Anxiety, Depression, and Somatic Distress: Developing a Transdiagnostic Internalizing Toolbox for Pediatric Practice

doi:10.1016/j.cbpra.2011.06.002

Cognitive and Behavioral Practice

Volume 19, Issue 1, February 2012, Pages 68-82

https://doi.org/10.1016/j.cbpra.2011.06.002 Get rights and content

Abstract

Anxiety, depression, and somatic complaints are a common set of comorbid problems in children and adolescents. This “internalizing cluster” is highly prevalent, impairing during youth and into adulthood, and has substantial impacts on health-care systems. Fortunately, these problem areas may share several etiological factors and, thus, respond to similar interventions. In this paper, we present (a) the rationale for focusing on this cluster, (b) clinical theory on transdiagnostic processes uniting these problems, (c) description of core treatment techniques for this group, with a description of clinical outcomes for two sample cases, and (d) implications of this approach for new transdiagnostic treatment development and everyday clinical practice.

Highlights

► We review theory and literature on youth anxiety, depression, and somatic complaints. ► Rationale presented for transdiagnostic psychosocial intervention for these problems. ► Present development of two such transdiagnostic protocols, with case examples. ► Discuss protocols in relation to future research and clinical use.

Section snippets

Prevalence and Impact

Separately and in conjunction, youth anxiety, depression, and somatic symptoms are distressing, disabling, and prevalent (e.g., Campo, Bridge, et al., 2004, Bell-Dolan et al., 1990, Lewinsohn et al., 1993, Scharff, 1997, Walker et al., 1993). In the pediatric population, prevalence of anxiety is estimated to be as high as 20% (Bell-Dolan et al., 1990), depression estimates reach up to 25% (Lewinsohn et al., 1993), and rates of impairing somatic complaints vary from 7% to 25% (e.g., recurrent

Evidence for Transdiagnostic Processes From the Psychopathology Literature

The strong evidence for nonrandom associations between pediatric anxiety, depressive, and functional somatic distress raises questions about the nature of the observed comorbidity. Current theories of the development and maintenance of each of these problem areas focus on the interplay between (a) biological sensitivity to life stress, (b) heightened anticipation and experience of pain and emotional distress, (c) maladaptive cognitions and poor problem solving, and (d) behavioral inhibition and

Evidence for Transdiagnostic Processes From the Treatment Literature

Most evidence-based treatments for youth have been designed to treat specific, single disorders; however, even within this literature, there are glimmers of support for a transdiagnostic treatment approach. The best evidence comes from studies on the positive response of all three problems to cognitive behavioral therapy (CBT) and to selective serotonin-reuptake inhibitors (SSRIs).

Developing a Transdiagnostic Treatment Approach

In our work, we have begun developing a psychosocial internalizing toolbox to treat this cluster of related problems. In this next section, we briefly review our rationale for focusing on psychosocial treatment and our progress to date in manual development and pilot testing.

Clinical Case Examples¹

Two cases are presented here to illustrate application of the above-described interventions in the pediatric primary care setting.²

Future Directions

In this report, we describe our group's efforts to develop an internalizing toolbox for youths struggling with anxiety, depression, and/or somatic symptoms. At this point, our work has coalesced into two parallel protocols—one targeting the “emotional cluster” of anxiety and depression, and one targeting the “physical cluster” of anxious arousal and somatic symptoms. This two-protocol distinction, however, hides considerable overlap in the practical implementation of our treatments. As

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To report on broad-based outcomes of the Brief Behavioral Therapy (BBT) trial for pediatric anxiety and depression. Secondary data analyses expand on previous reports by assessing diagnostic remission and independent functioning, impact on targeted psychopathology, and spillover effects on non-targeted outcomes.
Youth (N = 185; 8-16.9 years; 58% female; 78% White; 21% Hispanic) with anxiety and/or depression were eligible for this multi-site trial. Enrolled youth were randomly assigned to receive 8 to 12 sessions of BBT in primary care or assisted referral to outpatient care (ARC). Assessments were conducted 16 and 32 weeks post randomization.
BBT was superior to ARC on remission of all targeted diagnoses (week 16: 56.8% vs 28.2%, p < .001; week 32: 62.5% vs 38.9%, p = .004), clinician-rated independent functioning (week 16: 75.0% vs 45.7%, p < .001; week 32: 81.2% vs 55.7%, p < .001), and on measures of anxiety, depression, suicide items, total comorbid behavioral and emotional problems, and hyperactivity (d = 0.21-0.49). Moderation analyses revealed superior outcomes for Hispanic youth in BBT vs ARC for diagnostic remission, anxiety, emotional problems, and parent−child conflict. Youth depression at baseline moderated effects on peer problems and parent−child conflict, with effects favoring BBT. Significant main and moderated effects of BBT on change in non-targeted outcomes were largely mediated by change in anxiety (24.2%-49.3% of total effects mediated).
BBT has positive effects on youth, mediated by the strong impact of the intervention on anxiety. Analyses continue to support positive outcomes for Hispanic youth, suggesting that BBT is a broadly effective transdiagnostic treatment option for diverse populations.
Brief Cognitive Behavioral Therapy (CBT) for Pediatric Anxiety and Depression in Primary Care; https://clinicaltrials.gov; NCT01147614.
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Citation Excerpt :
Written assent and consent from youths and parents was obtained in accordance with procedures approved by the Institutional Review Boards of the University of Pittsburgh, Kaiser Permanente Southern California, and the San Diego State University Human Research Protection Program. As noted above, Brief Behavioral Therapy (BBT) is a transdiagnostic intervention designed to address depression, anxiety, and their co-occurrence.12,21 BBT consists of psychoeducation about depression and anxiety for parents and youths, “graded engagement” through exposure and behavioral activation to avoided (and consequential) activities, along with relaxation to manage somatic symptoms and problem-solving skills for stress management.
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^☆: Data collection and manuscript preparation were facilitated by support from the National Institute of Mental Health, the Robert Wood Johnson Foundation, and the William T. Grant Foundation. We gratefully acknowledge the following colleagues who aided in the conduct of these studies: Araceli Gonzalez, Carrie Fascetti, Jennifer Strohm, Sheree Shafer, Fallon Gallatin, Steve Savorelli, and Erin Warnick.

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Anxiety, Depression, and Somatic Distress: Developing a Transdiagnostic Internalizing Toolbox for Pediatric Practice☆

Abstract

Highlights

Section snippets

Prevalence and Impact

Evidence for Transdiagnostic Processes From the Psychopathology Literature

Evidence for Transdiagnostic Processes From the Treatment Literature

Developing a Transdiagnostic Treatment Approach

Clinical Case Examples1

Future Directions

Behavior Therapy

Journal of the American Academy of Child & Adolescent Psychiatry

Child and Adolescent Psychiatric Clinics of North America

Journal of the American Academy of Child and Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Current Opinions in Pharmacology

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of Adolescent Health

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of Pediatrics

Journal of the American Academy of Child & Adolescent Psychiatry

Behavior Therapy

Journal of the American Academy of Child & Adolescent Psychiatry

Behavior Therapy

Journal of the American Academy of Child & Adolescent Psychiatry

Clinical Psychology Review

Pain

American Journal of Medicine

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of Anxiety Disorders

Biological Psychiatry

Pediatric Clinics of North America

Journal of the American Academy of Child & Adolescent Psychiatry

Clinical Psychology Review

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of Affective Disorders

Cognitive and Behavioral Practice

Diagnostic and statistical manual of mental disorders

Comorbidity and the general neurotic syndrome

British Journal of Psychiatry

Comorbidity

Journal of Child Psychology, Psychiatry, and Allied Disciplines

Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: A randomized controlled trial

Journal of the American Medical Association

Explaining high rates of depression in chronic pain: A diathesis-stress framework

Psychological Bulletin

Anxiety and its disorders: The nature and treatment of anxiety and panic

Unraveling the mysteries of anxiety and its disorders from the perspective of emotion theory

American Psychologist

Further evidence of association between behavioral inhibition and social anxiety in children

American Journal of Psychiatry

What do childhood anxiety disorders predict?

Journal of Child Psychology and Psychiatry

Comorbidity of anxiety and depression in children and adolescents

Psychological Bulletin

Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: The TORDIA randomized controlled trial

Journal of the American Medical Association

A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive treatments

Archives of General Psychiatry

Recurrent abdominal pain, anxiety, and depression in primary care

Pediatrics

Adult outcomes of pediatric recurrent abdominal pain: Do they “just grow out of it”?

Pediatrics

Somatoform disorders

Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene

Science

The therapeutic role of 5-HT1A and 5-HT2A receptors in depression

Journal of Psychiatry and Neuroscience

The role of family factors in pediatric pain

Research note: Temperament and behaviour in six-year-olds with recurrent abdominal pain: A follow up

Journal of Child Psychology and Psychiatry

Clinical Case Examples¹