Queen, 2014

7212019 Queen 2014

httpslidepdfcomreaderfullqueen-2014 111

The trajectories of adolescent anxiety and depressive symptoms over

the

course

of

a

transdiagnostic

treatment

Alexander H Queen a David H Barlowb Jill Ehrenreich-MayaaDepartment of Psychology University of Miami United StatesbCenter for Anxiety and Related Disorders Boston University United States

A R T I C L E I N F O

Article history

Received 31 January 2014Accepted 12 May 2014

Available online 2 June 2014

Keywords

Anxiety

Depression

Adolescence

Transdiagnostic

Treatment

A B S T R A C T

Anxiety and depressive disorders commonly co-occur during adolescence sharemultiple vulnerability

factors and respond to similar psychosocial and pharmacological interventions However anxiety anddepression may also be considered distinct constructs and differ on some underlying properties Prior

research efforts on evidence-based treatments for youth have been unable to examine the concurrent

trajectories of primary anxiety and depressive concerns across the course of treatment The advent of

transdiagnostic approaches for these emotional disorders in youth allows for such examination The

present study examined the separate trajectories of adolescent anxiety and depressive symptoms over

the course of a transdiagnostic intervention the Uni1047297ed Protocol for the Treatment of Emotional

Disordersin Adolescence (UP-A Ehrenreich et al 2008) aswell asupto sixmonths followingtreatment

The sample included 59 adolescents ages 12ndash17 years old (M =1542 SD= 171) who completed at least

eight sessions of the UP-A as part of an open trial or randomized controlled trial across two treatment

sites Piecewise latent growth curve analyses found adolescent self-rated anxiety and depressive

symptoms showed similar rates of improvement during treatment but while anxiety symptoms

continued to improve during follow-up depressive symptoms showed non-signi1047297cant improvement

after treatment Parent-rated symptoms also showed similar rates of improvement for anxiety and

depression during the UP-A to those observed for adolescent self-report but little improvement after

treatment across either anxiety or depressive symptoms To a certain degree the results mirror thoseobservedamong otherevidence-based treatments for youthwithanxietyanddepression though results

hold implications for future iterationsof transdiagnostictreatmentsregarding optimization of outcomes

for adolescents with depressive symptoms

atilde 2014 Elsevier Ltd All rights reserved

1 Introduction

Anxiety

disorders

are

the

most

prevalent

psychiatric

disorders

in adolescence with prevalence estimates of 10ndash21 in the general

population in the United States (Costello Mustillo Erkanli Keeler

amp

Angold

2003)

Considered

through

the

lens

of

DSM-IV

(American

Psychiatric

Association

2000) unipolar

depressive

disorders (ie major depressive disorder [MDD] dysthymic

disorder) as a whole are also common mental health conditions

and

become

more

prevalent

during

adolescence

as

compared

to

earlier

in

development

(Costello

et

al

2002)

Anxiety

and

depressive disorders commonly co-occur with one another in

adolescence Between 16 and 62 of youth with an anxiety

disorder also meet criteria for depression with the highest

comorbidity

rates

found

among

treatment-seeking

adolescents

(Brady

amp

Kendall

1992 Ollendick

Shortt

amp

Sander

2005)

In

addition self-report measures of youth anxiety and depressive

symptoms show moderate correlations with one another (eg

r

=

034)

even

after

controlling

for

overlapping

items

on

these

instruments

(Stark

amp

Laurent

2001)

In addition to their high comorbidity with one another youth

anxiety and depression share a number of biological environmen-

tal

and

psychological

risk

factors

(for

a

more

thorough

review

see

Garber

amp

Weersing

2010) For

instance

behavioral

inhibition

in

early childhood is a risk factor for the later development of both

anxiety and depression (Kagan Reznick amp Snidman 1987) and

both anxiety and depressive disorders are associated with

neuroendocrine

(Dahl

et

al

2000 Weems

Zakem

Costa

Cannon

amp Watts 2005) and neurotransmitter dysregulation (Flores et al

2004 Fox et al 2005) In addition high negative affect (NA) has

shown to be a latent factor underlying all of the anxiety and

Corresponding author at Department of Psychology University of Miami Flipse

315 5665 Ponce de Leon Boulevard Coral Gables FL 33146 United States

E-mail address jehrenreichpsymiamiedu (J Ehrenreich-May)

httpdxdoiorg101016jjanxdis201405007

0887-6185atilde 2014 Elsevier Ltd All rights reserved

Journal of Anxiety Disorders 28 (2014) 511ndash521

Contents

lists

available

at

ScienceDirect

Journal of Anxiety Disorders

7212019 Queen 2014


depressive disorders (Brown Chorpita amp Barlow 1998 Trosper

Whitton Brown amp Pincus 2012)

Youth anxiety and depressive disorders also demonstrate

similar responses to pharmacological and psychosocial interven-

tions For instance both anxiety and depression are responsive to

selective serotonin reuptake inhibitor (SSRI) medications (eg

Treatment for Adolescents with Depression Study (TADS) Team

2004 Walkup et al 2008) Prior work with cognitive-behavioral

therapy (CBT) trials have found ldquospill-overrdquo effects onto comorbid

anxiety or depressive disorders regardless of the principal

disorder For example anxiety-focused CBT has demonstrated

positive effects on comorbid depressive symptoms (Kendall

Safford Flannery-Schroeder amp Webb 2004) and a meta-analysis

of CBT for youth depression found effect sizes in anxiety symptom

reduction (ES = 039) that were only slightly less than those for

depressive symptom improvement (ES = 057 Weisz McCarty amp

Valeri 2006)

Given their frequent comorbidity shared vulnerability factors

and similar response to treatment some (eg Barlow Allen amp

Choate 2004) have advocated for a transdiagnostic or disorder-

non-speci1047297c treatment approach that targets higher-order psy-

chological factors common to the emotional disorders Such an

approach is hypothesized to allow for greater clinical

1047298exibility and

use with patients presenting with multiple emotional disorders aswell as reduce clinician burden in learning multiple disorder-

speci1047297c treatment manuals (McHugh amp Barlow 2010) As such

recent clinical research has focused upon the development and

evaluation of transdiagnostic treatments that may effectively

target anxiety and depressive disorders within a single protocol

The Uni1047297ed Protocol for the Treatment of Emotional Disorders

in Adolescence (UP-A Ehrenreich et al 2008) is a developmental

adaptation of the adult Uni1047297ed Protocol (UP Barlow et al 2010)

designed for adolescents ages 12ndash17 years old presenting with any

primary anxiety disorder unipolar depressive disorder or their

combination The UP-A has theoretical roots in emotion regulation

cognitive science and behavior modi1047297cation and distills common

evidence-based

techniques

that

cut

across

disorder-speci1047297c

treatment manuals for youth anxiety and depression (egpsychoeducation non-judgmental awareness cognitive reapprais-

al exposure behavioral activation etc) within a singular protocol

The

UP-A

incorporates

standard

evidence-based

principles

within

the

broader

function

context

and

regulation

of

a

range

of

positive

and negative emotions (eg sadness anger fear) Therefore it is

theorized to positively affect how adolescents attend to modulate

and

experience

emotions

that

cut

across

speci1047297c

disorders

Similar

to

the

UP

the

UP-A

targets

1047297ve

higher-order

principles

thought

to

be latent constructs underlying lower-order speci1047297c anxiety and

depressive disorders (1) increase present-focused awareness of

emotions

(2)

enhance

cognitive

1047298exibility

(3)

prevent

emotional

avoidance

and

maladaptive

emotion-driven

behaviors

(4)

increase

acceptance of uncomfortable emotion-related physiological sen-

sations

and

(5)

facilitate

exposure

to

bodily

and

environmentaltriggers

of

emotional

experiences

(Barlow

et

al

2010)

A prior

open

trial

of

the

UP-A

established

initial

ef 1047297cacy

with

subjects demonstrating signi1047297cant pre-post reductions in clini-

cian-rated diagnostic severity across anxiety and depressive

disorder

diagnoses

(Trosper

Buzzella

Bennett

amp

Ehrenreich

2009)

and

an

immediate

treatment

(TX)

condition

of

the

UP-A

has found to outperform an 8-week treatment-delayed waitlist

(WL) condition in clinician-rated diagnostic severity for the

principal

disorder

in

a

recently

completed

randomized

controlled

trial

(RCT

Ehrenreich-May

Queen

Rodriguez

amp

Rosen1047297eld

2012)

Analyses from this RCT also found that the presence of a depressive

disorder did not moderate treatment outcomes in the UP-A

(Ehrenreich-May

et

al

2012)

whereas

many

previous

CBT

trials

for

youth

anxiety

have

found

poorer

outcomes

for

patients

with

comorbid depression (eg Berman Weems Silverman amp Kurtines

2000 Ginsburg et al 2011 OrsquoNeil amp Kendall 2012)

To summarize youth anxiety and depression are known to

commonly co-occur with one another share multiple vulnerability

factors and may be effectively treated with a uni1047297ed treatment

approach However despite their similarities anxiety and depres-

sion have also shown to be distinct constructs For instance factor

analytic studies with school-based (Crowley amp Emerson 1996) and

clinical samples (Stavrakaki Vargo Boodoosingh amp Roberts 1987)

have found stronger support for two-factor models of anxiety and

depression compared to single factor models In addition while

both anxiety and depression are characterized by high negative

affect low positive affect has shown stronger associations with

depressive symptoms than with anxiety symptoms (for more

comprehensive reviews see Anderson amp Hope 2008 De Bolle amp De

Fruyt 2010) Given these important differences a next step in

investigating transdiagnostic treatment approaches is to examine

the separate trajectories of symptom change for anxiety and

depression over the course of treatment in order to assess if they

show similar or differential rates of change

The present study examined the separate trajectories of anxiety

and depressive symptoms over the course of the UP-A and up to

six months following the end of treatment for adolescent subjects

completing the UP-A as part of the open trial or RCT investigationWe used piecewise latent growth curve modeling (LGCM) to model

these trajectories over two separate time periods during the

course of treatment (ldquotreatment sloperdquo) and up to six months after

treatment ended (ldquofollow-up sloperdquo) Piecewise LGCM is often

recommended when examining change during treatment and

follow-up given likely non-linear change (Brown 2004) Separate

models were conducted for anxiety and depressive symptoms

Separate models were also conducted for self-rated and parent-

rated symptoms in order to examine informant differences in

symptom change trajectories Therefore a total of four piecewise

LGCMs were conducted

2

Method

21 Participants

Participants

were

59

adolescents

(576

female)

ages

12ndash17

years

old

(M

=

1542

SD

=

171)

who

received

at

least

eight

sessions

of the UP-A and completed at least one post-baseline assessment

Given the aim of the study was to examine separate trajectories of

anxiety

and

depression

symptom

change

for

those

completing

the

intervention

we

decided

to

restrict

analyses

to

those

receiving

at

least 8 sessions as this represented the minimum dosage possible

to be considered a treatment completer This subsample of 59

participants

was

culled

from

a

total

sample

of

67

participants

who

were

enrolled

in

either

the

open

trial

or

RCT

investigation

of

the

UP-A Eight (1194) of the 67 participants that did not complete at

least

eight

sessions

of

the

intervention

were

part

of

the

open

trial(n

=

2)

or

RCT

(n

=

6)

respectively

and

did

not

have

any

post-

baseline

assessment

data

T -test

and

chi-square

analyses

revealed

that those completing at least eight sessions (n = 59) did not

signi1047297cantly differ from those who dropped out prior to eight

sessions

(n

=

8)

with

regard

to

age

gender

ethnicity

severity

of

principal

diagnosis

depressive

disorder

comorbidity

status

or

baseline levels of anxiety or depressive symptoms (child or parent

report)

Participants

were

evenly

divided

between

HispanicLatino

(n

=

26

441)

and

White

Non-Hispanic

ethnicities

(n

=

26

441) The remaining subjects identi1047297ed themselves as having

BlackAfrican-American (n = 2 34) Asian-American (n = 1 17)

and

ldquootherrdquo ethnicity

(n

=

4

68)

The

median

reported

annual

family

income

was

$100000

(SD

=

$80000)

The

majority

of

512 AH Queen et al Journal of Anxiety Disorders 28 (2014) 511ndash521

7212019 Queen 2014


participants had parents who were married (n = 40 678)

Remaining participants had parents who were separateddivorced

(n = 13 2203) widowed (n = 2 34) or never married (n = 4

678)

Eligibility requirements for both the open trial and RCT

included being between 12 and 17 years old (participants could

be 18 if they were still in high school) and having a primary

diagnosis of any DSM-IV anxiety andor unipolar depressive

disorder Adolescents with other psychiatric dif 1047297culties including

attention-de1047297cithyperactivity disorder (ADHD) eating disorders

and non-treatment-interfering substance abuse were eligible for

participation However the primary diagnosis had to be an anxiety

or depressive disorder Exclusion criteria included bipolar disorder

treatment-interfering substance abuse severe suicidal ideation or

recent psychiatric hospitalization treatment-interfering cognitive

functioning (eg IQ below 80) and a prior course of CBT for anxiety

or depression Participants and at least one parent were also

required to read and comprehend English well enough to complete

study measures Those concurrently receiving psychiatric medica-

tion were required to have been on a stable dosage of an SSRI

medication for three months andor a stable dosage of benzodiaz-

epine medication for one month prior to study enrollment

Adolescents completing the UP-A as part of the open trial

participated at a university-based clinic in a large urban area in theNortheastern United States (n = 15) while those in a subsequent

RCT participated at a university-based clinic in a large urban area in

the Southeastern United States (n = 44) There were no signi1047297cant

site differences with regard to gender depressive disorder

comorbidity treatment length or severity of anxiety and depres-

sive symptoms However subjects in the RCT were slightly older

(M = 1569 SD = 170) than open trial participants (M

= 1463

SD = 155) t (57) = 213 p = 004 d = 064 In addition as expected

based upon demographic characteristics of the surrounding

communities RCT participants were more likely to be Hispanic

Latino (6136) whereas all of the open trial participants were

White Non-Hispanic x2 (3) = 2553 p lt 0001 There were no

differences

among

ethnicities

with

regard

to

any

study

variables

at

any time pointsPrincipalco-principal diagnoses and comorbid diagnoses at

baseline are displayed in Table 1 (Diagnoses assigned as co-

principal

are

included

for

totals

within

the

principal

diagnosis

category)

The

most

common

principal

diagnoses

were

generalized

anxiety disorder (n = 23 3898) followed by social phobia (n= 19

3220) and major depressive disorder (n = 11 1864) Sixteen

participants (2712) were assigned co-principal diagnoses with

the most common combination being generalized anxiety disorder

and social phobia (n = 4) All of the DSM-IV anxiety disorders were

represented with either a principalco-principal or comorbid

diagnosis including obsessive-compulsive disorder (n = 8 1356)

panic disorder (n = 7 1186) speci1047297c phobia (n = 8 1356)

separation anxiety disorder (n = 2 339) and post-traumatic

stress disorder (n = 1 169)

The great majority of participants (n = 47 797) were assigned

a primary anxiety disorder diagnosis while nine participants

(153) received a primary depressive disorder diagnosis and three

participants (51) were assigned co-principal anxiety and

depressive disorder diagnoses Although only 12 participants

(2034) received a principal or co-principal depressive disorder

diagnosis comorbid depression was well-represented with 23

participants (3898) assigned a secondary comorbid depressive

disorder Therefore the majority of participants (n = 35 6102)

were assigned a depressive disorder The majority of those with a

depressive disorder were diagnosed with major depressive

disorder (n = 25) although dysthymic disorder (n = 5) and depres-

sive disorder not otherwise speci1047297ed (NOS

n = 6) were also

present (One participant was diagnosed with both major

depressive disorder and dysthymic disorder) In addition toanxiety and depression comorbidity other psychiatric conditions

were also present including ADHD (n = 4 678) oppositional-

de1047297ant disorder (n = 1 169) and eating disorder NOS (n = 1

169) No participants were assigned a diagnosis of a current

substance abuse disorder

The majority of participants (n = 46 78) were not currently

taking psychiatric medication at the time of the study Seven

participants (1186) were taking a SSRI medication alone one

participant (169) was taking benzodiazepine alone and two

participants (339) were taking both an SSRI and benzodiaze-

pine With regard to stimulant medication for ADHD symptoms

two participants (339) were taking a stimulant medication

alone

while

one

participant

(169)

was

taking

a

stimulant

medication in combination with an SSRI medication Analyses of those taking medication (n = 13) compared to those not taking

medication (n = 46) revealed no signi1047297cant differences on any

baseline

variables

In

addition

medication

status

was unrelated

to

anxiety

or

depressive

symptom

severity

during

treatment

or

at

follow-up

Table 1

Frequencies of diagnoses at baseline

Diagnosis Principal diagnosis ()a Comorbid diagnoses () Total ()

Generalized anxiety disorder 23 (3898) 15 (2542) 38 (6441)

Social phobia 19 (3220) 7 (1186) 26 (4407)

Major depressive disorder 11 (1864) 14 (2373) 25 (4237)

Obsessive-compulsive disorder 4 (678) 4 (678) 8 (1356)

Panic disorder with agoraphobia 3 (508) 3 (508)

Speci1047297c phobia 3 (508) 5 (847) 8 (1356)

Panic disorder without agoraphobia 2 (339) 2 (339) 4 (678)

Tic disorder 1 (169) 1 (169)

Anxiety disorder NOS 5 (847) 2 (339) 7 (1186)

Dysthymic disorder 2 (339) 3 (508) 5 (847)

Trichotillomania 1 (169) 1 (169)

ADHD combined type 1 (169) 2 (339) 3 (508)

Separation anxiety disorder 2 (339) 2 (339)

Depressive disorder NOS 6 (1017) 6 (1017)

Post-traumatic stress disorder 1 (169) 1 (169)

Enuresis 1 (169) 1 (169)

ADHD inattentive type 1 (169) 1 (169)

Oppositional-de1047297ant disorder 1 (169) 1 (169)

Eating disorder NOS 1 (169) 1 (169)

a Percentages do not add to 100 because some subjects had co-principal diagnoses

AH Queen et al Journal of Anxiety Disorders 28 (2014) 511ndash521 513

7212019 Queen 2014


22 Procedure

The Institutional Review Boards of the two universities

participating in this trial granted approval for the study

Adolescents were referred for evaluation and treatment services

at the clinics by school personnel pediatricians psychiatrists

other mental health care professionals community agencies or

were self-referred through community online or radio advertise-

ments Upon contacting the clinic the adolescentrsquos parent

completed an initial telephone screen to assess primary concerns

and rule out exclusionary criteria If the primary concern was

determined to be anxiety or mood related the adolescent and

parent were scheduled for an in-person diagnostic evaluation at

the clinic Parents of adolescents not deemed eligible were

provided with appropriate treatment referrals

Fig 1 displays the CONSORT diagram outlining participant

recruitment and assignment At the initial diagnostic evaluation

the adolescent and parent separately completed the Anxiety

Disorders Interview Schedule for the DSM-IV Child Version Parent

and Child Reports (ADIS-IV-CP Silverman amp Albano 1996) with a

PhD-level clinical psychologist or doctoral student in clinical child

psychology In addition the adolescent and parent completed

paper-and-pencil questionnaires at this evaluation After obtaining

both parental consent and adolescent assent the adolescentparticipated in the ADIS-IV while the parent completed measures

in the waiting room Similarly the adolescent completed their

measures while the parent completed their interview Symptom

data collected at this initial diagnostic evaluation were used as

Time 1 data for subjects in the open trial and for those in the TX

condition in the RCT

Following the diagnostic evaluation clinician-rated composite

diagnoses were assigned by compiling information from adoles-

cent and parent responses to ADIS-IV-CP The assessor assigned a

clinical severity rating (CSR) value an indicator of diagnostic

severity and impairment to every composite diagnosis CSR values

can range from 0 to 8 with values 4 indicating clinical levels of

impairment

Only

participants

receiving

a

primary

diagnosis

of

an

anxiety or depressive disorder assigned a CSR 4 were eligible toparticipate in UP-A trial Final diagnoses and CSR values were

con1047297rmed at a weekly supervision meeting On average partic-

ipants

presented

with

moderately

severe

impairment

with

regard

to

their

primary

anxiety

or

depressive

disorder

diagnosis

(M

=

581

SD = 078 range = 4ndash7)

Adolescents assigned a primary diagnosis of an anxiety or

depressive

disorder

and who

did not

meet exclusion

criteria

were

eligible

to

enroll

in

treatment

trial Upon

obtaining

written

parental consent and adolescent assent participants in the RCT

were randomized to either the TX or the WL condition

Participants

in

the

open trial

and

TX

arm

of

the

RCT

began

treatment

immediately

All

participants and

their parent

com-

pleted symptom measures at Time 2 (8 weeks after beginning

treatment

considered

the ldquomid-treatment

rdquo

point for most)

Time3

(end

of

treatment) Time 4

(three

months after

treatment

termination)

and

Time 5

(six

months after

treatment

termina-

tion)

Participants in the WL condition did not receive treatment

during

the

8-week

WL period

but

did

brief

telephone

ldquocheck-insrdquo

with

their

assigned

therapist

to

assess

for

clinical

deterioration

every other week At the end of the WL period participants and

their parent completed symptom measures at the clinic These data

were

used

as

Time

1

data

for

WL

participants

Analyses

revealed

no

signi1047297cant

changes

in

WL participantsrsquo

data

from

initial

diagnostic

evaluation to the end of the WL period on symptom measures all

prsquos gt 020 Participants in the WL arm then began UP-A and

completed

assessments

at

same

intervals

as

those

in

the

open

trial

and

TX

arm

of

RCT

221 Treatment structure and content

The UP-A follows a principle-based

1047298exible treatment struc-

ture The intervention can be delivered over a varying length of

time (between 8 and 21 weekly sessions administered in an

individual format) There are 1047297ve required modules which

correspond to the

1047297ve core principles underlining the UPUP-A

(Barlow et al 2010) Therapists are allowed to devote more

sessions to a required module dependent upon patient needs but

ideally all modules are completed during the course of treatment

Therefore while treatment length may differ among patients all

subjects receive the same

1047297ve core modules and relevant skills

(eg psychoeducation non-judgmental awarenessmindfulness

cognitive reappraisal exposure behavioral activation) See Table 2

for a display of the

1047297ve required modules and suggested session

length for each module including treatment skills delivered within

each module and the corresponding UPUP-A core principles

targeted Importantly one of the unique features of the UP models

is the ability to target emotion regulation de1047297cits across a broader

range of positive and negative emotions compared to traditional

disorder-speci1047297c treatment manuals

In addition to the 1047297verequired modules three optional modules

are available to the therapist as needed to address parenting skills

motivational enhancement and clinical deterioration and can be

used at any point in treatment At least one parent is required to beactively involved in treatment While some variability is allowable

typically a parent is involved in the last 10ndash15min of every session

to review content and the assigned homework Individual sessions

with the parent may be used as part of an optional module if the

therapist feels that certain parenting behaviors (eg overprotec-

tion high criticism parentndashteen con1047298ict etc) are counterproduc-

tive to treatment progress or as needed for exposure planning

Motivational interviewing (Miller amp Rollnick 2002) techniques can

be used in sessions as part of a second optional module for

adolescents who appear reluctant to engage in treatment Finally

sessions within the third optional module can be used to develop a

safety plan with the adolescent and his or her parent in the event

the

patient

experiences

impulses

for

self-harm

However

adoles-

cents who show immediate risk for suicide or other pronouncedclinical deterioration could also be discontinued from UP-A studies

and referred for more intensive services if appropriate

23

Measures

231 Anxiety Disorders Interview Schedule for DSM-IV-childparent

version

(ADIS-IV-CP

Silverman

amp

Albano

1996)

The

ADIS-IV-CP

was

completed

at

the

adolescentrsquos

baseline

assessment to determine diagnostic eligibility The ADIS-IV-CP is a

semi-structured diagnostic interview for children and adolescents

ages

7ndash17years

that

assesses

all

DSM-IV

anxiety

disorders

The

ADIS-

IV-CP

also

assesses

for

unipolar

depressive

disorders

and

external-

izing disorders (ie ADHD oppositional-de1047297ant disorder conduct

disorder)

and

screens

for

substance

abuse

schizophrenia

pervasivedevelopmental

disorders

eating

disorders

and

somatoform

dis-

orders

In

addition

participants

were screened

for

bipolar

disorder

Inter-rater reliability for the primary diagnosis within this sample

was very good (k= 82 p lt 0001) All assessors were previously

trained

in

ADIS-IV-CP

administration

and

participated

in

weekly

supervision

meetings

led

by

the

third

author

(JEM)

After

an

initial

training workshop new examiners were required to reach

agreement on all clinical diagnoses and CSR levels (ie within 1

CSR

value)

with

an

expert

rater

(JEM)

on

three

consecutive

assessments

before

conducting

interviews

independently

232 Revised Childrenrsquo s Anxiety and Depression Scale

Subjects

completed

the

Revised

Childrenrsquos Anxiety

and

Depression

Scale

(RCADS

Chorpita

Yim

Mof 1047297tt

Umemoto

amp


7212019 Queen 2014


A s s e s s e

d

f o r e l i g i b i l i t y ( n = 1 2 2 )

E x c l u d e d

o r D e c l i n e d ( n = 5 5 )

D i d n o t

m e e t

i n c l u s i o n c r i t e r i

a

S o u

g h t t r e a t m e

n t e l

s e w h e r e

O p t e d f o

r p r i

v a

t e t r e a t m e n t

D a t a

A v a i l a b l e

8 -

W e e k ( n

= 2 0

)

E n d o f T r e a t m e n t ( n

= 2 0

)

3 M o n t h F o l

l o w

- U p ( n = 1 0

)

6 M o n t h F o l

l o w

- U p ( n = 1 1

)

E n r o l

l e d i n

R C T a n d r

a n d o m i z e d t o T X

( n = 2 6 )

R e c e

i v e d a t l e a s t 8

s e s s

i o n s

( n

= 2 3

)

D i d n o

t r e c e

i v e a t l e a s t 8

s e s s

i o n s

( n

= 3 )

D a t a a v a i l a b l e

8 - W e e k ( n

= 2 0

)


= 1 5

)

3 M o n t h F o l

l o w

- U p ( n = 8 )

6 M o n t h F o l

l o w

- U p ( n = 6 )

E n r o l

l e d i n

R C T a n d r a n d o m i z e d t o

W

L

( n = 2 4 )

R e c e


s e s s

i o n s

( n = 2 1

)

D i d n o t r

e c e i v e

a t l e a s t 8

s e s s

i o n s

( n = 3 )

E n

r o l

l e d ( n

= 6 7

)

E n r o l

l e d i n o p e n t

r i a l (

n = 1 7

)

R e c e i v e d

a t

l e a s t 8 s e s s

i o n s

( n = 1 5

)

D i d n o

t r e c e


s e s s

i o n s

( n = 2 )

D a t a

a v a i l a b l e

8 - W e e

k ( n

=

1 5

)


= 1 3

)

3 M o n t h

F o l

l o w

- U p

( n = 1 1

)

6 M o n t h

F o l

l o w

- U p

( n = 7 )

F i g

1

U P - A C O N S O R T 1047298 o w

d i a g r a m


7212019 Queen 2014


Francis 2000) at all

1047297ve time points The RCADS is a 47-item self-

report measure of anxiety and depressive symptoms that containssix distinct subscales based upon DSM-IV criteria separation

anxiety social phobia generalized anxiety disorder obsessive-

compulsive disorder panic disorder and major depressive disor-

der Respondents are asked to indicate how much each item

describes them using never (0) sometimes (1) often (2) or always

(3) A Total Anxiety subscale score is comprised of 37 items and

summed from responses to the

1047297ve anxiety subscales A major

depressive disorder (MDD) subscale score is comprised of 10 items

Raw

scores

were

converted

to

T -scores

using

child

age

and

gender

to place the two subscales on the same metric with

T-scores of 65

or greater indicating borderline levels of clinical severity and T-

scores of 70 and above representing clinically signi1047297cant elevations

(Weiss

amp

Chorpita

2011)

Internal

consistency

values

for

the

RCADS

Total Anxiety subscale were as follows a= 094 at Time 1 a= 095at Time 2 a= 091 at Time 3 a= 087 at Time 4 and a= 093 at Time

5 Internal consistency values for RCADS MDD subscale were as

follows

a=

085

at

Time

1 a=

090

at

Time

2

a=

091

at

Time

3

a=

091

at

Time

4

and a=

093

at

Time

5

233 Revised childrenrsquo s anxiety and depression scales ndash parent

version

The

adolescentrsquos parent

completed

the

Revised

Childrenrsquos

Anxiety and Depression Scales-Parent version (RCADS-P Ebesu-

tani Bernstein Nakamura Chorpita amp Weisz 2010) at all 1047297ve time

points

The

RCADS-P

is

a

47-item

parent-rated

measure

of

their

childadolescentrsquos

anxiety

and

depressive

symptoms

The

RCADS-P

contains the same six subscales as the RCADS and has previously

shown

good

psychometric

properties

with

school-based

(Ebesu-tani

et

al

2011)

and

clinical

samples

(Ebesutani

et

al

2010) For

the

current

sample

internal

consistency

values

for

RCADS-P

Total

Anxiety subscale were as follows a= 092 at Time 1 a= 091 at

Time 2 a= 094 at Time 3 a= 078 at Time 4 and a= 088 at Time 5

Internal

consistency

values

for

the

RCADS-P

MDD

subscale

were

as

follows

a=

078

at

Time

1

a=

088

at

Time

2

a=

091

at

Time

3

a= 060 at Time 4 and a= 092 at Time 5

24

Data

analytic

plan

For the present study we used piecewise LGCM to model

symptom trajectories over (1) the course of treatment and (2)

during the

six-month

follow-up

period

Several

indices

of

model

1047297t

were

used

including

chi square

comparative 1047297x index

(CFI)

root mean square error of approximation (RMSEA) and stan-

dardized root mean square residual (SRMR) For purposes of interpretation indices of good model 1047297t include a non-signi1047297cant

chi square ( p gt 005) CFI gt 095 RMSEA

lt 006 and SRMR lt 008

(Kline 2011) Signi1047297cant tests for parameter estimates were

conducted with the z -statistic using a two-tailed test LGCM

analyses were conducted using MPLUS Fifth version (Muthen amp

Muthen 2005)

3 Results

The data were

1047297rst screened for normality and to determine if

there were any statistical outliers Skewness and kurtosis levels

were within acceptable ranges (Kline 2011) No signi1047297cant

outliers ( z

3)

were

identi1047297ed

at

any

time

points

All

subjects

had complete data for Time 1 as well as at least one other post-baseline assessment Fifty-1047297ve subjects (9322) had data at the 8-

week assessment (Time 2) and 48 participants (8136) had data at

the

end

of

treatment

(M

=

1558

sessions)

assessment

(Time

3)

However

there

was

considerable

missing

data

at

the

two

follow-

up time points with 29 subjects (4915) having available data

three months after treatment (Time 4) and 24 participants

(4068)

having

data

six

months

after

treatment

(Time

5)

although

6271

of

subjects

had

available

data

for

at

least

one

follow-up time point Attrition analyses revealed no signi1047297cant

differences between those with complete data and those with

missing

data

on

any

indicators

of

symptom

severity

at

baseline

or

any

demographic

variables

(eg

age

gender

ethnicity)

Further-

more those with and without follow-up data did not show

signi1047297cant

differences

on

any

variables

at

the

post-treatmentassessment

31 Descriptive statistics

See

Table

3

for

observed

means

and

standard

deviations

of

RCADSRCADS-P

Total

Anxiety

T -scores

and

RCADSRCADS-P

MDD

T -scores at each time point In addition the percentage of

participants with T -scores 65 and T -scores 70 are presented

Mean

T -scores

on

all

four

measures

reduced

to

below

65

by

Time

3

indicating

that

mean

levels

of

both

self-rated

and

parent-rated

anxiety and depressive symptoms were within the normative

range by the end of treatment Analysis of percentages of

participants

with

T -scores

65

and

T -scores

70

also

revealed

reductions

in

those

with

borderline

elevated

and

clinically

elevated

Table 2

UP-A structure and content

Required

module

Suggested

number of

sessions

Techniquesskills Core UPUP-A principle(s) targeted

1 1ndash3 Psychoeducation of emotions functional assessment of

antecedents behaviors and consequences associated

with emotional experiences

Present-focused emotional awareness

2 1ndash3 Generalized emotion exposures practice of non-

judgmental awareness

Present-focused awareness preventing

emotional avoidance acceptance of emotion-

related physiological sensations3 1ndash3 Identifying thinking traps detective thinking skills

generating alternative thoughts problem-solving skills

Enhancing cognitive 1047298exibility

4 4+ Interoceptive exposures in-vivo exposures behavioral

activation

Preventing emotional avoidance acceptance of

physiological sensations facilitating exposure to

interoceptive and in-vivo emotional triggers

5 1ndash2 Skill consolidation relapse prevention

Optional module Suggested number of sessions Techniquesskills

1 As needed Motivational enhancement

2 0ndash3 Safety planning crisis management

3 0ndash3 (at least 1 recommended) Parenting skills


7212019 Queen 2014


7212019 Queen 2014


The 1047297nal model imposing equality constraints for the residual

variances of the

1047297rst three indicators and last two indicators

demonstrated acceptable model 1047297t by most indices

x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019

There was a signi1047297cant mean intercept (M i= 5368 SE = 165

p lt 0001) treatment slope factor (M s1= 476 SE = 074

p lt 0001)

and follow-up slope factor (M s2= 148 SE = 050 p lt 001) The

means of the slopes indicated that on average participantsrsquo RCADS

Total Anxiety T -scores decreased by 476 units every eight weeks

during treatment and by 148 units every eight weeks during the

follow-up period The variances for the intercept (di= 13072

SE = 2991 p lt 0001) treatment slope factor (ds1= 1532 SE = 623

p = 001) and follow-up slope factor (ds2= 515 SE = 217 p lt 002)

were all statistically signi1047297cant This indicated signi1047297cant variation

in participantsrsquo baseline anxiety symptom levels as well as

variability in the rate of change in anxiety symptom reduction

during treatment and follow-up The intercept and treatment slope

factor were signi1047297cantly correlated with one another

r = 059

p lt 0001 indicating that participants who reported greater

anxiety symptom severity at baseline demonstrated faster

symptom reduction during treatment In addition the treatment

and follow-up slopes were signi1047297cantly and negatively correlated

r = 051

p = 001 Participants who demonstrated faster anxiety

symptom reduction during treatment showed slower changeduring follow-up The intercept and follow-up slope factor were

not signi1047297cantly correlated

r = 023

p gt 030

322 Depressive symptoms

The 1047297nal model for self-rated depressive symptoms demon-

strated acceptable

1047297t by most indices

x2 (7) = 1042

p = 017

CFI = 098 RMSEA = 009 SRMR = 006 The residual variances of

the 1047297nal two indicators were constrained equal however

imposing equality constraints on the residual variances of the

1047297rst three time indicators did signi1047297cantly worsen model

1047297t

x2D

(2) = 1429 p lt 0001 and therefore these residual variances were

freely estimated

There was a signi1047297cant mean intercept (M i = 5791 SE = 181

p lt 0001) and treatment slope (M s1= 482 SE = 082

p lt 0001)

However contrary to the LGCM for adolescentsrsquo self-rated anxiety

symptoms the mean follow-up slope was not statistically

signi1047297cant (M s2= 067 SE = 055 p gt 020) The non-signi1047297cant

slope indicated that on average participants did not display

signi1047297cant reductions in self-rated depressive symptoms after

treatment ended The variances of the intercept (di = 18425

SE = 4274 p lt 0001) and treatment slope factor (ds1= 2716

SE = 1089

p = 001) were statistically signi1047297cant while the variance

of the follow-up slope factor approached statistical signi1047297cance

(ds2= 424 SE = 254 p = 009) Similar to the LGCM for self-rated

anxiety the intercept and treatment slope factor were signi1047297cantly

and positively correlated

r = 048

p

lt 001 while the intercept and

follow-up slope were non-signi1047297cantly correlated

r = 020

p = 042 However in contrast to the LGCM for self-rated anxiety

symptoms the treatment and follow-up slopes for self-rated

depressive symptom were not signi1047297cantly correlated

r = 024

p = 035

33 LGCMs for parent-rated symptoms

331 Anxiety

symptoms

Parent-rated anxiety and depressive symptom trajectories

(observed and estimated) are displayed in Fig 3 The piecewise

LGCM for RCADS-P Total Anxiety

T -scores demonstrated poor

1047297t

x2

(6) = 1427

p = 003 CFI = 091 RMSEA = 018 SRMR = 023 In

addition the follow-up slope factor mean was non-signi1047297cant

50

52

54

56

58

60

62

64

66

68

70

Baseline 8-Week Post 3-month fu 6-month fu

Observed

Estimated

RCADS-P Total Anxiety T -Scores

50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated

RCADS-P Major Depressive Disorder T -Scores

Fig 3 Parent-rated symptom change during UP-A and follow-up


7212019 Queen 2014


(M s2= 116 p = 032) and had a non-signi1047297cant negative residual

variance forcing the residual variance to be

1047297xed at 0 Given poor

model 1047297t and little growth or variability during follow-up period

an LGCM with a single slope factor to represent change during both

treatment and follow-up was conducted

The

1047297rst three loadings were

1047297xed at 0 1 and 2 while the

last two time points were freely estimated Based upon modi1047297ca-

tion indices we 1047297xed the residual variances for the 1047297rst and last

time points to be equal and the residual variances for the second

third and fourth time points to be equal These equality constraints

did not signi1047297cantly worsen model

1047297t and this

1047297nal model showed

acceptable 1047297t x2 (11) = 1585 p = 015 CFI = 096 RMSEA = 010

SRMR = 023 The loadings for the last two time points of the single

slope factor were estimated at 297 and 326 respectively

indicating that reductions in RCADS-P Total Anxiety T -scores

quickly leveled out following the end of treatment

There was a statistically signi1047297cant intercept mean (M i= 6482

SE = 214

p

lt 0001) and slope mean (M s1= 409 SE = 070

p

lt 0001) The variance of the intercept was statistically signi1047297cant

(di = 18895 SE = 4383 p lt 0001) but the variance of the slope did

not reach statistical signi1047297cance (ds = 403 SE = 301 p = 018)

Similar to the LGCM for adolescent-rated anxiety there was a

signi1047297cant and positive correlation between intercept and slope

r = 081 p lt 0001

332

Depressive

symptoms

The piecewise model displayed poor

1047297tx2 (7) = 2114

p = 0004

CFI = 086 RMSEA = 021 SRMR = 021 and the follow-up slope

factor mean was non-signi1047297cant (M s2= 0004 p = 099) indicating

virtually no continued reduction in RCADS-P MDD

T -scores after

the end of treatment Therefore we speci1047297ed a single slope factor

and allowed the loadings for the 1047297nal two time points to be freely

estimated Modi1047297cation indices suggested allowing the residual

variance of the

1047297nal time point to be freely estimated while

constraining the residual variances of the 1047297rst four time points did

not signi1047297cantly worsen model 1047297t In addition it was recom-

mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time

points to co-vary and the residual variances of the third and fourthtime points to co-vary The 1047297nal model demonstrated acceptable

1047297t x2 (9) = 1382 p = 013 CFI = 095 RMSEA = 011 SRMR = 014

The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction

in RCADS-P MDD T -scores during the follow-up period

The intercept mean was statistically signi1047297cant (M i = 6815

SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant

(di = 20752 SE = 5527 p lt 0001) but the variance of the slope

failed to reach statistical signi1047297cance (di = 20752 SE = 5527

p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared

association with the latent factor the residual variances for the

fourth

and

1047297fth time

points

were

signi1047297cantly

and

negativelycorrelated

r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively

correlated r = 064 p lt 0001

4

Discussion

This study examined the separate trajectories of adolescent

anxiety and depressive symptom reduction over the course of a

transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise

LGCMs for adolescent self-rated and parent-rated symptoms

Results from LGCMs for self-rated symptoms revealed similar rates

of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable

difference was that whereas anxiety symptoms continued to show

signi1047297cant reduction during follow-up depressive symptoms

showed little change after treatment In addition the correlations

between change during treatment and change during follow-up

were stronger for anxiety symptoms compared to depressive

symptoms Results from LGCMs for parent-rated symptoms

showed poor model

1047297t for piecewise growth curves due to very

small symptom reduction in the six months following the end of

treatment This was true for both parent-rated anxiety and

depressive symptoms

These

1047297ndings may offer important implications First mean

rates of change for anxiety and depressive symptom reduction

were nearly equivalent during the treatment phase of the UP-A

These results suggest that the UP-A may effectively target anxiety

and depressive symptoms for adolescents with emotional dis-

orders These results are similar to prior work showing improve-

ments in both anxiety and depressive symptoms regardless of the

principal diagnosis in both anxiety-focused and depression-

focused CBT interventions (eg Kendall Safford Flannery-

Schroeder amp Webb 2004 Weisz et al 2006) However this

study differed in two important ways from prior work that may

offer particularly compelling evidence for this transdiagnostic

treatment First we actively recruited a more comorbid sample

than has been typically reported in prior CBT trials (eg Walkupet al 2008) with participants showing a high rate of anxiety and

depressive disorder comorbidity Second to our knowledge this

was the

1047297rst study to examine the separate rates of change in

anxiety and depression symptoms during treatment and follow-

up Thus our 1047297ndings add to prior work by suggesting that not only

do anxiety and depressive symptoms improve within a evidence-

based transdiagnostic intervention but that they also change at

similar rates during treatment

Although anxiety and depressive symptoms showed similar

rates of change during treatment our work also highlights they

may show important differences in reduction after treatment

Speci1047297cally within LGCMs for self-rated symptoms anxiety

symptoms

showed

continued

and

signi1047297cant

reduction

during

follow-up whereas depressive symptoms showed non-signi1047297cantreduction after treatment Although speculative in nature there

are potential explanations for these 1047297ndings Since this was a

primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg

exposure work) than depression (eg behavioral activation) As a

result adolescents may have perceived more opportunities to

practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note

that other trials have also observed a plateau in depressive

symptom reduction for depression-focused CBT (The Treatment for

Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was

non-signi1047297cant

for depressive symptoms This 1047297nding suggests that the rate of

change during treatment is more strongly associated with change

during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result

may also be explained by less variance in the follow-up slope for

depressive symptoms compared to anxiety symptoms The

negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had

greater symptom change during treatment

Finally there were observed differences between adolescent

self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014


Fox N A Nichols K E Henderson H A Rubin K Schmidt L Hamer D amp Pine DS (2005) Evidence for a gene-environment interaction in predicting behavioralinhibition in middle childhood Psychological Science 16(12) 921ndash926 httpdxdoiorg101111j1467-9280200501637x

Garber J amp Weersing V (2010) Comorbidity of anxiety and depression in youthImplications for treatment and prevention Clinical Psychology science and practice 17 (4) 293ndash306 httpdxdoiorg101111j1468-2850201001221x

Ginsburg G S Kendall P C Sakolsky D Compton S N Piacentini J Albano A ampMarch J (2011) Remission after acute treatment in children and adolescentswith anxiety disorders Findings from the CAMS Journal of Consulting andClinical Psychology 79(6) 806ndash813 httpdxdoiorg101037a0025933

Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response

tothe unfamiliar In NA Krasnegor EM Blass amp MA Hofer (Eds) Perinataldevelopment a psychobiological perspective (pp 421ndash440) San Diego CAAcademic Press

Kendall P C Flannery-Schroeder E Panichelli-Mindel S M Southam-Gerow MHenin A amp Warman M (1997) Therapy for youths with anxiety disorders Asecond randomized clinical trial Journal of Consulting and Clinical Psychology 65(3) 366ndash380 httpdxdoiorg1010370022-006X653366

Kendall P C Safford S Flannery-Schroeder E amp Webb A (2004) Child anxietytreatment Outcomes in adolescence and impact on substance use anddepression at 74-year follow-up Journal of Consulting and Clinical Psychology72(2) 276ndash287 httpdxdoiorg1010370022-006X722276

Kline R B (2011) Principles and practice of structural equation modeling 3rd ed NewYork NY Guilford Press

McHugh R amp Barlow D H (2010) The dissemination and implementation of evidence-based psychological treatments A review of current efforts AmericanPsychologist 65(2) 73ndash84 httpdxdoiorg101037a0018121

Miller W R amp Rollnick S (2002) Motivational interviewing Preparing people for change 2nd ed New York US Guilford Press

OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and

co-occurringdepressive symptoms in outcomes for anxiety-disordered youth treated withcognitive-behavioral therapy Child amp Family Behavior Therapy 34(3) 197ndash209httpdxdoiorg101080073171072012707086

Ollendick T H Shortt A L amp Sander J B (2005) Internalizing disorders of childhood and adolescence In JE Maddux BA Winstead JE Maddux amp BAWinstead (Eds) Psychopathology foundations for a contemporary understanding (pp 353ndash376) Mahwah NJ Lawrence Erlbaum Associates Publishers

Silverman W K amp Albano A M (1996) Anxiety disorders interview schedule forDSM-IV Child and parent versions San Antonio psychological corporation

Stark K D amp Laurent J (2001) Joint factor analysis of the Childrens Depression IInventoryandtheRevisedChildrensManifestAnxietyScale Journalof ClinicalChildPsychology 30(4) 552ndash567 httpdxdoiorg101207S15374424JCCP3004_11

Stavrakaki C Vargo B Boodoosingh L amp Roberts N (1987) The relationshipbetween anxiety and depression in children Rating scales and clinical variablesThe Canadian Journal of PsychiatryLa Revue Canadienne de Psychiatrie 32(6)433ndash439

The Treatment for Adolescents with Depression Study (TADS) (2009) Outcomesover 1 year of naturalistic follow-up The American Journal of Psychiatry 166(10)

1141ndash

1149

httpdxdoiorg101176appiajp200908111620Treatment for Adolescents with Depression Study (TADS) Team (2004) Fluoxetinecognitive-behavioral therapy and their combination for adolescents withdepression Treatment for Adolescents With Depression Study (TADS)randomized controlled trial Journal of the American Medical Association 292(7) 807ndash820 httpdxdoiorg101001jama2927807

Trosper S E Buzzella B A Bennett S M amp Ehrenreich J T (2009) Emotionregulation in youth with emotional disorders Implications for a uni1047297edtreatment approach Clinical Child and Family Psychology Review 12(3) 234ndash254httpdxdoiorg101007s10567-009-0043-6

Trosper S E Whitton S W Brown T A amp Pincus D B (2012) Understanding thelatent structure of the emotional disorders in children and adolescents Journalof Abnormal Child Psychology 40(4) 621ndash632 httpdxdoiorg101007s10802-011-9582-7

Walkup J T Albano A Piacentini J Birmaher B Compton S N Sherrill J T ampKendall P C (2008) Cognitive behavioral therapy sertraline or a combinationin childhood anxiety The New England Journal of Medicine 359(26) 2753ndash2766httpdxdoiorg101056NEJMoa0804633

Weems C F Zakem A H Costa N M Cannon M F amp Watts S E (2005)

Physiological

response

and

childhood

anxiety

Association

with

symptoms

of anxiety disorders and cognitive bias Journal of Clinical Child and Adolescent Psychology 34(4) 712ndash723 httpdxdoiorg101207s15374424jccp3404_13

Weiss D C amp Chorpita B F (2011) Revised childrenrsquos anxiety and depression scaleuserrsquos guide Los Angeles University of California Unpublished manuscript

Weisz J R McCarty C A amp Valeri S M (2006) Effects of psychotherapy fordepression in children and adolescents A meta-analysis Psychological Bulletin132(1) 132ndash149 httpdxdoiorg1010370033-29091321132


7212019 Queen 2014


depressive disorders (Brown Chorpita amp Barlow 1998 Trosper

Whitton Brown amp Pincus 2012)

Youth anxiety and depressive disorders also demonstrate

similar responses to pharmacological and psychosocial interven-

tions For instance both anxiety and depression are responsive to

selective serotonin reuptake inhibitor (SSRI) medications (eg

Treatment for Adolescents with Depression Study (TADS) Team

2004 Walkup et al 2008) Prior work with cognitive-behavioral

therapy (CBT) trials have found ldquospill-overrdquo effects onto comorbid

anxiety or depressive disorders regardless of the principal

disorder For example anxiety-focused CBT has demonstrated

positive effects on comorbid depressive symptoms (Kendall

Safford Flannery-Schroeder amp Webb 2004) and a meta-analysis

of CBT for youth depression found effect sizes in anxiety symptom

reduction (ES = 039) that were only slightly less than those for

depressive symptom improvement (ES = 057 Weisz McCarty amp

Valeri 2006)

Given their frequent comorbidity shared vulnerability factors

and similar response to treatment some (eg Barlow Allen amp

Choate 2004) have advocated for a transdiagnostic or disorder-

non-speci1047297c treatment approach that targets higher-order psy-

chological factors common to the emotional disorders Such an

approach is hypothesized to allow for greater clinical

1047298exibility and

use with patients presenting with multiple emotional disorders aswell as reduce clinician burden in learning multiple disorder-

speci1047297c treatment manuals (McHugh amp Barlow 2010) As such

recent clinical research has focused upon the development and

evaluation of transdiagnostic treatments that may effectively

target anxiety and depressive disorders within a single protocol

The Uni1047297ed Protocol for the Treatment of Emotional Disorders

in Adolescence (UP-A Ehrenreich et al 2008) is a developmental

adaptation of the adult Uni1047297ed Protocol (UP Barlow et al 2010)

designed for adolescents ages 12ndash17 years old presenting with any

primary anxiety disorder unipolar depressive disorder or their

combination The UP-A has theoretical roots in emotion regulation

cognitive science and behavior modi1047297cation and distills common

evidence-based

techniques

that

cut

across

disorder-speci1047297c

treatment manuals for youth anxiety and depression (egpsychoeducation non-judgmental awareness cognitive reapprais-

al exposure behavioral activation etc) within a singular protocol

The

UP-A

incorporates

standard

evidence-based

principles

within

the

broader

function

context

and

regulation

of

a

range

of

positive

and negative emotions (eg sadness anger fear) Therefore it is

theorized to positively affect how adolescents attend to modulate

and

experience

emotions

that

cut

across

speci1047297c

disorders

Similar

to

the

UP

the

UP-A

targets

1047297ve

higher-order

principles

thought

to

be latent constructs underlying lower-order speci1047297c anxiety and

depressive disorders (1) increase present-focused awareness of

emotions

(2)

enhance

cognitive

1047298exibility

(3)

prevent

emotional

avoidance

and

maladaptive

emotion-driven

behaviors

(4)

increase

acceptance of uncomfortable emotion-related physiological sen-

sations

and

(5)

facilitate

exposure

to

bodily

and

environmentaltriggers

of

emotional

experiences

(Barlow

et

al

2010)

A prior

open

trial

of

the

UP-A

established

initial

ef 1047297cacy

with

subjects demonstrating signi1047297cant pre-post reductions in clini-

cian-rated diagnostic severity across anxiety and depressive

disorder

diagnoses

(Trosper

Buzzella

Bennett

amp

Ehrenreich

2009)

and

an

immediate

treatment

(TX)

condition

of

the

UP-A

has found to outperform an 8-week treatment-delayed waitlist

(WL) condition in clinician-rated diagnostic severity for the

principal

disorder

in

a

recently

completed

randomized

controlled

trial

(RCT

Ehrenreich-May

Queen

Rodriguez

amp

Rosen1047297eld

2012)

Analyses from this RCT also found that the presence of a depressive

disorder did not moderate treatment outcomes in the UP-A

(Ehrenreich-May

et

al

2012)

whereas

many

previous

CBT

trials

for

youth

anxiety

have

found

poorer

outcomes

for

patients

with

comorbid depression (eg Berman Weems Silverman amp Kurtines

2000 Ginsburg et al 2011 OrsquoNeil amp Kendall 2012)

To summarize youth anxiety and depression are known to

commonly co-occur with one another share multiple vulnerability

factors and may be effectively treated with a uni1047297ed treatment

approach However despite their similarities anxiety and depres-

sion have also shown to be distinct constructs For instance factor

analytic studies with school-based (Crowley amp Emerson 1996) and

clinical samples (Stavrakaki Vargo Boodoosingh amp Roberts 1987)

have found stronger support for two-factor models of anxiety and

depression compared to single factor models In addition while

both anxiety and depression are characterized by high negative

affect low positive affect has shown stronger associations with

depressive symptoms than with anxiety symptoms (for more

comprehensive reviews see Anderson amp Hope 2008 De Bolle amp De

Fruyt 2010) Given these important differences a next step in

investigating transdiagnostic treatment approaches is to examine

the separate trajectories of symptom change for anxiety and

depression over the course of treatment in order to assess if they

show similar or differential rates of change

The present study examined the separate trajectories of anxiety

and depressive symptoms over the course of the UP-A and up to

six months following the end of treatment for adolescent subjects

completing the UP-A as part of the open trial or RCT investigationWe used piecewise latent growth curve modeling (LGCM) to model

these trajectories over two separate time periods during the

course of treatment (ldquotreatment sloperdquo) and up to six months after

treatment ended (ldquofollow-up sloperdquo) Piecewise LGCM is often

recommended when examining change during treatment and

follow-up given likely non-linear change (Brown 2004) Separate

models were conducted for anxiety and depressive symptoms

Separate models were also conducted for self-rated and parent-

rated symptoms in order to examine informant differences in

symptom change trajectories Therefore a total of four piecewise

LGCMs were conducted

2

Method

21 Participants

Participants

were

59

adolescents

(576

female)

ages

12ndash17

years

old

(M

=

1542

SD

=

171)

who

received

at

least

eight

sessions

of the UP-A and completed at least one post-baseline assessment

Given the aim of the study was to examine separate trajectories of

anxiety

and

depression

symptom

change

for

those

completing

the

intervention

we

decided

to

restrict

analyses

to

those

receiving

at

least 8 sessions as this represented the minimum dosage possible

to be considered a treatment completer This subsample of 59

participants

was

culled

from

a

total

sample

of

67

participants

who

were

enrolled

in

either

the

open

trial

or

RCT

investigation

of

the

UP-A Eight (1194) of the 67 participants that did not complete at

least

eight

sessions

of

the

intervention

were

part

of

the

open

trial(n

=

2)

or

RCT

(n

=

6)

respectively

and

did

not

have

any

post-

baseline

assessment

data

T -test

and

chi-square

analyses

revealed

that those completing at least eight sessions (n = 59) did not

signi1047297cantly differ from those who dropped out prior to eight

sessions

(n

=

8)

with

regard

to

age

gender

ethnicity

severity

of

principal

diagnosis

depressive

disorder

comorbidity

status

or

baseline levels of anxiety or depressive symptoms (child or parent

report)

Participants

were

evenly

divided

between

HispanicLatino

(n

=

26

441)

and

White

Non-Hispanic

ethnicities

(n

=

26

441) The remaining subjects identi1047297ed themselves as having

BlackAfrican-American (n = 2 34) Asian-American (n = 1 17)

and

ldquootherrdquo ethnicity

(n

=

4

68)

The

median

reported

annual

family

income

was

$100000

(SD

=

$80000)

The

majority

of


7212019 Queen 2014





678)



























= 1463






differences

among

ethnicities

with

regard

to

any

study

variables

at



principal

are

included

for

totals

within

the

principal

diagnosis

category)

The

most

common

principal

diagnoses

were

generalized
























n = 6) were also














alone

while

one

participant

(169)

was

taking

a

stimulant



baseline

variables

In

addition

medication

status

was unrelated

to

anxiety

or

depressive

symptom

severity

during

treatment

or

at

follow-up

Table 1




Social phobia 19 (3220) 7 (1186) 26 (4407)




Speci1047297c phobia 3 (508) 5 (847) 8 (1356)


Tic disorder 1 (169) 1 (169)








Enuresis 1 (169) 1 (169)






7212019 Queen 2014


22 Procedure


































impairment

Only

participants

receiving

a

primary

diagnosis

of

an



ipants

presented

with

moderately

severe

impairment

with

regard

to

their

primary

anxiety

or

depressive

disorder

diagnosis

(M

=

581



depressive

disorder

and who

did not

meet exclusion

criteria

were

eligible

to

enroll

in

treatment

trial Upon

obtaining

written



Participants

in

the

open trial

and

TX

arm

of

the

RCT

began

treatment

immediately

All

participants and

their parent

com-


treatment

considered


rdquo

point for most)

Time3

(end

of

treatment) Time 4

(three

months after

treatment

termination)

and

Time 5

(six

months after

treatment

termina-

tion)


during

the

8-week

WL period

but

did

brief

telephone

ldquocheck-insrdquo

with

their

assigned

therapist

to

assess

for

clinical

deterioration



were

used

as

Time

1

data

for

WL

participants

Analyses

revealed

no

signi1047297cant

changes

in


data

from

initial

diagnostic



completed

assessments

at

same

intervals

as

those

in

the

open

trial

and

TX

arm

of

RCT







correspond to the

































the

patient

experiences

impulses

for

self-harm

However

adoles-



23

Measures


version

(ADIS-IV-CP

Silverman

amp

Albano

1996)

The

ADIS-IV-CP

was

completed

at

the

adolescentrsquos

baseline



ages

7ndash17years

that

assesses

all

DSM-IV

anxiety

disorders

The

ADIS-

IV-CP

also

assesses

for

unipolar

depressive

disorders

and

external-


disorder)

and

screens

for

substance

abuse

schizophrenia


disorders

eating

disorders

and

somatoform

dis-

orders

In

addition

participants

were screened

for

bipolar

disorder



trained

in

ADIS-IV-CP

administration

and

participated

in

weekly

supervision

meetings

led

by

the

third

author

(JEM)

After

an

initial



CSR

value)

with

an

expert

rater

(JEM)

on

three

consecutive

assessments

before

conducting

interviews

independently


Subjects

completed

the

Revised


and

Depression

Scale

(RCADS

Chorpita

Yim

Mof 1047297tt

Umemoto

amp


7212019 Queen 2014


A s s e s s e

d


E x c l u d e d

o r D e c l i n e d ( n = 5 5 )

D i d n o t

m e e t


a

S o u

g h t t r e a t m e

n t e l

s e w h e r e

O p t e d f o

r p r i

v a


D a t a

A v a i l a b l e

8 -

W e e k ( n

= 2 0

)


= 2 0

)

3 M o n t h F o l

l o w

- U p ( n = 1 0

)

6 M o n t h F o l

l o w

- U p ( n = 1 1

)

E n r o l

l e d i n

R C T a n d r


( n = 2 6 )

R e c e


s e s s

i o n s

( n

= 2 3

)

D i d n o

t r e c e


s e s s

i o n s

( n

= 3 )


8 - W e e k ( n

= 2 0

)


= 1 5

)

3 M o n t h F o l

l o w

- U p ( n = 8 )

6 M o n t h F o l

l o w

- U p ( n = 6 )

E n r o l

l e d i n


W

L

( n = 2 4 )

R e c e


s e s s

i o n s

( n = 2 1

)

D i d n o t r

e c e i v e

a t l e a s t 8

s e s s

i o n s

( n = 3 )

E n

r o l

l e d ( n

= 6 7

)

E n r o l

l e d i n o p e n t

r i a l (

n = 1 7

)

R e c e i v e d

a t

l e a s t 8 s e s s

i o n s

( n = 1 5

)

D i d n o

t r e c e


s e s s

i o n s

( n = 2 )

D a t a

a v a i l a b l e

8 - W e e

k ( n

=

1 5

)


= 1 3

)

3 M o n t h

F o l

l o w

- U p

( n = 1 1

)

6 M o n t h

F o l

l o w

- U p

( n = 7 )

F i g

1

U P - A C O N S O R T 1047298 o w

d i a g r a m


7212019 Queen 2014













Raw

scores

were

converted

to

T -scores

using

child

age

and

gender


T-scores of 65



(Weiss

amp

Chorpita

2011)

Internal

consistency

values

for

the

RCADS



follows

a=

085

at

Time

1 a=

090

at

Time

2

a=

091

at

Time

3

a=

091

at

Time

4

and a=

093

at

Time

5


version

The


completed

the

Revised

Childrenrsquos



points

The

RCADS-P

is

a

47-item

parent-rated

measure

of

their


anxiety

and

depressive

symptoms

The

RCADS-P


shown

good

psychometric

properties

with

school-based

(Ebesu-tani

et

al

2011)

and

clinical

samples

(Ebesutani

et

al

2010) For

the

current

sample

internal

consistency

values

for

RCADS-P

Total



Internal

consistency

values

for

the

RCADS-P

MDD

subscale

were

as

follows

a=

078

at

Time

1

a=

088

at

Time

2

a=

091

at

Time

3


24

Data

analytic

plan



during the

six-month

follow-up

period

Several

indices

of

model

1047297t

were

used

including

chi square


(CFI)








Muthen 2005)

3 Results

The data were




outliers ( z

3)

were

identi1047297ed

at

any

time

points

All

subjects



the

end

of

treatment

(M

=

1558

sessions)

assessment

(Time

3)

However

there

was

considerable

missing

data

at

the

two

follow-



(4068)

having

data

six

months

after

treatment

(Time

5)

although

6271

of

subjects

had

available

data

for

at

least

one



missing

data

on

any

indicators

of

symptom

severity

at

baseline

or

any

demographic

variables

(eg

age

gender

ethnicity)

Further-


signi1047297cant

differences

on

any

variables

at

the



See

Table

3

for

observed

means

and

standard

deviations

of

RCADSRCADS-P

Total

Anxiety

T -scores

and

RCADSRCADS-P

MDD



Mean

T -scores

on

all

four

measures

reduced

to

below

65

by

Time

3

indicating

that

mean

levels

of

both

self-rated

and

parent-rated



participants

with

T -scores

65

and

T -scores

70

also

revealed

reductions

in

those

with

borderline

elevated

and

clinically

elevated

Table 2


Required

module

Suggested

number of

sessions














activation










7212019 Queen 2014


7212019 Queen 2014



variances of the



x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019



p lt 0001)













r = 059





r = 051




r = 023

p gt 030



strated acceptable


x2 (7) = 1042

p = 017





1047297t

x2D


freely estimated



p lt 0001)








SE = 1089






r = 048

p



r = 020




r = 024

p = 035


331 Anxiety

symptoms





1047297t

x2

(6) = 1427



50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated


50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated




7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014





678)



























= 1463






differences

among

ethnicities

with

regard

to

any

study

variables

at



principal

are

included

for

totals

within

the

principal

diagnosis

category)

The

most

common

principal

diagnoses

were

generalized
























n = 6) were also














alone

while

one

participant

(169)

was

taking

a

stimulant



baseline

variables

In

addition

medication

status

was unrelated

to

anxiety

or

depressive

symptom

severity

during

treatment

or

at

follow-up

Table 1




Social phobia 19 (3220) 7 (1186) 26 (4407)




Speci1047297c phobia 3 (508) 5 (847) 8 (1356)


Tic disorder 1 (169) 1 (169)








Enuresis 1 (169) 1 (169)






7212019 Queen 2014


22 Procedure


































impairment

Only

participants

receiving

a

primary

diagnosis

of

an



ipants

presented

with

moderately

severe

impairment

with

regard

to

their

primary

anxiety

or

depressive

disorder

diagnosis

(M

=

581



depressive

disorder

and who

did not

meet exclusion

criteria

were

eligible

to

enroll

in

treatment

trial Upon

obtaining

written



Participants

in

the

open trial

and

TX

arm

of

the

RCT

began

treatment

immediately

All

participants and

their parent

com-


treatment

considered


rdquo

point for most)

Time3

(end

of

treatment) Time 4

(three

months after

treatment

termination)

and

Time 5

(six

months after

treatment

termina-

tion)


during

the

8-week

WL period

but

did

brief

telephone

ldquocheck-insrdquo

with

their

assigned

therapist

to

assess

for

clinical

deterioration



were

used

as

Time

1

data

for

WL

participants

Analyses

revealed

no

signi1047297cant

changes

in


data

from

initial

diagnostic



completed

assessments

at

same

intervals

as

those

in

the

open

trial

and

TX

arm

of

RCT







correspond to the

































the

patient

experiences

impulses

for

self-harm

However

adoles-



23

Measures


version

(ADIS-IV-CP

Silverman

amp

Albano

1996)

The

ADIS-IV-CP

was

completed

at

the

adolescentrsquos

baseline



ages

7ndash17years

that

assesses

all

DSM-IV

anxiety

disorders

The

ADIS-

IV-CP

also

assesses

for

unipolar

depressive

disorders

and

external-


disorder)

and

screens

for

substance

abuse

schizophrenia


disorders

eating

disorders

and

somatoform

dis-

orders

In

addition

participants

were screened

for

bipolar

disorder



trained

in

ADIS-IV-CP

administration

and

participated

in

weekly

supervision

meetings

led

by

the

third

author

(JEM)

After

an

initial



CSR

value)

with

an

expert

rater

(JEM)

on

three

consecutive

assessments

before

conducting

interviews

independently


Subjects

completed

the

Revised


and

Depression

Scale

(RCADS

Chorpita

Yim

Mof 1047297tt

Umemoto

amp


7212019 Queen 2014


A s s e s s e

d


E x c l u d e d

o r D e c l i n e d ( n = 5 5 )

D i d n o t

m e e t


a

S o u

g h t t r e a t m e

n t e l

s e w h e r e

O p t e d f o

r p r i

v a


D a t a

A v a i l a b l e

8 -

W e e k ( n

= 2 0

)


= 2 0

)

3 M o n t h F o l

l o w

- U p ( n = 1 0

)

6 M o n t h F o l

l o w

- U p ( n = 1 1

)

E n r o l

l e d i n

R C T a n d r


( n = 2 6 )

R e c e


s e s s

i o n s

( n

= 2 3

)

D i d n o

t r e c e


s e s s

i o n s

( n

= 3 )


8 - W e e k ( n

= 2 0

)


= 1 5

)

3 M o n t h F o l

l o w

- U p ( n = 8 )

6 M o n t h F o l

l o w

- U p ( n = 6 )

E n r o l

l e d i n


W

L

( n = 2 4 )

R e c e


s e s s

i o n s

( n = 2 1

)

D i d n o t r

e c e i v e

a t l e a s t 8

s e s s

i o n s

( n = 3 )

E n

r o l

l e d ( n

= 6 7

)

E n r o l

l e d i n o p e n t

r i a l (

n = 1 7

)

R e c e i v e d

a t

l e a s t 8 s e s s

i o n s

( n = 1 5

)

D i d n o

t r e c e


s e s s

i o n s

( n = 2 )

D a t a

a v a i l a b l e

8 - W e e

k ( n

=

1 5

)


= 1 3

)

3 M o n t h

F o l

l o w

- U p

( n = 1 1

)

6 M o n t h

F o l

l o w

- U p

( n = 7 )

F i g

1

U P - A C O N S O R T 1047298 o w

d i a g r a m


7212019 Queen 2014













Raw

scores

were

converted

to

T -scores

using

child

age

and

gender


T-scores of 65



(Weiss

amp

Chorpita

2011)

Internal

consistency

values

for

the

RCADS



follows

a=

085

at

Time

1 a=

090

at

Time

2

a=

091

at

Time

3

a=

091

at

Time

4

and a=

093

at

Time

5


version

The


completed

the

Revised

Childrenrsquos



points

The

RCADS-P

is

a

47-item

parent-rated

measure

of

their


anxiety

and

depressive

symptoms

The

RCADS-P


shown

good

psychometric

properties

with

school-based

(Ebesu-tani

et

al

2011)

and

clinical

samples

(Ebesutani

et

al

2010) For

the

current

sample

internal

consistency

values

for

RCADS-P

Total



Internal

consistency

values

for

the

RCADS-P

MDD

subscale

were

as

follows

a=

078

at

Time

1

a=

088

at

Time

2

a=

091

at

Time

3


24

Data

analytic

plan



during the

six-month

follow-up

period

Several

indices

of

model

1047297t

were

used

including

chi square


(CFI)








Muthen 2005)

3 Results

The data were




outliers ( z

3)

were

identi1047297ed

at

any

time

points

All

subjects



the

end

of

treatment

(M

=

1558

sessions)

assessment

(Time

3)

However

there

was

considerable

missing

data

at

the

two

follow-



(4068)

having

data

six

months

after

treatment

(Time

5)

although

6271

of

subjects

had

available

data

for

at

least

one



missing

data

on

any

indicators

of

symptom

severity

at

baseline

or

any

demographic

variables

(eg

age

gender

ethnicity)

Further-


signi1047297cant

differences

on

any

variables

at

the



See

Table

3

for

observed

means

and

standard

deviations

of

RCADSRCADS-P

Total

Anxiety

T -scores

and

RCADSRCADS-P

MDD



Mean

T -scores

on

all

four

measures

reduced

to

below

65

by

Time

3

indicating

that

mean

levels

of

both

self-rated

and

parent-rated



participants

with

T -scores

65

and

T -scores

70

also

revealed

reductions

in

those

with

borderline

elevated

and

clinically

elevated

Table 2


Required

module

Suggested

number of

sessions














activation










7212019 Queen 2014


7212019 Queen 2014



variances of the



x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019



p lt 0001)













r = 059





r = 051




r = 023

p gt 030



strated acceptable


x2 (7) = 1042

p = 017





1047297t

x2D


freely estimated



p lt 0001)








SE = 1089






r = 048

p



r = 020




r = 024

p = 035


331 Anxiety

symptoms





1047297t

x2

(6) = 1427



50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated


50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated




7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014


22 Procedure


































impairment

Only

participants

receiving

a

primary

diagnosis

of

an



ipants

presented

with

moderately

severe

impairment

with

regard

to

their

primary

anxiety

or

depressive

disorder

diagnosis

(M

=

581



depressive

disorder

and who

did not

meet exclusion

criteria

were

eligible

to

enroll

in

treatment

trial Upon

obtaining

written



Participants

in

the

open trial

and

TX

arm

of

the

RCT

began

treatment

immediately

All

participants and

their parent

com-


treatment

considered


rdquo

point for most)

Time3

(end

of

treatment) Time 4

(three

months after

treatment

termination)

and

Time 5

(six

months after

treatment

termina-

tion)


during

the

8-week

WL period

but

did

brief

telephone

ldquocheck-insrdquo

with

their

assigned

therapist

to

assess

for

clinical

deterioration



were

used

as

Time

1

data

for

WL

participants

Analyses

revealed

no

signi1047297cant

changes

in


data

from

initial

diagnostic



completed

assessments

at

same

intervals

as

those

in

the

open

trial

and

TX

arm

of

RCT







correspond to the

































the

patient

experiences

impulses

for

self-harm

However

adoles-



23

Measures


version

(ADIS-IV-CP

Silverman

amp

Albano

1996)

The

ADIS-IV-CP

was

completed

at

the

adolescentrsquos

baseline



ages

7ndash17years

that

assesses

all

DSM-IV

anxiety

disorders

The

ADIS-

IV-CP

also

assesses

for

unipolar

depressive

disorders

and

external-


disorder)

and

screens

for

substance

abuse

schizophrenia


disorders

eating

disorders

and

somatoform

dis-

orders

In

addition

participants

were screened

for

bipolar

disorder



trained

in

ADIS-IV-CP

administration

and

participated

in

weekly

supervision

meetings

led

by

the

third

author

(JEM)

After

an

initial



CSR

value)

with

an

expert

rater

(JEM)

on

three

consecutive

assessments

before

conducting

interviews

independently


Subjects

completed

the

Revised


and

Depression

Scale

(RCADS

Chorpita

Yim

Mof 1047297tt

Umemoto

amp


7212019 Queen 2014


A s s e s s e

d


E x c l u d e d

o r D e c l i n e d ( n = 5 5 )

D i d n o t

m e e t


a

S o u

g h t t r e a t m e

n t e l

s e w h e r e

O p t e d f o

r p r i

v a


D a t a

A v a i l a b l e

8 -

W e e k ( n

= 2 0

)


= 2 0

)

3 M o n t h F o l

l o w

- U p ( n = 1 0

)

6 M o n t h F o l

l o w

- U p ( n = 1 1

)

E n r o l

l e d i n

R C T a n d r


( n = 2 6 )

R e c e


s e s s

i o n s

( n

= 2 3

)

D i d n o

t r e c e


s e s s

i o n s

( n

= 3 )


8 - W e e k ( n

= 2 0

)


= 1 5

)

3 M o n t h F o l

l o w

- U p ( n = 8 )

6 M o n t h F o l

l o w

- U p ( n = 6 )

E n r o l

l e d i n


W

L

( n = 2 4 )

R e c e


s e s s

i o n s

( n = 2 1

)

D i d n o t r

e c e i v e

a t l e a s t 8

s e s s

i o n s

( n = 3 )

E n

r o l

l e d ( n

= 6 7

)

E n r o l

l e d i n o p e n t

r i a l (

n = 1 7

)

R e c e i v e d

a t

l e a s t 8 s e s s

i o n s

( n = 1 5

)

D i d n o

t r e c e


s e s s

i o n s

( n = 2 )

D a t a

a v a i l a b l e

8 - W e e

k ( n

=

1 5

)


= 1 3

)

3 M o n t h

F o l

l o w

- U p

( n = 1 1

)

6 M o n t h

F o l

l o w

- U p

( n = 7 )

F i g

1

U P - A C O N S O R T 1047298 o w

d i a g r a m


7212019 Queen 2014













Raw

scores

were

converted

to

T -scores

using

child

age

and

gender


T-scores of 65



(Weiss

amp

Chorpita

2011)

Internal

consistency

values

for

the

RCADS



follows

a=

085

at

Time

1 a=

090

at

Time

2

a=

091

at

Time

3

a=

091

at

Time

4

and a=

093

at

Time

5


version

The


completed

the

Revised

Childrenrsquos



points

The

RCADS-P

is

a

47-item

parent-rated

measure

of

their


anxiety

and

depressive

symptoms

The

RCADS-P


shown

good

psychometric

properties

with

school-based

(Ebesu-tani

et

al

2011)

and

clinical

samples

(Ebesutani

et

al

2010) For

the

current

sample

internal

consistency

values

for

RCADS-P

Total



Internal

consistency

values

for

the

RCADS-P

MDD

subscale

were

as

follows

a=

078

at

Time

1

a=

088

at

Time

2

a=

091

at

Time

3


24

Data

analytic

plan



during the

six-month

follow-up

period

Several

indices

of

model

1047297t

were

used

including

chi square


(CFI)








Muthen 2005)

3 Results

The data were




outliers ( z

3)

were

identi1047297ed

at

any

time

points

All

subjects



the

end

of

treatment

(M

=

1558

sessions)

assessment

(Time

3)

However

there

was

considerable

missing

data

at

the

two

follow-



(4068)

having

data

six

months

after

treatment

(Time

5)

although

6271

of

subjects

had

available

data

for

at

least

one



missing

data

on

any

indicators

of

symptom

severity

at

baseline

or

any

demographic

variables

(eg

age

gender

ethnicity)

Further-


signi1047297cant

differences

on

any

variables

at

the



See

Table

3

for

observed

means

and

standard

deviations

of

RCADSRCADS-P

Total

Anxiety

T -scores

and

RCADSRCADS-P

MDD



Mean

T -scores

on

all

four

measures

reduced

to

below

65

by

Time

3

indicating

that

mean

levels

of

both

self-rated

and

parent-rated



participants

with

T -scores

65

and

T -scores

70

also

revealed

reductions

in

those

with

borderline

elevated

and

clinically

elevated

Table 2


Required

module

Suggested

number of

sessions














activation










7212019 Queen 2014


7212019 Queen 2014



variances of the



x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019



p lt 0001)













r = 059





r = 051




r = 023

p gt 030



strated acceptable


x2 (7) = 1042

p = 017





1047297t

x2D


freely estimated



p lt 0001)








SE = 1089






r = 048

p



r = 020




r = 024

p = 035


331 Anxiety

symptoms





1047297t

x2

(6) = 1427



50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated


50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated




7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014


A s s e s s e

d


E x c l u d e d

o r D e c l i n e d ( n = 5 5 )

D i d n o t

m e e t


a

S o u

g h t t r e a t m e

n t e l

s e w h e r e

O p t e d f o

r p r i

v a


D a t a

A v a i l a b l e

8 -

W e e k ( n

= 2 0

)


= 2 0

)

3 M o n t h F o l

l o w

- U p ( n = 1 0

)

6 M o n t h F o l

l o w

- U p ( n = 1 1

)

E n r o l

l e d i n

R C T a n d r


( n = 2 6 )

R e c e


s e s s

i o n s

( n

= 2 3

)

D i d n o

t r e c e


s e s s

i o n s

( n

= 3 )


8 - W e e k ( n

= 2 0

)


= 1 5

)

3 M o n t h F o l

l o w

- U p ( n = 8 )

6 M o n t h F o l

l o w

- U p ( n = 6 )

E n r o l

l e d i n


W

L

( n = 2 4 )

R e c e


s e s s

i o n s

( n = 2 1

)

D i d n o t r

e c e i v e

a t l e a s t 8

s e s s

i o n s

( n = 3 )

E n

r o l

l e d ( n

= 6 7

)

E n r o l

l e d i n o p e n t

r i a l (

n = 1 7

)

R e c e i v e d

a t

l e a s t 8 s e s s

i o n s

( n = 1 5

)

D i d n o

t r e c e


s e s s

i o n s

( n = 2 )

D a t a

a v a i l a b l e

8 - W e e

k ( n

=

1 5

)


= 1 3

)

3 M o n t h

F o l

l o w

- U p

( n = 1 1

)

6 M o n t h

F o l

l o w

- U p

( n = 7 )

F i g

1

U P - A C O N S O R T 1047298 o w

d i a g r a m


7212019 Queen 2014













Raw

scores

were

converted

to

T -scores

using

child

age

and

gender


T-scores of 65



(Weiss

amp

Chorpita

2011)

Internal

consistency

values

for

the

RCADS



follows

a=

085

at

Time

1 a=

090

at

Time

2

a=

091

at

Time

3

a=

091

at

Time

4

and a=

093

at

Time

5


version

The


completed

the

Revised

Childrenrsquos



points

The

RCADS-P

is

a

47-item

parent-rated

measure

of

their


anxiety

and

depressive

symptoms

The

RCADS-P


shown

good

psychometric

properties

with

school-based

(Ebesu-tani

et

al

2011)

and

clinical

samples

(Ebesutani

et

al

2010) For

the

current

sample

internal

consistency

values

for

RCADS-P

Total



Internal

consistency

values

for

the

RCADS-P

MDD

subscale

were

as

follows

a=

078

at

Time

1

a=

088

at

Time

2

a=

091

at

Time

3


24

Data

analytic

plan



during the

six-month

follow-up

period

Several

indices

of

model

1047297t

were

used

including

chi square


(CFI)








Muthen 2005)

3 Results

The data were




outliers ( z

3)

were

identi1047297ed

at

any

time

points

All

subjects



the

end

of

treatment

(M

=

1558

sessions)

assessment

(Time

3)

However

there

was

considerable

missing

data

at

the

two

follow-



(4068)

having

data

six

months

after

treatment

(Time

5)

although

6271

of

subjects

had

available

data

for

at

least

one



missing

data

on

any

indicators

of

symptom

severity

at

baseline

or

any

demographic

variables

(eg

age

gender

ethnicity)

Further-


signi1047297cant

differences

on

any

variables

at

the



See

Table

3

for

observed

means

and

standard

deviations

of

RCADSRCADS-P

Total

Anxiety

T -scores

and

RCADSRCADS-P

MDD



Mean

T -scores

on

all

four

measures

reduced

to

below

65

by

Time

3

indicating

that

mean

levels

of

both

self-rated

and

parent-rated



participants

with

T -scores

65

and

T -scores

70

also

revealed

reductions

in

those

with

borderline

elevated

and

clinically

elevated

Table 2


Required

module

Suggested

number of

sessions














activation










7212019 Queen 2014


7212019 Queen 2014



variances of the



x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019



p lt 0001)













r = 059





r = 051




r = 023

p gt 030



strated acceptable


x2 (7) = 1042

p = 017





1047297t

x2D


freely estimated



p lt 0001)








SE = 1089






r = 048

p



r = 020




r = 024

p = 035


331 Anxiety

symptoms





1047297t

x2

(6) = 1427



50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated


50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated




7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014













Raw

scores

were

converted

to

T -scores

using

child

age

and

gender


T-scores of 65



(Weiss

amp

Chorpita

2011)

Internal

consistency

values

for

the

RCADS



follows

a=

085

at

Time

1 a=

090

at

Time

2

a=

091

at

Time

3

a=

091

at

Time

4

and a=

093

at

Time

5


version

The


completed

the

Revised

Childrenrsquos



points

The

RCADS-P

is

a

47-item

parent-rated

measure

of

their


anxiety

and

depressive

symptoms

The

RCADS-P


shown

good

psychometric

properties

with

school-based

(Ebesu-tani

et

al

2011)

and

clinical

samples

(Ebesutani

et

al

2010) For

the

current

sample

internal

consistency

values

for

RCADS-P

Total



Internal

consistency

values

for

the

RCADS-P

MDD

subscale

were

as

follows

a=

078

at

Time

1

a=

088

at

Time

2

a=

091

at

Time

3


24

Data

analytic

plan



during the

six-month

follow-up

period

Several

indices

of

model

1047297t

were

used

including

chi square


(CFI)








Muthen 2005)

3 Results

The data were




outliers ( z

3)

were

identi1047297ed

at

any

time

points

All

subjects



the

end

of

treatment

(M

=

1558

sessions)

assessment

(Time

3)

However

there

was

considerable

missing

data

at

the

two

follow-



(4068)

having

data

six

months

after

treatment

(Time

5)

although

6271

of

subjects

had

available

data

for

at

least

one



missing

data

on

any

indicators

of

symptom

severity

at

baseline

or

any

demographic

variables

(eg

age

gender

ethnicity)

Further-


signi1047297cant

differences

on

any

variables

at

the



See

Table

3

for

observed

means

and

standard

deviations

of

RCADSRCADS-P

Total

Anxiety

T -scores

and

RCADSRCADS-P

MDD



Mean

T -scores

on

all

four

measures

reduced

to

below

65

by

Time

3

indicating

that

mean

levels

of

both

self-rated

and

parent-rated



participants

with

T -scores

65

and

T -scores

70

also

revealed

reductions

in

those

with

borderline

elevated

and

clinically

elevated

Table 2


Required

module

Suggested

number of

sessions














activation










7212019 Queen 2014


7212019 Queen 2014



variances of the



x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019



p lt 0001)













r = 059





r = 051




r = 023

p gt 030



strated acceptable


x2 (7) = 1042

p = 017





1047297t

x2D


freely estimated



p lt 0001)








SE = 1089






r = 048

p



r = 020




r = 024

p = 035


331 Anxiety

symptoms





1047297t

x2

(6) = 1427



50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated


50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated




7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014


7212019 Queen 2014



variances of the



x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019



p lt 0001)













r = 059





r = 051




r = 023

p gt 030



strated acceptable


x2 (7) = 1042

p = 017





1047297t

x2D


freely estimated



p lt 0001)








SE = 1089






r = 048

p



r = 020




r = 024

p = 035


331 Anxiety

symptoms





1047297t

x2

(6) = 1427



50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated


50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated




7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014



variances of the



x2 (9) = 1363

p = 014 CFI = 097 RMSEA = 009 SRMR = 019



p lt 0001)













r = 059





r = 051




r = 023

p gt 030



strated acceptable


x2 (7) = 1042

p = 017





1047297t

x2D


freely estimated



p lt 0001)








SE = 1089






r = 048

p



r = 020




r = 024

p = 035


331 Anxiety

symptoms





1047297t

x2

(6) = 1427



50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated


50

52

54

56

58

60

62

64

66

68

70


Observed

Estimated




7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014








The








1047297t and this








SE = 214

p


p






r = 081 p lt 0001

332

Depressive

symptoms


1047297tx2 (7) = 2114

p = 0004




T -scores after




variance of the




mended

to

allow

the

residual

variances

of

the

fourth

and

1047297fth time



The

loadings

for

the

1047297nal

two time

points

were

estimated

at 219

and 241

respectively

indicating

very

little

continued

reduction



SE

=

244

p

lt

0001)

as

was

the

slope

mean

(M s1=

478

SE

=

102

p

lt

0001)

The

variance

of

the

intercept

was

statistically

signi1047297cant



p

lt

0001)

The

intercept

and

slope

were

signi1047297cantly

and

positively

correlated

r

=

071 p

lt

001 Controlling

for

their

shared


fourth

and

1047297fth time

points

were

signi1047297cantly

and


r

= 075

p

lt

001 while

the

residual

variances

for

the

third

and

fourth

time

points

were

signi1047297cantly

positively


4

Discussion



transdiagnostic

emotion-focused

intervention

as

well

as

up

to

six

months

following

treatment

We

conducted

separate

piecewise



of

change

in

anxiety

(M

=

476)

and

depressive

symptoms

(M

=

482)

during

the

course

of

the

UP-A However

one

notable







showed poor model




depressive symptoms

These
















was the











symptoms

showed

continued

and

signi1047297cant

reduction

during



primarily

anxious

sample

it

is

possible

that

relapse

prevention

efforts

were

focused

upon

techniques

geared

more

for

anxiety

(eg



practice

treatment

strategies

more

relevant

to

anxiety

than

depression

during

the

follow-up

phase

It

is

important

to

note



Adolescents

with

Depression

Study

(TADS)

2009) and

anxiety-

focused

CBT

(Kendall

et

al

1997)

Thus

our

1047297ndings

are

consistent

with prior work

Another

interesting

difference

was

that

while

treatment

andfollow-up

slopes

were

signi1047297cantly

and

negatively

correlated

for

self-rated

anxiety

symptoms

their

correlation

was




during

follow-up

for

anxiety

symptoms

compared

to

depressive

symptoms

for

adolescents

receiving

the

UP-A However

this

result



negative

correlation

observed

for

anxiety

symptoms

may

be

explained

by

less

room

for

improvement

for

participants

who

had



self-rated

and

parent-rated

symptom

change

Parent-rated

symp-

tom

models

showed

poor

1047297t to

piecewise

growth

curves

as

a

result


7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014


7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





7212019 Queen 2014





Kagan

J

Reznick

J

amp

Snidman

N

(1987)

Temperamental

variation

in

response







OrsquoNeil

K

A

amp

Kendall

P

C

(2012)

Role

of

comorbid

depression

and







1141ndash

1149






Physiological

response

and

childhood

anxiety

Association

with

symptoms





Queen, 2014

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