Single Subject Design Childhood Anxiety Cbt Peer Reviewed Articles
Introduction
For the past decade, personalised mental health intervention has been touted equally the new frontier in clinical psychology. The notion that psychotherapy can be tailored to the needs of the private is likewise gaining momentum in the field of childhood anxiety research (Ng and Weisz, 2016). As the about prevalent of babyhood mental disorders affecting fifteen–xx% of children, anxiety disorders lead to significant damage beyond several domains of functioning and oftentimes follows a chronic course into machismo (Polanczyk et al., 2015; Asselmann et al., 2018). At present, cerebral behavioural therapy (CBT) is the prove-based treatment of option producing positive results for approximately one-half of broken-hearted children (James et al., 2020). The fact that well-nigh 5 out of 10 children still run across criteria for an feet disorder afterwards handling, along with the enormous private, societal and economic brunt of anxiety disorders (Kyu et al., 2016; Lee et al., 2017), underscores the need to sympathize and predict differential treatment response. It is crucial in personalising interventions in ii means: showtime, in matching the best treatment to an individual kid and second, by developing new or modifying existing interventions (Simon and Perlis, 2010), which will both greatly benefit children and adolescents living with feet.
The movement towards personalised intervention is considered to be the answer to the question posed by Gordon Paul (1967): 'what treatment, by whom, is about effective for this individual with that specific problem, and nether which set of circumstances?' Defined as evidence-based methods for tailoring treatments to individuals, personalised intervention implies that patient-specific features may guide a practitioner's treatment decisions to optimise handling outcome (Schneider et al., 2015; Ng and Weisz, 2016). Farther, the three overarching goals of personalised intervention include making an accurate diagnosis, predicting individual risk and achieving an constructive treatment response (Ozomaro et al., 2013). Despite substantial research efforts, evidence in support of predicting individual risk is inconsistent, and nosotros withal do not know how to improve outcomes for those children who do non optimally respond to treatment.
As the current 'gold standard' therapy, CBT is associated with considerable decreases in feet compared to control weather condition at post-treatment, with good show of lasting changes at longer term follow-upwardly (Gibby et al., 2017) and widespread positive outcomes across other functional areas (Kreuze et al., 2018). Further, CBT addresses anxiety through a cadre fix of strategies comprising skill building based on psychoeducation about anxiety, somatic management strategies, cognitive restructuring techniques and gradual exposure to feared situations (Albano and Kendall, 2002). Consisting of strategies derived from cerebral and behavioural principles (Beck and Haigh, 2014), CBT has positioned itself as a prime candidate for personalisation. However, the questions of for whom, why and how this treatment works remain largely unanswered.
To better understand which children are most likely to do good, and why, researchers have investigated predictors, moderators and mediators of treatment outcomes following CBT (Kraemer, 2013), with the focus on identifying the factors underlying successful response, or alternatively, the partial or lack of response from anxious children. Therefore, the objective of this mini-review was to evaluate existing inquiry methodologies and current personalisation approaches that tailors CBT to treat child and adolescent anxiety.
Predictors, Moderators and Mediators of Cbt Outcomes
A combination of narrative, systematic and meta-analytic reviews was identified and examined alongside relevant individual studies to evaluate the virtually prominent enquiry methodologies currently employed in childhood anxiety enquiry. To ensure we consulted the most recent show, we conducted a rapid review of the literature and identified 15 studies published in the concluding decade. Further information regarding the search strategy and inclusion criteria is presented in the online Supplementary Cloth. A summary of the studies and reported findings is discussed and presented in Tabular array 1.
Table ane. Summary of predictors, moderators and mediators of CBT outcomes.
Predictors
About babyhood anxiety inquiry have investigated baseline characteristics that have a direct influence on how children answer to feet handling, identifying predictors associated with treatment outcome independent of handling modality (Kraemer et al., 2002). Reasons for the extensive predictor research prove may include the availability of pre-treatment characteristics prior to handling decisions being made, as well as the ease and low toll of data collection (Kunas et al., 2021). A number of systematic review and meta-review evaluated predictors of outcome following CBT across several RCTs which provided contradictory findings for several child demographic (age and gender), clinical (symptom severity and comorbidity) and parental factors (parental psychopathology; Mychailyszyn et al., 2012; Nilsen et al., 2013; Knight et al., 2014; Thulin et al., 2014). Withal, past utilising larger sample sizes, subsequent treatment studies identified a diagnosis of social anxiety disorder (SoAD), comorbid depression and parent psychopathology equally more than robust baseline predictors of poorer treatment response (Hudson et al., 2015). A recent systematic and meta-analytic review of predictors of youth anxiety and depression concluded that severity of the primary disorder and parental psychopathology significantly predicted negative CBT outcome for broken-hearted children (Kunas et al., 2021). In dissimilarity, some studies institute that higher severity of the primary disorder predicted better response (i.e., decrease in anxiety symptoms; Kerns et al., 2013), while others reported poorer outcome (i.e., fewer children diagnosis gratis) at mail service-treatment and long-term follow-up (Gibby et al., 2017). Another systematic and meta-analytic review identified two handling factors with results suggesting that increased parental involvement and longer duration of overall handling were 2 robust factors associated with greater CBT effects (Perihan et al., 2020). Overall, the findings suggest that CBT is comparably constructive for children and adolescents across all genders, ages, ethnicity and socio-economic condition (Knight et al., 2014), and it may, still, point to the need to research latent factors that may accept a direct influence on handling outcome. Inconsistent predictor findings may too be ascribed to methodological issues, such as lack of statistical power, variations in methodology and variations in consequence measurement (response vs. remission), as possible reasons for not observing main effects across studies. Additionally, predictors fail to identify those who will benefit most from a given treatment and provide no recommendations for modification to treatment to optimise response (Kraemer, 2013) nor do they lend themselves to identifying processes that may serve every bit mechanisms for treatment outcome (Kraemer et al., 2002). Therefore, researching moderators and mediators of handling outcome alongside predictors of outcome is paramount to improving the effectiveness of CBT past being able to personalise treatment (Huibers et al., 2021).
Moderators
These factors refer to specific characteristics that predict greater do good from one handling over another to provide understanding for whom they may be constructive (Kraemer et al., 2002). Despite considerable inquiry attempt, few variables have been identified every bit consequent moderators. Earlier systematic reviews of moderators of babyhood anxiety and low outcomes reported inconclusive moderation effects for the moderators nether investigation (Mychailyszyn et al., 2012; Bennett et al., 2013; Nilsen et al., 2013; Manassis et al., 2014; Ung et al., 2015). Nilsen et al. (2013) noted that a lack of variability in the moderators may have complicated the comparing of results across studies as almost studies primarily examined the efficacy of handling. However, one systematic review reported a moderation upshot for blazon of primary diagnosis (Higa-McMillan et al., 2016). Compton et al. (2014) examined potential moderating furnishings of chief anxiety diagnoses across four treatment conditions: anxiety medication sertraline (SRT), CBT, combined SRT+CBT and pill placebo. Results showed that youth with generalised anxiety disorder (GAD) demonstrated improved outcomes with CBT compared to SRT, whereas children with social feet disorder (SoAD) responded more favourably to handling including SRT (combination and SRT lone) than CBT alone. A recent narrative review concluded that more often than not, no child demographic, clinical or parental characteristics consistently moderate treatment result (Norris and Kendall, 2021). Future research requires appropriate moderator study designs to identify the factors that robustly differentiate between treatments to assistance in the clinician's decision of which handling is best for which child.
Mediators
These factors identify critical processes and possible mechanisms through which treatment causes clinical change to understand how a treatment works (Kraemer et al., 2002). Regrettably, fifty-fifty fewer studies of potential mediators accept been conducted for treatment effect in babyhood anxiety disorders, with footling testify in back up of implying mechanistic change. CBT appears to be effective through content and procedure changes in relation to cognition and behaviour, as well equally emotional and somatic outcomes (Herres et al., 2015). A recent systematic review and meta-assay of mediators of CBT reported evidence for change in negative self-talk and coping, as well as change in depressive and externalising symptoms, every bit potential mechanisms (Luo and McAloon, 2021). Higa-McMillan et al. (2016) reported on mediators identified in studies and trials within their systematic review which showed that parental intrusiveness and post-exposure processing may be two further factors that mediate feet result. Farther individual studies suggest that positive self-talk (Hogendoorn et al., 2014), coping self-efficacy (Kendall et al., 2016) and perceived control over anxiety (Marker et al., 2013) may also be potential cognitive mediators, while problem-solving and attention reallocation may correspond behavioural mechanisms that increase coping (Hogendoorn et al., 2014). Questions remain regarding the effect of CBT on melancholia and physiological outcomes for children with anxiety, such equally fright and physiological indicators of fear (Herres et al., 2015). The limited and unconvincing mediator findings have too been ascribed to the challenging nature of mediator inquiry and insufficient methodologies, such as not demonstrating temporal precedence of the mediator (Huibers et al., 2021). Therefore, inquiry with potent written report designs to appraise variables at multiple time points are required to delineate mechanisms of change (Luo and McAloon, 2021). Further, future research should consider the inclusion of a treatment comparison to examine effects of treatment components, for example when findings show that participants experienced greater treatment furnishings when engaged in grouping CBT vs. private CBT (Luo and McAloon, 2021). This is known every bit moderated arbitration (Baron and Kenny, 1986), which provides us with information regarding potential mechanisms of alter and for which children they may produce change.
Personalised Intervention Approaches
In combination, predictor, moderator and mediator inquiry marshal with the goals of personalising CBT intervention for childhood anxiety, for example, past identifying which factors predict gamble of poorer treatment outcome, provide preliminary evidence of which CBT treatment factors may work best for a child with a certain risk profile and which mechanisms may be responsible for therapeutic modify. Furthermore, these research methodologies too inform the evolution and testing of several personalised intervention approaches. A conceptual model depicting these associations is presented in Effigy one.
Effigy 1. Conceptual Model of Personalised CBT for Childhood Anxiety. one. Predictors predict take chances of optimal/non-optimal response (i.eastward., parental psychopathology); 2. moderators predict benefit of 1 handling over another for a subgroup of children (i.e., CBT over SRT for children with generalised feet disorder (GAD)); 3. mediators highlight mechanisms of alter that influence outcome (i.e., reduce negative cocky-talk and increment coping abilities); 4 & 5. authentic diagnosis may facilitate subgroup and modular approaches (i.e., could children with SoAD benefit from boosted social skills training or could anxious youth with comorbid depression do good more from additional mood direction modules?); and six. understanding factors that predict individual risk facilitates the utilise of metrics and predictive analytics to inform treatment decisions (personalisation) to improve handling outcomes.
Ng and Weisz (2016) produced a comprehensive review of current strategies to personalised intervention for youth mental health, including approaches for which examples of CBT accommodation could be found. The nearly evaluated approach adapts existing therapies for specific subgroups that have been identified through predictor and moderator studies as at risk for poorer outcomes, for example children and adolescents with SoAD. Positive results have been demonstrated when using Social Effectiveness Therapy for Children (Set up-C; Beidel et al., 2003), a group behaviour therapy plan that specifically targets social deficits past combining social skills training, peer generalisation and individualised exposure. In an RCT examining the efficacy of SET-C compared to fluoxetine medication and pill placebo (Beidel et al., 2007), findings showed that both fluoxetine and SET-C outperformed placebo, simply SET-C as well enhanced social skills. This finding has been supported by a more recent meta-analysis reporting that when social skill training was included in treatment, it had an boosted consequence in reducing anxiety (Scaini et al., 2016).
A 2d arroyo is modular therapy. For instance, a child diagnosed with comorbid depression may receive modified treatment for anxiety past adding a module for mood direction. An example is the Modular Arroyo to Therapy for Children with Anxiety, Depression, Trauma or Conduct Problems (MATCH) with treatment specifically targeting children who have i or a combination of these disorders (Chorpita and Weisz, 2009). An RCT conducted past Weisz et al. (2012) showed that modular therapy outperformed usual care and standard CBT with results indicating greater improvement and fewer diagnoses for children assigned to Match. Organising CBT into self-contained modules using individual or a combination of modules every bit required volition contribute to a more flexible, dynamic and responsive handling strategy (Ng and Weisz, 2016). More enquiry is needed for empirically based methods to best select, combine and sequence modules for optimal handling outcomes.
Individualised metrics offers a promising approach to personalised intervention, by quantifying the expected benefit each patient volition receive, based on the child's characteristics (Ng and Weisz, 2016). I example of an anxiety metric is the probability of treatment benefit (Lindhiem et al., 2012) modelled on the Child/Adolescent Anxiety Multimodal Study (CAMS) data ready. This metric provided probabilities of experiencing improvement and positive outcomes for different levels of baseline severity and its interaction with treatment modality. It showed that children with astringent baseline severity receiving a combination of SRT+CBT had a 62% probability of returning to normative anxiety, compared to 27% for SRT alone and 46% of CBT alone. All the same, children with moderate baseline severity had around 79% probability of returning to normative feet, regardless of treatment modality. While this study and its metric reported the effectiveness of CBT in terms of both response and effect, it did non contain a control group to calculate differential probabilities, and farther inquiry on larger samples is required.
Another example of an individualised metric is a risk index, utilised equally a clinical tool prior to handling to identify children less likely to respond to standard CBT and who thus require modified intervention (Hudson et al., 2013). The researchers identified pregnant predictors of effect and used their beta weights to calculate individual risk scores and examined the validity of the score to predict the likelihood of remission. The results showed that not-remission increased in a linear manner inside each take chances category, with 23% of low-gamble scores (0–2) showing not-remission compared with 62% of loftier-risk scores (v–8). Future inquiry is needed to replicate the results with larger samples and to include boosted predictors of partial or non-remission.
Relatedly, another important approach represents the increasing interest in data and statistical driven methods to overcome several methodological difficulties on the road to personalised intervention. Information technology is being argued that predictive analytics, such equally machine learning methods, can integrate and make sense of bigger sets of healthcare data, because it is a natural extension to traditional statistical approaches (Beam and Kohane, 2018). Additionally, such methods accept many advantages relative to linear models which is ordinarily used in mental health inquiry (DeRubeis, 2019). For instance, machine learning methods can be used for multivariate model building with multidimensional psychological data and increases predictive ability while reducing overfitting of the model (Coutanche and Hallion, 2020). In sum, predictive analytics has the potential to facilitate personalised intervention in three ways: prediction of treatment response, supporting differential response and individual hazard prediction (Hahn et al., 2017), providing increased incentive for its utilize in mental health.
Barriers, Benefits and Future Directions: What Do We Need Now?
It is evident that clinical and research efforts to personalise interventions have the potential to significantly ameliorate the lives of children with anxiety. Although the prospects are promising, this new frontier presents important challenges including generalisability of findings from the group to the individual-level (Norris and Kendall, 2021), implementation scientific discipline (Williams and Beidas, 2019), extending access to care (Allen et al., 2020) and cultural accommodation of treatment (Naeem, 2019). However, it is the aforementioned methodological difficulties that remain the predominant challenge to the field. Valuable efforts take been made for standardising psychology inquiry procedures to amend consistency and clarity in how RCTs and other treatment outcome studies are reported (Creswell et al., 2021). Further, the increase in babyhood anxiety research over the past ii decades created opportunities to combine data for a better understanding of differential treatment responses (e.g., The Genes for Treatment (GxT) study (Hudson et al., 2015)), along with the added benefits of increased statistical ability and improved generalisability of findings (Lee, 2019). Further, methodological standardisation will facilitate meaningful synthesis of findings across studies when drawing conclusions regarding the extent to which CBT works for which children.
Because the barriers, benefits and futurity directions of the babyhood feet research, the field requires a strategic programme of research that will bridge the gap betwixt our current understanding of differential CBT response and the optimisation of treatment for immature people at take chances of poor result. Similar to a recently proposed agenda for personalising CBT for depression (Huibers et al., 2021), adjacent steps should include the following: continued search for evidence of predictors, moderators and mediators and how they interact to affect alter using large data sets and rigorous study methodologies, a considered enquiry endeavour into the identification of treatment ingredients beyond common factors and their touch on therapeutic alter (Norris and Kendall, 2021) and continued evolution and testing of modified CBT interventions in RCTs with strong control atmospheric condition.
This mini-review provides an evaluation of contempo literature on current research methodologies, equally well as approaches to the personalisation of CBT for childhood anxiety. A rapid review of the virtually recent narrative, systematic and meta-analytic reviews provided empirical support for the novel conceptual model that presents the associations between existing research methodologies, the goals of personalisation and current person-centred CBT treatment for childhood anxiety. Limitations include the evaluation of only a few approaches to personalising CBT, that is, there may exist more potentially viable approaches and examples that were non considered given the limited scope of a mini-review.
Conclusion
The process of personalised intervention for childhood anxiety is complex and enormous in scope. Clinical psychology research has fabricated substantial progress in addressing differential CBT response within the context of childhood anxiety, producing evidence-based research strategies and approaches to personalising interventions. While the field has much to do to address persistent methodological challenges, rich opportunities be for tailoring both treatment content and delivery to increase admission to show-based care. With increasing collaboration among clinical researchers resulting in larger sample sizes, time to come enquiry should consider the heady still untapped potential of predictive analytics to enhance personalisation efforts. This mini-review provides a novel explication of electric current research methodologies that provide content for personalised interventions with clinical relevance. Further, this review provides the outset known conceptual model of personalised intervention research in childhood feet, while as well supporting a call for a research agenda that is aligned with the goals of personalisation. Overall, the one thousand challenge for researchers remains to find innovative methods to personalise CBT interventions, which holds potential to significantly reduce the burden for children and adolescents living with anxiety disorders.
Author Contributions
L-AB contributed to formulation and wrote the beginning draft of the manuscript. JH contributed to manuscript revision and editing. All authors contributed to the article and canonical the submitted version.
Disharmonize of Interest
The authors declare that the enquiry was conducted in the absence of any commercial or fiscal relationships that could be construed as a potential conflict of interest.
Publisher's Note
All claims expressed in this article are solely those of the authors and do not necessarily correspond those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may exist fabricated by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary Cloth
The Supplementary Cloth for this article can be found online at: https://world wide web.frontiersin.org/articles/10.3389/fpsyg.2021.722546/full#supplementary-fabric
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Source: https://www.frontiersin.org/articles/10.3389/fpsyg.2021.722546/full
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