Moving to Second-Stage Treatments Faster: Identifying Midtreatment Tailoring Variables for Youth with Anxiety Disorders

Abstract

Objective The current study presents an approach for empirically identifying tailoring variables at midtreatment of cognitive behavioral therapy (CBT) protocols for youth with anxiety disorders that can be used to guide moves to second stage treatments. Method Using two independent data sets (Study 1 N = 240, M age = 9.86 years; Study 2 N = 341; M age = 9.53 years), we examined treatment response patterns after eight sessions of CBT (i.e., CBT midtreatment). Results We identified and replicated three classes of response patterns at CBT midtreatment: Early Responders, Partial Responders, and Nonresponders. Class membership at CBT midtreatment was predictive of outcome at CBT post. Receiver operating characteristics curves were used to derive guidelines to optimize accuracy of assignment to classes at CBT midtreatment. Conclusions These findings support the promise of treatment response at CBT midtreatment to identify tailoring variables for use in abbreviating first stage treatments and facilitating moves to second stage treatments.

Can less be more? Open trial of a stepped care approach for child and adolescent anxiety disorders

“…In the present study, youths with higher clinician rated anxiety severity at baseline and co-occurring ADHD were significantly more likely to step up in treatment intensity than youths without these characteristics. These findings are consistent with the broader literature on predictors of youth anxiety response to psychosocial treatments (Compton et al, 2014; Halldorsdottir et al, 2015; Hudson et al, 2013; Pettit et al, 2016), although co-occurring ADHD does not predict poor response to serotonin reuptake inhibitors (RUPP Anxiety Study Group, 2003; Halldorsdottir et al, 2015). Youth with these characteristics may not be good candidates for psychosocial treatments, including ABM, at a first step.…”

“…In future studies on stepped care approaches, researchers might a priori select potential tailoring variables that could be assessed regularly throughout treatment and provide information about final treatment response (Silverman et al, 2016). We recently illustrated an approach to identifying tailoring variables and generating decision rules in youth with anxiety disorders who were treated with CBTs (Pettit et al, 2016). Researchers could apply this approach in future studies on stepped care to identify tailoring variables and generate decision rules about the optimal time to step up in treatment intensity.…”

“…On one hand, we can see the merits of starting Step 1 with a high intensity treatment because, as is true of many dose-response relationships, starting strong might yield a more effective response (i.e., ‘more might be more’). On the other hand, not all youth with anxiety disorders necessarily require a high intensity treatment from the ‘get-go’ (Kendall et al, 2016; Pettit, Silverman, Rey, Marin, & Jaccard, 2016); rather, starting Step 1 with a less intense treatment might be more effective and/or efficient (i.e., less might be more; Silverman, Pettit, & Lebowitz, 2016). The current open trial represents an initial effort to study this possibility.…”

“…We could not find any studies that examined predictors of youth response to ABM. In the broader anxiety treatment literature, however, high anxiety severity at baseline, a primary diagnosis of social phobia, and co-occurring diagnoses of ADHD and unipolar depressive disorders are associated with poor treatment response (e.g., Compton et al, 2014; Halldorsdottir et al, 2015; Hudson et al, 2013; Pettit et al, 2016). We thus examined each of these characteristics at the baseline evaluation and expected that youths with each of these characteristics would be the ones who stepped up their treatment intensity to Step 2, CBT.…”

Adaptive Interventions in Child and Adolescent Mental Health

“…Two of the nine manuscripts describe interesting secondary data analyses aimed at generating hypotheses about potential tailoring variables for the development of adaptive interventions in anxiety (Pettit, Silverman, Rey, Marin, & Jaccard, 2015) and autism (Shih, Patterson, & Kasari, 2014). These two papers nicely complement other, recent work, which uses different methodology for identifying critical treatment decision points during the course of intervention (Fitzpatrick et al, 2014; Gunlicks-Stoessel & Mufson, 2011; Steidtmann et al, 2013).…”