Change motivation and mindfulness in individual psychotherapy: Examining a sample of adult outpatients with depression and/or anxiety.

OBJECTIVES: Existing literature has demonstrated that both motivation to change and mindfulness are associated with therapy outcomes in samples with mental disorders. Between the constructs of mindfulness and motivation to change occurs some theoretical-related and empirical overlap. However, it is still little known about the association of these two constructs. For this reason, we investigated the relationship of motivation to change and mindfulness in a sample of 116 adult outpatients with a primary diagnosis of depression or anxiety. METHODS: An outpatient sample of 116 depressive and/or anxious patients filled in the German short version of the University of Rhode Island Change Assessment (URICA-S) and the German version of the Kentucky Inventory of Mindfulness Skills (KIMS) before the start of cognitive-behavioral therapy (pre) and after the 25th cognitive-behavioral therapy session (post). To assess the association between change motivation and mindfulness, we calculated correlations, hierarchical regressions and cross-lagged panel models (CLPM). RESULTS: Several positive and negative significant correlations at the premeasurement time point, at the postmeasurement time point, and over time (from pre to postmeasurement time point) demonstrated a relation between the KIMS and the URICA-S. Hierarchical regression analyses and CLPM pointed towards relations between mindfulness and change motivation over time and in both directions for some subscales of the KIMS and the URICA-S. CONCLUSION: A bidirectional relation between motivation to change and mindfulness was supported in our naturalistic psychotherapy setting for several subscales. For a better understanding of the interconnection between the two constructs, future research should focus on the application of interventions to improve either mindfulness or motivation to change in psychotherapy. Additionally, the interactional effects of mindfulness and change motivation on therapy outcomes should be investigated.

The impact of session-introducing mindfulness and relaxation interventions in individual psychotherapy for children and adolescents: a randomized controlled trial (MARS-CA).

BACKGROUND: The investigation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past years. However, most MBI research with youth focuses on structured, manualized group programs, conducted in school settings. Knowledge about the implementation and effects of MBIs in individual psychotherapy with children and adolescents is scarce. To fill this research gap, the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is designed. It aims to assess the effects of short session-introducing interventions with mindfulness elements on juvenile patients' symptomatic outcome and therapeutic alliance in individual child and adolescent psychotherapy. METHODS: MARS-CA is conducted at a university outpatient training center for cognitive-behavior therapy. Short session-introducing interventions with mindfulness elements will be compared to short session-introducing relaxation interventions and no session-introducing intervention to explore their effects on symptomatic outcome and therapeutic alliance. The session-introducing interventions will take place at the beginning of 24 subsequent therapy sessions. We hypothesize that patients' symptomatic outcome and therapeutic alliance improve more strongly in the mindfulness condition than in the other two conditions and that the mindfulness condition moderates the relationship between therapeutic alliance and symptomatic outcome. Patients and their trainee therapists will be randomized to one of the three treatment arms. Participants aged between 11 and 19 years and having a primary diagnosis of either a depressive disorder, an anxiety disorder, or a hyperkinetic disorder will be included. Therapeutic alliance will be assessed after every therapy session (therapy session 1 to therapy session 24), symptomatic outcome will be assessed before the start of treatment (pre), after the 3rd, the 10th, and the 17th therapy sessions, at the end of treatment (24th therapy session, post), and at a 6-month follow-up. Additionally, mindfulness and mindfulness-related measures as well as demographic data, adherence, allegiance, and therapeutic techniques will be assessed. It is our aim to assess a sample of 135 patients. We will conduct multilevel modeling to address the nested data structure. DISCUSSION: The study can provide information about how add-on MBIs, conducted by trainee therapists, influence therapeutic alliance and symptomatic outcome in individual psychotherapy in children and adolescents. TRIAL REGISTRATION: ClinicalTrials.gov NCT04034576. Registered on July 17, 2019.

Randomized Controlled Evaluation of a Group-Based Training for Parents of Adolescents with Gaming Disorder or Social Network Use Disorder.

BACKGROUND: Internet Use Disorder (IUD), Gaming Disorder (GD), and Social Network Use Disorder (SNUD) are common phenomena among adolescents and young adults. Negative consequences of such disorders can be observed in the individuals themselves and in the family system. Although parents can influence their children in many ways, they are rarely considered in interventions. The present study examines the effectiveness of a group-based training for parents of adolescents with IUD, GD, or SNUD. METHODS: A total of 76 parents of adolescents (12 to 20 years) were randomly assigned to the intervention group (IG) or the waiting list control group. Parents in the IG participated over eight weeks in six sessions of training (topics: psychoeducation, parenting behaviour, parent-child relationships, parent-child communication, and stress and relaxation). Questionnaires on adolescent symptomatology, parent-child relationships, and parental burden were collected before and after the intervention/waiting period. RESULTS: The training reduced the IUD symptomatology of adolescents from the parents' perspective. GD symptomatology improved for at-risk users, though not for pathological users. Some aspects of the parent-child relationships improved in the mothers' judgment. Parental stress was already low before the training. CONCLUSIONS: The presented parent group training can be used to improve IUD symptomatology in adolescents and is effective in the context of early intervention for at-risk computer gamers.

Estimated Prevalence of Unreported IGD Cases in Routine Outpatient Children and Adolescent Psychotherapy.

Internet Gaming Disorder (IGD) has been included in the DSM-5 as a diagnosis for further study, and Gaming Disorder as a new diagnosis in the ICD-11. Nonetheless, little is known about the clinical prevalence of IGD in children and adolescents. Additionally, it is unclear if patients with IGD are already identified in routine psychotherapy, using the ICD-10 diagnosis F 63.8 (recommended classification of IGD in ICD-10). This study investigated N = 358 children and adolescents (self and parental rating) of an outpatient psychotherapy centre in Germany using the Video Game Dependency Scale. According to self-report 4.0% of the 11- to 17-year-old patients met criteria for a tentative IGD diagnosis and 14.0% according to the parental report. Of the 5- to 10-year-old patients, 4.1% were diagnosed with tentative IGD according to parental report. Patients meeting IGD criteria were most frequently diagnosed with hyperkinetic disorders, followed by anxiety disorders, F 63.8, conduct disorders, mood disorders and obsessive-compulsive disorders (descending order) as primary clinical diagnoses. Consequently, this study indicates that a significant amount of the clinical population presents IGD. Meaning, appropriate diagnostics should be included in routine psychological diagnostics in order to avoid "hidden" cases of IGD in the future.

Treatment outcomes of a CBT-based group intervention for adolescents with Internet use disorders.

BACKGROUND AND AIMS: Instances of Internet use disorders (IUD) including Internet gaming disorder (IGD) and non-gaming pathological Internet use (ng-PIU) have the extent that they are now a growing mental health issue. Individuals suffering from IUD show a large range of symptoms, high comorbidities and impairments in different areas of life. To date there is a lack of efficient and evidence-based treatment programs for such adolescents. The present registered single-arm trial (ClinicalTrials.gov: NCT03582839) aimed to investigate the long-term effects of a brief manualized cognitive behavioral therapy (CBT) program for adolescents with IUD. METHODS: N = 54 patients (16.7% female), aged 9-19 years (M = 13.48, SD = 1.72) received the CBT group program PROTECT+. IUD symptom severity (primary outcome variable) as well as comorbid symptoms, risk-related variables and potentially protective skills (secondary outcome variables) were assessed at pretest, posttest, as well as 4 and 12 months after admission. RESULTS: Patients showed a significant reduction in IUD symptom severity at the 12-month follow-up. Effect sizes were medium to large depending on the measure. Beyond the statistical significance, the clinical significance was confirmed using the reliable change index. Secondary outcome variables showed a significant reduction in self-reported depression, social anxiety, performance anxiety and school anxiety as well as in parental-reported general psychopathology. DISCUSSION AND CONCLUSIONS: The present study shows long-term effects of a manual-based CBT treatment for adolescents suffering from IUD. The results indicate that even a 4-session brief intervention can achieve a medium to large effect over 12 months. Future work is needed to confirm the efficacy within a randomized controlled trial (RCT).

[Mindfulness in Trainee Psychotherapies with Children and Adolescents]. / Achtsamkeit in Ausbildungspsychotherapien bei Kindern und Jugendlichen.

Mindfulness in Trainee Psychotherapies with Children and Adolescents The implementation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past few years. However, there is little research about the implementation of MBIs in individual child and adolescent psychotherapy. The present paper gives an overview of current MBIs and their efficacy in children and adolescents. A depiction of the implementation of MBIs in individual therapy and a description of the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is given. The study aims to examine the effects of short session-introducing interventions with mindfulness elements on juvenile patients' psychopathological symptomatology and therapeutic alliance. For this reason, the authors compare session-introducing interventions with mindfulness elements with session-introducing relaxation interventions and no session-introducing intervention. Qualitative results of the pre-study show that both interventions with mindfulness elements and relaxation interventions work well with juvenile patients.

[Effectiveness of an early intervention program for adolescents with Internet Gaming and Internet Use Disorder: Medium-term effects of the PROTECT+ Study]. / Die Wirksamkeit eines Frühinterventionsprogramms für Jugendliche mit Computerspiel- und Internetabhängigkeit: Mittelfristige Effekte der PROTECT+ Studie.

Effectiveness of an early intervention program for adolescents with Internet Gaming and Internet Use Disorder: Medium-term effects of the PROTECT+ Study Abstract. Objective: Internet Gaming and Internet Use Disorder (IGD and IUD) have gained increasing attention in the scientific community over the last few years. The inclusion of "Gaming Disorder" in the ICD-11 (International Statistical Classification of Diseases and Related Health Problems) promoted the need for evidence-based and effective treatments. PROTECT+ is such a cognitive-behavioral group therapy program for adolescents with IGD and IUD. The present study evaluates the medium-term effects after 4 months. Method: N = 54 patients, aged 9 to 19 years (M = 13.48, SD = 1.72), participated in the early intervention study between April 2016 and December 2017 in Heidelberg, Germany. Symptom severity was assessed at baseline, at the end of the treatment, and at 4-month follow-up using standardized diagnostic tools. Results: Multilevel analyses showed a significant reduction in symptom severity using the Video Game Dependency Scale (CSAS) at 4-month follow-up. We found a small effect size in self-reported reduction of symptom severity (d = 0.35) and a moderate effect size in parental ratings (d = 0.77). The Reliable Change Index measured by the Compulsive Internet Use Scale (CIUS) indicated a high heterogeneity in individual symptom changes over time. Patients showed high satisfaction regarding the treatment program at 1- und 4-month follow-up. Conclusions: This study is internationally one of the few to show a significant reduction of IGD and IUD symptoms after 4 months.

[Direct Costs of Social Phobia in Adolescents and Cost-Effectiveness of Psychotherapy]. / Direkte Kosten sozialer Angststörung bei Jugendlichen und Kosteneffektivität der Psychotherapie.

OBJECTIVES: Social anxiety disorder is one of the most prevalent mental disorders and often manifests in youth or adolescence. Our aim was to determine direct costs of adolescents with social anxiety disorder and the cost-effectiveness of cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) compared to waiting list (WL). METHODS: Baseline data (n = 103) of a randomized controlled trial was used to determine direct costs. Cost-effectiveness of CBT and PDT compared to WL was analyzed using quality-adjusted life years (QALYs) based on the EQ-5D index as measure of health effects. RESULTS: Total six-month direct costs were 809 € (SE 508 €). Especially costs of outpatient physician treatment (325 €; SE 301 €) and psychiatric hospital stays (377 €; SE 258 €) were high. The incremental cost-effectiveness ratio (ICER) of CBT compared to WL was 18,824 €/QALY, with a probability of 63 % for the ICER being below 50,000 €/QALY. PDT did not prove to be cost-effective. CONCLUSIONS: Direct costs were mainly caused by psychiatric hospital stays and outpatient physician treatments. CBT is likely to be cost-effective compared to WL, whereas PDT is unlikely to be cost-effective.

Cognitive-Behavioral and Psychodynamic Therapy in Adolescents with Social Anxiety Disorder: A Multicenter Randomized Controlled Trial.

BACKGROUND: Although social anxiety disorder (SAD) has an early onset and is frequently found in adolescence, evidence for psychotherapeutic treatments of SAD in adolescents is rather scarce. Within the Social Phobia Psychotherapy Research Network (SOPHO-NET), we examined the efficacy of cognitive-behavioral (CBT) and psychodynamic therapy (PDT) compared to a waiting list (WL) in these patients. METHODS: In a multicenter randomized controlled superiority trial, 107 patients, aged 14-20 years, were randomized to CBT (n = 34), PDT (n = 34), or WL (n = 39). Assessments were made at baseline, at the end of treatment, and 6 and 12 months after termination. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA) applied by raters masked to the treatment condition was used as the primary outcome. As secondary outcomes, rates of response and remission and the Social Phobia Anxiety Inventory (SPAI) were used. RESULTS: Both treatments were superior to WL in the LSAS-CA (CBT: p = 0.0112, d = 0.61, 95% CI 0.14-1.08; PDT: p = 0.0261, d = 0.53, 95% CI 0.06-1.00). At the end of treatment, response rates were 66, 54, and 20% for CBT, PDT, and WL. The corresponding remission rates were 47, 34, and 6%, respectively. CBT and PDT were significantly superior to WL regarding remission (CBT: p = 0.0009, h = 1.0; PDT: p = 0.0135, h = 0.74), response (CBT: p = 0.0004, h = 0.97; PDT: p = 0.0056, h = 0.72), and the SPAI (CBT: p = 0.0021, d = 0.75, 95% CI 0.27-1.22; PDT: p = 0.0060, d = 0.66, 95% CI 0.19-1.13). Treatment effects were stable at 6- and 12-month follow-ups. CONCLUSIONS: These results are comparable to the large SOPHO-NET trial in adults (n = 495). Early treatments for social anxiety are needed in order to prevent chronic manifestation of SAD.

An analysis of integrated health care for Internet Use Disorders in adolescents and adults.

Background and aims Although first treatment approaches for Internet Use Disorders (IUDs) have proven to be effective, health care utilization remained low. New service models focus on integrated health care systems, which facilitate access and reduce burdens of health care utilization, and stepped-care interventions, which efficiently provide individualized therapy. Methods An integrated health care approach for IUD intended to (a) be easily accessible and comprehensive, (b) cover a variety of comorbid syndromes, and (c) take heterogeneous levels of impairment into account was investigated in a one-armed prospective intervention study on n = 81 patients, who were treated from 2012 to 2016. Results First, patients showed significant improvement in Compulsive Internet Use over time, as measured by hierarchical linear modeling. Effect sizes of outcome change from baseline to 6-month follow-up ranged from d = 0.48 to d = 1.46. Second, differential effects were found depending on patients' compliance, demonstrating that high compliance resulted in significantly higher rates of change. Third, patients referred to minimal interventions did not differ significantly in amount of change from patients referred to intensive psychotherapy. Discussion Tailored interventions result in higher efficiency through optimized resource allocation and equal amounts of symptom change in all treatment conditions. Moreover, comprehensive, low-threshold interventions seem to increase health service utilization.

The German version of the self-injurious thoughts and behaviors interview (SITBI-G): a tool to assess non-suicidal self-injury and suicidal behavior disorder.

BACKGROUND: Self-injurious thoughts and behaviors (SITBs) are common in adolescents. While there is no standardized interview in German to assess SITBs to date, the Self-Injurious Thoughts and Behaviors Interview (SITBI) is widely used in English-speaking countries. However, the SITBI has not been validated for the assessment of the recently issued DSM-5 Section 3 diagnoses of nonsuicidal self-injury (NSSI) and suicidal behavior disorder (SBD) yet. In the present study the psychometric properties of the German version of the SITBI (SITBI-G) were assessed. We also evaluated whether SITBI-G is a reliable and valid instrument to establish diagnoses of NSSI and SBD. METHODS: A clinical adolescent sample (N = 111, f/m = 73/38, age range = 12-19 years) was recruited from the inpatient units of three departments of child and adolescent psychiatry in Germany. All participating patients were interviewed by using the SITBI-G, and DSM-5 criteria of NSSI and SBD were operationalized from the SITBI-G data. Additionally, participants were given the Self-Harm Behavior Questionnaire (SHBQ), and SITBI-G was retested in a subsample. RESULTS: The SITBI-G shows moderate to good test-retest reliability, a very good interrater reliability, and a good construct validity. The results demonstrate that diagnoses of NSSI and SBD can be established using the SITBI-G, achieving moderate to good test-retest reliabilities and very good to perfect interrater reliabilities. CONCLUSIONS: Overall, the good psychometric properties of SITBI-G are comparable to the original version of the interview. Therefore, SITBI-G seems to be highly appropriate to assess SITBs, including the new DSM-5 Section 3 diagnoses NSSI and SBD in research and clinical contexts.

[Assessment of temperament with the Infant Behavior Questionnaire Revised (IBQ-R) - the psychometric properties of a German version]. / Erfassung des frühkindlichen Temperaments mit dem Infant Behavior Questionnaire Revised.

OBJECTIVE: The Infant Behavior Questionnaire Revised (IBQ-R; Gartstein & Rothbart, 2003) is one of the most common parent-report instruments for assessing infant temperament. This study evaluated the psychometric properties of a German version. METHOD: We studied item characteristics, internal consistency, and descriptive statistics for all 14 scales in a sample of 7- to 9-month-old infants and their mothers (N = 119). Factor analysis was conducted to identify higher-order relationships between the scales. RESULTS: Item analysis showed mixed corrected item-total correlations. Internal consistencies were all moderate to high. Results of the factor analysis confirmed the two dimensions of Surgency/Extraversion and Negative Affectivity, whereas the dimension Orienting/Regulation was not replicated. In contrast to the American sample, activity level in the German sample loaded on the factor Negative Affectivity. The scales low intensity pleasure and soothability, which loaded on factor Orienting/Regulation in the original version, showed substantial loadings on both dimensions Surgency/Extraversion and Negative Affectivity (inverted), whereas the scale duration of orienting was located on the factor Surgency/Extraversion. CONCLUSIONS: The German version of the IBQ-R provides a satisfying instrument for investigating infant temperament. However, further work is needed to improve the methodological quality of the questionnaire. Further research should especially focus on the factor structure of infant temperament. We suggest developing a shorter version and testing it with a larger and more diverse sample.

[Depression, deliberate self-harm and suicidal behaviour in adolescents engaging in risky and pathological internet use]. / Depressivität, selbstverletzendes und suizidales Verhalten bei Jugendlichen mit riskanter und pathologischer Internetnutzung.

To investigate associations between risky and pathologic internet use with depression, deliberate self-harm and suicidal behaviour among a representative sample of German adolescents. A total of 1,435 students (48% boys, 52% girls) from the area of Heidelberg/Germany were recruited during the SEYLE study, a European school-based intervention study and completed an assessment of different questionnaires, including the Young Diagnostic Questionnaire for the assessment of risky and pathological internet use, the Beck Depression Inventory, the Deliberate Self Harm Inventory, and the Paykel Suicide Scale. 80.7% of the students reported regular, 14.5% risky, and 4.8% pathological internet use. The risky and the pathological internet users showed significant higher rates of depression, deliberate self-harm and suicidal behaviour compared to students with regular internet use. Remarkably, there were no significant differences of levels of depression and suicidal behaviour between risky and pathological users. These results suggest that not only pathologic internet use but also risky internet use is associated with symptoms of depression, self-harm and suicidal behaviour. Therefore, more attention should be paid to adolescents with risky internet use for the early recognition of depression, self-harm and suicidality in adolescence.

Infant temperament and information processing in a visual categorization task.

This study investigates the relation between temperament and information processing in 7-month-old infants. Infant temperament was assessed on multiple dimensions, using mothers' ratings on the Infant Behavior Questionnaire (IBQ). Information processing was measured during a paired-comparison visual categorization task. Infants (N=50) were familiarized with five different pairs of visual stimuli from one category, followed by two test trials, each contrasting a novel familiar-category item with a novel out-of-category item (animals vs. vehicles). Drop-out rate in this task was within a normal range (21%). No differences in temperament were found between completers and non-completers, but high reactivity to novelty and low motor activity were positively correlated with the strength of infants' familiarization response. Group comparisons between infants scoring high and low on these two dimensions of temperament confirmed this general finding: infants high on distress to novelty and low on motor activity showed stronger familiarization responses. Furthermore, infants scoring low on motor activity showed a stronger categorization response than highly active infants. This study provides evidence that performance in a cognitive categorization task and dimensions of infant temperament are systematically related during the second half of the first year of life. Implications for cognitive research with infants of this age-range will be discussed.