A Natural Helper Intervention to Address Disparities in Parent Child-Interaction Therapy: A Randomized Pilot Study.

OBJECTIVE: Parent-child interaction therapy (PCIT) is an effective intervention to address child externalizing behaviors. However, disparities in access and retention are pervasive, which relate to the availability of PCIT in low-income communities, inadequate workforces to provide culturally appropriate care, and distrust in services due to systemic discrimination. This study incorporated natural helpers who had been trained as community health workers into PCIT delivery to improve disparities in engagement and outcomes. METHOD: Families from three low-income, predominately Latino/a/x and Black neighborhoods in Miami qualified for services if they had a child aged 2-8 with clinically elevated externalizing behaviors. Families were randomly assigned into either Standard-PCIT group (N = 30 families; 80% boys, 57% Latino/a/x, 27% Black) or a PCIT plus Natural helper (PCIT+NH) group (N = 51 families; 66% boys, 76% Latino/a/x, 18% Black). Families in the PCIT+NH group received home visits and support addressing barriers to care from a natural helper. Path analyses within an intention-to-treat framework examined group-differences in treatment engagement, child behavior, and parenting skills and stress. RESULTS: Families in both groups demonstrated large improvements in child externalizing behavior, caregiver stress, and parenting skills from pre-to-post-treatment. Externalizing behavior improved significantly more in the PCIT+NH group compared to the Standard-PCIT group. There were no significant group differences in parenting skills or caregiver stress. Though differences in engagement were not significant, the PCIT+NH group had a small effect on treatment retention. CONCLUSIONS: Natural helpers may help to address structural barriers that systematically impact communities of color, apply treatment in naturalistic environments, and promote improved treatment outcomes.

A Preliminary Analysis of Parent-Child Interaction Therapy Plus Natural Helper Support to Increase Treatment Access and Engagement for Low-Income Families of Color.

Disparities in care for low-income children of color call for innovative culturally and linguistically responsive solutions to better engage marginalized populations in evidence-based interventions. In partnership with a community organization, the addition of natural helper support as an adjunct to Parent-Child Interaction Therapy (PCIT+NH) was examined as a strategy to increase recruitment, engagement, and retention in PCIT for families historically unreached by a university-based clinic. Natural helpers provided home-based skills practice and support for forty-two families whose parents were more racially and linguistically diverse and had lower income and lower caregiver education than the typical population served by the same program (i.e., program population). Families who received PCIT+NH had comparable or higher rates of engagement and improvements in clinical outcomes (i.e., decreased child externalizing and internalizing behaviors, increased child compliance, decreased caregiver stress, increased caregiver parenting skills) relative to the program population. Furthermore, higher doses of natural helper support were associated with higher rates on most measures of treatment engagement (i.e., treatment completion, completion of the Child Directed Interaction phase of treatment, PCIT sessions, homework in the Parent Directed Interaction phase of treatment), with the exception of homework in the Child Directed Interaction phase of treatment and overall session attendance rate. Next steps for testing the treatment engagement and clinical outcome effects of the PCIT+NH model are discussed.

A person-centered approach to understanding heterogeneity of youth receiving transdiagnostic treatment for emotional disorders.

OBJECTIVE: Transdiagnostic models of youth psychopathology posit shared, underlying core features of emotional disorders that confer risk for and/or maintain symptoms. Youth may differ in the presence and severity of these underlying core features, and matching intervention strategies to such features may help personalize transdiagnostic interventions. We used latent profile analysis (LPA) to identify profiles of youth based on core underlying transdiagnostic dysfunctions and examined associations of profiles with treatment outcome. METHOD: LPA was conducted with 298 youth ages 7-18.8 (Mage = 12, SD = 3.2; 48.7% female; primarily White and Hispanic/Latinx) with a primary emotional disorder. Indicators for LPA included self-report measures of affect, anxiety sensitivity (AS), distress tolerance (DT), and emotion regulation (ER). Longitudinal associations between profile membership and treatment outcome were examined in a subset of 177 youth (Mage = 11.8, SD = 3.2; 52% female; primarily White and Hispanic/Latinx). RESULTS: LPA identified three profiles characterized by differing levels of DT, affect, and ER. A Moderately Distressed and Dysregulated profile had the largest membership (65.1%) and poorer youth-reported anxiety and depression outcomes compared to a Distress Tolerant, Regulated Expressive profile (24.9%). A Distressed, High Affect Avoidant profile (10%) had the greatest baseline severity and the poorest depression outcomes, although most youth improved. CONCLUSIONS: Youth characterized by certain profiles of transdiagnostic core processes appear to have the poorest functioning and treatment prognosis, although most youth improved. Targeting these processes more directly and/or earlier in treatment may help to improve outcomes for youth. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Youth Top Problems and Early Treatment Response to the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents.

The Top Problems assessment is an idiographic measure of client concerns that may allow clinicians to identify early treatment response. Few studies have examined early response to evidence-based therapies using Top Problems. We collected weekly Top Problems ratings from 95 youth with emotional disorders who received treatment using the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/UP-A). We assessed Top Problems rating change from session 1 to session 4, the role of pre-treatment variables in early Top Problems rating change, and the role of early Top Problems rating change in post-treatment symptom outcomes. Top Problems ratings decreased significantly from session 1 to session 4. Younger child age and higher parent cognitive flexibility were associated with early Top Problems improvement. Controlling for pre-treatment, early Top Problems rating change did not explain the variance in post-treatment outcomes. Future research should examine Top Problems trajectories over treatment course.

Brief Transdiagnostic Intervention for Parents With Emotional Disorder Symptoms During the COVID-19 Pandemic: A Case Example.

Concerns regarding parent mental health and well-being during the COVID-19 pandemic are justifiably on the rise. Although anxiety, depression, and traumatic stress levels have risen precipitously across all demographics during the pandemic, parents residing with their children are under particular and unique strain. Caregivers with children in the home are responsible not only for their own health, financial security, and safety during this time, but often full-time caregiving, household management and, in many cases, their children's schooling. In this case paper, we describe the development of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for Caregivers (UP-Caregiver) and provide a case example of its implementation. This 4-session indicated prevention for caregivers is a modification of existing versions of the Unified Protocols for adults and children, modified to maximize its responsiveness to issues faced by parents and caregivers living with youth (ages 6-13) during the current pandemic. UP-Caregiver was offered as part of a randomized, controlled trial via telehealth in a small group format to any parent with a child in the specified age range with mild or greater anxiety, depression or traumatic stress symptoms during an initial screening. The case example provided is of a White, Hispanic mother with a range of self-reported emotional disorder concerns at an initial assessment. Declines in anxiety, depression and traumatic stress symptoms were all noted, as well as improvements in parenting self-efficacy and distress tolerance 6-weeks after initiating UP-Caregiver. An ongoing randomized, controlled trial of UP-Caregiver will further evaluate the utility and feasibility of this approach to alleviate parental distress during COVID-19.

Transdiagnostic cognitive behavioral therapy for misophonia in youth: Methods for a clinical trial and four pilot cases.

BACKGROUND: Misophonia is a condition marked by dysregulated emotions and behaviors in response to trigger sounds, often chewing, breathing, or coughing. Evidence suggests that misophonia develops in adolescence and the emotions and behaviors are a conditioned response to distress, resulting in social avoidance, stress, and family conflict. In addition, co-occurrence with other psychiatric illnesses such as anxiety, OCD, and Tourette syndrome is common. A transdiagnostic cognitive behavioral therapeutic (CBT) approach appears appropriate. There are currently no controlled studies of youth with misophonia. The current paper describes the approach to a pilot randomized, blinded family-based treatment study for youth ages 8-16 years. Preliminary results from a pilot open trial also are described. METHODS: A 2-phase dual site telehealth treatment study using a transdiagnostic CBT approach, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A; Ehrenreich-May et al., 2018), is proposed. Phase 1 consisted of a 4-case pilot of UP-C/A. Phase 2 includes a randomized trial comparing the UP-C/A to a standard relaxation and education protocol. RESULTS: Preliminary results from the pilot show modest improvements in evaluator-rated misophonia symptoms on the Clinical Global Impression Severity and Improvement scales. LIMITATIONS: There is little research to inform evidence-based practice for youth with misophonia. Study limitations include lack of standardized misophonia assessment instruments and an absence of formal diagnostic criteria. CONCLUSIONS: The current paper describes proposed methods for the first randomized controlled trial for youth with misophonia and their families along with results from a 4-case pilot.

Tailoring the Unified Protocol for Adolescents for a Stepped-Care Approach: Case Exemplars.

Emotional disorders, including anxiety, depressive, and obsessive-compulsive spectrum disorders are prevalent and impairing for youth. Dissemination efforts have been implemented to address these disorders in youth, but these are limited by cost and barriers to accessing mental health services. Stepped care is a method of treatment delivery meant to be cost-effective and less time intensive than administering a full treatment manual. Much, if not all of the research, assessing the efficacy of stepped care delivery has utilized disorder-specific treatment manuals. However, transdiagnostic stepped care approaches may prove more efficacious given that youth commonly present to treatment with more than one disorder and that such problems are not always comprehensively assessed at intake. This manuscript provides details regarding the implementation of a transdiagnostic stepped-care delivery (UPA-SC) using three case examples. Youth evidenced significant improvement in anxiety, depression, and quality of life. Future work to investigate the efficacy of UPA-SC in a larger, more heterogeneous sample of youth may be warranted.

Relationship of affect intolerance with anxiety, depressive, and obsessive-compulsive symptoms in youth.

BACKGROUND: Structural research on the construct of affect intolerance (an overarching latent construct indicated by distress tolerance and anxiety sensitivity) has only been conducted in adults. Given that a self-report measure of distress tolerance was recently validated for youth and affect intolerance may be a core mechanism of transdiagnostic interventions for internalizing disorders, we examined how affect intolerance relates to internalizing symptoms in youth. We predicted that a latent affect intolerance factor (indicated by distress tolerance and anxiety sensitivity) would be associated with self and parent-reports of youth anxiety, depressive, and obsessive-compulsive symptoms, controlling for age and gender. METHODS: At a pre-treatment evaluation, youth with a primary depressive, anxiety, or obsessive-compulsive spectrum disorder (N=277) aged 8-17, and their parent, completed questionnaires. RESULTS: Greater levels of the affect intolerance factor predicted greater youth- and parent-reported youth anxiety, depression, and obsessive-compulsive symptoms, controlling for age. LIMITATIONS: Future research should replicate findings in a sample with a greater proportion of depressed youth and utilize experimental or longitudinal methods. CONCLUSIONS: Importantly, distress tolerance and anxiety sensitivity are core transdiagnostic processes that can be targeted in cognitive-behavioral interventions. Future research should examine how transdiagnostic interventions for youth with internalizing disorders can target these cross-cutting emotional vulnerabilities.

Neuroticism as an underlying construct in youth emotional disorders.

Structural research on neuroticism, as indicated by Big Five personality traits and/or internalizing symptoms, has been conducted with youth. However, no structural research has investigated neuroticism as characterized by transdiagnostic risk factors such as distress tolerance (DT), negative affect (NA), and avoidance. No study has investigated whether DT, NA, and avoidance, as a group, are associated with anxiety, depressive, obsessive-compulsive (OC) symptoms, and independent evaluator (lE)-rated symptom severity in a clinical sample of youth. The purpose of the current investigation was to understand the proportion of variance in anxiety, depressive, OC symptoms, and independent evaluator-rated global symptom severity by a latent construct of neuroticism, as indicated by these modifiable features in youth with emotional disorders among a sample of 121 adolescents (ages 13-18, 51.2% female). A latent neuroticism factor was significantly associated with greater youth- and parent-reported anxiety, depressive, and OC symptoms, and greater IE-rated global severity.

Confirming the Factor Structure and Validity of the Distress Tolerance Scale (DTS) in Youth.

Distress tolerance (DT) is an individual's ability to handle uncomfortable emotion states or sensations (Simons and Gaher in Motiv Emot 29(2): 83-102, 2005). DT is associated with heightened risk for psychopathology, including internalizing symptoms. However, little research has examined the feasibility of assessing DT via youth self-report. The purpose of this investigation was to assess the psychometric properties of the Distress Tolerance Scale (DTS) (Simons and Gaher in Motiv Emot 29(2): 83-102, 2005) in community (n = 117; ages 10-19; 56.4% female) and clinical samples (n = 165; ages 10-18, 52.7% female) of youth. Predictors of DT and its association with internalizing symptoms were investigated. The majority of fit indices confirmed a four-factor hierarchical structure for the clinical sample data. Females reported lower DT than males and DT was associated with internalizing symptoms. Validation of the factor structure of the DTS allows for investigation of child and adolescent-reported perceptions of DT as a risk factor for psychopathology in youth.

Predictors of treatment outcome for the unified protocol for transdiagnostic treatment of emotional disorders in children (UP-C).

Various efficacious treatment packages exist for youth anxiety, and cognitive behavior therapy (CBT) is now considered to be a well-established treatment for child anxiety disorders (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). Improving outcomes for the significant proportion of anxious youth who demonstrate inadequate response to CBT is imperative, but our understanding of who does and does not benefit is incomplete. Further, there are no known empirical studies of predictors of treatment response for youth who receive a transdiagnostic intervention for anxiety or depression, and it is therefore unclear whether predictors of response to a transdiagnostic treatment for children are similar to those found in previous studies of anxiety-specific treatments. This study investigated potential predictors of outcome following administration of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C; Ehrenreich-May et al., 2018). Participants were 60 children ages 6-13 (M = 9.47, SD = 1.68) with a primary anxiety diagnosis (with or without comorbid depression) who received a 15-week UP-C group treatment. Consistent with prior literature on CBT for anxiety, social anxiety emerged as a consistent predictor of poorer response to the UP-C. Inconsistent with prior literature, depression, symptom severity, parent psychopathology, and child age were not significant predictors of poor outcome. Results indicate some differences between predictors for transdiagnostic versus anxiety-focused treatments, but point to a need for both types of interventions to better target social anxiety in children.

Examining the Stability of the Hospital Anxiety and Depression Scale Factor Structure in Adolescents and Young Adults With Cystic Fibrosis: A Confirmatory Factor Analysis.

Objective: The Hospital Anxiety and Depression Scale (HADS) is a widely used screening measure of anxiety and depression symptoms. However, prior analyses of the measure have found heterogeneous factor structures and called into question its ability to differentiate between symptoms of anxiety and depression. As part of efforts to implement mental health screening in cystic fibrosis (CF) care, the European Cystic Fibrosis Society (ECFS) and Cystic Fibrosis Foundation (CFF) conducted an international survey of 1,454 CF professionals. The HADS was the most commonly used measure in Europe and third most across all 48 countries surveyed. However, the HADS has not been validated for CF. Thus, the objective of this study was to examine its factor structure in a sample of adolescents and young adults with CF. Methods: Three theory-based models were tested in 727 individuals with CF (ages 12-25 years, 54% female) using confirmatory factor analyses, with an additional two models tested to improve model fit. Results: Chi-square difference tests and majority of fit indices indicated a three-factor structure based on Clark and Watson's tripartite model best fit the data. Conclusions: The original HADS two-factor structure demonstrated problematic fit in this sample, indicating poor discrimination between symptoms of anxiety and depression. A three-factor structure demonstrated best fit, indicating existing scoring guidelines and cutoffs would be inappropriate for use with this patient population. Use of the HADS to screen for anxiety and depression in CF could lead to an underestimation of clinically relevant symptomatology for depression and potential overestimation of anxiety symptoms.