Thesis (Ph.D.)--Boston University / Although meta-analytic studies support the efficacy of cognitive-behavioral therapy for social anxiety disorder, a proportion of patients drop out of treatment or fail to benefit. Research to date has explored patient- and treatment-specific predictors of poor treatment response, including comorbid depression, but has not evaluated variables related to the patient's social environment. Expressed emotion (EE), an index of critical, hostile, and overprotective attitudes expressed by a significant other toward an individual with a psychiatric or medical condition, has been found to predict psychiatric relapse and poor treatment outcome in a wide range of disorders. Because EE and a closely related construct, perceived criticism, have been shown to predict treatment outcome and course in anxiety and mood disorders, it was expected that EE and perceived criticism would also predict treatment outcome in social anxiety disorder. Forty patients undergoing 12-session group cognitive-behavioral therapy for social anxiety disorder completed questionnaires about their symptoms of social anxiety and depression, and levels of perceived criticism, before and after treatment. Each participant designated one significant other who was then assessed for EE using the Camberwell Family Interview, a semi-structured interview method. Results indicate that higher initial severity of social anxiety and lower levels of perceived criticism predicted treatment dropout. There was also a trend for participants with a significant other rated as high in emotional overinvolvement, one of the EE-subscales, to show less change on a composite measure of anxiety symptoms. Comorbid depression and critical EE were associated with pretreatment severity of social anxiety but not outcome. These findings add to an increasing body of literature showing that the manifestation of significant others' EE, and EE's effect on clinical outcome, can vary as a function of the identified patient's diagnosis. For socially anxious individuals, perceiving criticism in the social environment may provide an important impetus for seeking and adhering to treatment, whereas significant others' overprotective behavior may negatively impact their ability to benefit from treatment. Further research replicating these findings, clarifYing the mechanisms and developing supplemental interventions, are important future directions.

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<p>Cognitive Behavioral Therapy (CBT) is recognized as an evidenced-based psychological treatment for Generalized Anxiety Disorder (GAD). Despite proven efficacy of CBT (i.e., large effect sizes), not everyone responds. One promising alternative approach is Mindfulness-based therapy, which has been shown to be effective in preliminary research in GAD. The purpose of this study was to directly compare a brief (1 hour) Mindfulness to CBT intervention to determine efficacy in reducing excessive worry and associated anxiety symptoms in a GAD population. Forty-five participants with a principal diagnosis of GAD were assessed by the Structured Clinical Interview for DSM Disorders (SCID-IV) and randomly assigned to one of three conditions: Mindfulness, CBT, or Information (control condition). Following the intervention, all participants completed daily practice for one week. Assessment consisted of self-report measures of worry and factors associated with GAD symptoms pre-and post-intervention. Overall findings did not support the main hypothesis that the brief interventions (Mindfulness and CBT) would be associated with a significant reduction in worry compared to the control group. However, group differences on factors associated with GAD were found. Individuals in the CBT condition reported a significant reduction in current level of general anxiety symptoms compared to the Mindfulness and Information conditions. Individuals in both CBT and Mindfulness conditions reported a significant reduction in current stress symptoms compared to the Information condition. In addition the CBT condition also demonstrated a trend for reduction in symptoms of depression compared to both Mindfulness and Information conditions. In summary, although a more intensive intervention may be needed to affect chronic worry, the CBT intervention was associated with greater benefit then the mindfulness intervention and may be useful as a brief pre-treatment intervention for individuals on a waitlist for standard treatment.</p> / Master of Science (MSc)

Objective: Resistance is a therapeutic process variable that can play an important role in treatment. The present study examined whether observer-rated parental resistance during parent-only sessions of cognitive-behavioral therapy (CBT) for anxious youth predicted the number of parent-reported between-session exposures completed, posttreatment outcome, and 36-week follow-up. Method: Participants (N = 272) were parents or adult caregivers of youth (age 7 to 17 years old) who received CBT for an anxiety disorder as participants in the Child/Adolescent Anxiety Multimodal study (CAMS). Parent-only therapy sessions were rated for resistance by observers. Measures of anxiety and overall symptom severity were completed at posttreatment and 36-week follow-up. Mediation analyses examined the indirect effect of the number of parent-reported exposures completed on the relationship between parent in-session resistance and therapy outcomes at posttreatment and 36-week follow-up. Additionally, resistance levels in participants in the CBT-only condition of CAMS were compared with resistance levels for participants in the CBT plus sertraline condition. Results: Analyses demonstrated that there was no significant difference in mean resistance scores between the CBT-only group and the CBT plus sertraline group. None of the 12 mediation tests found statistically significant indirect effects of the number of parent-reported exposures completed on the relationship between parent in-session resistance and therapy outcomes at posttreatment and 36-week follow-up. A significant relationship was found, however, between number of exposures completed and posttreatment Pediatric Anxiety Rating Scale (PARS) total scores, indicating a significant relationship between number of parent-reported exposures and posttreatment therapy outcomes. Conclusions: Parental resistance is not associated with outcomes for youth receiving CBT for anxiety. Number of exposures was significantly associated with one measure of posttreatment therapy outcomes. / Psychology

Establishing evidence-based training for therapists is of paramount importance for effective dissemination of evidence-based interventions. Using cognitive-behavioral therapy (CBT) for child anxiety, this study compared three therapist training conditions: (1) routine training: a workshop that covered a specific manual, (2) computer training: computer-based training via an interactive DVD, and (3) augmented training: a workshop that included a focus on core CBT competencies and active learning with behavioral rehearsal. Training success was operationalized as: (1) adherence to CBT for child anxiety, (2) therapeutic skillfulness, (3) a knowledge test, (4) and training satisfaction. The study also investigated the degree to which consultation following training impacted therapist outcomes. Participants (115 therapists) were randomly assigned to training condition and, following training, were invited to participate in weekly consultation. The results indicate that all three training conditions were effective in improving therapist adherence, skill, and knowledge. Participants were most satisfied with the in-person conditions. With regard to consultation, the number of consultation hours attended significantly predicted therapist training outcomes. This finding underscores the importance of consultation when training therapists. / Psychology

Objective: Therapeutic processes that occur within session have been identified as a factor that may influence youth anxiety outcomes. The present study examined the relationships between positive and negative youth involvement, therapist therapeutic and nontherapeutic behaviors, and anxiety outcomes. Method: Sixty youth (aged 7-17) received cognitive-behavioral therapy for an anxiety disorder. Weekly session videos were rated by observers. Measures of anxiety severity were completed weekly and at posttreatment. Regression analyses examined the association between therapeutic processes and post-treatment outcomes. Univariate and bivariate latent difference score (LDS) models evaluated whether changes in one factor were prospectively associated with later changes in the same factor and in other factors. Results: Positive youth involvement significantly predicted reduced anxiety severity, greater improvement, and remission of principal anxiety disorder at posttreatment. Youth negative involvement during psychoeducation sessions predicted a reduced likelihood of remission. Therapist therapeutic behaviors during psychoeducation sessions predicted lower anxiety severity, greater improvement, and treatment response. Nontherapeutic behaviors in psychoeducation sessions were associated with increased anxiety severity, less improvement, and a reduced likelihood of treatment response and remission of principal anxiety disorder. When entered simultaneously, only nontherapeutic behaviors were significantly associated with increased anxiety severity. LDS models resulted in poor model fit, thus, the temporal sequence among involvement, therapist behaviors, and anxiety severity was not established. Conclusions: Youth involvement and therapist behaviors are associated with beneficial outcomes. Therapist nontherapeutic behaviors are strongly associated with poorer outcomes. Findings are discussed in relation to previous findings and future directions are proposed. / Psychology

Parental accommodation refers to the ways in which a parent modifies his/her behavior to avoid or reduce the distress their child experiences. Parental accommodation of youth anxiety is common, and reduction in accommodation is associated with reduced anxiety after treatment. The current study evaluated the efficacy of an adapted cognitive-behavioral therapy program (CBT) designed to address parental accommodation (Accommodation Reduction Intervention; ARI). Sixty children and adolescents (age 7-17) and their parents were evaluated for youth anxiety and parental accommodation before and after 16 weeks of treatment. Thirty youth received ARI and 30 received Coping Cat (CC). Both youth anxiety and parental accommodation were significantly reduced from pre to posttreatment in youth who received ARI as well as those who received CC. No significant difference was found between the two treatment conditions on any measure of anxiety or accommodation. Findings indicate that an adapted CBT that focuses on parent accommodation (ARI) produced favorable outcomes comparable to Coping Cat. Clinical implications and future directions are discussed. / Psychology

Clinicians are increasingly incorporating cognitive behavioral therapy (CBT)-based approaches into fluency treatment for children and adolescents who stutter. However, minimal research examines the efficacy of such programs. The present study assesses the efficacy of a CBT-based, intensive, five-day summer camp that promotes self-acceptance and aims to improve the quality of life of adolescents who stutter. Specifically, this study examines whether the camp is effective in reducing state and trait anxiety, decreasing the negative impact of stuttering on daily life, and increasing fluency. A single-subject design on a 14-year old, male adolescent who stutters, LM, and personal interview data with LM’s mother, MM, are utilized. Post-treatment, LM’s scores reflect improvements in self-efficacy surrounding communication situations, as measured by the Self-Efficacy for Adolescents Scale (SEA-Scale), and improvements in overall speaking-related quality of life, as measured by the Overall Assessment of the Speaker’s Experience of Stuttering – Teen (OASES-T). These improvements were maintained at one and three months follow-up. Nonetheless, a large degree of variation in percent syllables stuttered (%SS) and LM’s consistently low rates of state and trait anxiety, as measured by the State-Trait Anxiety Inventory for Children (STAIC), suggest that additional study is warranted before conclusions can be drawn about the efficacy of the summer camp program on reducing stuttering severity and anxiety. / Communication Sciences

Background: At the onset of the COVID-19 pandemic, there was an increased uptake in telehealth services. However, little research has compared the efficacy of individual cognitive behavioral therapy (CBT) for youth with anxiety administered via (a) telehealth and (b) in-person. The present study examined outcomes for youth with anxiety disorders (diagnosed by an Independent Evaluator; IE) treated via telehealth during the COVID-19 pandemic and youth treated via in-person therapy prior to the COVID-19 pandemic. Methods: Participants (n = 92) were 46 families who completed telehealth treatment and 46 families who completed services in-person, matched on age and principal anxiety diagnosis. One-sided t-tests for non-inferiority tested whether telehealth is non-inferior to in-person therapy, a gold standard treatment. ANOVAs and regression models estimated treatment differences and candidate moderators (e.g., social anxiety disorder, comorbid attention problems). Results: Results support non-inferiority across multiple indices of outcomes (i.e., self- and caregiver-reported anxiety symptoms, IE-rated functional impairment, and IE-rated treatment response). Analyses indicate that both treatments were effective in reducing anxiety symptoms and functional impairment. Caregivers reported higher levels of anxiety for youth treated via telehealth than youth treated in person. No variables moderated the differences in outcomes between treatment modality. Conclusions: Findings support that CBT administered via telehealth is similarly efficacious as CBT administered in-person. Implications regarding the availability and accessibility of evidence-based treatment for youth with anxiety are discussed. / Psychology