Implementing a Cognitive Behavioral Skills Program for Anxious Youth: A Knowledge Translation ...

121 Pages·2014·1.18 MB·English

Implementing a Cognitive Behavioral Skills Program for
Anxious Youth: A Knowledge Translation Project
by
Emily Jones
A thesis submitted in conformity with the requirements
for the degree of Masters of Science
Institute of Medical Science
University of Toronto
© Copyright by Emily Jones 2014
Implementing a Cognitive Behavioral Skills Program for Anxious
Youth: A Knowledge Translation Project
Emily Jones
Masters of Science
Institute of Medical Science
University of Toronto
2013
Abstract
Cognitive Behavioural Therapy (CBT) is an underutilized evidence-based treatment for Anxiety
Disorders. Increasing effective knowledge translation and implementation of CBT has significant
public health implications. This study sought to increase the use of CBT by providing a 20-week-
group-supervision program to Northern Ontario. Therapist measures of CBT knowledge
competence were collected pre and post training, and treatment outcome measures were obtained
by child and parent report. Clients in Northern Ontario were older (M=11.6years, Toronto
M=10.0 years), were more likely on medication, and more likely to have a comorbid diagnosis
than clients from an existing data-set in Toronto, Ontario. The training program was successful
in increasing CBT knowledge competence and decreasing client anxiety in both locations, with
greater improvements in self-reported anxiety in the Northern Ontario group. Therapist CBT
knowledge competence was predictive of client symptom change as reported by parent but not
child. Two therapist variables were found to be moderators.
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Acknowledgments

I would like to thank all those who have helped me along the way in developing who I am today.
Specifically I would like to thank my husband LeVar Jones and my parents for their constant
support. I would like to especially thank my supervisor Dr. Katharina Manassis and mother Dr.
Angela Fountain for their extensive help and contributions to this project. As well I would like to
thank my thesis committee members Dr. Paul Arnold, Dr. Judith Wiener, and Dr. Alice Charach.
Finally, I would like to thank all other collaborators on this project: Behdin Nowrouzi, Dr. Abel
Ickowicz, Dr. Sandra Mendlowitz, Dr. Pamela Wilansky-Traynor, Dr. Kathryn Bennett, Dr. Fred
Schmidt and Bell Canada for the research funding.
Table of Contents
Acknowledgments .......................................................................................................................... iii
List of Tables ................................................................................................................................. vi
List of Figures ................................................................................................................................ ix
List of Appendices .......................................................................................................................... x
Chapter 1: Literature Review .......................................................................................................... 1
1.1 Childhood Anxiety .............................................................................................................. 2
1.1.1 Evidence Based Treatments for Childhood Anxiety .............................................. 4
1.1.2 Cognitive Behavioural Therapy (CBT) for Childhood Anxiety ............................. 5
1.1.3 Treatment Outcome ................................................................................................ 6
1.2 Knowledge Translation ....................................................................................................... 8
1.2.1 Barriers to Knowledge Translation of CBT for Children with Anxiety ............... 12
1.2.2 Knowledge Translation to Rural Northern Ontario .............................................. 16
1.3 Summary ........................................................................................................................... 17
1.4 Research Aims and Hypotheses ........................................................................................ 18
Chapter 2: Implementing Cognitive Behavioural Therapy in Rural-Community versus Urban-
Academic Settings .................................................................................................................... 21
2.1 Introduction ....................................................................................................................... 21
2.2 Methods ............................................................................................................................. 24
2.2.1 Participants ............................................................................................................ 24
2.2.2 Measures ............................................................................................................... 25
2.2.3 Data Analysis ........................................................................................................ 28
2.3 Results ............................................................................................................................... 29
2.3.1 Secondary Analyses .............................................................................................. 31
2.4 Discussion ......................................................................................................................... 32
iv
Chapter 3: Translating Cognitive Behavioral Therapy for Anxious Youth to Rural-
Community Settings via Telepsychiatry .................................................................................. 36
3.1 Introduction ....................................................................................................................... 36
3.2 Methods ............................................................................................................................. 40
3.3 Measures ........................................................................................................................... 41
3.3.1 Child CBT Multiple Choice Test .......................................................................... 42
3.3.2 Multidimensional Anxiety Scale for Children ...................................................... 43
3.3.3 Achenbach System –Child Behaviour Checklist. ................................................. 43
3.4 Data Analysis .................................................................................................................... 44
3.5 Results ............................................................................................................................... 46
3.5.1 Secondary Analyses .............................................................................................. 55
3.6 Discussion ......................................................................................................................... 56
Chapter 4: General Discussion ...................................................................................................... 60
4.1 Addressing Barriers to Knowledge Translation ................................................................ 61
4.2 Supervised Training .......................................................................................................... 63
4.3 Urban-Academic Versus Rural-Community Clientele ..................................................... 63
4.4 Knowledge Translation to Therapists in Rural Communities ........................................... 65
4.5 Effect of Therapist Knowledge Competence on Child Outcomes .................................... 65
4.6 Moderators of Treatment Outcome ................................................................................... 66
4.7 Study Limitations .............................................................................................................. 67
Chapter 5: Conclusions ................................................................................................................. 70
Chapter 6: Future Directions ......................................................................................................... 71
References ..................................................................................................................................... 73
Appendix A: CHAPTER 2: EFFECTIVE TRAINING METHODS ............................................ 83
Appendix B: Child CBT Multiple Choice Test .......................................................................... 107
Copyright Acknowledgements .................................................................................................... 111
v
List of Tables

Chapter 2: Implementing Cognitive Behavioural Therapy in Rural versus Urban Settings
Table 1 Pre & Post-Treatment Means & Standard Deviations by Group……...29
Table 2 Demographic & Clinical Variable Means & Rates……………………..31
Table 3 Means & Standard Deviations between Completers and Non-
Completers of Training and Post-Packages…………………...............32
Chapter 3: Translating Cognitive Behavioral Therapy for Anxious Youth to Rural Settings
via Telepsychiatry
Table 1 Means & Standard Deviations Across Time for Client Measures…….46
Table 2 Means & Standard Deviations Across time for Therapists Measure....47
Table 3 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx)..…………………………….…………………………..48
Table 4 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Client Variable – Location.………………………..48
Table 5 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Client Variable – Socioeconomic Status by
Parent Education.…………………………………………...……………..49
Table 6 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Client Variable – Pre Treatment Anxiety
Symptoms by Client Report……………………..………………………..49
Table 7 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Client Variable – Pre Treatment Anxiety
Symptoms by Parent Report (CBCL-Anx/Dep).………………………..49
Table 8 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Client Variable – Pre Treatment Anxiety
Symptoms by Parent Report (CBCL DSM Anx)………………………..50
Table 9 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Client Variable – Comorbid Non-Anxiety
Disorder.…………………………………………………………..………..50
Table 10 Summary of Regression Analysis for Anxiety Symptom Change
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(CBCL DSM Anx) & Therapist Variable – Prior Child Therapy
Experience.………………………………………………………………..51
Table 11 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Percentage
of Time Using CBT.………………………………………………………..51
Table 12 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Pre CBT Knowledge
Competence………..………………………………………………………..52
Table 13 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Change in CBT Knowledge
Competence………...………………………………………………………..52
Table 14 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Confidence
Using CBT…………..………………………………………………………..52
Table 15 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Collaboration
with Other Colleagues..……………………………………………………..53
Table 16 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Efficient Use
of Time and Pacing Sessions.……………………………………………..53
Table 17 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Use of
Eliciting Feedback from Clients.…………………………………………...53
Table 18 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Use of Guided
Discovery in Sessions……………………………………………………....54
Table 19 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Use of
Homework in Session..……………………………………………………..54
Table 20 Summary of Regression Analysis for Anxiety Symptom Change
(CBCL DSM Anx) & Therapist Variable – Post Training Ability to
Conceptualize a CBT Case………………………………………………..54
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Table 21 Means & Standard Deviations between Completers and Non-
Completers of Training and Post=Packages……………………………………..56

viii
List of Figures

Figure 1. Model of Proposed Relationship Between Therapist Knowledge
Competence and Change in Client Anxiety……………………………………...40
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List of Appendices

Appendix A: CHAPTER 2: EFFECTIVE TRAINING METHODS ........................................ 83
Appendix B: Child CBT Multiple Choice Test ...................................................................... 107
x