| 1. |
- Fjermestad, Krister W., et al.
(author)
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Exposure Quality in Cognitive Behavioral Treatment for Youth Anxiety Disorders - Predictors and Associations with Outcomes
- 2022
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In: Journal of Child and Family Studies. - : Springer Science and Business Media LLC. - 1062-1024 .- 1573-2843. ; 31, s. 308-320
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Journal article (peer-reviewed)abstract
- To optimize cognitive behavioral therapy (CBT) outcomes for anxiety disorders in youth, more knowledge is needed about how specific CBT components work. Exposure to feared situations is an effective CBT component. However, there is little observation-based empirical research on how exposure relates to outcomes and other clinical variables. In a randomized controlled community clinic trial for youth with anxiety disorders, observers reliably rated exposure quality for 68 youths aged 8 to 15 years based on 118 videotaped sessions. The treatment program was the manual-based FRIENDS program. Three exposure quality elements (preparation, post-processing, and parent contribution to exposure) were examined in relation to pre-treatment demographic and clinical variables, outcomes, and youth- and therapist-rated alliance using multilevel hierarchical regression models. The outcomes were diagnostic recovery, clinical severity and anxiety symptoms change from pre- to post-treatment and one-year follow-up, and treatment dropout. The results showed that parent contribution to exposure was higher for boys and younger children. Parent contribution to exposure, but no other exposure element, was associated with a larger likelihood of diagnostic recovery and larger clinical severity reduction at one-year follow-up. Exposure quality was unrelated to outcomes at post-treatment, dropout, or alliance. We conclude that enhancing parent contribution to exposure during treatment could improve long-term outcomes after CBT for youth anxiety disorders. Exposure elements should be observed in larger samples to further examine their potential role for CBT outcomes.
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| 2. |
- Fjermestad, Krister W., et al.
(author)
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Therapist Alliance-Building Behaviors, Alliance, and Outcomes in Cognitive Behavioral Treatment for Youth Anxiety Disorders
- 2021
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In: Journal of clinical child and adolescent psychology (Print). - : Informa UK Limited. - 1537-4416 .- 1537-4424. ; 50:2, s. 229-242
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Journal article (peer-reviewed)abstract
- Objective: The alliance influences outcomes in CBT for youth anxiety disorders. Thus, knowledge about how therapists can enhance the alliance is needed.Method: Seventy-three youth with anxiety diagnoses (M age = 11.5 years, SD = 2.2; range 8 to 15 years; 47.9% boys; 90.4% white-European) participated in 10-session cognitive behavioral therapy in community clinics. Therapist alliance-building behaviors in session 2 was reliably coded with the observer-rated Adolescent Alliance-Building Behavior Scale (Revised) (AABS(R)). Alliance was measured as youth- and therapist-rated alliance, and youth-therapist alliance discrepancy in session 3. Outcomes were diagnostic recovery and anxiety symptom reduction at post-treatment and one-year follow-up, and treatment dropout. We examined the direct effects of alliance-building on alliance, alliance on outcomes, and alliance-building on outcomes in multilevel mediation models, and between- versus within-therapist variance across these effects.Results: The alliance-building behaviors collaborate, present treatment model, and explore motivation positively predicted alliance, whereas actively structuring the session (i.e., dominating) negatively predicted alliance. The alliance-building behaviors attend to experience, collaborate, explore motivation, praise, and support positively predicted outcomes. The alliance-building behaviors present treatment model, express positive expectations, explore cognitions, and support negatively predicted outcomes. The effect of collaborate on symptom reduction was mediated by youth-therapist alliance discrepancy. There was almost zero between-therapist variance in alliance-building, and considerable within-therapist variance.Conclusion: Therapist alliance-building behaviors were directly (positively and negatively) associated with alliance and/or outcomes, with only one effect mediated by alliance. Alliance-building behaviors varied far more within therapists (i.e., across clients) than between therapists.
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| 3. |
- Fjermestad, Krister W., et al.
(author)
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Therapist-youth agreement on alliance change predicts long-term outcome in CBT for anxiety disorders
- 2016
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In: Journal of Child Psychology and Psychiatry. - : Wiley. - 0021-9630 .- 1469-7610. ; 57:5, s. 625-632
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Journal article (peer-reviewed)abstract
- Background: In individual cognitive behavioral therapy (ICBT) for youth anxiety disorders, it is unclear whether, and from whose perspective, the alliance predicts outcome. We examined whether youth- and therapist-rated alliance, including level of youth-therapist alliance agreement, predicted outcome in a randomized controlled trial.Methods: Youth (N = 91, M age = 11.4 years (SD = 2.1), 49.5% boys, 86.8% Caucasian) diagnosed with separation anxiety disorder, social phobia, or generalized anxiety disorder drawn from the ICBT condition of an effectiveness trial were treated with an ICBT program. Youth- and therapist-rated alliance ratings, assessed with the Therapeutic Alliance Scale for Children (TASC-C/T), were collected following session 3 (early) and 7 (late). Early alliance, change in alliance from early to late, and level of youth-therapist agreement on early alliance and alliance change were examined, in relation to outcomes collected at posttreatment and 1-year follow-up. Outcome was defined as primary diagnosis loss and reduction in clinicians' severity ratings (CSR; Anxiety Disorders Interview Schedule; ADIS-C/P) based on youth- and parent-report at posttreatment and follow-up, and youth treatment satisfaction collected at posttreatment (Client Satisfaction Scale; CSS).Results: Early TASC-C scores positively predicted treatment satisfaction at posttreatment. Higher levels of agreement on change in TASC-C and TASC-T scores early to late in treatment predicted diagnosis loss and CSR reduction at follow-up.Conclusions: Only the level of agreement in alliance change predicted follow-up outcomes in ICBT for youth anxiety disorders. The findings support further examination of the role that youth-therapist alliance discrepancies may play in promoting positive outcomes in ICBT for youth anxiety disorders. Clinical trial number NCT00586586, clinicaltrials.gov.
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| 4. |
- Kodal, Arne, et al.
(author)
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Predictors of long-term outcome of CBT for youth with anxiety disorders treated in community clinics
- 2018
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In: Journal of Anxiety Disorders. - : Elsevier BV. - 0887-6185 .- 1873-7897. ; 59, s. 53-63
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Journal article (peer-reviewed)abstract
- Cognitive behavioral therapy (CBT) has proven long-term effects in youth with anxiety disorders. However, only a few studies have examined predictors of long-term outcomes of CBT treatment. The present study investigated possible predictors of long-term treatment outcomes in youth with mixed anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11–21 years) with a principal diagnosis of separation anxiety disorder, social anxiety disorder, and/or generalized anxiety disorder were evaluated a mean of 3.9 years post-treatment (range 2.2–5.9 years). Outcomes were loss of all inclusion anxiety diagnoses, loss of the principal inclusion anxiety diagnosis, and changes in youth- and parent-rated youth anxiety symptoms. Predictors encompassed youth, parent and demographic factors, and post-treatment recovery. The most consistent finding was that low family social class predicted poorer outcomes. Higher treatment motivation was associated with better outcome whereas a diagnosis of social anxiety was associated with poorer outcome. Identified predictors extend on previous findings from efficacy trials, and the results indicate a need for more specific treatment protocols.
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| 5. |
- Riise, Eili N., et al.
(author)
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Cognitive behavior therapy for externalizing disorders in children and adolescents in routine clinical care : A systematic review and meta-analysis
- 2021
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In: Clinical Psychology Review. - : Elsevier BV. - 0272-7358 .- 1873-7811. ; 83
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Research review (peer-reviewed)abstract
- Various Cognitive Behavioral Therapy (CBT) programs for externalizing disorders in children and adolescents are supported by a substantial body of empirical evidence. Most of the research evidence comes from efficacy studies conducted in university settings, but there is less knowledge about the effect of these treatments in routine clinical care. The purpose of this meta-analysis was to investigate the effectiveness of CBT in non-university settings for Attention Deficit Hyperactivity Disorder (ADHD), Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD). Embase OVID, Ovid MEDLINE and PsycINFO were systematically searched for eligible studies published up to May 2020. In total, 51 treatment effectiveness studies involving 5295 patients were included. The average within-group effect size at post-treatment was significant (g = 0.91), and there were large effect sizes for both ADHD (g = 0.80) and CD/ODD (g = 0.98). At post treatment, remission rates were 38% for ADHD and 48% for CD/ODD, and the overall attrition rate was 14%. Benchmarking against efficacy studies showed that CBT in routine clinical care yields remission rates, within-group effect sizes and attrition rates that are very similar to those found in university settings. The findings support the transportability of CBT for externalizing disorders from university settings to routine clinical care.
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| 6. |
- Wergeland, Gro Janne H., et al.
(author)
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An effectiveness study of individual vs. group cognitive behavioral therapy for anxiety disorders in youth
- 2014
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In: Behaviour Research and Therapy. - : Elsevier BV. - 0005-7967 .- 1873-622X. ; 57, s. 1-12
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Journal article (peer-reviewed)abstract
- Objective: Conducted a randomized controlled trial to investigate the effectiveness of cognitive behavioral therapy (CBT), and compared the relative effectiveness of individual (ICBT) and group (GCBT) treatment approaches for anxiety disorders in children and adolescents.Methods: Referred youth (N = 182, M age = 11.5 years, range 8-15 years, 53% girls) with separation anxiety, social phobia, or generalized anxiety disorder were randomly assigned to ICBT, GCBT or a waitlist control (WLC) in community clinics. Pre-, post-, and one year follow-up assessments included youth and parent completed diagnostic interview and symptom measures. After comparing CBT (ICBT and GCBT combined) to WLC, ICBT and GCBT were compared along diagnostic recovery rates, clinically significant improvement, and symptom measures scores using traditional hypothesis tests, as well as statistical equivalence tests.Results: Significantly more youth lost all anxiety disorders after CBT compared to WLC. Full diagnostic recovery rate was 25.3% for ICBT and 20.5% in GCBT, which was not significantly different. There was continued lack of significant differences between ICBT and GCBT at one year follow-up. However, equivalence between GCBT and ICBT could only be demonstrated for clinical severity rating of the principal anxiety disorder and child reported anxiety symptoms post-treatment.Conclusion: Findings support the effectiveness of CBT compared to no intervention for youth with anxiety disorders, with no significant differences between ICBT and GCBT. However, the relatively low recovery rates highlight the need for further improvement of CBT programs and their transportability from university to community settings.
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| 7. |
- Wergeland, Gro Janne H., et al.
(author)
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Cognitive behavior therapy for internalizing disorders in children and adolescents in routine clinical care : A systematic review and meta-analysis
- 2021
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In: Clinical Psychology Review. - : Elsevier BV. - 0272-7358 .- 1873-7811. ; 83
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Research review (peer-reviewed)abstract
- Cognitive behavioral therapy (CBT) has received considerable empirical support for internalizing disorders including anxiety, depression, obsessive-compulsive disorder, and post-traumatic stress disorder in children and adolescents. However, there is less knowledge regarding how CBT performs when delivered in routine clinical care. A systematic review and meta-analysis was conducted of CBT for internalizing disorders in children and adolescents in routine clinical care. Ovid MEDLINE, Embase OVID, and PsycINFO were systematically searched for articles published until October 2019. The effectiveness of CBT, methodological quality, and moderators of treatment outcome were examined. The effects of CBT in routine clinical care were benchmarked by comparing with efficacy studies for the same disorders. Fifty-eight studies were included, comprising 4618 participants. Large effect sizes for outcome were detected at post-treatment (g = 1.28–2.54), and follow-up (g = 1.72–3.36). Remission rates across diagnoses ranged from 50.7% - 77.4% post-treatment, to 53.5% -83.3% at follow-up. Attrition rate across the disorders was 12.2%. Quality of the included studies was fair, and heterogeneity was high. Similarities between the effectiveness and efficacy studies were greater than the differences in outcome. CBT delivered in routine clinical care is efficacious in reducing internalizing disorders and symptoms. The outcomes are comparable with results obtained in efficacy studies.
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| 8. |
- Wergeland, Gro Janne H., et al.
(author)
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Early behavioral interventions for children and adolescents with autism spectrum disorder in routine clinical care : A systematic review and meta-analysis
- 2022
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In: Clinical psychology. - : American Psychological Association (APA). - 0969-5893 .- 1468-2850. ; 29:4, s. 400-414
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Research review (peer-reviewed)abstract
- The current paper systematically reviews and meta-analyses the effectiveness of early behavioral interventions (BI) for children with autism spectrum disorder (ASD) in routine clinical care. The effectiveness of BI, methodological study quality, and moderators of treatment outcome were examined and benchmarked with efficacy studies. The quality of the evidence was assessed with the Cochrane risk of bias tool. Twenty-nine studies were included, comprising 1,422 participants. Medium to large within-group effect sizes (g = 0.76–1.27) were found post-treatment for the outcome domains adaptive behavior, cognition, communication, and socialization, with large average effect size at post (g = 0.94) and at follow-up (g = 1.08). Comparison of effectiveness and efficacy studies showed that evidence-based early BI in routine clinical care yielded effects comparable to university research settings. The limitations include potential language and publication bias. The findings support evidence-based behavioral treatments delivered in routine clinical care as efficacious in reducing ASD symptoms.
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| 9. |
- Wergeland, Gro Janne H., et al.
(author)
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Predictors of dropout from community clinic child CBT for anxiety disorders
- 2015
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In: Journal of Anxiety Disorders. - : Elsevier BV. - 0887-6185 .- 1873-7897. ; 31, s. 1-10
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Journal article (peer-reviewed)abstract
- The aim was to investigate predictors of treatment dropout among 182 children (aged 8-15 years) participating in an effectiveness trial of manual-based 10-session individual and group cognitive behavior therapy (CBT) for anxiety disorders in community clinics. The dropout rate was 14.4%, with no significant difference between the two treatment conditions. We examined predictors for overall dropout (n=26), early (<= session 4, n = 15), and late dropout (>= session 5, n = 11). Overall dropout was predicted bylaw child and parent rated treatment credibility, and high parent self-rated internalizing symptoms. Low child rated treatment credibility predicted both early and late dropout. High parent self-rated internalizing symptoms predicted early dropout, whereas low parent rated treatment credibility predicted late dropout. These results highlight the importance of addressing treatment credibility, and to offer support for parents with internalizing symptoms, to help children and families remain in treatment.
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| 10. |
- Wergeland, Gro Janne H., et al.
(author)
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Predictors of school-based cognitive behavior therapy outcome for youth with anxiety
- 2023
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In: Behaviour Research and Therapy. - : Elsevier. - 0005-7967 .- 1873-622X. ; 169
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Journal article (peer-reviewed)abstract
- Meta-analyses of school-based CBT have shown that prevention for anxiety symptoms typically report small but significant effects. There is limited knowledge regarding which youths may benefit most and least from such programs, and characteristics of youth who respond differentially to interventions of different intensity. The present study examined predictors of school-based CBT outcomes among 302 youths (mean age 14.0 years, SD 0.8, 84% female) who participated in a randomized waitlist-controlled trial comparing a 10-session and a 5-session group intervention. Potential predictors included youth and parental factors, and credibility and expectancy of the interventions. Pre-intervention anxiety and depression levels, and clinician rated severity were examined as moderators of intervention effects. Outcomes were youth-, and parent-reported youth anxiety and depressive symptoms at post-intervention and 1-year follow-up. Higher parent-reported impairment from youth anxiety predicted larger parent-reported anxiety and depressive symptom change, whereas higher caregiver strain was associated with less symptom change. Higher parent rated credibility and expectancy was associated with improved outcomes at post-intervention. At 1-year follow-up, no predictors of outcome were identified. No moderators were identified. Families with high levels of caregiver strain associated with youth anxiety may need extra support regardless of length of intervention program. Parents’ credibility and expectancy of interventions should be targeted to optimize school-based CBT.
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