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Editorial: Treating Social Anxiety Disorder in Children and Young People: Challenges and Opportunities.
In this issue of the Journal, Rapee et al.1 report a rigorous randomized controlled trial (RCT) comparing transdiagnostic treatment and specialized social anxiety treatment for children and young people with social anxiety disorder (SAD). The study is a welcome addition to the literature that highlights the need to renew our efforts to improve understanding and treatment of SAD in childhood.
Cognitive predictors of adolescent social anxiety.
BACKGROUND: Identifying psychological processes that maintain social anxiety holds promise for improving treatment outcomes for young people. Experimental and prospective studies in adults suggest negative social cognitions, safety behaviours, self-focused attention, and pre- and post-event processing are all implicated in the maintenance of social anxiety. Despite social anxiety typically starting in adolescence, prospective studies examining these cognitive processes in youth are lacking. The current study examined prospective associations between these five cognitive processes and social anxiety in a sample of 614 participants (53% girls; aged 11-14 years). METHODS: Psychological processes, social anxiety symptoms, and depressive symptoms were assessed using self-report questionnaires at two time points. RESULTS: Negative social cognitions, safety behaviours, self-focused attention, and post-event processing predicted prospective levels of social anxiety over and above the effect of baseline levels of social anxiety. When these process variables were entered together in a regression model, three of them were independently associated with prospective social anxiety. Neither pre- nor post-event processing independently predicted later social anxiety over and above the effects of other psychological process variables. CONCLUSIONS: The findings indicate that these psychological processes are promising targets for treatment in adolescent social anxiety.
Development and Preliminary Validation of the Child & Adolescent Social Cognitions Questionnaire.
Negative cognitions play a central role in adolescent social anxiety, and yet there is a lack of empirically validated measures assessing these in detail. This study describes the adaptation of the Child & Adolescent Social Cognitions Questionnaire (CASCQ) from the adult version of the scale and its preliminary validation in a general adolescent school sample (N = 671). Exploratory and confirmatory factor analysis on split halves of the data indicated two factors, labelled 'negative self-concept' and 'anxious appearance', provided the best fit. Totals and subscales possessed good internal consistency and convergent validity. Findings suggest that the CASCQ is a reliable and valid measure of social anxiety-related cognitions in youth and may be useful for research and clinical purposes. Further examination of the scale with pre-adolescents and clinical samples is warranted.
A Prospective Study of Rumination and Irritability in Youth.
Although youth irritability is linked with substantial psychiatric morbidity and impairment, little is known about how personal characteristics influence its course. In this study we examined the prospective associations between angry and depressive rumination and irritability. A sample of 165 school pupils aged 12-14 years were assessed at two time points six months apart. They completed measures of irritability at Times 1 and 2 and depressive and angry rumination at Time 1. In line with our hypotheses, we found that angry rumination is significantly associated with irritability six months later, over and above baseline irritability and depressive rumination. The present findings suggest angry rumination is relevant to the genesis of irritability in adolescents, and point to possible routes for prevention and early intervention.
Computerised CBT for depressed adolescents: Randomised controlled trial.
BACKGROUND: Depression in adolescents is a common and impairing problem. Effective psychological therapies for depression are not accessed by most adolescents. Computerised therapy offers huge potential for improving access to treatment. AIMS: To test the efficacy of Stressbusters, a Computerised-CBT (C-CBT) programme for depression in young people. METHOD: Multi-site, schools-based, RCT of C-CBT compared to Waiting List, for young people (N = 112; aged 12-16) with significant symptoms of depression, using multiple-informants (adolescents, parents, teachers), with follow-up at 3 and 6 months. RESULTS: Relative to being on a Waiting List, C-CBT was associated with statistically significant and clinically meaningful improvements in symptoms of depression and anxiety according to adolescent self-report; and with a trend towards improvements in depression and anxiety according to parent-report. Improvements were maintained at follow-up. Treatment gains were similar for boys and girls across the participating age range. Treatment effect was partially mediated by changes in ruminative thinking. Teachers rated adolescents as having few emotional or behavioural problems, both before and after intervention. C-CBT had no detectable effect on academic attainment. In the month after intervention, young people who received C-CBT had significantly fewer absences from school than those on the Waiting List. CONCLUSIONS: C-CBT shows considerable promise for the treatment of mild-moderate depression in adolescents.
Differential constraints on the working memory and reading abilities of individuals with learning difficulties and typically developing children.
This study examined the factors that constrain the working memory span performance and reading ability of individuals with generalized learning difficulties. In the study, 50 individuals with learning difficulties (LD) and 50 typically developing children (TD) matched for reading age completed two working memory span tasks. Participants also completed independent measures of the processing and storage operations involved in each working memory span task and Raven's Coloured Progressive Matrices. The results showed that despite an equivalent level of working memory span, the relative importance of the constraints on working memory differed between the groups. In addition, working memory span was not closely related to word recognition or sentence comprehension performance in the LD group. These results suggest that the working memory span performance of LD and TD individuals may reflect different working memory limitations and that individuals with generalized learning difficulties may approach cognitive tasks in a qualitatively different way from that of typically developing individuals.
Mood regulation in youth: research findings and clinical approaches to irritability and short-lived episodes of mania-like symptoms.
PURPOSE OF REVIEW: Mood regulation problems, such as severe chronic irritability or short episodes of mania-like symptoms, are common, impairing and a topic of intense recent interest to clinicians, researchers and the Diagnostic and Statistical Manual (DSM)-5 process. Here, we review the most recent findings about these two presentations and discuss the approaches to their treatment. RECENT FINDINGS: Longitudinal and genetic findings suggest that chronic irritability should be regarded as a mood problem that is distinct from bipolar disorder. A proportion of children with short (less than 4 days) episodes of mania-like symptoms seem to progress to classical (Type I or II) bipolar disorder over time in the US clinic samples. In a UK sample, such episodes were independently associated with psychosocial impairment. The evidence base for the treatment of either irritability or short-lived episodes of mania-like symptoms is still small. Clinicians should be cautious with extrapolating treatments from classical bipolar disorder to these mood regulation problems. Cognitive and behavioural therapy (CBT)-based approaches targeting general mood regulation processes may be effective for cases with severe irritability or short episodes of mania-like symptoms. SUMMARY: There is increasing research evidence for the importance of mood regulation problems in the form of either irritability or short episodes of mania-like symptoms in youth. The evidence base for their drug treatment has yet to be developed. CBT-based interventions to modify the processes of mood regulation may be a useful and well tolerated intervention for patients with these presentations.
Practitioner review: Self-harm in adolescents.
BACKGROUND: Repeated self-harm in adolescents is common and associated with elevated psychopathology, risk of suicide, and demand for clinical services. Despite recent advances in the understanding and treatment of self-harm there have been few systematic reviews of the topic. AIMS: The main aim of this article is to review randomised controlled trials (RCTs) reporting efficacy of specific pharmacological, social or psychological therapeutic interventions (TIs) in reducing self-harm repetition in adolescents presenting with self-harm. METHOD: Data sources were identified by searching Medline, PsychINFO, EMBASE, and PubMed from the first available year to December 2010. RCTs comparing specific TIs versus treatment as usual or placebo in adolescents presenting with self-harm were included. RESULTS: Fourteen RCTs reported efficacy of psychological and social TIs in adolescents presenting with self-harm. No independently replicated RCTs have been identified reporting efficacy of TIs in self-harm reduction. Developmental Group Psychotherapy versus treatment as usual was associated with a reduction in repeated self-harm, however, this was not replicated in subsequent studies. Multisystemic Therapy (MST) versus psychiatric hospitalisation was associated with a reduction of suicidal attempts in a sample of adolescents with a range of psychiatric emergencies. However, analyses focusing only on the smaller subgroup of adolescents presenting with deliberate self-harm at the initial psychiatric emergency, did not indicate significant benefits of MST versus hospitalisation. CONCLUSIONS: Further research is urgently needed to develop TIs for treating self-harm in adolescents. MST has shown promise but needs to be evaluated in a sample of adolescents with self-harm; dialectic behavioural therapy and cognitive behavioural therapy for self-harm require RCTs to evaluate efficacy and effectiveness.
Appraisals of Internal States and their Consequences: Relationship to Adolescent Analogue Bipolar Symptoms.
BACKGROUND: Extreme appraisals of internal states correlate with and prospectively predict mood symptoms in adults, and discriminate individuals with bipolar disorder from individuals with unipolar depression and non-clinical controls. AIMS: These findings required replication in adolescents. This study sought to investigate the relationships between appraisals of internal states, mood symptoms and risk for bipolar disorder in an adolescent sample. METHOD: A non-clinical sample (n = 98) of adolescents completed measures of mood symptoms, appraisals, and mania risk, alongside covariates. RESULTS: Appraisals of internal states were associated with analogue bipolar symptoms, independently of impulsivity and responses to positive affect. Positive appraisals of activated mood states were uniquely associated with hypomania, whilst negative appraisals were uniquely associated with depression and irritability symptoms. Individuals who appraised activated states as both extremely positive and extremely negative were more likely to score at high or moderate risk for future mania. CONCLUSIONS: This study is the first to demonstrate associations between appraisals of internal states, analogue mood symptoms and mania risk in adolescents. Clinical implications are discussed.
Worry in imagery and verbal form: effect on residual working memory capacity.
Worry-prone individuals have less residual working memory capacity during worry compared to low-worriers (Hayes, Hirsch, & Mathews, 2008). People typically worry in verbal form, and the present study investigated whether verbal worry depletes working memory capacity more than worry in imagery-based form. High and low-worriers performed a working memory task, random interval generation, whilst thinking about a worry in verbal or imagery form. High (but not low) worriers had less available working memory capacity when worrying in verbal compared to imagery-based form. The findings could not be accounted for by general attentional control, amount of negatively-valenced thought, or appraisals participants made about worry topics. The findings indicate that the verbal nature of worry is implicated in the depletion of working memory resources during worry among high-worriers, and point to the potential value of imagery-based techniques in cognitive-behavioural treatments for problematic worry.
Cognitive Therapy for Social Anxiety Disorder in Adolescents: A Development Case Series.
BACKGROUND: Social anxiety disorder is common and typically starts in childhood or adolescence. Cognitive Therapy for Social Anxiety Disorder (CT-SAD) in adults is a well-established treatment that shows strong evidence of differential effectiveness when compared to other active treatments. In contrast, CBT approaches to social anxiety in young people have yet to demonstrate differential effectiveness and there is some evidence that young people with social anxiety disorder respond less well than those with other anxiety disorders. AIMS: To adapt CT-SAD for use with adolescents and conduct a pilot case series. METHOD: Five adolescents, aged 11-17 years, with a primary DSM-5 diagnosis of social anxiety disorder received a course of CT-SAD adapted for adolescents. Standardized clinical interview and questionnaire assessments were conducted at pre and posttreatment, and 2 to 3-month follow-up. RESULTS: All five participants reported severe social anxiety at baseline and achieved remission by the end of treatment. Significant improvements were also observed in general anxiety, depression, concentration in the classroom, and putative process measures (social anxiety related thoughts, beliefs and safety behaviours). CONCLUSIONS: An adapted form of CT-SAD shows promise as a treatment for adolescents.
Measurement Issues: Measurement of posttraumatic stress disorder in children and young people - lessons from research and practice.
BACKGROUND: Many young people are exposed to traumatic events and a significant minority of these individuals will go on to experience posttraumatic stress disorder (PTSD). Valid and reliable measurement tools for assessing PTSD are essential and can aid screening, clinical diagnosis, treatment planning and outcome monitoring. METHODS: This article outlines the range of instruments available for these aspects of measurement, including assessment of PTSD in very young children, with a focus on those scales with good clinical utility and sound psychometric properties. FINDINGS: This is a particularly challenging time for clinicians working with children and young people with PTSD: all instruments will need to be revised and updated in order to better reflect the recent revisions to the diagnostic criteria for PTSD with the publication of the DSM-5 and no doubt the anticipated ICD-11. Despite this, measurement tools can still play a vital role in assessing PTSD in children and young people.
Mindfulness-based cognitive therapy for depression in adolescents.
BACKGROUND: Mindfulness-Based Cognitive Therapy (MBCT) has been shown to be effective in preventing relapse of depression in adults, but has not previously been applied to adolescents who have residual symptoms of depression following treatment. METHOD: An 8-week MBCT group was adapted for adolescents, and evaluated using qualitative and quantitative measures. RESULTS: Participants report high levels of satisfaction with the group intervention. Qualitative analysis of semi-structured interviews provides areas for future development of this intervention. Pilot data indicate reductions in depressive symptoms, alongside positive change in mindfulness skills, quality of life and rumination. CONCLUSIONS: Preliminary evidence for the use of MBCT with this group of adolescents is provided.
Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995).
Social anxiety disorder is a condition characterised by a marked and persistent fear of being humiliated or scrutinised by others. Age-of-onset data point to adolescence as a developmentally sensitive period for the emergence of the condition, at a time when the peer group becomes increasingly important. Social anxiety in adolescence is associated with considerable impairment that persists through to adulthood. There are clear potential benefits to delivering effective interventions during adolescence. However, there is limited evidence on the specific efficacy of available therapies. This is in contrast to adults, for whom we have interventions with very specific treatment effects. One such treatment is individual cognitive therapy. Cognitive therapy is based on the cognitive model of social anxiety proposed by Clark and Wells (in: Heimberg, Leibowitz, Hope, Scheiber (eds) Social phobia: diagnosis, assessment and treatment, The Guilford Press, New York, 1995). The present review examines the potential application of this adult cognitive model to the understanding of adolescent social anxiety and considers additional adolescent-specific factors that need to be accommodated. It is suggested that a developmentally sensitive adoption of the cognitive model of social anxiety disorder (Clark and Wells 1995) for adolescents may lead to better treatment outcomes.
HoNOS-ABI: A reliable outcome measure of neuropsychiatric sequelae to brain injury?
Aims and method. The Health of the Nation Outcome Scale for Acquired Brain Injury (HoNOS-ABI) is a relatively new outcome measure designed to assess the neuropsychiatric sequelae of brain damage.This study investigated the interrater reliability of this scale. Fifty patients with traumatic brain injury receiving rehabilitation were each rated twice on the HoNOS-ABI, by two different raters.There were 24 raters in total. Results. Weighted kappa values ranged from 0.43 to 0.84 and intraclass correlation coefficients from 0.58 to 0.97 for the ten items assessed.This indicated that agreement was moderate to substantial for all items. Clinical implications. The scales consistently measured the items of interest across different raters.This indicates that HoNOS-ABI is a reliable outcome measure when applied by different raters in routine clinical practice.
'All these negative thoughts come flooding in': How young people with depression describe their experience of rumination
Rumination, or dwelling repeatedly on negative thoughts about the past, can prolong depression and make it worse. When treating clients with depression, it can be important to consider the behavioural, cognitive and emotional impact of rumination on their life. Previous research has examined adult experience of rumination, but the current study was the first to examine how young people with depression experience rumination. Seven young people with depression were interviewed about the cognitive content of their rumination episodes, the associated feelings, and any behavioural start and stop triggers. Interview transcripts were analysed using interpretative phenomenological analysis (IPA). Participants reported experiencing rumination as a disorientating cognitive battle, in which they felt under attack. The process elicited sadness predominantly, but also anger and anxiety, with mood and rumination often maintaining each other. Interpersonal interaction played a key role in starting and stopping rumination episodes. CBT-based interventions specifically targeting the ruminative process may be important for young people with depression, particularly interventions which consider the impact of family members or other systemic factors on rumination behaviour.