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In-Session Involvement in Anxious Youth Receiving CBT with/without Medication

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Abstract

Although in-session factors of CBT for youth anxiety (e.g., youth involvement; therapist behaviors) have demonstrated significant associations with treatment outcomes, no study has examined the role of concurrent selective-serotonin reuptake inhibitors (SSRI) on in-session behavior affecting youth outcomes. The combination of SSRI and CBT have demonstrated robust outcomes over either treatment alone. Research has also neglected to examine in-session behavior based on treatment phase (i.e., psychoeducation, exposure) and the association between in-session factors and treatment outcome. Youth (N = 190) were participants in the Children/Adolescent Anxiety Multimodal Study (Walkup et al. New England Journal of Medicine, 359, 2753-2766, 2008) who completed CBT; of these, n = 94 received concurrent sertraline. Tapes of psychoeducation/skill-building (first half) and exposure sessions (second half) were rated by reliable coders for positive youth involvement (e.g., participation, understanding), negative youth involvement (e.g., safety-behaviors, negative affect), and therapist behaviors. Youth and therapist in-session behaviors were examined as predictors of the trajectory of anxiety outcomes using multilevel modeling. Medication (sertraline) was examined as a moderator. Results indicated that positive and negative youth involvement in CBT was significantly associated with outcomes. Positive youth involvement during psychoeducation and exposure sessions predicted better outcomes, and negative youth involvement during psychoeducation sessions predicted less favorable outcomes. Sertraline did not moderate these findings. Therapist behaviors were not significantly associated with outcomes, likely due to limited variability and low frequency of observed behaviors. Youth in-sessions behaviors are associated with treatment outcomes in anxiety treatment. However, medication does not appear to have a differential impact on youth in-session behaviors.

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Acknowledgements

We thank Elana Kagan, Ph.D., Anna Swan, Ph.D., Rogelio Mercado, Ph.D., Hannah Frank, M.A., Mark Knepley, M.A., Gerald Martin, Morgan Rohrbach, and Samantha Dzurkoc for their tireless work coding.

Funding

Parts of this project were supported by NIMH grants (MH063747 to Kendall; MH64003 to Birmaher; MH64003 to Compton; MH64088 to Piacentini; MH64089 to Walkup; MH64092 to Albano).

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Authors and Affiliations

  1. Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Erika A. Chiappini

  2. Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA

    Elizabeth Gosch

  3. Duke University Medical Center, Durham, NC, USA

    Scott N. Compton

  4. Department of Psychology, Temple University, Philadelphia, PA, USA

    Thomas M. Olino & Philip C. Kendall

  5. University of Pittsburgh Medical Center Pittsburgh, Pittsburgh, PA, USA

    Boris Birmaher & Dara Sakolsky

  6. UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA

    Tara S. Peris & John Piacentini

  7. Columbia University Medical Center, New York, NY, USA

    Anne Marie Albano

  8. Anxiety Treatment Center of Maryland, Columbia, MD, USA

    Courtney P. Keeton

  9. Lurie Children’s Hospital of Chicago, Chicago, IL, USA

    John T. Walkup

  10. University of Connecticut School of Medicine, Farmington, CT, USA

    Golda Ginsburg

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  1. Erika A. Chiappini
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  2. Elizabeth Gosch
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Correspondence to Philip C. Kendall.

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Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all parents/youth, respectively.

Conflict of Interest

Dr. Kendall has received honoraria from professional societies for speaking at conventions. He receives royalties from the sales of materials related to the treatment of anxiety in youth, from Guildford Press, Ericsson, Workbook Publishing (his spouse’s employment), and Oxford University Press. Dr. Birmaher has or will receive royalties from Random House, Inc., Lippincott Williams & Wilkins, and UpToDate. Dr. Sakolsky serves as an editorial board member of Child & Adolescent Psychopharmacology News and specialty consultant for the Prescriber’s Letter. She has received consulting fee from LEK consulting in 2015. Dr. Piacentini has received research support from Pfizer Pharmaceuticals through the Duke University Clinical Research Institute. Dr. Walkup has past research support for federally funded studies including free drug and placebo from Pfizer’s pharmaceuticals in 2007 to support the Child Adolescent Anxiety Multimodal study; free medication from Abbott pharmaceuticals in 2005 for the Treatment of the Early Age Media study; free drug and placebo from Eli Lilly in 2003 for the Treatment of Adolescents with Depression study. He currently receives research support from the Tourette’s Association of America and the Hartwell Foundation. He also receives royalties from Guilford Press and Oxford Press for multi-author books published about Tourette syndrome and royalties from Wolters Kluwer for CME activity on childhood anxiety. Dr. Walkup has received honoraria and has had travel expenses covered for speaking engagements and meetings sponsored by the Tourette Association of America. Drs. Chiappini, Gosch, Olino, Peris, and Ginsburg do not report any conflicts of interest.

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Chiappini, E.A., Gosch, E., Compton, S.N. et al. In-Session Involvement in Anxious Youth Receiving CBT with/without Medication. J Psychopathol Behav Assess 42, 615–626 (2020). https://doi.org/10.1007/s10862-020-09810-x

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