Therapeutic Alliance, Attendance, and Outcomes in Youths Receiving CBT or Client-Centered Therapy for Anxiety.

OBJECTIVE: Positive associations between therapeutic alliance and outcome (e.g. youth symptom severity) have been documented in the youth anxiety literature; however, little is known about the conditions under which early alliance contributes to positive outcomes in youth. The present study examined the relations between therapeutic alliance, session attendance, and outcomes in youths (N = 135; 55.6% female) who participated in a randomized clinical trial testing the efficacy of cognitive-behavioral therapy or client-centered therapy for anxiety. METHOD: We evaluated a conceptual model wherein: (1) early alliance indirectly contributes to positive outcomes by improving session attendance; (2) alliance-outcome associations differ by intervention type, with stronger associations in cognitive-behavioral therapy compared to client-centered therapy; and (3) alliance-outcome associations vary across outcome measurement timepoints, with the effect of early alliance on outcomes decaying over time. RESULTS: Contrary to hypotheses, provider ratings of early alliance predicted greater youth-rated anxiety symptom severity post-treatment (i.e. worse treatment outcomes). Session attendance predicted positive youth-rated outcomes, though there was no indirect effect of early alliance on outcomes through session attendance. CONCLUSIONS: Results show that increasing session attendance is important for enhancing outcomes and do not support early alliance as a predictor of outcomes.

Demonstrating the learning and impact of embedding participant involvement in a pandemic research study: the experience of the SARS-CoV-2 immunity & reinfection evaluation (SIREN) study UK, 2020-2023.

BACKGROUND: Participant involvement in research studies is not a new concept, yet barriers to implementation remain and application varies. This is particularly true for pandemic response research studies, where timeframes are condensed, pressure is high and the value and inclusion of participant involvement can be overlooked. The SIREN Participant Involvement Panel (PIP) provides a case study for participant involvement in pandemic research, working in partnership with people who the research is for and about. METHODS: SIREN and the British Society for Immunology (BSI) recruited and ran two phases of the PIP, involving 15 members in total over a 16-month period. Phase 1 ran between January and August 2022 and Phase 2 between October 2022 and March 2023. Activity figures including recruitment interest and PIP meeting attendance were recorded. To evaluate how the PIP has influenced SIREN, feedback was collected from (a) researchers presenting at the PIP and (b) PIP members themselves. Evaluation at the end of Phase 1 informed our approach to Phase 2. Thematic grouping was planned to identify key lessons learned. RESULTS: Applications increased from n = 30 to n = 485 between Phase 1 and Phase 2 of the PIP, a more than 15-fold increase. The SIREN PIP positively impacted the design, implementation and evaluation phases of the study and sub-studies. Feedback from PIP members themselves was positive, with members highlighting that they found the role rewarding and felt valued. Learnings from the PIP have been condensed into five key themes for applying to future pandemic response research studies: the importance of dedicated resources; recruiting the right panel; understanding motivations for participant involvement; providing flexible options for involvement and enabling the early involvement of participants. CONCLUSIONS: The SIREN PIP has demonstrated the value of actively involving people who research is for and about. The PIP has provided an active feedback mechanism for research and demonstrated a positive influence on both SIREN study researchers and PIP members themselves. This paper makes the case for participant involvement in future pandemic research studies. Future work should include improved training for researchers and we would support the development of a national PIP forum as part of future pandemic research preparedness.

The SARS-Cov2 Immunity & Reinfection Evaluation (SIREN) study was set-up at speed during the early stages of the pandemic to help answer key questions about COVID-19 and inform the national pandemic response. It has provided valuable insight into COVID-19 infections, reinfections, and how well the vaccines work. SIREN helped to find these answers by regularly testing over 44,000 healthcare staff working at 135 NHS organisations. To support participant retention, SIREN established a Participant Involvement Panel (PIP) involving 15 SIREN participants to date. PIP members provide guidance and feedback to SIREN researchers on key research priorities, changes to the study and strategies for maximising participant engagement. This paper provides insight into how the PIP was set-up, run and the resources required from the perspective of the PIP and SIREN researchers. Lessons learned from establishing the PIP are summarised to help inform future pandemic response research studies. The paper adds to the evidence base, and makes the case for, the valuable role participant involvement can play in pandemic response research studies.

How Flexible are Treatments for Youth Internalizing Disorders? Examining Modification Guidelines Included across Supported Treatments.

OBJECTIVE: Treatment protocols for youth-internalizing disorders have been developed, however these protocols have yielded mixed findings in routine care settings. Despite increased recognition of the importance of flexibility when delivering evidence-based treatments (EBTs), little is known about the extent to which protocols offer guidance to providers in flexible EBT implementation. The current study examined the extent to which supported EBTs for youth internalizing disorders explicitly incorporate guidance for treatment modification. METHODS: Supported treatment protocols for youth internalizing disorders were identified (N = 44), from which 4,021 modification guidelines were extracted and coded using a structured coding system to classify modification strategies (i.e., the forms that recommended modifications take), and associated tailoring factors (i.e., the rationale for which modifications are recommended). RESULTS: Across all EBTs, modification guidelines were quite common, with the average protocol including almost 91 text passages providing guidance for modification. The majority of modification guidelines functionally increase session or treatment length by recommending the addition or repetition of material, whereas less than 5% of modification guidelines provided strategies for condensing or streamlining care. Strikingly, less than 2% of modification guidelines in EBT protocols address patient cultural factors, and rarely address provider or setting issues that can challenge standard implementation. CONCLUSIONS: Findings highlight critical gaps in the available guidance to modify EBTs for youth internalizing disorders, and suggest EBT protocols may not be optimally poised to flexibly address the broad diversity of children and adolescents across varied settings in need of mental health care.

Brief modular approach to target perceived burdensomeness in clinic-referred youth.

INTRODUCTION: Existing CBT protocols for internalizing disorders target thoughts and behaviors related to anxiety and/or depression, but do not explicitly target other identified risk factors for suicide ideation, including perceived burdensomeness toward others. The aims of the current study were to (1) develop a novel, brief module (the "Give program") targeting perceived burdensomeness toward others that can be embedded within existing CBT protocols for youth internalizing disorders, (2) evaluate the acceptability and feasibility of the module with an eye toward intervention refinement, and (3) examine reductions in perceived burdensomeness. METHODS: Participants were 18 clinic-referred youths with anxiety or depressive disorders who endorsed burdensomeness. We used a quasi-experimental interrupted time-series design to evaluate changes in burdensomeness scores following the administration of the module. RESULTS: The module was clinically feasible and well-accepted. Youth burdensomeness scores increased in the first half of the CBT protocol and decreased immediately following the administration of the Give program module. Burdensomeness scores were significantly associated with suicide ideation. CONCLUSION: The current study is the first to develop and evaluate a module targeting burdensomeness in at-risk youth in an outpatient setting, demonstrating that burdensomeness can be efficiently and effectively targeted within existing evidence-based treatment protocols for internalizing disorders in youth.

Low Parental Warmth and High Youth Impairment: A Recipe for Perceived Burdensomeness?

Theory and research document the role of perceived burdensomeness in the development of suicide ideation, including in youth. There is a critical need to identify and evaluate variables that foster perceived burdensomeness in youth, with an eye toward advancing etiological models and informing prevention approaches for at-risk youth who are not yet actively suicidal. The current study examined and replicated a conceptual model wherein the association between low parental warmth and burdensomeness is moderated by youth impairment. Participants were 75 and 150 clinic referred youths in Study 1 and Study 2, respectively, with anxiety-related difficulties. Youth impairment significantly moderated the association between low parental warmth and youth perceived burdensomeness such that the association was negative and statistically significant at high levels of impairment, but not at low levels of impairment. The moderation effect was statistically significant in both studies while controlling for anxiety and depressive symptoms. These findings provide insight into variables that are associated with a sense of burdensomeness toward others in youth, and identify potential targets for preventing or intervening to reduce perceived burdensomeness in clinic-referred youth.

Efficacy of Attention Bias Training for Child Anxiety Disorders: A Randomized Controlled Trial.

A growing evidence base supports attention bias modification (ABM) as a novel intervention for anxiety. However, research has been largely conducted with adults and analogue samples, leaving the impact of ABM for child anxiety be fully elucidated. Thus, we conducted a double-blind, randomized controlled trial testing ABM efficacy versus an attention control condition (CC) in 31 children diagnosed with anxiety disorder. Youth were assigned to 4 weeks of ABM where attention was trained away from threat, or a sham CC in which no bias training occurred. Findings indicate that significantly more youth in the ABM versus CC group were considered treatment responders post training. The ABM versus CC group also demonstrated a greater decrease in anxiety severity, with this difference being marginally significant. Findings lend support for the potential of ABM in reducing youth anxiety. Further work regarding mechanisms of action is warranted to advance ABM research.

Benchmarking Treatment Response in Tourette's Disorder: A Psychometric Evaluation and Signal Detection Analysis of the Parent Tic Questionnaire.

This study assessed the psychometric properties of a parent-reported tic severity measure, the Parent Tic Questionnaire (PTQ), and used the scale to establish guidelines for delineating clinically significant tic treatment response. Participants were 126 children ages 9 to 17 who participated in a randomized controlled trial of Comprehensive Behavioral Intervention for Tics (CBIT). Tic severity was assessed using the Yale Global Tic Severity Scale (YGTSS), Hopkins Motor/Vocal Tic Scale (HMVTS) and PTQ; positive treatment response was defined by a score of 1 (very much improved) or 2 (much improved) on the Clinical Global Impressions - Improvement (CGI-I) scale. Cronbach's alpha and intraclass correlations (ICC) assessed internal consistency and test-retest reliability, with correlations evaluating validity. Receiver- and Quality-Receiver Operating Characteristic analyses assessed the efficiency of percent and raw-reduction cutoffs associated with positive treatment response. The PTQ demonstrated good internal consistency (α = 0.80 to 0.86), excellent test-retest reliability (ICC = .84 to .89), good convergent validity with the YGTSS and HM/VTS, and good discriminant validity from hyperactive, obsessive-compulsive, and externalizing (i.e., aggression and rule-breaking) symptoms. A 55% reduction and 10-point decrease in PTQ Total score were optimal for defining positive treatment response. Findings help standardize tic assessment and provide clinicians with greater clarity in determining clinically meaningful tic symptom change during treatment.