Examining the Effectiveness of an Intensive Telemental Health Treatment for Pediatric Anxiety and OCD During the COVID-19 Pandemic and Pediatric Mental Health Crisis.

Despite research supporting the efficacy of weekly outpatient videoconferencing-based cognitive behavioral therapy (VCBT), limited evidence exists about the benefits of leveraging VCBT for brief intensive formats. We examined the effectiveness of an intensive outpatient VCBT targeting pediatric anxiety and OCD. Quasi-experimental design was used to compare outcomes of intensive, in-person, group-based cognitive-behavioral therapy with medication management and caregiver guidance pre-pandemic, to a similar VCBT peri-pandemic (n = 130). Pretreatment and posttreatment assessments included patient- and caregiver-report of anxiety and functional impairment. Analyses of covariance were conducted, examining changes in anxiety and impairment between treatment groups, controlling for admission levels. No significant differences in posttreatment anxiety or impairment were observed between conditions. This study illustrates that intensive, group-based treatment for pediatric anxiety and OCD using VCBT is associated with comparable reductions in anxiety and impairment. It marks a crucial step toward providing broader access to quality care for youth in need.

Disqualified qualifiers: evaluating the utility of the revised DSM-5 definition of potentially traumatic events among area youth following the Boston marathon bombing.

BACKGROUND: The DSM-5 includes a revised definition of the experiences that qualify as potentially traumatic events. This revised definition now offers a clearer and more exclusive definition of what qualifies as a traumatic exposure, but little is known about the revision's applicability to youth populations. The present study evaluated the predictive utility of the revised DSM definitional boundaries of traumatic exposure in a sample of youth exposed to the 2013 Boston Marathon bombing and related events METHODS: Caregivers (N = 460) completed surveys 2 to 6 months postbombing about youth experiences during the events and youth posttraumatic stress (PTS) symptoms RESULTS: Experiencing DSM-5 qualifying traumatic events (DSM-5 QTEs) significantly predicted child PTS symptoms (PTSS), whereas DSM-5 nonqualifying stressful experiences (DSM-5 non-QSEs) did not after accounting for DSM-5 QTEs. Importantly, child age moderated the relationship between DSM-5 QTEs and PTSS such that children 7 and older who experienced DSM-5 QTEs showed greater postbombing PTSS, whereas there was no such relationship in children ages 6 and below CONCLUSIONS: Data largely support the revised posttraumatic stress disorder (PTSD) definition of QTEs in older youth, and also highlight the need for further refinement of the QTE definition for children ages 6 and below.

Event-Related Household Discussions Following the Boston Marathon Bombing and Associated Posttraumatic Stress Among Area Youth.

Despite research documenting the scope of disaster-related posttraumatic stress (PTS) in youth, less is known about how family processes immediately postdisaster might associate with child outcomes. The 2013 Boston Marathon bombing affords a unique opportunity to assess links between immediate family discussions about community trauma and child mental health outcomes. The present study examined associations between attack-related household discussions and child PTS among Boston-area youth ages 4 to 19 following the Marathon bombing (N = 460). Caregivers completed surveys 2 to 6 months postattack about immediate household discussions about the events, child exposure to potentially traumatic attack-related experiences, and child PTS. During the Marathon bombing and manhunt, there was considerable heterogeneity in household discussions across area families, and several discussion items were differentially predictive of variability in children's PTS. Specifically, after controlling for children's direct exposure to the potentially traumatic attack/manhunt events, children showed lower PTS when it was their caregivers who informed them about the attack and manhunt, and when their caregivers expressed confidence in their safety and discussed their own feelings about the manhunt with their child. Children showed higher PTS when their caregivers did not discuss the events in front of them, asked others to avoid discussing the events in front of them, and expressed concern at the time that their child might not be safe. Child age and traumatic attack/manhunt exposure moderated several links between household discussions and child PTS. Findings underscore the importance of family communication and caregiver modeling during times of community threat and uncertainty.

Moderators of intensive CBT for adolescent panic disorder: the of fear and avoidance.

BACKGROUND: Research supports the efficacy of intensive cognitive behavioral therapy (CBT) for the treatment of adolescent panic disorder with or without agoraphobia (PDA). However, little is known about the conditions under which intensive treatment is most effective. The current investigation examined the moderating roles of baseline fear and avoidance in the intensive treatment of adolescent PDA. METHODS: Adolescents with PDA (ages 11-17; N = 54) were randomized to either an intensive CBT treatment (n = 37) or a waitlist control condition (n = 17). PDA diagnosis, symptom severity, and number of feared and avoided situations were assessed at baseline and 6-week post-treatment/post-waitlist. Hierarchical regression analyses examined the relative contributions of treatment condition, number of baseline feared or avoided situations, and their interactions in the prediction of post-treatment/waitlist PDA symptoms. RESULTS: The main effect of intensive CBT on post-treatment PDA symptoms was not uniform across participants, with larger treatment effects found among participants with lower, relative to higher, baseline levels of fear and avoidance. CONCLUSIONS: Findings help clarify which adolescents suffering with PDA may benefit most from an intensive treatment format.

Adjustment among children with relatives who participated in the manhunt following the Boston Marathon attack.

BACKGROUND: Following the Boston Marathon attack, the extraordinary interagency manhunt and shelter-in-place made for a truly unprecedented experience for area families. Although research on Boston youth has found robust associations between manhunt-related experiences and post-attack functioning, such work does little to identify the specific needs of a particularly vulnerable population--i.e., children with a relative who participated in the manhunt. Understanding the adjustment of these youth is critical for informing clinical efforts. METHODS: Survey of Boston-area parents/caretakers (N = 460) reporting on their child's attack/manhunt-related experiences, as well as psychosocial functioning in the first six post-attack months; analyses compared youth with and without a relative in law enforcement or the armed services who participated in the manhunt. RESULTS: The proportion of youth with likely PTSD was 5.7 times higher among youth with relatives in the manhunt than among youth without. After accounting for child demographics, blast exposure, and children's own exposure to manhunt events (e.g., hearing/seeing gunfire/explosions, having officers enter/search home), having a relative in the manhunt significantly predicted child PTSD symptoms, emotional symptoms, and hyperactivity/inattention. Fear during the manhunt that a loved one could be hurt mediated relationships between having a relative in the manhunt and clinical outcomes; living within the zone of greatest manhunt activity did not moderate observed relationships. CONCLUSIONS: Children with relatives called upon to participate in the unprecedented interagency manhunt following the Boston Marathon attack carried a particularly heavy mental health burden. Continued research is needed to clarify the clinical needs of youth with relatives in high-risk occupations.

Pilot implementation of computerized cognitive behavioral therapy in a university health setting.

This study evaluated the implementation of computerized cognitive-behavioral therapy (cCBT) for depression and anxiety in a university health center. Students reporting symptoms of depression and/or anxiety were offered cCBT and randomized to a session email reminder or no-reminder condition. Participants reported significant symptom and functional improvement after receiving treatment, comparable to outcomes achieved in controlled efficacy trials. However, rates of session completion were low, and reminders did not enhance retention. Results suggest that cCBT is a promising intervention in this population, with little attenuation of gains relative to efficacy trials but low levels of treatment completion.

Promoting Mental Health and Wellness in Youth Through Physical Activity, Nutrition, and Sleep.

The medical benefits to youth conferred by physical activity, balanced nutrition, and quality sleep have been increasingly encouraged by medical and mental health providers. Emerging evidence continues to reveal benefits for youth mental health and well-being, including for youth with psychiatric disorders. This evidence seems multifactorial through both neurobiological and psychosocial systems, with common mechanisms present between physical activity, nutrition, and sleep. This article reviews the benefits of optimizing physical activity, nutrition, and sleep; how to assess these lifestyle domains with patients and their parents; and appropriate interventions to optimize well-being in youth.

A Psychometric Evaluation of the Distress Intolerance Index for Youth.

Distress Intolerance (DI), defined as the perceived inability to tolerate negative mood states and experiential discomfort, has been posited as a vulnerability factor for several anxiety and emotional disorders. There is a relative paucity of research on DI in youth samples, in large part due to the absence of a psychometrically sound measure of DI in youth. The current study evaluated the psychometric properties of the Distress Intolerance Index for Youth (DII-Y) and the Distress Intolerance Index for Youth-Parent Report (DII-Y-P), which are downward extension adaptations of the adult-oriented Distress Intolerance Index (McHugh & Otto, 2012). Participants were 176 youth (ages 9-17) and their parents who were seeking treatment for child anxiety problems. The DII-Y and DII-Y-P demonstrated good-to-excellent internal consistency. Convergent validity of the DII-Y and the DII-Y-P was supported by large, significant associations with measures of intolerance of uncertainty, as well as with anxiety sensitivity in the case of the DII-Y. Discriminant validity of the DII-Y and the DII-Y-P was supported by the absence of significant direct relationships with a measure of defiant behavior. Results support the use of DII-Y and DII-Y-P as reliable and valid instruments for the assessment of youth DI, providing a practical and efficient tool to study DI as a potential factor in the etiology and maintenance of youth anxiety and emotional disorders.

Assessment and Treatment of Anxiety Among Children and Adolescents.

Among children and adolescents, anxiety disorders are common psychiatric disorders that confer risk of comorbid psychiatric disorders and social and academic impairment. This review focuses on the assessment and treatment of anxiety disorders among children and adolescents, with attention to separation anxiety disorder, social phobia disorder (social anxiety disorder), panic disorder, and generalized anxiety disorder. Comprehensive assessment of child and adolescent anxiety disorders benefits from a multimethod approach to evaluation and diagnosis, including semistructured interviews; child and informant questionnaires; collateral information from parents, teachers, pediatricians, and school psychologists; and behavioral observations. Because anxiety symptoms can include avoidance behaviors, somatic complaints, social difficulties, and sleep disturbances, consideration of a differential diagnosis is important. Among the available psychosocial interventions, cognitive-behavioral therapy (CBT) and exposure-based therapies have emerged as the most well-established treatment approaches for addressing anxiety disorders among children and adolescents. Pharmacologically, selective serotonin reuptake inhibitors (SSRIs) have been established to be safe and efficacious for the treatment of pediatric anxiety and are considered the medications of choice for this population. Research indicates that CBT plus SSRI medication is the most effective treatment of anxiety for youths ages seven to 17, compared with either CBT or medication alone. Medication monotherapy and CBT monotherapy have also been demonstrated to be effective treatments.

Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered parent-child interaction therapy (I-PCIT).

OBJECTIVE: Remote technologies are increasingly being leveraged to expand the reach of supported care, but applications to early child-behavior problems have been limited. This is the first controlled trial examining video-teleconferencing to remotely deliver behavioral parent training to the home setting with a live therapist. METHOD: Racially/ethnically diverse children ages 3-5 years with disruptive behavior disorders, and their caregiver(s), using webcams and parent-worn Bluetooth earpieces, participated in a randomized trial comparing Internet-delivered parent-child interaction therapy (I-PCIT) versus standard clinic-based PCIT (N = 40). Major assessments were conducted at baseline, midtreatment, posttreatment, and 6-month follow-up. Linear regressions and hierarchical linear modeling using maximum-likelihood estimation were used to analyze treatment satisfaction, diagnoses, symptoms, functioning, and burden to parents across conditions. RESULTS: Intent-to-treat analyses found 70% and 55% of children treated with I-PCIT and clinic-based PCIT, respectively, showed "treatment response" after treatment, and 55% and 40% of children treated with I-PCIT and clinic-based PCIT, respectively, continued to show "treatment response" at 6-month follow-up. Both treatments had significant effects on children's symptoms and burden to parents, and many effects were very large in magnitude. Most outcomes were comparable across conditions, except that the rate of posttreatment "excellent response" was significantly higher in I-PCIT than in clinic-based PCIT, and I-PCIT was associated with significantly fewer parent-perceived barriers to treatment than clinic-based PCIT. Both treatments were associated with positive engagement, treatment retention, and very high treatment satisfaction. CONCLUSION: Findings build on the small but growing literature supporting the promising role of new technologies for expanding the delivery of behavioral parent training. (PsycINFO Database Record

Internet-delivered, family-based treatment for early-onset OCD: A pilot randomized trial.

OBJECTIVE: Despite advances in supported treatments for early onset obsessive-compulsive disorder (OCD), progress has been constrained by regionally limited expertise in pediatric OCD. Videoteleconferencing (VTC) methods have proved useful for extending the reach of services for older individuals, but no randomized clinical trials (RCTs) have evaluated VTC for treating early onset OCD. METHOD: RCT comparing VTC-delivered family based cognitive-behavioral therapy (FB-CBT) versus clinic-based FB-CBT in the treatment of children ages 4-8 with OCD (N = 22). Pretreatment, posttreatment, and 6-month follow-up assessments included mother-/therapist-reports and independent evaluations masked to treatment condition. Primary analyses focused on treatment retention, engagement and satisfaction. Hierarchical linear modeling preliminarily evaluated the effects of time, treatment condition, and their interactions. "Excellent response" was defined as a 1 or 2 on the Clinical Global Impressions-Improvement Scale. RESULTS: Treatment retention, engagement, alliance and satisfaction were high across conditions. Symptom trajectories and family accommodation across both conditions showed outcomes improving from baseline to posttreatment, and continuing through follow-up. At posttreatment, 72.7% of Internet cases and 60% of Clinic cases showed "excellent response," and at follow-up 80% of Internet cases and 66.7% of Clinic cases showed "excellent response." Significant condition differences were not found across outcomes. CONCLUSIONS: VTC methods may offer solutions to overcoming traditional barriers to care for early onset OCD by extending the reach of real-time expert services regardless of children's geographic proximity to quality care. (PsycINFO Database Record

The effects of cognitive-behavioral therapy for youth anxiety on sleep problems.

The present study examined (a) whether sleep related problems (SRPs) improved following cognitive-behavioral therapy (CBT) for youth with anxiety disorders, (b) whether variables that may link anxiety and SRPs (e.g., pre-sleep arousal, family accommodation, sleep hygiene) changed during treatment, and (c) whether such changes predicted SRPs at posttreatment. Youth were diagnosed with anxiety at pretreatment and received weekly CBT that targeted their principal anxiety diagnosis at one of two specialty clinics (N=69 completers, Mage=10.86). Results indicated that parent-reported SRPs improved from pre- to post-treatment and that treatment responders with regard to anxiety yielded greater SRP improvements than nonresponders. Parent report of bedtime resistance and sleep anxiety showed significant improvements. Youth reported lower rates of SRPs compared to their parents and did not demonstrate pre- to post-treatment changes in SRPs. Pre-sleep arousal and family accommodation decreased over treatment but did not predict lower SRPs at posttreatment. Higher accommodation was correlated with greater SRPs. Sleep hygiene evidenced no change and did not mediate links between accommodation and posttreatment SRPs.

A psychometric evaluation of the panic disorder severity scale for children and adolescents.

The Panic Disorder Severity Scale (PDSS; Shear et al., 1997) is a well-validated measure that assesses symptoms of panic disorder with or without agoraphobia (PDA) in adults. The Panic Disorder Severity Scale for Children (PDSS-C) is an adaptation of the PDSS for youth ages 11-17. The current study evaluated the psychometric properties of the PDSS-C. Participants included 60 adolescents from a randomized controlled trial investigating the efficacy of an intensive cognitive behavioral treatment (CBT) for adolescent PDA. Convergent and discriminant validity of PDSS-C scores were evaluated via observed associations between the PDSS-C and the Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991), Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), and Children's Depression Inventory (CDI; Kovacs, 2003). Baseline and posttreatment data afforded the opportunity to evaluate the measure's sensitivity to treatment-related change. PDSS-C scores demonstrated acceptable internal consistency (α = .82) and adequate 1-day test-retest reliability (r = .79). Convergent and discriminant validity of the PDSS-C scores were supported through significant associations with the CASI and the MASC, and nonsignificant associations with the CDI, respectively. Linear regression analysis demonstrated sensitivity to treatment-related changes-that is, greater PDSS-C change scores were significantly associated with assignment to CBT vs. waitlist condition. Clinical utility was further established through significant associations between PDSS-C change scores and MASC and CASI change scores, and through nonsignificant associations with CDI change scores. Results support the use of PDSS-C scores as reliable, valid, and clinically useful for the assessment of youth panic disorder in research and clinical settings.

Inattention symptoms and the diagnosis of comorbid attention-deficit/hyperactivity disorder among youth with generalized anxiety disorder.

Generalized anxiety disorder (GAD) and attention-deficit/hyperactivity disorder (ADHD) commonly co-occur in childhood. Inattention symptoms can be hallmarks of both conditions, however assessment tools of inattention may not effectively distinguish between the two conditions. The present study used receiver operating characteristic (ROC) analyses to examine the high-end specificity of the Attention Problems Scale of the Child Behavior Checklist (CBCL) for detecting comorbid ADHD among youth with GAD (N=46). Results support the utility of the Attention Problems Scale for accurately distinguishing between the two groups (AUC=.84, SE=.06). Specifically, a cut score of 63 achieved the most favorable values across diagnostic utility indices; 74% of GAD youth with ADHD scored above this cutoff and 91% of GAD youth without ADHD scored below this cutoff. Findings provide support for the use of the CBCL Attention Problems Scale to supplement diagnostic interviews and identify inattention associated with ADHD among GAD youth.

Caregiver distress, shared traumatic exposure, and child adjustment among area youth following the 2013 Boston Marathon bombing.

BACKGROUND: Disasters are associated with myriad negative outcomes in youth, including posttraumatic stress disorder and related psychopathology. Prior work suggests links between caregiver distress and child mental health outcomes following community traumas, but the extent to which caregiver distress is directly linked to post-disaster child functioning, or whether such associations may simply be due to shared traumatic exposure, remains unclear. METHODS: The current study examined relationships among caregiver distress, caregiver-child shared traumatic exposure, and child outcomes in Boston-area families (N=460) during the six months following the 2013 Boston Marathon bombing. Parents completed surveys about their and their child׳s potentially traumatic experiences during the bombing and subsequent manhunt. Post-attack caregiver distress and child psychological functioning were also assessed. RESULTS: After accounting for caregiver-child shared traumatic exposure, significant associations were retained between caregiver distress and child functioning across several domains. Furthermore, after accounting for caregiver traumatic exposure, caregiver distress moderated relationships between child traumatic exposure and child posttraumatic stress and conduct problems, such that associations between child traumatic exposure and child posttraumatic stress and conduct problems were particularly strong among children of highly distressed caregivers. LIMITATIONS: The cross-sectional design did not permit evaluations across time, and population-based methods were not applied. CONCLUSIONS: Findings clarify links between caregiver distress and child psychopathology in the aftermath of disaster and can inform optimal allocation of clinical resources targeting disaster-affected youth and their families.

Adjustment among area youth after the Boston Marathon bombing and subsequent manhunt.

BACKGROUND: The majority of research on terrorism-exposed youth has examined large-scale terrorism with mass casualties. Limited research has examined children's reactions to terrorism of the scope of the Boston Marathon bombing. Furthermore, the extraordinary postattack interagency manhunt and shelter-in-place warning made for a truly unprecedented experience in its own right for families. Understanding the psychological adjustment of Boston-area youth in the aftermath of these events is critical for informing clinical efforts. METHODS: Survey of Boston-area parents/caretakers (N = 460) reporting on their child's experiences during the attack week, as well as psychosocial functioning in the first 6 attack months. RESULTS: There was heterogeneity across youth in attack- and manhunt-related experiences and clinical outcomes. The proportion of youth with likely attack/manhunt-related posttraumatic stress disorder (PTSD) was roughly 6 times higher among Boston Marathon-attending youth than nonattending youth. Attack and manhunt experiences each uniquely predicted 9% of PTSD symptom variance, with manhunt exposures more robustly associated than attack-related exposures with a range of psychosocial outcomes, including emotional symptoms, conduct problems, hyperactivity/inattention, and peer problems. One-fifth of youth watched >3 hours of televised coverage on the attack day, which was linked to PTSD symptoms, conduct problems, and total difficulties. Prosocial behavior and positive peer functioning buffered the impact of exposure. CONCLUSIONS: Clinical efforts must maintain a broadened focus beyond simply youth present at the blasts and must also include youth highly exposed to the intense interagency pursuit and manhunt. Continued research is needed to understand the adjustment of youth after mass traumas and large-scale manhunts in residential communities.

Improving the transportability of CBT for internalizing disorders in children.

Research provides strong support for the efficacy and effectiveness of cognitive behavioral therapy (CBT) for the treatment of childhood internalizing disorders. Given evidence for limited dissemination and implementation of CBT outside of academic settings, efforts are underway to improve its transportability so that more children with mental health needs may benefit from treatment. Creative modifications to existing treatments aim to deliver CBT for anxiety disorders and depression in a more transportable format. Notable progress has been made within the areas of computerized CBT, camp-based CBT, school-based CBT, and CBT delivered through primary care settings. These approaches are discussed within the context of key elements of transportability that are particularly germane to the dissemination and implementation of child treatments.