A systematic review of parental involvement in cognitive behavioural therapy for adolescent anxiety disorders

Anxiety disorders are common among adolescents and lead to poor long-term outcomes. Cognitive Behavioural Therapy (CBT) is an evidenced-based intervention for adolescent anxiety disorders, but little is known about whether and how parents should be involved. This systematic review evaluated how parents have been involved and associated treatment outcomes in studies of CBT for adolescent anxiety disorders. Electronic systematic searches were conducted in PsycINFO, Embase, CINAHL, Medline, AMED databases, to identify studies investigating CBT for adolescent anxiety disorder(s) that included parents in treatment. Twenty-three studies were identified. Parents were involved in treatment in a number of different ways: by attending separate parent sessions, joint parent-adolescent sessions, or both, or through provision of a workbook while attending some adolescent sessions. Content varied but was most typically aimed at the parent developing an understanding of core CBT components and skills to help them manage their adolescent’s anxiety and avoidance. Treatment outcomes indicate that CBT with parental involvement is an effective intervention for adolescent anxiety disorders, however it is not possible to draw conclusions regarding whether parental involvement (generally or in any particular form) enhances treatment outcomes. Poor reporting and methodological issues also limit the conclusions. Further research is required to identify whether there are particular types of parental involvement in CBT that bring clinical benefits to adolescents with anxiety disorders generally, as well as in particular circumstances

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study

Background The mental health of children and young people (CYP) is a major UK public health concern. Recent policy reviews have identified that service provision for CYP with mental health needs is not as effective, responsive, accessible or child-centred as it could be. Following on from a previous National Institute for Health Research (NIHR) study into self-care support for CYP with long-term physical health needs, this study explored self-care support’s potential in CYP’s mental health. Objectives To identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision. Design Two inter-related systematic literature reviews (an effectiveness review with meta-analysis and a perceptions review), together with a service mapping exercise and case study. Setting Global (systematic reviews); England and Wales (mapping exercise and case study). Participants (case study) Fifty-two individuals (17 CYP, 16 family members and 19 staff) were interviewed across six sites. Main outcome measures (meta-analysis) A measure of CYP’s mental health symptomatology. Data sources (literature reviews) MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, All Evidence-Based Medicine (EBM) Reviews, Applied Social Sciences Index and Abstracts (ASSIA) and Education Resources Information Center (ERIC). Review methods Titles and abstracts of papers were screened for relevance then grouped into studies. Two independent reviewers extracted data from studies meeting the inclusion criteria. A descriptive analysis and meta-analysis were conducted for the effectiveness review; descriptive analyses were conducted for the perceptions review. These analyses were integrated to elicit a mixed-methods review. Results Sixty-five of 71 included studies were meta-analysable. These 65 studies elicited 71 comparisons which, when meta-analysed, suggested that self-care support interventions were effective at 6-month [standardised mean difference (SMD) = −0.20; 95% confidence interval (CI) −0.28 to −0.11] and 12-month (SMD = −0.12; 95% CI −0.17 to −0.06) follow-ups. However, judged against Cochrane criteria, the studies were mostly low quality. Key elements of self-care support identified in the perceptions review were the acquisition of knowledge and skills, peer support and the relationship with the self-care support agent; CYP also had different perceptions from adults about what is important in self-care support. The mapping exercise identified 27 providers of 33 self-care support services. According to the case study data, effective self-care support services are predicated on flexibility; straightforward access; non-judgemental, welcoming organisations and staff; the provision of time and attention; opportunities to learn and practise skills relevant to self-care; and systems of peer support. Conclusions Mental health self-care support interventions for CYP are modestly effective in the short to medium term. Self-care support can be conceptualised as a process which has overlap with ‘recovery’. CYP and their families want choice and flexibility in the provision of such interventions and a continued relationship with services after the nominal therapy period. Those delivering self-care support need to have specific child-centred attributes. Future work Future work should focus on under-represented conditions (e.g. psychosis, eating disorders, self-harm); the role of technology, leadership and readiness in self-care support; satisfaction in self-care support; the conceptualisation of self-care support in CYP’s mental health; and efficacy and cost-effectiveness

Cognitive behavioural therapy for anxiety disorders in children and adolescents

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To carry out a meta‐analysis of identified studies to determine whether CBT leads to remission of 1) the primary child/adolescent anxiety disorder and 2) all anxiety diagnoses, and/or 3) a clinically significant reduction in anxiety symptoms in comparison with passive (waiting list) controls, active controls, treatment as usual, or medication. To determine the comparative efficacy of CBT alone, and the combination of CBT and medication, versus drug placebo. To determine whether post‐treatment gains of CBT are maintained at longer‐term follow‐up. To describe the age range of participants included in CBT trials in order to determine the age of the youngest participants. To determine whether CBT for anxiety leads to a clinically significant reduction in depressive symptoms, and/or improvements in global functioning. To carry out subgroup analyses of different types of CBT according to 1) amount of therapist contact time; and 2) delivery format (child‐focused individual, group, and with/without family involvement, and parent‐delivered). To carry out a subgroup analysis of CBT for children and adolescents with ASD and for children and adolescents with intellectual impairments

An Evaluation of a Mental Health Promotion Programme to Improve Emotional, Social and Coping Skills in Children and Young People Attending Special Schools

Background: Research evidence suggests that a child's emotional, social and psychological well-being influences their future health, education and social prospects, and that positive, well-developed coping skills and high emotional literacy lead to improved self-esteem, reduced stress, and reduced incidence of serious emotional problems in later life. Children with special educational needs and disabilities (SEND) are at a disadvantage as they tend to have lower levels of emotional literacy and may have limited opportunities or capacity to develop coping skills. Few targeted, evidence-based programmes aimed at improving emotional literacy and coping skills are currently available for use in SEND schools.Aims: To evaluate the effectiveness, acceptability and feasibility of the school-based mental health promotion programme Zippy's Friends in SEND schools. The study concentrated on the first three modules of the programme, implemented over the course of an academic year in a cohort of children and young people with SEND.Methods: Fifty-three children and young people attending eight SEND schools participated in the educational programme and study. Quantitative and qualitative data were collected using standardized assessment scales, purposed-designed questionnaires, emotion recognition tasks and interviews to assess typical and maximal behavior of the children as well feedback on the programme. Data were collected from children, parents/guardians/care givers, and teachers before and after the intervention. The results of the qualitative data will be presented elsewhere.Results: Teachers' ratings indicated that the children's and young people's social skills, emotional literacy, and emotional recognition improved over the course of the study. Significant improvements were observed in teachers' ratings of communication, cooperation, assertion, responsibility, and self-awareness. Parental ratings did not change over time.Conclusions: This small-scale study indicates that the Zippy's Friends programme is feasible and may lead to improved emotional literacy. However, further research is needed that uses a comparison group to isolate the effects of the programme from factors such as age-related maturation, development, and usual school-based learning

Cognitive behavioral therapy of socially phobic children focusing on cognition: a randomised wait-list control study

BACKGROUND: Although literature provides support for cognitive behavioral therapy (CBT) as an efficacious intervention for social phobia, more research is needed to improve treatments for children. METHODS: Forty four Caucasian children (ages 8-14) meeting diagnostic criteria of social phobia according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; APA, 1994) were randomly allocated to either a newly developed CBT program focusing on cognition according to the model of Clark and Wells (n = 21) or a wait-list control group (n = 23). The primary outcome measure was clinical improvement. Secondary outcomes included improvements in anxiety coping, dysfunctional cognitions, interaction frequency and comorbid symptoms. Outcome measures included child report and clinican completed measures as well as a diagnostic interview. RESULTS: Significant differences between treatment participants (4 dropouts) and controls (2 dropouts) were observed at post test on the German version of the Social Phobia and Anxiety Inventory for Children. Furthermore, in the treatment group, significantly more children were free of diagnosis than in wait-list group at post-test. Additional child completed and clinician completed measures support the results. DISCUSSION: The study is a first step towards investigating whether CBT focusing on cognition is efficacious in treating children with social phobia. Future research will need to compare this treatment to an active treatment group. There remain the questions of whether the effect of the treatment is specific to the disorder and whether the underlying theoretical model is adequate. CONCLUSION: Preliminary support is provided for the efficacy of the cognitive behavioral treatment focusing on cognition in socially phobic children. Active comparators should be established with other evidence-based CBT programs for anxiety disorders, which differ significantly in their dosage and type of cognitive interventions from those of the manual under evaluation (e.g. Coping Cat)

Study design of 'FRIENDS for Life': process and effect evaluation of an indicated school-based prevention programme for childhood anxiety and depression

Background: Anxiety disorders and depression are highly prevalent in children and affect their current and future functioning. 'FRIENDS for Life' is a cognitive-behavioural programme teaching children skills to cope more effectively with feelings of anxiety and depression. Although 'FRIENDS for Life' is increasingly being implemented at Dutch schools, its effectiveness as a preventive intervention in Dutch schools has never been investigated. The aim of the study is to evaluate the effectiveness of 'FRIENDS for Life' as an indicated school-based prevention programme for children with early or mild signs of anxiety or depression. Methods/Design. This study is a controlled trial with one pre-intervention and three post-intervention measurements (directly after, and 6 and 12 months after the end of the programme). The study sample consists of children aged 10-12 years (grades 6, 7 and 8 of Dutch primary schools), who show symptoms of anxiety or depressive disorder. Data are collected through self-report, teacher report and peer nomination. A process evaluation is conducted to investigate programme integrity (whether the programme has been executed according to protocol) and to evaluate children's and parents' opinions about 'FRIENDS for Life' using online focus groups and interviews. Discussion. The present study will provide insight into the effectiveness of 'FRIENDS for Life' as an indicated school-based prevention programme for children with early or mild signs of anxiety or depression

A brief early intervention for adolescent depression that targets emotional mental images and memories: protocol for a feasibility randomised controlled trial (IMAGINE trial)

This is the final version of the article. Available from BioMed Central via the DOI in this record.Background: Adolescent depression is common and impairing. There is an urgent need to develop early interventions to prevent depression becoming entrenched. However, current psychological interventions are difficult to access and show limited evidence of effectiveness. Schools offer a promising setting to enhance access to interventions, including reducing common barriers such as time away from education. Distressing negative mental images and a deficit in positive future images, alongside overgeneral autobiographical memories, have been implicated in depression across the lifespan, and interventions targeting them in adults have shown promise. Here, we combine techniques targeting these cognitive processes into a novel, brief psychological intervention for adolescent depression. This feasibility randomised controlled trial will test the feasibility and acceptability of delivering this imagery-based cognitive behavioural intervention in schools. Methods/design: Fifty-six adolescents (aged 16-18) with high symptoms of depression will be recruited from schools. Participants will be randomly allocated to the imagery-based cognitive behavioural intervention (ICBI) or the control intervention, non-directive supportive therapy (NDST). Data on feasibility and acceptability will be recorded throughout, including data on recruitment, retention and adherence rates as well as adverse events. In addition, symptom assessment will take place pre-intervention, post-intervention and at 3-month follow-up. Primarily, the trial aims to establish whether it is feasible and acceptable to carry out this project in a school setting. Secondary objectives include collecting data on clinical measures, including depression and anxiety, and measures of the mechanisms proposed to be targeted by the intervention. The acceptability of using technology in assessment and treatment will also be evaluated. Discussion: Feasibility, acceptability and symptom data for this brief intervention will inform whether an efficacy randomised controlled trial is warranted and aid planning of this trial. If this intervention is shown in a subsequent definitive trial to be safe, clinically effective and cost-effective, it has potential to be rolled out as an intervention and so would significantly extend the range of therapies available for adolescent depression. This psychological intervention draws on cognitive mechanism research suggesting a powerful relationship between emotion and memory and uses imagery as a cognitive target in an attempt to improve interventions for adolescent depression. Trial registration: ISRCTN85369879.This study represents independent research from a Clinical Doctoral Research Fellowship (Dr Victoria Pile, ICA-CDRF-2015-01-007) supported by the National Institute for Health Research and Health Education England

Predictors of Treatment Attrition Among an Outpatient Clinic Sample of Youths With Clinically Significant Anxiety

Predictors of treatment attrition were examined in a sample of 197 youths (ages 5–18) with clinically-significant symptoms of anxiety seeking psychotherapy services at a community-based outpatient mental health clinic (OMHC). Two related definitions of attrition were considered: (a) clinician-rated dropout (CR), and (b) CR dropout qualified by phase of treatment (pre, early, or late phases) (PT). Across both definitions, rates of attrition in the OMHC sample were higher than those for anxious youths treated in randomized controlled trials, and comorbid depression symptoms predicted dropout, with a higher rate of depressed youths dropping out later in treatment (after 6 sessions). Using the PT definition, minority status also predicted attrition, with more African-American youths lost pre-treatment. Other demographic (age, gender, single parent status) and clinical (externalizing symptoms, anxiety severity) characteristics were not significantly associated with attrition using either definition. Implications for services for anxious youths in public service settings are discussed. Results highlight the important role of comorbid depression in the treatment of anxious youth and the potential value of targeted retention efforts for ethnic minority families early in the treatment process

Meta-analysis and systematic review of teacher-delivered mental health interventions for internalizing disorders in adolescents

A large proportion of emotional problems begin in adolescence and negatively impact quality of life into adulthood. There have been multiple teacher-delivered, classroom-based programs created to reduce symptoms of internalizing problems amongst young people. This meta-analysis and systematic review aims to examine the effectiveness of teacher-delivered interventions for depression, anxiety, post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) symptoms in adolescents, and a range of factors that may impact outcomes. Database searches were conducted from PsycInfo, Medline (PubMed), Scopus, the Cochrane Library and the British Educational Index (from database inception to January 2020). Quality assessment of studies was conducted using the EPHPP Quality Assessment Tool. Fifty-two intervention studies were identified that quantitatively assessed, via controlled design, intervention effects on internalizing disorder symptoms. Two meta-analyses found teacher-delivered interventions were significantly better than control conditions at improving depression (g = -0.12), anxiety (g = -0.13) and PTSD symptoms (g = -0.66) in students. Improvements were only maintained at follow-up for anxiety symptoms and no effect sizes reached a ‘small’ threshold. However, the effect sizes were ‘moderate’ within the context of universal prevention programs for young people. No interventions measured OCD outcomes. Overall, the findings suggest that teachers may not be the optimal deliverers of mental health interventions. Improved outcomes were associated with interventions that lasted up to 16 weeks, had program sessions of 45-90 minute duration, and included two or more days of training for teachers. Future studies should aim to improve reporting quality on number of sessions, teacher training and fidelity of intervention. Increased reporting of outcomes from adolescents with high versus low baseline mental health scores would enable a better understanding of for whom interventions are most effective