Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders - an international consensus statement.

BACKGROUND: Anxiety disorders in children and young people are common and bring significant personal and societal costs. Over the last two decades, there has been a substantial increase in research evaluating psychological and pharmacological treatments for anxiety disorders in children and young people and exciting and novel research has continued as the field strives to improve efficacy and effectiveness, and accessibility of interventions. This increase in research brings potential to draw together data across studies to compare treatment approaches and advance understanding of what works, how, and for whom. There are challenges to these efforts due largely to variation in studies' outcome measures and variation in the way study characteristics are reported, making it difficult to compare and/or combine studies, and this is likely to lead to faulty conclusions. Studies particularly vary in their reliance on child, parent, and/or assessor-based ratings across a range of outcomes, including remission of anxiety diagnosis, symptom reduction, and other domains of functioning (e.g., family relationships, peer relationships). METHODS: To address these challenges, we convened a series of international activities that brought together the views of key stakeholders (i.e., researchers, mental health professionals, young people, parents/caregivers) to develop recommendations for outcome measurement to be used in treatment trials for anxiety disorders in children and young people. RESULTS AND CONCLUSIONS: This article reports the results of these activities and offers recommendations for selection and reporting of outcome measures to (a) guide future research and (b) improve communication of what has been measured and reported. We offer these recommendations to promote international consistency in trial reporting and to enable the field to take full advantage of the great opportunities that come from data sharing going forward.

Internet-delivered, family-based treatment for early-onset OCD: a preliminary case series.

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as "excellent." The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

"Not Just Right Experiences" in adolescents: phenomenology and associated characteristics.

Efforts to understand the nature of "Not Just Right Experiences" (NJREs) have expanded the scientific understanding of obsessive-compulsive (OC) behavior. Approximately 80% of unselected adults report experiencing NJREs and these experiences have been found to highly correlate with OC behavior. The purpose of this study was to assess NJREs in an unselected sample of adolescents (ages 14-17; N = 152), to compare their experience with adults (N = 237), and to assess the relation between NJREs and OC symptoms. Findings from questionnaires completed on the Internet were consistent with previous findings in adults, 81% of adolescents endorsed recently having an NJRE. Some reactions differed according to age: adults reported NJREs as more frequent and adolescents endorsed feeling more compelled to respond. Surprisingly, OC symptoms were not significantly related to NJREs in the adolescents. Implications, limitations, and future directions for the study of NJREs in youth are discussed.

Implementation fidelity, student outcomes, and cost-effectiveness of train-the-trainer strategies for Masters-level therapists in urban schools: results from a cluster randomized trial.

BACKGROUND: Little is known about the effectiveness and cost-effectiveness of train-the-trainer implementation strategies in supporting mental health evidence-based practices in schools, and about the optimal level of support needed for TT strategies. METHODS: The current study is part of a larger type 2 hybrid cluster randomized controlled trial. It compares two train-the-trainer strategies, Train-the-Trainer (TT) and Train-the-Trainer plus ongoing consultation for trainers (TT +) on the delivery of a group cognitive behavioral treatment protocol for anxiety disorders. Participants were 33 therapists, 29 supervisors, and 125 students who were at risk for anxiety disorders from 22 urban schools. Implementation outcomes were implementation fidelity and treatment dosage. Student outcomes were child- and parent-reported symptoms of anxiety, child-reported symptoms of depression, and teacher-reported academic engagement. We estimated the cost of implementing the intervention in each condition and examined the probability that a support strategy for supervisors (TT vs TT +) is a good value for varying values of willingness to pay. RESULTS: Therapists in the TT and TT + conditions obtained similarly high implementation fidelity and students in the conditions received similar treatment dosages. A mixed effects modeling approach for student outcomes revealed time effects for symptoms of anxiety and depression reported by students, and emotional disaffection reported by teachers. There were no condition or condition × times effects. For both conditions, the time effects indicated an improvement from pre-treatment to post-treatment in symptoms of anxiety and depression and academic emotional engagement. The average cost of therapist, supervisor, and consultant time required to implement the intervention in each condition was $1002 for TT and $1431 for TT + (p = 0.01). There was a greater than 80% chance that TT was a good value compared to TT + for all values of willingness to pay per one-point improvement in anxiety scores. CONCLUSIONS: A TT implementation approach consisting of a thorough initial training workshop for therapists and supervisors as well as ongoing supervision for therapists resulted in adequate levels of fidelity and student outcomes but at a lower cost, compared to the TT + condition that also included ongoing external expert consultation for supervisors. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02651402.

Development of an Online Training Platform and Implementation Strategy for School-Based Mental Health Professionals in Rural Elementary Schools: A Mixed-Methods Study.

Children in rural settings are less likely to receive mental health services than their urban and suburban counterparts and even less likely to receive evidence-based care. Rural schools could address the need for mental health interventions by using evidence-based practices within a tiered system of supports such as positive behavioral interventions and supports. However, very few school professionals, with or without mental health training, have received training on evidence-based practices. Rural schools need implementation strategies focused on training to prepare school personnel for the implementation of interventions with fidelity. Little is known about training strategies that are feasible and appropriate for the rural school context. User-centered design is an appropriate framework for the development of training strategies for professionals in rural schools because of its participatory approach and the development of products that fit the context where they are going to be used. The purpose of the study was to develop and assess components of an online training platform and implementation strategy based on the user-centered design. Quantitative and qualitative data from 25 participants from an equal number of schools in rural areas of Pennsylvania were used in the study. A mixed-methods design utilizing complementary descriptive statistics and theme analyses indicated that the training platform and implementation strategy were perceived as highly acceptable, appropriate, feasible and usable by school professionals. The resulting training platform and implementation strategy will fill a void in the training literature in rural schools.

Therapist and supervisor perspectives about two train-the-trainer implementation strategies in schools: A qualitative study.

Background: Train-the-trainer (TT) implementation strategies (in which designated clinicians are trained to then train others in an intervention) are promising approaches to support mental health clinician use of evidence-based interventions in school contexts. However, there is little evidence to date examining clinicians' perceptions of the acceptability and feasibility of TT strategies, or comparing clinicians' perceptions of different types of TT strategies. Methods: The current study was conducted as part of a larger hybrid effectiveness-implementation trial, in which school-based therapists and supervisors received one of two different types of implementation support to implement cognitive behavioral therapy (CBT) groups for anxiety: TT (i.e., initial training for therapists and supervisors) or enhanced TT (TT+; i.e., initial training for therapists and supervisors, and ongoing external consultation for supervisors). We used applied thematic analysis to compare qualitative interview transcripts from 28 therapist interviews and 33 supervisor interviews from therapists and supervisors who received TT or TT+ support and report themes that were similar and different across the two groups. Results: Most themes were similar across the TT and TT+ conditions: therapists and supervisors in both conditions perceived the group anxiety intervention as acceptable and viewed supervision as acceptable, helpful, and feasible. Therapists and supervisors in both conditions had mixed impressions of the contextual appropriateness of the group anxiety intervention, and some reported logistical challenges with weekly supervision. Some unique themes were identified among the TT+ condition, including supervisors experiencing professional growth, and therapists and supervisors perceiving supervision as critically important and enjoyable. Conclusions: These results suggest that TT implementation support, using a model in which an internal supervisor receives initial training and then provides ongoing supervision, is acceptable and feasible to support a group CBT intervention in schools. The results also highlight additional benefits that therapists and supervisors perceived when supervisors received ongoing consultation. Clinical Trial Registration Information: The clinical trial from which these data were derived was registered at ClinicalTrials.gov (https://clinicaltrials.gov/) prior to the time of first patient enrollment. The registration number is: NCT02651402.

It is important to understand how to best support mental health clinicians in using evidence-based interventions in school contexts. Train-the-trainer (TT) strategies, in which designated clinicians receive training to then support others in using the intervention, may be promising, and it is important to determine the optimal TT model. However, little is known about how clinicians perceive the acceptability and feasibility of implementing evidence-based mental health interventions with different types of TT support, which can include training and/or ongoing consultation for internal trainers. To address this gap, we used a qualitative approach to examine and compare themes from semistructured interviews with therapists and supervisors participating in two different types of TT implementation support to deliver an evidence-based group CBT intervention for anxiety within schools. Therapists and supervisors receiving both kinds of support had mostly positive perceptions of the intervention and implementation support. They viewed the group anxiety intervention as acceptable and impactful, although they had mixed perceptions about its contextual appropriateness. They viewed supervision as acceptable, helpful, and generally feasible, although challenging at times. However, unique themes among the group who received the more intensive type of TT support, such as supervisors experiencing professional growth over time, suggest that there may be additional benefits to the more intensive support. Overall, these results suggest that TT strategies are an acceptable and feasible approach to support clinicians in delivering group CBT in schools. This study highlights the benefit of embedding qualitative interviews within randomized controlled trials to better understand clinician experiences and perspectives.

A comparison of two group cognitive behavioral therapy protocols for anxiety in urban schools: appropriateness, child outcomes, and cost-effectiveness.

Background: Cognitive behavioral therapy (CBT) for pediatric anxiety is efficacious for reducing anxiety symptoms and improving functioning, but many children are unable to access CBT for anxiety in community settings. Schools are an important setting in which children access mental health care, including therapy for anxiety. In this setting, therapy is usually delivered by Masters-level therapists. Objectives: Friends for Life (FRIENDS), a 12-session, manualized, group CBT program for anxiety has demonstrated effectiveness when implemented in schools. However, prior research has also found challenges regarding feasibility and cultural fit when delivering FRIENDS in the urban school context. To address these challenges, we adapted FRIENDS for implementation in the school setting so that it might be more feasible and culturally appropriate for low-income, urban schools in the United States, while maintaining the core components of treatment. The current study uses a mixed-method approach to compare the effectiveness, cost-effectiveness, and perceived appropriateness of FRIENDS and CATS when delivered by Masters-level therapists with train-the-trainer support. Materials and methods: First, we compared change scores for student outcomes (i.e., child-report MASC-2 total score, parent-report MASC-2 total score, teacher-report Engagement and Disaffection subscale scores) from pre- to post- treatment between students receiving FRIENDS and students receiving CATS to assess whether the two conditions resulted in equivalent outcomes. Second, we compared the cost and cost-effectiveness between the groups. Finally, we used an applied thematic analysis to compare appropriateness of the interventions as perceived by therapists and supervisors. Results: The mean change score for the child-reported MASC-2 was 1.9 (SE = 1.72) points in the FRIENDS condition and 2.9 (SE = 1.73) points in the CATS condition; results indicated that the conditions were similar in their treatment effects, and symptom reductions were small in both groups. The modified protocol, CATS, was shown to cost significantly less to implement compared to FRIENDS and showed greater cost-effectiveness. Finally, compared to therapists and supervisors in the CATS condition, therapists and supervisors in the FRIENDS condition more strongly described aspects of the intervention that were not appropriate for their context and in need of more extensive adaptations. Conclusion: Relatively brief, group CBT for anxiety, with adaptations to improve cultural fit, is a promising approach to treat youth anxiety symptom when delivered by school-based therapists with train-the-trainer implementation support.

Development and evaluation of a remote training strategy for the implementation of mental health evidence-based practices in rural schools: pilot study protocol.

BACKGROUND: An increasing number of schools in rural settings are implementing multi-tier positive behavioral interventions and supports (PBIS) to address school-climate problems. PBIS can be used to provide the framework for the implementation of evidence-based practices (EBPs) to address children's mental health concerns. Given the large service disparities for children in rural areas, offering EBPs through PBIS can improve access and lead to better long-term outcomes. A key challenge is that school personnel need technical assistance in order to implement EBPs with fidelity and clinical effectiveness. Providing ongoing on-site support is not feasible or sustainable in the majority of rural schools, due to their remote physical location. For this reason, remote training technology has been recommended for providing technical assistance to behavioral health staff (BHS) in under-served rural communities. OBJECTIVES: The purpose of this study is to use the user-centered design, guided by an iterative process (rapid prototyping), to develop and evaluate the appropriateness, feasibility, acceptability, usability, and preliminary student outcomes of two online training strategies for the implementation of EBPs at PBIS Tier 2. METHODS: The study will employ a pragmatic design comprised of a mixed-methods approach for the development of the training platform, and a hybrid type 2, pilot randomized controlled trial to examine the implementation and student outcomes of two training strategies: Remote Video vs. Remote Video plus Coaching. DISCUSSION: There is a clear need for well-designed remote training studies focused on training in non-traditional settings. Given the lack of well-trained mental health professionals in rural settings and the stark disparities in access to services, the development and pilot-testing of a remote training strategy for BHS in under-served rural schools could have a significant public health impact. ETHICS AND DISSEMINATION: The project was reviewed and approved by the institutional review board. Results will be submitted to ClinicalTrials.gov and disseminated to community partners and participants, peer-reviewed journals, and academic conferences. TRIAL REGISTRATION: ClinicialTrials.gov, NCT05034198 and NCT05039164.

Study protocol: cluster randomized trial of consultation strategies for the sustainment of mental health interventions in under-resourced urban schools: rationale, design, and methods.

BACKGROUND: The school is a key setting for the provision of mental health services to children, particularly those underserved through traditional service delivery systems. School-wide Positive Behavioral Interventions and Supports (PBIS) is a tiered approach to service delivery based on the public health model that schools use to implement universal (Tier 1) supports to improve school climate and safety. As our prior research has demonstrated, PBIS is a useful vehicle for implementing mental and behavioral health evidence-based practices (EBPs) at Tier 2 for children with, or at risk for, mental health disorders. Very little research has been conducted regarding the use of mental health EBPs at Tier 2 or how to sustain implementation in schools. METHODS/DESIGN: The main aim of the study is to compare fidelity, penetration, cost-effectiveness, and student outcomes of Tier 2 mental health interventions across 2 sustainment approaches for school implementers in 12 K-8 schools. The study uses a 2-arm, cluster randomized controlled trial design. The two arms are: (a) Preparing for Sustainment (PS)-a consultation strategy implemented by school district coaches who receive support from external consultants, and (b) Sustainment as Usual (SAU)-a consultation strategy implemented by school district coaches alone. Participants will be 60 implementers and 360 students at risk for externalizing and anxiety disorders. The interventions implemented by school personnel are: Coping Power Program (CPP) for externalizing disorders, CBT for Anxiety Treatment in Schools (CATS) for anxiety disorders, and Check-in/Check-out (CICO) for externalizing and internalizing disorders. The Interactive Systems Framework (ISF) for Dissemination and Implementation guides the training and support procedures for implementers. DISCUSSION: We expect that this study will result in a feasible, effective, and cost-effective strategy for sustaining mental health EBPs that is embedded within a multi-tiered system of support. Results from this study conducted in a large urban school district would likely generalize to other large, urban districts and have an impact on population-level child mental health. Trial registration ClinicalTrials.gov identifier number NCT04869657. Registered May 3, 2021.

Computers and psychosocial treatment for child anxiety: recent advances and ongoing efforts.

Building on the empirical data supporting the efficacy of cognitive-behavioral therapy (CBT) for child anxiety, researchers are working on the development and evaluation of cost-effective and transportable CBT approaches. Related to this, a widely endorsed goal is to disseminate evidence-based treatments from research settings to community settings. Computer-assisted treatments have emerged as a means to provide cost-effective and efficient service to an increased number of anxious youth for whom a CBT treatment would be otherwise unavailable. We offer a rationale for the development and evaluation of computer-assisted psychosocial treatments for anxiety in youth, offer illustrative advances made in this area, and describe our efforts in using computers to enhance dissemination of CBT for child anxiety. Specifically, our illustrations include a description of (a) Camp-Cope-A-Lot (CCAL), a computer-assisted CBT for the treatment of anxiety disorders in youth ages 7-12, and (b) CBT4CBT: Computer-based training in CBT for anxious youth. Findings from evaluations of these programs are summarized, and further advances are proposed and discussed.

Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) randomized controlled trial.

CONTEXT: The extant literature on the treatment of pediatric obsessive-compulsive disorder (OCD) indicates that partial response to serotonin reuptake inhibitors (SRIs) is the norm and that augmentation with short-term OCD-specific cognitive behavior therapy (CBT) may provide additional benefit. OBJECTIVE: To examine the effects of augmenting SRIs with CBT or a brief form of CBT, instructions in CBT delivered in the context of medication management. DESIGN, SETTING, AND PARTICIPANTS: A 12-week randomized controlled trial conducted at 3 academic medical centers between 2004 and 2009, involving 124 pediatric outpatients between the ages of 7 and 17 years with OCD as a primary diagnosis and a Children's Yale-Brown Obsessive Compulsive Scale score of 16 or higher despite an adequate SRI trial. INTERVENTIONS: Participants were randomly assigned to 1 of 3 treatment strategies that included 7 sessions over 12 weeks: 42 in the medication management only, 42 in the medication management plus instructions in CBT, and 42 in the medication management plus CBT; the last included 14 concurrent CBT sessions. MAIN OUTCOME MEASURES: Whether patients responded positively to treatment by improving their baseline obsessive-compulsive scale score by 30% or more and demonstrating a change in their continuous scores over 12 weeks. RESULTS: The medication management plus CBT strategy was superior to the other 2 strategies on all outcome measures. In the primary intention-to-treat analysis, 68.6% (95% CI, 53.9%-83.3%) in the plus CBT group were considered responders, which was significantly better than the 34.0% (95% CI, 18.0%-50.0%) in the plus instructions in CBT group, and 30.0% (95% CI, 14.9%-45.1%) in the medication management only group. The results were similar in pairwise comparisons with the plus CBT strategy being superior to the other 2 strategies (P < .01 for both). The plus instructions in CBT strategy was not statistically superior to medication management only (P = .72). The number needed-to-treat analysis with the plus CBT vs medication management only in order to see 1 additional patient at week 12, on average, was estimated as 3; for the plus CBT vs the plus instructions in CBT strategy, the number needed to treat was also estimated as 3; for the plus instructions in CBT vs medication management only the number needed to treat was estimated as 25. CONCLUSIONS: Among patients aged 7 to 17 years with OCD and partial response to SRI use, the addition of CBT to medication management compared with medication management alone resulted in a significantly greater response rate, whereas augmentation of medication management with the addition of instructions in CBT did not. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00074815.

Implementation of targeted mental health interventions in urban schools: Preliminary findings for impact of training strategy on program fidelity.

School-based mental health programs are increasingly recognized as methods by which to improve children's access to evidence-based practices (EBPs), particularly in urban under resourced communities. School-wide positive behavior interventions and supports (PBIS) is one approach to integrating mental health services into school-based programming; however, school providers require training and support to implement programs as intended. We have conducted a randomized controlled trial to compare two models for training school-based personnel to deliver group EBPs to children at high risk of developing internalizing or externalizing problems. School personnel (N = 24) from 6 schools in a large urban school district were trained with either a basic training and consultation strategy, or an enhanced training and consultation strategy. Preliminary findings show that the enhanced strategy resulted in 9% higher content fidelity than the basic strategy. School personnel who were switched to the basic strategy had slightly lower content fidelity for the last two years of the trial and school personnel who continued to receive basic consultation during the step-down phase saw their fidelity decline. The two conditions did not differ with regard to process fidelity.

Depression, anxiety, and functional impairment in children with trichotillomania.

BACKGROUND: Trichotillomania (TTM) remains understudied in children. Adult research suggests that TTM is accompanied by significant depression, anxiety, and functional impairment. The purpose of this study is to examine the occurrence of depression and anxiety in a relatively large sample of youth with TTM and the extent to which these symptoms mediate the relationship between TTM severity and associated impairment. METHODS: The study utilized data from the Child and Adolescent Trichotillomania Impact Project (CA-TIP), an internet-based sample of 133 youth aged 10-17 (inclusive) with TTM. RESULTS: Over 45% of children with TTM endorsed depressive symptoms and 40% endorsed anxiety symptoms in excess of one standard deviation (SD) above published community norms. More remarkably, 25% of our sample reported depressive and 20% reported anxiety symptoms in excess of 2 SD above these norms. Older participants reported more symptoms of depression and anxiety than younger ones; age of onset (children with later onset), but not duration of illness, was predictive of higher reports of both depressive and anxiety symptoms. Neither depressive nor anxiety symptoms were related to pulling site. Depressive symptoms partially mediated the relationship between TTM severity and functional impairment. CONCLUSIONS: Based on an internet sample recruited from the homepage of the Trichotillomania Learning Center, data from this study suggests that symptoms of depression and anxiety may be pervasive among youth with TTM and likely impact functional impairment. Longitudinal studies using directly assessed samples are needed to replicate and extend these findings.

Children's Florida Obsessive Compulsive Inventory: psychometric properties and feasibility of a self-report measure of obsessive-compulsive symptoms in youth.

This report describes the development and psychometric properties of the Children's Florida Obsessive Compulsive Inventory (C-FOCI). Designed specifically as a brief measure for assessing obsessive-compulsive symptoms, the C-FOCI was created for use in both clinical and community settings. Study 1 included 82 children and adolescents diagnosed with primary Obsessive-Compulsive Disorder, and their parents. The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) was administered to assess symptom severity. Thereafter, parents completed the Child Obsessive-Compulsive Impact Scale-Parent Version and Child Behavior Checklist, and youth completed the C-FOCI, Child Obsessive-Compulsive Impact Scale-Child Version, Multidimensional Anxiety Scale for Children, and Children's Depression Inventory-Short Form. A subgroup of 21 individuals was retested with the C-FOCI after completing 14 sessions of intensive cognitive-behavioral therapy. Construct validity of the C-FOCI was supported vis-à-vis evidence of treatment sensitivity, and moderate relations with clinician-rated symptom severity, the CY-BOCS Symptom Checklist, child- and parent-rated functional impairment, child-rated anxiety, and parent-rated internalizing symptoms. Discriminant validity was evidenced by weak relationships with parent-reports of externalizing symptoms. For Study 2, 191 non-clinical adolescents completed the C-FOCI to assess the feasibility of internet administration. Overall, internal consistency was acceptable for the C-FOCI Symptom Checklist and Severity Scale, and respondents were able to complete the measure with little difficulty. Taken together, the findings of Studies 1 and 2 provide initial support for the reliability and validity of the C-FOCI for the assessment of pediatric obsessive-compulsive symptoms.

Group CBT for Externalizing Disorders in Urban Schools: Effect of Training Strategy on Treatment Fidelity and Child Outcomes.

Public schools are an ideal setting for the delivery of mental health services to children. Unfortunately, services provided in schools, and more so in urban schools, have been found to lead to little or no significant clinical improvements. Studies with urban school children seldom report on the effects of clinician training on treatment fidelity and child outcomes. This study examines the differential effects of two levels of school-based counselor training: training workshop with basic consultation (C) vs. training workshop plus enhanced consultation (C+) on treatment fidelity and child outcomes. Fourteen school staff members (counselors) were randomly assigned to C or C+. Counselors implemented a group cognitive behavioral therapy protocol (Coping Power Program, CPP) for children with or at risk for externalizing behavior disorders. Independent coders coded each CPP session for content and process fidelity. Changes in outcomes from pre to post were assessed via a parent psychiatric interview and interviewer-rated severity of illness and global impairment. Counselors in C+ delivered CPP with significantly higher levels of content and process fidelity compared to counselors in C. Both C and C+ resulted in significant improvement in interviewer-rated impairment; the conditions did not differ from each other with regard to impairment. Groups did not differ with regard to pre- to- posttreatment changes in diagnostic severity level. School-based behavioral health staff in urban schools are able to implement interventions with fidelity and clinical effectiveness when provided with ongoing consultation. Enhanced consultation resulted in higher fidelity. Enhanced consultation did not result in better student outcomes compared to basic consultation. Implications for resource allocation decisions with staff training in EBP are discussed.

Navigating the development and dissemination of internet cognitive behavioral therapy (iCBT) for anxiety disorders in children and young people: A consensus statement with recommendations from the #iCBTLorentz Workshop Group.

Initial internet-based cognitive behavioral therapy (iCBT) programs for anxiety disorders in children and young people (CYP) have been developed and evaluated, however these have not yet been widely adopted in routine practice. The lack of guidance and formalized approaches to the development and dissemination of iCBT has arguably contributed to the difficulty in developing iCBT that is scalable and sustainable beyond academic evaluation and that can ultimately be adopted by healthcare providers. This paper presents a consensus statement and recommendations from a workshop of international experts in CYP anxiety and iCBT (#iCBTLorentz Workshop Group) on the development, evaluation, engagement and dissemination of iCBT for anxiety in CYP.

Web-Based Parent-Training for Parents of Youth With Impairment From Anxiety.

Child Anxiety Tales, an online web-based cognitive-behavioral parent-training program for parents of youth with anxiety, was developed and evaluated. Parents (N = 73; 59 females; 52.1% Caucasian, 42.5% African American, 4.1% Hispanic) who reported concerns about anxiety in their child (aged 7-14 yrs; Mean=10.1 ±1.6) were randomly assigned to (a) parent-training provided through Child Anxiety Tales (CAT), (b) parent-training provided via bibliotherapy (BIB), or (c) a waitlist control (WLC). Measures of parent knowledge, the acceptability of training, and child symptomatology were completed at pre- and post-parent-training and at 3-month follow-up. Findings support the feasibility, acceptability, and beneficial effects on knowledge of Child Anxiety Tales for parents of youth with impairment from anxiety.

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

A hybrid effectiveness-implementation cluster randomized trial of group CBT for anxiety in urban schools: rationale, design, and methods.

BACKGROUND: Schools present a context with great potential for the implementation of psychosocial evidence-based practices. Cognitive behavioral therapy (CBT) is an evidence-based practice that has been found to be very effective in treating anxiety in various community settings, including schools. Friends for Life (FRIENDS) is an efficacious group CBT protocol for anxiety. Unfortunately, evidence-based practices for anxiety are seldom employed in under-resourced urban schools, because many treatment protocols are not a good fit for the urban school context or the population, existing behavioral health staff do not receive adequate training or support to allow them to implement the treatment with fidelity, or school districts do not have the resources to contract with external consultants. In our prior work, we adapted FRIENDS to create a more culturally sensitive, focused, and feasible CBT protocol for anxiety disorders (CBT for Anxiety Treatment in Schools (CATS)). METHODS/DESIGN: The aim of this 5-year study is to evaluate both the effectiveness of CATS for urban public schools compared to the original FRIENDS as well as compare the implementation strategies (train-the-trainer vs. train-the-trainer + ongoing consultation) by conducting a three-arm, parallel group, type 2 hybrid effectiveness-implementation trial in 18 K-8 urban public schools. We will also assess the cost-effectiveness and the mediators and moderators of fidelity. Ninety therapists, 18 agency supervisors, and 360 children will participate. The interactive systems framework for dissemination and implementation guides the training and support procedures for therapists and supervisors. DISCUSSION: This study has the potential to demonstrate that agency therapists and supervisors who have had little to no prior exposure to evidence-based practices (EBPs) can implement an anxiety disorder EBP with fidelity. Comparisons of the implementation strategies would provide large urban mental health systems with data to make decisions about the adoption of EBPs. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02651402.

Obsessive-Compulsive Symptoms and Beliefs in Adolescents: A Cross-Sectional Examination of Cognitive Models.

Cognitive models of obsessive-compulsive disorder (OCD) posit that particular beliefs transform normal intrusions into disturbing obsessions. A wealth of data shows that such beliefs and obsessive-compulsive (OC) symptoms are related in adults. However, there is markedly less information regarding OCD-related beliefs in youth. The purpose of this study was to assess the relation between OCD-related beliefs and OC symptoms in unselected adolescents (ages 13-18 years; N = 159). Findings from questionnaires completed on the Internet were consistent with previous findings in adults. Increased levels of OCD-related beliefs were related to increased levels of OC symptoms. Perfectionism and certainty beliefs had a specific relation with symmetry and ordering symptoms. Contrary to expectation, levels of OCD-related beliefs in this unselected sample were similar to those found in prior studies of youth diagnosed with OCD. Implications, limitations, and future directions for the study of OCD-related beliefs in youth are discussed.