Patterns of sub-optimal change following CBT for childhood anxiety.

BACKGROUND: Children and adolescents demonstrate diverse patterns of symptom change and disorder remission following cognitive behavioural therapy (CBT) for anxiety disorders. To better understand children who respond sub-optimally to CBT, this study investigated youths (N = 1,483) who continued to meet criteria for one or more clinical anxiety diagnosis immediately following treatment or at any point during the 12 months following treatment. METHODS: Data were collected from 10 clinical sites with assessments at pre-and post-treatment and at least once more at 3, 6 or 12-month follow-up. Participants were assigned to one of three groups based on diagnostic status for youths who: (a) retained an anxiety diagnosis from post to end point (minimal responders); (b) remitted anxiety diagnoses at post but relapsed by end point (relapsed responders); and (c) retained a diagnosis at post but remitted to be diagnosis free at end point (delayed responders). Growth curve models assessed patterns of change over time for the three groups and examined predictors associated with these patterns including demographic, clinical and parental factors, as well as treatment factors. RESULTS: Higher primary disorder severity, being older, having a greater number of anxiety disorders, having social anxiety disorder, as well as higher maternal psychopathology differentiated the minimal responders from the delayed and relapsed responders at the baseline. Results from the growth curve models showed that severity of the primary disorder and treatment modality differentiated patterns of linear change only. Higher severity was associated with significantly less improvement over time for the minimal and relapsed response groups, as was receiving group CBT, when compared to the delayed response group. CONCLUSIONS: Sub-optimal response patterns can be partially differentiated using variables assessed at pre-treatment. Increased understanding of different patterns of change following treatment may provide direction for clinical decision-making and for tailoring treatments to specific groups of clinically anxious youth. Future research may benefit from assessing progress during treatment to detect emerging response patterns earlier.

Group cohesion and alliance predict cognitive-behavioral group treatment outcomes for youth with anxiety disorders.

Knowledge about how to enhance group cognitive behavioral therapy (GCBT) outcomes is needed. In a randomized controlled effectiveness trial, we examined group cohesion (the bond between group members) and the alliance (the client-clinician bond) as predictors of GCBT outcomes. The sample was 88 youth (M age 11.7 years, SD = 2.1; 54.5% girls; 90.7% White) with anxiety disorders. Observers rated group cohesion and alliance in 32 sessions from 16 groups. We examined early group cohesion and alliance (r = .50, p < .001) and group cohesion and alliance change from early to late in treatment in relation to outcomes using generalized estimation equations accounting for nesting within groups (ICCs .31 to .55). The outcomes were diagnostic recovery, clinical severity, and parent- and youth-reported anxiety symptoms, each at post-treatment, 12-months, and 4-years follow-up. There were more significant associations with 4-years follow-up than earlier outcomes. Clinical severity and parent-reported anxiety symptoms were more frequently predicted than diagnostic recovery. Clinician- and parent-reported outcomes were far more frequently significantly predicted by cohesion and alliance than youth-rated outcomes. We conclude that group cohesion and alliance are related but distinct variables, both associated with some GCBT outcomes for as long as 4 years after treatment.

Comprehensive Health Assessment for Children in Out-of-Home Care: An Exploratory Study of Service Needs and Mental Health in a Norwegian Population.

A comprehensive model for routine multi-disciplinary health assessment for children in out-of-home care was piloted in a Norwegian region. This paper reports on identified service needs and mental disorders among 196 children (0-17 years) receiving the assessment. Cross-sectional data was extracted from assessment reports. Results show needs across a range of services, with a mean of 2.8 recommended services for children aged 0-6 and 3.3 for children aged 7-17. Mental disorders were identified in 50% of younger children, and 70% of older children. For all children, overall service need was associated with mental disorders, in addition to male gender among younger children. Need for specialized mental health services was associated with mental disorders among younger children and increasing age among older children. The high frequency of service needs and mental disorders illustrate the importance of offering comprehensive health assessments routinely to this high-risk child population and necessitates coordinated service delivery.

Do clinical experience, formal cognitive behavioural therapy training, adherence, and competence predict outcome in cognitive behavioural therapy for anxiety disorders in youth?

OBJECTIVE: The aim was to investigate whether clinical experience, formal cognitive behavioural therapy (CBT) training, adherence, and competence predict outcome in CBT for anxiety disorders in youth. METHOD: Videotapes (N = 181) from the sessions in a randomized controlled effectiveness trial (Wergeland et al., 2014, Behaviour Research and Therapy, 57, 1-12) comprising youth (N = 182, M age = 11.5 years) with mixed anxiety disorders were assessed for treatment adherence and competence using the Competence and Adherence Scale for CBT for anxiety disorders in youth (Bjaastad et al., 2016, Psychological Assessment, 28, 908-916). Therapists' (N = 17) clinical experience and educational background were assessed. Participants completed a diagnostic interview (Anxiety Disorders Interview Schedule, child and parent versions) and an anxiety symptom measure (Spence Children's Anxiety Scale, child and parent versions) at pretreatment, posttreatment, and 1-year follow-up. RESULTS: Higher therapist adherence was related to better treatment outcomes, whereas number of years of clinical experience and competence was related to worse outcomes. However, these findings were not consistent across informants and the time points for the assessments. Interaction effects suggested that competence among therapists with formal CBT training was related to better patient outcomes. CONCLUSIONS: Therapist adherence, competence, and clinical experience are associated with outcomes of manualized CBT for youth anxiety disorders, but mixed findings indicate the need for more research in this area.

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.

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.

Therapist-youth agreement on alliance change predicts long-term outcome in CBT for anxiety disorders.

BACKGROUND: In individual cognitive behavioral therapy (ICBT) for youth anxiety disorders, it is unclear whether, and from whose perspective, the alliance predicts outcome. We examined whether youth- and therapist-rated alliance, including level of youth-therapist alliance agreement, predicted outcome in a randomized controlled trial. METHODS: Youth (N = 91, M age = 11.4 years (SD = 2.1), 49.5% boys, 86.8% Caucasian) diagnosed with separation anxiety disorder, social phobia, or generalized anxiety disorder drawn from the ICBT condition of an effectiveness trial were treated with an ICBT program. Youth- and therapist-rated alliance ratings, assessed with the Therapeutic Alliance Scale for Children (TASC-C/T), were collected following session 3 (early) and 7 (late). Early alliance, change in alliance from early to late, and level of youth-therapist agreement on early alliance and alliance change were examined, in relation to outcomes collected at posttreatment and 1-year follow-up. Outcome was defined as primary diagnosis loss and reduction in clinicians' severity ratings (CSR; Anxiety Disorders Interview Schedule; ADIS-C/P) based on youth- and parent-report at posttreatment and follow-up, and youth treatment satisfaction collected at posttreatment (Client Satisfaction Scale; CSS). RESULTS: Early TASC-C scores positively predicted treatment satisfaction at posttreatment. Higher levels of agreement on change in TASC-C and TASC-T scores early to late in treatment predicted diagnosis loss and CSR reduction at follow-up. CONCLUSIONS: Only the level of agreement in alliance change predicted follow-up outcomes in ICBT for youth anxiety disorders. The findings support further examination of the role that youth-therapist alliance discrepancies may play in promoting positive outcomes in ICBT for youth anxiety disorders. Clinical trial number NCT00586586, clinicaltrials.gov.

Standard individual cognitive behaviour therapy for paediatric obsessive-compulsive disorder: a systematic review of effect estimates across comparisons.

BACKGROUND: Previous meta-analyses of paediatric obsessive-compulsive disorder (OCD) have shown much higher effect size for standard individual cognitive behaviour therapy (SI-CBT) compared with control conditions than for serotonin reuptake inhibitors (SRIs) compared with placebo. Other factors, such as systematic differences in the provided care or exposure to factors other than the interventions of interest (performance bias) may be stronger confounders in psychotherapy research than in pharmacological research. AIMS: These facts led us to review SI-CBT studies of paediatric OCD with the aim to compare the effect estimates across different comparisons, including active treatments. METHOD: We included only randomized controlled trials (RCTs) or cluster RCTs with treatment periods of 12-16 weeks. Outcome was post-test score on the Children's Yale-Brown Obsessive Compulsive Scale (CYBOCS). RESULTS: Thirteen papers reporting from 13 RCTs with 17 comparison conditions were included. SI-CBT was superior to wait-list and placebo therapy but not active treatments. Effect estimates for SI-CBT in wait-list comparison studies were significantly larger than in placebo-therapy comparison studies. In addition, the SI-CBT effect estimate was not significantly different when compared with SRIs alone or combined SRIs and CBT. CONCLUSIONS: Performance bias may have inflated previous effect estimates for SI-CBT when comparison contingencies included wait-list. However, the calculated SI-CBT effect estimate was lower but significant when compared with placebo therapy. The effects of SI-CBT and active treatments were not significantly different. In conclusion, our data support the current clinical guidelines, although better comparisons between SI-CBT and SRIs are needed.

Anxiety Symptom Trajectories Predict Depression Symptom Trajectories up to Four Years After CBT for Youth Anxiety Disorders.

Long-term data on depression symptoms after cognitive behavioral therapy (CBT) for youth anxiety disorders are scant. We examined depression symptoms up to four years post CBT for anxiety addressing youth age and gender, family social class, and parent mental health as predictors. The sample comprised 179 youth (M age at pre-treatment = 11.5 years; SD = 2.1) in a randomized controlled trial. Clinically assessed anxiety diagnoses and youth and parent-reported anxiety and depression symptoms were measured before, after, and one and four years after CBT. Parent self-reported mental health was measured before CBT. We used regression analyses to determine whether full diagnostic recovery at post-CBT predicted depression trajectories across the four-year assessment period. We used growth curve models to determine whether anxiety trajectories predicted depression trajectories across the four-year assessment period. Youth who lost their anxiety diagnoses after CBT had significantly lower parent-reported depression levels over time, but not lower youth self-reported depression levels. The anxiety symptom trajectory predicted the depression symptom trajectory up to four years post-treatment. There was more explained variance for within-informant (youth-youth; parent-parent) than cross-informants. Being older, female, having lower socio-economic status and parents with poorer mental health were associated with more youth-rated depression over time. However, these demographic predictors were not significant when anxiety symptoms trajectories were added to the models. Successful CBT for anxiety in children is associated with less depression symptoms for as long as four years. Anxiety symptom improvement appears to be a stronger predictor that demographic variables and parent mental health.

Behavioral Inhibition and Social Anxiety Disorder as Predictors of Long-Term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders.

The temperamental trait behavioral inhibition (BI) is related to the development and maintenance of anxiety, particularly much so to social anxiety disorder. We investigated if BI and social anxiety disorder predicted cognitive behavioral therapy (CBT) outcomes for youth anxiety. Youth (N = 179; Mage = 11.6 years) were assessed 4 years following a randomized controlled CBT effectiveness trial. BI was measured by the parent-reported Behavioral Inhibition Questionnaire at baseline. The outcomes were diagnostic recovery, youth- and parent-reported anxiety symptoms, and clinical severity at post-treatment, 1-year, and 4-year follow-up. Having social anxiety disorder negatively predicted diagnostic recovery and predicted higher clinical severity at all assessment points and was the only significant predictor of outcomes at 4-year follow-up. Higher BI negatively predicted diagnostic recovery and predicted higher clinical severity and parent-reported symptom levels at post-treatment and 1-year follow-up, and predicted higher youth-reported anxiety levels at 1-year follow-up. Higher BI was the only predictor of youth- and parent-reported anxiety symptoms. BI and social anxiety disorder seem to be unique predictors of CBT outcomes among youth with anxiety disorders. CBT adaptations may be indicated for youth with high BI and social anxiety disorder.

Adherence, Competence, and Alliance as Predictors of Long-term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders.

The present study investigated therapist adherence, therapist competence, and patient-therapist alliance as predictors of long-term outcomes of cognitive behavioral therapy (CBT) for anxiety disorders in youth. Potential differential effects for group versus individual CBT, for therapists with or without formal CBT training, and based on youth symptom severity were examined. Videotapes (n = 181) from treatment sessions in a randomized controlled effectiveness trial comprising youth (N = 170, M age = 11.6 years, SD = 2.1) with anxiety disorders were assessed for therapist adherence and competence. Alliance was rated by therapists and youth. Participants completed a diagnostic interview and an anxiety symptom measure at pre-treatment, post-treatment, one-year follow-up, and long-term follow-up (M = 3.9 years post-treatment, SD = 0.8, range = 2.2-5.9 years). The change in anxiety symptoms or diagnostic status from pre-treatment to long-term follow-up was not significantly related to any predictor variables. However, several interaction effects were found. For loss of principal diagnosis, therapist competence predicted positive outcome when therapist adherence also was high. Adherence was found to predict positive outcome if CBT was provided individually. Therapist-rated alliance was related to both loss of principal diagnosis and loss of all diagnoses when CBT was provided in groups. Interaction effects suggested that therapists displaying both high adherence and high competence produced better long-term outcomes. Further, the alliance may be particularly important for outcomes in group CBT, whereas adherence may be particularly important for outcomes in individual CBT.

Factor structure and validity of the therapy process observational coding system for child psychotherapy-alliance scale.

The aim of this study was to examine the factor structure and psychometric properties of an observer-rated youth alliance measure, the Therapy Process Observational Coding System for Child Psychotherapy-Alliance scale (TPOCS-A). The sample was 52 youth diagnosed with anxiety disorders (M age = 12.43, SD = 2.23, range = 8-15; 56% boys; 98% Caucasian) drawn from a randomized controlled trial. Participants received a manualized individual cognitive behavioral treatment, the FRIENDS for life program, in public community clinics in Norway. Diagnostic status, treatment motivation, and perceived treatment credibility were assessed at pretreatment. Using the TPOCS-A, independent observers rated child-therapist alliance from the third therapy session. Child- and therapist-reported alliance measures were collected from the same session. An exploratory factor analysis supported a one-factor solution, which is consistent with previous studies of self- and observer-rated youth alliance scales. Psychometric analyses supported the interrater reliability, internal consistency, and convergent/divergent validity of the TPOCS-A. Accumulating psychometric evidence indicate that the TPOCS-A has the potential to fill a measurement gap in the youth psychotherapy field. In youth psychotherapy, alliance may be unidimensional, so establishing a strong bond and engaging the child in therapeutic activities may both be instrumental to establishing good alliance early in treatment. However, it is important to be cautious when interpreting the factor analytic findings, because the sample size may have been too small to identify additional factors. Future research can build upon these findings by examining the factor structure of youth alliance measures with larger, more diverse samples.

Measurement Equivalence and Convergent Validity of a Mental Health Rating Scale.

Emotional and behavioral problems among children and adolescents may be studied using the Strengths and Difficulties Questionnaire, containing five subscales, based on ratings by parents, teachers, or adolescents themselves. We investigate two measurement issues using data from a longitudinal sample of 8,806 participants aged 7 to 9 years and 11 to 13 years from the Bergen Child Study in Bergen, Norway. First, convergent validity of parent and teacher ratings is studied using a multitrait-multimethod approach. Second, longitudinal measurement equivalence is studied using confirmatory factor analysis, which requires us to deal with the considerable attrition. The multitrait-multimethod indicates not only good convergent validity but also considerable method variance for parents and teachers. The reliability and validity of some subscales are relatively low. Attrition analysis indicates that attrition is not missing completely at random, but estimation assuming missing at random makes no real difference. We conclude that assuming missing completely at random is acceptable. Comparing ratings by parents and teachers results in partial scalar equivalence. In addition, all subscales exhibit (partial) longitudinal scalar measurement equivalence. We recommend using latent variable modeling and not summated scales for longitudinal modeling using the Strengths and Difficulties Questionnaire.

Parental internalizing symptoms as predictors of anxiety symptoms in clinic-referred children.

BACKGROUND: Mothers' and fathers' internalizing symptoms may influence children's anxiety symptoms differently. OBJECTIVE: To explore the relationship between parental internalizing symptoms and children's anxiety symptoms in a clinical sample of children with anxiety disorders. METHOD: The sample was recruited through community mental health clinics for a randomized controlled anxiety treatment trial. At pre-intervention, children (n = 182), mothers (n = 165), and fathers (n = 72) reported children's anxiety symptoms. Mothers and fathers also reported their own internalizing symptoms. The children were aged 8 to 15 years (M age = 11.5 years, SD = 2.1, 52.2% girls) and all had a diagnosis of separation anxiety, social phobia, and/or generalized anxiety disorder. We examined parental internalizing symptoms as predictors of child anxiety symptoms in multiple regression models. RESULTS: Both mother and father rated internalizing symptoms predicted children's self-rated anxiety levels (adj. R 2 = 22.0%). Mother-rated internalizing symptoms predicted mother-rated anxiety symptoms in children (adj. R 2 = 7.0%). Father-rated internalizing symptoms did not predict father-rated anxiety in children. CONCLUSIONS: Clinicians should incorporate parental level of internalizing symptoms in their case conceptualizations.

DNA methylation changes in infants between 6 and 52 weeks.

Infants undergo extensive developments during their first year of life. Although the biological mechanisms involved are not yet fully understood, changes in the DNA methylation in mammals are believed to play a key role. This study was designed to investigate changes in infant DNA methylation that occurs between 6 and 52 weeks. A total of 214 infant saliva samples from 6 or 52 weeks were assessed using principal component analyses and t-distributed stochastic neighbor-embedding algorithms. Between the two time points, there were clear differences in DNA methylation. To further investigate these findings, paired two-sided student's t-tests were performed. Differently methylated regions were defined as at least two consecutive probes that showed significant differences, with a q-value < 0.01 and a mean difference > 0.2. After correcting for false discovery rates, changes in the DNA methylation levels were found in 42 genes. Of these, 36 genes showed increased and six decreased DNA methylation. The overall DNA methylation changes indicated decreased gene expression. This was surprising because infants undergo such profound developments during their first year of life. The results were evaluated by taking into consideration the extensive development that occurs during pregnancy. During the first year of life, infants have an overall three-fold increase in weight, while the fetus develops from a single cell into a viable infant in 9 months, with an 875-million-fold increase in weight. It is possible that the findings represent a biological slowing mechanism in response to extensive fetal development. In conclusion, our study provides evidence of DNA methylation changes during the first year of life, representing a possible biological slowing mechanism. We encourage future studies of DNA methylation changes in infants to replicate the findings by using a repeated measures model and less stringent criteria to see if the same genes can be found, as well as investigating whether other genes are involved in development during this period.

The utility of the SCAS-C/P to detect specific anxiety disorders among clinically anxious children.

Questionnaire measures offer a time and cost-effective alternative to full diagnostic assessments for identifying and differentiating between potential anxiety disorders and are commonly used in clinical practice. Little is known, however, about the capacity of questionnaire measures to detect specific anxiety disorders in clinically anxious preadolescent children. This study aimed to establish the ability of the Spence Children's Anxiety Scale (SCAS) subscales to identify children with specific anxiety disorders in a large clinic-referred sample (N = 1,438) of children aged 7 to 12 years. We examined the capacity of the Separation Anxiety, Social Phobia, Generalized Anxiety, and Physical Injury Fears (phobias) subscales to discriminate between children with and without the target disorder. We also identified optimal cutoff scores on subscales for accurate identification of children with the corresponding disorder, and examined the contribution of child, mother, and father reports. The Separation Anxiety subscale was able to accurately identify children with separation anxiety disorder, and this was replicated across all 3 reporters. Mother- and father-reported Social Phobia subscales also accurately identified children with social anxiety disorder, although child report was only able to accurately detect social anxiety disorder in girls. Using 2 or more reporters improved the sensitivity of the Separation Anxiety and Social Phobia subscales but reduced specificity. The Generalized Anxiety and Physical Injury Fears subscales failed to accurately identify children with the corresponding disorders. These findings have implications for the potential use of mother-, father-, and child-report SCAS subscales to detect specific disorders in preadolescent children in clinical settings. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A genome-wide association meta-analysis of prognostic outcomes following cognitive behavioural therapy in individuals with anxiety and depressive disorders.

Major depressive disorder and the anxiety disorders are highly prevalent, disabling and moderately heritable. Depression and anxiety are also highly comorbid and have a strong genetic correlation (rg ≈ 1). Cognitive behavioural therapy is a leading evidence-based treatment but has variable outcomes. Currently, there are no strong predictors of outcome. Therapygenetics research aims to identify genetic predictors of prognosis following therapy. We performed genome-wide association meta-analyses of symptoms following cognitive behavioural therapy in adults with anxiety disorders (n = 972), adults with major depressive disorder (n = 832) and children with anxiety disorders (n = 920; meta-analysis n = 2724). We estimated the variance in therapy outcomes that could be explained by common genetic variants (h2SNP) and polygenic scoring was used to examine genetic associations between therapy outcomes and psychopathology, personality and learning. No single nucleotide polymorphisms were strongly associated with treatment outcomes. No significant estimate of h2SNP could be obtained, suggesting the heritability of therapy outcome is smaller than our analysis was powered to detect. Polygenic scoring failed to detect genetic overlap between therapy outcome and psychopathology, personality or learning. This study is the largest therapygenetics study to date. Results are consistent with previous, similarly powered genome-wide association studies of complex traits.

Cognitive behavior therapy for child and adolescent anxiety disorders: an update on recent evidence.

PURPOSE OF REVIEW: To present an updated review of recent studies into the effect of cognitive behavior therapy (CBT) for anxiety disorders in children and adolescents, ways to increase access to therapy, and predictors and moderators of therapy effect. RECENT FINDINGS: The evidence base of CBT for anxiety disorders in children and adolescents continues to grow, demonstrating short and long-term efficacy and effectiveness. However, compared with active control conditions its effect appear to be modest; and a substantial percentage of youth do not show stable long-term remission. Standard CBT is often costly, with high noncompletion rates. New strategies to increase access to effective therapy for the large number of youth with anxiety disorders is therefore of priority. Additionally, there is a need for developing new ways to treat nonresponders, and to identify predictors and moderators of the effects of CBT. SUMMARY: Although there is evidence for the efficacy and effectiveness of CBT for youth with anxiety disorders, there is doubt regarding its superiority over active control comparisons. Long-term outcome is uncertain, as a substantial percentage of youth remains impaired at follow-up. It is essential to develop more cost-efficient strategies to reach youth with anxiety disorders with effective treatments, and to identify early indicators for youth needing additional therapy.

Predictors of long-term outcome of CBT for youth with anxiety disorders treated in community clinics.

Cognitive behavioral therapy (CBT) has proven long-term effects in youth with anxiety disorders. However, only a few studies have examined predictors of long-term outcomes of CBT treatment. The present study investigated possible predictors of long-term treatment outcomes in youth with mixed anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11-21 years) with a principal diagnosis of separation anxiety disorder, social anxiety disorder, and/or generalized anxiety disorder were evaluated a mean of 3.9 years post-treatment (range 2.2-5.9 years). Outcomes were loss of all inclusion anxiety diagnoses, loss of the principal inclusion anxiety diagnosis, and changes in youth- and parent-rated youth anxiety symptoms. Predictors encompassed youth, parent and demographic factors, and post-treatment recovery. The most consistent finding was that low family social class predicted poorer outcomes. Higher treatment motivation was associated with better outcome whereas a diagnosis of social anxiety was associated with poorer outcome. Identified predictors extend on previous findings from efficacy trials, and the results indicate a need for more specific treatment protocols.