Family and group cognitive behavior therapy: Evaluation of treatment outcome and treatment specificity

This dissertation examined the efficacy of family cognitive behavior treatment (FCBT) and group cognitive behavior treatment (GBCT) for reducing anxiety disorders in children and adolescents using several approaches: clinical significant change, equivalence testing, and analyses of variance. It also examined treatment specificity in terms of targeting family/parents (in FCBT) and peers/group (in GCBT) contextual variables using two main approaches: analyses of variance and structural equation modeling (SEM). The sample consisted of 143 children and their parents who presented to the Child Anxiety and Phobia Program housed within the Child and Family Psychosocial Research Center at Florida International University. Diagnostic interviews and questionnaires were administered to assess youth anxiety. Questionnaires were administered to assess child and parent views of family/parents and peers/group contextual variables. In terms of clinical significant change, results indicated that 84.6% of youth in FCBT and 71.2% of youth in GBCT no longer met diagnostic criteria for their primary/targeted anxiety disorder. In addition, results from analyses of variance indicated that FCBT and GCBT were both efficacious in reducing anxiety disorders in youth across both child and parent ratings. Results using both analyses of variance and structural equation modeling also indicated that there was no meaningful treatment specificity between FCBT and GCBT in terms of either family/parents or peers/group contextual variables. That is, child social skills improved in GCBT in which these skills were targeted and in FCBT in which these skills were not targeted; parenting skills improved in FCBT in which these skills were targeted and in GCBT in which these skills were not targeted. Clinical implications and future research recommendations are discussed.

Cognitive behavior therapy for anxiety disorders in youth: Treatment specificity and mediation effects

The present study investigated the efficacies of Individual CBT (ICBT), Parent Relationship Skill Training (RLST, which targets increasing parental acceptance of youth and increasing autonomy granting) and Parent Reinforcement Skills Training (RLST, which targets increasing parental positive reinforcement and decreasing negative reinforcement). The specific aims were to examine treatment specificity and mediation effects of parenting variables. ICBT was used as a baseline comparison condition. The sample consisted of 253 youth (ages 5-16 years; M = 9.38; SD = 2.42) and their parents. To examine treatment outcome and specificity, the data were analyzed using analysis of variance within a structural equation modeling framework. Mediation was analyzed via structural equation modeling using MPlus. Results indicated that ICBT, RLST, and RFST produced positive treatment outcomes across all indices of change (i.e., clinically significant improvement, anxiety symptom reduction) and across all informants (i.e., youths and parents). RLST was associated with incremental reduction in youth anxiety symptoms beyond ICBT, as per youth report. Treatment specificity effects were found for participants in RFST in terms of parental reinforcement, as per parent report only. Treatment mediation was not found for any of the hypothesized parenting variables (i.e., parental acceptance, parental autonomy granting, parental reinforcement). The results support the use of CBT involving only the youth and the parent and youth together for treating youth anxiety. The findings’ implications are further discussed in terms of the need to conduct further meditational treatment outcome designs in order to continue to advance theory and research in youth anxiety treatment.

Group cognitive -behavioral therapy for heterogeneous anxiety disorders in children and adolescents: A multiple baseline study

This study investigated the efficacy of Group Cognitive-Behavioral Therapy (GCBT) in the treatment of heterogeneous anxiety disorders in children. A partially nonconcurrent multiple baseline across groups design was used to assess the effects of the treatment on 12 clinically referred children and adolescents between 6 and 16 years of age who met DSM-IV criteria for an anxiety disorder. Targeted diagnoses included Obsessive Compulsive Disorder, Simple Phobia, Separation Anxiety Disorder, Social Phobia, and Generalized Anxiety Disorder, with three of the children also presenting with school refusal behavior. Duration of baseline for each of the three groups varied and ran for one, two, or three weeks. Dependent measures included diagnostic status, child and parent-completed reports, and daily child and parent ratings of child anxiety severity. Results indicated that GCBT was efficacious in reducing anxious symptoms in children and adolescents treated in diagnostically heterogeneous groups, and that gains were generally maintained at 6 and 12 month follow-ups. Findings are discussed in terms of their theoretical and practical implications for the efficient treatment of children and adolescents with anxiety disorders. ^

Individual child cognitive behavioral treatment versus child-parent cognitive behavioral treatments for anxiety disorders in children and adolescents: Comparative outcomes

Anxiety disorders; such as separation anxiety disorder, generalized anxiety disorder, social phobia and specific phobia, are widespread in children and adolescents. Cognitive behavioral therapy (CBT) has been shown to be effective in reducing excessive fears and anxieties in children and adolescents. Research has produced equivocal findings that involving parents in treatment of child anxiety enhances effects over individual CBT (ICBT). The present dissertation study examined whether parental involvement can enhance individual treatment effect if the parent conditions are streamlined by targeting specific parental variables. The first parent condition, Parent Reinforcement Skills Training (RFST), involved increasing mothers' use of positive reinforcement and decreasing use of negative reinforcement. The second parent condition, Parent Relationship Skill Training (RLST), involved increasing maternal child acceptance and decreasing maternal control (or increasing autonomy granting). Results of the present dissertation findings support the use of all three treatment conditions (ICBT, RLST, RFST) for child anxiety; that is, significant reductions in anxiety were found in each of the three treatment conditions. No significant differences were found between treatment conditions with respect to diagnostic recovery rate, clinician rating, and parent rating of child anxiety. Significant differences between conditions were found on child self rating of anxiety, with some evidence to support the superiority of RLST and RFST to ICBT. These findings support the efficacy of individual, as well as parent involved CBT, and provide mixed evidence with respect to the superiority of parent involved CBT over ICBT. The conceptual, empirical, and clinical implications of the findings are discussed. ^

Individual Child Cognitive Behavioral Treatment versus Child-Parent Cognitive Behavioral Treatments for Anxiety Disorders in Children and Adolescents: Comparative Outcomes

Anxiety disorders; such as separation anxiety disorder, generalized anxiety disorder, social phobia and specific phobia, are widespread in children and adolescents. Cognitive behavioral therapy (CBT) has been shown to be effective in reducing excessive fears and anxieties in children and adolescents. Research has produced equivocal findings that involving parents in treatment of child anxiety enhances effects over individual CBT (ICBT). The present dissertation study examined whether parental involvement can enhance individual treatment effect if the parent conditions are streamlined by targeting specific parental variables. The first parent condition, Parent Reinforcement Skills Training (RFST), involved increasing mothers’ use of positive reinforcement and decreasing use of negative reinforcement. The second parent condition, Parent Relationship Skill Training (RLST), involved increasing maternal child acceptance and decreasing maternal control (or increasing autonomy granting). Results of the present dissertation findings support the use of all three treatment conditions (ICBT, RLST, RFST) for child anxiety; that is, significant reductions in anxiety were found in each of the three treatment conditions. No significant differences were found between treatment conditions with respect to diagnostic recovery rate, clinician rating, and parent rating of child anxiety. Significant differences between conditions were found on child self rating of anxiety, with some evidence to support the superiority of RLST and RFST to ICBT. These findings support the efficacy of individual, as well as parent involved CBT, and provide mixed evidence with respect to the superiority of parent involved CBT over ICBT. The conceptual, empirical, and clinical implications of the findings are discussed.

Treatment moderation and secondary outcomes: Results from a randomized clinical trial

The present study pursued two objectives in the context of a randomized clinical trial of cognitive-behavioral therapy with parent (CBT/P) and group (GCBT) involvement. The first objective was to examine the variability in treatment outcome. There were three specific aims within the first objective, to evaluate: (1) youth characteristics (age, depressive, and externalizing disorders) as moderators of treatment outcome; (2) the differential outcome of the treatment approaches as a function of youth characteristics; and (3) the relative efficacy of the treatment approaches at each level of the moderators. ^ The second objective was to evaluate the efficacy of anxiety treatments along secondary depressive symptoms and externalizing behaviors. There were five specific aims within the second objective, to evaluate: (1) whether anxiety treatment yields reductions in secondary problems, (2) the efficacy of anxiety treatments in reducing secondary problems as a function of approach and youth characteristics, (3) whether reductions in anxiety symptoms significantly mediate changes in secondary problems, (4) the directionality of change in the hypothesized mediated relations, and (5) whether the hypothesized mediated relations are moderated by treatment approach and youth characteristics. The specific aims were pursued using data collected from 183 youth and their mothers. Research questions were tested using multiple regressions and structural equation modeling. ^ Age, depressive, and externalizing disorders were significant moderators. CBT/P relative to GCBT lowered anxiety more for younger than older youth. GCBT relative to CBT/P lowered anxiety more for older than younger youth. GCBT relative to CBT/P lowered anxiety more for depressed youth than non-depressed youth. GCBT relative to CBT/P lowered anxiety less for externalizing youth than non-externalizing youth. Treatment reduced depressive symptoms and externalizing problem behaviors. Reductions in anxiety mediated changes in depressive symptoms and externalizing problem behaviors. Reversed directionality was found in the relation between social anxiety and depressive symptoms. In CBT/P the direction of change was from depressive to social anxiety. The opposite was true in GCBT. Reductions in social anxiety mediated posttreatment changes in depressive symptoms in GCBT but not CBT/P. The reverse was true at follow-up. Reductions in social anxiety mediated changes in depressive symptoms for girls but not boys.^

Anxious children who received treatment grow -up: An 8-to-13 year follow-up study

This dissertation examined the long-term efficacy (8-to-13 years, M = 9.54, SD = 1.689) of exposure-based cognitive-behavioral therapy (CBT) for phobic and anxiety disorders in youths. Long-term efficacy was examined in terms of diagnostic recovery, symptom reductions, and clinically significant change. This dissertation also examined predictors of long-term efficacy (e.g., age, gender, and other clinical characteristics) as well as the relative long-term efficacy of CBT for Hispanic/Latino and European American youth. ^ Participants consisted of 67 youth (age range 15–26 years; M = 19.43, SD = 3.02 years at time of follow-up assessment), (47.8% females, 37.3% Hispanic/Latino) who had participated in one of two clinical trials (Silverman et al., 1999a, b). After providing informed consent to participate in the long term follow-up, youths completed a diagnostic interview and a battery of questionnaires. Results indicated that treatment gains were maintained about 9.5 years after treatment was completed. Maintenance of treatment gains was evident in terms of diagnostic recovery, symptom reductions, and clinically significant change. Long-term treatment gains extended to both ethnic groups and the two ethnic groups were functionally equivalent along most indices examined. Analyses of predictors of long-term outcome showed that parent self-reported pre-treatment depression, youth-reported pre-treatment depression, and youths retrospective reports of negative life events were significantly associated with less favorable long-term gains in terms of total symptoms of anxiety at long-term follow-up. In terms of long-term sequelae, youths with less successful post-treatment outcomes reported seeking-out additional treatment as well as using/abused substances and substance dependence significantly more than youths with successful post-treatment outcomes. Results are discussed in terms of the contribution of the present study to knowledge base about the long-term efficacy of exposure-based CBT procedures for phobic and anxiety disorders in youth. Findings also are discussed in terms of the need to modify CBT procedures to target youths with less successful post-treatment outcomes. Limitations and future directions are presented. ^

Evaluation of a mentored self -help intervention for the management of psychotic symptoms

Cognitive behavioral therapy has been shown to be promising for the treatment of individuals experiencing psychotic symptoms, who are often diagnosed with schizophrenia. Using a non-random non-equivalent comparison group design (n = 26), this study explores whether an individually mentored self-help and self-paced intervention based upon cognitive behavioral approaches to auditory hallucinations or "hearing voices" makes a significant positive difference for individuals with major mental disorder diagnoses and psychotic symptoms who are residing in the community and receiving community mental health services. The mentored self-help intervention uses a workbook (Coleman & Smith, 1997) that stemmed from the British psychiatric survivor and "voice hearers"' movements and from cognitive behavioral approaches to treating psychotic symptoms. Thirty individuals entered the study. Pre- and post-intervention assessments of 15 participants in the intervention group and 11 participants in the comparison group were carried out using standardized instruments, including the Rosenberg Self-Esteem Scale, the Brief Psychiatric Rating Scale, and the Hoosier Assurance Plan Inventory - Adult. Four specific research questions address whether levels of self-esteem, overall psychotic symptoms, depression-anxiety, and disruption in life improved in the intervention group, relative to the comparison group. Pre- and post-assessment scores were analyzed using repeated measures analysis of variance. Results showed no significant difference on any measure, with the exception of the Brief Psychiatric Rating subscale for Anxious Depression, which showed a statistically significant pre-post difference with a strong effect size. A conservative interpretation of this single positive result is that it is due to chance. An alternative interpretation is that the mentored self-help intervention made an actual improvement in the level of depression-anxiety experienced by participants. If so, this is particularly important given high levels of depression and suicide among individuals diagnosed with schizophrenia. This alternative interpretation supports further research on the intervention utilized in this study. ^

The Influence of Psychological Predictors and Cognitive Behavioral Stress Management Intervention on Antiretroviral Therapy (ART) Adherence Among HIV-Positive Female Haitian Alcohol Users

Purpose: Over half the HIV-infected persons in the Caribbean, the second most HIV-impacted region in the world, live in Haiti. Using secondary data from a parent study, this research assessed the effects of psychological and social factors on antiretroviral therapy (ART) adherence among Haitian, HIV-positive, female alcohol users. Theoretical Foundation and Research Questions: Using the Theory of Planned Behavior/Reasoned Action and the Information, Motivation, Behavior skills model as guiding theoretical frameworks, the study examined the effectiveness of an adapted cognitive behavioral stress management (CBSM-A) intervention in improving ART adherence. The effect of psychological factors (depression, anxiety, beliefs about medicine, and social support), social factors (stigma, relationship status, and educational attainment), and alcohol on adherence to ART was assessed. Methods: The sample consisted of 116 female ART patients who were randomly assigned to the CBSM-A intervention or the wait-list control group. Participants completed intervention sessions as well as pre- and post-test assessments. Analyses of variance, t-tests, and point biserial correlations were used to test hypotheses. Results: Surprisingly, ART adherence rates significantly decreased for both groups combined [F (1, 108) = 8.79, p = .004]; there was no significant difference between the intervention and control groups with regard to the magnitude of change between baseline and post assessment. On average, depression decreased significantly among participants in the CBSM-A group only [(t (62) = 5.54, p < .001)]. For both groups combined, alcohol use significantly decreased between baseline and post-assessment [(F (1, 78) = 34.70, p < .001)]; there was no significant difference between the intervention and control groups with regard to the magnitude of change between baseline and post-assessment. None of the variables were significantly correlated with ART adherence. Discussion: Adherence to ART did not improve in this sample, nor were any of the variables significantly associated with adherence. The findings suggest that additional supportive and psychological services may be needed in order to promote higher adherence to ART among HIV-positive females. More research may be needed on this sample; a focus on mental health issues, partner conflict, family and sexual history may allow for better targeting and more successful interventions.

The role of individualism and collectivism as predictors of attributions for unethical work behavior: An empirical examination across two culturally diverse groups

This dissertation addresses how the cultural dimensions of individualism and collectivism affect the attributions people make for unethical behavior at work. The moderating effect of ethnicity is also examined by considering two culturally diverse groups: Hispanics and Anglos. The sample for this study is a group of business graduate students from two universities in the Southeast. A 20-minute survey was distributed to master's degree students at their classroom and later on returned to the researcher. Individualism and collectivism were operationalized as by a set of attitude items, while unethical work behavior was introduced in the form of hypothetical descriptions or scenarios. Data analysis employed multiple group confirmatory factor analysis for both independent and dependent variables, and subsequently multiple group LISREL models, in order to test predictions. Results confirmed the expected link between cultural variables and attribution responses, although the role of independent variables shifted, due to the moderating effect of ethnicity, and to the nuances of each particular situation. ^

Impact of a cognitive-behavioral weight control program on body weight, diet quality, and smoking cessation in weight-concerned female smokers

Many people use smoking as a weight control mechanism and do not want to quit because they fear weight gain. These weight-concerned smokers tend to be female, are significantly less likely to stop smoking, are less likely to join smoking cessation programs, and will relapse more often than smokers who are not weight-concerned. Research suggests that a woman’s confidence in her ability to control her weight after quitting relates positively with her intention to quit smoking. Likewise, success in smoking cessation has been associated with increased self-efficacy for weight control. It has been shown that success in changing one negative health behavior may trigger success in changing another, causing a synergistic effect. Recently research has focused on interventions for weight-concerned smokers who are ready to quit smoking. The present study investigated the effect of a cognitive based weight control program on self-efficacy for weight control and the effect on smoking behavior for a group of female weight concerned smokers. Two hundred and sixteen subjects who wanted to lose weight but who were not ready to quit smoking were recruited to participate in a 12-week, cognitive-behavioral weight control program consisting of twelve one-hour sessions. Subjects were randomly assigned to either (1) the weight-control program (intervention group), or (2) the control group. Results of this study demonstrated that subjects in the intervention group increased self-efficacy for weight control, which was associated with improved healthy eating index scores, weight loss, increased self-efficacy for quitting smoking, a decrease in number of cigarettes smoked and triggered positive movement in stage of change towards smoking cessation compared to the control subjects. For these subjects, positive changes in self-efficacy for one behavior (weight control) appeared to have a positive effect on their readiness to change another health behavior (smoking cessation). Further study of the psychological variables that influence weight-concerned female smokers’ decisions to initiate changes in these behaviors and their ability to maintain those changes are warranted.

Examination of the impact of personality, social, and cognitive factors on the co-occurrence of health risk behaviors among multi-problem youth: The utility of an integrative framework

Research has identified a number of putative risk factors that places adolescents at incrementally higher risk for involvement in alcohol and other drug (AOD) use and sexual risk behaviors (SRBs). Such factors include personality characteristics such as sensation-seeking, cognitive factors such as positive expectancies and inhibition conflict as well as peer norm processes. The current study was guided by a conceptual perspective that support the notion that an integrative framework that includes multi-level factors has significant explanatory value for understanding processes associated with the co-occurrence of AOD use and sexual risk behavior outcomes. This study evaluated simultaneously the mediating role of AOD-sex related expectancies and inhibition conflict on antecedents of AOD use and SRBs including sexual sensation-seeking and peer norms for condom use.^ The sample was drawn from the Enhancing My Personal Options While Evaluating Risk (EMPOWER: Jonathan Tubman, PI), data set (N = 396; aged 12-18 years). Measures used in the study included Sexual Sensation-Seeking Scale, Inhibition Conflict for Condom Use, Risky Sex Scale. All relevant measures had well-documented psychometric properties. A global assessment of alcohol, drug use and sexual risk behaviors was used.^ Results demonstrated that AOD-sex related expectancies mediated the influence of sexual sensation-seeking on the co-occurrence of alcohol and other drug use and sexual risk behaviors. The evaluation of the integrative model also revealed that sexual sensation-seeking was positively associated with peer norms for condom use. Also, peer norms predicted inhibition conflict among this sample of multi-problem youth. ^ This dissertation research identified mechanisms of risk and protection associated with the co-occurrence of AOD use and SRBs among a multi-problem sample of adolescents receiving treatment for alcohol or drug use and related problems. This study is informative for adolescent-serving programs that address those individual and contextual characteristics that enhance treatment efficacy and effectiveness among adolescents receiving substance use and related problems services.^

The Theory of Planned Behavior and Ethnically Diverse Community College Students and Their Intentions to Exercise: A Preliminary Analysis

Although regular exercise is the key to a healthy lifestyle, college students are insufficiently active to maintain good health. Motivations to exercise may vary among different ethnic groups. The results of a pilot study using the Theory of Planned Behavior (Gordon, 2008) showed that ethnically diverse college students can rate their beliefs (behavioral, social, and cognitive) pertaining to physical activity.

Cognitive performance and the thymus among HIV-infected subjects receiving HAART

Objective: To evaluate the impact of alcohol use, which is widespread in human immunodeficiency virus (HIV)+ individuals, on highly active antiretroviral therapy (HAART)-associated immune and cognitive improvements and the relationship between those two responses. Methods: In a case-control longitudinal study, thymic volume, cognition, and immune responses were evaluated at baseline and after 6 months therapy in HIV+ and HIV- controls. Cognitive performance was evaluated using the HIV Dementia Score (HDS) and the California Verbal Learning Test (CVLT). Results: Prior to HAART, thymic volume varied considerably from 2.7 to 29.3 cm3 (11 ± 7.2 cm3). Thymic volume at baseline showed a significantly inverse correlation with the patient’s number of years of drinking (r2 = 0.207; p < 0.01), as well as HDS and the CVLT scores in both HIV-infected (r2 = 0.37, p = 0.03) and noninfected (r2 = 0.8, p = 0.01). HIV-infected individuals with a small thymic volume scored in the demented range, as compared with those with a larger thymus (7 ± 2.7 vs. 12 ± 2.3, p = 0.005). After HAART, light/moderate drinkers exhibited thymus size twice that of heavy drinkers (14.8 ± 10.4 vs. 6.9 ± 3.3 cm3). Conclusions: HAART-associated increases of thymus volume appear to be negatively affected by alcohol consumption and significantly related to their cognitive status. This result could have important clinical implications.

Subject -centered and problem -based approaches to teaching clinical competence in physical therapy

Physical therapy students must apply the relevant information learned in their academic and clinical experience to problem solve in treating patients. I compared the clinical cognitive competence in patient care of second-year masters students enrolled in two different curricular programs: modified problem-based (M P-B; n = 27) and subject-centered (S-C; n = 41). Main features of S-C learning include lecture and demonstration as the major teaching strategies and no exposure to patients or problem solving learning until the sciences (knowledge) have been taught. Comparatively, main features of M P-B learning include case study in small student groups as the main teaching strategy, early and frequent exposure to patients, and knowledge and problem solving skills learned together for each specific case. Basic and clinical orthopedic knowledge was measured with a written test with open-ended items. Problem solving skills were measured with a written case study patient problem test yielding three subscores: assessment, problem identification, and treatment planning. ^ Results indicated that among the demographic and educational characteristics analyzed, there was a significant difference between groups on ethnicity, bachelor degree type, admission GPA, and current GPA, but there was no significant difference on gender, age, possession of a physical therapy assistant license, and GRE score. In addition, the M P-B group achieved a significantly higher adjusted mean score on the orthopedic knowledge test after controlling for GRE scores. The S-C group achieved a significantly higher adjusted mean total score and treatment management subscore on the case study test after controlling for orthopedic knowledge test scores. These findings did not support their respective research hypotheses. There was no significant difference between groups on the assessment and problem identification subscores of the case study test. The integrated M P-B approach promoted superior retention of basic and clinical science knowledge. The results on problem solving skills were mixed. The S-C approach facilitated superior treatment planning skills, but equivalent patient assessment and problem identification skills by emphasizing all equally and exposing the students to more patients with a wider variety of orthopedic physical therapy needs than in the M P-B approach. ^