Thomas H. Ollendick - US grants

The overall aim of the proposed investigation is to examine the efficacy of a cognitive-behavioral treatment (One- Session Treatment; Ost, 1989a) in reducing symptoms and sequellae of Specific Phobia in children and adolescents. Findings indicate that clinically significant specific phobias are present in approximately 5 percent of children in community samples and in about 15 percent to 20 percent of children presenting at phobic and anxiety disorders clinics. Furthermore, findings indicate that clinic-referred children who present with specific phobias in specialized clinics are likely to be co-morbid with other anxiety disorders, affective disorders, and disruptive behavior disorders. For many children, the phobia results in considerable academic, social, and personal distress, as well as interference in day-to-day activities. Phobias may persist for a lifetime. One-Session Treatment has been found to be a rapid and effective treatment for adults with phobic disorders. Surprisingly, this treatment has not been evaluated in countries other than Sweden, and its utility in the treatment of childhood phobias has not been examined. A systematic evaluation of its efficacy in Virginia and Sweden is proposed. Specific aims are threefold: 1) to evaluate the efficacy of One- Session Treatment with children in a controlled, randomized trial; 2) to undertake systematic evaluation of its efficacy in Virginia and Sweden; and 3) to explore predictors of treatment outcome, including parental psychopathology, over-involved parenting styles, and child co-morbidity. One-hundred-and twenty children in Virginia (60 boys, 60 girls) and 120 children in Sweden (60 boys, 60 girls) between 8 and 14 years of age and meeting DSM-IV criteria for a primary diagnosis of specific phobia will be randomly assigned to One-Session Treatment, Education/Support, or Waitlist Control conditions. Following the waitlist period, children still meeting criteria for a Specific Phobia in the waitlist control and the Education/Support conditions will be provided One-Session Treatment. Depending upon remission and attrition rates, this strategy will permit a relatively robust examination of the efficacy of One-Session Treatment, its systematic evaluation in Sweden and Virginia, and the predictors of treatment outcome. As such, the present investigation will build on strengths in the current literature by using cognitive-behavioral procedures that have some, albeit limited, support in the treatment of phobic children (Ollendick and King, 1998, in press). At the same time, it will address shortcomings in extant studies by examining a treatment not studied heretofore with children (but with considerable support for its use with adults) and by examining the role of parental psychopathology, parental over- protectiveness, and child co-morbidity in moderating treatment outcome. Effectiveness studies in "real-world" clinical settings (Hoagwood, Hibbs, Brent, and Jensen, 1995) await results of this more laboratory-based controlled trial.

DESCRIPTION (provided by applicant): The overall aim of the proposed investigation is to compare the efficacy of One-Session Treatment (OST: a variant of Cognitive-Behavior Therapy) to family-enhanced OST (Augmented OST) in the treatment of Specific Phobia in children. In our presently funded NIMH project, we have shown that OST is more effective in treating specific phobias in youth than Education/Support Treatment (EST) or Wait List Control conditions at post-treatment (60%, 26%, and 0% diagnosis free, respectively) and at 6-month follow-up (60% for OST and 42% for EST, with Waitlist participants randomly assigned to either OST or EST conditions following a 1 month wait). Although OST was shown to be superior to these conditions, it is evident that 40% of the youth who received this treatment were not diagnosis free at post-treatment or 6 month follow-up and that they continued to experience distressing symptoms. Herein, based on feedback from our parent stakeholders, we propose to augment standard OST procedures with a parent-management supplement that provides education to the parents about the nature, course, and causes of specific phobias and equips them with effective strategies to address lingering distress and avoidance in their children following OST. In brief, we propose to compare the standard OST procedure to a parent-enhanced one in a randomized clinical control trial with 154 children between 7 and 12 years of age. Specific aims are twofold: 1) to evaluate the efficacy of OST and a parent-augmented OST (Augmented OST) with children in a randomized trial;and 2) to explore moderators of treatment outcome, including the effects of parental psychopathology and overprotective parenting practices. One hundred and fifty-four children (77 boys, 77 girls) between 7 and 12 years of age who meet DSM-IV criteria for a specific phobia will be randomly assigned to individual OST or to Augmented OST treatments. (The age range is restricted to 7 to 12 years of age because family-based enhancement strategies have been found to be most effective with this age group). Post-Treatment and 1,6, and 12 month follow-up evaluations will be conducted. As such, this project will recruit the largest sample of phobic youth ever undertaken in the Unified States. It will provide valuable information about the disorder, its treatment, and the moderators of treatment outcome. This efficacy trial will lay the foundation for an effectiveness trial.

[unreadable] DESCRIPTION (provided by applicant): The primary aim of this second resubmission is to evaluate the efficacy of Parent Management Training (PMT) and a relatively new Cognitive Behavior Therapy, Collaborative Problem Solving (CPS), in the treatment of 150 children between 8 and 12 years of age who are diagnosed with Oppositional Defiant Disorder (ODD). Children and their parents will be randomly assigned to PMT, CPS, or wait list control conditions. The current proposal will evaluate these children prior to treatment, throughout treatment, immediately following treatment, and 1 year thereafter. [unreadable] [unreadable] The secondary aim is to examine the predictors of durable gains associated with treatment. Research suggests a matrix of predictor variables worthy of investigation including child sociodemographics, severity of the disorder, comorbidity with other disorders, parental psychopathology, and family functioning. These potential predictors of treatment outcome will be obtained before treatment begins to determine their utility in the prediction of treatment outcome. Identification of these predictors might constitute the first step in determining which children with which characteristics respond best to treatment and which ones do not. Some of these predictors might function as moderators of treatment outcomes whereas others might serve as "nonspecific" predictors of treatment outcome. It is possible that such findings might also lead to enhanced treatment outcomes by altering treatments to address certain characteristics associated with change. [unreadable] [unreadable] The tertiary aim is to investigate various treatment mechanisms (mediating variables) thought to be associated with treatment outcomes. The identification of such variables is necessary in order to understand how treatments such as PMT and CPS actually work. Specifically we hope to examine changes in parenting practices as a mediator of PMT and changes in parent-child problem solving as a mediator of CPS. ODD is a childhood disorder that is characterized by a recurrent pattern of developmentally inappropriate levels of negativistic, defiant, disobedient, and hostile behavior toward authority figures, and is estimated to occur in 2 to 16 percent of children. Behaviors associated with ODD include temper outbursts; persistent stubbornness; resistance to directions; unwillingness to compromise, give in, or negotiate with adults or peers; deliberate or persistent testing of limits; and verbal (and minor physical) aggression. Parents of children with ODD are more likely to utilize child mental health services than parents of children with other behavior disorders, presumably due to the deleterious effects of ODD-related behaviors on interactions between children and their adult caretakers. Studies have shown that ODD, independent of its association with attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD), is a highly comorbid disorder with adverse effects on children's social and family functioning and long-term outcomes. [unreadable] [unreadable] Given its adverse outcomes the pursuit of treatments that work, both in the short-term and the long-term, are desired. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Anxiety disorders are extremely common in childhood and have detrimental effects on various domains of functioning. Anxiety is also highly concordant between children and their mothers, with studies suggesting that the intergenerational transmission of an interpretation bias for threatening information may explain this relationship. The primary objectives of this study are to: 1) determine the feasibility of adapting intrapersonal interpretation bias modification programs into experimental paradigms that are interpersonal in nature and 2) determine if modifying the child-referent threat interpretations of anxious mothers can alter the transmission of an interpretation bias for threatening information to their children. Results will contribute to an emerging body of research exploring the ameliorating effects of experimental paradigms that target information processing biases in anxious youth. Findings may have implications for improving the current prevention and treatment options available for anxious children. The specific aims of the study are to: 1) investigate whether interpretation modification training using child-referent information can alter the transmission of an anxious information processing style from clinically anxious mothers to their children in the context of a specific anxiety- provoking task and 2) examine the effect that specific interpretation modification has on general interpretation biases in anxious mothers and their children. To address these aims, an experimental study will randomly assign clinically anxious mothers to receive either a training paradigm that teaches them to interpret child- referent ambiguous situations in a positive, benign manner or a control condition that does not train interpretation of such situations in either a positive or negative direction. Children will then be asked to participate in an anxiety-provoking speech task. They will be given time to discuss how they will approach the task with their mother and mothers' behavior during this interaction will be coded by objective observers. Following the discussion, children and mothers will be asked how threatening they perceive the task to be. Finally, children's anxiety, physiological activation, and performance during the task will be assessed. Research shows that anxious mothers interact with their children in ways that train them toward seeing threat in their environment. It is therefore hypothesized that the positive interpretation training, compared to the control condition, will result in less of this type of anxious maternal behavior, decreased perception of threat (i.e., anxious cognitions) in mothers and children, as well as less anxious child behavior, less physiological arousal, and better performance on the speech task. Lastly, it is predicted that this procedure will decrease both mother and child general interpretation biases. PUBLIC HEALTH RELEVANCE: The high rates of anxiety disorders among children and adolescents make it a public health issue; however, the gold standard treatment for such disorders is currently only effective for about 60-70% of these youth. We know that anxiety disorders run in families and may be passed on by parents who inadvertently train their children to see threat in their surroundings. This research aims to re-train anxious mothers to see less threat in their children's environment and therefore has the potential to help prevent the onset of anxiety disorders in at-risk youth.

DESCRIPTION (provided by applicant): The primary objective of this study is to develop an Attention Training (AT) protocol for adolescents with social anxiety disorder (SAD). Attentional biases to threat have been shown to be associated with the development and maintenance of anxiety disorders, in both adults and youth (Bar-Haim et al., 2007; Cowart & Ollendick, 2010; Perez-Edgar et al., 2010; Schechner et al., 2011). Given these relations, AT paradigms have been developed to modify these attentional biases. Such paradigms have been shown to be promising in the treatment of adult anxiety (Amir et al, 2009; Buckner & Timpano, 2009; Klumpp & Amir, 2010; MacLeod & Bridle, 2006; Richey & Schmidt, 2006). However, to date, only two small studies have examined the use of AT with children, and no ATT protocol has been developed specifically for use with children or adolescents. This is important, given the complications and possible ineffectiveness of applying adult-designed therapies to youth (Ollendick & Vasey, 2001). Given this gap in the literature, the primary aims of the current study are intended to develop a treatment program to address attentional biases and anxiety in adolescents with SAD, to collect preliminary data regarding the program's short-term efficacy and feasibility, and to explore attention biases as a mediator and moderator of initial treatment outcomes. It is hypothesized that the AT protocol developed in the current project, compared to a placebo control comparator condition, will result in reductions in social anxiety among a sample of adolescents with SAD. Further, the AT protocol is expected to reduce attentional biases to threat among those adolescents who possess such biases prior to treatment (not all adolescents are expected to show this bias yet AT has been shown to be potentially effective with these youth; the presence/absence of attention bias will be explored as a moderator of change). The proposed study will be a pivotal step towards assessing the feasibility of an adolescent-focused AT procedure for the treatment of SAD. Results will contribute to an emerging body of research exploring the ameliorating effects of experimental paradigms that target information processing biases in anxious youth. Given emerging evidence regarding the use of AT in adult populations, findings from this study may have implications for improving the current prevention and treatment options available for anxious adolescents.

PROJECT SUMMARY/ABSTRACT Dental phobia is associated with avoidance of proper dental care, poor dental health, and decrements in social and oral quality of life. Although dental phobia may persist for many years, the disorder usually first manifests during childhood or adolescence. Hispanic youth may be at particularly high risk of developing dental phobia because, on the whole, Hispanic/Latino families are less likely to take a preventative stance toward dental health? meaning that Hispanic youths' first encounters with a dentist are more likely to be for treatment that is associated with pain, discomfort, or shame ? the types of learning experiences related to the development of dental phobia. While our knowledge about the etiology of dental phobia is somewhat well developed, we know considerably less about how to treat it. Recently, however, a one-session exposure therapy treatment (OST) for specific phobias has proven successful in addressing a variety of phobias in youth, but youth with dental/medical phobias have not been included in the trials assessing OST because of the need to include medical professionals in the treatment. However, we have been able to build a research team that includes academic and practicing dentists. Therefore, the aim of this project is to prepare for a trial testing the effectiveness of OST for dental phobia in children and adolescents. More specifically, we propose to prepare the manual of procedures, training manuals, and IRB application necessary for the submission of a U01 application to test the effectiveness of OST compared to treatment as usual (TAU) delivered by dental hygienists in the Rio Grande Valley (RGV) of Texas ? an area with a very high concentration of Hispanic youth at risk for dental phobia. This clinical trial would randomize dental clinics in the RGV to one of the two treatment arms (OST vs. TAU) so that patient response, treatment feasibility (including provider response to treatment and cost-effectiveness), as well as a hypothesized mediator of treatment can be assessed. It is expected that OST can provide a feasible and effective treatment option that can be delivered by hygienists in the dental office. That is, that the treatment can decrease both anxiety and phobic avoidance in youth while giving treatment providers a cost-effective option that will be more acceptable to children and their parents when compared to current treatments such as sedation and restraint. Moreover, although exposure therapy has a high level of empirical support in youth and a good deal of laboratory work has been conducted to develop the theory to explain its effects, to our knowledge, the main hypothesized mechanism of action ? inhibitory learning ? has not been studied within the context of a clinical trial; therefore, the study we propose could advance our understanding of the mechanism driving one of the most promising treatments for individuals with anxiety disorders.