The Role of Gender and Culture in Treating Youth With Anxiety Disorders

The purpose of this article is to discuss the complexities of working with anxious children and adolescents of diverse cultures within the context of cognitive-behavioral treatment. Our discussion will examine how culture, gender, and minority status affect anxious symptomatology in children and adolescents and how this may be addressed in treatment. The authors discuss the importance of considering the cultural variations in symptom expression, cultural norms and issues of acculturation, effects of discrimination, and finally the ways that gender can moderate symptom expression. Case examples are incorporated into each section. Recommendations include an emphasis on research on working with children of diverse cultures and the need for ongoing training that helps therapists to examine the impact of their own cultural beliefs on clinical care.

Parental Involvement When Conducting Cognitive-Behavioral Therapy for Children With Anxiety Disorders

Discusses the potential roles of parents in cognitive-behavioral therapy (CBT) with anxious youth and how parents can both facilitate and/or impede treatment progress. Parents facilitate the attainment of treatment goals by providing invaluable information regarding the child’s level of functioning and assisting the therapist with the development and implementation of treatment components such as exposure tasks. Parental involvement in treatment also gives the therapist an opportunity to more fully assess and address family factors that may be maintaining the child’s anxiety. Common challenges encountered with parents that may impede treatment progress include rescuing the child from anxious situations, under- or over-involvement in the treatment process, difficulty setting limits, and the presence of parental psychopathology. Finally, the relevance of developmental level, child gender, diagnosis, and the presence of parental psychopathology to the decision of how and when to include parents in treatment is discussed.

Gender role orientation and anxiety symptoms among African american adolescents

The present study evaluated gender role theory as an explanation for the observed gender differences in anxiety symptoms among adolescents. Specifically, the relation between gender, gender role orientation (i.e., masculinity and femininity), self-esteem, and anxiety symptoms was examined in a community sample of 114 African Americans aged 14 to 19 (mean age 15.77; 57 girls). Results revealed that masculinity was negatively associated with anxiety symptoms whereas femininity was positively associated with anxiety symptoms. Gender role orientation accounted for unique variance in anxiety scores above biological gender and self-esteem, and self-esteem moderated the relation between femininity (but not masculinity) and overall anxiety symptoms. Consistent with research on children and Caucasians, findings supported gender role theory as a partial explanation for the observed gender disparity in anxiety symptoms among African American adolescents.

Childhood predictors of anxiety symptoms: a longitudinal study

The present study examined the concurrent and prospective relation between a select number of potential predictors and symptoms of anxiety among a high-risk community sample of 149 predominately African American children. Parent and child reports of anxiety were assessed in the first and seventh grade. Six domains of childhood risk factors (i.e., Loss-Death, Loss-Separation, Social Adversity, Negative Family Environment, Academic Difficulties, and Peer Rejection) were assessed using multiple informants in the first grade. Results indicated that children who experienced a more negative family environment, had a greater number of losses and deaths, and experienced academic failures in the first grade exhibited higher levels of anxiety (concurrently and/or at the six year follow-up). Findings provide empirical support to etiological models that posit both parental/familial and environmental factors contribute to the development of heightened anxiety in children.

Screen for Child Anxiety Related Emotional Disorders (SCARED): psychometric properties in an African-American parochial high school sample

OBJECTIVE

To examine the psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED) for a community sample of African-American high school students.

METHOD

The 41-item SCARED was administered to 111 adolescents (57 girls; mean age 15.75) in an urban parochial school. Item frequency, internal consistency, test-retest reliability, and construct validity were assessed.

RESULTS

Approximately 30% of the sample had scores high enough to warrant further assessment for anxiety disorders, and girls reported significantly higher anxiety symptoms than boys. Internal consistency (alpha =.89) and test-retest reliability (r = 0.47) over 6 months for the SCARED's total score were good. The SCARED's total score was positively correlated with other measures of anxiety symptoms and inattention and was negatively correlated with perceived self-worth. Unlike the five-factor structure reported for primarily white samples, only three factors emerged for this African-American sample.

CONCLUSIONS

The SCARED shows utility as a self-report anxiety screening instrument in a community sample of African-American youths.

School-based treatment for anxious african-american adolescents: a controlled pilot study

OBJECTIVE

To evaluate the feasibility and effectiveness of a school-based group cognitive-behavioral treatment (CBT) for anxiety disorders with African-American adolescents.

METHOD

Twelve adolescents (mean age = 15.6 years) with anxiety disorders were randomly assigned to CBT (n = 6) or a group attention-support control condition (AS-Control; n = 6). Both groups met for 10 sessions in the same high school. Key treatment ingredients in CBT involved exposure, relaxation, social skills, and cognitive restructuring. Key ingredients in AS-Control involved therapist and peer support. At pre- and posttreatment, diagnostic interviews were conducted, and adolescents completed self-report measures of anxiety.

RESULTS

At posttreatment and among those who attended more than one treatment session, 3/4 adolescents in CBT no longer met diagnostic criteria for their primary anxiety disorder, compared with 1/5 in AS-Control. Clinician ratings of impairment and self-report levels of overall anxiety were significantly lower at posttreatment in CBT compared with AS-Control. Teenagers in both groups reported lower levels of social anxiety from pre- to posttreatment.

CONCLUSIONS

Findings support the feasibility of implementing a manual-based CBT in an urban school setting. Responder rates among African-American adolescents were similar to those found in studies with white youths.

Personalized medicine: revolutionizing drug discovery and patient care

Advances in human genome research are opening the door to a new paradigm for practising medicine that promises to transform healthcare. Personalized medicine, the use of marker-assisted diagnosis and targeted therapies derived from an individual's molecular profile, will impact the way drugs are developed and medicine is practiced. Knowledge of the molecular basis of disease will lead to novel target identification, toxicogenomic markers to screen compounds and improved selection of clinical trial patients, which will fundamentally change the pharmaceutical industry. The traditional linear process of drug discovery and development will be replaced by an integrated and heuristic approach. In addition, patient care will be revolutionized through the use of novel molecular predisposition, screening, diagnostic, prognostic, pharmacogenomic and monitoring markers. Although numerous challenges will need to be met to make personalized medicine a reality, with time, this approach will replace the traditional trial-and-error practice of medicine.

Atherosclerosis: a cancer of the blood vessels?

A series of molecular pathways have in common a significant role in the pathogenesis and progression of atherosclerosis and cancer. Shared mechanisms implicated for both diseases include oxidative stress and the cellular damage that results from it, toxic metabolites produced by cigarette smoking, and increased dietary fat intake. Atherosclerosis may begin when an injury or infection mutates or transforms a single arterial smooth muscle cell in the progenitor of a proliferative clone, similar to the most widely held carcinogenesis theory. Cell proliferation regulatory pathways have been associated with plaque progression, stenosis, and restenosis after angioplasty and with cancer progression. Alterations in cell adhesion molecules have been linked to plaque formation and thrombosis and to tumor invasion and metastasis. Altered expression of proteases associated with thrombolysis has been implicated in atherosclerotic plaque expansion and hemorrhage and in the invasion and metastasis of malignant neoplasms. Ligand-growth factor receptor interactions have been associated with early atherosclerotic lesions and with cancer development and spread. Nuclear transcription factors have been associated with progression of both diseases. Angiogenesis modulators have been linked to plaque expansion and restenosis of atherosclerotic lesions and to local and metastatic tumor expansion.

Atherosclerosis and cancer: common molecular pathways of disease development and progression

Recently, a series of shared molecular pathways have emerged that have in common a significant role in the pathogenesis and progression of both atherosclerosis and cancer. Oxidative stress and the cellular damage that results from it have been implicated in a wide variety of disease processes including atherogenesis and neoplasia. Toxic metabolites produced by cigarette smoking and increased dietary fat intake are implicated in the pathogenesis of both diseases. It has been hypothesized that atherosclerosis may begin when an injury or infection mutates or transforms a single arterial smooth muscle cell in the progenitor of a proliferative clone similar to the most widely held theory of carcinogenesis. Cell proliferation regulatory pathways including genes involved in the GIS checkpoint (p53, pRb, p15, p16, and cyclins A, D, E, and cdk 2,4) have been associated with plaque progression, stenosis and restenosis after angioplasty as well as in cancer progression. Alterations in cell adhesion molecules (integrins, cadherin-catenins) have been linked to plaque formation and thrombosis as well as to tumor invasion and metastasis. Altered expression of proteases associated with thrombolysis has been implicated in atherosclerotic plaque expansion and hemorrhage and in the invasion and metastasis of malignancy. Ligand-growth factor receptor interactions (tyrosine kinases) have been associated with early atherosclerotic lesions as well as cancer development and spread. Nuclear transcription factors such as NFkappaB have been associated with progression of both diseases. Angiogenesis modulators have recently been linked to plaque expansion and restenosis of atherosclerotic lesions as well as local and metastatic tumor expansion. Common disease treatments, such as the use of growth factor inhibitors and radiation treatment, established anticancer treatments, were recently introduced into atherosclerosis therapeutic strategies to prevent restenosis after angioplasty and endarterectomy. In conclusion, a series of molecular pathways of disease development and progression common to atherosclerosis and cancer support that the world's two most common diseases are far more closely aligned than previously believed and that emerging anti-inflammatory and antiproliferative therapeutic strategies may ultimately be efficacious in both conditions.

Psychostimulants in preschool children with attention-deficit/hyperactivity disorder: clinical evidence from a developmental disorders institution

OBJECTIVE

To examine psychostimulant response in preschool children with attention-deficit/hyperactivity disorder (ADHD) in an outpatient child psychiatry clinic (housed within a developmental disorders institution) over 3, 12, and 24 months of treatment.

METHOD

A systematic retrospective chart review was conducted for 27 preschool children with ADHD who were started on psychostimulants between the ages of 3 and 5 years, inclusive. Two child and adolescent psychiatrists reviewed each chart independently, using the Clinical Global Impressions (CGI) scale to rate the severity of illness and global improvement and the Side Effects Rating Form to rate side effects.

RESULTS

Over 24 months, psychostimulants were stopped in three children (11%) because of side effects and concomitant psychotropic medications were added in seven children (26%). The CGI severity-of-illness ratings showed a significant effect of time over 3, 12, and 24 months of psychostimulant treatment (all p values < .0001). Rate of response was 74% at 3 months and 70% at 12 and 24 months. Side effects were mostly mild and occurred in 63% of the children at 3 months, 41% at 12 months, and 29% at 24 months.

CONCLUSIONS

The findings suggest that preschool children with developmental disorders respond to psychostimulants but need close monitoring because of frequent side effects. Inasmuch as the study participants were recruited from a child psychiatry clinic housed within a developmental disorders institution and had a high rate of developmental disorders, the findings may not generalize to other preschool children with ADHD.

Gender differences in exercise-induced changes in sex hormone levels and lipid peroxidation in athletes participating in the Hawaii Ironman triathlon. Ginsburg-gender and exercise-induced lipid peroxidation

BACKGROUND

Exercise reduces the risk of coronary heart disease in men and women but paradoxically, may promote free-radical formation, lipid peroxidation and vascular tissue injury. In this study, we assessed whether exercise-induced oxidative stress similarly affected men and women who participated in the Hawaii Ironman triathlon.

METHODS AND RESULTS

Fifty-seven athletes (38 males) who completed the triathlon (3.9 km swim, 180.2 km bike, 42.2 km run) participated in this study. Blood samples were obtained 2 days before and immediately after the triathlon for the measurement of lipids, antioxidants and sex hormones and for the assessment of the susceptibility of plasma lipids to peroxidation. Lipid changes after exercise were similar for men and women. However, the susceptibility of plasma lipids to peroxidation was reduced by 61% (P < 0.001) in men and only 14% (P = NS) in women postrace. These changes were not associated with the supplemental use or levels of antioxidants. In addition, in men there was an increase of 58% in the antioxidant sex hormone estradiol and a decrease of 58% in testosterone (P < 0.001) postrace. No significant changes were noted for these two hormones in women.

CONCLUSIONS

There are significant gender-specific differences in the susceptibility of lipids to peroxidation and in changes in estradiol and testosterone levels as a result of ultra-endurance exercise. These changes may in part explain the salutary effect of exercise on the development of vascular disease.

Contingency management, self-control, and education support in the treatment of childhood phobic disorders: a randomized clinical trial

This study evaluated the relative efficacy of an exposure-based contingency management (CM) treatment condition and an exposure-based cognitive self-control (SC) treatment condition relative to an education support (ES) control condition for treating children with phobic disorders. Eighty-one children and their parents completed a 10-week treatment program in which children and parents were seen in separate treatment sessions with the therapist, followed by a brief conjoint meeting. Children in both the CM and SC conditions showed substantial improvement on all of the outcome measures. These gains were maintained at 3-, 6-, and 12-month follow-ups. Interestingly, children in the ES condition also showed comparable improvements at posttreatment and at 3-, 6-, and 12-month follow-ups. Implications of the findings are discussed with respect to knowledge development and clinical practice.

Treating anxiety disorders in children with group cognitive-behaviorial therapy: a randomized clinical trial

A randomized clinical trial evaluated the therapeutic efficacy of group cognitive-behavioral therapy (GCBT) versus a wait-list control (WLC) condition to treat anxiety disorders in children. Results indicated that GCBT, with concurrent parent sessions, was highly efficacious in producing and maintaining treatment gains. Children in GCBT showed substantial improvement on all the main outcome measures, and these gains were maintained at 3-, 6-, and 12-month follow-ups. Children in the WLC condition did not show improvements from the pre- to the postwait assessment point. These findings are discussed in terms of the need to continue to advance the development of practical, as well as conceptual, knowledge of efficacious treatment for anxiety disorders in children.

Gender role orientation and fearfulness in children with anxiety disorders

Research on gender differences in children's fears has generally shown that girls are more fearful than boys. A common hypothesis offered for this finding is that gender role orientations or expectations may be operating. However, this hypothesis has not been directly investigated in child samples. The present study examined the relation between a self-report measure of gender role orientation (i.e., masculinity/femininity) and the intensity of self-reported fears in a clinic sample of children (N = 66; ages 6-11; 41 boys and 25 girls) with anxiety disorders. Results revealed that masculinity was negatively related to overall levels of fearfulness as well as specific fears of failure and criticism, medical fears, and fears of the unknown. In contrast, no relation was found between femininity and fearfulness. These findings suggest that gender role orientation, especially masculinity, may play a role in the development and/or maintenance of fearfulness in children.

The treatment of anxiety disorders in children and adolescents

Anxiety disorders are the most common psychiatric conditions in the pediatric population, with prevalence estimates ranging from 5-18%. Children and adolescents with excessive anxiety often meet diagnostic criteria for a number of disorders within the DSM-IV. Unfortunately, the current diagnostic system is controversial because of high rates of symptom overlap, comorbidity with other psychiatric disorders, and lack of biological markers that would support a more empirical anxiety nosology. Treatment strategies for pediatric anxiety disorders have important historical roots. Several controlled studies of cognitive-behavioral therapy (CBT) demonstrate efficacy for pediatric anxiety disorders. In contrast, no controlled psychopharmacology studies have demonstrated efficacy in children and adolescents with anxiety disorders, except obsessive-compulsive disorder; however, several large, methodologically sound psychopharmacotherapy trials are underway for pediatric anxiety disorders. This update will review the current status of psychosocial and psychopharmacologic treatment of pediatric anxiety disorders. In addition, a brief discussion of nosology, epidemiology, and developmental course of anxiety is included. Preliminary psychopharmacology treatment and CBT treatment algorithms are presented for pediatric anxiety disorders, based on the best available data. Recommendations for future research directions are also discussed.

Treating anxiety disorders in children with group cognitive-behaviorial therapy: a randomized clinical trial

A randomized clinical trial evaluated the therapeutic efficacy of group cognitive-behavioral therapy (GCBT) versus a wait-list control (WLC) condition to treat anxiety disorders in children. Results indicated that GCBT, with concurrent parent sessions, was highly efficacious in producing and maintaining treatment gains. Children in GCBT showed substantial improvement on all the main outcome measures, and these gains were maintained at 3-, 6-, and 12-month follow-ups. Children in the WLC condition did not show improvements from the pre- to the postwait assessment point. These findings are discussed in terms of the need to continue to advance the development of practical, as well as conceptual, knowledge of efficacious treatment for anxiety disorders in children.

Contingency management, self-control, and education support in the treatment of childhood phobic disorders: a randomized clinical trial

This study evaluated the relative efficacy of an exposure-based contingency management (CM) treatment condition and an exposure-based cognitive self-control (SC) treatment condition relative to an education support (ES) control condition for treating children with phobic disorders. Eighty-one children and their parents completed a 10-week treatment program in which children and parents were seen in separate treatment sessions with the therapist, followed by a brief conjoint meeting. Children in both the CM and SC conditions showed substantial improvement on all of the outcome measures. These gains were maintained at 3-, 6-, and 12-month follow-ups. Interestingly, children in the ES condition also showed comparable improvements at posttreatment and at 3-, 6-, and 12-month follow-ups. Implications of the findings are discussed with respect to knowledge development and clinical practice.

Factor structure of the childhood anxiety sensitivity index

We developed various factor models of the Childhood Anxiety Sensitivity Index [Silverman, W. K., Fleisig, W., Rabian, B. & Peterson, R. A. (1991). Childhood anxiety sensitivity index. Journal of Clinical Child Psychology, 20, 162-168] and tested the goodness of fit of the models in an independent sample. Of primary interest was to examine the question that characterized the factor analytic studies conducted on the adult version of the anxiety sensitivity index, i.e. the ASI [Reiss, S., Peterson, R. A., Gursky, D. M. & McNally, R. J. (1986). Anxiety sensitivity, anxiety frequency and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1-8]: is anxiety sensitivity in children a unidimensional construct, an orthogonal multidimensional construct, or a hierarchical construct? Two independent samples (a clinic sample and a nonclinical sample) were used for development and replication of the factor models. The clinic sample consisted of 258 children (105 girls and 153 boys) who presented to a child anxiety disorders specialty clinic. The unselected, nonclinic sample consisted of 249 children (122 girls and 127 boys) enrolled in an elementary school. The results provided strong empirical support for a hierarchical multidimensional model with either three or four first-order factors. The two factors that emerged that appeared to be robust were Physical Concerns and Mental Incapacitation Concerns. What remains unresolved is whether Control of anxiety symptoms and Social Concerns are to be differentiated (as in the hierarchical model with four first-order factors) or not (as in the hierarchical model with three first-order factors). In addition to discussing this issue, the convergence of the present study's findings with past findings obtained with the ASI is discussed.

Acute changes in serum lipids and lipoprotein subclasses in triathletes as assessed by proton nuclear magnetic resonance spectroscopy

Exercise is associated with changes in lipids that may protect against coronary heart disease (CHD). In this study of 28 triathletes, we analyzed acute changes in serum lipid and lipoprotein concentrations after completion of the 1995 World Championship Hawaii Ironman Triathlon. With standard laboratory assays, we demonstrate significant decreases in total cholesterol, VLDL cholesterol, ApoB100, and Lp(a). Total HDL cholesterol increased significantly immediately after the race. With a novel proton NMR spectroscopy assay, we demonstrate that smaller diameter LDL particles, corresponding to small, dense LDL, declined by 62%. Moreover, larger HDL subclasses, whose levels are inversely associated with CHD, increased significantly by 11%. Smaller HDL subclasses, which have been directly associated with CHD in some studies, acutely decreased by 16%. Therefore, exercise not only acutely induces changes in lipoprotein concentrations among the standard species in a manner that favorably affects CHD risk, but also induces favorable changes in specific lipoprotein subclass size distribution that also may alter CHD risk independently of the total lipoprotein serum concentration.