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Predictors of Treatment Outcome for Parent-Led, Transdiagnostic Cognitive Behavioral Therapy for Youth with Emotional Problems Related to the COVID-19 Pandemic

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Title: Predictors of Treatment Outcome for Parent-Led, Transdiagnostic Cognitive Behavioral Therapy for Youth with Emotional Problems Related to the COVID-19 Pandemic
Language: English
Authors: David B. Riddle (ORCID 0000-0002-3821-0842), Andrew G. Guzick, Alison Salloum, Sarah Kennedy, Asim Shah, Wayne K. Goodman, David S. Mathai, Alicia W. Leong, Emily M. Dickinson, Daphne M. Ayton, Saira A. Weinzimmer, Jill Ehrenreich-May, Eric A. Storch
Source: Child & Youth Care Forum. 2024 53(5):1125-1140.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 16
Publication Date: 2024
Sponsoring Agency: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (DHHS/NIH)
Contract Number: P50HD103555
Document Type: Journal Articles
Reports - Research
Descriptors: COVID-19, Pandemics, Children, Emotional Problems, Predictor Variables, Homework, Severity (of Disability), Anxiety, Depression (Psychology), Symptoms (Individual Disorders), Behavior Modification, Cognitive Restructuring, Parent Participation
DOI: 10.1007/s10566-023-09789-y
ISSN: 1053-1890
1573-3319
Abstract: A brief, parent-led, transdiagnostic cognitive behavioral therapy (CBT) approach demonstrated utility among youth struggling with emotional problems during the COVID-19 pandemic. Homework completion between sessions is directly associated with psychotherapy treatment outcomes in non-parent-led CBT interventions. The present study sought to examine the relationship between homework completion and treatment response in a parent-led transdiagnostic CBT protocol. The first aim was to determine if completion of between session CBT homework was associated with change in symptom severity. The second aim was to determine if pre-treatment anxiety severity, social anxiety severity, and depressive symptoms were associated with treatment outcomes. One-hundred twenty-nine parents of youth (ages 5-13) with significant emotional problems received 6 sessions of telehealth parent-led CBT during the COVID-19 pandemic. Data on children's anxiety symptomology, clinical severity, homework compliance, depression, family relationships, perceptions on the impacts of the pandemic, treatment response, and therapists rating of symptom improvement were collected. Homework completion explained 9% of the variance in symptom improvement at post-treatment. Greater homework completion was associated with a significantly higher odds of treatment response (OR = 1.52, p = 0.001). Child anxiety severity, depressive symptoms, family relationships, and perceptions on the impacts of the COVID-19 pandemic were not significantly related to treatment outcome. Completion of homework predicted treatment outcomes in parent-led, transdiagnostic CBT for youth with emotional problems during the COVID-19 pandemic, while controlling for parent-rated anxiety, depression, family relationships, and COVID-related distress. Enhancing and targeting homework compliance between CBT sessions should be a central element of parent-led treatment.
Abstractor: As Provided
Entry Date: 2024
Accession Number: EJ1437148
Database: ERIC
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  Value: <anid>AN0179278204;5jr01oct.24;2024Aug29.05:40;v2.2.500</anid> <title id="AN0179278204-1">Predictors of Treatment Outcome for Parent-Led, Transdiagnostic Cognitive Behavioral Therapy for Youth with Emotional Problems Related to the COVID-19 Pandemic </title> <p>Background: A brief, parent-led, transdiagnostic cognitive behavioral therapy (CBT) approach demonstrated utility among youth struggling with emotional problems during the COVID-19 pandemic. Homework completion between sessions is directly associated with psychotherapy treatment outcomes in non-parent-led CBT interventions. The present study sought to examine the relationship between homework completion and treatment response in a parent-led transdiagnostic CBT protocol. Objective: The first aim was to determine if completion of between session CBT homework was associated with change in symptom severity. The second aim was to determine if pre-treatment anxiety severity, social anxiety severity, and depressive symptoms were associated with treatment outcomes. Methods: One-hundred twenty-nine parents of youth (ages 5–13) with significant emotional problems received 6 sessions of telehealth parent-led CBT during the COVID-19 pandemic. Data on children's anxiety symptomology, clinical severity, homework compliance, depression, family relationships, perceptions on the impacts of the pandemic, treatment response, and therapists rating of symptom improvement were collected. Results: Homework completion explained 9% of the variance in symptom improvement at post-treatment. Greater homework completion was associated with a significantly higher odds of treatment response (OR = 1.52, p =.001). Child anxiety severity, depressive symptoms, family relationships, and perceptions on the impacts of the COVID-19 pandemic were not significantly related to treatment outcome. Conclusions: Completion of homework predicted treatment outcomes in parent-led, transdiagnostic CBT for youth with emotional problems during the COVID-19 pandemic, while controlling for parent-rated anxiety, depression, family relationships, and COVID-related distress. Enhancing and targeting homework compliance between CBT sessions should be a central element of parent-led treatment.</p> <p>Keywords: Cognitive behavioral therapy; Children; Adolescents; Anxiety; Depression; Predictors; Transdiagnostic cognitive behavioral therapy; Parent-led</p> <p>Copyright comment Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</p> <p>Mental health problems during childhood are common (Center for Disease Control and Prevention, [<reflink idref="bib6" id="ref1">6</reflink>]) and associated with both concurrent and prospective impairment (Merikangas et al., [<reflink idref="bib28" id="ref2">28</reflink>]). Effective interventions exist for these conditions including psychological and pharmacological treatments. Recent innovations in treatment development have focused on designing psychological interventions that are mechanistically informed in order to target underlying variables that are hypothesized to be associated with psychopathology. Two particular types of interventions include transdiagnostic cognitive behavioral therapy (CBT) models and parent-led CBT interventions (Marchette & Weisz, [<reflink idref="bib24" id="ref3">24</reflink>]; Creswell et al., [<reflink idref="bib7" id="ref4">7</reflink>]).</p> <p>Recent developments have explored the concept of addressing co-occurring and related disorders through transdiagnostic CBT (Marchette & Weisz, [<reflink idref="bib24" id="ref5">24</reflink>]). Transdiagnostic CBT integrates several key intervention principles with the goal of treating underlying psychological processes that cut across internalizing disorders (McEvoy et al., [<reflink idref="bib26" id="ref6">26</reflink>]; Marchette & Weisz, [<reflink idref="bib24" id="ref7">24</reflink>]). The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for Children and Adolescents (UP-C/A) is a form of transdiagnostic CBT that targets negative affect and aversive behavioral and emotions reactions to triggers (Barlow et al., [<reflink idref="bib1" id="ref8">1</reflink>]; Ehrenreich-May et al., [<reflink idref="bib8" id="ref9">8</reflink>]). Transdiagnostic CBT has demonstrated efficacy for improving the core presenting problem but has also demonstrated positive effects on symptoms of comorbid diagnoses (Carlucci et al., [<reflink idref="bib5" id="ref10">5</reflink>]). Transdiagnostic approaches to treatment may hold particular utility in treating comorbid conditions as well as facilitating intervention dissemination (Barlow et al., [<reflink idref="bib2" id="ref11">2</reflink>]).</p> <p>Parent-led CBT engages parents to take an active role in the therapeutic process by learning therapeutic strategies to teach their child, shift their own behavior (e.g., accommodation), and ultimately implement treatment components across naturalistic settings (Creswell et al., [<reflink idref="bib7" id="ref12">7</reflink>]; Lebowitz & Majdick, [<reflink idref="bib21" id="ref13">21</reflink>]). This intervention approach also provides support for parents in navigating their own stress and may reduce treatment barriers of family-based CBT (i.e., time and cost; Creswell et al., [<reflink idref="bib7" id="ref14">7</reflink>]).</p> <p>Recent efforts integrated these intervention approaches to develop a brief, parent-led, therapist-assisted, transdiagnostic CBT intervention called "Coping with COVID" (Guzick et al., [<reflink idref="bib11" id="ref15">11</reflink>]). The Coping with COVID program (Guzick et al., [<reflink idref="bib11" id="ref16">11</reflink>]) was designed using the foundations of the UP-C/A (Ehrenreich-May et al., [<reflink idref="bib8" id="ref17">8</reflink>]). This parent-led CBT approach included psychoeducation about anxiety and depression, building parents' capacity on utilizing CBT-based skills (e.g., anxiety-based exposures and behavioral activation techniques) while also providing psychoeducation on topics such as avoidance behaviors and emotional parenting behaviors. Additionally, parents were provided with training on helping their child to identify cognitive distortions and develop ways to think more flexibly through cognitive reappraisals of distressing triggers. Although this brief program was associated with improved depressive, anxiety, and stress symptoms, significant variability in outcomes were observed, with 38% of participants classified as non-responders (Guzick et al., [<reflink idref="bib11" id="ref18">11</reflink>]). Examining possible predictors of treatment outcome is important to understand who may benefit most from brief, parent-led, transdiagnostic CBT, and who may be more likely to need additional or alternative services. Based on the literature, two classes of predictors were conceptualized to be theoretically related to outcomes, namely homework adherence and several clinical characteristics.</p> <p>A key component of the Coping with COVID program required parents to take ownership of implementing homework between each session in order to facilitate the overall treatment process. Although research has shown that implementing weekly homework in between therapeutic sessions can improve patient outcomes and engagement in child psychotherapy (Rees et al., [<reflink idref="bib31" id="ref19">31</reflink>]), homework compliance has received less empirical attention in parent-led interventions despite its centrality to this modality. Homework is a core element of CBT in that it facilitates engagement in therapeutic concepts and skills within individuals' natural environment and settings. Given that patients typically see a therapist once/twice per week, this allows for intervention continuity between sessions. In the case of working with anxious youth, homework facilitates further opportunities for the child to learn that feared outcomes do not occur (i.e., through exposures; McGuire & Storch, [<reflink idref="bib27" id="ref20">27</reflink>]) and how to effectively cope with anxiogenic triggers. Therapeutic homework generally consists of taking skills learned during sessions and applying them in naturalistic environments. Incorporating homework is a vital component to effective CBT, with research demonstrating its utilization to have significant impacts on treatment outcomes (LeBeau et al., [<reflink idref="bib20" id="ref21">20</reflink>]; Rees et al., [<reflink idref="bib31" id="ref22">31</reflink>]). Studies have further demonstrated the utility of implementing in-between-session homework for youth and adolescents with anxiety and depressive disorders, indicating that the quantity of homework as well as the quality of the tasks assigned between sessions is directly correlated to treatment outcomes (Kazantzis et al., [<reflink idref="bib15" id="ref23">15</reflink>]). However, little is known about the effects of homework compliance on treatment outcomes within parent-led CBT interventions.</p> <p>In addition to homework compliance, clinical characteristics of children have also been examined as possible predictors of CBT outcomes. Although this literature yields inconsistent findings (Knight et al., [<reflink idref="bib17" id="ref24">17</reflink>]), several clinical factors have emerged as potentially relevant. First, youth with primary social anxiety disorder are less likely to benefit from CBT than youth with other anxiety disorders (Evans et al., [<reflink idref="bib9" id="ref25">9</reflink>]; Knight et al., [<reflink idref="bib17" id="ref26">17</reflink>]). Second, higher baseline anxiety and depressive symptom severity has been associated with attenuated response in another recent meta-analysis of CBT with children and adolescents with both depressive and anxiety disorders (Kunas et al., [<reflink idref="bib19" id="ref27">19</reflink>]).</p> <p>Comparatively, there has been minimal research into baseline predictors of outcome in parent-led CBT. In one study, Thirlwall and colleagues ([<reflink idref="bib39" id="ref28">39</reflink>]) found that a primary diagnosis of generalized anxiety disorder was predictive of improved outcomes (relative to separation anxiety or social anxiety disorders); anxiety severity, depressive symptoms, and comorbid externalizing behaviors were not associated with treatment outcomes. In contrast, Storch et al. ([<reflink idref="bib37" id="ref29">37</reflink>]) found that lower baseline anxiety was associated with improved treatment outcomes in parent-led CBT for anxiety in autistic youth. Among youth with posttraumatic stress disorder, externalizing symptoms predicted non-response to parent-led stepped care trauma-focused CBT (Salloum et al., [<reflink idref="bib32" id="ref30">32</reflink>]). Notably, this literature has generally focused on youth diagnosed with depressive or anxiety disorders, though it is unclear whether these factors would predict outcome in a program like Coping with COVID that supported youth with more modest levels of internalizing symptoms (not necessarily reaching diagnostic threshold) in association with a major stressor.</p> <p>The goal of the present study was to examine predictors of treatment outcomes among children and adolescents who received a brief, parent-led, therapist-assisted transdiagnostic CBT program. Given the expansion of parent-led interventions (e.g., Salloum et al., [<reflink idref="bib33" id="ref31">33</reflink>]; Storch et al., [<reflink idref="bib36" id="ref32">36</reflink>]), understanding the relative contribution of homework adherence and clinical predictors to treatment outcomes has clear implications for personalizing treatment and maximizing outcomes. There were two primary aims. First, to determine if completion of between session CBT homework was associated with change in symptom severity. We predicted that participants who had higher levels of homework completion between sessions would demonstrate greater reduction in symptom severity than those with lower levels of homework completion. Second, to determine if lower pre-treatment anxiety severity, social anxiety severity, and depressive symptoms were associated with significant improvement in treatment outcomes. Specifically, we predicted that participants with lower severity ratings at pre-treatment timepoints would be more likely to demonstrate greater reduction in symptom severity at post-treatment. Family relationships and COVID-related distress were examined as exploratory predictors of greater reduction in symptom severity.</p> <hd id="AN0179278204-2">Methods</hd> <p></p> <hd id="AN0179278204-3">Procedures</hd> <p>A brief, parent-led, transdiagnostic CBT program was advertised through social media platforms, school and community-based presentations, local news coverage, and by word-of-mouth to families in the greater Houston, TX area. Interested parents and youth were screened, and potentially appropriate families scheduled for a baseline assessment at which they provided consent and assent to participate. Once consented, participants were assessed by an evaluator not involved in treatment to determine eligibility. Eligible families were assigned a therapist and received six weekly telehealth sessions (see below). Approximately one week after the final session, families were scheduled for a post-assessment. Any family who was not clinically appropriate for the program was provided with referrals to additional mental health resources and providers. The local Institutional Review Board (IRB) approved review and analysis of patients' de-identified data for this study.</p> <hd id="AN0179278204-4">Participants</hd> <p>Participants were caregivers of children and adolescents between the ages of 5 and 13. Children in the Coping with COVID program presented with modest levels of psychological difficulties such as anxiety, stress, feelings of sadness and loneliness related to and/or worsened by the COVID-19 pandemic as assessed by an intake evaluator (doctoral students in psychology and/or a psychiatry resident). Inclusion criteria included: families resided Texas; caregivers had to be the parent or legal guardian of the participating youth; English speaking. Children did not need to have a formal DSM-5 diagnosis. Exclusion criteria included significant developmental or intellectual disability or severe presentation of psychological distress best suited for more intensive services (e.g., youth presenting with active suicidality). Parents and guardians were asked about a history of previous diagnosis of autism, bipolar disorder, psychotic disorder, conduct disorder, and oppositional defiant disorder. If any of these diagnoses were endorsed, participants were included on a case-by-case basis based on all available information. This was a community-based clinical program, and thus specific diagnoses/cutoff scores were not required for participation. Participants were not compensated for their participation but services were provided free of charge.</p> <p>One hundred and twenty-nine children and adolescents between the ages of 5 and 13 years old were included (age M [SD] = 8.7[2.5], 65 (50%) female youth). The majority of participants were identified as White (78%). The most common presenting concern at baseline assessment was anxiety (74%). Mothers were the most common parent/guardian to participate (92%). See Table 1 for a complete summary of baseline participant characteristics.</p> <p>Table 1 Demographics and sample characteristics</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left"><p>Demographics</p></th><th align="left"><p>(<italic>n</italic> = 129)</p></th></tr></thead><tbody><tr><td align="left" colspan="2"><p>Started therapy, N (%) <sup>a</sup></p></td></tr><tr><td align="left"><p> July-October, 2020</p></td><td align="left"><p>67 (52%)</p></td></tr><tr><td align="left"><p> November, 2020-February, 2021</p></td><td align="left"><p>44 (34%)</p></td></tr><tr><td align="left"><p> March-May, 2021</p></td><td align="left"><p>18 (14%)</p></td></tr><tr><td align="left" colspan="2"><p>Primary concern at baseline, N (%) <sup>b</sup></p></td></tr><tr><td align="left"><p> Anxiety</p></td><td align="left"><p>96 (74%)</p></td></tr><tr><td align="left"><p> Stress</p></td><td align="left"><p>55 (43%)</p></td></tr><tr><td align="left"><p> Sleep problems</p></td><td align="left"><p>44 (34%)</p></td></tr><tr><td align="left"><p> Sadness</p></td><td align="left"><p>52 (40%)</p></td></tr><tr><td align="left"><p> Anger</p></td><td align="left"><p>60 (47%)</p></td></tr><tr><td align="left"><p> Disruptiveness</p></td><td align="left"><p>35 (27%)</p></td></tr><tr><td align="left" colspan="2"><p>Treatment history, N (%)</p></td></tr><tr><td align="left"><p> Psychotherapy</p></td><td align="left"><p>39 (30%)</p></td></tr><tr><td align="left"><p> Medication</p></td><td align="left"><p>16 (12%)</p></td></tr><tr><td align="left"><p>Age, M (SD)</p></td><td align="left"><p>8.7 (2.5)</p></td></tr><tr><td align="left" colspan="2"><p>Child Gender, N (%)</p></td></tr><tr><td align="left"><p> Male</p></td><td align="left"><p>64 (50%)</p></td></tr><tr><td align="left"><p> Female</p></td><td align="left"><p>65 (50%)</p></td></tr><tr><td align="left"><p>Child Hispanic/Latinx Ethnicity, N (%)</p></td><td align="left"><p>40 (31%)</p></td></tr><tr><td align="left" colspan="2"><p>Race, N (%)</p></td></tr><tr><td align="left"><p> Asian</p></td><td align="left"><p>20 (16%)</p></td></tr><tr><td align="left"><p> Black or African American</p></td><td align="left"><p>13 (10%)</p></td></tr><tr><td align="left"><p> White</p></td><td align="left"><p>101 (78%)</p></td></tr><tr><td align="left"><p> Other</p></td><td align="left"><p>15 (12%)</p></td></tr><tr><td align="left" colspan="2"><p>Household income</p></td></tr><tr><td align="left"><p> $10,000–39,999</p></td><td align="left"><p>6 (5%)</p></td></tr><tr><td align="left"><p> $40,000–79,999</p></td><td align="left"><p>31 (24%)</p></td></tr><tr><td align="left"><p> $80,000 and over</p></td><td align="left"><p>91 (71%)</p></td></tr><tr><td align="left" colspan="2"><p>Guardian relationship</p></td></tr><tr><td align="left"><p> Mother</p></td><td align="left"><p>119 (92%)</p></td></tr><tr><td align="left"><p> Father</p></td><td align="left"><p>7 (5%)</p></td></tr><tr><td align="left"><p> Grandmother</p></td><td align="left"><p>1 (1%)</p></td></tr><tr><td align="left" colspan="2"><p>Proportion elevated (T score ≥ 65)</p></td></tr><tr><td align="left"><p> Spence Child Anxiety Scale</p></td><td align="left"><p>37 (29%)</p></td></tr><tr><td align="left"><p> PROMIS-Depression</p></td><td align="left"><p>33 (26%)</p></td></tr><tr><td align="left" colspan="2"><p>Proportion elevated (T score ≤ 35)<sup>c</sup></p></td></tr><tr><td align="left"><p> PROMIS-Family Relationships</p></td><td align="left"><p>11 (8.6%)</p></td></tr></tbody></table> </ephtml> </p> <p> <sups>a</sups> Recruitment periods are divided into three roughly even periods for interpretability <sups>b</sups> Parents could select multiple options for primary concerns <sups>c</sups> PROMIS-Family Relationships T-Scores ≤ 35 indicate significantly weaker family relationships Note: PROMIS = Patient-Reported Outcomes Measurement Information System</p> <hd id="AN0179278204-5">Treatment</hd> <p>The treatment protocol included telehealth parent-led CBT sessions that were based on the UP-C/A (Ehrenreich-May et al., [<reflink idref="bib8" id="ref33">8</reflink>]) that were provided weekly for a six-week period. Children and adolescents did not participate in the telehealth sessions. The goal of the program was to provide parents with skills needed to implement CBT with their children and to provide strategies for engaging in CBT exercises. Sessions were provided through a HIPAA-compliant videoconferencing platform and were led by advanced doctoral students in counseling/school psychology under supervision by a licensed psychologist. The initial session included psychoeducation on treatment, emotions, and goal setting. The second session included psychoeducation on the developing parent-led transdiagnostic opposite action exercises. The third session in the program provided additional support related to exposures as well as psychoeducation on parenting behaviors that contribute to anxiety and related symptoms (i.e., accommodation, avoidance, overprotection, criticism, and modeling inappropriate behaviors). Session four included "opposite parenting behaviors," which help counteract "emotional parenting behaviors" such as overinvolvement or overly critical communication, as well as continued support for exposures and behavioral activation. The fifth session provided ongoing support for exposures while also introducing mindfulness and awareness exercises for parents to teach their children and to use themselves. The sixth and final session provided parents with guidance on helping their child identify cognitive distortions and to think more flexibly by considering alternative interpretations to stressful and anxiety-provoking situations.</p> <p>Therapists were trained by the developers of the UP-C/A, where they were required to complete readings, attend didactics, and engage in weekly case consultations to assure adherence to the treatment protocol. A licensed psychologist provided weekly supervision. Therapists included advanced doctoral students in counseling and school psychology who specialized in working with children and adolescents.</p> <hd id="AN0179278204-6">Measures</hd> <p>Spence Children's Anxiety Scale (SCAS): Anxiety was assessed using the Spence Children's Anxiety Scale (Spence, [<reflink idref="bib35" id="ref34">35</reflink>]). The SCAS is a 38-item, parent-rated, normed measure for children and adolescents aged 7 to 17 years old and has strong psychometric properties, including diagnostic predictive validity (Ramme, [<reflink idref="bib30" id="ref35">30</reflink>]). Items on the SCAS are scored on a 3-point Likert scale. Examples of items include, "My child worries about things", "My child complains of feeling afraid", and "When my child has a problem, s/he feels shaky." The total anxiety subscale (<emph>α</emph> = 0.88) and social anxiety subscale (<emph>α</emph> = 0.78) were used in this study.</p> <p>Patient-Reported Outcomes Measurement Information System (PROMIS): Other psychosocial variables were monitored using the patient-reported outcomes measurement information system (PROMIS; Irwin et al., [<reflink idref="bib13" id="ref36">13</reflink>]) questionnaire. Specifically, the PROMIS Parent Proxy Short Form – V2.0 was utilized to assess depressive symptoms (<emph>α</emph> = 0.87) and family relationships (<emph>α</emph> = 0.85) domains. Examples of items include: "My child felt lonely", and "It was hard for my child to have fun." The PROMIS has demonstrated psychometric properties, with moderate to high internal validity and test-retest reliability (Varni et al., [<reflink idref="bib41" id="ref37">41</reflink>]). These questionnaires were completed by the identified youths' parents before and after treatment to assess depressive symptoms and family relationships.</p> <p>Clinical Global Impressions Scale (CGI): Clinical severity and improvement were assessed using the Clinical Global Impressions-Severity Scale (CGI-S) and Improvement Scale (CGI-I; Guy, [<reflink idref="bib10" id="ref38">10</reflink>]) respectively. Ratings on the CGI-S range from a 1 (normal) to a 7 (among the most extremely ill patients) while ratings on the CGI-I range from a 1 (very much improved) to a 7 (very much worse). The CGI is a widely used measurement that provides an efficient method for assessment patient improvement and gestalt severity (Busner & Targum, [<reflink idref="bib4" id="ref39">4</reflink>]). The CGI-S/I were rated at each session by the treating therapists based on their overall impression of clinical severity and improvement. Therapist-completed CGI-S/I ratings demonstrate strong convergence with both independent evaluator and parent assessments (Lewin et al., [<reflink idref="bib22" id="ref40">22</reflink>]).</p> <p>Homework: Homework assignments were given at the end of each session and determined in collaboration with the family. Completion and review of homework was conducted at the beginning of each subsequent visit. Homework content was personalized to the participant's treatment goals. Homework completion over the previous between-session interval was rated on a 1–8 scale at each session by therapists, ranging from 1 (did not do it at all) to 8 (did it completely and in the manner, it was supposed to be done). This approach has been utilized by others (Hughes & Kendall, [<reflink idref="bib12" id="ref41">12</reflink>]; Tolin et al., [<reflink idref="bib40" id="ref42">40</reflink>]) and a recent meta-analysis found that use of Likert rating scales to measure homework completion between therapeutic sessions has been associated with significantly higher effect sizes than studies that utilized percentage ratings of homework completion (Mausbach et al., [<reflink idref="bib25" id="ref43">25</reflink>]).</p> <p>Children and adolescents' thoughts and distress related to the COVID-19 pandemic were assessed using the parent proxy-rated COVID-Thoughts and Behavioral Symptoms scale (COV-TaBS; Schneider et al., [<reflink idref="bib34" id="ref44">34</reflink>]). This measure captures emotional responses that youth may have experienced during the COVID-19 pandemic. Experiences included in this measure consist of social distancing, school closures, fears and worries, separation from caregivers, experiencing illness due to COVID-19, and facing loss of family and friends due to COVID-19. Though there have not been formal psychometric analyses of this measure, this measure was used because there were no COVID distress measures available at program initiation and has been previously described (Schneider et al., [<reflink idref="bib34" id="ref45">34</reflink>]). It showed adequate internal consistency in this study (<emph>α</emph> = 0.76).</p> <hd id="AN0179278204-7">Analysis Plan</hd> <p>First, data were examined for missingness and conformity to normal distribution assumptions. 17% of CGI-I data and homework completion were missing, as all participants who initiated treatment were included in this analysis (<emph>n</emph> = 129), and only 102 finished (i.e., data were missing from sessions not attended). Thus, relatively more data were missing for later sessions. Sixteen participants (12%) did not return for a second session and thus CGI-I ratings were not available for these participants. No data were missing on baseline parent questionnaires. Little's test suggested data were not missing completely at random, <emph>X</emph><sups><emph>2</emph></sups> (<reflink idref="bib47" id="ref46">47</reflink>) = 132.92, <emph>p</emph> <.001. Maximum likelihood estimates were used to impute missing data. Missing data (i.e., among participants who finished early) were estimated using a maximum likelihood estimation approach using an intent-to-treat approach. All data were normally distributed, falling within − 1 to + 1 on skewness and kurtosis values.</p> <p>To investigate predictors of change in CGI-S scores, hierarchical linear modeling was used with CGI-S scores as the dependent variable (Tasca & Gallop, [<reflink idref="bib38" id="ref47">38</reflink>]). The CGI-S rating was selected as the primary outcome measure in this study because: (<reflink idref="bib1" id="ref48">1</reflink>) it has been shown to provide valid, reliable ratings across blinded and unblinded raters (as done in this study; Lewin et al., [<reflink idref="bib22" id="ref49">22</reflink>]), (<reflink idref="bib2" id="ref50">2</reflink>) it captures emotional disorder severity and thus was universally clinically relevant to all youth in the study regardless of their specific presenting concern, and (<reflink idref="bib3" id="ref51">3</reflink>) it was administered at each session, enabling a more reliable assessment of change than other measures, which were administered at only two timepoints. Several nested models were included, examining fit relative to the previous best-fitting model (-2LL, AIC, BIC), beginning with (A) a null model, (B) linear time, (C) quadratic time, (D) PROMIS-Depression, SCAS-Anxiety, and SCAS-Social phobia, (E) homework completion, (F) PROMIS-Family Relationships, and (G) COVID-TaBS. If model fit did not improve, the variables were dropped from the subsequent model. Pseudo-R<sups>2</sups> estimates are provided in HLMs by examining the percentage change in intercept-related variance across nested models (Kreft & De Leeuw, [<reflink idref="bib18" id="ref52">18</reflink>]). Each model investigating predictors included both the mean value as well as the interaction of the variable with time (i.e., is rate of change moderated by the specific variable). HLMs with 50 level 2 variables (participants) and 5 level 1 variables (visit number) have been recommended (Maas & Hox, [<reflink idref="bib23" id="ref53">23</reflink>]); with 129 participants and an average of 5.0 ratings per participant, this study was considered well-powered to detect effects.</p> <p>Logistic regression was used to evaluate variables significant associated with treatment response, defined as a CGI-I rating of "much" or "very much" improved. The same independent variables that were included in the HLM were included in the logistic regression.</p> <hd id="AN0179278204-8">Results</hd> <p></p> <hd id="AN0179278204-9">Predicting Trajectories of Improvement</hd> <p>Across several nested models, the only variables with significant fixed effects included linear time, quadratic time, and the homework*time interaction. The model with the best fit (Model E in Table 2) included the fixed effect of the intercept term, linear time, quadratic time, and homework variables. A significant negative linear effect, <emph>b</emph> = − 0.13, <emph>p</emph> <.01, as well as q quadratic effect, <emph>b</emph> = − 0.019, <emph>p</emph> <.05, was observed across treatment, and parents who completed more CBT homework experienced more rapid symptom reduction, homework*time: <emph>b</emph> = − 0.043, <emph>p</emph> <.01. Homework completion explained 9.09% of the variance in CGI-S scores across therapy. None of the baseline clinical variables (SCAS-Anxiety, SCAS-Social phobia, PROMIS-Depression, PROMIS-Family Relationships, or COVID-TaBS) demonstrated effects across treatment. Please see Table 2 for a complete summary of model parameters.</p> <p>Table 2 Multilevel model predicting CGI-S</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>Unconditional Means Model</p></th><th align="left"><p>Model B: Time</p></th><th align="left"><p>Model C: Quadratic Time</p></th><th align="left"><p>Model D: Anxiety and Depression</p></th><th align="left"><p>Model E: Home-work</p></th><th align="left"><p>Model F: Family Relation-ships</p></th><th align="left"><p>Model G: COVID-related distress</p></th></tr></thead><tbody><tr><td align="left"><p><bold><italic>Fixed Effects</italic></bold></p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Intercept</p></td><td align="left"><p>2.61***</p></td><td align="left"><p>3.12***</p></td><td align="left"><p>3.06***</p></td><td align="left"><p>2.29***</p></td><td align="left"><p>2.90***</p></td><td align="left"><p>3.65***</p></td><td align="left"><p>2.91***</p></td></tr><tr><td align="left"><p>Time</p></td><td align="left" /><td align="left"><p>− 0.22***</p></td><td align="left"><p>− 0.13**</p></td><td align="left"><p>− 0.22**</p></td><td align="left"><p>− 0.13**</p></td><td align="left"><p>− 0.13**</p></td><td align="left"><p>− 0.13**</p></td></tr><tr><td align="left"><p>Quadratic Time</p></td><td align="left" /><td align="left" /><td align="left"><p>− 0.020**</p></td><td align="left"><p>− 0.020*</p></td><td align="left"><p>− 0.019*</p></td><td align="left"><p>− 0.019*</p></td><td align="left"><p>− 0.019*</p></td></tr><tr><td align="left"><p>SCAS-Anxiety</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>0.013</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>SCAS-Anxiety*Time</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>< 0.001</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>SCAS-Social phobia</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>− 0.020</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>SCAS-Social phobia</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>0.0077</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>PROMIS-Depression</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>0.036</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>PROMIS-Depression*Time</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>< 0.001</p></td><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Homework completion</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>0.028</p></td><td align="left"><p>0.035</p></td><td align="left"><p>0.028</p></td></tr><tr><td align="left"><p>Homework*time</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>− 0.043**</p></td><td align="left"><p>− 0.043**</p></td><td align="left"><p>− 0.043**</p></td></tr><tr><td align="left"><p>PROMIS-Family Relationships</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>− 0.017</p></td><td align="left" /></tr><tr><td align="left"><p>PROMIS-Family Relationships*time</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>− 0.0034</p></td><td align="left" /></tr><tr><td align="left"><p>COVID Thoughts and Behaviors</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>− 0.0072</p></td></tr><tr><td align="left"><p>COVID Thoughts and Behaviors*time</p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left"><p>− 0.0016</p></td></tr><tr><td align="left"><p><bold><italic>Random Effects</italic></bold></p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>Residual</p></td><td align="left"><p>0.59***</p></td><td align="left"><p>0.22***</p></td><td align="left"><p>0.22***</p></td><td align="left"><p>0.22***</p></td><td align="left"><p>0.22***</p></td><td align="left"><p>0.22***</p></td><td align="left"><p>0.22***</p></td></tr><tr><td align="left"><p>Intercept</p></td><td align="left"><p>0.61***</p></td><td align="left"><p>0.87***</p></td><td align="left"><p>0.88***</p></td><td align="left"><p>0.81***</p></td><td align="left"><p>0.80***</p></td><td align="left"><p>0.79***</p></td><td align="left"><p>0.80***</p></td></tr><tr><td align="left"><p>Time</p></td><td align="left" /><td align="left"><p>0.052***</p></td><td align="left"><p>0.052***</p></td><td align="left"><p>0.050***</p></td><td align="left"><p>0.048***</p></td><td align="left"><p>0.047***</p></td><td align="left"><p>0.048***</p></td></tr><tr><td align="left"><p><bold><italic>Fit Statistics</italic></bold></p></td><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /><td align="left" /></tr><tr><td align="left"><p>-2LL</p></td><td align="left"><p>1692.77</p></td><td align="left"><p>1379.57</p></td><td align="left"><p>1372.72</p></td><td align="left"><p>1370.52 <sup>a</sup></p></td><td align="left"><p>1336.75</p></td><td align="left"><p>1334.81 <sup>a</sup></p></td><td align="left"><p>1336.75 <sup>a</sup></p></td></tr><tr><td align="left"><p>AIC</p></td><td align="left"><p>1698.77</p></td><td align="left"><p>1389.57</p></td><td align="left"><p>1384.72</p></td><td align="left"><p>1392.52</p></td><td align="left"><p>1352.75</p></td><td align="left"><p>1354.81</p></td><td align="left"><p>1356.75</p></td></tr><tr><td align="left"><p>BIC</p></td><td align="left"><p>1712.15</p></td><td align="left"><p>1411.87</p></td><td align="left"><p>1411.48</p></td><td align="left"><p>1441.58</p></td><td align="left"><p>1388.32</p></td><td align="left"><p>1399.27</p></td><td align="left"><p>1401.21</p></td></tr></tbody></table> </ephtml> </p> <p>*<emph>p</emph> <.05, **<emph>p</emph> <.01, ***<emph>p</emph> <.001 <sups>a</sups> Non-significant improvement in -2LL <emph>Note.</emph> -2LL: -2 Log Likelihood; AIC: Akaike's Information Criterion; BIC: Schwarz's Bayesian Criterion; CGI-S: Clinical Global Impressions Scale-Severity; PROMIS: Patient-Reported Outcome Measurement Information System; SCAS: Spence Child Anxiety Scale. The random effect of quadratic time was not estimable in models and thus was not retained.</p> <p>Figure 1 displays trajectories of improvement in overall clinical severity across six sessions of the Coping with COVID program. Separate lines are depicted for the 33% of participants who completed the highest degree of homework, the 33% of participants who completed the least homework, and the 33% in between.</p> <p>Graph: Fig. 1 Change in clinical severity based on homework completion. Note. CGI-S: Lines represent the lower, middle, and upper third of parents in terms of homework completion across treatment.</p> <hd id="AN0179278204-10">Predicting Treatment Response</hd> <p>Echoing results in the HLM, homework completion was the only variable significantly associated with treatment response, <emph>OR</emph> = 1.52, <emph>p</emph> =.001, explaining 10% of the variance in treatment response, and significantly improving the fit of the model, χ<sups>2</sups> (<reflink idref="bib1" id="ref54">1</reflink>) = 12.78, <emph>p</emph> <.001. Including other categories of baseline predictors (Step 1: anxiety and depressive severity, Step 3: family relationships, and Step 4: COVID-related distress) did not significantly predict treatment response. Please see Table 3 for the final logistic regression with all included variables.</p> <p>Table 3 Logistic regression predicting treatment response on the CGI-I</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" /><th align="left"><p>Cox and Snell R<sup>2</sup></p></th><th align="left"><p>χ<sup>2</sup></p></th><th align="left"><p>OR</p></th></tr></thead><tbody><tr><td align="left"><p>Step 1. Anxiety and depression</p></td><td align="left"><p>0.04</p></td><td align="left"><p>4.64</p></td><td align="left" /></tr><tr><td align="left"><p> SCAS-Social phobia</p></td><td align="left" /><td align="left" /><td align="left"><p>0.90</p></td></tr><tr><td align="left"><p> SCAS-Total Anxiety</p></td><td align="left" /><td align="left" /><td align="left"><p>1.02</p></td></tr><tr><td align="left"><p> PROMIS-Depression</p></td><td align="left" /><td align="left" /><td align="left"><p>0.99</p></td></tr><tr><td align="left"><p>Step 2. Homework</p></td><td align="left"><p>0.14</p></td><td align="left"><p>12.78***</p></td><td align="left" /></tr><tr><td align="left"><p> SCAS-Social phobia</p></td><td align="left" /><td align="left" /><td align="left"><p>0.90</p></td></tr><tr><td align="left"><p> SCAS-Total Anxiety</p></td><td align="left" /><td align="left" /><td align="left"><p>1.02</p></td></tr><tr><td align="left"><p> PROMIS-Depression</p></td><td align="left" /><td align="left" /><td align="left"><p>0.98</p></td></tr><tr><td align="left"><p> Homework</p></td><td align="left" /><td align="left" /><td align="left"><p>1.52**</p></td></tr><tr><td align="left"><p>Step 3. Family relationships</p></td><td align="left"><p>0.15</p></td><td align="left"><p>0.56</p></td><td align="left" /></tr><tr><td align="left"><p> SCAS-Social phobia</p></td><td align="left" /><td align="left" /><td align="left"><p>0.91</p></td></tr><tr><td align="left"><p> SCAS-Total Anxiety</p></td><td align="left" /><td align="left" /><td align="left"><p>1.01</p></td></tr><tr><td align="left"><p> PROMIS-Depression</p></td><td align="left" /><td align="left" /><td align="left"><p>0.99</p></td></tr><tr><td align="left"><p> Homework</p></td><td align="left" /><td align="left" /><td align="left"><p>1.52**</p></td></tr><tr><td align="left"><p> PROMIS-Family Relationships</p></td><td align="left" /><td align="left" /><td align="left"><p>1.04</p></td></tr><tr><td align="left"><p>Step 4. COVID distress</p></td><td align="left"><p>0.16</p></td><td align="left"><p>1.22</p></td><td align="left" /></tr><tr><td align="left"><p> SCAS-Social phobia</p></td><td align="left" /><td align="left" /><td align="left"><p>0.90</p></td></tr><tr><td align="left"><p> SCAS-Total Anxiety</p></td><td align="left" /><td align="left" /><td align="left"><p>1.01</p></td></tr><tr><td align="left"><p> PROMIS-Depression</p></td><td align="left" /><td align="left" /><td align="left"><p>0.98</p></td></tr><tr><td align="left"><p> Homework</p></td><td align="left" /><td align="left" /><td align="left"><p>1.52**</p></td></tr><tr><td align="left"><p> PROMIS-Family Relationships</p></td><td align="left" /><td align="left" /><td align="left"><p>1.03</p></td></tr><tr><td align="left"><p> COVID-Thoughts and Behaviors</p></td><td align="left" /><td align="left" /><td align="left"><p>1.53</p></td></tr></tbody></table> </ephtml> </p> <p>***<emph>p</emph> <.001, **<emph>p</emph> <.01 <emph>Note.</emph> CGI-I: Clinical Global Impressions Scale-Improvement; PROMIS: Patient-Reported Outcome Measurement Information System; SCAS: Spence Child Anxiety Scale</p> <hd id="AN0179278204-11">Discussion</hd> <p>This study investigated predictors of clinical improvement in a brief, transdiagnostic, parent-led, therapist-assisted approach to virtual CBT. Results indicated that between session homework completion was directly associated with treatment outcome. Pre-treatment psychosocial variables including overall anxiety severity, depressive symptoms, family relationship, and COVID-related distress were not associated with treatment outcomes.</p> <p>Our findings emphasize the importance of between-session homework completion in explaining parent-led CBT outcome. Given the central role of parental homework completion in promoting outcomes, it may be that certain familial characteristics are necessary to maximize benefits from parent-led CBT, i.e., one with a highly motivated parent with the time and resources to invest in regular parent-led therapy sessions <emph>as well as</emph> one-on-one time with their child to complete CBT exercises together. In youth with trauma, parental depression has been associated with attenuated treatment response to parent-led treatment (Salloum et al., [<reflink idref="bib32" id="ref55">32</reflink>]) which may reflect diminished ability to engage in therapeutic tasks. Individual or family-based approaches may be appropriate in the presence of significant psychosocial stressors/variables.</p> <p>Unlike others (Evans et al., [<reflink idref="bib9" id="ref56">9</reflink>]; Knight et al., [<reflink idref="bib17" id="ref57">17</reflink>]; Kunas et al., [<reflink idref="bib19" id="ref58">19</reflink>]; Storch et al., [<reflink idref="bib37" id="ref59">37</reflink>]), overall anxiety severity and social anxiety severity were not significant predictors of treatment outcome. Similarly, depression severity was not a significant predictor of treatment outcome, which aligns with previous studies examining depression severity impacts on anxiety-focused interventions (Kunas et al., [<reflink idref="bib19" id="ref60">19</reflink>]) but conflicts with other findings on depression severity on depression-focused approaches (Nilsen et al., [<reflink idref="bib29" id="ref61">29</reflink>]). Our findings may reflect the relatively modest clinical severity of our sample in which youth with more severe anxiety/depression were referred for more intensive services. While it will be important for findings to be replicated in a more clinically diverse sample, it may be that brief, parent-led interventions are not appropriate for more severe cases.</p> <p>It is important to note study limitations. First, we did not include a control group. Second, our sample consisted of largely White, higher income category families who participated in the initial phase of the pandemic; results may not generalize to individuals of minority status, those from lower socioeconomic groups, or those who participated during later stages of the pandemic. Some data suggest attenuated response to parent-led treatment for those who are Hispanic and of lower income status (Salloum et al., [<reflink idref="bib32" id="ref62">32</reflink>]; Wamser-Nanney & Steinzor, [<reflink idref="bib42" id="ref63">42</reflink>]). Third, the study did not include child self-report measures. Fourth, the SCAS has not been validated for children ages 5- and 6-years old. Fifth, the CGI, which was utilized to measure overall impression of global severity, was completed by the treating therapist based on parent-report and the therapist's clinical impressions, which may affect the reliability of therapist ratings on participant improvement. Finally, the study included youth with mild to moderate clinical concerns and findings cannot be generalized to more clinically severe populations.</p> <p>Clinical implications of these findings, not surprisingly, suggest that like individual treatment (Kazantzis et al., [<reflink idref="bib15" id="ref64">15</reflink>]), parent-led CBT should emphasize the inclusion of homework exercises. Strategies such as making meaningful time to review homework, eliciting reactions from the patient, troubleshooting, and providing rationale for given homework assignments can have significant effects on homework adherence (Jungbluth & Shirk, [<reflink idref="bib14" id="ref65">14</reflink>]). Efforts to enhance parent-led CBT should include psychoeducation and resources that assist parents in building skills and capacity to strengthen their own understanding of therapeutic homework and how to navigate barriers and facilitators to their child's homework completion. In instances where motivating patients and their parents may be difficult, the inclusion of reward systems for children or regular reminders for parents/youth to complete homework between sessions may result in greater levels of homework adherence (Bunnell et al., [<reflink idref="bib3" id="ref66">3</reflink>]). Additionally, incorporating motivational interviewing has improved outcomes in youth with anxiety receiving CBT (Westra et al., [<reflink idref="bib43" id="ref67">43</reflink>]) by encouraging and building the capacity for the patient to become their own change agent. However, when working with younger patients, it is often the parent/guardian who becomes the focus of motivational strategies. Engaging in conversations and techniques that enhance parents' buy-in and overall beliefs about treatment may positively impact engagement in homework (King et al., [<reflink idref="bib16" id="ref68">16</reflink>]).</p> <hd id="AN0179278204-12">Conclusion</hd> <p>Homework completion was directly associated with treatment outcome in parent-led transdiagnostic CBT for youth with emotional problems during the COVID-19 pandemic, above and beyond parent-rated anxiety, depression, family relationship positivity, and COVID-related distress. Other baseline clinical variables were not significantly associated with outcomes. Overall, this study demonstrates the significance of incorporating and monitoring the use of between-session homework in parent-led transdiagnostic CBT. Finding ways to encourage homework participation should be emphasized in clinical practice.</p> <hd id="AN0179278204-13">Acknowledgements</hd> <p>We express our thanks to Katherine Zopatti, Jamie Manis, Allison Meinert, Alex Barth, and Mayra Perez for their roles as therapists in this project.</p> <hd id="AN0179278204-14">Funding</hd> <p>Research reported in this publication was supported by the Greater Houston Community Foundation and the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number P50HD103555 for use of the Clinical and Translational Core facilities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.</p> <hd id="AN0179278204-15">Declarations</hd> <p></p> <hd id="AN0179278204-16">Conflict of interest</hd> <p>Dr. Riddle receives grant support from the Texas Higher Education Coordinating Board.</p> <p>Dr. Andrew Guzick receives grant support from the Ream Foundation/Misophonia Research Fund and the Texas Higher Education Coordinating Board.</p> <p>Dr. Eric Storch receives grant support from NIH, the Ream Foundation, Greater Houston Community Foundation, International OCD Foundation, and Texas Higher Education Coordinating Board. He receives book royalties from Elsevier, Springer, American Psychological Association, Jessica Kingsley, Oxford, and Lawrence Erlbaum. He was a consultant for Brainsway and Biohaven. 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Storch</p> <p>Reported by Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib28" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib24" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib26" firstref="ref6"></nolink> <nolink nlid="nl4" bibid="bib21" firstref="ref13"></nolink> <nolink nlid="nl5" bibid="bib11" firstref="ref15"></nolink> <nolink nlid="nl6" bibid="bib31" firstref="ref19"></nolink> <nolink nlid="nl7" bibid="bib27" firstref="ref20"></nolink> <nolink nlid="nl8" bibid="bib20" firstref="ref21"></nolink> <nolink nlid="nl9" bibid="bib15" firstref="ref23"></nolink> <nolink nlid="nl10" bibid="bib17" firstref="ref24"></nolink> <nolink nlid="nl11" bibid="bib19" firstref="ref27"></nolink> <nolink nlid="nl12" bibid="bib39" firstref="ref28"></nolink> <nolink nlid="nl13" bibid="bib37" firstref="ref29"></nolink> <nolink nlid="nl14" bibid="bib32" firstref="ref30"></nolink> <nolink nlid="nl15" bibid="bib33" firstref="ref31"></nolink> <nolink nlid="nl16" bibid="bib36" firstref="ref32"></nolink> <nolink nlid="nl17" bibid="bib35" firstref="ref34"></nolink> <nolink nlid="nl18" bibid="bib30" firstref="ref35"></nolink> <nolink nlid="nl19" bibid="bib13" firstref="ref36"></nolink> <nolink nlid="nl20" bibid="bib41" firstref="ref37"></nolink> <nolink nlid="nl21" bibid="bib10" firstref="ref38"></nolink> <nolink nlid="nl22" bibid="bib22" firstref="ref40"></nolink> <nolink nlid="nl23" bibid="bib12" firstref="ref41"></nolink> <nolink nlid="nl24" bibid="bib40" firstref="ref42"></nolink> <nolink nlid="nl25" bibid="bib25" firstref="ref43"></nolink> <nolink nlid="nl26" bibid="bib34" firstref="ref44"></nolink> <nolink nlid="nl27" bibid="bib47" firstref="ref46"></nolink> <nolink nlid="nl28" bibid="bib38" firstref="ref47"></nolink> <nolink nlid="nl29" bibid="bib18" firstref="ref52"></nolink> <nolink nlid="nl30" bibid="bib23" firstref="ref53"></nolink> <nolink nlid="nl31" bibid="bib29" firstref="ref61"></nolink> <nolink nlid="nl32" bibid="bib42" firstref="ref63"></nolink> <nolink nlid="nl33" bibid="bib14" firstref="ref65"></nolink> <nolink nlid="nl34" bibid="bib43" firstref="ref67"></nolink> <nolink nlid="nl35" bibid="bib16" firstref="ref68"></nolink>
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  Data: Predictors of Treatment Outcome for Parent-Led, Transdiagnostic Cognitive Behavioral Therapy for Youth with Emotional Problems Related to the COVID-19 Pandemic
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  Data: English
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  Label: Authors
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  Data: <searchLink fieldCode="AR" term="%22David+B%2E+Riddle%22">David B. Riddle</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-3821-0842">0000-0002-3821-0842</externalLink>)<br /><searchLink fieldCode="AR" term="%22Andrew+G%2E+Guzick%22">Andrew G. Guzick</searchLink><br /><searchLink fieldCode="AR" term="%22Alison+Salloum%22">Alison Salloum</searchLink><br /><searchLink fieldCode="AR" term="%22Sarah+Kennedy%22">Sarah Kennedy</searchLink><br /><searchLink fieldCode="AR" term="%22Asim+Shah%22">Asim Shah</searchLink><br /><searchLink fieldCode="AR" term="%22Wayne+K%2E+Goodman%22">Wayne K. Goodman</searchLink><br /><searchLink fieldCode="AR" term="%22David+S%2E+Mathai%22">David S. Mathai</searchLink><br /><searchLink fieldCode="AR" term="%22Alicia+W%2E+Leong%22">Alicia W. Leong</searchLink><br /><searchLink fieldCode="AR" term="%22Emily+M%2E+Dickinson%22">Emily M. Dickinson</searchLink><br /><searchLink fieldCode="AR" term="%22Daphne+M%2E+Ayton%22">Daphne M. Ayton</searchLink><br /><searchLink fieldCode="AR" term="%22Saira+A%2E+Weinzimmer%22">Saira A. Weinzimmer</searchLink><br /><searchLink fieldCode="AR" term="%22Jill+Ehrenreich-May%22">Jill Ehrenreich-May</searchLink><br /><searchLink fieldCode="AR" term="%22Eric+A%2E+Storch%22">Eric A. Storch</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Child+%26+Youth+Care+Forum%22"><i>Child & Youth Care Forum</i></searchLink>. 2024 53(5):1125-1140.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: Y
– Name: Pages
  Label: Page Count
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  Data: 16
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  Label: Publication Date
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  Data: 2024
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  Data: Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (DHHS/NIH)
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  Data: P50HD103555
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  Label: Document Type
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  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22COVID-19%22">COVID-19</searchLink><br /><searchLink fieldCode="DE" term="%22Pandemics%22">Pandemics</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Problems%22">Emotional Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Predictor+Variables%22">Predictor Variables</searchLink><br /><searchLink fieldCode="DE" term="%22Homework%22">Homework</searchLink><br /><searchLink fieldCode="DE" term="%22Severity+%28of+Disability%29%22">Severity (of Disability)</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety%22">Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22Depression+%28Psychology%29%22">Depression (Psychology)</searchLink><br /><searchLink fieldCode="DE" term="%22Symptoms+%28Individual+Disorders%29%22">Symptoms (Individual Disorders)</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Modification%22">Behavior Modification</searchLink><br /><searchLink fieldCode="DE" term="%22Cognitive+Restructuring%22">Cognitive Restructuring</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Participation%22">Parent Participation</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10566-023-09789-y
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1053-1890<br />1573-3319
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: A brief, parent-led, transdiagnostic cognitive behavioral therapy (CBT) approach demonstrated utility among youth struggling with emotional problems during the COVID-19 pandemic. Homework completion between sessions is directly associated with psychotherapy treatment outcomes in non-parent-led CBT interventions. The present study sought to examine the relationship between homework completion and treatment response in a parent-led transdiagnostic CBT protocol. The first aim was to determine if completion of between session CBT homework was associated with change in symptom severity. The second aim was to determine if pre-treatment anxiety severity, social anxiety severity, and depressive symptoms were associated with treatment outcomes. One-hundred twenty-nine parents of youth (ages 5-13) with significant emotional problems received 6 sessions of telehealth parent-led CBT during the COVID-19 pandemic. Data on children's anxiety symptomology, clinical severity, homework compliance, depression, family relationships, perceptions on the impacts of the pandemic, treatment response, and therapists rating of symptom improvement were collected. Homework completion explained 9% of the variance in symptom improvement at post-treatment. Greater homework completion was associated with a significantly higher odds of treatment response (OR = 1.52, p = 0.001). Child anxiety severity, depressive symptoms, family relationships, and perceptions on the impacts of the COVID-19 pandemic were not significantly related to treatment outcome. Completion of homework predicted treatment outcomes in parent-led, transdiagnostic CBT for youth with emotional problems during the COVID-19 pandemic, while controlling for parent-rated anxiety, depression, family relationships, and COVID-related distress. Enhancing and targeting homework compliance between CBT sessions should be a central element of parent-led treatment.
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  Data: 2024
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  Data: EJ1437148
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        Value: 10.1007/s10566-023-09789-y
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      – Text: English
    PhysicalDescription:
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        PageCount: 16
        StartPage: 1125
    Subjects:
      – SubjectFull: COVID-19
        Type: general
      – SubjectFull: Pandemics
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      – SubjectFull: Children
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      – SubjectFull: Emotional Problems
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      – SubjectFull: Predictor Variables
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      – SubjectFull: Severity (of Disability)
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      – SubjectFull: Behavior Modification
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      – SubjectFull: Cognitive Restructuring
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      – SubjectFull: Parent Participation
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