Examining outcome variability: correlates of treatment response in a child and adolescent anxiety clinic.

Examined correlates of treatment response in a clinic providing cognitive-behavioral therapy for children with anxiety disorders. Youth (ages 7 to 15) with a primary Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., or 4th ed.; American Psychiatric Association, 1987, 1994) anxiety-disorder diagnosis (overanxious disorder, generalized anxiety disorder, separation anxiety disorder, social phobia, or avoidant disorder) participated. After completing a full course of treatment and posttreatment (n = 135) and 1-year follow-up (n = 107) assessments, participants were classified into 1 of 2 groups--poor treatment response and good treatment response--using parent diagnostic reports. Discriminant function analyses indicated that higher levels of maternal- and teacher-reported child-internalizing psychopathology at pretreatment, higher levels of maternal self-reported depressive symptoms, and older-child age were all associated with less favorable treatment response. Other factors, such as child ethnicity, child sex, family income, family composition (i.e., dual parent vs. single parent), child-reported symptomatology, and maternal-reported level of child-externalizing behavior problems did not predict treatment response. Both practical and conceptual implications of the findings are discussed.

Screening for anxiety and depression in early adolescence.

OBJECTIVE: To examine the level of diagnostic and discriminative accuracy of three dimensional rating scales for detecting anxiety and depressive disorders in a school-based survey of 9th grade youths. METHOD: Classroom screening instruments, the Center for Epidemiologic Studies-Depression Scale (CES-D), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Multidimensional Anxiety Scale for Children (MASC) were administered to 632 youths from three sites in 1998. On the basis of rating scale results, samples of high-scoring and non-high-scoring youths were invited to participate in a diagnostic interview conducted within 2 months of the screening sessions. RESULTS: MASC scores were most strongly associated with individual anxiety disorders, particularly among females, whereas the CES-D composite score was associated with a diagnosis of major depression, after controlling for comorbid disorders. The RCMAS was least successful in discriminating anxiety and depression. When receiver operator characteristic curves were examined, diagnostic accuracy was moderate. CONCLUSIONS: The ability of the MASC and CES-D to discriminate within and between categorically defined diagnostic groups has important implications for the accurate identification of youths in need of services.

Comorbidity in childhood anxiety disorders and treatment outcome.

OBJECTIVE: Psychiatric comorbidity is common in anxious children. The purpose of this study was to investigate the impact of comorbidity on treatment outcome in anxious children. METHOD: Participants were 173 children between the ages of 8 and 13 years who met primary DSM-III-R/DSM-IV diagnoses of separation anxiety disorder, overanxious disorder/generalized anxiety disorder, or avoidant disorder/social phobia assessed by the Anxiety Disorders Interview Schedule for Children (ADIS-C). The majority (79%) had at least one comorbid diagnosis. Participants were randomly assigned to cognitive-behavioral therapy or waitlist. Group differences in ADIS-C diagnoses were compared after treatment. Multiple parent and child self-report measures were used to measure symptoms as well. RESULTS: Pretreatment comorbidity was not associated with differences in treatment outcome: 68.4% of noncomorbid participants and 70.6% of comorbid participants were free of their primary diagnosis after treatment. Regarding parent and child self-report symptoms, multivariate analyses of variance revealed significant time (treatment) main effects, but no significant main effect for group (comorbid status) or time/group interaction. CONCLUSIONS: The cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders; both groups showed clinically significant reductions in pretreatment diagnoses and symptoms.

Normative data for normative comparisons.

Normative comparisons are a procedure for evaluating the clinical significance of therapeutic interventions. Although a step-by-step statistical methodology for conducting normative comparisons has been reported elsewhere (P. C. Kendall, A. Marrs-Garcia, S. R. Nath, & R. C. Sheldrick, 1999), questions regarding the collecting of normative data remain. For this study, all treatment outcome studies published in the Journal of Consulting and Clinical Psychology from 1988 to 1997 were examined and reviewed, and the 5 most commonly used outcome measures were identified. For these outcome measures, multiple sources of normative data were located. Although we identified a dearth of normative data on measures used for treatment outcome, results discussed here nevertheless provide information that may be of use to therapy outcome evaluators when conducting normative comparisons. In addition, equations to determine the minimum sample size needed in a normative sample for a given treatment outcome study are provided.

A preliminary study of the emotion understanding of youths referred for treatment of anxiety disorders.

Examined the emotion understanding of children and adolescents referred for treatment of Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994) anxiety disorders (separation anxiety disorder, generalized anxiety disorder, or social phobia). Referred youths (n = 17) and nonreferred youths (n = 21) and their parents participated by completing self-report and parent-report questionnaires and structured diagnostic interviews. We interviewed all youths by using an emotion understanding interview. Referred youths demonstrated poorer understanding of hiding emotions and changing emotions compared with nonreferred youth. The 2 groups were not significantly different regarding their understanding of emotion cues and multiple emotions, however. No statistically significant relation emerged between general intelligence and emotion understanding. Future research directions are discussed.

The role of parental emotional distress in parent report of child anxiety.

Evaluated the role of maternal and paternal emotional distress in parent report of anxiety in their child. Participants were 239 children (ages 7.5 to 15 years) diagnosed with a primary anxiety disorder and their parents (193 fathers, 238 mothers). Parents individually completed the State-Trait Anxiety Inventory, the Beck Depression Inventory (BDI), and the State-Trait Anxiety Inventory for Children-Parent Version (a report of the child's anxiety). Children completed the State-Trait Anxiety Inventory for Children. Mothers and fathers reported more anxiety in their children than the children reported themselves. No significant relations were found between parental anxiety and parent report of child anxiety. When we examined girls only, both maternal and paternal BDI scores were significant predictors of parent report of the child's anxiety after we controlled for parental anxiety. Separate analyses by child age revealed that parent reports of child anxiety were more correlated with the self-reports of younger children. The implications of these findings are discussed.

Retrospective self-reports of therapist flexibility in a manual-based treatment for youths with anxiety disorders.

Evaluated retrospective therapist ratings of the flexibility used when applying the procedures and strategies prescribed in the treatment manual. Flexibility ratings were collected from 18 therapists who had treated 148 children with anxiety disorders (ages 9 through 13). Analyses revealed strong reliabilities for a flexibility questionnaire and that flexibility was used by therapists; however, significant relations between therapist-rated flexibility and treatment outcome were not found. Discussion focuses on the role of flexibility in manual-based psychological treatments and future directions for study.

Conceptualizing mental disorders in children: where have we been and where are we going?

Conceptions of mental illness in children are bound by cultural and social conventions of what constitutes healthy and unhealthy development. To understand current conceptualizations of disorders in children, we review the history of these conceptualizations from three intertwined perspectives: a sociopolitical history of American children and families, the history of the mental health fields and scientific disciplines involved in diagnosing children, and the evolution of children's role in the Diagnostic and Statistical Manual of Mental Disorders. We review where the field has been in its conception of childhood mental illness throughout the past century, where we believe it is now, and raise questions about the direction in which child diagnosis may be headed as we enter the new millennium. We conclude with social policy recommendations based on theory and research regarding mental disorders in children.

Clinical significance.

This article initiates the special section on clinical significance. Within a brief précis and overview, the 4 methodological articles and the integrative commentary of the special section are introduced. A call for the inclusion of the assessment of clinical significance in treatment evaluations is extended.

Normative comparisons for the evaluation of clinical significance.

Normative comparisons are a procedure for evaluating the clinical significance of therapeutic interventions. This procedure, consisting of comparing data on treated individuals with that of normative individuals, is described, and a step-by-step statistical methodology for conducting normative comparisons in the context of treatment-outcome research is presented. Four examples of the methodology are outlined in detail. Attention is paid to potential theoretical, statistical, and methodological challenges to the implementation of normative comparisons, as well as to the advantages of normative comparisons in providing evidence for the beneficial gains of treatment.

Differentiating anxious and depressive self-statements in youth: factor structure of the Negative Affect Self-Statement Questionnaire among youth referred to an anxiety disorders clinic.

Conducted a factor analysis on the items from the Negative Affect Self-Statement Questionnaire (NASSQ; Ronan, Kendall, & Rowe, 1994). This analysis yielded 4 factors (Depressive Self-Statements, Anxiety/Somatic Self-Statements, Negative Affect Self-Statements, and Positive Affect Self-Statements) broadly consistent with both the content-specificity hypothesis (Beck & Clark, 1988) and L. A. Clark and Watson's (1991b) tripartite model of anxiety and depression. The association between children's self-talk and measures of trait anxiety and depression was also examined. Self-statements with content theoretically specific to depression were the best predictors of self-reported depressive symptoms, but the results were less clear for trait anxiety. Overall, these results provide evidence for the discriminability of anxious and depressive self-talk in youth and for the utility of the NASSQ as a cognitive assessment instrument.

Current progress and future plans for developing effective treatments: comments and perspectives.

Examined the conclusions and implications of articles in this special issue. Treatments can be differentiated on their empirical basis and, for the problems reviewed, one can identify treatments of choice. To build on the documented advances, we provide a blueprint for progress in treatment research. The blueprint focuses on a series of steps that involve conceptualization of clinical dysfunction and treatment, supportive research on these conceptual views, careful specification of treatment, evaluation of treatment outcome, and tests of mediators and moderators of treatment. To improve research, we recommend expanding assessment, addressing a broad range of questions about treatment, attending to measures of clinical significance, replicating key findings, and investigating the transportability of the findings to service-oriented clinical settings.

Methodological issues in treatment research for anxiety disorders in youth.

This article identifies and addresses three methodological domains relevant to the treatment of anxiety disorders in youth: (a) procedural matters, (b) the assessment of anxious distress, and (c) the analysis of treatment-produced change. Procedural topics include the need to manualize treatment, have diversity among participants and comparability of the duration of treatment and control conditions, and control for medication status. Multiple-method measurement issues include child and parent reports, observations, and structured interviewing. Our examination of change issues considers comorbidity, analyzing the intent-to-treat sample, treatment "spillover," and clinical as well as statistical significance. Problems are identified and potential ameliorative strategies are offered.

Empirically supported psychological therapies.

This article introduces the special section of the Journal of Consulting and Clinical Psychology on empirically supported psychological therapies. After a discussion of the rationale for the selection of the specific terms in the label, several justifications are considered for conducting and learning from empirical evaluations of psychological therapies. Finally, the process that guided the special section is described.

Attrition in the treatment of childhood anxiety disorders.

The present study explored the differences between completers and terminators (including both refusers and dropouts) of an individual cognitive-behavioral treatment for childhood anxiety. Participants were 190 children with anxiety disorders and their parents: 146 completed treatment and 44 terminated. Terminators were more likely to live in a single-parent household, be ethnic minorities, and self-report less anxious symptomatology. Follow-up interviews indicated that identifiable child factors were influential in terminators' decisions to discontinue treatment. Among terminators, differences between refusers and dropouts were also investigated.

Social expectancies and self-perceptions in anxiety-disordered children.

The link between anxiety and negative social expectancies was examined by comparing 47 anxiety-disordered children with 31 nonanxiety-disordered controls on social expectancies, social anxiety, and self-perceived social competence. Participants were exposed to a videotape of confederate children playing a game, being told the children were next door. In anticipation of joining the play, social expectations were assessed via thought-listing and a questionnaire. Parent, teacher, and child measures of sociability were completed prior to the experimental session. Results indicated that anxiety-disordered children reported significantly more negative social expectations, lower social self-competence, and higher levels of social anxiety than controls. Parents and teachers each rated the anxiety-disordered children as significantly more socially maladjusted than controls. Social anxiety was the best predictor of social expectancies. Given the importance of healthy peer relations, treatment implications for anxiety-disordered children are highlighted.

Therapy for youths with anxiety disorders: a second randomized clinical trial.

Ninety-four children (aged 9-13 years) with anxiety disorders were randomly assigned to cognitive behavioral treatment or waiting-list control. Outcomes were evaluated using diagnostic status, child self-reports, parent and teacher reports, cognitive assessment and behavioral observation: maintenance was examined using 1-year follow-up data. Analyses of dependent measures indicated significant improvements over time, with the majority indicating greater gains for those receiving treatment. Treatment gains returned cases to within nondeviant limits (i.e., normative comparisons) and were maintained at 1-year follow-up. Client age and comorbid status did not moderate outcomes. A preliminary examination of treatment segments suggested that the enactive exposure (when it follows cognitive-educational training) was an active force in beneficial change. Discussion includes suggestions for future research.

Maternal expectations and attributions about coping in anxious children.

This study examined maternal expectations and attributions regarding their child's ability to cope with a stressful situation. Children either met DSM III-R criteria for an Anxiety Disorder or were normal. Results indicated that it was not the perception of threat that differentiated the expectations of mothers in both groups, but rather their expectations for coping, both generally and in terms of specific behavior. Mothers of anxiety-disorder (AD) children expected their children to be more upset, less able to make themselves feel comfortable, and were less confident in their children's abilities to perform task related behavior. In general, maternal expectations for coping appear to reflect the actual lower coping ability of anxious children. Concerning attributions, mothers of AD children made fewer causal distinctions between high and low coping than did mothers of normal control (NC) children. Discussion considers how lowered expectations for coping may relate to protective parenting and how such patterns may unwittingly maintain anxious behavior in children.