Asthma and anxiety in children and adolescents: characteristics and treatment outcomes.

OBJECTIVE: This study (a) examined anxious youth with and without asthma on measures of negative self-talk, parental psychopathology, worry content, physical symptoms, panic symptoms, generalized symptoms, and separation anxiety symptoms, and (b) tested if outpatient CBT or medication were differentially effective in reducing anxiety for youth with asthma and anxiety. METHODS: This secondary analysis separated youth with an anxiety disorder into asthma and non-asthma groups. Youth were also compared on response to treatments (i.e. CBT, sertraline, combined, and placebo). RESULTS: A total of 488 participants participated in the original study, with an average age of 10 years (SD 2.87). Youth with comorbid asthma and anxiety demonstrated higher rates of negative self-talk. Youth with comorbid asthma and anxiety did not differ from the non-asthma group on measures of physical symptoms, anxiety disorder specific symptoms, parental psychopathology, or worry content. Youth with asthma and anxiety responded similarly to the non-asthma group to treatment across treatment conditions. CONCLUSIONS: Treatment was comparably effective for youth with comorbid asthma and anxiety and youth with anxiety. Future research could examine the effects of psychopharmaceuticals on asthma and anxiety comorbidity.

Genetic associations among internalizing and externalizing traits with polysubstance use among young adults.

Though most genetic studies of substance use focus on specific substances in isolation or generalized vulnerability across multiple substances, few studies to date focus on the concurrent use of two or more substances within a specified time frame (i.e., polysubstance use; PSU). We evaluated whether distinct genetic factors underlying internalizing and externalizing traits were associated with past 30-day PSU above variance shared across general psychopathology and substance use (SU). Using Genomic Structural Equation Modeling, we constructed theory-driven, multivariate genetic factors of 16 internalizing, externalizing, and SU traits using genome-wide association studies (GWAS) summary statistics. Next, we fit a model with a higher order SU-related psychopathology factor as well as genetic variance specific to externalizing and internalizing (i.e., residual genetic variance not explained by SU or general psychopathology). GWAS-by-subtraction was used to obtain single nucleotide polymorphism effects on each of these factors. Polygenic scores (PGS) were then created in an independent target sample with data on PSU, the National Longitudinal Study of Adolescent to Adult Health. To evaluate the effect of genetic variance due to internalizing and externalizing traits independent of variance related to SU, we regressed PSU on the PGSs, controlling for sex, age, and genetic principal components. PGSs for SU-related psychopathology and non-SU externalizing traits were associated with higher PSU factor scores, while the non-SU internalizing PGS was not significantly associated with PSU. In total, the three PGSs accounted for an additional 4% of the variance in PSU above and beyond a null model with only age, sex, and genetic principal components as predictors. These findings suggest that there may be unique genetic variance in externalizing traits contributing to liability for PSU that is independent of the genetic variance shared with SU.

Trajectory of Change in Parental Accommodation and Its Relation to Symptom Severity and Impairment in Pediatric OCD.

Family accommodation (FA) has been shown to relate to poorer treatment outcomes in pediatric obsessive compulsive disorder (OCD), yet few studies have examined the trajectory of change in FA throughout treatment and its relation to treatment outcomes. This study examined change in FA in relation to change in symptom severity and impairment in 63 youth receiving a family-based intervention for early-onset OCD. FA, symptom severity and functional impairment were assessed at baseline, week 5, week 9, and post-treatment (week 14). Results suggested that changes in FA in the beginning stages of treatment preceded global symptom improvement (but not OCD specific improvement) whereas changes in functional impairment preceded changes in FA. In the latter half of treatment, changes in FA preceded improvement in global and OCD specific symptom severity as well as functional impairment. These findings highlight the importance of reducing FA, especially in the later stages of treatment, in order to optimize treatment outcomes in early-onset OCD.

Using the Montreal cognitive assessment to identify individuals with subtle cognitive decline.

OBJECTIVE: Dementia is a devastating neurological disease that may be better managed if diagnosed earlier when subclinical neurodegenerative changes are already present, including subtle cognitive decline and mild cognitive impairment. In this study, we used item-level performance on the Montreal Cognitive Assessment (MoCA) to identify individuals with subtle cognitive decline. METHOD: Individual MoCA item data from the Alzheimer's Disease Neuroimaging Initiative was grouped using k-modes cluster analysis. These clusters were validated and examined for association with convergent neuropsychological tests. The clusters were then compared and characterized using multinomial logistic regression. RESULTS: A three-cluster solution had 77.3% precision, with Cluster 1 (high performing) displaying no deficits in performance, Cluster 2 (memory deficits) displaying lower memory performance, and Cluster 3 (compound deficits) displaying lower performance on memory and executive function. Age at MoCA (older in compound deficits), gender (more females in memory deficits), and marital status (fewer married in compound deficits) were significantly different among clusters. Age was not associated with increased odds of membership in the high-performing cluster compared to the others. CONCLUSIONS: We identified three clusters of individuals classified as cognitively unimpaired using cluster analysis. Individuals in the compound deficits cluster performed lower on the MoCA and were older and less often married than individuals in other clusters. Demographic analyses suggest that cluster identity was due to a combination of both cognitive and clinical factors. Identifying individuals at risk for future cognitive decline using the MoCA could help them receive earlier evidence-based interventions to slow further cognitive decline. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Associations between depression-relevant genetic risk and youth stress exposure: Evidence of gene-environment correlations.

Familial risk for depression is associated with youth exposure to self-generated dependent stressful life events and independent events that are out of youth's control. Familial risk includes both genetic and environmental influences, raising the question of whether genetic influences, specifically, are associated with youth exposure to both dependent and independent stressful life events. To address this question, this study examined the relation between a genome-wide association study (GWAS)-derived depression-based polygenic risk score (DEP-PRS) and youth experiences of dependent and independent stress. Participants were 180 youth (ages 8 to 14, 52.2% female) of European ancestry and their biological mothers recruited based on the presence versus absence of a history of major depressive disorder (MDD) in the mothers. Youth and mothers were interviewed every 6 months for 2 years regarding the occurrence of stressful life events, which were coded as independent or dependent (self-generated). Results indicated that youth's DEP-PRS and maternal history of MDD were uniquely associated with increased exposure to both dependent and independent events. Similar results were observed when examining major versus minor events separately, with the additional finding of a DEP-PRS × mother MDD interaction for major dependent events such that levels of moderate to severe dependent life stressors were highest among youth with high DEP-PRSs who also had mothers with MDD. These results not only support the presence of depression-relevant gene-environment correlations (rGEs), but also highlight the possibility that rather than only capturing depression-specific genetic liability, GWAS-derived polygenic risk scores may also capture genetic variance contributing to stress exposure. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Changes in Affective Network Variability Among Youth Treated for Anxiety Disorders.

Cognitive behavioral therapy (CBT) has been shown to be an efficacious treatment for youth anxiety, but we need to know more about the process of change. Affective network variability, or the "spread" of positive and negative emotions activated across a given time period, has been found to be positively associated with anxiety disorder symptomatology, but it is not yet known how this construct changes in response to intervention or its association with anxiety-focused treatment outcomes. The present study used a dynamical systems framework to model ecological momentary assessment (EMA) data collected via a cellular telephone from 114 youth aged 9-14 years (Mage = 10.94, SD = 1.46) who were seeking treatment for a primary anxiety disorder. We examined patterns of affective network variability over time and across (a) CBT and (b) client-centered therapy (CCT) to determine whether affective network changes were specific to CBT or due to nonspecific factors. Associations between treatment outcomes and patterns of affect at pretreatment and over the course of the treatments were also examined. Results revealed significant decreases in affective network variability over the course of treatment for youth who received CBT, but not for youth who received CCT. Changes in affective network variability over the course of treatment did not predict treatment outcomes. Findings provide initial support for the dynamical systems approach to examining changes that occur during treatment. Implications and future research are discussed.

Editorial: Applications of Cognitive and Behavioral Therapy in Response to COVID-19.

The corona virus (COVID-19) continues to have a devastating health, economic, and social impact on our local and international communities. Cognitive and Behavioral Therapies (CBTs), as a family of therapies that posit cognitive, behavioral, emotional, and interpersonal change processes in the understanding and successful treatment of mental health disorders, have risen to the challenge. This special issue represents contributions from CBT experts on the impact on psychopathology, new assessment methods, adaptations of integrated behavioral health, telehealth, psychology training, and discusses a public health framework. The issue includes a series of articles offering guidance for the clinician on interventions for those impacted by trauma, CBT for youth and families, and telehealth for psychotic spectrum disorders and group therapy for social anxiety.

Mediators of youth anxiety outcomes 3 to 12 years after treatment.

OBJECTIVE: Test changes in perceived coping efficacy, negative self-statements, and interpretive biases to threat during treatment as potential mediators of the relationship between randomly assigned treatment conditions and long-term anxiety follow-ups. Age at randomization was also tested as a moderator of mediational relationships. METHOD: Participants included 319 youth (ages 7-17) from the Child/Adolescent Multimodal Study (CAMS) who participated in a naturalistic follow-up beginning an average of 6.5 years after the end of the CAMS intervention. The intervention conditions included cognitive behavioral therapy (CBT; Coping Cat), pharmacotherapy (sertraline), combined CBT and sertraline, and pill placebo. Putative mediators were measured four times during the intervention phase. Follow-up consisted of four annual assessments of current anxiety. RESULTS: Reductions on a measure of interpretive bias to threat over the course of the combined condition intervention, as compared to the placebo condition, mediated anxiety outcomes at the first follow-up visit. This mediated effect was not significant for the CBT-only or sertraline-only conditions when compared to the placebo condition. No other significant mediated effects were found for putative mediators. Age did not significantly moderate any mediated effects. CONCLUSION: Changes in youth-reported interpretive biases to threat over the course of combined youth anxiety interventions, as compared to a placebo intervention, may be associated with lower anxiety an average of 6.5 years following treatment.

An Analysis of the Child Behavior Checklist Anxiety Problems Scale's Predictive Capabilities.

The Child Behavior Checklist (CBCL) is widely used to assess behavioral and emotional problems in youth. The CBCL Diagnostic and Statistical Manual (DSM)-Oriented Anxiety Problems subscale (CBCL-AP) was developed for the identification of DSM-IV anxiety disorders. Using data from 298 youth aged 6- to 18, the CBCL-AP scale was examined to determine its ability to differentially predict, via Receiver Operating Characteristics (ROC) analysis, the presence of (a) generalized anxiety disorder (GAD), (b) separation anxiety disorder (SAD), (c) specific phobia (SPPH), or (d) the presence of any of these disorders. Independent Evaluators (IEs) administered the Anxiety Disorders Interview Schedule for Children (ADIS-C/P) to determine the presence of an anxiety disorder. The ability of the CBCL-AP to predict to anxiety disorders was compared to the ability of the CBCL Anxious/Depressed (CBCL-A/D) scale and the seven empirically derived CBCL syndrome subscales and five DSM-Oriented subscales to predict anxiety disorder diagnoses. Results revealed that CBCL-AP scores significantly predicted all diagnoses. CBCL-A/D scores significantly predicted SAD (AUC = 0.67), GAD (AUC = 0.69), and the presence of any of the three disorders (AUC = 0.72), but not the presence of SPPH (AUC = 0.52). Although the CBCL-AP scale may not be a substitute for extensive diagnostics, it has demonstrated utility as an instrument for assessing anxiety and can serve to identify anxious youth in need of mental health services.

Testing the Habituation-Based Model of Exposures for Child and Adolescent Anxiety.

Exposure has been identified as key to effective treatment of youth anxiety. However, the precise theoretical mechanisms of exposure are a matter of debate. Emotional processing theory emphasizes the need for fear activation during exposure and its habituation both within and across exposures. Despite the popularity of the theory to explain exposure, it has not been tested with anxious youth. To determine whether emotional processing theory parameters predict anxiety severity, coping abilities, and global functioning after cognitive-behavioral treatment. The present study examined 72 youth (Mage = 10.50 years; 45% female; 87.5% non-Hispanic Caucasian) diagnosed with an anxiety disorder and who received family or individual CBT. Three exposure habituation variables-initial fear activation (peak anxiety), within-session habituation, and between-session habituation-were assessed using Subjective Units of Distress and examined as predictors of outcome at posttreatment and at 1-year follow-up. Outcomes were measured using the Coping Questionnaire, Multidimensional Anxiety Scale for Children, Revised Children's Manifest Anxiety Scale, Children's Global Assessment Scale, and clinician severity ratings on the Anxiety Disorder Interview Schedule. Emotional processing theory variables did not predict any anxiety outcomes at posttreatment or follow-up with one exception: Initial fear activation predicted less anxiety at follow-up among youth without GAD. In addition, within- and between-session habituation were not associated with one another. Between-session habituation was not associated with initial fear activation. These findings suggest a limited role of habituation within cognitive-behavioral therapy for anxiety in youth. An alternative to emotional processing theory, inhibitory learning theory, is discussed.

Exploring the occurrence of sudden gains among anxious youth receiving evidence-based cognitive-behavioral therapy.

BACKGROUND: There is limited information on the occurrence of 'sudden gains' - recognized improvements of substantial magnitude occurring between individual sessions of treatment. This study explores changes in anxiety across sessions of CBT for youth anxiety disorders to determine whether evidence exists for sudden gains in this population. METHOD: A total of 133 anxious youth (Mage  = 10.16 years; 55.6% male) were randomly assigned to receive 16 sessions of individual cognitive-behavioral therapy (ICBT), family-based CBT (FCBT), or a family-based educational support and attention control (FESA). At each treatment session, youth completed a measure of anxiety. Sudden gains were calculated from weekly state anxiety scores using methods consistent with previous research (i.e., Tang & DeRubeis, 1999). RESULTS: Three participants experienced a sudden gain at any point during treatment; all experienced a reversal of the sudden gain, although one experienced a regain of the improvement that occurred during the sudden gain. CONCLUSIONS: While sudden gains have been demonstrated in some studies, in a relatively new topic to the literature such as this, it should also be considered that many evidence-based treatments are actually intended to produce more steady/gradual gains - which may be particularly true for youth who are not as cognitively advanced as adults and who have much to learn about how psychopathology - and for this analysis, anxiety - operates.

Future Directions for the Examination of Mediators of Treatment Outcomes in Youth.

How do psychological therapies work? How can we enhance treatment to improve outcomes? Questions of mediation lie at the heart of these inquiries. However, within the child and adolescent treatment literature, studies of mediation often rely on methodological and statistical approaches that limit the inferences that can be drawn from study findings. This future directions review delineates some of these issues and suggests improvements through two interrelated paths. We propose that mediation studies in the youth treatment literature will be enhanced (a) by adopting best practices in nomothetic (group-based) methodologies for assessing putative mediating variables and conducting appropriate statistical analyses and (b) by increasing the use of idiographic (individual-focused) approaches to youth outcome research through mediation studies that use innovative designs, data collection techniques, and analytic methods. We discuss the applicability of findings using these approaches to the treatment of youth in particular.

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.

Multimedia Field Test Thinking About Exposures? There's an App for That!

Anxiety Coach is a smartphone application ("app") for iOS devices that is billed as a self-help program for anxiety in youth and adults. The app is currently available in the iTunes store for a one-time fee of $4.99. Anxiety Coach is organized around three related content areas: (a) self-monitoring of anxiety symptoms, (b) learning about anxiety and its treatment, and (c) guiding users through the development of a fear hierarchy and completion of exposure tasks. Although the app includes psychoeducation about anxiety as well as information regarding specific skills individuals can use to cope with anxiety (e.g., cognitive restructuring), the primary focus of the app is on exposure tasks. As such, the app includes a large library of potential exposure tasks that are relevant to treating common fears and worries, making Anxiety Coach useful to clients and clinicians alike. Additionally, Anxiety Coach prompts users to provide fear ratings while they are carrying out an exposure task and displays a message instructing users to stop the exposure once fear ratings drop by half. These features work together to create an app that has the potential to greatly increase the reach of exposure-based cognitive behavioral therapy for anxiety.

On the importance of temporal precedence in mediational analyses.

This response to the commentary by Gaynor (in press) (a) underscores the importance of defining terms (predictor, moderator, and mediator variables) used in psychological treatment outcome research, (b) notes the improvements in mediation analyses using treatment of youth anxiety as the illustration, and (c) encourages continued advancement in the methodology for mediation analyses. We agree with Gaynor (in press) both on the importance of temporal precedence and on the use of cautious language with regard to interpreting mediational analyses. (PsycINFO Database Record

In Pursuit of Generalization: An Updated Review.

Stokes and Osnes (1989) outlined three principles to facilitate the generalization and maintenance of therapeutic gains. Use of functional contingencies, training diversely, and incorporating functional mediators were recommended. Our review, with most illustrations from studies of youth, updates Stokes and Osnes's original paper with a focus on evidence-based strategies to increase generalization of therapeutic gains across settings, stimuli, and time. Research since 1989 indicates that training for generalization by increasing the frequency of naturally occurring reinforcers for positive behaviors, and altering maladaptive contingencies that inadvertently reinforce problem behaviors, are associated with favorable treatment outcomes. Training diversely by practicing therapy skills across contexts and in response to varying stimuli is also implicated in clinical outcomes for internalizing, externalizing, and neurodevelopmental disorders. Preliminary research recommends the use of internal (e.g., emotion identification) and external (e.g., coping cards) functional mediators to prompt effective coping in session and at home. Strategies for increasing generalization, including the use of technology, are examined and future research directions are identified.

Pathways to anxiety-depression comorbidity: A longitudinal examination of childhood anxiety disorders.

BACKGROUND: Anxiety disorders are prevalent in youth and associated with later depressive disorders. A recent model posits three distinct anxiety-depression pathways. Pathway 1 represents youth with a diathesis to anxiety that increases risk for depressive disorders; Pathway 2 describes youth with a shared anxiety-depression diathesis; and Pathway 3 consists of youth with a diathesis for depression who develop anxiety as a consequence of depression impairment. This is the first partial test of this model following cognitive-behavioral treatment (CBT) for child anxiety. METHOD: The present study included individuals (N = 66; M age = 27.23 years, SD = 3.54) treated with CBT for childhood anxiety disorders 7-19 years (M = 16.24; SD = 3.56) earlier. Information regarding anxiety (i.e., social phobia (SoP), separation anxiety disorder (SAD), generalized anxiety disorder (GAD)) and mood disorders (i.e., major depressive disorder (MDD) and dysthymic disorders) was obtained at pretreatment, posttreatment, and one or more follow-up intervals via interviews and self-reports. RESULTS: Evidence of pathways from SoP, SAD, and GAD to later depressive disorders was not observed. Treatment responders evidenced reduced GAD and SoP over time, although SoP was observed to have a more chronic and enduring pattern. CONCLUSIONS: Evidence for typically observed pathways from childhood anxiety disorders was not observed. Future research should prospectively examine if CBT treatment response disrupts commonly observed pathways.

ACCOMMODATION AND TREATMENT OF ANXIOUS YOUTH.

BACKGROUND: Parental accommodation refers to the ways in which a parent modifies their behavior to avoid or reduce the distress their child experiences. Parents of youth with anxiety disorders have been found to accommodate their child's anxiety in a variety of ways that contribute to the maintenance of the disorder. The current study evaluated the relationship between parental accommodation and the outcome of treatment for youth with anxiety. METHODS: Sixty-two youth (age 6-17) and their parents were evaluated for youth anxiety and parental accommodation before and after treatment. All youth received individual cognitive behavioral therapy (CBT). RESULTS: Parental accommodation was significantly reduced from before to after treatment. Reduction in parent-rated accommodation was significantly associated with the severity of youth's posttreatment anxiety, even when controlling for pretreatment youth anxiety. Level of pretreatment accommodation was significantly associated with treatment response. CONCLUSIONS: Findings indicate that parental accommodation is significantly reduced after individual youth CBT, and suggest that accommodation may be an important treatment focus. Clinical implications and future directions are discussed.

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

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

Anxiety disorders and comorbid sleep problems in school-aged youth: review and future research directions.

This review examines the relationship between anxiety disorders and sleep related problems (SRPs) in school-aged youth. Following an overview of normative sleep patterns and maturational sleep changes, the review addresses issues related to sleep measurement. SRPs are reviewed in relation to executive functions (e.g. affect regulation) as is the shared role of neurological regions in the regulation of anxiety and sleep. Studies of the association between SRPs and anxiety in anxiety-disordered samples are reviewed with explicit consideration of the potential mechanisms underlying the sleep-anxiety relationship (e.g., arousal, sleep hygiene, parental accommodation). Specific cognitive-behavioral treatments for SRPs and anxiety are reviewed with regard to their impact on comorbid anxiety or SRPs. Methodological limitations are noted and recommendations for future research are proposed.