Effectiveness and long-term stability of outpatient cognitive behavioural therapy (CBT) for children and adolescents with anxiety and depressive disorders under routine care conditions.

BACKGROUND: Randomised controlled trials (RCTs) have provided considerable evidence for the short-term efficacy of cognitive behavioural therapy (CBT) in children and adolescents with depressive and anxiety disorders. However, the effectiveness and long-term stability of treatment effects under routine care conditions remain unproven. AIMS: This observational study investigates the effectiveness and stability of CBT under routine care conditions within a large sample of clinically referred youth with depressive and anxiety disorders. METHOD: Two hundred and twenty former patients (age 6-18 years at start of treatment) underwent a follow-up assessment (follow-up interval: M=5.3 years, SD=2.47). Parent and self-ratings of behavioural and emotional problems were obtained at the beginning and end of treatment and at follow-up. Additionally, at follow-up, a telephone interview and questionnaires exploring other mental symptoms and life satisfaction were administered. RESULTS: A repeated measures ANOVA yielded statistically significant, medium to large pre- post symptom reductions (ηp2=.15 to ηp²=.47) and small to medium post-follow-up symptom reductions (ηp²=.03 to ηp²=.19). At follow-up, between 57 and 70% of the sample reported a decrease in different emotional symptoms since the end of treatment, and 80% reported improved life satisfaction. CONCLUSIONS: These findings provide evidence for the effectiveness and stability of treatment effects of CBT in youth with depressive and anxiety disorders under routine care conditions. Due to the lack of a direct control condition and a substantial proportion of missing data, the results must be interpreted with caution.

Webcam-Based Online Coaching with Children and Adolescents with Obsessive-Compulsive Disorders - A Single-Case Study.

Objective: Although there is clear evidence-based knowledge regarding state-of-the-art treatment for pediatric obsessive-compulsive disorder (OCD), two main issues remain in clinical practice: (1) Exposure-based cognitive behavioral therapy (CBT) is limited in terms of availability and accessibility or is not adequately provided, and (2) despite large effect sizes of exposure-based CBT, the achieved recovery rates of 50-60 % still show room for improvement. These issues have prompted an increasing focus on delivering exposure-based CBT in new and innovative ways. This study aims to evaluate an intensive therapist-administered online coaching program consisting of exposure with response prevention via video teleconferencing (VTC) as an add-on to weekly outpatient CBT (blended therapy). Method: The blended therapy is examined in n = 5 children and adolescents with OCD using an AB design and multi-informant ratings. Results: This single-case study shows promising results, indicating that a decrease in OCD severity and related functional impairment can be attributed to blended therapy. Moreover, satisfaction with online coaching was high. Conclusions: Despite some principal limitations, the results support the effectiveness and feasibility of blended therapy.

Extended treatment of multimodal cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder improves symptom reduction: a within-subject design.

BACKGROUND: Based on the current state of research regarding the treatment in pediatric obsessive-compulsive disorder (OCD), cognitive behavioral therapy (CBT) (in severe cases with additional pharmacotherapy) is considered as the first-line treatment according to internationally recognized guidelines. Research is mostly based on randomized controlled trials (RCTs; efficacy research). Thus, examined treatment conditions, especially the treatment duration, and patients' characteristics do not necessarily correspond to those found within routine care. Studies showed CBT packages as a whole to be efficacious, but less is known about the effects of individual CBT components. Furthermore, effects on comorbid symptoms or psychosocial impairment have been often neglected and different rater perspectives have been hardly considered in previous research. METHODS: This effectiveness study aimed to examine the effects of multimodal CBT in children, adolescents, and young adults (age 6-20 years) with OCD (n = 38) within routine care. Effects on obsessive-compulsive and co-existing symptoms were evaluated in a within-subject design by comparing changes during the assessment phase with 12-week standard treatment and with individually tailored extended treatment. Additionally, within the standard treatment, non-exposure treatment was compared to exposure treatment. Multi-informant assessment was applied, and the analyses included multilevel modeling and t-tests for pre-post comparisons. RESULTS: During the standard treatment and extended treatment, obsessive-compulsive symptoms, strain, and functional impairment significantly decreased. Moreover, a significant reduction of overall comorbid symptoms emerged, particularly regarding internalizing symptoms, including anxiety and depression. Comparisons of treatment components indicated that adding exposure with response prevention (ERP) has an additional positive effect. Clinical improvement and remission rates increased considerably when more treatment sessions were provided. CONCLUSIONS: These results suggest that improvement after an initial 12-week course of treatment may not allow for the prediction of non-responders/non-remitters and for the termination of treatment. Overall, the findings show that results from randomized controlled trials are transferrable to routine care. Trial registration number This study was registered retrospectively at the German Clinical Trials Register ( https://drks.de/search/de/trial/DRKS00030050 ).

Implementation and Evaluation of Therapeutic Online Coaching Using Habit Reversal Training in Children With Tourette's Disorder - A Pilot Study.

Cognitive-behavioral interventions can be difficult to implement in daily routine, which is often essential for generalizing treatment effects to natural settings. Furthermore, there is a lack of adequate care options concerning habit reversal training for children with Tourette's disorder. The objective of this study is to evaluate therapeutic online coaching via videoconferencing in the natural environment of children with Tourette's disorder in addition to face-to-face therapy (blended therapy). Online coaching took place twice a week for a maximum of 12 weeks. In a single-case study (n = 5; patients aged 8-11 years), the first results were obtained for exploratory purposes, especially with regard to the feasibility and reduction of symptoms and impairment. Various outcome measures were assessed (severity of symptoms, impairment, practical implementation, and satisfaction). Despite some principal limitations, the findings provide first hints that blended therapy is feasible and improves symptoms in some children with tics. Clinical Trial Registration: [https://clinicaltrials.gov/], identifier [DRKS00017199].

Progress feedback in children and adolescents with internalizing and externalizing symptoms in routine care (OPTIE study): study protocol of a randomized parallel-group trial.

BACKGROUND: Progress feedback provides therapists with progress notes on a regular basis through the continuous assessment of participants throughout their treatment (e.g., symptoms, therapeutic alliance). While for adults the evidence base has increased over the years, progress feedback in the therapy of children and adolescents has not been sufficiently investigated. This manuscript describes the trial protocol of the OPTIE study: a randomized trial that tests the efficacy of a progress feedback system in children and adolescents under conditions of routine care. METHODS: The study is based on a randomized parallel-group trial with two treatment groups (routine, feedback) at an outpatient unit of a university hospital. The target sample size is 439 families consisting of children and adolescents aged 6 to17 years old with internalizing and/or externalizing symptoms. Both the patients and the therapists are independently assigned to the treatment groups by stratified block randomization. In both treatment groups patients receive routine care behavioral therapy for a study-related 12 months; additionally, in the feedback group, a progress feedback system with three components is applied (monitoring, report, and supervision). For three informants (caregiver, child [≥ 11 years], therapist) surveys are conducted every 6 weeks (e.g., symptoms, goals, motivation). For both treatment groups, comparison data is collected at baseline and at six and 12 months after the beginning of the intervention (pre, inter, post), and includes five informants (blinded clinician, therapist, caregiver, child [≥ 11 years], teacher). DISCUSSION: The OPTIE study will contribute to the evidence base of progress feedback in children and adolescents and has the potential to uncover treatments' effects in the small to medium range. Noteworthy features are the inclusion of children younger than 10 years old and the consideration of a blinded clinician rating. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) DRKS00016737 ( https://www.drks.de/DRKS00016737 ). Registered 17 September, 2019.

Effectiveness of usual-care cognitive-behavioral therapy for adolescents with depressive disorders rated by parents and patients - an observational study.

BACKGROUND: Depressive disorders are common in adolescence and are associated with a wide range of negative long-term outcomes. Highly controlled randomized controlled trials (RCT) provide considerable evidence for the efficacy of cognitive-behavioral therapy (CBT) as a treatment for depression, but studies examining the effectiveness of CBT in clinical settings are very rare . METHODS: In the present observational study, the changes achieved through routine CBT in adolescents with depressive disorders treated in a clinical setting in terms of a university outpatient clinic were analyzed, and compared to a historical control group of adolescents with depressive disorders who had received treatment as usual. At the start and end of treatment (pre- and post-assessment), parent and self-ratings of the German versions of the Youth Self-Report (YSR), the Child Behavior Checklist (CBCL) and rating scales for depressive symptoms (FBB-DES, SBB-DES) were assessed. A total of 331 adolescents aged 11-18 years with complete data were assessed for the main analysis. RESULTS: The analysis yielded small to large pre-post effect sizes (Cohen's d) for the total sample (d = 0.33 to d = 0.82) and large effect sizes for adolescents who were rated in the clinical range on each (sub) scale at the start of treatment (d = 0.85 to d = 1.30). When comparing patients in the clinical range with historical controls, medium to large net effect sizes (d = 0.53 to d = 2.09) emerged for the total scores in self- and parent rating. However, a substantial proportion of the sample remained in the clinical range at the end of treatment. CONCLUSIONS: These findings suggest that CBT is effective for adolescents with depressive disorders when administered under routine care conditions, but the results must be interpreted with caution due to the lack of a direct control condition. TRIAL REGISTRATION: DRKS, DRKS00021518 . Registered 27 April 2020 - Retrospectively registered, http://drks.de.

Parent- and therapist-rated treatment satisfaction following routine child cognitive-behavioral therapy.

This observational study examined treatment satisfaction (TS) following routine outpatient cognitive-behavioral therapy (CBT) in a large sample of children (n = 795; aged 6 to 10 years). TS was investigated in parent and therapist rating. Means, standard deviations and inter-rater correlations were calculated to investigate TS. Regression analysis was conducted to examine potential correlates of TS (patient-related variables, mental disorder characteristics, socio-demographic factors and treatment variables). High TS in parent and therapist rating was found, with therapists showing a lower degree of TS than parents (completely or predominantly satisfied: parent rating 94.1%, therapist rating 69.5%). A statistically significant, moderate inter-rater correlation was found. Regression analysis explained 21.8% of the variance in parent rating and 57.2% in therapist rating. Most of the TS variance was explained by mental disorder characteristics (parent-rated symptoms and therapist-rated global impairment at treatment end) and by treatment variables (especially the therapist-rated cooperation of parents and patients), whereas socio-demographic and patient-related variables did not show any relevant associations with TS. Based on these results, to optimize TS, therapists should concentrate on establishing a sustainable cooperation of parents and children during therapy, and work to achieve a low global impairment at treatment end.

[The clinical assessment of obsessive-compulsive symptoms in children and adolescents - A study with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS-D)]. / Die klinische Beurteilung von Zwangssymptomen bei Kindern und Jugendlichen.

The clinical assessment of obsessive-compulsive symptoms in children and adolescents - A study with the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS-D) Abstract. Objective: The CY-BOCS is internationally the most widely used instrument for the assessment of juvenile obsessive-compulsive disorder (OCD). In this study, for the first time, the psychometric properties of a German version of the CY-BOCS (CY-BOCS-D) are examined in a pediatric OCD sample (n = 169; age 11-18 years). Method: The factor structure, internal consistencies, convergent and divergent validity are analyzed. Results: The exploratory factor analyses confirm a two-factor structure of the CY-BOCS-D Rating Scale and reveal a four-factor structure of the CY-BOCS-D Checklist. The internal consistencies are satisfactory to very good, convergent and divergent validity are confirmed. Conclusions: The results support the CY-BOCS as a "gold standard" also for OCD-diagnostics in German-speaking countries.

Psychometric evaluation of a parent-rating and self-rating inventory for pediatric obsessive-compulsive disorder: German OCD Inventory for Children and Adolescents (OCD-CA).

BACKGROUND: This study assesses the psychometric properties of the German version of the Padua Inventory-Washington State University Revision for measuring pediatric OCD. METHODS: The parent-rating and self-rating inventory is assessed in a clinical sample (CLIN: n = 342, age range = 6-18 years) comprising an OCD subsample (OCDS: n = 181) and a non-OCD clinical subsample (non-OCD: n = 161), and in a community sample (COS: n = 367, age range = 11-18 years). RESULTS: An exploratory factor analysis yielded a four-factor solution: (1) Contamination & Washing, (2) Catastrophes & Injuries, (3) Checking, and (4) Ordering & Repeating. Internal consistencies of the respective scales were acceptable to excellent across all samples, with the exception of the self-report subscale Ordering and Repeating in the community sample. The subscales correlated highly with the total score. Intercorrelations between the subscales were mainly r ≤ .70, indicating that the subscales were sufficiently independent of each other. Convergent and divergent validity was supported. Participants in the OCD subsample scored significantly higher than those in the non-OCD clinical subsample and the COS on all scales. In the COS, self-rating scores were significantly higher than parent-rating scores on all scales, while significant mean differences between informants were only found on two subscales in the OCD subsample. CONCLUSION: The German version of the Padua Inventory-Washington State University Revision for measuring pediatric OCD is a promising, valid and reliable instrument to assess self-rated and parent-rated pediatric OCD symptoms in clinical and non-clinical (community) populations.

Treatment satisfaction following routine outpatient cognitive-behavioral therapy of adolescents with mental disorders: a triple perspective of patients, parents and therapists.

The present study investigates treatment satisfaction (TS) rated by multiple informants (patient, parent, therapist) following routine outpatient cognitive-behavioral therapy (CBT) within a large sample (n = 965) of clinically referred adolescents aged 11-20 years. Moreover, potential predictors of TS were analyzed (patient-related variables, mental disorder characteristics, socio-demographic factors and treatment variables). Overall, our results show a high treatment satisfaction in patient, parent and therapist ratings, with the therapists being the most critical raters (completely/predominantly satisfied: 87.8% in patient, 92.0% in parent, and 64.0% in therapist ratings). Correlations between the three raters were only small to moderate, but statistically significant. Regression analysis examining differential effects found that mental disorder characteristics (parent- and patient-reported symptoms at post) and treatment variables (especially cooperation of patients and parents as rated by therapists) explained most of the variance in TS, whereas patient-related or socio-demographic variables did not emerge as relevant predictors of TS. The amounts of explained variance were R adj. 2 = 0.594 in therapist rating, R adj. 2 = 0.322 in patient rating and R adj. 2 = 0.203 in parent rating.

Parent- and Teacher-Rated Effectiveness of Cognitive-Behavioral Therapy for Children and Adolescents Under Usual Care Conditions in a University Outpatient Clinic.

Compared to randomized controlled trials, studies examining the effectiveness of cognitive behavioral therapy (CBT) in children and adolescents with mental disorders are rare, and a teacher perspective is scarce. The present study investigated the effectiveness of routine CBT in 519 patients aged 6-18 years with mental disorders. Changes in mental health problems were assessed in teacher (Teacher Report Form, TRF) and parent rating (Child Behavior Checklist, CBCL) and were analyzed within the total sample, yielding statistically significant, small to medium effect sizes (teacher rating: d = .74-2.39; parent rating: d = .65-1.18). Changes in a subgroup of patients with elevated symptom scores at treatment start were compared to a historical control group receiving weekly academic tutoring. Net total score effect sizes lay between d = 0.98 and d = 1.29 for teacher rating (parent rating: d = 0.84 to d = 1.01). Nevertheless, a substantial number of patients remained in the clinical range. Symptom changes during family- and patient-based CBT interventions did not differ from treatments including additional school-based interventions, as was also the case for the comparison of treatments with and without additional pharmacotherapy.

Effectiveness of outpatient cognitive-behavioral therapy for adolescents under routine care conditions on behavioral and emotional problems rated by parents and patients: an observational study.

Few studies have examined the effectiveness of outpatient cognitive-behavioral therapy (CBT) delivered in routine care settings for children and adolescents with mental disorders. This observational study examined changes in behavioral and emotional problems of adolescents with mental disorders during routine outpatient CBT delivered at a university outpatient clinic and compared them with a historical control group of youths who received academic tutoring of comparable length and intensity. Assessments were made at the start and end of treatment (pre- and post-assessment) using parent ratings of the German versions of the Child Behavior Checklist (CBCL) and self-ratings of the Youth Self-Report (YSR) scale. For the main analysis, 677 adolescents aged 11‒21 years had complete data. Changes from pre- to post-assessment showed significant reductions in mental health problems on both parent- and self-ratings. Pre- to post-effect sizes (Cohen's d) were small-to-medium for the total sample (d = 0.23 to d = 0.62) and medium-to-large for those adolescents rated in the clinical range on each (sub)scale at the start of treatment (d = 0.65 to d = 1.48). We obtained medium net effect sizes (d = 0.69) for the CBCL and YSR total scores when patients in the clinical range were compared to historical controls. However, a substantial part of the sample remained in the clinical range at treatment end. The results suggest that CBT is effective for adolescents with mental disorders when administered under routine care conditions but must be interpreted conservatively due to the lack of a direct control condition.

[Effectiveness of cognitive-behavioral therapy in children and adolescents with obsessive-compulsive disorders treated in an outpatient clinic]. / Alltagswirksamkeit kognitiver Verhaltenstherapie bei Kindern und Jugendlichen mit Zwangsstörungen in einer Ausbildungsambulanz.

Background: Cognitive-behavioral therapy (CBT) is considered as treatment of first choice for children and adolescents with obsessive-compulsive disorders (OCD). However, its effectiveness has so far mostly been examined in randomized controlled trials with strictly manualized interventions. Only few studies have examined whether the effectiveness of CBT for juvenile OCD generalizes to clinical practice. Method: To test the effectiveness of CBT under routine care conditions, data of n = 53 patients with parent-ratings and n = 53 patients with self-ratings that were treated in a university-based outpatient clinic for child and adolescent psychotherapy was analyzed. Pre-post-mean-comparisons, effect sizes and the clinical significance of changes of the symptoms were examined. Results: OCD and comorbid symptoms were significantly reduced during treatment. Strong effect sizes (Cohen's d) were found for parent rated (d = 0.91) and patient rated (d = 0.88) OCD symptoms. Moderate to strong pre-post-effect sizes were found for the reduction of parent rated (d = 0.55 to d = 0.87) and patient rated (d = 0.46 to d = 0.74) comorbid symptoms. The percentage of children and adolescents who achieved clinically significant improvements and no longer showed dysfunctional OCD symptoms post-treatment was 46.3 % according to the parent-ratings and 59.4 % according to the self-ratings. Concerning comorbid symptoms the same was reached for between 22.5 % and 45.5 % of the patients (parent-ratings) and between 32.0 % and 81.8 % (self-ratings) respectively. Conclusions: Significant reductions in both OCD and comorbid symptoms were demonstrated over the course of cognitive-behavioral therapy of juvenile OCD disorders in a university outpatient clinic for child and adolescent psychotherapy. These results indicate that routine CBT treatment is an effective way to treat juvenile OCD disorders in clinical practice.

[Effectiveness of cognitive-behavioral therapy in childhood anxiety disorders in a university psychiatric outpatient clinic]. / Alltagswirksamkeit kognitiver Verhaltenstherapie bei Kindern und Jugendlichen mit Angststörungen in einer Ausbildungsambulanz

BACKGROUND: Only few studies have examined whether the efficacy of cognitive-behavioral therapy for childhood anxiety disorders as demonstrated in randomized controlled trials (RCTs) generalizes to clinical practice. This study examines the effectiveness of cognitive-behavioral therapy for juvenile anxiety disorders under routine care conditions in a university-based psychiatric outpatient clinic. METHOD: 92 children and adolescents with parent-ratings regarding anxiety and comorbid symptoms and 61 children and adolescents with self-ratings regarding anxiety and comorbid symptoms were treated with cognitive-behavioral interventions. Pre/post mean comparisons, effect sizes, and the clinical significance of changes in symptoms were examined. RESULTS: The effect size for reduction of anxiety symptoms was .81 for children whose parents had completed the rating scale and .79 for children who had filled in a self-rating scale. Effect sizes for reduction of comorbid symptoms varied between .37 and .84 for parent ratings and between .21 and .62 for self-ratings. The percentage of children and adolescents who achieved clinically significant improvements in anxiety symptoms was 55.1 % according to the parent ratings and 65.7 % according to the children's self-ratings. More than 50 % of parents and children reported clinically significant improvements in comorbid symptoms. CONCLUSIONS: Significant reductions in both anxiety and comorbid symptoms were demonstrated over the course of cognitive-behavioral therapy of juvenile anxiety disorders in a university psychiatric outpatient clinic. The effect sizes for anxiety symptoms were found to be comparable to the effect sizes reported in RCTs. Similarly, clinically significant improvements were as frequent as the rates of remission of anxiety symptoms reported in RCTs.