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The Impact of Treatment Expectations on Exposure Process and Treatment Outcome in Childhood Anxiety Disorders

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Abstract

This study examined the relationship between caregivers’ and youths’ treatment expectations and characteristics of exposure tasks (quantity, mastery, compliance) in cognitive-behavioral therapy (CBT) for childhood anxiety. Additionally, compliance with exposure tasks was tested as a mediator of the relationship between treatment expectations and symptom improvement. Data were from youth (N = 279; 7–17 years old) enrolled in the Child/Adolescent Anxiety Multimodal Study (CAMS) and randomized to cognitive-behavioral therapy (CBT) or the combination of CBT and sertraline for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. Caregivers and youth independently reported treatment expectations prior to randomization, anxiety was assessed pre- and post-treatment by independent evaluators blind to treatment condition, and exposure characteristics were recorded by the cognitive-behavioral therapists following each session. For both caregivers and youths, more positive expectations that anxiety would improve with treatment were associated with greater compliance with exposure tasks, and compliance mediated the relationship between treatment expectations and change in anxiety symptoms following treatment. Additionally, more positive parent treatment expectations were related to a greater number and percentage of sessions with exposure. More positive youth treatment expectations were associated with greater mastery during sessions focused on exposure. Findings underscore the importance of addressing parents’ and youths’ treatment expectations at the outset of therapy to facilitate engagement in exposure and maximize therapeutic gains.

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Acknowledgements

The authors would like to acknowledge all of the children and families who participated in this research study. Appropriate institutional review board approval at each study site and informed consent from the families were obtained prior to the commencement of any study procedures.

Funding

This research was supported by grants from the National Institute of Mental Health (U01 MH064089 to Dr. Walkup; U01 MH64092 to Dr. Albano; U01 MH64003 to Dr. Birmaher; U01 MH63747 to Dr. Kendall; U01 MH64088 to Dr. Piacentini; and U01 MH064003 to Dr. Compton). Sertraline and matching placebo were supplied free of charge by Pfizer.

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Authors and Affiliations

  1. UCLA Semel Institute for Neuroscience and Human Behavior, 760 Westwood Plaza, Room 47-417B, Los Angeles, CA, 90095, USA

    Monica S. Wu, Tara S. Peris, Jocelyn Pérez, Hardian Thamrin & John Piacentini

  2. American University, Washington, DC, USA

    Nicole E. Caporino

  3. New York State Psychiatric Institute-Columbia University Medical Center, New York, NY, USA

    Anne Marie Albano

  4. Department of Psychology, Temple University, Philadelphia, PA, USA

    Philip C. Kendall

  5. Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    John T. Walkup

  6. Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    Boris Birmaher

  7. Duke University Medical Center, Durham, NC, USA

    Scott N. Compton

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  1. Monica S. Wu
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  2. Nicole E. Caporino
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  3. Tara S. Peris
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  4. Jocelyn Pérez
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  6. Anne Marie Albano
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  7. Philip C. Kendall
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  8. John T. Walkup
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  9. Boris Birmaher
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  10. Scott N. Compton
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  11. John Piacentini
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Corresponding author

Correspondence to Monica S. Wu.

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Ethical Approval

Appropriate institutional review board approval at each study site and informed consent from the families were obtained prior to the commencement of any study procedures.

Conflict of Interest

Dr. Wu has received funding from the National Institute of Mental Health (2T32MH073517). Dr. Caporino has received grant funding from the American Psychological Foundation and the Anna-Maria and Stephen Kellen Foundation, and an honorarium from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Dr. Peris has received research funding from the National Institute of Mental Health and the Society of Clinical Child and Adolescent Psychology and book royalties from Oxford University Press. Dr. Kendall has received research support from the National Institute of Mental Health. He has received honoraria from professional societies for speaking at conventions. He has received royalties from Guildford Press, Ericsson, Workbook Publishing (his spouse’s employment), and Oxford University Press. Dr. Walkup has received past research support from the National Institute of Mental Health for federally funded studies including free drug and placebo from Pfizer in 2007 to support the Child Adolescent Anxiety Multimodal study; free medication from Abbott in 2005 for the Treatment of the Early Age Media study; free drug and placebo from Eli Lilly and Co. in 2003 for the Treatment of Adolescents with Depression study. He currently receives research support from the Tourette Association of America and The Hartwell Foundation. He has served as an unpaid advisor to the Anxiety Disorders Association of America and the Trichotillomania Learning Center. He has received honoraria and travel expenses for speaking engagements and meetings sponsored by the Tourette Association of America. He has received royalties from Guilford Press and Oxford University Press for multi-author books published about Tourette syndrome and from Wolters Kluwer for CME activity on childhood anxiety. He has served as a paid speaker for the Tourette Syndrome Center for Disease Control and Prevention outreach educational programs, the American Academy of Child and Adolescent Psychiatry, and the American Psychiatric Association. Dr. Albano has received royalties from Oxford University Press, including use of the ADIS. However, the ADIS was provided at no cost for this study and CAMS. She has received honoraria from the American Psychological Association. Dr. Birmaher has received research support from the National Institute of Mental Health. He has or will receive royalties from Random House, Inc., Lippincott Williams and Wilkins, and UpToDate. Dr. Piacentini has received grant or research support from the National Institute of Mental Health, the Petit Family Foundation, the Tourette Association of America, the TLC Foundation for Body-Focused Repetitive Behaviors, and Pfizer Pharmaceuticals. He is a co-author of the Child OCD Impact Scale-Revised (COIS-R), the Child Anxiety Impact Scale - Revised (CAIS-R), the Parent Tic Questionnaire (PTQ), and the Premonitory Urge for Tics Scale (PUTS) assessment tools, all of which are in the public domain therefore no royalties are received. He has served as a consultant for an NIMH R01 grant at the University of Michigan. He has received honoraria and travel support for lectures at academic institutions and from the Tourette Association of America and the International Obsessive Compulsive Disorder Foundation for behavior therapy trainings. He has received royalties from Guilford Press and Oxford University Press. Dr. Compton has received research support from the National Institute of Mental Health, NC GlaxoSmithKline Foundation, Pfizer, and Mursion, Inc. He has served as a consultant for Shire and Mursion, Inc. He has received honoraria from the Journal of Consulting and Clinical Psychology, Nordic Long-Term OCD Treatment Study Research Group, and the Centre for Child and Adolescent Mental Health, Eastern and Southern Norway. He has served on the scientific advisory board of Tourette’s Association of American and Mursion, Inc. He has given expert testimony for Duke University. Ms. Pérez and Mr. Thamrin report no biomedical financial interests or potential conflicts of interest.

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Wu, M.S., Caporino, N.E., Peris, T.S. et al. The Impact of Treatment Expectations on Exposure Process and Treatment Outcome in Childhood Anxiety Disorders. Res Child Adolesc Psychopathol 48, 79–89 (2020). https://doi.org/10.1007/s10802-019-00574-x

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