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In randomized control trials (RCTs), a focus on average differences between treatment arms often limits our understanding of whether individuals show clinically significant improvement or deterioration. The present study examined differences in individual-level clinical significance trajectories between Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) and Relapse Prevention (RP). Eighty-one treatment-seeking veterans with a comorbid PTSD/SUD diagnosis were randomized to COPE or RP; data from an additional n = 48 patients who did not meet criteria for both disorders was used to establish a normative threshold. A newly developed, modernized approach to the Jacobson and Truax (1991) clinically significant change framework, using (a) moderated nonlinear factor analysis (MNLFA) scale scoring and (b) measurement error-corrected multilevel modeling (MEC-MLM) was used; this approach was compared to other approaches using conventional total scores and/or assuming no measurement error. Using a conventional approach to estimating the Reliable Change Index (RCI) yielded no differences between COPE and RP in the percentage of patients achieving statistically significant improvement (SSI; 88.9% for both groups). However, under MNLFA/MEC-MLM, higher percentages of patients receiving COPE (75.0%) achieved SSI compared to RP (40.7%). Findings suggest that, even though COPE and RP appear to reduce the same number of PTSD symptoms, MNLFA scoring of outcome measures gives greater weight to interventions that target and reduce "hallmark" PTSD symptoms.

Objective: The co-occurrence of substance use disorders (SUD) and trauma-exposure is a risk factor for suicidal thoughts and behaviors (STB). However, traditional methods of measurement for suicidal thoughts and behaviors are limited by an overreliance on dichotomous (i.e., yes or no) and averaged/summed scale score measurements. Further, among trauma-exposed individuals with SUD, it remains unclear which specific demographic factors, types of SUDs, and trauma sequelae (e.g., posttraumatic stress disorder [PTSD] symptom clusters) may be associated with elevated STB. The present study utilized item response theory to (a) generate empirically derived STB severity scores and, (b) examine which demographic factors, SUD diagnoses, and DSM-IV PTSD symptom clusters are associated with suicidality in a trauma-exposed sample with SUDs. Method: Female trauma-exposed participants with SUDs (N = 544) were recruited from community substance use treatment facilities in the National Drug Abuse Treatment Clinical Trials Network (CTN). Clinician-administered interviews assessed STB, SUDs, and PTSD symptoms. Results: Results indicated that the unidimensional item response theory (IRT) model used to estimate latent STB severity scores fit well, with strong local reliability at higher levels of latent STB severity. Regression predictors of elevated STB severity included younger age, opioid dependence, and higher PTSD reexperiencing symptoms. Conclusions: Clinicians are advised to screen for and target opioid use disorders and reexperiencing symptoms when addressing suicidal thoughts and behavior in trauma-exposed individuals with SUDs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

We compared the effectiveness of audio care to usual care for managing mental health and substance use disorders.

Treatment efficacy for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders is well established, yet direct evidence for comparative effectiveness across treatments is lacking. The present study compared the effectiveness of several behavioral and pharmacological therapies for adults with co-occurring PTSD and alcohol or other drug use disorders.A systematic search of PsycINFO, MEDLINE, and ClinicalTrials.gov was conducted through December 2020 for trials targeting PTSD, alcohol or other drug use disorders, or both disorders (36 studies, N=4,046). Primary outcomes were severity scores for PTSD, alcohol use, and drug use, estimated via moderated nonlinear factor analysis. Propensity score weight-adjusted multilevel models were used. Model-predicted effect sizes were estimated for each treatment, and comparative effect sizes for each active arm against treatment as usual, at end of treatment and at 12-month follow-up.Compared with treatment as usual, combining trauma-focused therapy and pharmacotherapy for substance use disorders showed the largest comparative effect sizes for PTSD severity (d=-0.92, 95% CI=-1.57, -0.30) and alcohol use severity (d=-1.10, 95% CI=-1.54, -0.68) at end of treatment. Other treatments with large comparative effect sizes included pharmacotherapies for alcohol or other drug use disorders, trauma-focused integrated therapies, and trauma-focused nonintegrated therapies. Reductions in outcomes for PTSD symptoms and alcohol use were observed for nearly all treatments.The findings provide support for treating comorbid PTSD and substance use disorders using a variety of approaches, with alcohol-targeted pharmacotherapies and trauma-focused behavioral therapies as a combination of treatments that lead to early and sustained improvements in PTSD and alcohol use severity. Further treatment development is indicated for combining behavioral and pharmacological treatments for synergized impact and understanding the mechanisms of action and conditions under which each treatment type is optimized.

We used a Boolean search strategy of PubMed, PsycINFO, and Embase to identify eligible publications from January 1990 to March 2020 and narrative analysis to synthesize the evidence.The database search identified 1267 independent citations; 29 publications met inclusion criteria. Nearly all the studies demonstrated high risk of bias, most often due to selection and confounding bias. Most of the studies in the review (This review highlights the importance of social connection as a correlate to opioid misuse. However, the extensive variability among research studies points to a need for standardization of measurement and larger studies with diverse populations to allow for consequential recommendations for prevention or treatment of opioid misuse. Evidence regarding the associations between social connection and opioid misuse or disorder is sparse. We provide suggestions for advancing this research, including clarification of the complex influences between social connections and opioid misuse.

The Helping to End Addiction Long-Term (HEAL) Prevention Cooperative (HPC) is rapidly developing 10 distinct evidence-based interventions for implementation in a variety of settings to prevent opioid misuse and opioid use disorder. One HPC objective is to compare intervention impacts on opioid misuse initiation, escalation, severity, and disorder and identify whether any HPC interventions are more effective than others for types of individuals. It provides a rare opportunity to prospectively harmonize measures across distinct outcomes studies. This paper describes the needs, opportunities, strategies, and processes that were used to harmonize HPC data. They are illustrated with a strategy to measure opioid use that spans the spectrum of opioid use experiences (termed involvement) and is composed of common "anchor items" ranging from initiation to symptoms of opioid use disorder. The limitations and opportunities anticipated from this approach to data harmonization are reviewed. Lastly, implications for future research cooperatives and the broader HEAL data ecosystem are discussed.

Across multiple RCTs, discrepancies between patient and clinician reports of PTSD symptoms are at least a partial contributing factor to large discrepancies between treatment outcome effect sizes from self-report and clinician reports within the same patients. Using secondary data from the NIDA-funded Women and Trauma Study, we demonstrated Common Persons Item Response Theory (IRT) Calibration for calibrating self-reported and clinician-reported PTSD severity scores in a manner similar to the process used to produce equated scores across multiple forms of standardized tests (e.g., SAT, GRE). Under IRT calibration, treatment effect sizes between the CAPS and MPSS-SR did not differ, while with the noncalibrated measures, the CAPS effect size was 85% larger than the MPSS-SR. Further, across the range of a combined CAPS/MPSS-SR gold standard, IRT-calibrated CAPS and MPSS-SR individual scores did not differ; for uncalibrated individual scores, MPSS scores were higher than CAPS scores at higher levels of PTSD severity while the reverse was true at lower levels of severity. The use of IRT calibration approaches for calibrating self-report and clinical interview measures of PTSD will allow treatment researchers to reflect the treatment effect on PTSD as a construct (regardless of reporter) as opposed to being limited to reporting treatment effects that may be discrepant within patients and specific to the particular assessment measure being employed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Introduction The “Women and Trauma” Study (WTS) conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN-0015) resulted in research publications, presentations, and a train-the-trainer workshop to support dissemination efforts for skills-based trauma treatment in substance use community treatment. Twelve years after its completion, this paper aims to examine whether and how the WTS contributed to knowledge in the field of trauma and addictions and inspired community treatment programs (CTPs) to train staff to identify and provide trauma-related services. Method: We present findings from two different analyses that explored longer term study impacts on treatment and dissemination: (1) a post-study site survey covering 4 domains from 4/7 programs that participated in delivering the WTS to evaluate their perceptions of study impact on their treatment community; and (2) an analysis of citations of its publications to determine impact on the scientific community. Results: Surveys from responding sites indicated that participation in the study significantly increased their agencies’' awareness of the need to take a focused approach to treating trauma issues in this population. Specifically, these sites increased their commitment to using skills-based trauma treatment with the study's target population of female patients with SUD and trauma histories, as well as expanding it to other groups affected by trauma. Citation analysis revealed that according to the Web of Science, as of August 2019, the number of citations of 24 CTN-0015 articles, ranged from 1 to 135 (Mean = 20, SD = 33; Median = 6). Four of the most influential are discussed. Conclusions: This manuscript provides original information about the contributions of the WTS study, demonstrating how the study contributed to serving women with trauma in community substance use treatment.

The negative consequences for victims and perpetrators of school violence are significant, multifaceted and, if left unchecked, can have personal costs that may last well into their adult lives. Universal violence preventive interventions may not be sufficiently effective in mitigating problems among middle school youth who exhibit risk of violent behavior. School-based mental health (SBMH) approaches show promise for reducing problems among the minority of youth responsible for violence perpetration, although the impact of teacher-delivered SBMH has been somewhat limited. The present study examines the impact of practitioner-delivered SBMH in middle school settings, with (a) a three-armed randomized controlled trial (RCT) comparing Expanded SBMH and Enhanced SBMH to Standard SBMH and (b) a separate quasi-experiment comparing the three SBMH arms in the RCT to a separate set of non-randomized, non-SBMH schools. SBMH schools who expanded their services saw decreases in aggressive behavior and victimization, across both study structures, that were either statistically significant, meaningful based on Cohen effect size conventions or both. These results suggest that the expansion of practitioner-delivered mental health services to youth who are at risk of violence perpetration, but would otherwise be ineligible for, or unable to afford, services achieves a significant impact on the larger school environment.

Research studies suggest racial/ethnic differences in posttraumatic stress disorder (PTSD) diagnosis and symptom severity. Few studies to date, however, have examined the extent to which these findings are due to differences in measurement properties of existing PTSD scales. This study examined measurement equivalence across race/ethnicity in the Clinician-Administered PTSD Scale (CAPS) by testing for differential item functioning (DIF) in the item response theory (IRT) framework. Participants were 506 trauma-exposed women (M = 39.41 years, SD = 8.94) who participated in the National Drug Abuse Treatment Clinical Trials Network Women and Trauma Study. PTSD severity score estimates were improved upon as part of IRT estimation incorporating symptom "weights" (i.e., factor loadings) and group-specific DIF. Six symptoms from the CAPS showed DIF, with the majority of differences in measurement driven by White/African American and White/Latina differences, particularly for (a) avoidance of thoughts and (b) a sense of foreshortened future. Despite both racial/ethnic minority groups being slightly (not significantly) more likely to receive a PTSD diagnosis, African Americans (p = .014; Cohen's d = -.22) and Latinas (p < .001; d = -.73) had significantly lower PTSD severity scores than Whites as estimated under IRT with group-specific DIF. Examination of PTSD severity scores based on symptom counts revealed these differences were either dampened (White/Latina difference d = -.39) or entirely negated (White/African American difference d = -.08). The findings suggest the importance of considering differences in symptom relevance across race/ethnicity and their impact on capturing symptom severity parallel to diagnostic criteria. Implications for clinical practice are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

This paper describes Project Harmony, a Virtual Clinical Trial (VCT) funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to harmonize and analyze data from over 40 independent psychological, pharmacologic and/or combined pharmacological treatment studies for posttraumatic stress disorder and comorbid alcohol and other drug use disorders (PTSD/AOD). The study attends to three distinct analysis challenges: (1) variation in measurement of PTSD/AOD across studies, time, populations and reporters, (2) cross-study variation in treatment effect sizes and (3) non-randomized, cross-study variation in the classification of treatments (despite within-study randomization of treatment arms). To address these challenges, the study combines meta-analysis of individual patient data (MIPD), integrative data analysis (IDA) and propensity score weighting (PSW) to integrate raw data from these clinical trials. This protocol shows how this VCT analytic framework was used to (1) develop commensurate scale scores of PTSD and AOD severity when measures vary across studies, (2) compare the efficacy of evidence-based treatment models for PTSD/AOD, (3) test for potential mediators of treatment effects on AOD and PTSD across treatment models, and (4) explore individual- and study-level moderators to inform for whom each of the treatment models works best. The advantages of the general VCT approach are juxtaposed against the limitations of single randomized controlled trials and conventional meta-analysis.

OBJECTIVE: Integrative data analysis was used to combine existing data from nine trials of cognitive-behavioral therapy (CBT) for anxious youth (N = 832) and identify trajectories of symptom change and predictors of trajectories.METHOD: Youth- and parent-reported anxiety symptoms were combined using item-response theory models. Growth mixture modeling assessed for trajectories of treatment response across pre-, mid-, and posttreatment and 1-year follow-up. Pretreatment client demographic and clinical traits and treatment modality (individual- and family-based CBT) were examined as predictors of trajectory classes.RESULTS: Growth mixture modeling supported three trajectory classes based on parent-reported symptoms: steady responders, rapid responders, and delayed improvement. A 4-class model was supported for youth-reported symptoms: steady responders, rapid responders, delayed improvement, and low-symptom responders. Delayed improvement classes were predicted by higher number of diagnoses (parent and youth report). Receiving family CBT predicted membership in the delayed improvement class compared to all other classes and membership in the steady responder class compared with rapid responders (youth report). Rapid responders were predicted by older age (parent report) and higher number of diagnoses (parent report). Low-symptom responders were more likely to be male (youth report).CONCLUSIONS: Integrative data analysis identified distinct patterns of symptom change. Diagnostic complexity, age, gender, and treatment modality differentiated response classes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Background : Most of the work on understanding subthreshold PTSD has focused on inconsistencies in defining subthreshold PTSD and how those inconsistencies impact prevalence rates. The present study distinguishes between full and subthreshold PTSD using empirical categorization and assesses the circumstances under which empirical categorization is discordant with full and subthreshold PTSD diagnoses. Methods : Using data from the NIDA CTN Women and Trauma Study (N = 353), we use a modernized adaptation of the Jacobson and Truax (1991) framework, assessing whether patients were above or below an empirical threshold on latent PTSD severity scores estimated under categorical confirmatory factor analysis; the empirical categorizations were then crossed with the diagnoses to form four diagnostic by empirical categorization groupings. Results : Compared to a reference group (full PTSD diagnosis and empirical categorization), patients who had a full PTSD diagnosis but a subthreshold empirical categorization had lower symptom endorsement rates on 15 PTSD symptoms, were more likely to be married, ethnic minorities with fewer lifetime traumas. Conversely, patients with a subthreshold PTSD diagnosis and a full PTSD empirical grouping looked similar to “Full/Fulls”, only differing on avoidance symptoms. Limitations : Alternative definitions of subthreshold PTSD and coding of symptom endorsement may impact results. The use of DSM-IV symptoms (though reconciled against overlapping symptoms from DSM-5) is also a key limitation. Conclusions : Empirical categorization can be a useful supplement to diagnosis in distinguishing subthreshold PTSD from full PTSD, using a methodology that could provide a platform for melding dimensional and categorical nosology approaches in the DSM.

As suicide rates have risen in the last decade, there has been greater emphasis on targeting early risk conditions for suicidality among youth and adolescents as a form of suicide “inoculation”. Two particular needs that have been raised in this nascent literature are a) the dearth of examination of early intervention effects on distal suicide risk that target externalizing behaviors and b) the need to harmonize multiple existing intervention datasets for greater precision in modeling intervention effects on low base rate outcomes such as suicidal behaviors. This project, entitled “Integrative Data Analysis of Coping Power (CP): Effects on Adolescent Suicidality”, funded by the National Institute of Mental Health (NIMH), will harmonize and analyze data from 11 randomized controlled trials of CP (total individual-level N = 3,183, total school-level N = 189). CP is an empirically-supported, child- and family-focused preventive intervention that focuses on reducing externalizing more broadly among youth who exhibit early aggression, which makes it ideally suited to targeting externalizing pathways to suicidality. The project utilizes three measurement and data analysis frameworks that have emerged across multiple independent disciplines: integrative data analysis (IDA), random treatment effects multilevel modeling (RTE-MLM), and propensity score weighting (PSW). If successful, the project will a) provide initial evidence that CP would have gender-specific indirect effects on suicidality through reductions in externalizing for boys and reductions in internalizing for girls and b) identify optimal conditions under which CP is delivered (e.g., groups, individuals, online) across participants on reductions in suicidality and other key intermediate endpoints.

The purpose of this study was to explore the influence of maternal depressive symptoms on adolescent alcohol use among a sample of Latino/Latina youth aged 10 to 16 years from a high-risk community. Direct and mediating effects of youth depressive symptoms, controlling for levels of concurrent emotion dysregulation, on alcohol use were examined. Participants consisted of 525 children and their mothers randomly sampled from low-income schools with high rates of substance use. The panel design included four waves, and we used structural equation modeling with a longitudinal mediational framework. Results indicated that the relationship between maternal depressive symptoms and adolescent alcohol use was mediated by adolescents’ symptoms of depression for girls only. Findings are discussed in the context of the development of skills to cope with negative affect and the influence parental depressive symptoms may have on this process.

Recent federal legislation and a renewed focus on integrative care models underscore the need for economical, effective, and science-based behavioral health care treatment. As such, maximizing the impact and reach of treatment research is of great concern. Behavioral health issues, including the frequent co-occurrence of substance use disorders (SUD) and posttraumatic stress disorder (PTSD), are often complex, with a myriad of factors contributing to the success of interventions. Although treatment guides for comorbid SUD/PTSD exist, most patients continue to suffer symptoms following the prescribed treatment course. Further, the study of efficacious treatments has been hampered by methodological challenges (e.g., overreliance on "superiority" designs (i.e., designs structured to test whether or not one treatment statistically surpasses another in terms of effect sizes) and short term interventions). Secondary analyses of randomized controlled clinical trials offer potential benefits to enhance understanding of findings and increase the personalization of treatment. This paper offers a description of the limits of randomized controlled trials as related to SUD/PTSD populations, highlights the benefits and potential pitfalls of secondary analytic techniques, and uses a case example of one of the largest effectiveness trials of behavioral treatment for co-occurring SUD/PTSD conducted within the National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) and producing 19 publications. The paper concludes with implications of this secondary analytic approach to improve addiction researchers' ability to identify best practices for community-based treatment of these disorders. Innovative methods are needed to maximize the benefits of clinical studies and better support SUD/PTSD treatment options for both specialty and non-specialty healthcare settings. Moving forward, planning for and description of secondary analyses in randomized trials should be given equal consideration and care to the primary outcome analysis.

The use of antipsychotics, particularly second generation antipsychotics, among children and adolescents has increased markedly during the past 20 years. Existing evidence gaps make this practice controversial and hinder treatment decision-making. This article describes and prioritizes future research needs regarding antipsychotic treatment in youth, focusing on within-class and between-class drug comparisons with regard to key population subgroups, efficacy and effectiveness outcomes, and adverse event outcomes. Using as a foundation a recent systematic review of antipsychotic treatment among youth, which was completed by a different Evidence-based Practice Center, we worked with a diverse group of 12 stakeholders representing researchers, funders, health care providers, patients, and families to identify and prioritize research needs. From an initial list of 16 evidence gaps, we enumerated 6 high-priority research needs: 1) long-term comparative effectiveness across all psychiatric disorders; 2) comparative long-term risks of adverse outcomes; 3) short-term risks of adverse events; 4) differentials of efficacy, effectiveness, and safety for population subgroups; 5) comparative effectiveness among those with attention-deficit/hyperactivity disorder and disruptive behavior disorders and common comorbidities; 6) comparative effectiveness among those with bipolar disorder and common comorbidities. In this article, we describe these future research needs in detail and discuss study designs that could be used to address them.

Objectives This study examined in- and post-treatment mediation effects of a 12-session dose of Seeking Safety (SS)—an integrative cognitive behavioral treatment for comorbid PTSD and SUDs—on alcohol and cocaine outcomes in comparison to Women's Health Education (WHE) in a seven-site randomized controlled effectiveness trial. Methods Women (n = 353) enrolled in outpatient substance abuse treatment, who had experienced multiple traumas in childhood and/or adulthood and who had comorbid PTSD, were randomly assigned to receive SS or WHE delivered in open enrollment groups for 12 sessions in 6 weeks (unlike the full 25-topic SS protocol). Data were analyzed under two forms of longitudinal mediation analysis, each accounting for changes over time in group membership and group context, respectively. Results Women in SS, compared to WHE, showed significantly steeper decreases in PTSD frequency and severity, which in turn, showed significant impact in reducing both cocaine and alcohol use. This pattern was strongest for those who completed most of the treatment sessions, which was the majority of patients in the trial; these patterns only emerged during the in-treatment phase. Conclusions Use of an integrated approach to PTSD/SUD such as SS can be helpful to more rapidly reduce PTSD, which consequently reduce SUD symptoms, particularly for those who attend most of the available treatment sessions. Scientific Significance This is one of the first studies to illustrate such effects in treating comorbid PTSD and SUD in the context of a highly impaired population delivered by community-based providers. (Am J Addict 2014;23:218–225)

Objective This study evaluated relations between sexual sensation seeking, co-occurring sex and alcohol use, and sexual risk behaviors (eg, unprotected intercourse and multiple sex partners) among adolescents receiving treatment for substance abuse problems. Method The ethnically diverse sample included 394 adolescents recruited from outpatient treatment (280 males; Mage = 16.33 years, SDage = 1.15). Structural equation modeling (SEM) was used to test direct and indirect paths between sexual sensation seeking and sexual risk behaviors via the frequency of co-occurring sex and alcohol use. Conditional indirect effects by gender were also tested. Results Analyses identified significant direct and indirect effects from sexual sensation seeking to sexual risk behaviors via co-occurring sex and alcohol. The path from co-occurring sex and alcohol use to unprotected intercourse was significantly stronger among adolescent girls, suggesting a mediation effect moderated by gender. The path from sexual sensation seeking to past year number of partners via co-occurring sex and alcohol was stronger among adolescent boys. However, this gender path difference was not statistically significant. Conclusions Selected prevention efforts are needed to promote HIV risk reduction among adolescents in substance abuse treatment. The documented conditional indirect effect for unprotected intercourse suggests that HIV prevention programs should pay special attention to gender-specific patterns of alcohol use and sexual risk behavior when tailoring program content. (Am J Addict 2013;XX:000–000)

Modeling turnover in group membership has been identified as a key barrier contributing to a disconnect between the manner in which behavioral treatment is conducted (open-enrollment groups) and the designs of substance abuse treatment trials (closed-enrollment groups, individual therapy). Latent class pattern mixture models (LCPMMs) are emerging tools for modeling data from open-enrollment groups with membership turnover in recently proposed treatment trials. The current article illustrates an approach to conducting power analyses for open-enrollment designs based on the Monte Carlo simulation of LCPMM models using parameters derived from published data from a randomized controlled trial comparing Seeking Safety to a Community Care condition for women presenting with comorbid posttraumatic stress disorder and substance use disorders. The example addresses discrepancies between the analysis framework assumed in power analyses of many recently proposed open-enrollment trials and the proposed use of LCPMM for data analysis.

Background: The present study’s aim was to examine the long-term effects (8 to 13 years post-treatment; M = 9.83 years; SD = 1.71) of the most widely used treatment approaches of exposure-based cognitive behavioral treatment for phobic and anxiety disorders in children and adolescents (i.e., group treatment and two variants of individual treatment). An additional aim was to compare the relative longterm efficacy of the treatment approaches. Method: At long-term follow-up, participants (N = 67) were between 16 and 26 years of age (M = 19.43 years, SD = 3.02). Primary outcome was the targeted anxiety disorder and targeted symptoms. Secondary outcomes were other disorders and symptoms not directly targeted in the treatments including (1) other anxiety disorders and symptoms, (2) depressive disorders and symptoms, and (3) substance use disorders and symptoms. Results: Long-term remission for anxiety disorders and symptoms targeted in the treatments was evident 8 to 13 years post-treatment. Long-term remission also was found for the secondary outcomes. There were more similarities than differences in the long-term gains when comparing the treatment approaches. Conclusions: Consistent with past research, the study’s findings provide further evidence that the short-term benefits of exposure-based CBT for childhood phobic and anxiety disorders using both group and individual treatment may extend into the critical transition years of young adulthood. Keywords: Anxiety disorders, long-term, follow-up, individual, group, cognitive behavioral therapy.

This article provides a summary of what is currently known about the classification of anxiety disorders in children and adolescents; the issues of reliability and validity, both external and internal validity, are the focus. Anxiety disorders can be reliably diagnosed in children and adolescents when structured and/or semi-structured diagnostic interview schedules are used. Although there is strong evidence for the external validity of the broad category of anxiety disorders, the findings are uneven for the specific disorders. Findings relating to external validity also vary depending on the criteria used in the external validation process. Considerably less research has been conducted on internal validity. The little work that has been done generally supports the DSM-IV's internal structure, although this remains an issue that is controversial and requires more research attention. Issues that remain unknown include the reliability of anxiety diagnoses with relative low prevalence in youth, the specifici...

With onset often occurring before 6 years of age, attention-deficit/hyperactivity disorder (ADHD) involves attention problems, impulsivity, overactivity, and sometimes disruptive behavior. Impairment usually persists into adulthood, with an estimated worldwide prevalence in adults of 2.5%. Existing gaps in evidence concerning ADHD hinder decision-making about treatment. This article describes and prioritizes future research needs for ADHD in three areas: treatment effectiveness for at-risk preschoolers; long-term treatment effectiveness; and variability in prevalence, diagnosis, and treatment.Using a recent systematic review concerning ADHD completed by a different evidence-based practice center as a foundation, we worked with a diverse group of 12 stakeholders, who represented researchers, funders, healthcare providers, patients, and families, to identify and prioritize research needs. From an initial list of 29 evidence gaps, we enumerated 8 high-priority research needs: a) accurate, brief standardized diagnosis and assessment; b) comparative effectiveness and safety of pharmacologic treatments for children under 6 years of age; c) comparative effectiveness of different combinations of psychosocial and pharmacologic treatments for children under 6 years of age; d) case identification and measurement of prevalence and outcomes; e) comparative effectiveness of psychosocial treatment alone versus pharmacologic and combination treatments for children under 6 years of age; f) comparative long-term treatment effectiveness for people 6 years of age and older; g) relative efficacy of specific psychosocial program components for children under 6 years of age; and h) identification of person-level effect modifiers for people 6 years of age and older. In this article, we describe these future research needs in detail and discuss study designs that could be used to address them.

Examined Revised Children's Manifest Anxiety Scale (RCMAS) Lie scores in a sample of 284 anxious children. Lie scores were examined in relation to children's age, ethnicity/race, and gender, and in relation to Total Anxiety scores. The utility of Lie scores also was examined in terms of whether they were predictive of children's anxiety levels as rated by children themselves, parents, and clinicians. Between-group differences in children's Lie scores were examined as well. Results indicated that younger children had significantly higher Lie scores than older children, and Hispanic American children had significantly higher Lie scores than European American children. There were no significant gender differences in Lie scores, and no significant relation was found between RCMAS Lie scores and Total Anxiety scores for the total sample. Subgroup analyses indicated that Lie scores were predictive of children's anxiety levels. Results also indicated that Lie scores were significantly different between children who presented with anxiety disorders and children who presented with anxiety and externalizing disorders. Findings are discussed in terms of the usefulness of RCMAS Lie scores.

This study examined the linkages between negative cognitive errors and anxiety in a sample of children and adolescents referred for anxiety problems (N 251). The Children’s Negative Cognitive Error Questionnaire was used to assess cognitive errors and several self-report measures of anxiety were used to examine the specific linkages between cognitive errors and different aspects of children’s anxiety phenomenology. Results indicated that each of the measures of anxiety (i.e., trait anxiety, manifest anxiety, and anxiety sensitivity) were significantly related to each of the cognitive errors examined (i.e., catastrophizing, overgeneralization, personalizing, and selective

The discriminant validity of children's and parents' ratings of the child's fear on the Revised Fear Survey Schedule for Children (FSSC-R; Ollendick, 1983) was examined using a clinic sample of children who met DSM criteria for phobic disorders (N = 120). Discriminant function analyses and item analyses were conducted to determine if children meeting diagnostic criteria for a primary disorder of social phobia, simple phobia of the dark/sleeping alone, simple phobia of animals, or a simple phobia of shots/doctors could be differentiated on the basis of FSSC-R subscale scores and items. Results of the discriminant function analyses indicated that the child-completed as well as the parent-completed FSSC-Rs were similarly useful in differentiating the specific types of phobias. Results of the item analyses indicated that child-completed FSSC-R items could discriminate among the different simple phobias but not social phobia and that parent-completed FSSC-R items could discriminate not only the different simple phobias but also social phobia. Results are discussed in terms of the utility of the FSSC-R in the assessment of clinically significant fears in children with phobic disorders and the relative utility of child and parent ratings in the assessment of childhood fears.

This study examined in- and post-treatment mediation effects of a 12-session dose of Seeking Safety (SS)-an integrative cognitive behavioral treatment for comorbid PTSD and SUDs-on alcohol and cocaine outcomes in comparison to Women's Health Education (WHE) in a seven-site randomized controlled effectiveness trial.Women (n = 353) enrolled in outpatient substance abuse treatment, who had experienced multiple traumas in childhood and/or adulthood and who had comorbid PTSD, were randomly assigned to receive SS or WHE delivered in open enrollment groups for 12 sessions in 6 weeks (unlike the full 25-topic SS protocol). Data were analyzed under two forms of longitudinal mediation analysis, each accounting for changes over time in group membership and group context, respectively.Women in SS, compared to WHE, showed significantly steeper decreases in PTSD frequency and severity, which in turn, showed significant impact in reducing both cocaine and alcohol use. This pattern was strongest for those who completed most of the treatment sessions, which was the majority of patients in the trial; these patterns only emerged during the in-treatment phase.Use of an integrated approach to PTSD/SUD such as SS can be helpful to more rapidly reduce PTSD, which consequently reduce SUD symptoms, particularly for those who attend most of the available treatment sessions.This is one of the first studies to illustrate such effects in treating comorbid PTSD and SUD in the context of a highly impaired population delivered by community-based providers. (Am J Addict 2014;23:218-225).

The Recovery Management paradigm provides a conceptual framework for the examination of joint impact of a focal treatment and post-treatment service utilization on substance abuse treatment outcomes. We test this framework by examining the interactive effects of a treatment for comorbid PTSD and substance use, Seeking Safety, and post-treatment Twelve-Step Affiliation (TSA) on alcohol and cocaine use.Data from 353 women in a six-site, randomized controlled effectiveness trial within the NIDA Clinical Trials Network were analyzed under latent class pattern mixture modeling. LCPMM was used to model variation in Seeking Safety by TSA interaction effects on alcohol and cocaine use.Significant reductions in alcohol use among women in Seeking Safety (compared to health education) were observed; women in the Seeking Safety condition who followed up with TSA had the greatest reductions over time in alcohol use. Reductions in cocaine use over time were also observed but did not differ between treatment conditions nor were there interactions with post-treatment TSA.Findings advance understanding of the complexities for treatment and continuing recovery processes for women with PTSD and SUDs, and further support the chronic disease model of addiction.

Epidemiological and clinical studies have established that the majority of women in substance abuse treatment have been exposed to interpersonal trauma in their lifetimes (Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995; Lincoln, Liebschutz, Chernoff, Nguyen, & Amaro, 2006; Mills, Lynskey, Teesson, Ross, & Dark, 2005) and commonly meet diagnosis for co-occurring post-traumatic stress disorder (Brady, 2001; Najavits, Weiss, & Shaw, 1997). As the extent of such comorbidity and its implications for treatment have come to light, a number of manualized cognitive behavior therapy approaches have been developed to address the complex needs of this population with the aim of improving treatment outcomes. Empirical support for these cognitive behavioral approaches, such as the Seeking Safety program (Najavits, Weiss, Shaw, & Muenz, 1998) and substance dependence posttraumatic stress disorder (PTSD) therapy (Triffleman, 2000), has been promising overall. However, the lack of well-controlled and sufficiently powered trials combined with small effect sizes among trials that were controlled (e.g., Hien, Cohen, Miele, Litt, & Capstick, 2004) have resulted in limited evidence that trauma treatments can significantly impact substance use outcomes. To date, no single treatment study has shown a magnitude of symptom improvement such that it could be recommended among guidelines for best clinical practices among women with co-occurring PTSD and addiction. As we have detailed elsewhere (Hien, Cohen, & Campbell, 2009), applying conventional statistical methodologies for randomized controlled trials using an intent-to-treat approach can be problematic when examining the efficacy of treatments for co-occurring disorders because of a number of assumptions typically made in group therapy treatment trials for substance abuse (Feaster, Newman, & Rice, 2003). These assumptions and the ways that they fail to fit the comorbid PTSD/SUD population are examined and include (a) homogeneity of patient population and treatment response, (b) a dose–response relationship between treatment attendance and outcome, and (c) similarity between patient attendance in groups.

OBJECTIVE: This study evaluated relations between sexual sensation seeking, co-occurring sex and alcohol use, and sexual risk behaviors (eg, unprotected intercourse and multiple sex partners) among adolescents receiving treatment for substance abuse problems. METHOD: The ethnically diverse sample included 394 adolescents recruited from outpatient treatment (280 males; M(age) = 16.33 years, SD(age) = 1.15). Structural equation modeling (SEM) was used to test direct and indirect paths between sexual sensation seeking and sexual risk behaviors via the frequency of co-occurring sex and alcohol use. Conditional indirect effects by gender were also tested. RESULTS: Analyses identified significant direct and indirect effects from sexual sensation seeking to sexual risk behaviors via co-occurring sex and alcohol. The path from co-occurring sex and alcohol use to unprotected intercourse was significantly stronger among adolescent girls, suggesting a mediation effect moderated by gender. The path from sexual sensation seeking to past year number of partners via co-occurring sex and alcohol was stronger among adolescent boys. However, this gender path difference was not statistically significant. CONCLUSIONS: Selected prevention efforts are needed to promote HIV risk reduction among adolescents in substance abuse treatment. The documented conditional indirect effect for unprotected intercourse suggests that HIV prevention programs should pay special attention to gender-specific patterns of alcohol use and sexual risk behavior when tailoring program content.

The present study's aim was to examine the long-term effects (8 to 13 years post-treatment; M = 9.83 years; SD = 1.71) of the most widely used treatment approaches of exposure-based cognitive behavioral treatment for phobic and anxiety disorders in children and adolescents (i.e., group treatment and two variants of individual treatment). An additional aim was to compare the relative long-term efficacy of the treatment approaches.At long-term follow-up, participants (N = 67) were between 16 and 26 years of age (M = 19.43 years, SD = 3.02). Primary outcome was the targeted anxiety disorder and targeted symptoms. Secondary outcomes were other disorders and symptoms not directly targeted in the treatments including (1) other anxiety disorders and symptoms, (2) depressive disorders and symptoms, and (3) substance use disorders and symptoms.Long-term remission for anxiety disorders and symptoms targeted in the treatments was evident 8 to 13 years post-treatment. Long-term remission also was found for the secondary outcomes. There were more similarities than differences in the long-term gains when comparing the treatment approaches.Consistent with past research, the study's findings provide further evidence that the short-term benefits of exposure-based CBT for childhood phobic and anxiety disorders using both group and individual treatment may extend into the critical transition years of young adulthood.

We examined the comparability between mothers' and fathers' ratings in the assessment of their child's anxiety symptoms. The sample consisted of 78 youth (6 to 17 years) and their mothers and fathers who presented to a childhood anxiety disorders specialty research clinic. Using intraclass correlation coefficients, mother?father agreement of their child's anxiety symptoms was found to be moderate. Mean differences between mothers' and fathers' ratings of their child's anxiety were not significantly different. Both maternal and paternal self-ratings of psychopathology predicted respective ratings of their child's anxiety. Although either mothers or fathers can provide useful information, use of multiple informants is encouraged, especially when parental psychopathology is present. Additional implications and suggestions for future research are discussed.

To evaluate the external validity of comorbid patterns of anxiety disorders among youth who presented to an anxiety disorders clinic, comorbid cases were compared to “pure” anxiety disorder cases. Children and adolescents ( N = 329; mean age = 10.04 years) and parents were administered structured interviews and four groups were formed, Pure Anxiety, Anxiety + Anxiety, Anxiety + Externalizing, and Anxiety + Depressive, and compared along with four external validation criteria: sociodemographics, clinical phenomenology, psychosocial, and family factors. All comorbid groups were more severe than the pure anxiety group on clinical phenomenology and psychosocial factors. The Anxiety + Depressive Disorders group was most severe on all criteria except sociodemographics. Results provide evidence for the external validity of comorbid diagnostic presentations among anxiety disorders, as there was differential meaningfulness in the diagnostic presentation of a pure anxiety disorder versus anxiety disorder comorbid with other disorders. Assessment and future research implications are discussed.

This study examined the relation between comorbid and pure (non-comorbid) anxiety disorders and both substance dependence and substance use problems in a community sample of 1747 young adults ages 18-23 years. Results indicate that collectively anxiety disorders, both pure and comorbid with other psychiatric diagnoses, are predictive of substance dependence. When temporal order was controlled, anxiety disorders generally preceded the onset of substance dependence. However in analyses in which PTSD was excluded, anxiety disorders were no longer predictive of substance dependence, suggesting that the increased risk associated with anxiety disorders is largely if not wholly attributable to PTSD. Finally, comorbid and pure anxiety disorders were found to be predictive of the number of alcohol and drug use problems.

The role of disgust in childhood phobias has received limited attention in the psychiatric literature. Available studies suggest that attention to the emotion of disgust is optimal for reduction of phobic symptoms given that the interaction between fear and disgust has been found to maintain and even exacerbate phobias. Disgust was targeted via imagery exposures as part of an exposure-based cognitive-behavioral intervention for a 9-year-old Hispanic American boy who presented with a specific phobia of buttons. Posttreatment, 6-month, and 12-month follow-up assessment results demonstrated maintenance of treatment gains. The role of disgust in treating specific phobias in children is discussed.

Background: Evaluated five probability indices, including odds ratios, to determine relative contribution of Uncontrollable Excessive Worry (DSM-IV criterion A and criterion B) and Physiological Symptoms associated with uncontrollable excessive worry (DSM-IV criterion C) for diagnosing DSM-IV generalized anxiety disorder in youth. Method: One hundred eleven youths (6 to 17 years old) and their parents who presented to a childhood anxiety disorders specialty clinic were administered a semi-structured diagnostic interview schedule. Separate evaluations were conducted for children and adolescents. Results: Results showed that symptoms comprising DSM-IV's generalized anxiety disorder diagnosis vary relative to one another in the degree to which they contribute to the diagnosis, with certain symptoms having relatively higher diagnostic value than other symptoms. The relative value of symptoms also appeared to vary with children's and adolescents' reports, and parents' reports about their children and adolescents. Conclusions: Despite variations in symptoms' values, with only a few exceptions, almost all symptoms were still quite useful for diagnosis, whether reported by children, adolescents, or their parents.