Application of minority stress and the interpersonal theory of suicide in bisexual+ versus gay/lesbian young adults.

INTRODUCTION: Sexual minority young adults are at increased risk for suicidal ideation (SI) compared with heterosexual young adults. Though several frameworks exist to explain the development of suicide risk, including the Interpersonal Theory of Suicide (IPTS) and the Minority Stress Model, few studies have examined these frameworks simultaneously. This study examines these frameworks longitudinally among sexual minority young adults. METHODS: A total of 792 sexual minority young adults (50% bisexual+, 50% gay/lesbian) completed an online survey at baseline, one-month follow-up, and two-month follow-up assessing constructs related to IPTS, the minority stress model, and SI. RESULTS: Over half of our sample (52.9%) reported any SI at baseline. In the full sample, all types of minority stress at baseline were significantly associated with SI at two-month follow-up via perceived burdensomeness (PB) and thwarted belongingness (TB) at one-month follow-up. In the bisexual+ subsample, all bisexual-specific minority stressors at baseline were significantly associated with SI at two-month follow-up via PB at one-month follow-up; internalized binegativity was also associated with SI via TB. However, effects became non-significant when controlling for previous levels of the mediators and outcome variables. CONCLUSION: Both minority stress and IPTS are relevant for understanding suicide risk among sexual minority young adults.

The Psychological, Academic, and Economic Impact of COVID-19 on College Students in the Epicenter of the Pandemic.

Initial research has indicated that college students have experienced numerous stressors as a result of the pandemic. The current investigation enrolled the largest and most diverse sample of college students to date (N = 4714) from universities in New York (NY) and New Jersey (NJ), the epicenter of the North American pandemic in Spring 2020. We described the impact on the psychological, academic, and financial health of college students who were initially most affected and examined racial/ethnic group differences. Results indicated that students' mental health was severely affected and that students of color were disproportionately affected by academic, financial, and COVID-related stressors. Worry about COVID-19 infection, stressful living conditions, lower grades, and loneliness emerged as correlates of deteriorating mental health. COVID-19's mental health impact on college students is alarming and highlights the need for public health interventions at the university level.

Pilot Evaluation of a Tablet-Based Application to Improve Quality of Care in Child Mental Health Treatment.

Mental health systems need scalable solutions that can reduce the efficacy-effectiveness gap and improve mental health outcomes in community mental health service settings. Two major challenges to delivery of high-quality care are providers' fidelity to evidence-based treatment models and children's and caregivers' engagement in the treatment process. We developed a novel, tablet-based application designed to enhance via technology the quality of delivery of trauma-focused cognitive-behavioral therapy (TF-CBT). We piloted its use in four community mental health service organizations using a blocked randomized controlled trial to examine the feasibility of implementing tablet-facilitated TF-CBT versus standard TF-CBT with 13 providers and 27 families. Provider fidelity and child engagement in treatment were observationally measured via session audio recording. Parent and child perceptions of the tablet application were assessed using structured interviews and mixed-method analyses. Providers actively and appropriately used tablet TF-CBT to facilitate treatment activities. Providers and families expressed high satisfaction with its use, demonstrating acceptability of this approach. Youth and caregivers in both conditions reported high alliance with their providers. Overall, we found that tablet-facilitated treatment is accepted by providers and families and may be integrated into mental health treatment with minimal training. Further study is needed to examine the extent to which technology-based applications may enhance the reach, quality, and clinical outcomes of mental health treatment delivered to children and families.

Trajectories and predictors of response in youth anxiety CBT: Integrative data analysis.

OBJECTIVE: Integrative data analysis was used to combine existing data from nine trials of cognitive-behavioral therapy (CBT) for anxious youth (N = 832) and identify trajectories of symptom change and predictors of trajectories. METHOD: Youth- and parent-reported anxiety symptoms were combined using item-response theory models. Growth mixture modeling assessed for trajectories of treatment response across pre-, mid-, and posttreatment and 1-year follow-up. Pretreatment client demographic and clinical traits and treatment modality (individual- and family-based CBT) were examined as predictors of trajectory classes. RESULTS: Growth mixture modeling supported three trajectory classes based on parent-reported symptoms: steady responders, rapid responders, and delayed improvement. A 4-class model was supported for youth-reported symptoms: steady responders, rapid responders, delayed improvement, and low-symptom responders. Delayed improvement classes were predicted by higher number of diagnoses (parent and youth report). Receiving family CBT predicted membership in the delayed improvement class compared to all other classes and membership in the steady responder class compared with rapid responders (youth report). Rapid responders were predicted by older age (parent report) and higher number of diagnoses (parent report). Low-symptom responders were more likely to be male (youth report). CONCLUSIONS: Integrative data analysis identified distinct patterns of symptom change. Diagnostic complexity, age, gender, and treatment modality differentiated response classes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Predictors and Outcomes of Sudden Gains and Sudden Regressions in Cognitive Behavioral Therapy for Youth Anxiety.

Sudden gains (SGs), referring to large, stable symptom improvement occurring between consecutive treatment sessions, have been associated with improved outcomes among adults with various psychological disorders. Little research exists on SGs or sudden symptom worsening (i.e., sudden regressions [SRs]) during treatment for youth disorders. The current study examined predictors and outcomes of SGs/SRs via multiple informants in youth anxiety treatment. Participants were 118 youth (age M = 11.6, SD = 2.5; 53.8% female) and their caregivers receiving a cognitive-behavioral therapy protocol for a principal anxiety disorder. Anxiety symptom severity was assessed weekly via the State-Trait Anxiety Inventory for Children-Trait-Child/Parent versions. SGs and SRs occurred in 45.8 and 31.3% of youth, respectively. SRs were more common among youth with comorbid mood or externalizing disorders, while SGs occurred more often among youth with greater pretreatment anxiety symptom severity. SGs were not associated with posttreatment outcomes, but SRs predicted significantly higher posttreatment internalizing symptoms based on child report (ß = .23, p = .03) and externalizing symptoms based on child (ß = .15, p = .04) and parent report (ß = .16, p = .03), controlling for overall magnitude of symptom change. SRs among youth receiving cognitive-behavioral therapy for anxiety are associated with pretreatment clinical complexity and poorer posttreatment outcomes and may serve as a warning sign to clinicians of possible treatment failure.

What five decades of research tells us about the effects of youth psychological therapy: A multilevel meta-analysis and implications for science and practice.

Across 5 decades, hundreds of randomized trials have tested psychological therapies for youth internalizing (anxiety, depression) and externalizing (misconduct, attention deficit and hyperactivity disorder) disorders and problems. Since the last broad-based youth meta-analysis in 1995, the number of trials has almost tripled and data-analytic methods have been refined. We applied these methods to the expanded study pool (447 studies; 30,431 youths), synthesizing 50 years of findings and identifying implications for research and practice. We assessed overall effect size (ES) and moderator effects using multilevel modeling to address ES dependency that is common, but typically not modeled, in meta-analyses. Mean posttreatment ES was 0.46; the probability that a youth in the treatment condition would fare better than a youth in the control condition was 63%. Effects varied according to multiple moderators, including the problem targeted in treatment: Mean ES at posttreatment was strongest for anxiety (0.61), weakest for depression (0.29), and nonsignificant for multiproblem treatment (0.15). ESs differed across control conditions, with "usual care" emerging as a potent comparison condition, and across informants, highlighting the need to obtain and integrate multiple perspectives on outcome. Effects of therapy type varied by informant; only youth-focused behavioral therapies (including cognitive-behavioral therapy) showed similar and robust effects across youth, parent, and teacher reports. Effects did not differ for Caucasian versus minority samples, but more diverse samples are needed. The findings underscore the benefits of psychological treatments as well as the need for improved therapies and more representative, informative, and rigorous intervention science. (PsycINFO Database Record

Scalable Options for Extended Skill Building Following Didactic Training in Cognitive-Behavioral Therapy for Anxious Youth: A Pilot Randomized Trial.

A sizable gap exists between the availability of evidence-based psychological treatments and the number of community therapists capable of delivering such treatments. Limited time, resources, and access to experts prompt the need for easily disseminable, lower cost options for therapist training and continued support beyond initial training. A pilot randomized trial tested scalable extended support models for therapists following initial training. Thirty-five postdegree professionals (43%) or graduate trainees (57%) from diverse disciplines viewed an initial web-based training in cognitive-behavioral therapy (CBT) for youth anxiety and then were randomly assigned to 10 weeks of expert streaming (ES; viewing weekly online supervision sessions of an expert providing consultation), peer consultation (PC; non-expert-led group discussions of CBT), or fact sheet self-study (FS; weekly review of instructional fact sheets). In initial expectations, trainees rated PC as more appropriate and useful to meet its goals than either ES or FS. At post, all support programs were rated as equally satisfactory and useful for therapists' work, and comparable in increasing self-reported use of CBT strategies (b = .19, p = .02). In contrast, negative linear trends were found on a knowledge quiz (b = -1.23, p = .01) and self-reported beliefs about knowledge (b = -1.50, p < .001) and skill (b = -1.15, p < .001). Attrition and poor attendance presented a moderate concern for PC, and ES was rated as having the lowest implementation potential. Preliminary findings encourage further development of low-cost, scalable options for continued support of evidence-based training.

Transdiagnostic group behavioral activation and exposure therapy for youth anxiety and depression: Initial randomized controlled trial.

Anxiety and depression are debilitating and commonly co-occurring in young adolescents, yet few interventions are designed to treat both disorder classes together. Initial efficacy is presented of a school-based transdiagnostic group behavioral activation therapy (GBAT) that emphasizes anti-avoidance in vivo exposure. Youth (N = 35; ages 12-14; 50.9% male) were randomly assigned to either GBAT (n = 21) or WL (n = 14) after completing a double-gated screening process. Multi-reporter, multi-domain outcomes were assessed at pretreatment, posttreatment, and four-month follow-up (FU). GBAT was associated with greater posttreatment remission rates than WL in principal diagnosis (57.1% vs. 28.6%; X1(2) = 2.76, p = .09) and secondary diagnosis (70.6% vs. 10%; X1(2) = 9.26, p = .003), and greater improvement in Clinical Global Impairment - Severity ratings, B = -1.10 (0.42), p = .01. Symptom outcomes were not significantly different at posttreatment. GBAT produced greater posttreatment behavioral activation (large effect size) and fewer negative thoughts (medium effect), two transdiagnostic processes, both at the trend level. Most outcomes showed linear improvement from pretreatment to FU that did not differ depending on initial condition assignment. Sample size was small, but GBAT is a promising transdiagnostic intervention for youth anxiety and unipolar mood disorders that can feasibly and acceptably be applied in school settings.

Sustained Implementation of Cognitive-Behavioral Therapy for Youth Anxiety and Depression: Long-term Effects of Structured Training and Consultation on Therapist Practice in the Field.

Identifying factors that promote sustained implementation of evidence-based treatments (EBTs) after therapists receive training is critical for professional psychology. To address the field's minimal knowledge in this area, we interviewed community-based therapists (N = 23) who had completed intensive training in cognitive behavioral therapy (CBT) for either anxiety or depression as part of a randomized effectiveness trial (Southam-Gerow et al., 2010; Weisz et al., 2009). Therapists were interviewed three to five years after completion of the initial trial, representing one of the longest-term follow-ups of therapist practices after training. Therapists viewed each protocol and their individual CBT strategies as effective and appropriate for the majority of their current anxiety and depression caseloads. However, therapists used parts of each protocol much more frequently than the protocol as a whole (i.e., 78.5% used parts of the Coping Cat, and 7.5% used the whole protocol; 58.6% used parts of the PASCET, and 20% used the whole protocol). Therapists reported using problem-solving the most and exposure exercises the least for current anxious cases; they used cognitive restructuring the most and homework the least for current depression cases. Interventions that were more difficult to implement in usual care settings were less likely to be sustained. Future efforts should evaluate the characteristics and structure of EBTs that are most acceptable to therapists and should investigate which kinds of ongoing learning supports will maintain therapist skills in and continued use of EBTs.

Mediators of exposure therapy for youth obsessive-compulsive disorder: specificity and temporal sequence of client and treatment factors.

OBJECTIVE: Behavioral engagement and cognitive coping have been hypothesized to mediate effectiveness of exposure-based therapies. Identifying which specific child factors mediate successful therapy and which therapist factors facilitate change can help make our evidence-based treatments more efficient and robust. The current study examines the specificity and temporal sequence of relations among hypothesized client and therapist mediators in exposure therapy for pediatric Obsessive Compulsive Disorder (OCD). METHOD: Youth coping (cognitive, behavioral), youth safety behaviors (avoidance, escape, compulsive behaviors), therapist interventions (cognitive, exposure extensiveness), and youth anxiety were rated via observational ratings of therapy sessions of OCD youth (N=43; ages=8 - 17; 62.8% male) who had received Exposure and Response Prevention (ERP). Regression analysis using Generalized Estimation Equations and cross-lagged panel analysis (CLPA) were conducted to model anxiety change within and across sessions, to determine formal mediators of anxiety change, and to establish sequence of effects. RESULTS: Anxiety ratings decreased linearly across exposures within sessions. Youth coping and therapist interventions significantly mediated anxiety change across exposures, and youth-interfering behavior mediated anxiety change at the trend level. In CLPA, youth-interfering behaviors predicted, and were predicted by, changes in anxiety. Youth coping was predicted by prior anxiety change. CONCLUSIONS: The study provides a preliminary examination of specificity and temporal sequence among child and therapist behaviors in predicting youth anxiety. Results suggest that therapists should educate clients in the natural rebound effects of anxiety between sessions and should be aware of the negatively reinforcing properties of avoidance during exposure.

Client-therapist alliance discrepancies and outcome in cognitive-behavioral therapy for youth anxiety.

BACKGROUND: Studies exploring the association between alliance and outcome in youth cognitive-behavioral therapy (CBT) have yielded inconsistent results based upon whose perspective is measured. OBJECTIVE: The current study explored the degree to which youth with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, anxiety disorders and their therapists agree in their ratings of the alliance at multiple assessment points and evaluated whether inter-rater discrepancies predicted treatment outcome. METHOD: Youth (N = 62; Mage = 12.43, SD = .76) received empirically supported CBT. Paired samples t tests assessed for significant disagreement between youth- and therapist-rated alliance at sessions 4, 8, and 12. Regression analyses were conducted to evaluate whether discrepancies between raters at each time point predicted posttreatment anxiety symptom scores. RESULTS: Overall, alliance was positive for both child (aged 7-12 years) and adolescent (aged 13-16 years) clients. Discrepancies between youth and therapist ratings of alliance were statistically significant at session 4 for children and session 8 for adolescents, with youth rating the relationship more favorably than therapists. However, rating discrepancies did not predict youth- or parent-reported treatment outcome. CONCLUSIONS: Considerable variability may exist between youth and therapist perspectives on the therapeutic alliance, indicating potential attunement problems, particularly during earlier phases of treatment. However, these discrepancies did not negatively affect treatment response. Implications for alliance research and clinical practice are discussed.

Target problem (mis) matching: predictors and consequences of parent-youth agreement in a sample of anxious youth.

Parents and youth often report discrepant target problems upon seeking treatment for youth psychopathology, which can have important impact on therapy processes (e.g., dropout) and treatment outcomes, as entry-level attitudes have been found to be influential in ultimate use and benefit of treatment. The current study examined parent-youth agreement within an anxiety disordered sample by assessing demographic and diagnostic factors that may predict matching, as well as the impact of matching on attrition, treatment outcome, and parental satisfaction. Ninety-five youth with principal anxiety disorders received cognitive-behavioral treatment for anxiety at a university outpatient clinic. Youth and parents independently identified target problems during the pretreatment assessment. Target problems were coded into 25 qualitative categories representing diagnostic, symptom, and functional impairment domains, including diffuse anxiety, social anxiety, academic achievement, oppositional/behavior problems, sleep problems, suicidal ideation, and family functioning. The majority of parent-youth dyads (67.4%) agreed on at least one target problem. Although problems related to diffuse anxiety and social anxiety were reported most frequently, relatively low rates of agreement were found in these domains. Kappa values demonstrated higher levels of agreement for problems with specific fears, school attendance, and panic and lower levels of agreement for difficulties with worry, shame, and self-esteem. Further, youth diagnosed with comorbid externalizing disorders were less likely to agree with their parents on at least one target problem. No effects were found for gender, age, or number of diagnoses in predicting agreement. Target problem agreement did not significantly impact rates of attrition or diagnostic remission, but did predict some measures of parental satisfaction. Results suggest that disagreement on treatment goals exists even within a narrow treatment population and may predict important consumer variables such as satisfaction. Findings emphasize that initial goals disagreement warrants careful assessment and monitoring.

Trajectory and predictors of alliance in cognitive behavioral therapy for youth anxiety.

Multilevel growth analysis was used to establish the shape of change (mean growth trajectory) for youth- and therapist-rated alliance in cognitive behavioral therapy (CBT) for anxious youth and to identify between-youth predictors of alliance trajectory. Youth (N = 69; ages 7-17; 52.2% female) and their parents participated in an empirically supported CBT protocol. Therapists rated alliance each session and youth every four sessions. Data were fit to four growth models: linear, quadratic, a dual slope, and a novel "alliance rupture" model. Two-level models were estimated to examine the effect of youth age, sex, pretreatment symptom severity, diagnostic comorbidity, early treatment factors (use of Selective Serotonin Reuptake Inhibitors), and coping styles (engagement, disengagement, and involuntary coping). A dual slope model fit therapist data best, whereas youth data did not evidence systematic growth. Two-level growth models identified that pretreatment anxiety severity predicted higher initial alliance levels. Depressive symptoms predicted less linear growth and engagement coping predicted greater growth during exposure sessions. No variables predicted preexposure growth. In the therapist model, 22% of initial alliance, 50% of preexposure growth, and 75% of postexposure growth were accounted for by between youth variables (mood disorder, anxiety and depression symptoms, engagement and involuntary coping). Therapist-reported alliance ratings may grow over the course of manual-based CBT, even during exposure-focused sessions. Pretreatment youth factors and coping style may influence the absolute value and linear trajectory of alliance during CBT. Findings about alliance-influencing factors can help set expectations for, and enhance training in, empirically supported treatments.

Cross-ethnic measurement invariance of the SCARED and CES-D in a youth sample.

This study evaluated the cross-ethnic measurement invariance of 2 common screening measures of anxiety and depressive symptoms in youth. The measurement invariance of the Screen for Childhood Anxiety and Related Emotional Disorders (SCARED) and the Center for Epidemiologic Studies Depression Scale (CES-D) was tested across 881 African American (Black; n = 396), Hispanic (n = 185), non-Hispanic White (White; n = 166), and Asian/Indian (n = 134) youth in the 7th grade. The measures were administered as part of a grade-wide screening to identify youth with elevated anxiety and depressive symptoms. The 5-factor model of the SCARED and the 4-factor model of the CES-D best represented the data for all ethnic groups. Results provided support for strong invariance of the SCARED across all 4 ethnic groups. Results provided support for strong invariance of the CES-D across Black, White, and Asian/Indian youth, and partial strong invariance for Hispanic youth. Overall, results suggest that factor means and total scores can be compared across groups. Factor mean differences across groups were identified for both measures. In particular, Hispanic youth reported greater levels of anxiety and depression in certain domains than White, Black, and Asian youth. Our findings support the use of the SCARED and CES-D as tools for measuring anxiety and depressive symptoms in ethnically diverse youth in the United States. Results are discussed with respect to the importance of establishing measurement invariance for screening measures of anxiety and depressive symptoms prior to comparing symptom levels across ethnic groups.

The relationship between alliance and client involvement in CBT for child anxiety disorders.

Little is known about the nature of the relationship between the alliance and client involvement in child psychotherapy. To address this gap, we examined the relationship between these therapy processes over the course of cognitive-behavioral therapy (CBT) for child anxiety disorders. The sample was 31 child participants (M age = 9.58 years, SD = 2.17, range = 6-13 years, 67.7% boys; 67.7% Caucasian, 6.5% Latino, 3.2% Asian/Pacific Islander, and 22.6% mixed/other) diagnosed with a primary anxiety disorder. The participants received a manual-based individual CBT program for child anxiety or a manual-based family CBT program for child anxiety. Ratings of alliance and client involvement were collected on early (Session 2) and late (Session 8) treatment phases. Two independent coding teams rated alliance and client involvement. Change in alliance positively predicted late client involvement after controlling for initial levels of client involvement. In addition, change in client involvement positively predicted late alliance after controlling for initial levels of the alliance. The findings were robust after controlling for potentially confounding variables. In CBT for child anxiety disorders, change in the alliance appears to predict client involvement; however, client involvement also appears to predict the quality of the alliance. Our findings suggest that the nature of the relationship between alliance and client involvement may be more complex than previously hypothesized. In clinical practice, tracking alliance and level of client involvement could help optimize the impact and delivery of CBT for child anxiety.

Child involvement, alliance, and therapist flexibility: process variables in cognitive-behavioural therapy for anxiety disorders in childhood.

BACKGROUND: This study examined the relations between treatment process variables and child anxiety outcomes. METHOD: Independent raters watched/listened to taped therapy sessions of 151 anxiety-disordered (6-14 yr-old; M = 10.71) children (43% boys) and assessed process variables (child alliance, therapist alliance, child involvement, therapist flexibility and therapist functionality) within a manual-based cognitive-behavioural treatment. Latent growth modelling examined three latent variables (intercept, slope, and quadratic) for each process variable. Child age, gender, family income and ethnicity were examined as potential antecedents. Outcome was analyzed using factorially derived clinician, mother, father, child and teacher scores from questionnaire and structured diagnostic interviews at pretreatment, posttreatment and 12-month follow-up. RESULTS: Latent growth models demonstrated a concave quadratic curve for child involvement and therapist flexibility over time. A predominantly linear, downward slope was observed for alliance, and functional flexibility remained consistent over time. Increased alliance, child involvement and therapist flexibility showed some albeit inconsistent, associations with positive treatment outcome. CONCLUSION: Findings support the notion that maintaining the initial high level of alliance or involvement is important for clinical improvement. There is some support that progressively increasing alliance/involvement also positively impacts on treatment outcome. These findings were not consistent across outcome measurement points or reporters.

Shape of change in cognitive behavioral therapy for youth anxiety: symptom trajectory and predictors of change.

OBJECTIVE: Multilevel growth analysis was used to establish the mean growth trajectory (shape of change) for cognitive behavioral therapy (CBT) for youth with anxiety disorders. Two-level growth analysis was conducted to identify important between-youth predictors of session-by-session symptom change. METHOD: Fifty-five youth (ages 7-17; 50.9% male) and their parents participated in a 16- to 20-week CBT that emphasized affective, cognitive, and exposure-based exercises. Multilevel growth models (MLMs) were estimated to model session symptom data taking into account an "anxiety spike" hypothesized to occur at initiation of exposure sessions. Three models were compared: a cubic curve, a log-linear curve plus an exposure covariate, and a linear curve plus exposure covariate. Two-level MLM examined the effect of demographic traits (sex, age, race/ethnicity), pretreatment symptom severity, comorbid school refusal, early treatment factors (use of selective serotonin reuptake inhibitor medication, therapeutic alliance, treatment attrition), and pretreatment coping (engagement, disengagement, and involuntary coping). RESULTS: Fit indices provided support for the cubic growth model using either parent or youth anxiety data. Level 2 analysis identified youth age, symptom severity (anxiety, externalizing), early attrition, and engagement and disengagement coping as significant predictors of symptom trajectories. Predictors accounted for 34%-37% of between-youth variance in midtreatment anxiety scores. CONCLUSIONS: Findings suggest that the symptom course of CBT, and the effect of between-youth factors on treatment outcomes, is more complex than previously thought. Educating therapists and clients about findings can aid treatment expectations and dissemination efforts of empirically supported treatments.

Attention mechanisms in children with anxiety disorders and in children with attention deficit hyperactivity disorder: implications for research and practice.

Inattention is among the most commonly referred problems for school-aged youth. Research suggests distinct mechanisms may contribute to attention problems in youth with anxiety disorders versus youth with attention deficit hyperactivity disorder (ADHD). This study compared children (8-17 years) with anxiety disorders (n = 24) and children (8-16 years) with ADHD (n = 23) on neurocognitive tests of both general and emotion-based attention processes. As hypothesized, children with ADHD demonstrated poorer selective and sustained attention, whereas youth with anxiety disorders demonstrated greater attentional bias toward threatening faces on a visual probe task. Findings suggest the neuropsychological differentiation of attention problems in anxious and ADHD children, despite potentially similar phenotypes.

Does cognitive behavioral therapy for youth anxiety outperform usual care in community clinics? An initial effectiveness test.

OBJECTIVE: Most tests of cognitive behavioral therapy (CBT) for youth anxiety disorders have shown beneficial effects, but these have been efficacy trials with recruited youths treated by researcher-employed therapists. One previous (nonrandomized) trial in community clinics found that CBT did not outperform usual care (UC). The present study used a more stringent effectiveness design to test CBT versus UC in youths referred to community clinics, with all treatment provided by therapists employed in the clinics. METHOD: A randomized controlled trial methodology was used. Therapists were randomized to training and supervision in the Coping Cat CBT program or UC. Forty-eight youths (56% girls, 8 to 15 years of age, 38% Caucasian, 33% Latino, 15% African-American) diagnosed with DSM-IV anxiety disorders were randomized to CBT or UC. RESULTS: At the end of treatment more than half the youths no longer met criteria for their primary anxiety disorder, but the groups did not differ significantly on symptom (e.g., parent report, eta-square = 0.0001; child report, eta-square = 0.09; both differences favoring UC) or diagnostic (CBT, 66.7% without primary diagnosis; UC, 73.7%; odds ratio 0.71) outcomes. No differences were found with regard to outcomes of comorbid conditions, treatment duration, or costs. However, youths receiving CBT used fewer additional services than UC youths (χ(2)(1) = 8.82, p = .006). CONCLUSIONS: CBT did not produce better clinical outcomes than usual community clinic care. This initial test involved a relatively modest sample size; more research is needed to clarify whether there are conditions under which CBT can produce better clinical outcomes than usual clinical care. CLINICAL TRIAL REGISTRY INFORMATION: Community Clinic Test of Youth Anxiety and Depression Study, URL: http://clinicaltrials.gov, unique identifier: NCT01005836.

School violence, adjustment, and the influence of hope on low-income, African American youth.

The current study investigated the prevalence and impact of exposure to school violence using a cross-sectional design with a sample of 132 low-income, African American fifth graders (mean age = 10.20). Additionally, hope was examined in relation to adjustment and as a potential resilience factor in the context of school violence. Students completed self-report measures for exposure to school violence frequencies, self-concept, and hope. Teachers completed a teacher-rated survey assessing levels of problem behaviors, social skills, and academic competence. Results indicated that the majority of youth had been personally victimized or witnessed violence during a 3-month period. Exposure to school violence was positively associated with problem behaviors, and negatively associated with social skills, self-concept, and academic competence; hope was inversely related to externalizing behaviors and positively related to self-concept. Hope buffered the effects of personal victimization and witnessing violence on self-concept. Gender differences were observed for a number of the analyses. The implications of both the prevalence and impact of exposure to school violence, as well as the moderating effects of hope, are discussed.