Intervention Adherence and Self-Efficacy as Predictors of Child Outcomes in School Nurse-Delivered Interventions for Anxiety.

This study examined the association between two implementation factors, nurse-reported intervention adherence and self-efficacy, and children's outcomes in school nurse-delivered anxiety interventions. Data were collected in a pilot randomized controlled effectiveness trial with 54 children and 21 school nurses. Nurses implemented either a cognitive behavioral or relaxation-skills-only intervention. Nurse questionnaires assessed implementation factors. Independent evaluators assessed changes in children's anxiety symptoms at postintervention and at 3-month follow-up using clinical improvement and global functioning scales. Regression analyses indicated that greater intervention adherence was associated with greater anxiety symptom improvement at follow-up. Nurse self-efficacy interacted with intervention group, such that nurses with higher self-efficacy who implemented the cognitive behavioral intervention tended to have children show improvement and higher postintervention functioning. The impact of implementation factors on children's outcomes may differ depending on intervention type. Self-efficacy may be important for nurses using relatively complex interventions. Intervention adherence should be supported through training and consultation.

A pilot RCT of a school nurse delivered intervention to reduce student anxiety.

The goal of this study was to evaluate the feasibility and impact of brief school-nurse-administered interventions for reducing anxiety. Thirty school nurses in Connecticut and Maryland were randomly assigned to deliver the Child Anxiety Learning Modules (CALM; n = 14) or CALM-Relaxation only (CALM-R; n = 16). Students (N = 54) were ages 5-12 (M age = 8; 84.9% White; 68.5% female) with elevated anxiety symptoms and/or anxiety disorders. Feasibility was assessed based on recruitment, retention, attendance, training and intervention satisfaction, and intervention adherence. Multiple informants, including independent evaluators (IEs), completed measures of clinical improvement at postintervention and at a 3-month follow-up. Of nurses in CALM and CALM-R, 62% and 81%, respectively, enrolled a student and completed an average of 6 sessions. Youth retention was 85% and 94% in CALM and CALM-R, respectively. Training and intervention satisfaction were high. At postintervention and follow-up, youth in both groups showed significant reductions in anxiety and related symptoms and improvements in functioning. Within-group effect sizes were medium to large, and between-group effect sizes were small. Task shifting responsibility for delivering brief mental health interventions to school nurses is feasible and shows promise for reducing anxiety and related impairment. This approach may also be integrated within a response to intervention model used in schools.Public Health Significance: Brief school-nurse-administered anxiety reduction interventions were shown to be feasible and had a positive impact on student anxiety and related impairment highlighting that school nurses can be an important school resource.

School-Based Treatment for Anxiety Research Study (STARS): a Randomized Controlled Effectiveness Trial.

The current study compared the effectiveness of a school-clinician administered cognitive behavioral treatment (CBT) to treatment as usual (TAU) at post-treatment (i.e., after 12 weeks) and at a 1 year follow-up. Sixty-two school-based clinicians (37 in CBT; 25 in TAU) and 216 students (148 students in CBT; 68 in TAU) participated. Students were ages 6-18 (mean age 10.87; 64% Caucasian & 29% African American; 48.6% female) and all met DSM-IV diagnostic criteria for a primary anxiety disorder. Independent evaluators (IEs) assessed clinical improvement, global functioning, and loss of anxiety diagnoses; children and parents completed measures of anxiety symptoms. At post-treatment, no significant treatment main effects emerged on the primary outcome; 42% and 37% of youth were classified as treatment responders in CBT and TAU respectively. However, parent-report of child anxiety showed greater improvements in CBT relative to TAU (d = .29). Moderation analyses at post-treatment indicated that older youth, those with social phobia and more severe anxiety at baseline were more likely to be treatment responders in CBT compared to TAU. At the 1 year follow-up, treatment gains were maintained but no treatment group differences or moderators emerged. CBT and TAU for pediatric anxiety disorders, when delivered by school clinicians were generally similar in effectiveness for lowering anxiety and improving functioning at both post-treatment (on all but the parent measure and for specific subgroups) and 1 year follow-up. Implications for disseminating CBT in the school setting are discussed.

Family and Parent Predictors of Anxiety Disorder Onset in Offspring of Anxious Parents.

BACKGROUND: Offspring of anxious parents are at increased risk for developing anxiety disorders. There is a need to identify which youth are at greatest risk for disorder onset in this population. OBJECTIVE: This study prospectively examined several theory-based family and parent characteristics (e. g., family conflict, parental over-control, parental psychopathology) as predictors of anxiety disorder onset in children whose parents were clinically anxious. METHODS: Families were enrolled in a randomized controlled trial evaluating a familybased preventative intervention, relative to an information monitoring control condition, for offspring of anxious parents (N= 136; child mean age 8.69 years; 55% female; 85% Caucasian). Family and parent measures were collected using multiple informants and an observational task at baseline, post-intervention, and at a six and 12 month followup. Child anxiety disorder diagnosis was determined by independent evaluators using the Anxiety Disorders Interview Schedule for Children. RESULTS: Results indicated that none of the baseline family or parent variables examined predicted the onset of an anxiety disorder in children over the one year follow-up period. CONCLUSIONS: Findings raise questions about the short-term risk associated with family and parent factors in anxiety disorder development in this high risk population.

Child Anxiety Prevention Study: Impact on Functional Outcomes.

This study examined the impact of a selective anxiety prevention program for offspring of clinically anxious parents on three domains of child functioning: (1) social, (2) familial, and (3) emotional/behavioral. Dyads were randomized into either the Coping and Promoting Strength program (CAPS; n = 70) or Information Monitoring (IM; n = 66) comparison group. Multi-informant assessments were conducted at baseline, post intervention, and 6 and 12 months follow-ups. Random effects mixed models under the linear growth modeling (LGM) framework was used to assess the impact of CAPS on growth trajectories. Over time, children in the CAPS group had significantly lower anxiety, anxious/depressed symptoms, and lower total behavior problems (parent report), compared to children in IM group. The intervention did not impact other domains assessed (e.g., social functioning), which may be due to "floor effects" on these measures. Longitudinal follow-up data is needed to provide valuable information about this high risk population.

Preventing Onset of Anxiety Disorders in Offspring of Anxious Parents: A Randomized Controlled Trial of a Family-Based Intervention.

OBJECTIVE: The authors examined the efficacy of a family-based intervention to prevent the onset of anxiety disorders in offspring of anxious parents. METHOD: Participants were 136 families with a parent meeting DSM-IV criteria for an anxiety disorder and one child 6-13 years of age without an anxiety disorder. Families were randomly assigned to the family-based intervention (N=70) or to an information-monitoring control condition (N=66). All families were expected to complete assessments, administered by blind interviewers, at baseline, at the end of the intervention (or 8 weeks after randomization) and at 6- and 12-month follow-ups. Onset of any anxiety disorder and anxiety symptom severity (assessed using the Anxiety Disorders Interview Schedule for Children) at 12 months were the primary and secondary outcome measures, respectively. RESULTS: The incidence of child anxiety disorders was 31% in the control group and 5% in the intervention group (odds ratio=8.54, 95% CI=2.27, 32.06). At the 1-year follow-up, youths in the control group also had higher anxiety symptoms ratings than those in the intervention group. Effect sizes were medium to large (0.81 at 6 months and 0.57 at 12 months for anxiety symptoms), and the number needed to treat was 3.9 at 12 months. Significant moderators included baseline levels of child anxiety; significant mediators were parental distress and modeling of anxiety. Child maladaptive cognitions and parental anxiety did not mediate outcomes. CONCLUSIONS: A brief psychosocial prevention program holds promise for reducing the 1-year incidence of anxiety disorders among offspring of anxious parents.

Enhancing the Capacity of School Nurses to Reduce Excessive Anxiety in Children: Development of the CALM Intervention.

PROBLEM: Excessive anxiety is among the most common psychiatric problems facing youth. Because anxious youth tend to have somatic complaints, many seek help from the school nurse. Thus, school nurses are in an ideal position to provide early intervention. This study addresses this problem and describes the plans to develop and test a new intervention (Child Anxiety Learning Modules; CALM), delivered by school nurses, to reduce child anxiety and improve academic functioning. METHODS: An iterative development process including consultation with an expert panel, two open trials, and a pilot randomized controlled study comparing CALM to usual care is proposed. Feedback will be solicited from all participants during each phase and data on outcome measures will be provided by children, parents, teachers, and independent evaluators. FINDINGS: Data will be collected on intervention satisfaction and feasibility. Primary outcomes that include child anxiety symptoms, classroom behavior, and school performance (e.g., attendance, grades, standardized test scores) will be collected at pre- and post-interventions and at a 3-month follow-up evaluation. CONCLUSIONS: Pediatric anxiety is a common problem that school nurses frequently encounter. Consequently, they are well positioned to play a key role in enhancing access to behavioral health interventions to reduce anxiety and may therefore make a significant positive public health impact.

Anxiety-promoting parenting behaviors: a comparison of anxious mothers and fathers.

The majority of research identifying anxiety-promoting parenting behaviors has been conducted with mothers, leaving a gap in current knowledge about the role of fathers' parenting behaviors. In an attempt to fill this gap, this study compared anxiety-promoting parenting behaviors of anxious mothers and fathers. Parents completed self-report measures of parenting behavior and independent coders rated parenting behaviors (i.e., overcontrol, granting of autonomy, warmth, hostility, anxious behavior) of mothers (n = 34) and fathers (n = 21) during a challenging parent-child interaction task (children were ages 6-12). Results indicated that anxious fathers were observed to be more controlling than anxious mothers; while anxious mothers reported using more punishment and reinforcement of children's dependence in anxiety provoking situations compared to fathers. Findings extend our knowledge about anxious fathers, and highlight the need for additional research on the impact of fathers' parenting with respect to the development of child anxiety.

Benefits of child-focused anxiety treatments for parents and family functioning.

BACKGROUND: To examine (1) changes in parent (global psychological distress, trait anxiety) and family (dysfunction, burden) functioning following 12 weeks of child-focused anxiety treatment, and (2) whether changes in these parent and family factors were associated with child's treatment condition and response. METHODS: Participants were 488 youth ages 7-17 years (50% female; mean age 10.7 years) who met DSM-IV-TR criteria for social phobia, separation anxiety, and/or generalized anxiety disorder, and their parents. Youth were randomly assigned to 12 weeks of "Coping Cat" individual cognitive-behavioral therapy (CBT), medication management with sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) within the multisite Child/Adolescent Anxiety Multimodal Study (CAMS). At pre- and posttreatment, parents completed measures of trait anxiety, psychological distress, family functioning, and burden of child illness; children completed a measure of family functioning. Blinded independent evaluators rated child's response to treatment using the Clinical Global Impression-Improvement Scale at posttreatment. RESULTS: Analyses of covariance revealed that parental psychological distress and trait anxiety, and parent-reported family dysfunction improved only for parents of children who were rated as treatment responders, and these changes were unrelated to treatment condition. Family burden and child-reported family dysfunction improved significantly from pre- to posttreatment regardless of treatment condition or response. CONCLUSIONS: Findings suggest that child-focused anxiety treatments, regardless of intervention condition, can result in improvements in nontargeted parent symptoms and family functioning particularly when children respond successfully to the treatment.

Family factors in the development, treatment, and prevention of childhood anxiety disorders.

It is now widely accepted that anxiety disorders run in families, and current etiological models have proposed both genetic and environmental pathways to anxiety development. In this paper, the familial role in the development, treatment, and prevention of anxiety disorders in children is reviewed. We focus on three anxiety disorders in youth, namely, generalized, separation, and social anxiety as they often co-occur both at the symptom and disorder level and respond to similar treatments. We begin by presenting an overview of a broad range of family factors associated with anxiety disorders. Findings from these studies have informed intervention and prevention strategies that are discussed next. Throughout the paper we shed light on the challenges that plague this research and look toward the future by proposing directions for much needed study and discussing factors that may improve clinical practice and outcomes for affected youth and their families.

Parenting Practices of Anxious and Non-Anxious Mothers: A Multi-method Multi-informant Approach.

Anxious and non-anxious mothers were compared on theoretically derived parenting and family environment variables (i.e., over-control, warmth, criticism, anxious modeling) using multiple informants and methods. Mother-child dyads completed questionnaires about parenting and were observed during an interactional task. Findings revealed that, after controlling for race and child anxiety, maternal anxiety was associated with less warmth and more anxious modeling based on maternal-report. However, maternal anxiety was not related to any parenting domain based on child-report or independent observer (IO) ratings. Findings are discussed in the context of the impact of maternal anxiety on parenting and suggest that child, rather than maternal, anxiety may have a greater influence on parental behavior.

Predictors of treatment response in pediatric obsessive-compulsive disorder.

OBJECTIVE: To examine predictors of treatment response in pediatric obsessive-compulsive disorder (OCD). METHOD: A literature review of psychotherapy (i.e., cognitive-behavioral therapy) and medication studies for pediatric OCD published from 1985 to 2007 was conducted using several databases. RESULTS: The literature search produced a total of 21 studies (6 cognitive-behavioral therapy, 13 medication, and 2 combination studies) that met specific methodological criteria. Across studies, the following nine predictors were examined: child sex, child age, duration of illness/age at onset, baseline severity of obsessive-compulsive symptoms, type of obsessive-compulsive symptoms, comorbid disorders/symptoms, psychophysiological factors, neuropsychological factors, and family factors. Among all of the studies, there was little evidence that sex, age, or duration of illness (age at onset) was associated with treatment response. Baseline severity of obsessive-compulsive symptoms and family dysfunction were associated with poorer response to cognitive-behavioral therapy, whereas comorbid tics and externalizing disorders were associated with poorer response in medication-only studies. CONCLUSIONS: Overall, there are limited data on predictors of treatment response for pediatric OCD. The majority of studies are plagued with methodological limitations and post hoc approaches. Additional research is needed to better delineate the predictors of treatment response in pediatric OCD with the goal of developing individualized treatment approaches.

Anxiety sensitivity and panic attack symptomatology among low-income African-American adolescents.

This study examined the concurrent and prospective relation between anxiety sensitivity (AS) and panic attack symptomatology among a community sample of African-American adolescents (N = 107; mean age 15.6 years) from predominantly low-income, single-parent households. On two occasions, 6 months apart, youth completed self-report measures of AS, measured by the Childhood Anxiety Sensitivity Index (CAS I), and panic symptomatology, measured by the Panic Attack Questionnaire (PAQ) and/or the Panic subscale of the Screen for Child Anxiety-Related Emotional Disorders (SCARED-P). Results indicated that adolescents with high levels of AS reported higher concurrent levels of panic symptomatology, compared to their less anxious peers. Earlier levels of AS were correlated with panic symptoms 6 months later but did not predict later panic symptoms once initial levels of panic were controlled. Panickers, compared to non-panickers, also reported significantly higher levels of AS at Time 2. Overall, these findings are consistent with research on AS and panic in adult and Caucasian populations and support the hypothesis that elevated levels of AS may be one of several risk factors implicated in the development of panic attack symptomatology.

School-based treatment for anxious african-american adolescents: a controlled pilot study.

OBJECTIVE: To evaluate the feasibility and effectiveness of a school-based group cognitive-behavioral treatment (CBT) for anxiety disorders with African-American adolescents. METHOD: Twelve adolescents (mean age = 15.6 years) with anxiety disorders were randomly assigned to CBT (n = 6) or a group attention-support control condition (AS-Control; n = 6). Both groups met for 10 sessions in the same high school. Key treatment ingredients in CBT involved exposure, relaxation, social skills, and cognitive restructuring. Key ingredients in AS-Control involved therapist and peer support. At pre- and posttreatment, diagnostic interviews were conducted, and adolescents completed self-report measures of anxiety. RESULTS: At posttreatment and among those who attended more than one treatment session, 3/4 adolescents in CBT no longer met diagnostic criteria for their primary anxiety disorder, compared with 1/5 in AS-Control. Clinician ratings of impairment and self-report levels of overall anxiety were significantly lower at posttreatment in CBT compared with AS-Control. Teenagers in both groups reported lower levels of social anxiety from pre- to posttreatment. CONCLUSIONS: Findings support the feasibility of implementing a manual-based CBT in an urban school setting. Responder rates among African-American adolescents were similar to those found in studies with white youths.