- Email: [email protected]
The mediating role of changes in harm beliefs and coping efficacy in youth with specific phobias
Accepted Manuscript The mediating role of changes in harm beliefs and coping efficacy in youth with specific phobias Thomas H. Ollendick, Sarah M. Ryan, Nicole N. Capriola-Hall, Lena Reuterskiöld, Lars-Göran Öst PII:
S0005-7967(17)30211-5
DOI:
10.1016/j.brat.2017.10.007
Reference:
BRT 3208
To appear in:
Behaviour Research and Therapy
Received Date: 11 May 2017 Revised Date:
27 September 2017
Accepted Date: 16 October 2017
Please cite this article as: Ollendick, T.H., Ryan, S.M., Capriola-Hall, N.N., Reuterskiöld, L., Öst, Lars.Gö., The mediating role of changes in harm beliefs and coping efficacy in youth with specific phobias, Behaviour Research and Therapy (2017), doi: 10.1016/j.brat.2017.10.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running Head: HARM BELIEFS IN SPECIFIC PHOBIAS
1
The Mediating Role of Changes in Harm Beliefs and Coping Efficacy in Youth with Specific Phobias
RI PT
Thomas H. Ollendick1, Sarah M. Ryan1, Nicole N. Capriola-Hall1, Lena Reuterskiöld2, and Lars-
1
Virginia Tech
Child Study Center
SC
Göran Öst2
M AN U
Department of Psychology Blacksburg, VA 24061
Phone: (540) 231-6451; Fax: (540) 231-3652
Stockholm University
TE D
2
Department of Psychology
EP
SE-106 91 Stockholm, Sweden
AC C
Correspondence concerning this article should be addressed to: Sarah Ryan e-mail: [email protected] Tel (540) 231-3514 Fax (540) 231-3652
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
2 Abstract
Individuals with specific phobias (SPs) often experience catastrophic cognitions and compromised efficacy regarding their ability to cope when in the presence of the phobic
RI PT
object/situation. In the current study, 165 children (7-16 years; 62% male) received either One Session Treatment or Educational Support Therapy for their SP. The children identified their feared belief and rated “how bad” it was, “how likely” it was to occur, and their ability to cope if
SC
it did occur. All of these ratings were reduced from pre-treatment to 6-month follow-up, across both treatment conditions. However, ratings of “how bad” and “how likely” reduced to a
M AN U
significantly greater degree for children who received OST. Greater change in each of the three beliefs predicted lower clinician severity ratings (CSRs) at post-treatment and 6-month followup. Additionally, changes in “how bad” and “how likely” the children rated their beliefs, and their reported ability to cope, partially mediated the relationship between treatment and post-
TE D
treatment and follow-up CSRs. Overall, these findings suggest that although both treatment conditions produced changes in harm beliefs and coping efficacy, OST elicited greater changes
EP
and these changes may be important mechanisms in reduction of SP clinical severity.
Trial
AC C
Keywords: Phobic Beliefs, Specific Phobias, Children and Adolescents, Randomized Controlled
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
3
The Mediating Role of Changes in Harm Beliefs and Coping Efficacy in Youth with Specific Phobias Children often experience a range of fears throughout their development. Normative fears
RI PT
tend to rise in early childhood and wane by early adolescence (Muris, Merckelbach, Gadet, & Moulaert, 2000). For some youth, however, these fears persist and increase in intensity and
severity resulting in the development of a specific phobia (SP). In addition, for other youth,
SC
direct or vicarious adverse experiences occasion the onset of SPs. Although there are multiple etiological pathways for SPs, once they have developed they can then serve as a “gateway”
M AN U
disorder to other anxiety, mood, and substance use disorders (Ollendick & Muris, 2015). SPs are characterized by excessive and unreasonable fear or anxiety concerning a specific object or situation [American Psychiatric Association (APA), 2013]. Consistent with the tripartite conceptualization of anxiety disorders more broadly, hallmark characteristics of SPs include
TE D
physiological arousal, behavioral avoidance, and maladaptive thinking when in the presence of the feared stimulus (Lang, Cuthbert, & Bradley, 1998; Lang, Davis, & Öhman, 2000). Children’s beliefs in regards to the feared stimulus or situation are often catastrophic and unrealistic (i.e.,
EP
out of proportion to the “actual” danger or threat). These catastrophic cognitions are often directly tethered to avoidance behaviors and physiological hyperarousal which serve to maintain
AC C
the SP and to reduce coping efficacy in the presence of the feared object/situation (Byrne, Rapee, Malhi, Sweller, & Hudson, 2014; Öst, 2012; Ollendick & Davis, 2013; Zlomke & Davis, 2008). Although the role of harm beliefs and coping efficacy have been examined in the treatment of adults with SPs (Thorpe & Salkovskis, 1995), little research has examined the role of harm beliefs and coping efficacy in the treatment of youth with SPs.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
4
One-session treatment (OST) is a single session therapy based on cognitive behavioral therapy principles (Öst, 1989). Several recent randomized controlled trials (RCTs) and controlled single case design studies have shown that OST is a rapid and effective intervention to treat
RI PT
children and adolescents with a variety of SPs (Oar, Farrell, Waters, Conlon, & Ollendick, 2015; Ollendick et al., 2009; Ollendick et al., 2015; Öst, Svensson, Hellström, & Lindwall, 2001;
Waters, Farrell, Zimmer-Gembeck, Milliner … & Ollendick, 2014). The purpose of the present
SC
study was to examine harm beliefs and coping efficacy in a large sample of youth who
participated in a randomized control trial (RCT) comparing OST to an education support
M AN U
treatment (EST; Ollendick et al., 2009). Results of this RCT demonstrated that OST was superior to EST on clinician ratings of SP severity and children’s self-reported fear ratings during a behavioral avoidance test at post-treatment and 6-month follow-up. The primary aim of EST was to provide support and psychoeducation to the child about SPs; importantly, however, this
TE D
treatment did not include the systematic challenging of harm beliefs or attempts to build coping efficacy in the presence of the feared object/situation which are central to, and characteristic of, OST.
EP
Recently, in a re-analysis of data from this 2009 study, we showed that catastrophic beliefs and coping efficacy changed in the OST condition and that these changes were related to
AC C
changes in clinical severity ratings of the SP following treatment (Ollendick, Öst, Ryan, Capriola, & Reuterskiöld, 2017). Further, we compared the subjective beliefs of the youth to more objective probabilities associated with these beliefs. In line with information processing models of fear and anxiety (e.g., Beck, Emery, & Greenberg, 1985; Wright & Borden, 1991), results revealed that the youth’s subjective beliefs were overestimated compared to the more
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
5
objective evaluations determined by independent raters. These differences, however, were no longer evident following treatment. In the current study, we were interested in examining whether OST yielded superior
RI PT
outcomes in reduction of harm beliefs and enhancement of coping efficacies when compared to EST, and whether changes in harm beliefs and coping efficacy were related to clinical severity ratings following treatment in both conditions or were specific to OST. Because each of these
SC
variables was collected longitudinally, we were interested in addressing the possibility of
mediation, accounting for aspects of change between the two treatments. To our knowledge, no
M AN U
studies have considered the mediating role of reduction of harm beliefs and coping efficacy in treatment gains in a sample of youth with SPs (although Hogendoorn et al., 2014; Lau, Chan, Li, & Au, 2010: and Kendall et al., 2016, have done so with other anxiety disorders). Consistent with information processing models invoked in the treatment of fear and anxiety (e.g., Beck et
TE D
al., 1985; Hadwin, Garner, & Perez-Olivas, 2006), we predicted that youth randomized to the OST condition would demonstrate greater changes in harm beliefs and coping efficacy than children in the EST condition, that reductions in these beliefs and increases in coping estimates
outcomes.
EP
would be specific to the OST condition, and that these changes would mediate treatment
AC C
Finally, we were interested in comparing objective ratings of the children’s beliefs to
their own perceptions. We hypothesized that similar to the findings of Ollendick and colleagues (2017), when objective ratings are compared to the youths’ pre-treatment ratings the subjective ratings would be significantly higher (i.e., more catastrophic) than the objective ratings. Because Ollendick and colleagues (2017) found youth’s subjective ratings to significantly reduce following OST, we reasoned that following treatment the ratings of the children in the OST
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
6
group would no longer differ significantly from the objective ratings. Because the EST condition does not involve direct challenging of children’s beliefs, we hypothesized that the beliefs of
Method Participants
RI PT
children in the EST condition would remain significantly higher than the objective ratings.
Treatment seeking families from the United States of America and Sweden were
SC
recruited into a randomized clinical control trial (RCT) which examined the relative
effectiveness of OST and EST for youth with a SP (see Ollendick et al., 2009). In total, 195
M AN U
children and adolescents with a clinically confirmed SP diagnosis were randomized to one of the two treatment conditions. Participants were recruited through referrals from child psychiatric services, school health services, primary care settings, and print advertisements. SP was the primary reason for referral in all cases. The following inclusion criteria were enlisted:
TE D
participants had to be between 7-16 years of age and had to meet DSM-IV criteria for one or more of the most commonly occurring SPs (animal, environmental, or situational; APA, 1994), as determined by the Anxiety Disorders Interview Schedule for DSM-IV/Child and Parent
EP
Version (ADIS-IV-C/P; Silverman & Albano, 1996). In addition, the participant was required to discontinue other forms of psychotherapy or anti-anxiety medications for the duration of the
AC C
RCT and the participants could not meet criteria for exclusionary diagnoses of major depression with suicide intent, pervasive developmental disorder, and psychosis. The final sample consisted of 165 children: 79 children were randomized to the EST
condition (M age: 10.29, SD: 2.01; 62% male) and 86 children were randomized to the OST condition (M age: 10.45, SD: 2.25; 62% male). Of these 165 children, 76 were from the United States while 89 were from Sweden. Thirty of the original 195 participants were excluded from
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
7
the present analyses because they did not present with one of the more commonly occurring SPs (e.g., those who met criteria for Blood-Injection-Injury or “Other” type; see Ollendick et al., 2017). Of the 79 children randomized to the EST condition, 49 (62.0%) were treated for an
RI PT
animal phobia, 20 (25.3%) were treated for an environmental phobia, and 10 (12.7%) were
treated for a situational phobia. Of the 86 children randomized to the OST condition, 52 (60.5%) were treated for an animal phobia, 18 (20.9%) were treated for an environmental phobia, and 16
SC
(18.6%) were treated for a situational phobia. The mean family income for the 195 families in the original sample was $85,506 and $71,240 for families from Sweden and the United States,
M AN U
respectively. Additionally, 94% of the Sweden sample and 88% of the United States sample were Caucasian. No significant differences between youth from Sweden and the United States were evident on any of these indices hence were combined for the present analyses. Procedure
TE D
The research was approved by both institutions’ human research ethics committee. Following referral, potential participants’ parents completed a brief telephone screen to determine probable eligibility. Eligible families were invited to the respective clinics for a pre-
EP
treatment assessment session. All participants provided informed written consent/assent at the start of the study session. During the pre-treatment assessments, children and their parents
AC C
completed questionnaires, a Behavioral Approach Test (BAT), and the Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent Versions (ADIS-IV-C/P; Silverman & Albano, 1996). Clinicians also solicited the child’s primary phobic belief during the interview and the child completed the Phobic Beliefs Scale (PBS; see below). If appropriate for the study, the family was randomized to a treatment condition (OST or EST). Participants in both treatment conditions received treatment on a separate day from the pre-treatment assessment,
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
8
approximately one week later. Following the 3-hour treatment session, post assessment was conducted one week following treatment and follow-up was undertaken six months following treatment. The diagnostic modules endorsed at pre-treatment, the PBS, the BAT, and a battery of
RI PT
questionnaires was administered at post-treatment and 6-month follow-up. Further details on procedures of the original study can be found in Ollendick et al. (2009). Treatments
SC
The child focused OST treatment condition was based on principles developed by Öst (1989, 1997) for adults and subsequently manualized for the treatment of SPs in youth (Öst &
M AN U
Ollendick, 2001). OST is derived from cognitive behavioral therapy (CBT) and its guiding principles. The objective of the 3-hour session is to gradually expose the child to the phobic stimuli while simultaneously challenging the child’s distorted and catastrophic cognitions and enhancing their coping efficacy when in the presence of the feared object/situation. Treatment
TE D
components include graduated in vivo exposure in which youth are prompted to draw conclusions regarding their phobic beliefs using the evidence collected during the exposure. The therapist and the child work collaboratively throughout the treatment session to also enhance the
EP
child’s coping efficacy. Parents are not involved in the treatment session. The EST treatment condition was based on a treatment developed by Silverman and
AC C
colleagues (1999) with adaptations made by our research team. EST is also a 3-hour manualized treatment which primarily consists of psycho-educational components (i.e., definitions of fears and phobias, description of physiological factors associated with fear responses, etc.) and the provision of emotional support for sharing and discussing their fears and phobias. The youth are provided a colorful workbook with pictures, activities, and information regarding their feared object or situation that was created for this study. Children and adolescents randomized to the
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
9
EST condition worked collaboratively with a therapist in completing the workbook and learning more about their phobia. Importantly, EST did not include any elements of in vivo exposure, cognitive restructuring, or attempts to enhance the coping efficacy of the child. Similar to the
RI PT
OST condition, parents were not involved in the EST treatment condition. Measures
The Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent Versions
SC
(ADIS-IV-C/P; Silverman & Albano, 1996). The ADIS-IV-C/P is a semi-structured clinical interview which was used to assess the severity of the child’s SP diagnosis in addition to a range
M AN U
of other DSM-IV disorders. Parents and youth were interviewed separately by a graduate-level clinician who was blind to the assigned treatment condition. Clinicians independently assigned a clinician severity rating (CSR) on a 9-point scale (0–8), with a rating ≥ 4 suggesting a clinical level of interference for each endorsed disorder. At the subsequent assessment sessions, only the
TE D
ADIS-IV-C/P modules endorsed at pre-treatment were administered. Consensus CSRs and diagnoses were obtained at each assessment time point during weekly meetings with the respective project directors (both licensed clinical psychologists). Agreements on diagnoses was
EP
good for both the primary (к=.94) and secondary (к=.87) diagnoses (Ollendick et al., 2009).
study.
AC C
Changes in the SP CSR following treatment served as the primary outcome measure in this
Phobic Beliefs Scale (PBS; Ollendick et al., 2017). At the pre-treatment assessment
session, the child-assigned clinician interviewed the child to identify specific beliefs associated with her or his SP. In the absence of a validated harm beliefs scale for youth with SPs, the PBS was created specifically for our RCT. For purposes of the present study, only the child’s first or primary phobic belief was examined. The PBS includes three facets to assess the child’s beliefs:
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
10
how likely it is that the feared belief would occur (i.e., probability estimate), how “bad” it would be if the feared content of the belief actually occurred (i.e., perceived danger or threat), and the degree to which the child felt he or she would be able to cope with the event if the feared belief
RI PT
did in fact occur (i.e., coping efficacy). Each of the three PBS items was rated by the child on a 0 to 8 scale using an expectancy thermometer. From a cognitive-behavioral and information
processing perspective (Prins & Ollendick, 2003; Vasey & McLeod 2001), these three facets
SC
were used to specifically assess the specificity of dysfunctional thinking in youth with SPs. Further, the PBS was designed in order to measure the likely overestimation of the youths’
M AN U
distorted beliefs coupled with an underestimation of their abilities to cope with the danger or threat present in the phobic stimulus/situation. At the post-treatment and 6-month follow-up assessments the primary belief identified at the pre-treatment assessment was re-assessed (i.e., the children provided ratings on the PBS for the same belief at each assessment session).
TE D
In order to examine if the youth’s subjective beliefs differed from “objective” ratings based on probability estimates, our research team developed two rating scales which assessed the “how likely” and “how bad” facets of the PBS (for further details, see Ollendick et al., 2017). All
EP
beliefs were coded by two doctoral students. The child’s belief was coded by our objective raters on a 0 to 8 scale which paralleled the expectancy thermometer used by the child. Objective codes
AC C
served as an ecologically valid assessment of “how likely” and “how bad” the belief would be were it to occur. Further, our objective codes were used as a means for comparison and evaluated separately against the youths’ potentially catastrophic and biased perceptions. For the “how likely” facet, 25% of the sample was dual-coded with good reliability (ICC = .83); similarly, for the “how bad” facet, 25% of the sample was dual coded with excellent reliability (ICC = .96). The child’s coping efficacy estimate was not coded by our research team because coping
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
11
estimates are person centered (i.e., both environmental and factors within the child can influence child’s ability to cope) and therefore less amenable to an objective code. Analytic Plan
RI PT
Data were analyzed with IBM SPSS Statistics Version 23. Missing values at both the post-treatment and 6-month follow-up assessments were imputed using the multiple imputation procedure in SPSS (IBM Corp.). Bivariate correlations among child age, sex, PBS items, and
SC
treated phobia CSRs were calculated. Child age and sex failed to correlate significantly with the PBS items or with CSR ratings and thus were not included as covariates in subsequent analyses.
M AN U
Repeated measures ANOVAs were used to examine change in each of the PBS items between treatment conditions and across the three assessment time-points: pre-treatment, posttreatment, and 6-month follow-up. Subsequently, the change in each of the PBS items from the pre-treatment to post-treatment as well as pre-treatment to follow-up assessments was calculated,
TE D
mean-centered, and included in hierarchical regression analyses to determine the relations of these changes to post-treatment and six-month follow-up CSR scores. Mediation analyses were then undertaken using multiple regression analyses and bias-
EP
corrected 95% bootstrapped estimate of confidence intervals around the indirect effect (PROCESS; Hayes, 2012). A significant (p < .05) indirect effect is supported when the 95%
AC C
confidence interval that is generated by the bootstrapping procedure does not contain zero. A prerequisite of the establishment of longitudinal mediation is that change in the mediator variable must temporally precede changes in the outcome variable. Due to our study methodology, our models were not able to establish this temporal precedence. However, we proceeded with crosssectional mediation which examines the covariation of the mediator variable and the outcome variable across time to infer mediation (see Preacher, 2015, and Spence, Donavan, March,
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
12
Kenardy, & Hearn, 2017, for a recent use of this approach). According to Fritz and MacKinnon (2007), when using a bias-corrected bootstrap method to test mediation, in order to detect large, medium, and small effect sizes for paths α (i.e., IV → Mediator) and β (i.e., Mediator → DV)
165 we were able to detect large and medium effects.
RI PT
sample sizes of 34, 148, and 462, respectively, are required. Therefore, with our sample size of
Lastly, repeated-measures ANOVAs were used to compare participant “how likely” and
SC
“how bad” ratings to our objective ratings. Three ANOVAs were calculated for both “how
likely” and “how bad,” the first comparing pre-treatment participant ratings to our objective
M AN U
codes and the second and third comparing post-treatment and follow-up participant ratings to objective codes.
Results
Using repeated measures ANOVAs, significant time effects (including all three time
TE D
points) were found for all three items of the PBS (how likely, F (2, 162) = 98.05, p < .001, η2 = .55, how bad, F (2, 162) = 94.31, p < .001, η2 = .54, and ability to cope, F (2, 162) = 36.91, p < .001, η2 = .31), indicating that across both treatment conditions the PBS scores improved
EP
following treatment. Additionally, the time by treatment condition interaction effects were significant for the how likely, F (2, 162) = 3.16, p = .045, η2 = .04, and how bad, F (2, 162) =
AC C
6.10, p = .003, η2 = .04, items, indicating that scores on these items reduced to a significantly greater degree for children in the OST condition than in the EST condition. Results for ability to cope were similar but did not reach conventional levels of statistical significance, F (2, 162) = 3.00, p = .051, η2 = .02. See Figure 1. CSR scores at the post-treatment and six-month follow-up assessments were regressed on treatment condition dummy coded (EST = 0, OST = 1) and pre-treatment CSR scores (Step 1),
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
13
and the change in each of the PBS items from the pre-treatment to post-treatment or follow-up assessments (Step 2). For these analyses, each PBS item was included in a separate model. See Tables 1 and 2 for model outcomes.
RI PT
When the “how likely” item was examined in Step 2, the overall model was significant at post-treatment, (F(3, 161) = 17.89, p < .001) and six-month follow-up (F(3, 161) = 8.57, p <
rated their beliefs predicted lower CSR scores.
SC
.001). At both time points, main effects showed that greater change in “how likely” the children
When the “how bad” item was examined in Step 2, the overall model was again
M AN U
significant at post-treatment, (F(3, 161) = 23.18, p < .001) and six-month follow-up (F(3, 161) = 13.49, p < .001). At both time points, main effects showed that greater change in “how bad” the children rated their beliefs predicted lower CSR scores.
When the children’s reported ability to cope was examined in Step 2, the overall model
TE D
was also significant at post-treatment, (F(3, 161) = 16.46, p < .001) and six-month follow-up (F(3, 161) = 11.91, p < .001). Main effects showed that greater increases in ability to cope predicted lower CSR scores at the 6-month follow-up assessment; however, at the post-treatment
EP
assessment this effect was not significant.
Additionally, in the post-treatment and follow-up analyses for all three PBS items, the
AC C
main effect of the pre-treatment CSR of the treated phobia was significant, indicating that higher CSRs following treatment were related to higher CSR scores at pre-treatment. Furthermore, the main effect of treatment condition was significant, indicating that youth randomized to the OST condition demonstrated lower CSRs following treatment relative to youth randomized to the EST condition.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
14
When all three PBS items were entered simultaneously into the regression model, the overall model was again significant at post-treatment, (F(5, 159) = 14.47, p < .001) and sixmonth follow-up (F(5, 159) = 9.89, p < .001). At post-treatment, main effects showed that
RI PT
greater change in “how bad” the children rated their beliefs predicted lower CSR scores. The main effects of “how likely” and ability to cope were not significant in this combined model. At the 6-month follow-up, main effects showed that both greater changes in “how bad” the children
SC
rated their beliefs and greater changes in ability to cope predicted lower CSR scores. The main effect of “how likely” was not significant. See Table 3 for model outcomes.
M AN U
Mediation Analyses
Given these findings, mediation analyses, as suggested by Preacher (2015), were conducted to test for the potential mediating effects of each PBS item at both the post-treatment and follow-up assessments.
TE D
Results indicated that pre-to-post treatment change in “how likely” the children rated their beliefs significantly mediated the relationship between treatment condition and posttreatment CSR (β = -0.11; 95% CI [-.29, -.00]). This mediating effect was not found at the 6-
EP
month follow-up session.
Results indicated that pre-to-post-treatment change in “how bad” the children rated their
AC C
beliefs significantly mediated the relationship between treatment condition and post-treatment CSR (β = -0.27; 95% CI [-.54, -.11]). Results were similar at the 6-month follow-up. Change from pre-to-6-month follow-up in “how bad” the children rated their beliefs significantly mediated the relationship between treatment condition and 6-month follow-up CSR (β = -0.21; 95% CI [-.45, -.04]).
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
15
Additionally, results indicated that pre-to-6-month change in the children’s ratings of their ability to cope significantly mediated the relationship between treatment condition and 6-
when pre-to-post treatment changes were explored.
RI PT
month follow-up CSR (β = -0.11; 95% CI [-.33, -.01]). This mediating effect was not found
Hence, for each model, the effect of treatment on specific phobia severity is partly
explained by improvements in child perceptions of how likely a phobic event is to occur, how
SC
severe the phobic event would be if it occurred, and how well they could cope with the
occurrence of the phobic event. Notably in each model the direct effect of treatment condition on
M AN U
CSR remained significant, indicating that the PBS items only partially mediated this relationship. See Table 4 for a summary of the mediation analyses and coefficients. Comparisons to Objective Ratings
In order to determine if there were differential results between the two treatments in
TE D
terms of how the two belief items differed from our objective codes, exploratory analyses were conducted. At pre-treatment, participant ratings for how likely the feared event would be to occur were significantly higher than our independent ratings, F (1, 163) = 92.13, p < .001, η2 = .36.
EP
Additionally, participant ratings for how bad it would be if the feared event were to occur were also significantly higher than our objective ratings, F (1, 163) = 279.44, p < .001, η2 = .63. At
AC C
pre-treatment, the rater (i.e., participant or objective coder) by treatment condition interaction was not significant for either belief (how likely, F (1, 163) = 0.35, p = .557, η2 = .00, how bad, F (1, 163) = 2.35, p = .127, η2 = .01). See Table 5 for means and standard deviations. However, at post-treatment and six-month follow-up assessments there was a significant
rater (i.e., participant or objective coder) by treatment type interaction for both “how likely” (post-treatment, F (1, 163) = 11.25, p = .001, η2 = .07 and follow-up, F (1, 163) = 4.86, p = .029,
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
16
η2 = .03) and “how bad” (post-treatment, F (1, 163) = 16.83, p < .001, η2 = .09 and follow-up, F (1, 163) = 9.24, p = .003, η2 = .06). For “how likely,” participants in the OST condition rated their beliefs as significantly less likely to occur than the ratings of our objective coders, while
RI PT
there was no difference between objective coders and participants in the EST condition. For “how bad,” participants in the EST condition continued to rate their beliefs as more “bad” than
the OST condition. Discussion
SC
the objective coders, while there was no difference between objective coders and participants in
M AN U
The results are largely supportive of our hypotheses and suggest some specificity of changes in harm beliefs associated with our OST condition. Although significant reductions in harm beliefs following treatment were present for children in both the OST and EST conditions, a significant time by treatment condition interaction indicated greater reductions in the OST
TE D
condition for the how likely and how bad facets of our beliefs scale. This finding supports our first hypothesis that changes would be greater in the OST condition - a treatment designed specifically to produce such changes. Furthermore, although youth assigned to both the EST and
EP
OST conditions rated “how likely” and “how bad” it would be should their feared outcomes occur higher than that of our independent coders at pre-treatment, youth in the OST condition
AC C
rated their beliefs at post-treatment as significantly less likely to occur than our objective coders whereas youth in the EST condition did not. For “how bad,” youth in the EST condition continued to rate their beliefs as more “bad” than the objective coders, while there was no difference between objective coders and youth in the OST condition. Thus, changes in the subjective beliefs of the youth were not only greater in the OST condition than in the EST condition but their beliefs were more in accord with our objective raters following treatment in
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
17
the extent to which the beliefs were now less catastrophic (i.e., more in line with our objective raters). When these two beliefs, along with subjective estimates of coping efficacy with the
RI PT
phobic object/situation, were entered into separate models and regressed onto clinician severity ratings (CSRs), significant main effects emerged for the “how likely” and “how bad” items at both the post and follow up assessments. Main effects also showed that greater increases in
SC
coping efficacy predicted lower CSRs at the 6-month follow-up but these findings were only marginally significant at post-treatment (p < . 051). Further, the main effect of treatment
M AN U
condition was significant in the post and follow-up analyses, supporting that youth randomized to the OST condition demonstrated lower CSRs following treatment relative to youth randomized to the EST condition as noted in our original paper (Ollendick et al., 2009). Within a combined model when all three of these beliefs were entered simultaneously and regressed onto
TE D
the CSR, the main effects of “how likely” and ability to cope were not significant; however, “how bad” remained a significant main effect in this combined model. At the 6-month follow-up, main effects showed that both greater changes in “how bad” the youth rated their beliefs and
EP
greater changes in their coping-efficacy predicted lower CSR scores. These results offer support for focusing on challenging the perceived danger or threat in regards to the feared
AC C
object/situation and in addressing coping strategies for dealing with the anxiety-producing situation as has been suggested by Treadwell and Kendall (1996) and Kendall and Treadwell (2007).
Because the phobic beliefs and clinician severity ratings were collected across time, we
were also able to test for potential mediation, accounting for aspects of change between the two treatments. Using mediation analyses suggested by Preacher (2015), indirect effects were
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
18
supported between treatment condition and clinician severity ratings through change in “how bad” the youth rated their phobic cognition. Children who were assigned to the OST condition reported less perceived danger or threat in regards to the feared outcome or situation, and as
RI PT
child’s cognitions changed, SP severity also improved. Similar results were found for the
children’s subjective ability to cope with their feared belief and their rating of “how likely” the feared belief was to occur. Children who were assigned to the OST condition reported greater
SC
increases in their ability cope, and greater decreases in the likelihood of the belief, which subsequently predicted greater improvement in SP severity. Of course, in the absence of
M AN U
temporality, we cannot assert true mediation; nonetheless, the observed covariation in these phobic beliefs and changes in clinical severity ratings provide support for indirect mediation (see Preacher, 2015; Spence et al., 2017).
A primary limitation of the present study was the lack of temporal precedence that would
TE D
document changes in phobic beliefs and coping efficacy before changes in our outcome measure of clinical severity. Still, through our cross-sectional design, we were able to show that these changes were contemporaneous and associated with changes across time. Future studies should
EP
involve longitudinal designs which include more frequent assessment of phobic beliefs, coping efficacy, and clinical severity, allowing full mediation to be determined. A second limitation was
AC C
the lack of sociocultural diversity in our sample. Participants were predominantly Caucasian, which limits our ability to generalize our findings across diverse races, ethnicities, and cultures. A third limitation is associated with our Phobic Beliefs Scale which was designed for this study. We do not have reliability estimates for the ratings of the youth and we also had trained graduate clinicians code the child’s phobic cognition and serve as our objective raters rather than comparing ratings between youth with a SP and youth without a SP. Future research will need to
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
19
establish the reliability of this measure and examine whether differences exist in the ratings between youth with a SP and youth without a SP, not just between adult coders and youth with a SP. Fourth, given our sample size and the limited number of youth with any one subtype of SP,
RI PT
we were unable to explore moderators of change in this study. It is certainly conceivable that certain subtypes of SPs might be more amenable to changes in distorted beliefs and coping
efficacies than other subtypes (e.g. animal versus environmental/situational; see Ollendick &
SC
Muris, 2105). Finally, the changes observed in distorted beliefs and coping efficacy were
obviously examined following OST or EST only. We are unsure whether similar changes might
M AN U
be observed with other more standard psychological or pharmacological treatments (e.g. Walkup et al., 2008).
Our research is the first, to our knowledge, to examine how changes in terms of likelihood and danger expectancies and coping efficacy might vary between treatment
TE D
approaches for SPs. Our findings suggest that children and adolescents across both treatment conditions reported distorted beliefs in regards to their SP, similar to that of adults with a SP (Thorpe & Salkovskis, 1995). Youth in both the OST and EST treatment conditions
EP
demonstrated significant changes in their phobic beliefs and coping efficacy following treatment. The amount of change was greater, however, for youth assigned to OST. Still, these findings
AC C
offer limited support for the use of both OST and EST in reducing children and adolescents’ phobic beliefs and enhancing their coping efficacy. Although the primary aim of EST was not to challenge the identified harm beliefs or to enhance coping efficacy, we found that youth in the EST condition also demonstrated changes over time, albeit not commensurate to that observed for youth in the OST condition. While our results support challenging harm beliefs and enhancing coping efficacy are associated with enhanced outcomes, we do not want to discount
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
20
that other elements of CBT such as psychoeducation (like that provided in the EST condition) might also prove effective. Thus, in terms of critical treatment elements (see Deacon & Abramowitz, 2004), our findings also lend tentative support for focusing on the
RI PT
psychoeducational components present in both of these treatments. Although EST did not
directly challenge the youth’s harm beliefs or their coping efficacy via systematic exposure, it still produced significant changes. As such, it is arguably possible to change phobic beliefs and
SC
coping efficacy without exposure elements which might then prove efficient for therapist time and needed treatment resources.
M AN U
In brief, our findings illustrate both specificity associated with OST in changing distorted beliefs and coping efficacy in youth with SPs and a modicum of generality in that our EST condition also produced changes in beliefs and efficacy expectancies, although not to the same degree as in our OST condition. Such findings suggest that psychoeducational practices might be
TE D
particularly useful and appropriate when it is difficult to enact highly specific cognitive restructuring and exposure activities present in OST and related CBT approaches. Still, it is
EP
evident that CBT procedures produce greater gains and are preferred whenever possible.
AC C
Acknowledgements: This work was supported by the National Institute of Mental Health [Grant R01 MH59308]
The authors declare no conflict of interest.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
21
References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
(5th ed.). Washington, DC: Author.
RI PT
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
perspective. New York: Basic Book.
SC
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias. A cognitive
Byrne, S. P., Rapee, R. M., Malhi, G., Sweller, N., & Hudson, J. (2014). An examination of
M AN U
harm beliefs in children with dog phobia. Journal of Experimental Psychopathology, 7, 153-159.
Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for anxiety disorders: A review of meta‐analytic findings. Journal of Clinical Psychology, 60, 429-
TE D
441.
Fritz, M. S., & MacKinnon, D. P. (2007). Required sample size to detect the mediated effect. Psychological science, 18(3), 233-239.
EP
Hadwin, J. A., Garner, M., & Perez-Olivas, G. (2006). The development of information processing biases in childhood anxiety: A review and exploration of its
AC C
origins in parenting. Clinical Psychology Review, 26, 876-894.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. Retrieved from http://www.afhayes.com/public/process2012.pdf Hogendoorn, S. M., Prins, P. J. M., Boer, F., Vevoort, L., Wolters, L. H., Moorlag, H., … de Haan, E. (2014). Mediators of cognitive behavior therapy for anxiety-disordered children and
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
22
adolescents: Cognition, perceived control, and coping. Journal of Clinical Child and Adolescent Psychology, 43, 486-500.
Kendall, P.C., Cummings, C. M., Villabo, M. A., Narayanan, M. K., Treadwell, K … Albano.
RI PT
(2016). Mediators of change in the Child/Adolescent Anxiety Multimodal Treatment Study. Journal of Consulting and Clinical Psychology, 84, 1-14.
Kendall, P. C., & Treadwell, K. R. H. (2007). The role of self-statements as a mediator in
SC
treatment for youth with anxiety disorders. Journal of Consulting and Clinical Psychology, 75, 380-389.
M AN U
Lang, P. J., Cuthbert, B. N., & Bradley, M. M. (1998). Measuring emotions in therapy: Imagery, activation, and feeling. Behavior Therapy, 29, 655-674.
Lang, P. J., Davis, M., & Öhman, A. (2000). Fear and anxiety: Animal models and human cognitive psychophysiology. Journal of Affective Disorders, 61, 137-159.
TE D
Lau, W. Y., Chan, C. K. Y., Li, J. C. H., & Au, T. K. F. (2010). Effectiveness of group cognitive-behavioral treatment for childhood anxiety in community clinics. Behaviour Research and Therapy, 48, 1067-1077.
EP
Muris, P., Merckelbach, H., Gadet, B., & Moulaert, V. (2000). Fears, worries, and scary dreams in 4-to 12-year-old children: Their content, developmental pattern, and origins. Journal of
AC C
Clinical Child Psychology, 29, 43-52.
Oar, E.L., Farrell, L.J., Waters, A.M., Conlon, E.G., & Ollendick, T.H. (2015). One session treatment for pediatric blood-injection-injury phobia: A controlled multiple baseline trial. Behaviour Research and Therapy, 73, 131-142.
Ollendick, T. H., & Davis III, T. E. (2013). One-session treatment for specific phobias: A review of Öst's single-session exposure with children and adolescents. Cognitive Behaviour Therapy, 42, 275-283.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
23
Ollendick, T. H., Halldorsdottir, T., Fraire, M. G., Austin, K. E., Noguchi, R. J., Lewis, K. M., ... & Whitmore, M. J. (2015). Specific phobias in youth: A randomized controlled trial
Therapy, 46, 141-155.
RI PT
comparing one-session treatment to a parent-augmented one-session treatment. Behavior
Ollendick, T. H., & Muris, P. (2015). The scientific legacy of little hans and little albert: Future
Adolescent Psychology, 44, 689-706.
SC
directions for research on specific phobias in youth. Journal of Clinical Child &
Ollendick, T. H., Öst, L. G., Reuterskiöld, L., Costa, N., Cederlund, R., Sirbu, C., ... & Jarrett,
M AN U
M. A. (2009). One-session treatment of specific phobias in youth: A randomized clinical trial in the United States and Sweden. Journal of Consulting and Clinical Psychology, 77, 504-516.
Ollendick, T. H., Öst, L. G., Ryan, S. M., Capriola, N. N., & Reuterskiöld, L. (2017). Harm
Therapy, 91, 51-57.
TE D
beliefs and coping expectancies in youth with specific phobias. Behaviour Research and
Öst, L.-G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy,
EP
27, 1–7.
Öst, L.-G. (1997). Rapid treatment of specific phobias. In G. C. L. Davey (Ed.), Phobias: A
AC C
handbook of theory, research and treatment (pp. 227–247). Oxford, England: Wiley.
Öst, L. G. (2012). One-session treatment: Principles and procedures with adults. In Intensive one-session treatment of specific phobias (pp. 59-95). New York, NY: Springer.
Öst, L. G. & Ollendick, T. H. (2001). Manual for one-session treatment of specific phobias. Unpublished manuscript. (Available from the Phobia Project, Child Study Center, Virginia Tech, Blacksburg, VA 24060).
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
24
Öst, L.-G., Svensson, L., Hellström, K., & Lindwall, R. (2001). One session treatment of specific phobias in youths: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 69, 814–824.
developments. Annual Review of Psychology, 66, 825-852.
RI PT
Preacher, K. J. (2015). Advances in mediation analysis: A survey and synthesis of new
Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for DSM-IV:
SC
Child and Parent Versions. San Antonio, TX: Psychological Corporation.
Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Rabian, B., & Serafini, L. T.
M AN U
(1999). Contingency management, self-control, and education support in the treatment of childhood phobic disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 675-687.
Spence, S. H., Donovan, C. L., March, S., Kenardy, J. A., & Hearn, C. S. (2017). Generic versus
TE D
disorder specific cognitive behavior therapy for social anxiety disorder in youth: A randomized controlled trial using internet delivery. Behaviour Research and Therapy, 90, 41-57.
EP
Treadwell, K. R. H., & Kendall, P. C. (1996). Self-talk in youth with anxiety disorders: States of mind, content specificity, and treatment outcome. Journal of Consulting and Clinical
AC C
Psychology, 64, 941 -950.
Thorpe, S. J., & Salkovskis, P. M. (1995). Phobic beliefs: Do cognitive factors play a role in specific phobias? Behaviour Research and Therapy, 33, 805-816.
Walkup, J. T., Albano, A., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., … Kendall, P.C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. The New England Journal of Medicine, 359, 2753-2766.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
25
Waters, A. M., Farrell, L. J., Zimmer-Gembeck, M. J., Milliner, E., Tiralongo, E., Donovan, C. L., McConnell, H., Bradley, B. P., Mogg., K., & Ollendick, T. H. (2014). Augmenting
Behaviour Research and Therapy, 62, 107-119.
RI PT
one-session treatment of specific phobias with attention training to positive stimuli.
Zlomke, K., & Davis, T. E. (2008). One-session treatment of specific phobias: A detailed
AC C
EP
TE D
M AN U
SC
description and review of treatment efficacy. Behavior Therapy, 39, 207-223.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
26
6 5 4 OST
RI PT
3
EST
2 1 0 Post-Treatment
6-Month Follow-up
Figure 1a. How Likely ratings across assessment session.
M AN U
8
SC
Pre-Treatment
7 6 5 4
2 Pre-Treatment
EST
TE D
3
OST
Post-Treatment
6-Month Follow-up
5 4 3 2 1
AC C
6
EP
Figure 1b. How Bad ratings across assessment session.
OST EST
0 Pre-Treatment
Post-Treatment
6-Month Follow-up
Figure 1c. Ability to Cope ratings across assessment session.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
27
SC
RI PT
Table 1 Regression of Post-treatment CSRs on Change in Each PBS Item How Likely How “Bad” Ability to Cope 2 2 ∆R β ∆R β ∆R2 β .23*** .23*** .23*** Step 1 Pre-treatment CSR .32*** .32*** .33*** Treatment Condition -.36*** -.32*** -.38*** .02* .07*** .01 Step 2 Change in PBS Item -.15* -.28*** -.07 F-value 17.89*** 23.18*** 16.46*** Note. * p < .05, ** p < .01, *** p < .001. Change in PBS Item was measured from pre-treatment to post-treatment.
TE D
M AN U
Table 2 Regression of 6-Month Follow-up CSRs on Change in Each PBS Item How “Bad” Ability to Cope How Likely 2 2 ∆R β ∆R β ∆R2 β .11*** .11*** .11*** Step 1 Pre-treatment CSR .27*** .28*** .28*** Treatment Condition -.22** -.18* -.20** .02* .09*** .07*** Step 2 Change in PBS Item -.16* -.30*** -.26*** F-value 8.57*** 13.49*** 11.91*** Note. * p < .05, ** p < .01, *** p < .001. Change in PBS Item was measured from pre-treatment to 6-month follow-up.
AC C
EP
Table 3 Regression of Post-Treatment and 6-Month Follow-up CSRs on Change in PBS Items Post-Treatment 6-Month Follow-Up 2 ∆R β ∆R2 β .23*** .11*** Step 1 Pre-treatment CSR .32*** .27*** Treatment Condition -.31*** -.16* .08*** .12*** Step 2 Change in How Likely -.07 -.11 Change in How Bad -.31*** -.21** Change in Ability to Cope .09 -.18* F-value 14.47*** 9.89*** Note. * p < .05, ** p < .01, *** p < .001.
ACCEPTED MANUSCRIPT
Running Head: HARM BELIEFS IN SPECIFIC PHOBIAS
28
AC C
EP
TE D
M AN U
SC
RI PT
Table 4 Summary of the Mediating Effects of PBS Items Post-Treatment Potential “How Likely” “How Bad” Ability to Cope “How Likely” Mediators (MED) B t B t B t B t Paths 1.05 2.41* 2.65** 1.30 3.49*** 1.00 2.65** Treatment → MED 1.00 -0.05 -1.06 -0.11 -2.10* -0.21 -4.08*** -0.08 -1.38 MED → CSR Direct Effect -1.38 -5.36*** -4.63*** -0.80 -2.79** Treatment → CSR -1.32 -5.16*** -1.16 B LCI UCI B LCI UCI B LCI UCI B LCI UCI Indirect Effect Through MED Treatment → CSR -0.11 -0.29 -.00 -0.27 -0.54 -0.11 -0.05 -0.23 0.04 -0.08 -0.29 0.03 Note. * p < .05, ** p < .01, *** p < .001. B = Unstandardized Coefficient; CSR = Clinician Severity Rating; LCI = Lower 95% Confidence Interval; UCI = Upper 95% Confidence Interval
6-Month Follow-Up “How Bad”
Ability to Cope
B
t
B
t
0.86 -0.24
2.40* -4.18***
1.05 -0.11
2.41* -2.20*
-0.67 B
-2.46* LCI UCI
-0.76 B
-2.71** LCI UCI
-0.21 -0.45 -0.04 -0.11 -0.33 -0.01
ACCEPTED MANUSCRIPT
6-Month Follow-up How Likely How Bad Ability to Cope
2.10 (1.79) 4.89 (2.53) 4.15 (2.39)
Objective Codes How Likely How Bad
2.58 (1.02) 3.86 (1.48)
1.87 (1.67) 4.49 (2.52) 4.36 (2.28)
M AN U
2.67 (2.19) 5.75 (2.12) 3.46 (2.53)
TE D
Post-Treatment How Likely How Bad Ability to Cope
SC
Table 5 Means and Standard Deviations for PBS items and CSRs across Treatment Condition and Assessment Time Point Mean(SD) EST OST (n = 79) (n = 86) Pre-Treatment How Likely 4.28 (2.19) 4.41 (1.92) How Bad 6.81 (1.67) 6.80 (1.58) Ability to Cope 2.67 (1.93) 2.58 (2.03)
29
RI PT
Running Head: HARM BELIEFS IN SPECIFIC PHOBIAS
1.81 (1.41) 4.01 (2.22) 4.81 (2.07)
2.91 (1.05) 4.35 (1.66)
AC C
EP
CSRs Pre-Treatment 5.81 (0.95) 6.08 (0.92) Post-Treatment 4.67 (1.65) 3.42 (1.76) 6-Month Follow-up 3.91 (1.88) 3.19 (1.82) Note. Objective Codes were only rated once because the identified phobic beliefs of the children remained constant at each assessment time point
ACCEPTED MANUSCRIPT
Highlights
EP
TE D
M AN U
SC
RI PT
Phobic beliefs improved following both One Session Treatment and Educational Support Catastrophic beliefs reduce a greater degree following One Session Treatment Greater change in beliefs predicted lower clinical severity following treatment Change in beliefs partially mediated the relationship between treatment and CSR
AC C
• • • •
S0005-7967(17)30211-5
DOI:
10.1016/j.brat.2017.10.007
Reference:
BRT 3208
To appear in:
Behaviour Research and Therapy
Received Date: 11 May 2017 Revised Date:
27 September 2017
Accepted Date: 16 October 2017
Please cite this article as: Ollendick, T.H., Ryan, S.M., Capriola-Hall, N.N., Reuterskiöld, L., Öst, Lars.Gö., The mediating role of changes in harm beliefs and coping efficacy in youth with specific phobias, Behaviour Research and Therapy (2017), doi: 10.1016/j.brat.2017.10.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Running Head: HARM BELIEFS IN SPECIFIC PHOBIAS
1
The Mediating Role of Changes in Harm Beliefs and Coping Efficacy in Youth with Specific Phobias
RI PT
Thomas H. Ollendick1, Sarah M. Ryan1, Nicole N. Capriola-Hall1, Lena Reuterskiöld2, and Lars-
1
Virginia Tech
Child Study Center
SC
Göran Öst2
M AN U
Department of Psychology Blacksburg, VA 24061
Phone: (540) 231-6451; Fax: (540) 231-3652
Stockholm University
TE D
2
Department of Psychology
EP
SE-106 91 Stockholm, Sweden
AC C
Correspondence concerning this article should be addressed to: Sarah Ryan e-mail: [email protected] Tel (540) 231-3514 Fax (540) 231-3652
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
2 Abstract
Individuals with specific phobias (SPs) often experience catastrophic cognitions and compromised efficacy regarding their ability to cope when in the presence of the phobic
RI PT
object/situation. In the current study, 165 children (7-16 years; 62% male) received either One Session Treatment or Educational Support Therapy for their SP. The children identified their feared belief and rated “how bad” it was, “how likely” it was to occur, and their ability to cope if
SC
it did occur. All of these ratings were reduced from pre-treatment to 6-month follow-up, across both treatment conditions. However, ratings of “how bad” and “how likely” reduced to a
M AN U
significantly greater degree for children who received OST. Greater change in each of the three beliefs predicted lower clinician severity ratings (CSRs) at post-treatment and 6-month followup. Additionally, changes in “how bad” and “how likely” the children rated their beliefs, and their reported ability to cope, partially mediated the relationship between treatment and post-
TE D
treatment and follow-up CSRs. Overall, these findings suggest that although both treatment conditions produced changes in harm beliefs and coping efficacy, OST elicited greater changes
EP
and these changes may be important mechanisms in reduction of SP clinical severity.
Trial
AC C
Keywords: Phobic Beliefs, Specific Phobias, Children and Adolescents, Randomized Controlled
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
3
The Mediating Role of Changes in Harm Beliefs and Coping Efficacy in Youth with Specific Phobias Children often experience a range of fears throughout their development. Normative fears
RI PT
tend to rise in early childhood and wane by early adolescence (Muris, Merckelbach, Gadet, & Moulaert, 2000). For some youth, however, these fears persist and increase in intensity and
severity resulting in the development of a specific phobia (SP). In addition, for other youth,
SC
direct or vicarious adverse experiences occasion the onset of SPs. Although there are multiple etiological pathways for SPs, once they have developed they can then serve as a “gateway”
M AN U
disorder to other anxiety, mood, and substance use disorders (Ollendick & Muris, 2015). SPs are characterized by excessive and unreasonable fear or anxiety concerning a specific object or situation [American Psychiatric Association (APA), 2013]. Consistent with the tripartite conceptualization of anxiety disorders more broadly, hallmark characteristics of SPs include
TE D
physiological arousal, behavioral avoidance, and maladaptive thinking when in the presence of the feared stimulus (Lang, Cuthbert, & Bradley, 1998; Lang, Davis, & Öhman, 2000). Children’s beliefs in regards to the feared stimulus or situation are often catastrophic and unrealistic (i.e.,
EP
out of proportion to the “actual” danger or threat). These catastrophic cognitions are often directly tethered to avoidance behaviors and physiological hyperarousal which serve to maintain
AC C
the SP and to reduce coping efficacy in the presence of the feared object/situation (Byrne, Rapee, Malhi, Sweller, & Hudson, 2014; Öst, 2012; Ollendick & Davis, 2013; Zlomke & Davis, 2008). Although the role of harm beliefs and coping efficacy have been examined in the treatment of adults with SPs (Thorpe & Salkovskis, 1995), little research has examined the role of harm beliefs and coping efficacy in the treatment of youth with SPs.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
4
One-session treatment (OST) is a single session therapy based on cognitive behavioral therapy principles (Öst, 1989). Several recent randomized controlled trials (RCTs) and controlled single case design studies have shown that OST is a rapid and effective intervention to treat
RI PT
children and adolescents with a variety of SPs (Oar, Farrell, Waters, Conlon, & Ollendick, 2015; Ollendick et al., 2009; Ollendick et al., 2015; Öst, Svensson, Hellström, & Lindwall, 2001;
Waters, Farrell, Zimmer-Gembeck, Milliner … & Ollendick, 2014). The purpose of the present
SC
study was to examine harm beliefs and coping efficacy in a large sample of youth who
participated in a randomized control trial (RCT) comparing OST to an education support
M AN U
treatment (EST; Ollendick et al., 2009). Results of this RCT demonstrated that OST was superior to EST on clinician ratings of SP severity and children’s self-reported fear ratings during a behavioral avoidance test at post-treatment and 6-month follow-up. The primary aim of EST was to provide support and psychoeducation to the child about SPs; importantly, however, this
TE D
treatment did not include the systematic challenging of harm beliefs or attempts to build coping efficacy in the presence of the feared object/situation which are central to, and characteristic of, OST.
EP
Recently, in a re-analysis of data from this 2009 study, we showed that catastrophic beliefs and coping efficacy changed in the OST condition and that these changes were related to
AC C
changes in clinical severity ratings of the SP following treatment (Ollendick, Öst, Ryan, Capriola, & Reuterskiöld, 2017). Further, we compared the subjective beliefs of the youth to more objective probabilities associated with these beliefs. In line with information processing models of fear and anxiety (e.g., Beck, Emery, & Greenberg, 1985; Wright & Borden, 1991), results revealed that the youth’s subjective beliefs were overestimated compared to the more
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
5
objective evaluations determined by independent raters. These differences, however, were no longer evident following treatment. In the current study, we were interested in examining whether OST yielded superior
RI PT
outcomes in reduction of harm beliefs and enhancement of coping efficacies when compared to EST, and whether changes in harm beliefs and coping efficacy were related to clinical severity ratings following treatment in both conditions or were specific to OST. Because each of these
SC
variables was collected longitudinally, we were interested in addressing the possibility of
mediation, accounting for aspects of change between the two treatments. To our knowledge, no
M AN U
studies have considered the mediating role of reduction of harm beliefs and coping efficacy in treatment gains in a sample of youth with SPs (although Hogendoorn et al., 2014; Lau, Chan, Li, & Au, 2010: and Kendall et al., 2016, have done so with other anxiety disorders). Consistent with information processing models invoked in the treatment of fear and anxiety (e.g., Beck et
TE D
al., 1985; Hadwin, Garner, & Perez-Olivas, 2006), we predicted that youth randomized to the OST condition would demonstrate greater changes in harm beliefs and coping efficacy than children in the EST condition, that reductions in these beliefs and increases in coping estimates
outcomes.
EP
would be specific to the OST condition, and that these changes would mediate treatment
AC C
Finally, we were interested in comparing objective ratings of the children’s beliefs to
their own perceptions. We hypothesized that similar to the findings of Ollendick and colleagues (2017), when objective ratings are compared to the youths’ pre-treatment ratings the subjective ratings would be significantly higher (i.e., more catastrophic) than the objective ratings. Because Ollendick and colleagues (2017) found youth’s subjective ratings to significantly reduce following OST, we reasoned that following treatment the ratings of the children in the OST
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
6
group would no longer differ significantly from the objective ratings. Because the EST condition does not involve direct challenging of children’s beliefs, we hypothesized that the beliefs of
Method Participants
RI PT
children in the EST condition would remain significantly higher than the objective ratings.
Treatment seeking families from the United States of America and Sweden were
SC
recruited into a randomized clinical control trial (RCT) which examined the relative
effectiveness of OST and EST for youth with a SP (see Ollendick et al., 2009). In total, 195
M AN U
children and adolescents with a clinically confirmed SP diagnosis were randomized to one of the two treatment conditions. Participants were recruited through referrals from child psychiatric services, school health services, primary care settings, and print advertisements. SP was the primary reason for referral in all cases. The following inclusion criteria were enlisted:
TE D
participants had to be between 7-16 years of age and had to meet DSM-IV criteria for one or more of the most commonly occurring SPs (animal, environmental, or situational; APA, 1994), as determined by the Anxiety Disorders Interview Schedule for DSM-IV/Child and Parent
EP
Version (ADIS-IV-C/P; Silverman & Albano, 1996). In addition, the participant was required to discontinue other forms of psychotherapy or anti-anxiety medications for the duration of the
AC C
RCT and the participants could not meet criteria for exclusionary diagnoses of major depression with suicide intent, pervasive developmental disorder, and psychosis. The final sample consisted of 165 children: 79 children were randomized to the EST
condition (M age: 10.29, SD: 2.01; 62% male) and 86 children were randomized to the OST condition (M age: 10.45, SD: 2.25; 62% male). Of these 165 children, 76 were from the United States while 89 were from Sweden. Thirty of the original 195 participants were excluded from
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
7
the present analyses because they did not present with one of the more commonly occurring SPs (e.g., those who met criteria for Blood-Injection-Injury or “Other” type; see Ollendick et al., 2017). Of the 79 children randomized to the EST condition, 49 (62.0%) were treated for an
RI PT
animal phobia, 20 (25.3%) were treated for an environmental phobia, and 10 (12.7%) were
treated for a situational phobia. Of the 86 children randomized to the OST condition, 52 (60.5%) were treated for an animal phobia, 18 (20.9%) were treated for an environmental phobia, and 16
SC
(18.6%) were treated for a situational phobia. The mean family income for the 195 families in the original sample was $85,506 and $71,240 for families from Sweden and the United States,
M AN U
respectively. Additionally, 94% of the Sweden sample and 88% of the United States sample were Caucasian. No significant differences between youth from Sweden and the United States were evident on any of these indices hence were combined for the present analyses. Procedure
TE D
The research was approved by both institutions’ human research ethics committee. Following referral, potential participants’ parents completed a brief telephone screen to determine probable eligibility. Eligible families were invited to the respective clinics for a pre-
EP
treatment assessment session. All participants provided informed written consent/assent at the start of the study session. During the pre-treatment assessments, children and their parents
AC C
completed questionnaires, a Behavioral Approach Test (BAT), and the Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent Versions (ADIS-IV-C/P; Silverman & Albano, 1996). Clinicians also solicited the child’s primary phobic belief during the interview and the child completed the Phobic Beliefs Scale (PBS; see below). If appropriate for the study, the family was randomized to a treatment condition (OST or EST). Participants in both treatment conditions received treatment on a separate day from the pre-treatment assessment,
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
8
approximately one week later. Following the 3-hour treatment session, post assessment was conducted one week following treatment and follow-up was undertaken six months following treatment. The diagnostic modules endorsed at pre-treatment, the PBS, the BAT, and a battery of
RI PT
questionnaires was administered at post-treatment and 6-month follow-up. Further details on procedures of the original study can be found in Ollendick et al. (2009). Treatments
SC
The child focused OST treatment condition was based on principles developed by Öst (1989, 1997) for adults and subsequently manualized for the treatment of SPs in youth (Öst &
M AN U
Ollendick, 2001). OST is derived from cognitive behavioral therapy (CBT) and its guiding principles. The objective of the 3-hour session is to gradually expose the child to the phobic stimuli while simultaneously challenging the child’s distorted and catastrophic cognitions and enhancing their coping efficacy when in the presence of the feared object/situation. Treatment
TE D
components include graduated in vivo exposure in which youth are prompted to draw conclusions regarding their phobic beliefs using the evidence collected during the exposure. The therapist and the child work collaboratively throughout the treatment session to also enhance the
EP
child’s coping efficacy. Parents are not involved in the treatment session. The EST treatment condition was based on a treatment developed by Silverman and
AC C
colleagues (1999) with adaptations made by our research team. EST is also a 3-hour manualized treatment which primarily consists of psycho-educational components (i.e., definitions of fears and phobias, description of physiological factors associated with fear responses, etc.) and the provision of emotional support for sharing and discussing their fears and phobias. The youth are provided a colorful workbook with pictures, activities, and information regarding their feared object or situation that was created for this study. Children and adolescents randomized to the
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
9
EST condition worked collaboratively with a therapist in completing the workbook and learning more about their phobia. Importantly, EST did not include any elements of in vivo exposure, cognitive restructuring, or attempts to enhance the coping efficacy of the child. Similar to the
RI PT
OST condition, parents were not involved in the EST treatment condition. Measures
The Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent Versions
SC
(ADIS-IV-C/P; Silverman & Albano, 1996). The ADIS-IV-C/P is a semi-structured clinical interview which was used to assess the severity of the child’s SP diagnosis in addition to a range
M AN U
of other DSM-IV disorders. Parents and youth were interviewed separately by a graduate-level clinician who was blind to the assigned treatment condition. Clinicians independently assigned a clinician severity rating (CSR) on a 9-point scale (0–8), with a rating ≥ 4 suggesting a clinical level of interference for each endorsed disorder. At the subsequent assessment sessions, only the
TE D
ADIS-IV-C/P modules endorsed at pre-treatment were administered. Consensus CSRs and diagnoses were obtained at each assessment time point during weekly meetings with the respective project directors (both licensed clinical psychologists). Agreements on diagnoses was
EP
good for both the primary (к=.94) and secondary (к=.87) diagnoses (Ollendick et al., 2009).
study.
AC C
Changes in the SP CSR following treatment served as the primary outcome measure in this
Phobic Beliefs Scale (PBS; Ollendick et al., 2017). At the pre-treatment assessment
session, the child-assigned clinician interviewed the child to identify specific beliefs associated with her or his SP. In the absence of a validated harm beliefs scale for youth with SPs, the PBS was created specifically for our RCT. For purposes of the present study, only the child’s first or primary phobic belief was examined. The PBS includes three facets to assess the child’s beliefs:
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
10
how likely it is that the feared belief would occur (i.e., probability estimate), how “bad” it would be if the feared content of the belief actually occurred (i.e., perceived danger or threat), and the degree to which the child felt he or she would be able to cope with the event if the feared belief
RI PT
did in fact occur (i.e., coping efficacy). Each of the three PBS items was rated by the child on a 0 to 8 scale using an expectancy thermometer. From a cognitive-behavioral and information
processing perspective (Prins & Ollendick, 2003; Vasey & McLeod 2001), these three facets
SC
were used to specifically assess the specificity of dysfunctional thinking in youth with SPs. Further, the PBS was designed in order to measure the likely overestimation of the youths’
M AN U
distorted beliefs coupled with an underestimation of their abilities to cope with the danger or threat present in the phobic stimulus/situation. At the post-treatment and 6-month follow-up assessments the primary belief identified at the pre-treatment assessment was re-assessed (i.e., the children provided ratings on the PBS for the same belief at each assessment session).
TE D
In order to examine if the youth’s subjective beliefs differed from “objective” ratings based on probability estimates, our research team developed two rating scales which assessed the “how likely” and “how bad” facets of the PBS (for further details, see Ollendick et al., 2017). All
EP
beliefs were coded by two doctoral students. The child’s belief was coded by our objective raters on a 0 to 8 scale which paralleled the expectancy thermometer used by the child. Objective codes
AC C
served as an ecologically valid assessment of “how likely” and “how bad” the belief would be were it to occur. Further, our objective codes were used as a means for comparison and evaluated separately against the youths’ potentially catastrophic and biased perceptions. For the “how likely” facet, 25% of the sample was dual-coded with good reliability (ICC = .83); similarly, for the “how bad” facet, 25% of the sample was dual coded with excellent reliability (ICC = .96). The child’s coping efficacy estimate was not coded by our research team because coping
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
11
estimates are person centered (i.e., both environmental and factors within the child can influence child’s ability to cope) and therefore less amenable to an objective code. Analytic Plan
RI PT
Data were analyzed with IBM SPSS Statistics Version 23. Missing values at both the post-treatment and 6-month follow-up assessments were imputed using the multiple imputation procedure in SPSS (IBM Corp.). Bivariate correlations among child age, sex, PBS items, and
SC
treated phobia CSRs were calculated. Child age and sex failed to correlate significantly with the PBS items or with CSR ratings and thus were not included as covariates in subsequent analyses.
M AN U
Repeated measures ANOVAs were used to examine change in each of the PBS items between treatment conditions and across the three assessment time-points: pre-treatment, posttreatment, and 6-month follow-up. Subsequently, the change in each of the PBS items from the pre-treatment to post-treatment as well as pre-treatment to follow-up assessments was calculated,
TE D
mean-centered, and included in hierarchical regression analyses to determine the relations of these changes to post-treatment and six-month follow-up CSR scores. Mediation analyses were then undertaken using multiple regression analyses and bias-
EP
corrected 95% bootstrapped estimate of confidence intervals around the indirect effect (PROCESS; Hayes, 2012). A significant (p < .05) indirect effect is supported when the 95%
AC C
confidence interval that is generated by the bootstrapping procedure does not contain zero. A prerequisite of the establishment of longitudinal mediation is that change in the mediator variable must temporally precede changes in the outcome variable. Due to our study methodology, our models were not able to establish this temporal precedence. However, we proceeded with crosssectional mediation which examines the covariation of the mediator variable and the outcome variable across time to infer mediation (see Preacher, 2015, and Spence, Donavan, March,
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
12
Kenardy, & Hearn, 2017, for a recent use of this approach). According to Fritz and MacKinnon (2007), when using a bias-corrected bootstrap method to test mediation, in order to detect large, medium, and small effect sizes for paths α (i.e., IV → Mediator) and β (i.e., Mediator → DV)
165 we were able to detect large and medium effects.
RI PT
sample sizes of 34, 148, and 462, respectively, are required. Therefore, with our sample size of
Lastly, repeated-measures ANOVAs were used to compare participant “how likely” and
SC
“how bad” ratings to our objective ratings. Three ANOVAs were calculated for both “how
likely” and “how bad,” the first comparing pre-treatment participant ratings to our objective
M AN U
codes and the second and third comparing post-treatment and follow-up participant ratings to objective codes.
Results
Using repeated measures ANOVAs, significant time effects (including all three time
TE D
points) were found for all three items of the PBS (how likely, F (2, 162) = 98.05, p < .001, η2 = .55, how bad, F (2, 162) = 94.31, p < .001, η2 = .54, and ability to cope, F (2, 162) = 36.91, p < .001, η2 = .31), indicating that across both treatment conditions the PBS scores improved
EP
following treatment. Additionally, the time by treatment condition interaction effects were significant for the how likely, F (2, 162) = 3.16, p = .045, η2 = .04, and how bad, F (2, 162) =
AC C
6.10, p = .003, η2 = .04, items, indicating that scores on these items reduced to a significantly greater degree for children in the OST condition than in the EST condition. Results for ability to cope were similar but did not reach conventional levels of statistical significance, F (2, 162) = 3.00, p = .051, η2 = .02. See Figure 1. CSR scores at the post-treatment and six-month follow-up assessments were regressed on treatment condition dummy coded (EST = 0, OST = 1) and pre-treatment CSR scores (Step 1),
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
13
and the change in each of the PBS items from the pre-treatment to post-treatment or follow-up assessments (Step 2). For these analyses, each PBS item was included in a separate model. See Tables 1 and 2 for model outcomes.
RI PT
When the “how likely” item was examined in Step 2, the overall model was significant at post-treatment, (F(3, 161) = 17.89, p < .001) and six-month follow-up (F(3, 161) = 8.57, p <
rated their beliefs predicted lower CSR scores.
SC
.001). At both time points, main effects showed that greater change in “how likely” the children
When the “how bad” item was examined in Step 2, the overall model was again
M AN U
significant at post-treatment, (F(3, 161) = 23.18, p < .001) and six-month follow-up (F(3, 161) = 13.49, p < .001). At both time points, main effects showed that greater change in “how bad” the children rated their beliefs predicted lower CSR scores.
When the children’s reported ability to cope was examined in Step 2, the overall model
TE D
was also significant at post-treatment, (F(3, 161) = 16.46, p < .001) and six-month follow-up (F(3, 161) = 11.91, p < .001). Main effects showed that greater increases in ability to cope predicted lower CSR scores at the 6-month follow-up assessment; however, at the post-treatment
EP
assessment this effect was not significant.
Additionally, in the post-treatment and follow-up analyses for all three PBS items, the
AC C
main effect of the pre-treatment CSR of the treated phobia was significant, indicating that higher CSRs following treatment were related to higher CSR scores at pre-treatment. Furthermore, the main effect of treatment condition was significant, indicating that youth randomized to the OST condition demonstrated lower CSRs following treatment relative to youth randomized to the EST condition.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
14
When all three PBS items were entered simultaneously into the regression model, the overall model was again significant at post-treatment, (F(5, 159) = 14.47, p < .001) and sixmonth follow-up (F(5, 159) = 9.89, p < .001). At post-treatment, main effects showed that
RI PT
greater change in “how bad” the children rated their beliefs predicted lower CSR scores. The main effects of “how likely” and ability to cope were not significant in this combined model. At the 6-month follow-up, main effects showed that both greater changes in “how bad” the children
SC
rated their beliefs and greater changes in ability to cope predicted lower CSR scores. The main effect of “how likely” was not significant. See Table 3 for model outcomes.
M AN U
Mediation Analyses
Given these findings, mediation analyses, as suggested by Preacher (2015), were conducted to test for the potential mediating effects of each PBS item at both the post-treatment and follow-up assessments.
TE D
Results indicated that pre-to-post treatment change in “how likely” the children rated their beliefs significantly mediated the relationship between treatment condition and posttreatment CSR (β = -0.11; 95% CI [-.29, -.00]). This mediating effect was not found at the 6-
EP
month follow-up session.
Results indicated that pre-to-post-treatment change in “how bad” the children rated their
AC C
beliefs significantly mediated the relationship between treatment condition and post-treatment CSR (β = -0.27; 95% CI [-.54, -.11]). Results were similar at the 6-month follow-up. Change from pre-to-6-month follow-up in “how bad” the children rated their beliefs significantly mediated the relationship between treatment condition and 6-month follow-up CSR (β = -0.21; 95% CI [-.45, -.04]).
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
15
Additionally, results indicated that pre-to-6-month change in the children’s ratings of their ability to cope significantly mediated the relationship between treatment condition and 6-
when pre-to-post treatment changes were explored.
RI PT
month follow-up CSR (β = -0.11; 95% CI [-.33, -.01]). This mediating effect was not found
Hence, for each model, the effect of treatment on specific phobia severity is partly
explained by improvements in child perceptions of how likely a phobic event is to occur, how
SC
severe the phobic event would be if it occurred, and how well they could cope with the
occurrence of the phobic event. Notably in each model the direct effect of treatment condition on
M AN U
CSR remained significant, indicating that the PBS items only partially mediated this relationship. See Table 4 for a summary of the mediation analyses and coefficients. Comparisons to Objective Ratings
In order to determine if there were differential results between the two treatments in
TE D
terms of how the two belief items differed from our objective codes, exploratory analyses were conducted. At pre-treatment, participant ratings for how likely the feared event would be to occur were significantly higher than our independent ratings, F (1, 163) = 92.13, p < .001, η2 = .36.
EP
Additionally, participant ratings for how bad it would be if the feared event were to occur were also significantly higher than our objective ratings, F (1, 163) = 279.44, p < .001, η2 = .63. At
AC C
pre-treatment, the rater (i.e., participant or objective coder) by treatment condition interaction was not significant for either belief (how likely, F (1, 163) = 0.35, p = .557, η2 = .00, how bad, F (1, 163) = 2.35, p = .127, η2 = .01). See Table 5 for means and standard deviations. However, at post-treatment and six-month follow-up assessments there was a significant
rater (i.e., participant or objective coder) by treatment type interaction for both “how likely” (post-treatment, F (1, 163) = 11.25, p = .001, η2 = .07 and follow-up, F (1, 163) = 4.86, p = .029,
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
16
η2 = .03) and “how bad” (post-treatment, F (1, 163) = 16.83, p < .001, η2 = .09 and follow-up, F (1, 163) = 9.24, p = .003, η2 = .06). For “how likely,” participants in the OST condition rated their beliefs as significantly less likely to occur than the ratings of our objective coders, while
RI PT
there was no difference between objective coders and participants in the EST condition. For “how bad,” participants in the EST condition continued to rate their beliefs as more “bad” than
the OST condition. Discussion
SC
the objective coders, while there was no difference between objective coders and participants in
M AN U
The results are largely supportive of our hypotheses and suggest some specificity of changes in harm beliefs associated with our OST condition. Although significant reductions in harm beliefs following treatment were present for children in both the OST and EST conditions, a significant time by treatment condition interaction indicated greater reductions in the OST
TE D
condition for the how likely and how bad facets of our beliefs scale. This finding supports our first hypothesis that changes would be greater in the OST condition - a treatment designed specifically to produce such changes. Furthermore, although youth assigned to both the EST and
EP
OST conditions rated “how likely” and “how bad” it would be should their feared outcomes occur higher than that of our independent coders at pre-treatment, youth in the OST condition
AC C
rated their beliefs at post-treatment as significantly less likely to occur than our objective coders whereas youth in the EST condition did not. For “how bad,” youth in the EST condition continued to rate their beliefs as more “bad” than the objective coders, while there was no difference between objective coders and youth in the OST condition. Thus, changes in the subjective beliefs of the youth were not only greater in the OST condition than in the EST condition but their beliefs were more in accord with our objective raters following treatment in
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
17
the extent to which the beliefs were now less catastrophic (i.e., more in line with our objective raters). When these two beliefs, along with subjective estimates of coping efficacy with the
RI PT
phobic object/situation, were entered into separate models and regressed onto clinician severity ratings (CSRs), significant main effects emerged for the “how likely” and “how bad” items at both the post and follow up assessments. Main effects also showed that greater increases in
SC
coping efficacy predicted lower CSRs at the 6-month follow-up but these findings were only marginally significant at post-treatment (p < . 051). Further, the main effect of treatment
M AN U
condition was significant in the post and follow-up analyses, supporting that youth randomized to the OST condition demonstrated lower CSRs following treatment relative to youth randomized to the EST condition as noted in our original paper (Ollendick et al., 2009). Within a combined model when all three of these beliefs were entered simultaneously and regressed onto
TE D
the CSR, the main effects of “how likely” and ability to cope were not significant; however, “how bad” remained a significant main effect in this combined model. At the 6-month follow-up, main effects showed that both greater changes in “how bad” the youth rated their beliefs and
EP
greater changes in their coping-efficacy predicted lower CSR scores. These results offer support for focusing on challenging the perceived danger or threat in regards to the feared
AC C
object/situation and in addressing coping strategies for dealing with the anxiety-producing situation as has been suggested by Treadwell and Kendall (1996) and Kendall and Treadwell (2007).
Because the phobic beliefs and clinician severity ratings were collected across time, we
were also able to test for potential mediation, accounting for aspects of change between the two treatments. Using mediation analyses suggested by Preacher (2015), indirect effects were
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
18
supported between treatment condition and clinician severity ratings through change in “how bad” the youth rated their phobic cognition. Children who were assigned to the OST condition reported less perceived danger or threat in regards to the feared outcome or situation, and as
RI PT
child’s cognitions changed, SP severity also improved. Similar results were found for the
children’s subjective ability to cope with their feared belief and their rating of “how likely” the feared belief was to occur. Children who were assigned to the OST condition reported greater
SC
increases in their ability cope, and greater decreases in the likelihood of the belief, which subsequently predicted greater improvement in SP severity. Of course, in the absence of
M AN U
temporality, we cannot assert true mediation; nonetheless, the observed covariation in these phobic beliefs and changes in clinical severity ratings provide support for indirect mediation (see Preacher, 2015; Spence et al., 2017).
A primary limitation of the present study was the lack of temporal precedence that would
TE D
document changes in phobic beliefs and coping efficacy before changes in our outcome measure of clinical severity. Still, through our cross-sectional design, we were able to show that these changes were contemporaneous and associated with changes across time. Future studies should
EP
involve longitudinal designs which include more frequent assessment of phobic beliefs, coping efficacy, and clinical severity, allowing full mediation to be determined. A second limitation was
AC C
the lack of sociocultural diversity in our sample. Participants were predominantly Caucasian, which limits our ability to generalize our findings across diverse races, ethnicities, and cultures. A third limitation is associated with our Phobic Beliefs Scale which was designed for this study. We do not have reliability estimates for the ratings of the youth and we also had trained graduate clinicians code the child’s phobic cognition and serve as our objective raters rather than comparing ratings between youth with a SP and youth without a SP. Future research will need to
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
19
establish the reliability of this measure and examine whether differences exist in the ratings between youth with a SP and youth without a SP, not just between adult coders and youth with a SP. Fourth, given our sample size and the limited number of youth with any one subtype of SP,
RI PT
we were unable to explore moderators of change in this study. It is certainly conceivable that certain subtypes of SPs might be more amenable to changes in distorted beliefs and coping
efficacies than other subtypes (e.g. animal versus environmental/situational; see Ollendick &
SC
Muris, 2105). Finally, the changes observed in distorted beliefs and coping efficacy were
obviously examined following OST or EST only. We are unsure whether similar changes might
M AN U
be observed with other more standard psychological or pharmacological treatments (e.g. Walkup et al., 2008).
Our research is the first, to our knowledge, to examine how changes in terms of likelihood and danger expectancies and coping efficacy might vary between treatment
TE D
approaches for SPs. Our findings suggest that children and adolescents across both treatment conditions reported distorted beliefs in regards to their SP, similar to that of adults with a SP (Thorpe & Salkovskis, 1995). Youth in both the OST and EST treatment conditions
EP
demonstrated significant changes in their phobic beliefs and coping efficacy following treatment. The amount of change was greater, however, for youth assigned to OST. Still, these findings
AC C
offer limited support for the use of both OST and EST in reducing children and adolescents’ phobic beliefs and enhancing their coping efficacy. Although the primary aim of EST was not to challenge the identified harm beliefs or to enhance coping efficacy, we found that youth in the EST condition also demonstrated changes over time, albeit not commensurate to that observed for youth in the OST condition. While our results support challenging harm beliefs and enhancing coping efficacy are associated with enhanced outcomes, we do not want to discount
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
20
that other elements of CBT such as psychoeducation (like that provided in the EST condition) might also prove effective. Thus, in terms of critical treatment elements (see Deacon & Abramowitz, 2004), our findings also lend tentative support for focusing on the
RI PT
psychoeducational components present in both of these treatments. Although EST did not
directly challenge the youth’s harm beliefs or their coping efficacy via systematic exposure, it still produced significant changes. As such, it is arguably possible to change phobic beliefs and
SC
coping efficacy without exposure elements which might then prove efficient for therapist time and needed treatment resources.
M AN U
In brief, our findings illustrate both specificity associated with OST in changing distorted beliefs and coping efficacy in youth with SPs and a modicum of generality in that our EST condition also produced changes in beliefs and efficacy expectancies, although not to the same degree as in our OST condition. Such findings suggest that psychoeducational practices might be
TE D
particularly useful and appropriate when it is difficult to enact highly specific cognitive restructuring and exposure activities present in OST and related CBT approaches. Still, it is
EP
evident that CBT procedures produce greater gains and are preferred whenever possible.
AC C
Acknowledgements: This work was supported by the National Institute of Mental Health [Grant R01 MH59308]
The authors declare no conflict of interest.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
21
References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Association.
(5th ed.). Washington, DC: Author.
RI PT
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
perspective. New York: Basic Book.
SC
Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias. A cognitive
Byrne, S. P., Rapee, R. M., Malhi, G., Sweller, N., & Hudson, J. (2014). An examination of
M AN U
harm beliefs in children with dog phobia. Journal of Experimental Psychopathology, 7, 153-159.
Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for anxiety disorders: A review of meta‐analytic findings. Journal of Clinical Psychology, 60, 429-
TE D
441.
Fritz, M. S., & MacKinnon, D. P. (2007). Required sample size to detect the mediated effect. Psychological science, 18(3), 233-239.
EP
Hadwin, J. A., Garner, M., & Perez-Olivas, G. (2006). The development of information processing biases in childhood anxiety: A review and exploration of its
AC C
origins in parenting. Clinical Psychology Review, 26, 876-894.
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. Retrieved from http://www.afhayes.com/public/process2012.pdf Hogendoorn, S. M., Prins, P. J. M., Boer, F., Vevoort, L., Wolters, L. H., Moorlag, H., … de Haan, E. (2014). Mediators of cognitive behavior therapy for anxiety-disordered children and
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
22
adolescents: Cognition, perceived control, and coping. Journal of Clinical Child and Adolescent Psychology, 43, 486-500.
Kendall, P.C., Cummings, C. M., Villabo, M. A., Narayanan, M. K., Treadwell, K … Albano.
RI PT
(2016). Mediators of change in the Child/Adolescent Anxiety Multimodal Treatment Study. Journal of Consulting and Clinical Psychology, 84, 1-14.
Kendall, P. C., & Treadwell, K. R. H. (2007). The role of self-statements as a mediator in
SC
treatment for youth with anxiety disorders. Journal of Consulting and Clinical Psychology, 75, 380-389.
M AN U
Lang, P. J., Cuthbert, B. N., & Bradley, M. M. (1998). Measuring emotions in therapy: Imagery, activation, and feeling. Behavior Therapy, 29, 655-674.
Lang, P. J., Davis, M., & Öhman, A. (2000). Fear and anxiety: Animal models and human cognitive psychophysiology. Journal of Affective Disorders, 61, 137-159.
TE D
Lau, W. Y., Chan, C. K. Y., Li, J. C. H., & Au, T. K. F. (2010). Effectiveness of group cognitive-behavioral treatment for childhood anxiety in community clinics. Behaviour Research and Therapy, 48, 1067-1077.
EP
Muris, P., Merckelbach, H., Gadet, B., & Moulaert, V. (2000). Fears, worries, and scary dreams in 4-to 12-year-old children: Their content, developmental pattern, and origins. Journal of
AC C
Clinical Child Psychology, 29, 43-52.
Oar, E.L., Farrell, L.J., Waters, A.M., Conlon, E.G., & Ollendick, T.H. (2015). One session treatment for pediatric blood-injection-injury phobia: A controlled multiple baseline trial. Behaviour Research and Therapy, 73, 131-142.
Ollendick, T. H., & Davis III, T. E. (2013). One-session treatment for specific phobias: A review of Öst's single-session exposure with children and adolescents. Cognitive Behaviour Therapy, 42, 275-283.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
23
Ollendick, T. H., Halldorsdottir, T., Fraire, M. G., Austin, K. E., Noguchi, R. J., Lewis, K. M., ... & Whitmore, M. J. (2015). Specific phobias in youth: A randomized controlled trial
Therapy, 46, 141-155.
RI PT
comparing one-session treatment to a parent-augmented one-session treatment. Behavior
Ollendick, T. H., & Muris, P. (2015). The scientific legacy of little hans and little albert: Future
Adolescent Psychology, 44, 689-706.
SC
directions for research on specific phobias in youth. Journal of Clinical Child &
Ollendick, T. H., Öst, L. G., Reuterskiöld, L., Costa, N., Cederlund, R., Sirbu, C., ... & Jarrett,
M AN U
M. A. (2009). One-session treatment of specific phobias in youth: A randomized clinical trial in the United States and Sweden. Journal of Consulting and Clinical Psychology, 77, 504-516.
Ollendick, T. H., Öst, L. G., Ryan, S. M., Capriola, N. N., & Reuterskiöld, L. (2017). Harm
Therapy, 91, 51-57.
TE D
beliefs and coping expectancies in youth with specific phobias. Behaviour Research and
Öst, L.-G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy,
EP
27, 1–7.
Öst, L.-G. (1997). Rapid treatment of specific phobias. In G. C. L. Davey (Ed.), Phobias: A
AC C
handbook of theory, research and treatment (pp. 227–247). Oxford, England: Wiley.
Öst, L. G. (2012). One-session treatment: Principles and procedures with adults. In Intensive one-session treatment of specific phobias (pp. 59-95). New York, NY: Springer.
Öst, L. G. & Ollendick, T. H. (2001). Manual for one-session treatment of specific phobias. Unpublished manuscript. (Available from the Phobia Project, Child Study Center, Virginia Tech, Blacksburg, VA 24060).
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
24
Öst, L.-G., Svensson, L., Hellström, K., & Lindwall, R. (2001). One session treatment of specific phobias in youths: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 69, 814–824.
developments. Annual Review of Psychology, 66, 825-852.
RI PT
Preacher, K. J. (2015). Advances in mediation analysis: A survey and synthesis of new
Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule for DSM-IV:
SC
Child and Parent Versions. San Antonio, TX: Psychological Corporation.
Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Rabian, B., & Serafini, L. T.
M AN U
(1999). Contingency management, self-control, and education support in the treatment of childhood phobic disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 675-687.
Spence, S. H., Donovan, C. L., March, S., Kenardy, J. A., & Hearn, C. S. (2017). Generic versus
TE D
disorder specific cognitive behavior therapy for social anxiety disorder in youth: A randomized controlled trial using internet delivery. Behaviour Research and Therapy, 90, 41-57.
EP
Treadwell, K. R. H., & Kendall, P. C. (1996). Self-talk in youth with anxiety disorders: States of mind, content specificity, and treatment outcome. Journal of Consulting and Clinical
AC C
Psychology, 64, 941 -950.
Thorpe, S. J., & Salkovskis, P. M. (1995). Phobic beliefs: Do cognitive factors play a role in specific phobias? Behaviour Research and Therapy, 33, 805-816.
Walkup, J. T., Albano, A., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., … Kendall, P.C. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. The New England Journal of Medicine, 359, 2753-2766.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
25
Waters, A. M., Farrell, L. J., Zimmer-Gembeck, M. J., Milliner, E., Tiralongo, E., Donovan, C. L., McConnell, H., Bradley, B. P., Mogg., K., & Ollendick, T. H. (2014). Augmenting
Behaviour Research and Therapy, 62, 107-119.
RI PT
one-session treatment of specific phobias with attention training to positive stimuli.
Zlomke, K., & Davis, T. E. (2008). One-session treatment of specific phobias: A detailed
AC C
EP
TE D
M AN U
SC
description and review of treatment efficacy. Behavior Therapy, 39, 207-223.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
26
6 5 4 OST
RI PT
3
EST
2 1 0 Post-Treatment
6-Month Follow-up
Figure 1a. How Likely ratings across assessment session.
M AN U
8
SC
Pre-Treatment
7 6 5 4
2 Pre-Treatment
EST
TE D
3
OST
Post-Treatment
6-Month Follow-up
5 4 3 2 1
AC C
6
EP
Figure 1b. How Bad ratings across assessment session.
OST EST
0 Pre-Treatment
Post-Treatment
6-Month Follow-up
Figure 1c. Ability to Cope ratings across assessment session.
ACCEPTED MANUSCRIPT HARM BELIEFS IN SPECIFIC PHOBIAS
27
SC
RI PT
Table 1 Regression of Post-treatment CSRs on Change in Each PBS Item How Likely How “Bad” Ability to Cope 2 2 ∆R β ∆R β ∆R2 β .23*** .23*** .23*** Step 1 Pre-treatment CSR .32*** .32*** .33*** Treatment Condition -.36*** -.32*** -.38*** .02* .07*** .01 Step 2 Change in PBS Item -.15* -.28*** -.07 F-value 17.89*** 23.18*** 16.46*** Note. * p < .05, ** p < .01, *** p < .001. Change in PBS Item was measured from pre-treatment to post-treatment.
TE D
M AN U
Table 2 Regression of 6-Month Follow-up CSRs on Change in Each PBS Item How “Bad” Ability to Cope How Likely 2 2 ∆R β ∆R β ∆R2 β .11*** .11*** .11*** Step 1 Pre-treatment CSR .27*** .28*** .28*** Treatment Condition -.22** -.18* -.20** .02* .09*** .07*** Step 2 Change in PBS Item -.16* -.30*** -.26*** F-value 8.57*** 13.49*** 11.91*** Note. * p < .05, ** p < .01, *** p < .001. Change in PBS Item was measured from pre-treatment to 6-month follow-up.
AC C
EP
Table 3 Regression of Post-Treatment and 6-Month Follow-up CSRs on Change in PBS Items Post-Treatment 6-Month Follow-Up 2 ∆R β ∆R2 β .23*** .11*** Step 1 Pre-treatment CSR .32*** .27*** Treatment Condition -.31*** -.16* .08*** .12*** Step 2 Change in How Likely -.07 -.11 Change in How Bad -.31*** -.21** Change in Ability to Cope .09 -.18* F-value 14.47*** 9.89*** Note. * p < .05, ** p < .01, *** p < .001.
ACCEPTED MANUSCRIPT
Running Head: HARM BELIEFS IN SPECIFIC PHOBIAS
28
AC C
EP
TE D
M AN U
SC
RI PT
Table 4 Summary of the Mediating Effects of PBS Items Post-Treatment Potential “How Likely” “How Bad” Ability to Cope “How Likely” Mediators (MED) B t B t B t B t Paths 1.05 2.41* 2.65** 1.30 3.49*** 1.00 2.65** Treatment → MED 1.00 -0.05 -1.06 -0.11 -2.10* -0.21 -4.08*** -0.08 -1.38 MED → CSR Direct Effect -1.38 -5.36*** -4.63*** -0.80 -2.79** Treatment → CSR -1.32 -5.16*** -1.16 B LCI UCI B LCI UCI B LCI UCI B LCI UCI Indirect Effect Through MED Treatment → CSR -0.11 -0.29 -.00 -0.27 -0.54 -0.11 -0.05 -0.23 0.04 -0.08 -0.29 0.03 Note. * p < .05, ** p < .01, *** p < .001. B = Unstandardized Coefficient; CSR = Clinician Severity Rating; LCI = Lower 95% Confidence Interval; UCI = Upper 95% Confidence Interval
6-Month Follow-Up “How Bad”
Ability to Cope
B
t
B
t
0.86 -0.24
2.40* -4.18***
1.05 -0.11
2.41* -2.20*
-0.67 B
-2.46* LCI UCI
-0.76 B
-2.71** LCI UCI
-0.21 -0.45 -0.04 -0.11 -0.33 -0.01
ACCEPTED MANUSCRIPT
6-Month Follow-up How Likely How Bad Ability to Cope
2.10 (1.79) 4.89 (2.53) 4.15 (2.39)
Objective Codes How Likely How Bad
2.58 (1.02) 3.86 (1.48)
1.87 (1.67) 4.49 (2.52) 4.36 (2.28)
M AN U
2.67 (2.19) 5.75 (2.12) 3.46 (2.53)
TE D
Post-Treatment How Likely How Bad Ability to Cope
SC
Table 5 Means and Standard Deviations for PBS items and CSRs across Treatment Condition and Assessment Time Point Mean(SD) EST OST (n = 79) (n = 86) Pre-Treatment How Likely 4.28 (2.19) 4.41 (1.92) How Bad 6.81 (1.67) 6.80 (1.58) Ability to Cope 2.67 (1.93) 2.58 (2.03)
29
RI PT
Running Head: HARM BELIEFS IN SPECIFIC PHOBIAS
1.81 (1.41) 4.01 (2.22) 4.81 (2.07)
2.91 (1.05) 4.35 (1.66)
AC C
EP
CSRs Pre-Treatment 5.81 (0.95) 6.08 (0.92) Post-Treatment 4.67 (1.65) 3.42 (1.76) 6-Month Follow-up 3.91 (1.88) 3.19 (1.82) Note. Objective Codes were only rated once because the identified phobic beliefs of the children remained constant at each assessment time point
ACCEPTED MANUSCRIPT
Highlights
EP
TE D
M AN U
SC
RI PT
Phobic beliefs improved following both One Session Treatment and Educational Support Catastrophic beliefs reduce a greater degree following One Session Treatment Greater change in beliefs predicted lower clinical severity following treatment Change in beliefs partially mediated the relationship between treatment and CSR
AC C
• • • •