A Danish study of One-session Treatment for Specific Phobias in Children and Adolescents

Background: One-session treatment (OST) is a short-term massed exposure therapy for the treatment of specific phobias in children and adults. Systematic reviews have demonstrated the effectiveness of the treatment for children and adolescents across countries and age groups. Objective: A single-group open trial design was used to examine the feasibility and preliminary efficacy of OST for youths with specific phobias in a Danish context. Method: At the Anxiety Clinic of Aarhus University, 10 youths between the ages of 7 and 17 years who fulfilled the diagnostic criteria for specific phobias were treated in accordance with the OST manual. The participants were assessed via semi-structured diagnostic interviews, clinician severity ratings, a behavioral approach test, and self- and parent report measures. Feasibility was assessed with the use of patient- and parent-report measures. Assessments were completed at before and after treatment and at the 3-month follow-up appointment. Results: All outcome measures changed significantly from the pretreatment period to the 3-month follow-up assessment. Four (40%) of the participants were free of the targeted specific phobia after treatment, and eight (80%) were free of the phobia at the 3-month follow-up. The families were moderately satisfied with the treatment, and no patients dropped out of the study. Conclusion: On the basis of the results of this pilot study, it may be tentatively concluded that OST could be useful for the treatment of youths with specific phobias in Denmark

Barriers to adherence in adolescents and young adults with cystic fibrosis: a questionnaire study in young patients and their parents

Vibeke Bregnballe1, Peter Oluf Schiøtz1, Kirsten A Boisen2, Tacjana Pressler3, Mikael Thastum4 1Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark; 2Centre of Adolescent Medicine, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark; 3Cystic Fibrosis Centre, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark; 4Department of Psychology, University of Aarhus, Aarhus, Denmark Background: Treatment adherence is crucial in patients with cystic fibrosis, but poor adherence is a problem, especially during adolescence. Identification of barriers to treatment adherence and a better understanding of how context shapes barriers is of great importance in the disease. Adolescent reports of barriers to adherence have been studied, but studies of their parents' experience of such barriers have not yet been carried out. The aim of the present study was to explore barriers to treatment adherence identified by young patients with cystic fibrosis and by their parents. Methods: A questionnaire survey of a cohort of young Danish patients with cystic fibrosis aged 14–25 years and their parents was undertaken. Results: Barriers to treatment adherence were reported by 60% of the patients and by 62% of their parents. Patients and parents agreed that the three most common barriers encountered were lack of time, forgetfulness, and unwillingness to take medication in public. We found a significant positive correlation between reported number of barriers and perceived treatment burden. We also found a statistically significant relationship between the reported number of barriers and treatment adherence. A significant association was found between the number of barriers and the reactions of adolescents/young adults and those of their mothers and fathers, and between the number of barriers and the way the family communicated about cystic fibrosis. Conclusion: The present study showed that the majority of adolescents with cystic fibrosis and their parents experienced barriers to treatment adherence. Agreement between adolescents and their parents regarding the level and types of barriers indicates an opportunity for close cooperation between adolescents, their parents, and health care professionals in overcoming adolescent adherence problems. Keywords: cystic fibrosis, adolescents, parents, barriers, adherenc

Feasibility Study of Back2School, a Modular Cognitive Behavioral Intervention for Youth With School Attendance Problems

There is large heterogeneity among youth with school attendance problems (SAPs). For this reason, protocols for the treatment of SAPs need to be flexible. Back2School (B2S) is a new manual-based, modular transdiagnostic cognitive behavioral intervention to increase school attendance among youth with SAPs. It also aims to increase the self-efficacy of these youth and their parents. B2S includes evidence-based modules addressing youth anxiety, depression, and behavior problems, together with modules focused on parent guidance and school consultation. The current study examined the feasibility of evaluating B2S in an randomized controlled trial and acceptability of the B2S program in a non-randomized trial, including both qualitative and quantitative data, in preparation for a randomized controlled trial of its effectiveness. Youth, parents, and teachers completed questionnaires at baseline, post-intervention, and follow-up. School attendance data were collected from school registers. Twenty-four youth with a SAP (defined as more than 10% absenteeism during the last 3 months) were recruited from primary and lower secondary schools in Aarhus Municipality, Denmark. Their parents also participated in B2S. Two of the 24 families withdrew during the intervention, after sessions two and six respectively. Of the remaining 22 families, 19 (86%) completed all 10 sessions. Parents and youth rated their satisfaction with B2S as high, and high levels of satisfaction were maintained 1 year after the intervention. Teacher satisfaction was lower than that of youth and parents, but the majority found the school's participation in the intervention helpful. Preliminary evaluation of intervention outcomes showed significant increase in school attendance and decrease in psychological symptoms, as well as a significant increase in self-efficacy for both youth and parents. Based on this feasibility data, adaptations were made to the B2S manual and study procedures prior to commencement of a randomized controlled effectiveness trial. The main adaptation to the manual was to increase school consultation. The main procedural adaptation was to broaden recruitment. Furthermore, it was necessary to increase level of staffing by psychologists because treatment delivery was more time consuming than expected.Pathways through Adolescenc

HPA axis related genes and response to psychological therapies: genetics and epigenetics

Background Hypothalamic–pituitary–adrenal (HPA) axis functioning has been implicated in the development of stress-related psychiatric diagnoses and response to adverse life experiences. This study aimed to investigate the association between genetic and epigenetics in HPA axis and response to cognitive behavior therapy (CBT). Methods Children with anxiety disorders were recruited into the Genes for Treatment project (GxT, N = 1,152). Polymorphisms of FKBP5 and GR were analyzed for association with response to CBT. Percentage DNA methylation at the FKBP5 and GR promoter regions was measured before and after CBT in a subset (n = 98). Linear mixed effect models were used to investigate the relationship between genotype, DNA methylation, and change in primary anxiety disorder severity (treatment response). Results Treatment response was not associated with FKBP5 and GR polymorphisms, or pretreatment percentage DNA methylation. However, change in FKBP5 DNA methylation was nominally significantly associated with treatment response. Participants who demonstrated the greatest reduction in severity decreased in percentage DNA methylation during treatment, whereas those with little/no reduction in severity increased in percentage DNA methylation. This effect was driven by those with one or more FKBP5 risk alleles, with no association seen in those with no FKBP5 risk alleles. No significant association was found between GR methylation and response. Conclusions Allele-specific change in FKBP5 methylation was associated with treatment response. This is the largest study to date investigating the role of HPA axis related genes in response to a psychological therapy. Furthermore, this is the first study to demonstrate that DNA methylation changes may be associated with response to psychological therapies in a genotype-dependent manner

A genome-wide test of the differential susceptibility hypothesis reveals a genetic predictor of differential response to psychological treatments for child anxiety Disorders

Background: The differential susceptibly hypothesis suggests that certain genetic variants moderate the effects of both negative and positive environments on mental health and may therefore be important predictors of response to psychological treatments. Nevertheless, the identification of such variants has so far been limited to preselected candidate genes. In this study we extended the differential susceptibility hypothesis from a candidate gene to a genome-wide approach to test whether a polygenic score of environmental sensitivity predicted response to cognitive behavioural therapy (CBT) in children with anxiety disorders. Methods: We identified variants associated with environmental sensitivity using a novel method in which within-pair variability in emotional problems in 1,026 monozygotic twin pairs was examined as a function of the pairs' genotype. We created a polygenic score of environmental sensitivity based on the whole-genome findings and tested the score as a moderator of parenting on emotional problems in 1,406 children and response to individual, group and brief parent-led CBT in 973 children with anxiety disorders. Results: The polygenic score significantly moderated the effects of parenting on emotional problems and the effects of treatment. Individuals with a high score responded significantly better to individual CBT than group CBT or brief parent-led CBT (remission rates: 70.9, 55.5 and 41.6%, respectively). Conclusions: Pending successful replication, our results should be considered exploratory. Nevertheless, if replicated, they suggest that individuals with the greatest environmental sensitivity may be more likely to develop emotional problems in adverse environments but also benefit more from the most intensive types of treatment

Genetic variation in the endocannabinoid system and response to cognitive behavioural therapy for child anxiety disorders

Extinction learning is an important mechanism in the successful psychological treatment of anxiety. Individual differences in response and relapse following Cognitive Behavior Therapy may in part be explained by variability in the ease with which fears are extinguished or the vulnerability of these fears to re-emerge. Given the role of the endocannabinoid system in fear extinction, this study investigates whether genetic variation in the endocannabinoid system explains individual differences in response to CBT. Children (N = 1,309) with a primary anxiety disorder diagnosis were recruited. We investigated the relationship between variation in the CNR1, CNR2, and FAAH genes and change in primary anxiety disorder severity between pre- and post-treatment and during the follow-up period in the full sample and a subset with fear-based anxiety disorder diagnoses. Change in symptom severity during active treatment was nominally associated (P < 0.05) with two SNPs. During the follow-up period, five SNPs were nominally associated with a poorer treatment response (rs806365 [CNR1]; rs2501431 [CNR2]; rs2070956 [CNR2]; rs7769940 [CNR1]; rs2209172 [FAAH]) and one with a more favorable response (rs6928813 [CNR1]). Within the fear-based subset, the effect of rs806365 survived multiple testing corrections (P < 0.0016). We found very limited evidence for an association between variants in endocannabinoid system genes and treatment response once multiple testing corrections were applied. Larger, more homogenous cohorts are needed to allow the identification of variants of small but statistically significant effect and to estimate effect sizes for these variants with greater precision in order to determine their potential clinical utility

Patterns of sub‐optimal change following CBT for childhood anxiety

Background: Children and adolescents demonstrate diverse patterns of symptom change and disorder remission following cognitive behavioural therapy (CBT) for anxiety disorders. To better understand children who respond sub‐optimally to CBT, this study investigated youths (N = 1,483) who continued to meet criteria for one or more clinical anxiety diagnosis immediately following treatment or at any point during the 12 months following treatment. Methods: Data were collected from 10 clinical sites with assessments at pre‐and post‐treatment and at least once more at 3, 6 or 12‐month follow‐up. Participants were assigned to one of three groups based on diagnostic status for youths who: (a) retained an anxiety diagnosis from post to end point (minimal responders); (b) remitted anxiety diagnoses at post but relapsed by end point (relapsed responders); and (c) retained a diagnosis at post but remitted to be diagnosis free at end point (delayed responders). Growth curve models assessed patterns of change over time for the three groups and examined predictors associated with these patterns including demographic, clinical and parental factors, as well as treatment factors. Results: Higher primary disorder severity, being older, having a greater number of anxiety disorders, having social anxiety disorder, as well as higher maternal psychopathology differentiated the minimal responders from the delayed and relapsed responders at the baseline. Results from the growth curve models showed that severity of the primary disorder and treatment modality differentiated patterns of linear change only. Higher severity was associated with significantly less improvement over time for the minimal and relapsed response groups, as was receiving group CBT, when compared to the delayed response group. Conclusions: Sub‐optimal response patterns can be partially differentiated using variables assessed at pre‐treatment. Increased understanding of different patterns of change following treatment may provide direction for clinical decision‐making and for tailoring treatments to specific groups of clinically anxious youth. Future research may benefit from assessing progress during treatment to detect emerging response patterns earlier

The utility of the SCAS-C/P to detect specific anxiety disorders among clinically anxious children

Questionnaire measures offer a time and cost-effective alternative to full diagnostic assessments for identifying and differentiating between potential anxiety disorders and are commonly used in clinical practice. Little is known, however, about the capacity of questionnaire measures to detect specific anxiety disorders in clinically anxious preadolescent children. This study aimed to establish the ability of the Spence Children’s Anxiety Scale (SCAS) subscales to identify children with specific anxiety disorders in a large clinic-referred sample (N = 1,438) of children aged 7 to 12 years. We examined the capacity of the Separation Anxiety, Social Phobia, Generalized Anxiety, and Physical Injury Fears (phobias) subscales to discriminate between children with and without the target disorder. We also identified optimal cutoff scores on subscales for accurate identification of children with the corresponding disorder, and examined the contribution of child, mother, and father reports. The Separation Anxiety subscale was able to accurately identify children with separation anxiety disorder, and this was replicated across all 3 reporters. Mother- and father-reported Social Phobia subscales also accurately identified children with social anxiety disorder, although child report was only able to accurately detect social anxiety disorder in girls. Using 2 or more reporters improved the sensitivity of the Separation Anxiety and Social Phobia subscales but reduced specificity. The Generalized Anxiety and Physical Injury Fears subscales failed to accurately identify children with the corresponding disorders. These findings have implications for the potential use of mother-, father-, and child-report SCAS subscales to detect specific disorders in preadolescent children in clinical settings

Exercise and quality of life in patients with cystic fibrosis: A 12-week intervention study

It was hypothesised that increased exercise capacity is related to improved quality of life (QoL) in patients with cystic fibrosis (CF). A 12-week individually tailored unsupervised aerobic exercise programme was offered to 42 patients with CF. At the start and at the end of the exercise programme, data on QoL, current exercise habits and preferences, anthropometric data, exercise test, and lung function test were collected. Adherence was observed by a heart rate (HR) monitor. A total of 24 patients accepted to be enrolled in the exercise programme and 14 completed the programme. Another 14 patients declined to be enrolled in the exercise programme but completed the Cystic Fibrosis Questionnaire for Adolescents and Adults (CFQ-R 14+). Four patients did not want to participate at all. The 14 patients completing the exercise programme had a significantly increased VO2max, but they showed no significant change in total QoL score. However, the scores in the domain of treatment burden and emotional functioning increased significantly. There was no significant difference in QoL and lung function between patients participating in the exercise programme (n = 24) and non-participants (n = 14). A 12-week individually tailored unsupervised aerobic exercise programme where HR monitors were used significantly affected VO2max. Improvement in QoL could not be demonstrated in this study