Inattention symptoms and the diagnosis of comorbid attention-deficit/hyperactivity disorder among youth with generalized anxiety disorder

Generalized anxiety disorder (GAD) and attention-deficit/hyperactivity disorder (ADHD) commonly co-occur in childhood. Inattention symptoms can be hallmarks of both conditions, however assessment tools of inattention may not effectively distinguish between the two conditions. The present study used receiver operating characteristic (ROC) analyses to examine the high-end specificity of the Attention Problems Scale of the Child Behavior Checklist (CBCL) for detecting comorbid ADHD among youth with GAD (N=46). Results support the utility of the Attention Problems Scale for accurately distinguishing between the two groups (AUC=.84, SE=.06). Specifically, a cut score of 63 achieved the most favorable values across diagnostic utility indices; 74% of GAD youth with ADHD scored above this cutoff and 91% of GAD youth without ADHD scored below this cutoff. Findings provide support for the use of the CBCL Attention Problems Scale to supplement diagnostic interviews and identify inattention associated with ADHD among GAD youth.

The diagnostic utility of separation anxiety disorder symptoms: an item response theory analysis

At present, it is not clear whether the current definition of separation anxiety disorder (SAD) is the optimal classification of developmentally inappropriate, severe, and interfering separation anxiety in youth. Much remains to be learned about the relative contributions of individual SAD symptoms for informing diagnosis. Two-parameter logistic Item Response Theory analyses were conducted on the eight core SAD symptoms in an outpatient anxiety sample of treatment-seeking children (N = 359, 59.3 % female, M Age = 11.2) and their parents to determine the diagnostic utility of each of these symptoms. Analyses considered values of item threshold, which characterize the SAD severity level at which each symptom has a 50 % chance of being endorsed, and item discrimination, which characterize how well each symptom distinguishes individuals with higher and lower levels of SAD. Distress related to separation and fear of being alone without major attachment figures showed the strongest discrimination properties and the lowest thresholds for being endorsed. In contrast, worry about harm befalling attachment figures showed the poorest discrimination properties, and nightmares about separation showed the highest threshold for being endorsed. Distress related to separation demonstrated crossing differential item functioning associated with age-at lower separation anxiety levels excessive fear at separation was more likely to be endorsed for children ≥9 years, whereas at higher levels this symptom was more likely to be endorsed by children <9 years. Implications are discussed for optimizing the taxonomy of SAD in youth.

Caregiver distress, shared traumatic exposure, and child adjustment among area youth following the 2013 Boston Marathon bombing

BACKGROUND

Disasters are associated with myriad negative outcomes in youth, including posttraumatic stress disorder and related psychopathology. Prior work suggests links between caregiver distress and child mental health outcomes following community traumas, but the extent to which caregiver distress is directly linked to post-disaster child functioning, or whether such associations may simply be due to shared traumatic exposure, remains unclear.

METHODS

The current study examined relationships among caregiver distress, caregiver-child shared traumatic exposure, and child outcomes in Boston-area families (N=460) during the six months following the 2013 Boston Marathon bombing. Parents completed surveys about their and their child׳s potentially traumatic experiences during the bombing and subsequent manhunt. Post-attack caregiver distress and child psychological functioning were also assessed.

RESULTS

After accounting for caregiver-child shared traumatic exposure, significant associations were retained between caregiver distress and child functioning across several domains. Furthermore, after accounting for caregiver traumatic exposure, caregiver distress moderated relationships between child traumatic exposure and child posttraumatic stress and conduct problems, such that associations between child traumatic exposure and child posttraumatic stress and conduct problems were particularly strong among children of highly distressed caregivers.

LIMITATIONS

The cross-sectional design did not permit evaluations across time, and population-based methods were not applied.

CONCLUSIONS

Findings clarify links between caregiver distress and child psychopathology in the aftermath of disaster and can inform optimal allocation of clinical resources targeting disaster-affected youth and their families.

Adjustment among area youth after the Boston Marathon bombing and subsequent manhunt

BACKGROUND

The majority of research on terrorism-exposed youth has examined large-scale terrorism with mass casualties. Limited research has examined children's reactions to terrorism of the scope of the Boston Marathon bombing. Furthermore, the extraordinary postattack interagency manhunt and shelter-in-place warning made for a truly unprecedented experience in its own right for families. Understanding the psychological adjustment of Boston-area youth in the aftermath of these events is critical for informing clinical efforts.

METHODS

Survey of Boston-area parents/caretakers (N = 460) reporting on their child's experiences during the attack week, as well as psychosocial functioning in the first 6 attack months.

RESULTS

There was heterogeneity across youth in attack- and manhunt-related experiences and clinical outcomes. The proportion of youth with likely attack/manhunt-related posttraumatic stress disorder (PTSD) was roughly 6 times higher among Boston Marathon-attending youth than nonattending youth. Attack and manhunt experiences each uniquely predicted 9% of PTSD symptom variance, with manhunt exposures more robustly associated than attack-related exposures with a range of psychosocial outcomes, including emotional symptoms, conduct problems, hyperactivity/inattention, and peer problems. One-fifth of youth watched >3 hours of televised coverage on the attack day, which was linked to PTSD symptoms, conduct problems, and total difficulties. Prosocial behavior and positive peer functioning buffered the impact of exposure.

CONCLUSIONS

Clinical efforts must maintain a broadened focus beyond simply youth present at the blasts and must also include youth highly exposed to the intense interagency pursuit and manhunt. Continued research is needed to understand the adjustment of youth after mass traumas and large-scale manhunts in residential communities.

Adjustment among children with relatives who participated in the manhunt following the Boston Marathon attack

BACKGROUND

Following the Boston Marathon attack, the extraordinary interagency manhunt and shelter-in-place made for a truly unprecedented experience for area families. Although research on Boston youth has found robust associations between manhunt-related experiences and post-attack functioning, such work does little to identify the specific needs of a particularly vulnerable population--i.e., children with a relative who participated in the manhunt. Understanding the adjustment of these youth is critical for informing clinical efforts.

METHODS

Survey of Boston-area parents/caretakers (N = 460) reporting on their child's attack/manhunt-related experiences, as well as psychosocial functioning in the first six post-attack months; analyses compared youth with and without a relative in law enforcement or the armed services who participated in the manhunt.

RESULTS

The proportion of youth with likely PTSD was 5.7 times higher among youth with relatives in the manhunt than among youth without. After accounting for child demographics, blast exposure, and children's own exposure to manhunt events (e.g., hearing/seeing gunfire/explosions, having officers enter/search home), having a relative in the manhunt significantly predicted child PTSD symptoms, emotional symptoms, and hyperactivity/inattention. Fear during the manhunt that a loved one could be hurt mediated relationships between having a relative in the manhunt and clinical outcomes; living within the zone of greatest manhunt activity did not moderate observed relationships.

CONCLUSIONS

Children with relatives called upon to participate in the unprecedented interagency manhunt following the Boston Marathon attack carried a particularly heavy mental health burden. Continued research is needed to clarify the clinical needs of youth with relatives in high-risk occupations.

Paternal Autonomy Restriction, Neighborhood Safety, and Child Anxiety Trajectory in Community Youth

Intrusive parenting, primarily examined among middle to upper-middle class mothers, has been positively associated with the presence and severity of anxiety in children. This study employed cross-sectional linear regression and longitudinal latent growth curve analyses to evaluate the main and interactive effects of early childhood paternal autonomy restriction (AR) and neighborhood safety (NS) on the trajectory of child anxiety in a sample of 596 community children and fathers from the NICHD SECYD. Longitudinal analyses revealed that greater paternal AR at age 6 was actually associated with greater decreases in child anxiety in later childhood. Cross-sectional analyses revealed main effects for NS across childhood, and interactive effects of paternal AR and NS that were present only in early childhood, whereby children living in safer neighborhoods demonstrated increased anxiety when experiencing lower levels of paternal AR. Findings further clarify for whom and when paternal AR impacts child anxiety in community youth.

Family involvement in the psychological treatment of obsessive-compulsive disorder: a meta-analysis

Psychological treatments for obsessive-compulsive disorder (OCD) are increasingly aimed at improving outcomes by directly incorporating family members to address family disruption, dysfunction, or symptom accommodation. Much remains to be learned about the pooled effects of "family inclusive treatment" (FIT) for OCD and factors that may explain variation in response. Random-effects meta-analytic procedures were conducted to empirically evaluate the overall effect of FITs on OCD, and treatment moderators. Study search criteria yielded 29 studies examining FIT response in 1,366 OCD patients. Outcome variables included OCD symptoms and global functioning. Examined moderators included age group, gender, minority status, treatment length and format, and inclusion of specific family focused treatment elements. FITs for OCD demonstrated a large overall effect on OCD symptoms (pooled d = 1.68, SE = 0.14) and global functioning (pooled d = 0.98, SE = 0.14). Moderator analyses found that individual family treatments (vs. group) and FITs targeting family accommodation of symptoms (vs. those that did not target accommodation) were associated with greater improvements in patient functioning. Results indicate a robust overall response to FITs for OCD and clarify key moderators that inform optimal circumstances for effective treatment. Findings underscore the need for continued momentum in the development, evaluation, and dissemination of FITs for OCD.

A psychometric evaluation of the panic disorder severity scale for children and adolescents

The Panic Disorder Severity Scale (PDSS; Shear et al., 1997) is a well-validated measure that assesses symptoms of panic disorder with or without agoraphobia (PDA) in adults. The Panic Disorder Severity Scale for Children (PDSS-C) is an adaptation of the PDSS for youth ages 11-17. The current study evaluated the psychometric properties of the PDSS-C. Participants included 60 adolescents from a randomized controlled trial investigating the efficacy of an intensive cognitive behavioral treatment (CBT) for adolescent PDA. Convergent and discriminant validity of PDSS-C scores were evaluated via observed associations between the PDSS-C and the Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991), Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), and Children's Depression Inventory (CDI; Kovacs, 2003). Baseline and posttreatment data afforded the opportunity to evaluate the measure's sensitivity to treatment-related change. PDSS-C scores demonstrated acceptable internal consistency (α = .82) and adequate 1-day test-retest reliability (r = .79). Convergent and discriminant validity of the PDSS-C scores were supported through significant associations with the CASI and the MASC, and nonsignificant associations with the CDI, respectively. Linear regression analysis demonstrated sensitivity to treatment-related changes-that is, greater PDSS-C change scores were significantly associated with assignment to CBT vs. waitlist condition. Clinical utility was further established through significant associations between PDSS-C change scores and MASC and CASI change scores, and through nonsignificant associations with CDI change scores. Results support the use of PDSS-C scores as reliable, valid, and clinically useful for the assessment of youth panic disorder in research and clinical settings.

The occasional case against broad dissemination and implementation: retaining a role for specialty care in the delivery of psychological treatments

Mental illness imposes a staggering public health burden in the United States. Although the past 40 years have witnessed tremendous advances in the identification of evidence-based practices (EBPs) in psychological treatments, gaps persist between treatment in experimental settings and services available in the community. In response, considerable attention and large financial commitments have focused in recent years on broad dissemination and implementation efforts designed to improve the quality of psychological services delivered by a variety of generalist practitioners across practice settings. Increasingly, under the influence of the Patient Protection and Affordable Care Act, it is envisioned that these generalists will practice in integrated primary care settings. These advances hold enormous potential, and yet, given the tremendous diversity of mental health problems and human suffering, broad dissemination and implementation efforts to generalists alone may not be sufficient to adequately address the burden of mental illness. Some EBPs may prove too complex for universal dissemination, and the time and expense required for quality dissemination and implementation preclude large-scale training in the treatment of low base rate disorders. As dissemination and implementation efforts work to ensure a quality generalist mental health care workforce, herein we highlight the vital need for available specialty care in the delivery of psychological treatments. Given traditional barriers that interfere with the accessibility of specialty care, we propose the transformative potential of a specialty behavioral telehealth care workforce, transacting with the generalist practitioner workforce to collectively ensure the highest quality and timely delivery of needed treatments to affected individuals.

Maternal intrusiveness, family financial means, and anxiety across childhood in a large multiphase sample of community youth

Intrusive parenting has been positively associated with child anxiety, although examinations of this relationship to date have been largely confined to middle to upper middle class families and have rarely used longitudinal designs. With several leading interventions for child anxiety emphasizing the reduction of parental intrusiveness, it is critical to determine whether the links between parental intrusiveness and child anxiety broadly apply to families of all financial means, and whether parental intrusiveness prospectively predicts the development of child anxiety. This study employed latent growth curve analysis to evaluate the interactive effects of maternal intrusiveness and financial means on the developmental trajectory of child anxiety from 1st grade to age 15 in 1,121 children (50.7 % male) and their parents from the NICHD SECCYD. The overall model was found to provide good fit, revealing that early maternal intrusiveness and financial means did not impact individual trajectories of change in child anxiety, which were stable from 1st to 5th grade, and then decrease from 5th grade to age 15. Cross-sectional analyses also examined whether family financial means moderated contemporaneous relationships between maternal intrusiveness and child anxiety in 3rd and 5th grades. The relationship between maternal intrusiveness and child anxiety was moderated by family financial means for 1st graders, with stronger links found among children of lower family financial means, but not for 3rd and 5th graders. Neither maternal intrusiveness nor financial means in 1st grade predicted subsequent changes in anxiety across childhood. Findings help elucidate for whom and when maternal intrusiveness has the greatest link with child anxiety and can inform targeted treatment efforts.

Internet-delivered, family-based treatment for early-onset OCD: a preliminary case series

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as "excellent." The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

Direct-to-consumer marketing of psychological treatments for anxiety disorders

Progress disseminating and implementing evidence-based psychological treatments (EBPTs) for the anxiety disorders has been gradual. To date, the dominant approach for promoting the uptake of EBPTs in clinical settings has been to target the education and training of mental health providers, with many consumers remaining unaware of the potential benefits of EBPTs for anxiety disorders. Direct-to-consumer (DTC) marketing may be a promising vehicle for increasing EBPT utilization rates in the treatment of anxiety disorders. This paper provides an overview of the rationale and important considerations for applying DTC efforts to promote evidence-based care in the treatment of anxiety disorders, and reviews current DTC efforts in this area, including resources on the Internet and other media and in-person events. We conclude with recommendations for future efforts in the DTC marketing of EBPTs for the anxiety disorders, including the need for increased funding and grassroots efforts to inform consumers about anxiety disorders and their most effective treatments.

Evaluation of the proposed social anxiety disorder specifier change for DSM-5 in a treatment-seeking sample of anxious youth

BACKGROUND

The current proposal for the DSM-5 definition of social anxiety disorder (SAD) is to replace the DSM-IV generalized subtype specifier with one that specifies fears in performance situations only. Relevant evaluations to support this change in youth samples are sparse.

METHODS

The present study examined rates and correlates of the DSM-IV and proposed DSM-5 specifiers in a sample of treatment-seeking children and adolescents with SAD (N = 204).

RESULTS

When applying DSM-IV subtypes, 64.2% of the sample was classified as having a generalized subtype of SAD, with the remaining 35.2% classifying as having a nongeneralized subtype SAD. Youth with generalized SAD, relative to those with nongeneralized SAD, were older, had more clinically severe SAD, showed greater depressive symptoms, and were more likely to have a comorbid depressive disorder. No children in the current sample endorsed discrete fear in performance situations only in the absence of fear in other social situations.

CONCLUSIONS

The present findings call into question the meaningfulness of the proposed changes in treatment-seeking youth with SAD.

Co-occurring posttraumatic stress and depression symptoms after sexual assault: a latent profile analysis

BACKGROUND

Symptoms of posttraumatic stress disorder (PTSD) and depression frequently co-occur, but their distinctiveness following trauma remains unclear. We examined patterns of PTSD and depression symptoms after sexual assault to evaluate the extent to which assault survivors primarily reported symptoms of both disorders or whether there were meaningfully distinct subgroups with discordant PTSD and depression symptoms.

METHODS

Latent profile analysis was used to examine self-reported PTSD and depression symptoms among 119 female sexual assault survivors at 1-, 2-, 3-, and 4-months post-assault.

RESULTS

At all time points, a 4-class solution fit the data best, revealing four subgroups with low, low-moderate, high-moderate, and severe levels of both PTSD and depression symptoms. Within each subgroup, PTSD symptom severity co-occurred with comparable depression symptom severity. At no time point were there reliable subgroups with discordant PTSD and depression symptom severities. Emotional numbing, hyperarousal, and overall PTSD symptom severity reliably distinguished each class from the others. Class membership at 1-month post-assault predicted subsequent class membership and functional impairment.

LIMITATIONS

Additional research is needed to evaluate predictors of class membership, temporal stability of classes, and generalizability to other trauma populations.

CONCLUSIONS

Co-occurring and comparably severe PTSD and depression symptoms are pervasive among female sexual assault survivors. The absence of a distinct subset of individuals with only PTSD or depression symptoms suggests that PTSD and depression may be manifestations of a general posttraumatic stress response rather than distinct disorders after trauma. Integrated treatments targeting both PTSD and depression symptoms may therefore prove more efficient and effective.

Psychosocial treatment efficacy for disruptive behavior problems in very young children: a meta-analytic examination

OBJECTIVE

Service use trends showing increased off-label prescribing in very young children and reduced psychotherapy use raise concerns about quality of care for early disruptive behavior problems. Meta-analysis can empirically clarify best practices and guide clinical decision making by providing a quantitative synthesis of a body of literature, identifying the magnitude of overall effects across studies, and determining systematic factors associated with effect variations.

METHOD

We used random-effects meta-analytic procedures to empirically evaluate the overall effect of psychosocial treatments on early disruptive behavior problems, as well as potential moderators of treatment response. Thirty-six controlled trials, evaluating 3,042 children, met selection criteria (mean sample age, 4.7 years; 72.0% male; 33.1% minority youth).

RESULTS

Psychosocial treatments collectively demonstrated a large and sustained effect on early disruptive behavior problems (Hedges' g = 0.82), with the largest effects associated with behavioral treatments (Hedges' g = 0.88), samples with higher proportions of older and male youth, and comparisons against treatment as usual (Hedges' g = 1.17). Across trials, effects were largest for general externalizing problems (Hedges' g = 0.90) and problems of oppositionality and noncompliance (Hedges' g = 0.76), and were weakest, relatively speaking, for problems of impulsivity and hyperactivity (Hedges' g = 0.61).

CONCLUSIONS

In the absence of controlled trials evaluating psychotropic interventions, findings provide robust quantitative support that psychosocial treatments should constitute first-line treatment for early disruptive behavior problems. Against a backdrop of concerning trends in the availability and use of supported interventions, findings underscore the urgency of improving dissemination efforts for supported psychosocial treatment options, and removing systematic barriers to psychosocial care for affected youth.

Specifying child anxiety disorders not otherwise specified in the DSM-IV

BACKGROUND

Anxiety disorder not otherwise specified (ADNOS) is one of the more common and impairing DSM-IV diagnoses assigned in child practice settings, but it is not clear what percentage of these assignments simply reflect poor diagnostic practices.

METHODS

The present study evaluated patterns and correlates of child ADNOS in a large outpatient treatment seeking sample of anxious youth (N = 650), utilizing structured diagnostic interviewing procedures.

RESULTS

Roughly, 15% of youth met diagnostic criteria for ADNOS. Overall, these youth exhibited comparable levels of clinical problems relative to youth with DSM-IV-specified anxiety disorders (AD), and roughly two-thirds of ADNOS cases exhibited symptom presentations closely resembling generalized anxiety disorder (GAD). Among ADNOS presentations resembling GAD, those failing to meet the "worries more days than not" or "worries across multiple domains" criteria showed lower internalizing symptoms than GAD youth, but comparable anxious/depressed symptoms, somatic symptoms, social problems, externalizing problems, and total problems as measured by the Child Behavior Checklist.

CONCLUSIONS

Childhood ADNOS cases are prevalent and warrant clinical attention. In many cases there are only a couple, if any, clinical differences between these disorders and the ADs they closely resemble. Future work is needed to improve upon the current taxonomy of childhood ADs to specify a larger proportion of affected youth needing care.

Generalized anxiety disorder and the proposed associated symptoms criterion change for DSM-5 in a treatment-seeking sample of anxious youth

BACKGROUND

A current proposal for the DSM-5 general anxiety disorder (GAD) definition is to remove fatigue, difficulty concentrating, irritability, and sleep disturbance from the list of associated symptoms, and to require the presence of one of two retained symptoms (restlessness or muscle tension) for diagnosis. Relevant evaluations in youth to support such a change are sparse.

METHODS

The present study evaluated patterns and correlates of the DSM-IV GAD associated symptoms in a large outpatient sample of anxious youth (N = 650) to empirically consider how the proposed diagnostic change might impact the prevalence and sample composition of GAD in children.

RESULTS

Logistic regression found irritability to be the most associated, and restlessness to be the least associated, with GAD diagnosis. Fatigue, difficulty concentrating, and sleep disturbances-which have each been suggested to be nonspecific to GAD due to their prevalence in depression-showed sizable associations with GAD even after accounting for depression and attention problems. Among GAD youth, 10.9% would not meet the proposed DSM-5 associated symptoms criterion. These children were comparable to GAD youth who would meet the proposed criteria with regard to clinical severity, symptomatology, and functioning.

CONCLUSIONS

A substantial proportion of youth with excessive, clinically impairing worry may be left unclassified by the DSM-5 if the proposed GAD associated symptoms criterion is adopted. Despite support for the proposed criterion change in adult samples, the present findings suggest that in children it may increase the false negative rate. This calls into question whether the proposed associated symptoms criterion is optimal for defining childhood GAD.

The reciprocal relationship between alliance and symptom improvement across the treatment of childhood anxiety

This study examined changes in the therapeutic alliance and in self-reported anxiety over the course of 16 weeks of manual-based family treatment for child anxiety disorders. Eighty-six children (51.3% female; aged 7.15-14.44; 86.2% Caucasian, 14.8% minority) with a principal diagnosis of separation anxiety disorder, generalized anxiety disorder, and/or social phobia, and their parents, received family treatment for anxiety disorders in youth. Child, therapist, and parent ratings of therapeutic alliance and child ratings of state anxiety were measured each session. Latent difference score growth modeling investigated the interacting relationship. Therapeutic alliance change, as rated by the mother and by the therapist, was a significant predictor (medium effect) of latter change in child anxiety (with greater therapeutic alliance leading to later reduction in anxiety). However, changes in child-reported anxiety also predicted latter change in father- and therapist-reported alliance (small-to-medium effect). Prospective relationships between child-reported therapeutic alliance and child-reported symptom improvement were not significant. Results provide partial support for a reciprocal model in which therapeutic alliance improves outcome, and anxiety reduction improves therapeutic alliance.

Adapting parent-child interaction therapy to treat anxiety disorders in young children

Anxiety disorders are prevalent in children 7 years and younger; however, these children generally do not possess developmental skills required in cognitive behavior treatment. Recent efforts have adapted parent-child interaction therapy (PCIT), originally developed for disruptive and noncompliant behavior, for young children with anxiety. This article reviews the principles underlying PCIT and the rationale for adapting it to target anxiety symptoms. The authors describe two related treatment approaches that have modified PCIT to treat anxiety: (1) Pincus and colleagues' treatment for separation anxiety, and (2) Puliafico, Comer, and Albano's CALM Program for the range of early child anxiety disorders.

A pilot feasibility evaluation of the CALM Program for anxiety disorders in early childhood

As many as 9% of preschoolers suffer from an anxiety disorder, and earlier onset of disorder is associated with more intractable forms of psychopathology in later life. At present there is a relative dearth of empirical work examining the development of evidence-based treatments for anxiety disorders presenting in early childhood. Building on previous work supporting extensions of PCIT for separation anxiety disorder, the present study examines the preliminary feasibility and efficacy of an anxiety-based modification of PCIT (The CALM Program; Coaching Approach behavior and Leading by Modeling) for the treatment of youth between the ages of three and eight presenting with separation anxiety disorder, social anxiety disorder, generalized anxiety disorder, and/or specific phobias (N=9; M(age)=5.4 years, ranging 4-8 years; 55.6% of families endorsing racial or ethnic minority status). Intent-to-treat (ITT; N=9) and treatment completer (N=7) analyses were conducted to evaluate diagnostic and functional response across participants. Pre- and posttreatment structured diagnostic interviews were conducted (ADIS-C/P), and clinical impression measures were completed (e.g., CGI, CGAS). Roughly 80% of the sample completed all treatment sessions. All treatment completers were categorized as global treatment responders by independent evaluators, with all but one showing full diagnostic improvements, and all but one showing meaningful functional improvements. These findings lend preliminary support for the promising role of live parent coaching for the treatment of a range of anxiety disorders that present in early childhood. Future work is needed to replicate the present findings in larger samples utilizing randomized controlled comparisons.

National trends in the antipsychotic treatment of psychiatric outpatients with anxiety disorders

OBJECTIVE

The purpose of the present study was to examine patterns and recent trends in the antipsychotic medication treatment of anxiety disorders among visits to office-based psychiatrists in the United States.

METHOD

Annual data from the 1996-2007 National Ambulatory Medical Care Survey were analyzed to examine the patterns and trends in antipsychotic medication treatment within a nationally representative sample of 4,166 visits to office-based psychiatrists in which an anxiety disorder was diagnosed.

RESULTS

Across the 12-year period, antipsychotic prescriptions in visits for anxiety disorders increased from 10.6% (1996-1999) to 21.3% (2004-2007). Over the study period, the largest increase in antipsychotic prescribing occurred among new patient visits. Antipsychotic prescribing also significantly increased among privately insured visits and visits in which neither antidepressants nor sedative/hypnotics were prescribed. Among the common anxiety disorder diagnoses, the largest increase in antipsychotic medication treatment was observed in visits for panic disorder. Antipsychotic prescribing rose from 6.9% (1996-1999) to 14.5% (2004-2007) among visits for anxiety disorders in which there were no co-occurring diagnoses with an indication approved by the Food and Drug Administration for antipsychotic medications.

CONCLUSIONS

Although little is known about their effectiveness for anxiety disorders, antipsychotic medications are becoming increasingly prescribed to psychiatric outpatients with these disorders.