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Anger outbursts (AO) are associated with severe symptoms, impairment and poorer treatment outcomes for anxious children, though limited research has examined AO in youth with co-occurring autism and anxiety disorders. This study examined AO in children with autism and anxiety by evaluating clinical characteristics, family accommodation, and changes in AO following anxiety-focused treatment. The sample comprised 167 youth with autism and anxiety enrolled in a multi-site randomized clinical trial comparing standard care CBT for anxiety, CBT adapted for youth with autism, and usual care. Most participants (60%) had AO, which contributed to impairment above and beyond anxiety and autism. AO impacted functional impairment indirectly through a pathway of parental accommodation. AO reduced with anxiety-focused treatment. Findings highlight that AO are common in this population and uniquely contribute to functional impairment, indicating a need for direct targeting in treatment., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

A clear understanding of the item content of psychological assessments is critical but often overlooked. This study describes the content overlap of seven commonly used and psychometrically validated measures of anxiety among children and adolescents. Symptom codes were created for all items across measures and items were sorted by these codes, which all fell into specific symptom categories. We conducted two analyses of all items: a "bottom-up" content categorization approach, which used symptom categories that were developed during this study, and a "top-down" DSM-5 categorization which mapped items onto symptoms of anxiety disorders in the DSM-5. Findings reveal a weak mean overlap across the included measures of youth anxiety. This suggests that the scope of anxiety measures should be carefully considered when designing studies, interpreting research, or assessing youth in clinical practice. Further research is needed to develop and establish a coding scheme for a more objective, comprehensive content analysis., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Parent-led cognitive behavioral therapy (CBT) is an efficient, promising form of therapy that may be well suited for autistic youth with anxiety disorders, though to date it has been minimally tested. In this study, 87 autistic youth (7 to 13 years old) with anxiety disorders and their parents were randomized to two forms of parent-led CBT in which parents led their child through a guided CBT workbook across 12 weeks: one with low therapist contact (four 30-minute telehealth calls), and one with standard therapist contact (ten 60-minute telehealth calls). Anxiety, functional impairment, and autism features significantly declined across therapy, without differences between groups. High satisfaction was reported in both groups, though significantly higher satisfaction ratings were reported in standard-contact CBT. Responder rates were 69% of completers at posttreatment (70% in standard contact, 68% in low contact) and 86% at 3-month follow-up (86% in standard contact, 87% in low contact). Low-contact CBT was estimated to incur an average cost of $755.70 per family compared with $1,978.34 in standard-contact CBT. Parent-led CBT with minimal or standard therapist contact both appear to be effective CBT delivery formats for autistic youth with anxiety disorders, with significant cost savings for low-contact CBT., (Copyright © 2023 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.)

Background: Misophonia is a complex condition characterized by extreme emotional distress in response to specific sounds or specific visual stimuli. Despite a growing body of clinical and neuroscientific literature, the etiology of this condition remains unclear. Hyperarousal, that is, a state of heightened alertness and disinhibition, as a core feature of misophonia is supported by behavioral and neuroimaging literature and might represent a viable clinical target for the development of both behavioral and pharmacological interventions. The aim of this study was to investigate how hyperarousal might be linked to neurocognitive processes associated with vigilance and stimulus discrimination in youth with misophonia., Methods: We compared 72 children and adolescents with misophonia (13.74 ± 2.44 years) (64 % female) and 89 children and adolescents with anxiety (12.35 ± 2.57 years) (58.4 % female) on behavioral and signal detection performance of the immediate memory task (IMT). Anxiety patients were used as a clinical control group to distinguish attentional processes specific for misophonia., Results: Both groups demonstrated similar behavioral performance, including response rate and reaction time. However, misophonia was associated with elevated stimulus discrimination (d prime), which in turn was positively correlated with the severity of misophonia trigger reports., Conclusions: Our findings are in line with previous cognitive and neuroimaging studies, and support an arousal-based model of misophonia, where individuals with misophonia experience a state of heightened vigilance, being more aware of stimuli in the environment. Our findings provide a neurocognitive basis for future study of neurochemical imaging that might further progress towards clinical targets., Competing Interests: Declaration of competing interest N. Murphy has received grants/research support from NIMH (1R21MH119441-01A1); REAM Misophonia Research Fund (The REAM Foundation - YR01); Caroline Wiess Law Fund for Research in Molecular Medicine, and has previously received research support as a subinvestigator for clinical research for Neurocrine Biosciences Inc. M. Cervin receives research support from the Swedish Research Council for Health, Working Life and Welfare, the Lindhaga Foundation, Stiftelsen Clas Grochinskys Minnesfond, the Crown Princess Lovisa's Association, Region Skåne, and Skåne University Hospital's Foundations and Donations; and financial compensation from Springer for editorial work outside of the submitted work. Dr. Guzick receives grant support from the REAM Foundation/Misophonia Research Fund as well as the Texas Higher Education Coordinating Board. Dr. Storch reports receiving research funding to his institution from the Ream Foundation, International OCD Foundation, and NIH. He is a consultant for Brainsway and Biohaven Pharmaceuticals. He owns stock less than $5000 in NView (for distribution of the Y-BOCS and CY-BOCS) and Limbix. He receives book royalties from Elsevier, Wiley, Oxford, American Psychological Association, Guildford, Springer, Routledge, and Jessica Kingsley., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Exposure therapy is a highly effective, evidence-based treatment technique for children and adolescents with anxiety disorders. Regardless, therapists in the community are reported to use exposure relatively rarely compared with other approaches. The goal of the present study was to identify how practicing clinicians treat youth with anxiety disorders across the United States and what factors contribute to their use of exposure therapy. Recruited from public directories, 257 private practice therapists who treat anxious youth were surveyed. Non-exposure cognitive-behavioral techniques like cognitive restructuring and relaxation techniques were used significantly more frequently than exposure. Providers with more training in exposure therapy and fewer negative beliefs about this approach reported using exposure significantly more in the treatment of youth with social anxiety, obsessive-compulsive, and panic disorders. Self-identification as an anxiety disorder specialist significantly predicted exposure use for youth with posttraumatic stress disorder. Most therapists in private practice have minimal training in exposure therapy, perceive a lack of training options, and believe there would be a benefit to acquiring more training. The implications of these findings are discussed, including how to optimally design training opportunities in exposure therapy., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

This study investigated the prevalence of common barriers to the use of exposure therapy (ET) in the treatment of youth with anxiety disorders, specifically examining both logistical limitations and negative beliefs about ET. Results from 230 practicing clinicians who treat youth with anxiety disorders found that the top three barriers were session length (56%), lack of training (48%), and concern about parent reaction (47%). Endorsement of barriers to ET was associated with less ET utilization and less optimal implementation of ET. Results suggest that several barriers, especially logistical limitations, must be addressed in order to improve the dissemination of ET.

Anxiety/obsessive-compulsive disorders are common among youth with autism spectrum disorder (ASD). Two versions of cognitive behavior therapy (CBT) are effective, with some advantage for a personalized, adapted version. This study evaluated predictors and moderators of standard CBT and adapted CBT. Youth (N = 167) ages 7-13 were randomized to standard or adapted CBT, or treatment-as-usual. Age, IQ, ASD severity, and emotional-behavioral symptom severity were examined. More severe internalizing and emotional-behavioral problems predicted poorer treatment outcomes especially in standard versus personalized CBT. Elevated repetitive behaviors and restricted interests predicted poorer treatment outcomes across treatments, though youth with "moderate" repetitive behaviors and restricted interested experienced poorer outcomes only in standard but not personalized CBT. Externalizing symptoms directly predicted treatment outcomes. Older age predicted improved outcomes in adapted but not standard CBT. Findings highlight the need for further treatment refinements and the value in adapting treatment for youth with more complex presentations.

• Family accommodation has not been explored in youth with misophonia. • Accommodation was common and more frequent in anxious youth. • Family accommodation directly predicted misophonia severity. • Accommodation may be an important intervention target. Family accommodation (e.g., reassurance, modifying routines, assisting avoidance) has not been explored among youth with misophonia but may have important clinical and intervention implications. We examined family accommodation in 102 children and adolescents with interview-confirmed misophonia and compared its frequency and content to family accommodation in 95 children and adolescents with anxiety disorders. Findings showed that family accommodation was ubiquitous in pediatric misophonia and may be even more frequent than in youth with anxiety disorders. Assisting the child, participating in misophonia-related behaviors, and modifying family routines were endorsed by more than 70% of parents of children with misophonia. Further, compared to parents of children with anxiety disorders, parents of children with misophonia more frequently reported child distress and anger when they did not accommodate. Family accommodation was moderately to strongly associated with misophonia severity even when accounting for co-occurring internalizing and externalizing symptoms and sociodemographic factors. This first study of family accommodation in pediatric misophonia suggests accommodation may be an important clinical feature. A notable study limitation is that the measure of misophonia did not delineate between adaptive versus maladaptive accommodations. Excessive and maladaptive accommodation may be one potential candidate to target in interventions when considered within a broader treatment plan. Importantly, adaptive accommodations should also be considered in day-to-day management if they improve functioning and quality of life. [ABSTRACT FROM AUTHOR]

There is a tremendous need for brief, valid, and free assessments of anxiety in child mental healthcare. The goal of this study was to determine the psychometric properties of two such measures, the GAD-7 and PROMIS-Anxiety-4a, in 1000 children, adolescents, and young adults (8-20 years-old) with depression and/or suicidality. The GAD-7, the PROMIS-Anxiety-4a, and other validated assessments of anxiety, physical functioning, and psychiatric diagnoses were completed. Confirmatory factor analyses showed an acceptable fit for a single factor in both measures via all indices but the RMSEA. They demonstrated measurement invariance across pre-adolescents (8-12 years-old) and adolescents and emerging adults (13-20 years-old), though scalar invariance was not observed for the GAD-7. Both measures showed strong convergent validity, GAD-7: r = 0.68; PROMIS-Anxiety-4a: r = 0.75, divergent validity with a measure of physical function, GAD-7: r = -0.24; PROMIS-Anxiety-4a: r = -0.28, good internal consistency, ω = 0.89 for both, and high test-retest reliability, GAD-7: r = 0.69; PROMIS-Anxiety-4a: r = 0.71. Both measures also showed acceptable sensitivity and specificity in detecting the presence of any anxiety disorder, GAD-7 cut-off score of 10: AUC = 0.75; PROMIS-Anxiety-4a cutoff score of 12: AUC = 0.79. The GAD-7 correlated similarly with the Screen for Child Anxiety Related Disorders total score and generalized anxiety subscale, and also showed similar diagnostic sensitivity and specificity when used to detect the presence of any anxiety disorder vs. generalized anxiety disorder specifically. Results suggest that both of these brief, publicly available instruments are valid and reliable assessments of anxiety among youth in treatment for depression and/or suicidality. • Explored psychometrics of GAD-7 & PROMIS-Anxiety-4a among depressed/suicidal youth. • Both showed acceptable single factor fit. • Both showed strong convergent and divergent validity. • Both showed acceptable diagnostic utility in screening for anxiety disorders. • GAD-7 is valid in assessing anxiety broadly and generalized anxiety specifically. [ABSTRACT FROM AUTHOR]

Background: Anxiety disorders are the most frequently diagnosed psychiatric conditions in children and adolescents. Cognitive behavioural therapy (CBT) is a well-established and effective treatment for anxiety and related disorders across the lifespan. Expectations of psychotherapy have been demonstrated to affect outcomes, yet there is sparse existing literature on adolescent patient and parent perspectives of CBT prior to engagement with treatment. Aims: This study aimed to qualitatively explore the expectations and perceptions of CBT for anxiety and related disorders among adolescent patients and parents. Method: Fourteen adolescent patients and 16 parents participated in semi-structured individual interviews or focus groups consisting of 2–3 participants. Interview transcripts were analysed using inductive analysis. Results: Three themes were identified: worries about CBT, expectations and knowledge of the CBT process, and the role of parents and families. Overall, we found that adolescents and parents had generally positive views of CBT. The outset of CBT saw adolescents and parents express concern about stigma as well as the ambiguity of CBT. Parents continued to express a lack of understanding of what CBT entailed during their child's treatment course. Conclusion: These results suggest that both adolescents and parents would benefit from early discussion and reinforcement of expectations for CBT treatment. Further research efforts are warranted and should be directed towards determining appropriate expectations for parental involvement in a child's CBT course and effective communication of treatment expectations to both adolescents and parents. [ABSTRACT FROM AUTHOR]

There is little information on the clinical presentation, functional impact, and psychiatric characteristics of misophonia in youth, an increasingly recognized syndrome characterized by high emotional reactivity to certain sounds and associated visual stimuli. One-hundred-two youth (8–17 years-old) with misophonia and their parents were recruited and compared with 94 youth with anxiety disorders. Participants completed validated assessments of misophonia severity, quality of life, as well as psychiatric symptoms and diagnoses. The most common misophonia triggers included eating (96 %), breathing (84 %), throat sounds (66 %), and tapping (54 %). Annoyance/irritation, verbal aggression, avoidance behavior, and family impact were nearly universal. Misophonia severity was associated with internalizing symptoms, child-reported externalizing behaviors, and poorer quality of life. High rates of comorbidity with internalizing and neurodevelopmental disorders were found. Quality of life and externalizing behaviors were not significantly different between misophonia and anxiety samples; internalizing symptoms and autism characteristics were significantly higher among youth with anxiety disorders. This self-selected sample was characterized by limited multicultural diversity. This study presents misophonia as a highly impairing psychiatric syndrome. Future interdisciplinary work should clarify the mechanisms of misophonia, establish evidence-based treatments, and extend these findings to randomly sampled and more culturally diverse populations. • Misophonia was associated with substantial functional impairment in this sample • Anger/irritation, avoidance behavior, and impact to family life were nearly universal • Anxiety disorders were common (45%) as were current or past depressive disorders (46%) • Other common comorbidities were attention-deficit/hyperactivity disorder (21%) and tic disorders (13%) • Youth with misophonia had elevated internalizing symptoms and autism features (though less than youth with anxiety) [ABSTRACT FROM AUTHOR]

Objective: To evaluate improvement during the (a) cognitive and (b) exposure therapy phases of cognitive–behavioral therapy (CBT) for autistic youth with anxiety disorders. Method: Participants were 148 autistic youth (aged 7–13; 77% male; 64% White) with clinically significant anxiety who were randomized to standard or adapted CBT. Clinician-rated anxiety severity was recorded at each appointment. Trajectories of change during (a) the cognitive phase and (b) the exposure phase of treatment were analyzed using piecewise multilevel modeling. Results: Compared to the psychoeducation and cognitive therapy phases, the exposure phase corresponded with significantly more rapid symptom reduction, b = −.11, 95% CI [−.13, −.071]. This finding was true for standard CBT, which included nine sessions prior to exposure initiation (on average), as well as for CBT personalized for autistic youth, which introduced exposure following the fifth session (on average). In contrast, compared with improvements during initial psychoeducation sessions, the introduction of cognitive skills corresponded with significantly slower symptom reduction, b =.066, 95% CI [.020,.11]. This finding was also true for both adapted and standard CBT. Conclusions: Results underscore the central role of exposure in the treatment of anxiety among autistic youth and question the utility of cognitive strategies without subsequent practice of these skills during exposure. Assuming a working relationship, therapists should consider moving through the preexposure coping phase of CBT quickly. Future research should evaluate the extent to which exposure can maintain its potency while minimizing coping skill preparation. What is the public health significance of this article?: Clinically significant anxiety is highly prevalent and causes substantial functional impairment in autistic youth. This study identified an acceleration of improvement during the exposure therapy phase of cognitive–behavioral therapy and minimal change during the cognitive portion. This finding was the case in a protocol that introduced exposure after the fifth session and in a protocol that introduced exposure after the ninth session, suggesting that introducing exposure earlier in treatment has the potential to enhance the efficiency and efficacy of treatment. [ABSTRACT FROM AUTHOR]

Dental anxiety seems to be elevated in children with autism spectrum disorder (ASD), and may be associated with feelings of helplessness, loss of control, and sensory overload. Dental anxiety, a primary contributor to dental avoidance, can lead to unwanted long-term oral hygiene consequences. This manuscript characterizes the frequency and correlates of dental anxiety in children with ASD. Specifically, this study examined associations between child-reported dental anxiety and parent-reported autism symptom severity, anxiety symptom severity, sensory sensitivity, and internalizing/externalizing symptom severity. Participants included 76 children without cognitive impairment (age in years M = 9.9, SD = 1.8) who took part in a cognitive behavioral therapy study for children with ASD and co-occurring anxiety disorders. Elevated dental anxiety was found in 68% of participants based on a cut-off score from a dental anxiety measure, with fears related to pain being the most commonly endorsed concern; over half of youth endorsed feeling scared about pinching feelings or having a tooth pulled out at the dentist. No significant correlations between dental anxiety and other variables of interest were found, including overall anxiety severity, ASD symptoms, internalizing and externalizing symptoms, and sensory sensitivities. The findings contextualize the frequency of dental anxiety and its relationship to various variables, which may be useful in tailoring existing treatments to reduce dental anxiety in children with ASD. [ABSTRACT FROM AUTHOR]

Although exposure therapy (ET) is an effective treatment for anxiety disorders and obsessive-compulsive disorder, many clinicians report not utilizing it. The present study targeted common utilization barriers by evaluating an intensive ET training experience in a relatively inexperienced sample of pre-professionals. Thirty-two individuals at the undergraduate or college graduate level without formal clinical experience participated as camp counsellors in a 5day exposure-based therapeutic summer camp for youth with anxiety disorders and/or obsessive-compulsive disorder. Participants were trained in ET through a progressive cascading model and answered questionnaires before and after camp. Repeated measure MANOVA revealed significantly increased feelings of self-efficacy conducting exposures, and significantly decreased feelings of disgust sensitivity and contamination-related disgust from pre-camp to post-camp. A subset of individuals providing data 1 month after the camp maintained a significant gain in ET self-efficacy. Regression analyses revealed that contamination-related disgust, but not disgust sensitivity, significantly predicted post-camp ET self-efficacy. These findings suggest that individuals early into their post-secondary education can learn ET, and the progressive cascading model holds promise in its utility across experience levels and warrants further investigation. Disgust may also play a role in feelings of competency conducting ET. Implications on dissemination and implementation efforts are also discussed. Key learning aims: (1) How can training of CBT techniques such as exposure occur prior to graduate education? (2) Can self-efficacy in conducting exposures meaningfully increase in an experiential training of pre-professionals? (3) How does an individual's tolerance of disgust impact feelings of competence conducting exposures? [ABSTRACT FROM AUTHOR]

Objective: Deep brain stimulation (DBS) of the ventral capsule/ventral striatum (VC/VS) region has shown promise as a neurosurgical intervention for adults with severe treatment-refractory obsessive-compulsive disorder (OCD). Pilot studies have revealed improvement in obsessive-compulsive symptoms and secondary outcomes following DBS. We sought to establish the long-term safety and effectiveness of DBS of the VC/VS for adults with OCD. Materials and Methods: A long term follow-up study (73–112 months) was conducted on the six patients who were enrolled in the original National Institute of Mental Health pilot study of DBS for OCD. Qualitative and quantitative data were collected. Results: Reduction in OCD symptoms mirrored the one-year follow-up data. The same four participants who were treatment responders after one year of treatment showed a consistent OCD response (greater than 35% reduction in Yale Brown Obsessive Compulsive Scale (YBOCS)). Another subject, classified as a non-responder, achieved a 26% reduction in YBOCS score at long term follow-up. The only patient who did not achieve a 25% or greater reduction in YBOCS was no longer receiving active DBS treatment. Secondary outcomes generally matched the one-year follow-up with the exception of depressive symptoms, which significantly increased over the follow-up period. Qualitative feedback indicated that DBS was well tolerated by the subjects. Discussion: These data indicate that DBS was safe and conferred a long-term benefit in reduction of obsessive-compulsive symptoms. DBS of the VC/VS region did not reveal a sustained response for comorbid depressive symptoms in patients with a primary diagnosis of OCD. [ABSTRACT FROM AUTHOR]

Little has been written as to how clinicians in specialty treatment clinics go about training unlicensed trainees to work with patients with OCD. The University of Florida's OCD (UF OCD) treatment and training program was founded over 20 years ago by Drs. Wayne Goodman and Gary Geffken and has reported treatment response rates above the national average. The success of the program is largely due to a continued emphasis on trainee development through a progressive cascading model of mentorship. Using this competency based model, the UF OCD program focuses on skill acquisition and competency based evaluation through mentoring, collaboration, and co-therapy with clinicians and other trainees. Trainee satisfaction with this model was assessed using qualitative and questionnaire based feedback from trainees whom had completed at least one semester within the training program. Most trainees felt competent in implementing exposure therapy and were satisfied following their training within the program, reporting particular benefit from the co-therapy approach. Recommendations for implementation of this model in graduate training clinics are discussed. [ABSTRACT FROM AUTHOR]