences. Continued measurement of young people’s mental health, initiatives to identify young people who have been struggling and the provision of support (including evidence-based and accessible interventions) will be important for protecting young people from future adversities as we emerge from the pandemic.

Using evidence-based psychological approaches to accommodation anomalies

INTRODUCTION

Accommodation anomalies are frequently caused or exacerbated by psychological problems such as anxiety. Patients share many features with those with other anxiety based somatic symptoms such as stomach-ache, palpitations and headaches. They can be difficult to treat, and the ophthalmic literature rarely goes beyond diagnosis and ocular treatment. This study reports characteristics and outcomes of a short case series of patients with accommodation spasms and weaknesses assessed objectively, and outlines a psychological approach to treatment.

METHODS

23 patients (13 severe accommodative weakness or "paralysis," 10 accommodative spasm) aged between 8-30 years, were referred to our laboratory after diagnosis by their referring clinician and exclusion of pathology or drug-related causes. Their accommodation and convergence were assessed objectively with a laboratory photorefractive method, as well as by conventional orthoptic testing and dynamic retinoscopy. All interactions with the patients used an evidence-based psychological approach, to give them insight into how stress and anxiety can cause or exacerbate eye symptoms and help them to break a vicious cycle of anxiety and risk of deterioration.

RESULTS

83% were female and 57% had previously diagnosed anxiety or dyslexia (with many more acknowledging being "worriers"). Inconsistency of responses was the rule and all showed normal responses at some time during their visit. Responses were poorly related to the visual stimuli presented and objective responses often differed from subjective. Dissociation between convergence and accommodation was more common, compared to our large, previously reported, control groups. No participant had true paralysis of accommodation. Responses often improved dramatically within one session after discussion and explanation of the strong relationship between anxiety and accommodative anomalies. None have returned for further advice or treatment.

CONCLUSIONS

Our approach explicitly addresses psychological factors in causing, or worsening, accommodation (and co-existing convergence) anomalies. Many of these patients do not realize that a certain amount of blur is normal in everyday life. Ocular symptoms are often a sign of anxiety, not the primary problem. By recognizing this, patients can be helped to address the triggering issues and symptoms often subside or resolve spontaneously. Well-meaning professionals, offering only ocular treatments, can deflect attention away from the real cause and can unwittingly be making things worse.

A randomised controlled trial to compare clinical and cost-effectiveness of an online parent-led treatment for child anxiety problems with usual care in the context of COVID-19 delivered in Child and Adolescent Mental Health Services in the UK (Co-CAT): a study protocol for a randomised controlled trial

BACKGROUND

In the context of COVID-19, NHS Child and Adolescent Mental Health Services (CAMHS) and other children's mental health services have faced major challenges in providing psychological treatments that (i) work when delivered remotely and (ii) can be delivered efficiently to manage increases in referrals as social distancing measures have been relaxed. Anxiety problems are a common reason for referral to CAMHS, children with pre-existing anxiety problems are particularly vulnerable in the context of COVID-19, and there were concerns about increases in childhood anxiety as schools reopened. The proposed research will evaluate the clinical and cost-effectiveness of a brief online parent-led cognitive behavioural treatment (CBT) delivered by the OSI (Online Support and Intervention for child anxiety) platform with remote support from a CAMHS therapist compared to 'COVID-19 treatment as usual' (C-TAU) in CAMHS and other children's mental health services throughout the COVID-19 pandemic.

METHODS

We will conduct a two-arm, multi-site, randomised controlled non-inferiority trial to evaluate the clinical and cost-effectiveness of OSI with therapist support compared to CAMHS and other child mental health services 'COVID-19 treatment as usual' (C-TAU) during the COVID-19 outbreak and to explore parent and therapists' experiences.

DISCUSSION

If non-inferiority is shown, the research will provide (1) a solution for efficient psychological treatment for child anxiety disorders while social distancing (for the COVID-19 context and future pandemics); (2) an efficient means of treatment delivery as 'normal service' resumes to enable CAMHS to cope with the anticipated increase in referrals; and (3) a demonstration of rapid, high-quality evaluation and application of online interventions within NHS CAMHS to drive forward much-needed further digital innovation and evaluation in CAMHS settings. The primary beneficiaries will be children with anxiety disorders and their families, NHS CAMHS teams, and commissioners who will access a potentially effective, cost-effective, and efficient treatment for child anxiety problems.

TRIAL REGISTRATION

ISRCTN ISRCTN12890382 . Registered prospectively on 23 October 2020.

Adolescents' lived experience of panic disorder: an interpretative phenomenological analysis

Background

Panic disorder is a debilitating anxiety disorder that has a serious impact on adolescents’ social and academic functioning and general wellbeing. Panic disorder is experienced by around 1 to 3% of the adolescent population. The aim of this study was to examine adolescents’ experiences of having panic disorder.

Methods

Semi-structured interviews were conducted with eight adolescents with a primary diagnosis of panic disorder. Interpretative Phenomenological Analysis was used to gain an understanding of adolescents’ lived experience of panic disorder.

Results

Two superordinate themes were identified: (1) Drowning in sensations, and (2) An unacceptable self. The findings show that adolescents experience panic disorder as extremely overwhelming and unpleasant, with debilitating feelings of drowning in sensations. Adolescents’ experiences largely fit with the cognitive model of panic, in which catastrophic misinterpretation of bodily sensations is associated with anxiety, avoidance, and safety behaviours, creating a vicious cycle. Attempts to avoid or prevent the attacks appear to inadvertently make them worse. Social worries, feeling broadly misunderstood, and unhelpful responses from others, contributed to feelings of being different or abnormal and were connected to a negative self-concept. Negative social interactions with teachers and peers in the school environment were particularly damaging.

Conclusions

These findings offer new insight into these adolescents’ lived experience of panic disorder and highlight the need for adolescents to access timely, evidence-based treatment, as well as the need for increased awareness and understanding of panic disorder in schools.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00849-x.

Protocol for a randomised controlled feasibility study examining the efficacy of brief cognitive therapy for the treatment of panic disorder in adolescents (PANDA)

BACKGROUND

Panic disorder occurs in between 1 and 3% of adolescents, is associated with high levels of co-morbidity, and without treatment, appears to have a chronic course. To improve access to effective psychological interventions, briefer versions of cognitive behaviour therapy (CBT) have been developed and evaluated for preadolescent children with anxiety disorders. However, there are currently no brief evidence-based CBT interventions for adolescents with anxiety disorders that can be delivered in less than eight sessions. Given that a brief version of cognitive therapy has been shown to be effective in adults with panic disorder, it is possible that an adapted version could be effective for adolescents with panic disorder.

METHODS

The study will examine whether a definitive trial can be conducted, based on a single-centre feasibility randomised controlled trial using several well-defined criteria. Between 30 and 48 young people (age 11-18 years) who meet diagnostic criteria for panic disorder, attending a routine clinical service will be randomly allocated to receive either (i) brief cognitive therapy or (ii) a general form of CBT treatment that is more commonly used for adolescents with anxiety disorders. Both will be delivered 1:1 by a therapist and involve five treatment sessions and two booster sessions. Young people's outcomes will be assessed at the end of treatment and at 3-month follow-up, and qualitative interviews will be conducted to examine acceptability. We will also explore outcomes 1 year after the completion of treatment.

DISCUSSION

This study will test the feasibility of a randomised controlled trial to compare brief cognitive therapy to a general form of CBT for adolescents with panic disorder in the UK. The outputs from the study will provide a clear indication of the feasibility of a future definitive trial and, if indicated, the critical resources that will be required and key information to inform the design and maximise the successful completion of the trial. This has the potential to bring direct benefits to young people and their families, as well as services and society more broadly.

TRIAL REGISTRATION

This trial is registered on the ISRCTN Registry, registration number ISRCTN14884288 , registered retrospectively on 05/12/2019.

Adolescents' perceived barriers and facilitators to seeking and accessing professional help for anxiety and depressive disorders: a qualitative interview study

Anxiety and depressive disorders are the most common mental health disorders in adolescents, yet only a minority of young people with these disorders access professional help. This study aims to address this treatment gap by improving our understanding of barriers and facilitators to seeking/accessing professional help as perceived by adolescents with anxiety/depressive disorders identified in the community. Twenty-two adolescents, aged 11-17 years, who met diagnostic criteria for a current anxiety and/or depressive disorder were identified through school-based screening. In-depth qualitative interviews were conducted one-to-one with each adolescent and adolescents' parents were interviewed separately for the purpose of data triangulation. Data were analysed using reflexive thematic analysis. We identified four themes capturing adolescent perceived barriers and facilitators to seeking/accessing professional help for anxiety and depressive disorders: (1) making sense of difficulties, (2) problem disclosure, (3) ambivalence to seeking help, and (4) the instrumental role of others. Barriers/facilitators identified within each theme reflect important developmental characteristics of adolescence, such as a growing need for autonomy and concerns around negative social evaluation. At the same time, the results highlight adolescents' dependency on other people, mainly their parents and school staff, when it comes to successfully accessing professional help for their mental health difficulties. This study identifies a number of barriers/facilitators that influence help-seeking behaviour of adolescents with anxiety and/or depressive disorders. These factors need to be addressed when targeting treatment utilisation rates in this particular group of young people.

Examining changes in parent-reported child and adolescent mental health throughout the UK's first COVID-19 national lockdown

BACKGROUND

The COVID-19 pandemic has significantly changed the lives of children and adolescents, forcing them into periods of prolonged social isolation and time away from school. Understanding the psychological consequences of the UK's lockdown for children and adolescents, the associated risk factors, and how trajectories may vary for children and adolescents in different circumstances is essential so that the most vulnerable children and adolescents can be identified, and appropriate support can be implemented.

METHODS

Participants were a convenience sample of parents and carers (n = 2,988) in the UK with children and adolescents aged between 4 and 16 years who completed an online survey about their child's mental health. Growth curve analysis was used to examine the changes in conduct problems, hyperactivity/inattention, and emotional symptoms between the end of March/beginning of April and July using data from monthly assessments over four months. Additionally, growth mixture modelling identified mental health trajectories for conduct problems, hyperactivity/inattention, and emotional symptoms separately, and subsequent regression models were used to estimate predictors of mental health trajectory membership.

RESULTS

Overall levels of hyperactivity and conduct problems increased over time, whereas emotional symptoms remained relatively stable, though declined somewhat between June and July. Change over time varied according to child age, the presence of siblings, and with Special Educational Needs (SEN)/Neurodevelopmental Disorders (ND). Subsequent growth mixture modelling identified three, four, and five trajectories for hyperactivity/inattention, conduct problems, and emotional symptoms, respectively. Though many children maintained 'stable low' symptoms, others experienced elevated symptoms by July. These children were more likely to have a parent/carer with higher levels of psychological distress, to have SEN/ND, or to be younger in age.

CONCLUSIONS

The findings support previous literature and highlight that certain risk factors were associated with poorer mental health trajectories for children and adolescents during the pandemic.

Optimising exposure for adolescents with public speaking anxiety: Affect labelling or positive coping statements?

Cognitive Behavioural Therapy (CBT) is the first line treatment for anxiety disorders in youth however many adolescents do not benefit. Behavioural exposure is believed to be the critical ingredient of CBT and research with adults has shown that labelling affect, but not positive coping statements, enhances exposure outcomes. However, many CBT protocols for young people involve using positive coping statements alongside exposure. We compared the effects of exposure with positive coping statements, affect labelling, and neutral statements on fear responses in adolescents (age 13-14 years) with public speaking anxiety as they delivered a series of speeches in front of a pre-recorded classroom audience. Self-rated anxiety, heart rate, and observer ratings of expressed anxiety were assessed pre-test, immediate post-test and at 1-week follow-up. Neither affect labelling nor positive coping statements enhanced exposure on any measure from pre-test to 1-week follow-up. While there was an initial advantage of exposure with positive coping statements for post-speech self-reported anxiety, this effect was not maintained, and there was a significant increase in anxiety from immediate post-test to 1-week follow-up in this condition, compared to the other conditions. The short-term benefits from generating positive coping statements may explain why this is often employed in the treatment of anxiety problems in young people, but also indicate that it may not confer any advantage in the longer term. These intriguing findings highlight the urgent need for further attention to improve understanding of how to optimise exposure in young people and maximise treatment outcomes.

Relationships between local school closures due to the COVID-19 and mental health problems of children, adolescents, and parents in Japan

The widespread impacts of COVID-19 have affected both child and parent mental health worldwide. This study aimed to investigate the relationship between school closures due to COVID-19 and child and parent mental health in Japan. A sample of 1,984 Japanese parents with children and adolescents aged 6-15 years participated. The parents responded to online questionnaires about their own mental health and that of their children cross-sectionally. Participants were divided into three school situations based on the past week: full school closure, partial school closure, and full school open. Results indicated that 2.02% (n = 40) of the participants were in full school closure and 5.95% (n = 118) of the participants were in partial school closure. The results indicated that, after controlling for other variables regarding the pandemic, full school closure was associated with much higher scores in both child and parent mental health problems compared to full school open. Moderately higher scores were found only for anxiety symptoms in both children and parents under partial school closure compared to where schools were fully open. Consideration of the needs of families is necessary in the context of both full and partial school closures to prevent deteriorating mental health.

The acceptability of a therapist-assisted internet-delivered cognitive behaviour therapy program for the treatment of anxiety disorders in adolescents: a qualitative study

Computerized treatments have been shown to be effective in young people with anxiety disorders. However, there has been limited investigation into the experiences of adolescents in undertaking this treatment. This qualitative study explored adolescents' experiences of being treated for an anxiety disorder, using an online intervention with therapist support, as part of a randomised controlled trial. Individual semi-structured interviews were conducted with thirteen adolescents aged between 13 and 17 years, who had received the online intervention. Data were analysed using reflexive thematic analysis. Two cross-cutting themes were identified: (i) Usability of the program, and (ii) Putting techniques into practice. Although the convenience of online sessions was recognised as positive, many of the adolescents expressed a preference for face-to-face sessions. The length of sessions and the large amount of reading involved was highlighted by most participants. The transdiagnostic nature of the content meant some elements of the programme were seen as less relevant. While many participants appreciated the 'fun' aspect of the program, others felt that certain aspects of the program were not suitable for their age group. Exposure, psychoeducation and cognitive restructuring were generally received positively, whereas responses to the use of relaxation and rewards were much more mixed. Our findings highlight the potential utility for online treatments delivered with therapist support. However, they also highlight how issues with both the format and treatment components can impact the acceptability of a program. As such, further work is warranted to improve the acceptability of online treatments for adolescents with anxiety disorders.

How did the mental health symptoms of children and adolescents change over early lockdown during the COVID-19 pandemic in the UK?

Background

The COVID-19 pandemic has caused extensive disruption to the lives of children and young people. Understanding the psychological effects on children and young people, in the context of known risk factors is crucial to mitigate the effects of the pandemic. This study set out to explore how mental health symptoms in children and adolescents changed over a month of full lockdown in the United Kingdom in response to the pandemic.

Methods

UK-based parents and carers (n = 2673) of school-aged children and young people aged between 4 and 16 years completed an online survey about their child's mental health at two time points between March and May 2020, during early lockdown. The survey examined changes in emotional symptoms, conduct problems and hyperactivity/inattention.

Results

The findings highlighted particular deteriorations in mental health symptoms among preadolescent children, which translated to a 10% increase in those meeting possible/probable caseness criteria for emotional symptoms, a 20% increase in hyperactivity/inattention, and a 35% increase in conduct problems. In contrast, changes among adolescents were smaller (4% and 8% increase for hyperactivity/inattention and conduct problems, respectively) with a small reduction in emotional symptoms (reflecting a 3% reduction in caseness). Overall, there were few differences in change in symptoms or caseness over time according to demographic characteristics, but children and young people in low income households and those with special educational needs and/or neurodevelopmental disorders exhibited elevated symptoms (and caseness) at both time points.

Conclusions

The findings highlight important areas of concern in terms of the potential impact of the first national lockdown on children and young people's adjustment. Developing an understanding of who has been most severely affected by the pandemic, and in what ways, is crucial in order to target effective support where it is most needed.

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.

Safety behaviours in social anxiety: An examination across adolescence

BACKGROUND

Safety behaviours have been shown to be a key maintaining factor in Social Anxiety Disorder (SAD). In adults, a two-factor structure of safety behaviours reflecting 'avoidance' and 'impression-management' types has been identified. This has not yet been investigated in adolescents.

AIMS

We set out to investigate the factor structure of safety behaviours in relation to adolescent social anxiety symptoms and SAD, the extent to which this varies by age, and then to examine the association between the derived factor scores and other social anxiety related phenomena.

METHOD

Questionnaire measures of social anxiety symptoms, cognitions and safety behaviours, peer relationship outcomes, general anxiety and depression were collected from a community sample of 584 younger (11-14 years) and 208 older (16-18 years) adolescents, and a clinical sample of 80 adolescents (11-18 years) with a primary diagnosis of SAD. Four hypotheses were investigated using exploratory and confirmatory factor analyses, regressions, correlations and path analyses.

RESULTS

A two-factor structure reflecting 'avoidance' and 'impression-management' safety behaviours was supported in the community and clinical sample. Older adolescents were found to use 'impression-management' behaviours more than younger adolescents after controlling for overall safety behaviour score. Both types of safety behaviour were significantly positively associated with social anxiety symptoms and cognitions. Path analyses revealed an indirect effect of social anxiety symptoms on peer victimisation, social satisfaction and friendship quality via 'avoidance', but not 'impression-management' safety behaviours.

CONCLUSIONS

Both 'avoidance' and 'impression-management' safety behaviours are associated with social anxiety symptoms and cognitions in youth, with age-related differences in their frequency. 'Avoidance' behaviours are specifically associated with negative outcomes for quality of peer relationships.

Do oropharyngeal throat packs prevent fluid ingestion during orthognathic surgery?

The oropharyngeal throat pack is commonly used in oral and maxillofacial surgery despite debated evidence regarding its barrier function. The study objectives were to investigate whether the oropharyngeal pack reduces blood ingestion and to evaluate its relationship with postoperative nausea and vomiting (PONV) and throat pain. This was a single-center, parallel group, single-blind randomized controlled trial. Participants undergoing orthognathic surgery, age ≥16 years, were included in the study. After intubation and prior to surgery start, the treatment group received oropharyngeal packing; the control group received no packing. Outcome variables were the quality of gastric contents aspirated by nasogastric tube (bloody or not bloody), PONV, and throat pain (visual analog scale). Thirty patients (treatment n = 15; control n = 15) were randomized and analyzed. There was no difference between the groups in quality of gastric contents (P = 1.00) or incidence of PONV at 2 hours and 24 hours (P = 1.00). Throat pain incidence and severity at 2 hours were both higher in the treatment group, but this was not statistically significant (P = 0.128, P = 0.223). The results indicate that the oropharyngeal pack is not an effective barrier against blood ingestion. Oropharyngeal packs do not improve or worsen PONV, but may increase throat pain.

Annual Research Review: Immersive virtual reality and digital applied gaming interventions for the treatment of mental health problems in children and young people: the need for rigorous treatment development and clinical evaluation

BACKGROUND

Mental health problems in children and young people are common and can lead to poor long-term outcomes. Despite the availability of effective psychological interventions for mental health disorders, only a minority of affected children and young people access treatment. Digital interventions, such as applied games and virtual reality (VR), that target mental health problems in children and young people may hold a key to increasing access to, engagement with, and potentially the effectiveness of psychological treatments. To date, several applied games and VR interventions have been specifically developed for children and young people. This systematic review aims to identify and synthesize current data on the experience and effectiveness of applied games and VR for targeting mental health problems in children and young people (defined as average age of 18 years or below).

METHODS

Electronic systematic searches were conducted in Medline, PsycINFO, CINAHL, and Web of Science.

RESULTS

Nineteen studies were identified that examined nine applied games and two VR applications, and targeted symptoms of anxiety, depression, and phobias using both quantitative and qualitative methodologies. Existing evidence is at a very early stage and studies vary extensively in key methodological characteristics. For applied games, the most robust evidence is for adolescent depressive symptoms (medium clinical effect sizes). Insufficient research attention has been given to the efficacy of VR interventions in children and young people.

CONCLUSIONS

The evidence to date is at a very early stage. Despite the enthusiasm for applied games and VR, existing interventions are limited in number and evidence of efficacy, and there is a clear need for further co-design, development, and evaluation of applied games and VR before they are routinely offered as treatments for children and young people with mental health problems.

Supporting Parents & Kids Through Lockdown Experiences (SPARKLE): A digital parenting support app implemented in an ongoing general population cohort study during the COVID-19 pandemic: A structured summary of a study protocol for a randomised controlled trial

Objectives

The COVID-19 related lockdowns and distancing measures have presented families with unprecedented challenges. A UK-wide cohort study tracking changes in families’ mental health since early lockdown (Co-SPACE) found a significant rise in primary school-aged children’s behaviour problems and associated family-related stress. Three-quarters of parents in Co-SPACE also reported wanting extra support. In SPARKLE, we will examine whether providing Co-SPACE families with a smartphone application delivering information and parenting support, Parent Positive, can reverse the negative effects of the pandemic on children and parents. The efficacy on child and parent outcomes and cost-effectiveness of Parent Positive will be examined. We will also test whether the effects are moderated by pre-existing levels of child conduct problems and usage of Parent Positive. Exploratory analyses will examine whether other baseline characteristics or lockdown circumstances moderate the effects of Parent Positive.

Trial design

SPARKLE is a two-arm superiority parallel group randomised controlled trial embedded in an existing large UK-wide self-selected community cohort – Co-SPACE. Those who consent to SPARKLE will be randomised 1:1 to either Parent Positive or Follow-up As Usual (FAU).

Participants

Co-SPACE (a UK-wide longitudinal cohort study) parents aged ≥18 who have children aged 4-10 years will be eligible for SPARKLE.

Intervention and comparator

Parent Positive: is a digital public health intervention that can be delivered rapidly at scale to support parents in managing their children’s behaviour to reduce conduct problems and levels of family conflict, which were exacerbated during the first lockdown, and which may increase further in future months as families need to cope with continuous uncertainty and further disruption to their daily lives. Co-designed with parents and based on decades of parenting research, Parent Positive consists of three elements: (i) Parenting Boosters: where advice, delivered in the form of narrated animations, videos, graphics and text is provided to help parents with eight common parenting challenges; (ii) Parenting Exchange: a facilitated parent-to-parent communication and peer support platform and; (iii) Parent Resources: giving access to carefully selected high-quality, evidence-based online parenting resources.

Follow-up as Usual: FAU was selected as a comparator because the public health nature meant that an active comparator was not appropriate due to the pragmatic, rapid implementation of the trial. Individuals randomised to FAU will receive no intervention for the first two months while the data for baseline (T1), T2 and T3 are collected. They will then be given full access to the app until 30th November 2021.

Main outcomes

Outcome measures will be collected remotely through Qualtrics according to the Co-SPACE schedule at baseline (T1), which will be the Co-SPACE survey data obtained immediately prior to randomisation, and then at one month (T2) and two months (T3) post-randomisation. Measures will be collected to assess group differences in child and parent outcomes, costs and service utilisation, and adverse events. Usage of Parent Positive will also be tracked. The primary outcome is parent-reported child conduct problems at one-month post-randomisation measured using the Strengths and Difficulties Questionnaire conduct problems subscale.

Randomisation

Enrolled participants will be allocated to Parent Positive or FAU at the ratio of 1:1 by simple randomisation using the Randomizer function within the Qualtrics programme. Neither blocking nor stratification will be used.

Blinding (masking)

It is not possible to blind parents enrolled in the study and Qualtrics will automatically inform parents of their group allocation. Blinded members of the research team and the senior statistician will not be given access to the Qualtrics system or the data in order to remain blinded until after the analysis is complete. We do not anticipate any serious harms associated with taking part in the intervention, therefore there will be no need to unblind any blinded staff during the study. The junior statistician will be unblinded throughout.

Numbers to be randomised (sample size)

A total of 616 will be recruited into the trial with 308 consenting parents randomised to each treatment arm.

Trial status

V1.0; 15.03.2021. Not yet recruiting. Anticipated start date: 1^st April 2021. Anticipated end date for recruitment: 31^st July 2021.

Trial registration

Clinicaltrial.gov: NCT04786080. The trial was prospectively registered on 8 March 2021.

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05226-4.

Using the 11-item Version of the RCADS to Identify Anxiety and Depressive Disorders in Adolescents

The purpose of this study was to identify items from the Revised Children's Anxiety and Depression Scale - RCADS-C/P that provided a brief, reliable and valid screen for anxiety and/or depressive disorders in adolescents. In addition, we examined whether adding items assessing suicidal ideation (Moods and Feelings Questionnaire - MFQ- C/P) and symptom impact and duration (items adapted from the Strengths and Difficulties Questionnaire - SDQ) improved the identification of adolescents with anxiety and/or depressive disorders. We compared two samples of adolescents and their parents - a community sample, recruited through secondary schools in England (n = 214) and a clinic-referred sample, who met diagnostic criteria for anxiety and/or depressive disorder and were recruited through a university-based research clinic (n = 246). Participants completed the RCADS-C/P with additional symptom impact and duration items, and the MFQ-C/P. Using ROC curve analyses, we identified a set of 11 RCADS-C/P items (6 addressing anxiety and 5 depression symptoms) for adolescent- and parent-report. This set of 11 symptom items achieved sensitivity/specificity values > .75, which were comparable to corresponding values for the RCADS-47-C/P. Combining adolescent and parent-report improved the identification of anxiety/depression in adolescents compared to using adolescent-report alone. Finally, adding two symptom impact items further improved the sensitivity/specificity of the 11 symptom items, whereas adding suicidal ideation items did not. The 11 RCADS items accurately discriminated between the community and clinic-referred sample with anxiety and/or depressive disorders and have the potential to quickly and accurately identify adolescents with these disorders in community settings.

Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a qualitative analysis of the experiences of young people, their parents and clinicians-in-training

BACKGROUND

Social anxiety disorder (SAD) is common. It usually starts in adolescence, and without treatment can disrupt key developmental milestones. Existing generic treatments are less effective for young people with SAD than with other anxiety disorders, but an adaptation of an effective adult therapy (CT-SAD-A) has shown promising results for adolescents.

AIMS

The aim of this study was to conduct a qualitative exploration to contribute towards the evaluation of CT-SAD-A for adoption into Child and Adolescent Mental Health Services (CAMHS).

METHOD

We used interpretative phenomenological analysis (IPA) to analyse the transcripts of interviews with a sample of six young people, six parents and seven clinicians who were learning the treatment.

RESULTS

Three cross-cutting themes were identified: (i) endorsing the treatment; (ii) finding therapy to be collaborative and active; challenging but helpful; and (iii) navigating change in a complex setting. Young people and parents found the treatment to be useful and acceptable, although simultaneously challenging. This was echoed by the clinicians, with particular reference to integrating CT-SAD-A within community CAMHS settings.

CONCLUSIONS

The acceptability of the treatment with young people, their parents and clinicians suggests further work is warranted in order to support its development and implementation within CAMHS settings.

Cognitive therapy compared with CBT for social anxiety disorder in adolescents: a feasibility study

BACKGROUND

Social anxiety disorder (SAD) is common, typically starts in adolescence and has a low natural recovery rate. Existing psychological treatments for adolescent SAD are only moderately effective. It is possible that recovery rates for adolescents could be substantially improved by adapting a psychological therapy that is highly effective among adults with SAD.

OBJECTIVES

To train child and adolescent mental health services (CAMHS) therapists to deliver cognitive therapy for SAD in adolescents (CT-SAD-A) and assess therapist competence. To estimate the costs to the NHS of training therapists to deliver CT-SAD-A and the mean cost per adolescent treated. To examine the feasibility of a randomised controlled trial (RCT) to compare CT-SAD-A with the general form of cognitive-behavioural therapy that is more commonly used.

DESIGN

During the training phase of the study, it became clear that the RCT would not be feasible because of high staff turnover and unfilled posts within CAMHS and changes in the nature of referrals, which meant that few young people with primary SAD were accessing some of the participating services. The study design was altered to comprise the following: a training case series of CT-SAD-A delivered in routine CAMHS, an estimate of the cost to the NHS of training therapists to deliver CT-SAD-A and of the mean cost per adolescent treated, and qualitative interviews with participating young people, parents, therapists and service managers/leads.

SETTING

Five CAMHS teams within Berkshire Healthcare and Oxford Health NHS Foundation Trusts.

PARTICIPANTS

Eight therapists received training in CT-SAD-A. Twelve young people received CT-SAD-A, delivered by six therapists. Six young people, six parents, seven therapists and three managers participated in qualitative interviews.

INTERVENTIONS

Cognitive therapy for social anxiety disorder in adolescents (CT-SAD-A).

MAIN OUTCOME MEASURES

Measured outcomes included social anxiety symptoms and diagnostic status, comorbid symptoms of anxiety and depression, social and general functioning, concentration in class and treatment acceptability. Patient level utilisation of the intervention was collected using clinicians' logs.

RESULTS

Nine out of 12 participants achieved good outcomes across measures (r ≥ 0.60 across social anxiety measures). The estimated cost of delivering CT-SAD-A was £1861 (standard deviation £358) per person. Qualitative interviews indicated that the treatment was acceptable to young people, parents and therapists, but therapists and managers experienced challenges when implementing the training and treatment within the current CAMHS context.

LIMITATIONS

Findings were based on a small, homogeneous sample and there was no comparison arm.

CONCLUSIONS

CT-SAD-A is a promising treatment for young people with SAD, but the current CAMHS context presents challenges for its implementation.

FUTURE WORK

Further work is needed to ensure that CAMHS can incorporate and test CT-SAD-A. Alternatively, CT-SAD-A should be delivered and tested in other settings that are better configured to treat young people whose lives are held back by SAD. The new schools Mental Health Support Teams envisaged in the 2017 Children's Mental Health Green Paper may provide such an opportunity.

FUNDING

The National Institute for Health Research (NIHR) Health Technology Assessment programme. Individual funding was also provided for Cathy Creswell, David M Clark and Eleanor Leigh as follows: NIHR Research Professorship (Cathy Creswell); Wellcome Senior Investigator Award (Anke Ehlers and David M Clark); and the Wellcome Clinical Research Training Fellowship (Eleanor Leigh).

Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a clinical and cost analysis

BACKGROUND

Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed.

AIMS

Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment?

METHOD

CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training.

RESULTS

Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment.

CONCLUSIONS

This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.

Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies

Mental health disorders in children and adolescents are highly prevalent yet undertreated. A detailed understanding of the reasons for not seeking or accessing help as perceived by young people is crucial to address this gap. We conducted a systematic review (PROSPERO 42018088591) of quantitative and qualitative studies reporting barriers and facilitators to children and adolescents seeking and accessing professional help for mental health problems. We identified 53 eligible studies; 22 provided quantitative data, 30 provided qualitative data, and one provided both. Four main barrier/facilitator themes were identified. Almost all studies (96%) reported barriers related to young people's individual factors, such as limited mental health knowledge and broader perceptions of help-seeking. The second most commonly (92%) reported theme related to social factors, for example, perceived social stigma and embarrassment. The third theme captured young people's perceptions of the therapeutic relationship with professionals (68%) including perceived confidentiality and the ability to trust an unknown person. The fourth theme related to systemic and structural barriers and facilitators (58%), such as financial costs associated with mental health services, logistical barriers, and the availability of professional help. The findings highlight the complex array of internal and external factors that determine whether young people seek and access help for mental health difficulties. In addition to making effective support more available, targeted evidence-based interventions are required to reduce perceived public stigma and improve young people's knowledge of mental health problems and available support, including what to expect from professionals and services.

The identification and psychological treatment of panic disorder in adolescents: a survey of CAMHS clinicians

BACKGROUND

Panic disorder is experienced by around 1% of adolescents and has a significant impact on social and academic functioning. Preliminary evidence supports the effectiveness of panic disorder-specific treatment in adolescents with panic disorder; however, panic disorder may be overlooked in adolescents due to overlapping symptoms with other anxiety disorders and other difficulties being more noticeable to others. The aim of this study was to establish what training National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) clinicians have received in psychological therapies and panic disorder and how they identify and treat panic disorder in adolescents.

METHOD

CAMHS clinicians from a range of professions (n = 427), who were delivering psychological treatments to children and adolescents with anxiety disorders, participated. They completed a cross-sectional, online survey, including a vignette describing an adolescent with panic disorder, and were asked to identify the main diagnosis or presenting problem.

RESULTS

Less than half the clinicians (48.6%) identified panic disorder or panic symptoms as the main presenting problem from the vignette. The majority of clinicians suggested CBT would be their treatment approach. However, few identified an evidence-based treatment protocol for working with young people with panic disorder. Almost half the sample had received no training in cognitive behaviour therapy (CBT), and around a fifth had received no training in delivering psychological treatments.

CONCLUSIONS

Only half of CAMHS clinicians identified panic disorder from a vignette and although CBT treatments are widely offered, only a minority of adolescents with panic disorder are receiving treatments developed for and evaluated with young people with panic disorder. There is a vital need for clinician training, the use of tools that aid identification and the implementation of evidence-based treatments within CAMHS.

KEY PRACTITIONER MESSAGE

Panic disorder affects around 1% of adolescents, adversely impacting social, academic and long-term life functioning. There is preliminary evidence for the effectiveness of a panic disorder-specific treatment of panic disorder in adolescents. Clinicians struggle to identify panic disorder or suitable treatment protocols for treating adolescents, although most would use CBT as the treatment approach. There is a vital need for clinician training, tools that aid identification of young people with panic disorder and evidence-based treatments that can be delivered in routine clinical settings.

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: 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.

A randomized controlled trial of internet-delivered cognitive behaviour therapy for adolescent anxiety disorders in a routine clinical care setting with and without parent sessions

BACKGROUND

Computerized treatments have been shown to be effective in young people with anxiety disorders within research settings. The aims of this study were to evaluate a self-completed, therapist-supported online treatment for adolescent anxiety disorders in a routine clinical care setting and examine whether additional sessions for parents improved treatment outcome.

METHOD

Sixty adolescents (13-18 years) referred by primary and secondary care services for treatment of an anxiety disorder and their parent(s) were randomly allocated to begin treatment immediately or after a 16-week waitlist. Half the parents (receiving treatment immediately or after a waitlist) were allocated to receive sessions themselves. Assessments were conducted pre- and posttreatment and at 6-month follow-up.

RESULTS

There was no significant difference posttreatment between the immediate treatment and waitlist groups in remission of primary anxiety disorder (Odds Ratio (OR) = 2.19, 95% CI: 0.72-6.70). Parent sessions did not significantly improve adolescent outcomes immediately or at 6-month follow-up (OR = 0.75, 95% CI: 0.26-2.15; OR = 1.14, 95% CI: 0.42-3.15).

CONCLUSIONS

Within a routine clinical care setting, a therapist-supported online treatment failed to deliver significantly better outcomes for adolescents with anxiety disorders than a waitlist. Further research is needed to develop more effective treatments for this population.

Secondary school practitioners' beliefs about risk factors for school attendance problems: a qualitative study

School staff have an important role to play in identifying and assisting pupils who require additional support to regularly attend school, but their beliefs about risk factors might influence their decisions regarding intervention. This qualitative study investigated educational practitioners' beliefs about risk factors for attendance problems. Sixteen practitioners from three secondary schools were interviewed via focus groups. Data were analysed using thematic analysis. Practitioners identified risk factors related to the individual, their family, peers and school. Poor mental health was identified as a risk factor, but practitioners primarily focused on anxiety rather than other mental health problems like depression or behavioural disorders. The overall perception was that school factors were less important than individual, family and peer factors. Implications include a need for increased awareness of the role of school factors in attendance problems, focus on promoting positive peer and pupil-teacher relationships, and collaborative working between young people, families and schools.

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.

Comparisons of the Factor Structure and Measurement Invariance of the Spence Children's Anxiety Scale-Parent Version in Children with Autism Spectrum Disorder and Typically Developing Anxious Children

The Spence Children's Anxiety Scale-Parent version (SCAS-P) is often used to assess anxiety in children with autism spectrum disorder (ASD), however, little is known about the validity of the tool in this population. The aim of this study was to determine whether the SCAS-P has the same factorial validity in a sample of young people with ASD (n = 285), compared to a sample of typically developing young people with anxiety disorders (n = 224). Poor model fit with all of the six hypothesised models precluded invariance testing. Exploratory factor analysis indicated that different anxiety phenomenology characterises the two samples. The findings suggest that cross-group comparisons between ASD and anxious samples based on the SCAS-P scores may not always be appropriate.

Genetic variation in the endocannabinoid system and response to Cognitive Behavior Therapy for child anxiety disorders

Extinction learning is an important mechanism in the successful psychological treatment of anxiety. Individual differences in response and relapse following Cognitive Behavior Therapy may in part be explained by variability in the ease with which fears are extinguished or the vulnerability of these fears to re-emerge. Given the role of the endocannabinoid system in fear extinction, this study investigates whether genetic variation in the endocannabinoid system explains individual differences in response to CBT. Children (N = 1,309) with a primary anxiety disorder diagnosis were recruited. We investigated the relationship between variation in the CNR1, CNR2, and FAAH genes and change in primary anxiety disorder severity between pre- and post-treatment and during the follow-up period in the full sample and a subset with fear-based anxiety disorder diagnoses. Change in symptom severity during active treatment was nominally associated (P < 0.05) with two SNPs. During the follow-up period, five SNPs were nominally associated with a poorer treatment response (rs806365 [CNR1]; rs2501431 [CNR2]; rs2070956 [CNR2]; rs7769940 [CNR1]; rs2209172 [FAAH]) and one with a more favorable response (rs6928813 [CNR1]). Within the fear-based subset, the effect of rs806365 survived multiple testing corrections (P < 0.0016). We found very limited evidence for an association between variants in endocannabinoid system genes and treatment response once multiple testing corrections were applied. Larger, more homogenous cohorts are needed to allow the identification of variants of small but statistically significant effect and to estimate effect sizes for these variants with greater precision in order to determine their potential clinical utility. © 2016 The Authors. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics Published by Wiley Periodicals, Inc.

Genome-wide association study of response to cognitive-behavioural therapy in children with anxiety disorders

BACKGROUND

Anxiety disorders are common, and cognitive-behavioural therapy (CBT) is a first-line treatment. Candidate gene studies have suggested a genetic basis to treatment response, but findings have been inconsistent.

AIMS

To perform the first genome-wide association study (GWAS) of psychological treatment response in children with anxiety disorders (n = 980).

METHOD

Presence and severity of anxiety was assessed using semi-structured interview at baseline, on completion of treatment (post-treatment), and 3 to 12 months after treatment completion (follow-up). DNA was genotyped using the Illumina Human Core Exome-12v1.0 array. Linear mixed models were used to test associations between genetic variants and response (change in symptom severity) immediately post-treatment and at 6-month follow-up.

RESULTS

No variants passed a genome-wide significance threshold (P = 5 × 10(-8)) in either analysis. Four variants met criteria for suggestive significance (P<5 × 10(-6)) in association with response post-treatment, and three variants in the 6-month follow-up analysis.

CONCLUSIONS

This is the first genome-wide therapygenetic study. It suggests no common variants of very high effect underlie response to CBT. Future investigations should maximise power to detect single-variant and polygenic effects by using larger, more homogeneous cohorts.

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

Anxiety disorders are among the most common emotional difficulties experienced by children and young people. They cause significant disturbance to the lives of young people and their families and present a risk for lifelong psychological disturbance. Effective psychological (ie, cognitive-behaviour therapy (CBT)) and pharmacological interventions (eg, selective serotonin reuptake inhibitors (SSRIs)) have been established. However, the risk of adverse effects and unknown long-term effects of using SSRIs has led to recommendations that CBT is delivered as a first-line intervention. Recent innovations have included the development of low-intensity CBT programmes, delivered briefly via parents or online. These hold promise to increase access to psychological therapies for children and young people with these common and severe difficulties.

Non-replication of the association between 5HTTLPR and response to psychological therapy for child anxiety disorders

BACKGROUND

We previously reported an association between 5HTTLPR genotype and outcome following cognitive-behavioural therapy (CBT) in child anxiety (Cohort 1). Children homozygous for the low-expression short-allele showed more positive outcomes. Other similar studies have produced mixed results, with most reporting no association between genotype and CBT outcome.

AIMS

To replicate the association between 5HTTLPR and CBT outcome in child anxiety from the Genes for Treatment study (GxT Cohort 2, n = 829).

METHOD

Logistic and linear mixed effects models were used to examine the relationship between 5HTTLPR and CBT outcomes. Mega-analyses using both cohorts were performed.

RESULTS

There was no significant effect of 5HTTLPR on CBT outcomes in Cohort 2. Mega-analyses identified a significant association between 5HTTLPR and remission from all anxiety disorders at follow-up (odds ratio 0.45, P = 0.014), but not primary anxiety disorder outcomes.

CONCLUSIONS

The association between 5HTTLPR genotype and CBT outcome did not replicate. Short-allele homozygotes showed more positive treatment outcomes, but with small, non-significant effects. Future studies would benefit from utilising whole genome approaches and large, homogenous samples.

HPA AXIS RELATED GENES AND RESPONSE TO PSYCHOLOGICAL THERAPIES: GENETICS AND EPIGENETICS

BACKGROUND

Hypothalamic-pituitary-adrenal (HPA) axis functioning has been implicated in the development of stress-related psychiatric diagnoses and response to adverse life experiences. This study aimed to investigate the association between genetic and epigenetics in HPA axis and response to cognitive behavior therapy (CBT).

METHODS

Children with anxiety disorders were recruited into the Genes for Treatment project (GxT, N = 1,152). Polymorphisms of FKBP5 and GR were analyzed for association with response to CBT. Percentage DNA methylation at the FKBP5 and GR promoter regions was measured before and after CBT in a subset (n = 98). Linear mixed effect models were used to investigate the relationship between genotype, DNA methylation, and change in primary anxiety disorder severity (treatment response).

RESULTS

Treatment response was not associated with FKBP5 and GR polymorphisms, or pretreatment percentage DNA methylation. However, change in FKBP5 DNA methylation was nominally significantly associated with treatment response. Participants who demonstrated the greatest reduction in severity decreased in percentage DNA methylation during treatment, whereas those with little/no reduction in severity increased in percentage DNA methylation. This effect was driven by those with one or more FKBP5 risk alleles, with no association seen in those with no FKBP5 risk alleles. No significant association was found between GR methylation and response.

CONCLUSIONS

Allele-specific change in FKBP5 methylation was associated with treatment response. This is the largest study to date investigating the role of HPA axis related genes in response to a psychological therapy. Furthermore, this is the first study to demonstrate that DNA methylation changes may be associated with response to psychological therapies in a genotype-dependent manner.

Interpretation of ambiguity: Differences between children and adolescents with and without an anxiety disorder

BACKGROUND

Theory and treatment of anxiety disorders in young people are commonly based on the premise that interpretation biases found in anxious adults are also found in children and adolescents. Although there is some evidence that this may be the case, studies have not typically taken age into account, which is surprising given the normative changes in cognition that occur throughout childhood. The aim of the current study was to identify whether associations between anxiety disorder status and interpretation biases differed in children and adolescents.

METHODS

The responses of children (7-10 years) and adolescents (13-16 years) with and without anxiety disorders (n=120) were compared on an ambiguous scenarios task.

RESULTS

Children and adolescents with an anxiety disorder showed significantly higher levels of threat interpretation and avoidant strategies than non-anxious children and adolescents. However, age significantly moderated the effect of anxiety disorder status on interpretation of ambiguity, in that adolescents with anxiety disorders showed significantly higher levels of threat interpretation and associated negative emotion than non-anxious adolescents, but a similar relationship was not observed among children.

CONCLUSIONS

The findings suggest that theoretical accounts of interpretation biases in anxiety disorders in children and adolescents should distinguish between different developmental periods. For both ages, treatment that targets behavioral avoidance appears warranted. However, while adolescents are likely to benefit from treatment that addresses interpretation biases, there may be limited benefit for children under the age of ten.