Faculty Bibliography

OBJECTIVE: This study examined barriers facing parents who seek outpatient psychiatric care in a large state system for adolescents with depression. METHODS: A total of 264 outpatient facilities licensed to treat youths in New York were contacted by using a mystery shopper methodology. Callers tracked the number of call attempts, in-person appointments, and other steps required prior to seeing a psychiatrist. RESULTS: Fewer than two-thirds of parents made a psychiatry, therapy, or intake appointment. Of those who did not make an appointment, 19% received no referrals. Most callers made at least two calls and spoke with at least two people before initiating scheduling. Virtually all clinics required at least one intake or therapy appointment before receipt of a psychiatry appointment. Parental burden did not differ by region, urbanicity, clinic type, seasonality (spring or summer), or insurance status. CONCLUSIONS: Families of youths with mental health needs face considerable burden in accessing timely treatment.

A narrative synthesis was conducted to determine typical patient- and family-centered care (PFCC) components and their link to outcomes in pediatric populations. 68 studies with PFCC interventions and experimental designs were included. Study features were synthesized based on 5 core PFCC components (i.e., education from the provider to the patient and/or family, information sharing from the family to the provider, social-emotional support, adapting care to match family background, and/or s decision-making) and 4 outcome categories (health status; the experience, knowledge, and attitudes of the patient/family; patient/family behavior; or provider behavior). The most common PFCC component was education; the least common was adapting care to family background. The presence of social-emotional support alone, as well as educational interventions augmented with shared decision-making, social-emotional support, or adaptations of care based on family background, predicted improvements in families' knowledge, attitudes, and experience. Interventions that targeted the family were associated with positive outcomes.

BACKGROUND: Research supports the efficacy of intensive cognitive behavioral therapy (CBT) for the treatment of adolescent panic disorder with or without agoraphobia (PDA). However, little is known about the conditions under which intensive treatment is most effective. The current investigation examined the moderating roles of baseline fear and avoidance in the intensive treatment of adolescent PDA. METHODS: Adolescents with PDA (ages 11-17; N = 54) were randomized to either an intensive CBT treatment (n = 37) or a waitlist control condition (n = 17). PDA diagnosis, symptom severity, and number of feared and avoided situations were assessed at baseline and 6-week post-treatment/post-waitlist. Hierarchical regression analyses examined the relative contributions of treatment condition, number of baseline feared or avoided situations, and their interactions in the prediction of post-treatment/waitlist PDA symptoms. RESULTS: The main effect of intensive CBT on post-treatment PDA symptoms was not uniform across participants, with larger treatment effects found among participants with lower, relative to higher, baseline levels of fear and avoidance. CONCLUSIONS: Findings help clarify which adolescents suffering with PDA may benefit most from an intensive treatment format.

The present study investigated whether an 8-day intensive treatment for panic disorder in adolescents conferred a corollary benefit of ameliorating symptoms of depression. Participants included 57 adolescents between the ages of 11 and 18 who were randomly assigned to an intensive panic treatment for adolescents with or without parental involvement. Paired samples t tests and hierarchical linear models (HLM) indicated that participants' total depression score and scores on depression subscales declined from baseline to the 3-month follow-up. Additional HLM analyses indicated that the interaction term between age and parent involvement was a significant moderator in the negative slope for adolescent depression, with younger participants benefitting more from treatment without parent involvement than older participants with regard to depression symptoms.

Much remains to be learned about typical and individual growth trajectories across treatment for adolescent panic disorder with and without agoraphobia and about critical treatment points associated with key changes. The present study examined the rate and shape of change across an 8-day intensive cognitive behavioral therapy for adolescent panic disorder with and without agoraphobia (N = 56). Participants ranged in age from 12 to 17 (M = 15.14, SD = 1.70; 58.9% female, 78.6% Caucasian). Multilevel modeling evaluated within-treatment linear and nonlinear changes across three treatment outcomes: panic severity, fear, and avoidance. Overall panic severity showed linear change, decreasing throughout treatment. In contrast, fear and avoidance ratings both showed cubic change, peaking slightly at the first session of treatment, starting to decrease at the second session of treatment, and with large gains continuing then plateauing at the fourth session. Findings are considered with regard to the extent to which they may elucidate critical treatment components and sessions for adolescents with panic disorder with and without agoraphobia.

Progress disseminating and implementing evidence-based psychological treatments (EBPTs) for the anxiety disorders has been gradual. To date, the dominant approach for promoting the uptake of EBPTs in clinical settings has been to target the education and training of mental health providers, with many consumers remaining unaware of the potential benefits of EBPTs for anxiety disorders. Direct-to-consumer (DTC) marketing may be a promising vehicle for increasing EBPT utilization rates in the treatment of anxiety disorders. This paper provides an overview of the rationale and important considerations for applying DTC efforts to promote evidence-based care in the treatment of anxiety disorders, and reviews current DTC efforts in this area, including resources on the Internet and other media and in-person events. We conclude with recommendations for future efforts in the DTC marketing of EBPTs for the anxiety disorders, including the need for increased funding and grassroots efforts to inform consumers about anxiety disorders and their most effective treatments.

This study examined the comorbidity of anxiety disorders and its predictors in a large, clinically referred sample of children and adolescents. Participants were 608 youth aged 4-18 years presenting at a large anxiety clinic for assessment and treatment of anxiety or mood related problems. The diagnoses were determined using the Anxiety Disorder Interview Schedule, Child/Parent versions. Sixty three percent of the participants had an additional diagnosis of an anxiety or depressive disorder. Comorbidity patterns differed based on the principal diagnostic category. Older children and females with anxiety were more likely to have a comorbid anxiety disorder. The presence of a medical condition increased the odds of having a comorbid anxiety disorder as well. This is the largest clinical sample of children and adolescents in which comorbidity of emotional disorders has been examined. Understanding the common patterns of comorbidity has important implications for future classification and treatment planning of childhood anxiety disorders.

BACKGROUND: Anxiety disorder not otherwise specified (ADNOS) is one of the more common and impairing DSM-IV diagnoses assigned in child practice settings, but it is not clear what percentage of these assignments simply reflect poor diagnostic practices. METHODS: The present study evaluated patterns and correlates of child ADNOS in a large outpatient treatment seeking sample of anxious youth (N = 650), utilizing structured diagnostic interviewing procedures. RESULTS: Roughly, 15% of youth met diagnostic criteria for ADNOS. Overall, these youth exhibited comparable levels of clinical problems relative to youth with DSM-IV-specified anxiety disorders (AD), and roughly two-thirds of ADNOS cases exhibited symptom presentations closely resembling generalized anxiety disorder (GAD). Among ADNOS presentations resembling GAD, those failing to meet the "worries more days than not" or "worries across multiple domains" criteria showed lower internalizing symptoms than GAD youth, but comparable anxious/depressed symptoms, somatic symptoms, social problems, externalizing problems, and total problems as measured by the Child Behavior Checklist. CONCLUSIONS: Childhood ADNOS cases are prevalent and warrant clinical attention. In many cases there are only a couple, if any, clinical differences between these disorders and the ADs they closely resemble. Future work is needed to improve upon the current taxonomy of childhood ADs to specify a larger proportion of affected youth needing care.

Previous research findings have shown positive effects of cognitive-behavioral therapy for primary anxiety disorders as well as for nonprimary, co-occurring anxiety disorders. In this study, we analyzed data from an existing randomized controlled trial of intensive treatment for panic disorder with or without agoraphobia (PDA) to examine the effects of the treatment on comorbid psychiatric diagnoses. The overall frequency and severity of aggregated comorbid diagnoses decreased in a group of adolescents who received an 8-day treatment for PDA. Results suggest that an 8-day treatment for PDA can alleviate the symptoms of some specific comorbid clinical diagnoses; in particular specific phobias, generalized anxiety disorder, and social phobia. These findings suggest that an intensive treatment for PDA is associated with reductions in comorbid symptoms even though disorders other than PDA are not specific treatment targets.

One of the leading biosocial theories of borderline personality disorder (BPD) suggests that individuals with BPD have biologically based abnormalities in emotion regulation contributing to more intense and rapid responses to emotional stimuli, in particular, invalidation [Linehan, M.M., 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford, New York.]. This study used a 2 by 2 experimental design to test whether young women with features of BPD actually show increased physiological arousal in response to invalidation. Twenty-three women ages 18 to 29 who endorsed high levels of BPD symptoms and 18 healthy controls were randomly assigned to hear either a validating or invalidating comment during a frustrating task. Although we found preliminary support for differential response to these stimuli in self-report of valence, we found neither self-report nor physiological evidence of hyperarousal in the BPD features group, either at baseline or in response to invalidation. Interestingly, the BPD features group reported significantly lower comfort with emotion, and comfort was significantly associated with affective valence but not arousal. We discuss implications for understanding and responding to the affective intensity of this population.