Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V

Changes in genetic and environmental influences on trait anxiety ćfrom middle adolescence to early adulthood

BACKGROUND

Middle adolescence to early adulthood is an important developmental period for the emergence of anxiety. Genetically-influenced stable traits are thought to underlie internalizing psychopathology throughout development, but no studies have examined changes in genetic and environmental influences on trait anxiety during this period.

METHOD

A longitudinal twin study design was used to study same-sex twin pairs (485 monozygotic pairs, 271 dizygotic pairs) at three ages, 14, 18, and 21 years, to examine developmental shifts in genetic and environmental effects on trait anxiety.

RESULTS

The heritability of trait anxiety increased with age, particularly between ages 14 and 18, no significant new genetic influences emerged after age 14, and the genetic influences were highly correlated across the three ages, supporting developmentally stable genetic risk factors. The environmental effects shared by members of a family decreased in influence across adolescence, while the influence of environmental effects unique to each individual twin remained relatively stable over the course of development and were largely age-specific.

LIMITATIONS

The twin study design does not inform about specific genes and environmental risk factors.

CONCLUSIONS

Genetic influences increased in importance from middle to late adolescence but common genetic factors influenced trait anxiety across the three ages. Shared environmental influences decreased in importance and demonstrated negligible influence by late adolescence/early adulthood. Nonshared environmental effects were almost entirely age-specific. These findings support the importance of developmentally-sensitive interventions that target shared environmental factors prior to middle adolescence and shifting non-shared environmental risks at each age.

Reliability and validity of the Arabic Screen for Child Anxiety Related Emotional Disorders (SCARED) in a clinical sample

This study aimed at investigating the reliability and validity of the Arabic Screen for Child Anxiety Related Emotional Disorders (SCARED) as a first child and adolescent anxiety screening tool in the Arab World. The English parent (SCARED-P) and child (SCARED-C) versions were translated into Arabic and administered along with the Arabic Strengths and Difficulties Questionnaire (SDQ) to 77 parents and 67 children attending a Psychiatry clinic. DSM-IV-TR diagnoses were made by a psychiatrist without knowledge of the scale scores. Internal consistency was confirmed by Cronbach's α=0.92 for SCARED-P and 0.91 for SCARED-C. Their subscales had internal consistencies between 0.65 and 0.89. Parent-child agreement was r=0.67, p<0.001. SCARED-P demonstrated good discriminant validity between participants with anxiety disorders and those with other psychiatric disorders (t(72)=3.13, p=0.003). For SCARED-C, this difference was significant when participants with depressive disorders were excluded (t(43)=2.58, p=0.01). Convergent validity was evident through a significant correlation between SCARED-P and the parent SDQ emotional subscale (r=0.70, p<0.001), and SCARED-C and the child SDQ emotional subscale (r=0.70, p<0.001). Divergent validity with the SDQ hyperactivity subscale was observed as no significant correlation was found. Overall, the Arabic SCARED demonstrated satisfactory psychometric properties in a clinical sample in Lebanon.

Psychological, immunological and physiological effects of a Laughing Qigong Program (LQP) on adolescents

OBJECTIVES

One objective of this study was to assess the effects of laughter on the psychological, immunological and physiological systems of the body. Another objective was to introduce the Laughing Qigong Program (LQP), as a method of standardization for simulated laughter interventions.

DESIGN

A randomized, prospective, experimental study of the LQP was conducted in a group of adolescents (n=67) in Taiwan. During study-hall sessions, experimental subjects (n=34) attended the LQP for eight-weeks. Simultaneously, control subjects (n=33) read or did their homework. All subjects were tested before and after the intervention on the following: Rosenberg Self-Esteem scale (RSE), Chinese Humor Scale (CHS) and Face Scale (FS) as psychological markers; saliva cortisol (CS) as an immunological marker; blood pressure (BP), heart rate (HR), and heart rate variability (HRV) as physiological markers of the body's response to stress. Mood states (FS) were measured before/after each LQP session.

RESULTS

Mood states (p=.00) and humor (p=.004; p=.003) improved in the experimental group; no significant changes were found in the controls (p=69; p=60). The immunological marker of stress, cortisol levels, decreased significantly for those who participated in the LQP (p=.001), suggesting lower levels of stress after completion of the program.

CONCLUSIONS

The LQP is a non-pharmacological and cost-effective means to help adolescents mitigate stresses in their everyday life.

Early developmental emergence of human amygdala-prefrontal connectivity after maternal deprivation

Under typical conditions, medial prefrontal cortex (mPFC) connections with the amygdala are immature during childhood and become adult-like during adolescence. Rodent models show that maternal deprivation accelerates this development, prompting examination of human amygdala-mPFC phenotypes following maternal deprivation. Previously institutionalized youths, who experienced early maternal deprivation, exhibited atypical amygdala-mPFC connectivity. Specifically, unlike the immature connectivity (positive amygdala-mPFC coupling) of comparison children, children with a history of early adversity evidenced mature connectivity (negative amygdala-mPFC coupling) and thus, resembled the adolescent phenotype. This connectivity pattern was mediated by the hormone cortisol, suggesting that stress-induced modifications of the hypothalamic-pituitary-adrenal axis shape amygdala-mPFC circuitry. Despite being age-atypical, negative amygdala-mPFC coupling conferred some degree of reduced anxiety, although anxiety was still significantly higher in the previously institutionalized group. These findings suggest that accelerated amygdala-mPFC development is an ontogenetic adaptation in response to early adversity.

Translational neuroscience measures of fear conditioning across development: applications to high-risk children and adolescents

Several mental illnesses, including anxiety, can manifest during development, with onsets in late childhood. Understanding the neurobiological underpinnings of risk for anxiety is of crucial importance for early prevention and intervention approaches. Translational neuroscience offers tools to investigate such mechanisms in human and animal models. The current review describes paradigms derived from neuroscience, such as fear conditioning and extinction and overviews studies that have used these paradigms in animals and humans across development. The review also briefly discusses developmental trajectories of the relevant neural circuits and the emergence of clinical anxiety. Future studies should focus on developmental changes in these paradigms, paying close attention to neurobiological and hormonal changes associated with childhood and adolescence.

Neuroanatomic abnormalities in adolescents with generalized anxiety disorder: a voxel-based morphometry study

BACKGROUND

Despite recent data implicating functional abnormalities in the neurocircuitry underlying emotional processing in pediatric anxiety disorders, little is known regarding neurostructural abnormalities within these systems.

METHODS

Using voxel-based morphometry, gray and white matter volumes were compared in 15 medication-free adolescents with generalized anxiety disorder (GAD; and no comorbid major depressive disorder) and 28 age- and sex-matched healthy comparison subjects.

RESULTS

Compared to healthy adolescents, youth with GAD had larger gray matter volumes in the right precuneus and right precentral gyrus and decreased gray matter volumes in the left orbital gyrus and posterior cingulate. White matter volumes were decreased in the left medial and superior frontal gyrus and were increased in the left inferior temporal gyrus in youth with GAD relative to healthy subjects.

CONCLUSIONS

Adolescents with GAD, who are early in the course of their illness, exhibit abnormalities in neural structures that subserve threat appraisal, modulation of fear responses, attachment, and mentalization.

Reliability, validity, and clinical use of the Dominic Interactive: a DSM-based, self-report screen for school-aged children

OBJECTIVES

As no single informant can be considered the gold standard of child psychopathology, interviewing of children regarding their own symptoms is necessary. Our study focused on the reliability, validity, and clinical use of the Dominic Interactive (DI), a multimedia self-report screen to assess symptoms for the most frequent Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, mental disorders in school-aged children.

METHODS

A sample of 585 children aged 6 to 11 years from the community and psychiatric clinics was used to analyze the internal consistency, the test-retest estimate of reliability, and the criterion-related validity of the DI against the referral status. In addition, cross-informant correlation coefficients between this instrument (child report) and the Child Symptom Inventory (parent report) were explored in a subsample of 292 participants.

RESULTS

For the total sample, Cronbach alpha coefficients ranged from 0.63 to 0.91. Test-retest kappas varied from 0.42 to 0.62 for categories based on cut-off points, except for specific phobias. Intraclass correlation coefficients ranged from 0.70 to 0.81 for symptom scales. The DI discriminated between referred and non-referred children in psychiatric clinics for all symptom scales. Significant cross-informant correlation coefficients were higher for the externalizing symptoms (0.35 to 0.48) than the internalizing symptoms (0.14 to 0.27).

CONCLUSIONS

Findings of our study reasonably support adequate psychometric properties of the DI. This instrument offers a developmentally sensitive screening method to obtain unique information from young children about their mental health problems in front-line services, psychiatric clinics, and research settings.

Impact of early adolescent anxiety disorders on self-esteem development from adolescence to young adulthood

PURPOSE

To examine the association between early adolescent anxiety disorders and self-esteem development from early adolescence through young adulthood.

METHODS

Self-esteem was measured at mean ages 13, 16, and 22 for 821 participants from the Children in the Community Study, a population-based longitudinal cohort. Anxiety disorders were measured at mean age 13 years. Multilevel growth models were employed to analyze the change in self-esteem from early adolescence to young adulthood and to evaluate whether adolescent anxiety disorders predict both average and slope of self-esteem development.

RESULTS

Self-esteem increased during adolescence and continued to increase in young adulthood. Girls had lower average self-esteem than boys, but this difference disappeared when examining the effect of anxiety. Adolescents with anxiety disorder had lower self-esteem, on average, compared with healthy adolescents (effect size [ES] = -.35, p < .01). Social phobia was found to have the greatest relative impact on average self-esteem (ES = -.30, p < .01), followed by overanxious disorder (ES = -.17, p < .05), and simple phobia (ES = -.17, p < .05). Obsessive compulsive-disorder (OCD) predicted a significant decline in self-esteem from adolescence to young adulthood (β = -.1, p < .05). Separation anxiety disorder was not found to have any significant impact on self-esteem development.

CONCLUSIONS

All but one of the assessed adolescent anxiety disorders were related to lower self-esteem, with social phobia having the greatest impact. OCD predicted a decline in self-esteem trajectory with age. The importance of raising self-esteem in adolescents with anxiety and other mental disorders is discussed.

Prevalence, comorbidity and predictors of anxiety disorders in children and adolescents in rural north-eastern Uganda

BACKGROUND

Child and adolescent anxiety disorders are the most prevalent form of childhood psychopathology. Research on child and adolescent anxiety disorders has predominantly been done in westernized societies. There is a paucity of data on the prevalence, comorbidity, and predictors of anxiety disorders in children and adolescents in non-western societies including those in sub-Saharan Africa. This paper investigates the prevalence, comorbidity, and predictors of anxiety disorders in children and adolescents in north-eastern Uganda.

OBJECTIVE

To determine the prevalence of DSM-IV anxiety disorders, as well as comorbidity patterns and predictors in children and adolescents aged 3 to 19 years in north-eastern Uganda.

METHODS

Four districts (Lira, Tororo, Kaberamaido and Gulu) in rural north-eastern Uganda participated in this study. Using a multi-stage sampling procedure, a sample of 420 households with children aged 3-19 years from each district was enrolled into the study. The MINI International Neuropsychiatric Interview for children and adolescents (MINI KID) was used to assess for psychiatric disorders in 1587 of 1680 respondents.

RESULTS

The prevalence of anxiety disorders was 26.6%, with rates higher in females (29.7%) than in males (23.1%). The most common disorders in both males and females were specific phobia (15.8%), posttraumatic stress disorder (PTSD) (6.6%) and separation anxiety disorder (5.8%). Children below 5 years of age were significantly more likely to have separation anxiety disorder and specific phobias, while those aged between 14-19 were significantly more likely to have PTSD. Anxiety disorders were more prevalent among respondents with other psychiatric disorders; in respondents with two or more co-morbid psychiatric disorders the prevalence of anxiety disorders was 62.1%. Predictors of anxiety disorders were experience of war trauma (OR = 1.93, p < 0.001) and a higher score on the emotional symptom scale of the SDQ (OR = 2.58, p < 0.001). Significant socio-demograghic associations of anxiety disorders were found for female gender, guardian unemployment, living in permanent housing, living without parents, and having parents without education.

CONCLUSION

The prevalence of anxiety disorders in children and adolescents in rural north-eastern Uganda is high, but consistent in terms of gender ratio and progression over time with a range of prior work in other contexts. Patterns of comorbidity and predictors of anxiety disorders in this setting are also broadly consistent with previous findings from western community studies. Both psychosocial stressors and exposure to war trauma are significant predictors of anxiety disorders.Prevention and treatment strategies need to be put in place to address the high prevalence rates of anxiety disorders in children and adolescents in Uganda.

Pregabalin for the treatment of generalized anxiety disorder: an update

A PREVIOUS REVIEW SUMMARIZED WHAT WAS THEN KNOWN ABOUT THE POTENTIAL ROLE OF PREGABALIN IN THE TREATMENT OF PATIENTS WITH GENERALIZED ANXIETY DISORDER (GAD): this review provides an update on its pharmacological properties and presumed mechanism of action, the liability for abuse, and efficacy and tolerability in patients with GAD. Pregabalin has a similar molecular structure to the inhibitory neurotransmitter gamma amino butyric acid (GABA) but its mechanism of action does not appear to be mediated through effects on GABA. Instead, its anxiolytic effects may arise through high-affinity binding to the alpha-2-delta sub-unit of the P/Q type voltage-gated calcium channel in "over-excited" presynaptic neurons, thereby reducing the release of excitatory neurotransmitters such as glutamate. The findings of randomized controlled trials and meta-analyses together indicate that pregabalin is efficacious in both acute treatment and relapse prevention in GAD, with some evidence of an early onset of effect, and broad efficacy in reducing the severity of psychological and physical symptoms of anxiety. It also has efficacy as an augmenting agent after non-response to antidepressant treatment in GAD. Continuing vigilance is needed in assessing its potential abuse liability but the tolerability profile of pregabalin may confer some advantages over other pharmacological treatments in the short term for treatment in patients with GAD.

Patterns and predictors of anxiety among siblings of children with autism spectrum disorders

The purpose of this study was to examine patterns of anxiety among siblings of children with autism spectrum disorders (ASD), and determine the characteristics of the child with ASD and their parents that predicted anxiety. Data was collected from 1,755 siblings of children with ASD whose families participated in the Simons Simplex Collection; siblings ranged in age from 3 to 18 years (M = 9 years). Male siblings were at increased risk for sub-clinical anxiety problems during middle childhood. Parental history of anxiety disorders, higher maternal pragmatic language, and more proband behavior problems predicted higher anxiety. While siblings overall did not show elevated anxiety symptoms, higher rates of sub-clinical anxiety problems among males and siblings in middle childhood are cause for concern.

A developmental shift from positive to negative connectivity in human amygdala-prefrontal circuitry

Recent human imaging and animal studies highlight the importance of frontoamygdala circuitry in the regulation of emotional behavior and its disruption in anxiety-related disorders. Although tracing studies have suggested changes in amygdala-cortical connectivity through the adolescent period in rodents, less is known about the reciprocal connections within this circuitry across human development, when these circuits are being fine-tuned and substantial changes in emotional control are observed. The present study examined developmental changes in amygdala-prefrontal circuitry across the ages of 4-22 years using task-based functional magnetic resonance imaging. Results suggest positive amygdala-prefrontal connectivity in early childhood that switches to negative functional connectivity during the transition to adolescence. Amygdala-medial prefrontal cortex functional connectivity was significantly positive (greater than zero) among participants younger than 10 years, whereas functional connectivity was significantly negative (less than zero) among participants 10 years and older, over and above the effect of amygdala reactivity. The developmental switch in functional connectivity was paralleled by a steady decline in amygdala reactivity. Moreover, the valence switch might explain age-related improvement in task performance and a developmentally normative decline in anxiety. Initial positive connectivity followed by a valence shift to negative connectivity provides a neurobiological basis for regulatory development and may present novel insight into a more general process of developing regulatory connections.

Dimensional anxiety scales for DSM-5: sensitivity to clinical severity

PURPOSE

Psychometric properties and clinical sensitivity of brief self-rated dimensional scales to supplement categorical diagnoses of anxiety disorders in the DSM-5 were recently demonstrated in a German treatment seeking sample of adults. The present study aims to demonstrate sensitivity of these scales to clinical severity levels.

METHODS

The dimensional scales were administered to 102 adults at a university outpatient clinic for psychotherapy. Diagnostic status was assessed using the Munich-Composite International Diagnostic Interview. To establish a wide range of clinical severity, we considered subthreshold (n=83) and threshold anxiety disorders (n=49, including Social Phobia, Specific Phobia, Agoraphobia, Panic Disorder, and Generalized Anxiety Disorder).

RESULTS

Individuals with either subthreshold or threshold anxiety disorder scored higher on all dimensional scales relative to individuals without anxiety. In addition, individuals with a threshold anxiety disorder scored higher on the dimensional scales than individuals with a subthreshold anxiety disorder (except for specific phobia). Disorder-related impairment ratings, global functioning assessments and number of panic attacks were associated with higher scores on dimensional scales. Findings were largely unaffected by the number of anxiety disorders and comorbid depressive disorders.

CONCLUSION

The self-rated dimensional anxiety scales demonstrated sensitivity to clinical severity, and a cut-off based on additional assessment of impairment and distress may assist in the discrimination between subthreshold and threshold anxiety disorders. Findings suggest further research in various populations to test the utility of the scales for use in DSM-5.

Exploring patterns in cortisol synchrony among anxious and nonanxious mother and child dyads: a preliminary study

Given that anxiety is highly familial, the current pilot study explored the association between anxiety diagnosis and diurnal cortisol rhythm in mother-child dyads with the hypothesis that a predisposition toward homogenous cortisol profiles may partially explain the familial linkage of anxiety. The role of family environment in stress response was also examined. Participants were 27 mother-child dyads. Results indicated that patterns of cortisol secretion between mother and child are synchronous. Maternal anxiety and aspects of family functioning significantly predicted child awakening cortisol pattern. Further, affective involvement and gender of the child significantly predicted mother-child diurnal cortisol secretion synchrony. These findings provide support for the degree of synchrony in patterns of physiological responsiveness between mother and child, as well as the importance of a child's affective environment in the prediction of a diagnosis of anxiety.

A developmental shift from positive to negative connectivity in human amygdala-prefrontal circuitry

Recent human imaging and animal studies highlight the importance of frontoamygdala circuitry in the regulation of emotional behavior and its disruption in anxiety-related disorders. Although tracing studies have suggested changes in amygdala-cortical connectivity through the adolescent period in rodents, less is known about the reciprocal connections within this circuitry across human development, when these circuits are being fine-tuned and substantial changes in emotional control are observed. The present study examined developmental changes in amygdala-prefrontal circuitry across the ages of 4-22 years using task-based functional magnetic resonance imaging. Results suggest positive amygdala-prefrontal connectivity in early childhood that switches to negative functional connectivity during the transition to adolescence. Amygdala-medial prefrontal cortex functional connectivity was significantly positive (greater than zero) among participants younger than 10 years, whereas functional connectivity was significantly negative (less than zero) among participants 10 years and older, over and above the effect of amygdala reactivity. The developmental switch in functional connectivity was paralleled by a steady decline in amygdala reactivity. Moreover, the valence switch might explain age-related improvement in task performance and a developmentally normative decline in anxiety. Initial positive connectivity followed by a valence shift to negative connectivity provides a neurobiological basis for regulatory development and may present novel insight into a more general process of developing regulatory connections.

Cognitive-behavioral group therapy for youths with anxiety disorders in the community: effectiveness in low and middle income countries

BACKGROUND

Although cognitive-behavioral therapy (CBT) is established as a first line treatment for anxiety disorders in children and adolescents, there is little evidence about the effectiveness of CBT protocols in cases identified in the community in low and middle income countries (LaMICs).

AIMS

To evaluate the effectiveness of group CBT protocol for youths with anxiety disorders identified in a community sample in LaMICs.

METHOD

A total of 14 sessions of group CBT for youths and 2 concurrent sessions for parents based on Kendall's Coping Cat program were offered. Participants were selected from a cross-sectional community study; 45 subjects fulfilled inclusion criteria and 28 agreed to participate in the open clinical trial. Treatment effectiveness was evaluated with standard clinical, self- and parent-rated measures of anxiety, depression, externalizing symptoms and quality of life (QoL).

RESULTS

Twenty youths completed the protocol. All scales showed an improvement of anxiety and reduction in externalizing symptoms over time, with a moderate to large effect size (d = 0.59 to 2.06; p < .05), but not in depressive symptoms or QoL.

CONCLUSIONS

Consistent with previous evidence, group CBT is effective in treating anxiety disorders in youths. Results encourage further randomized clinical trials using CBT protocols adapted and developed to be used in LaMICs.

Gender-Specific Developmental Trajectories of Anxiety during Adolescence: Determinants and Outcomes. The TRAILS Study

OBJECTIVE

To identify developmental trajectories of anxiety symptoms for adolescent girls and boys. Trajectories were compared with regard to early-adolescent risk factors and psychiatric outcomes during adolescence and in young adulthood.

METHOD

A community sample of 2,230 adolescents was assessed three times across a six-year interval (10-17 years). Symptom scores of anxiety were analyzed with growth mixture models, stratified by gender.

RESULTS

Three gender-specific anxiety trajectories were identified for both girls (93.3% low, 4.1% mid-adolescence limited, 2.6% mid-adolescence increasing) and boys (84.4% low, 9.5% mid-adolescence limited, 6.1% early-adolescence decreasing). Child, family and peer factors at baseline predicted group membership of the mid-adolescence limited anxiety trajectory and the early-adolescence decreasing anxiety trajectory in boys. Parental emotional problems predicted the early-adolescence anxiety increase trajectory in girls. Prevalence of anxiety disorders and depression during adolescence and in early adulthood was higher in both the mid-adolescence limited and the mid-adolescence anxiety increase trajectory.

CONCLUSIONS

The longitudinal course of anxiety symptoms during adolescence was characterized by three distinct gender-specific developmental trajectories. The most at-risk trajectory in girls was the mid-adolescence anxiety increase trajectory, and in boys the mid-adolescence limited trajectory. None of the environmental (i.e., child, family and peer) factors distinguished the at-risk trajectories from the other trajectories.

Anxiety disorders

With the adoption of a developmental psychopathology perspective, the DSM-5 translates empirical evidence on the continuity of childhood anxiety disorders into diagnostic practice, thereby completing a process that started with the exclusion of the former childhood anxiety disorders overanxious disorder and avoidant disorder from DSM-III to DSM-IV. This change in perspective, however, leads to a low level of concordance between the DSM-5 and ICD-10. To reliably identify anxiety disorders at different points in development, and to take into account their developmental pathways, assessment instruments need to be sensitive to age-related manifestations and age-related subtypes of a disorder. This may best be achieved by a multi-informant, multi-method assessment approach. With regard to treatment, only cognitive-behavioral therapy (CBT) fulfills the criteria of an evidence-based treatment approach in youth. Disorder-specific treatments can lead to larger treatment effects and slightly higher remission rates as compared to more general treatment programs for childhood anxiety disorders (e.g., Coping Cat). Parental involvement seems not to add to treatment success. In conclusion, the evidence-based diagnostic approach of the DSM-5 needs to be complemented by the development and evaluation of child-friendly, developmentally sensitive assessment tools and evidence-based treatments for anxiety disorders in children. With regard to diagnostic concordance, the gap between the DSM-5 and ICD-10 needs to be bridged by more closely aligning the two nosological systems.

Preschool anxiety disorders: comprehensive assessment of clinical, demographic, temperamental, familial, and life stress correlates

This study examined correlates of preschoolers' anxiety disorders using a comprehensive, multimethod design. Participants included a community sample of 541 three-year-old children, of whom 106 (19.6%) met criteria for at least 1 anxiety disorder. Child and parental psychopathology and life stress were assessed with clinical interviews. Child temperament and parenting behavior were assessed with laboratory observations. Mothers and fathers reported on their parenting styles. Compared to preschoolers with no anxiety disorder, preschoolers with an anxiety disorder were more likely to meet criteria for comorbid depressive and oppositional defiant disorders and to exhibit greater temperamental behavioral inhibition and lower positive affectivity, and more sleep problems. Children with anxiety disorders also experienced more stressful life events in the previous 6 months, and their mothers had a higher rate of current anxiety disorders. Compared to children with other anxiety disorders, children with only specific phobia exhibited a somewhat different pattern of associations than children with other anxiety disorders. Overall, the findings suggest that many of the correlates observed in older youth with anxiety disorders are also observed in preschoolers.

Treatment of anxiety in children and adolescents: using child and adolescent anxiety psychodynamic psychotherapy

This article presents information on child and adolescent psychodynamic psychotherapy (CAPP). Following a definition of anxiety, the authors present study outcomes of nonpsychodynamic treatment approaches, alone and in combination with psychopharmacologic treatment, then explore psychodynamic approaches. A detailed overview of psychodynamic psychotherapy is presented, along with 2 cases illustrating the use of CAPP in young patients with anxiety. Also presented are tables and boxes summarizing CAPP therapeutic processes and strategies as intervention for anxious youth.

Specific phobia among U.S. adolescents: phenomenology and typology

BACKGROUND

Investigators have proposed the diagnostic value of a generalized subtype of specific phobia, with classification based upon the number of phobic fears. However, current and future typologies of specific phobia classify the condition by the nature of phobic fears. This study investigated the clinical relevance of these alternative typologies by: (1) presenting the prevalence and correlates of specific phobia separately by the number and nature of phobia types; and (2) examining the clinical and psychiatric correlates of specific phobia according to these alternative typologies.

METHODS

The National Comorbidity Survey Replication-Adolescent Supplement (NCS-A) is a nationally representative face-to-face survey of 10,123 adolescents aged 13-18 years in the continental United States.

RESULTS

Most adolescents with specific phobia met criteria for more than one type of phobia in their lifetime, however rates were fairly similar across DSM-IV/5 subtypes. Sex differences were consistent across DSM-IV/5 subtypes, but varied by the number of phobic types, with a female predominance observed among those with multiple types of phobias. Adolescents with multiple types of phobias exhibited an early age of onset, elevated severity and impairment, and among the highest rates of other psychiatric disorders. However, certain DSM-IV/5 subtypes (i.e. blood-injection-injury and situational) were also uniquely associated with severity and psychiatric comorbidity.

CONCLUSIONS

Results indicate that both quantitative and DSM-IV/5 typologies of specific phobia demonstrate diagnostic value. Moreover, in addition to certain DSM-IV/5 subtypes, a generalized subtype based on the number of phobias may also characterize youth who are at greatest risk for future difficulties.

Psychometric properties of the dimensional anxiety scales for DSM-V in an unselected sample of German treatment seeking patients

BACKGROUND

Dimensional assessments are planned to be included as supplements to categorical diagnoses in DSM-V. The aim of this study was to examine the unidimensionality, reliability, validity, and clinical sensitivity of brief self-rated scales for specific anxiety disorders in an unselected German sample of consecutive attendees to a psychological clinic. These scales use a common template to assess core constructs of fear and anxiety.

METHODS

Dimensional scales for social anxiety disorder, specific phobia, agoraphobia, panic disorder, and generalized anxiety disorder were administered along with established scales to 102 adults seeking treatment for mental health problems at a German university outpatient clinic for psychotherapy. The computer-assisted clinical version of the Munich-Composite International Diagnostic Interview was used to assess mental disorders according to DSM-IV criteria. Dimensionality and scale reliability were examined using confirmatory factor analyses. Convergent and discriminant validity were examined by testing differences in the size of correlations between each dimensional anxiety scale and each of the previously validated scales. Each dimensional scale's ability to correctly differentiate between individuals with versus without an anxiety diagnosis was examined via the area under the curve.

RESULTS

Analyses revealed unidimensionality for each scale, high reliability, and convergent and discriminant validity. Classification performance was good to excellent for all scales except for specific phobia.

CONCLUSIONS

The application of the dimensional anxiety scales may be an effective way to screen for specific anxiety disorders and to supplement categorical diagnoses in DSM-V, although further evaluation and refinement of the scales (particularly the specific phobia scale) is needed.

Pediatric social anxiety disorder: predictors of response to pharmacological treatment

OBJECTIVE

Pediatric social anxiety disorder (SAD) is associated with an increased risk of comorbid mental disorders, with implications for prognosis and treatment strategy. The aim of this study is to explore predictors of treatment response, and the role of comorbidity in affecting refractoriness.

METHODS

One hundred and forty consecutive youths (81 males, 57.9%), ages 7-18 years (mean age 13.7 ± 2.5 years, mean age at onset of SAD 10.6 ± 2.7 years) met American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) criteria for SAD as primary diagnosis, according to a structured clinical interview (Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime Version [K-SADS-PL]). All received a pharmacological treatment with serotonin reuptake inhibitors (SSRIs) targeted to SAD, associated with additional medications for comorbidities (mood stabilizers in 27.1%, antipsychotics in 12.8%) and 57.9% received an additional psychotherapy.

RESULTS

Eighty-nine patients (63.6%) responded to treatments after 3 months, namely 72.8% with psychotherapy plus medication and 50.8% with medication only. Nonresponders had more severe symptoms at baseline in terms of both clinical severity and functional impairment, and had more comorbid disruptive behavior disorders. The backward logistic regression indicated that clinical severity and functional impairment at baseline, comorbid disruptive behavior disorders, and bipolar disorders were predictors of nonresponse.

CONCLUSION

Our data suggest that SSRIs can be effective in pediatric SAD, but that the more severe forms of the disorder and those with heavier comorbidity are associated with poorer prognosis.

Developmental changes of rhesus monkeys in response to separation from the mother

The development of separation response behaviors in infant rhesus macaques across the first 6 months of life was assessed. Seventeen infants underwent a neonatal assessment at 7, 14, 21, and 30 days of age which included a brief period of social isolation. At 3 and 6 months of age these same monkeys and four additional subjects were again subjected to a period of brief social isolation and also exposed to a novel environment with their sedated mother. Results indicate a developmental increase followed by a steady decline in the frequency of separation vocalizations. A modest relationship between early-infancy locomotor profiles and separation responses was also observed at several time points suggesting a possible relationship between these measures. However, stable inter-individual measures of separation distress did not emerge until late in the infantile period. This could suggest that high levels of maternal contact-seeking behavior early in infancy are context specific and not a reliable index of enduring temperament.

Neurocircuitry of generalized anxiety disorder in adolescents: a pilot functional neuroimaging and functional connectivity study

BACKGROUND

Dysfunction of neural systems responsible for the processing of emotional stimuli is hypothesized to be involved in the pathophysiology of generalized anxiety disorder (GAD) in adolescents. We used standard fMRI and functional connectivity analyses to examine the functional neurocircuitry of GAD in adolescents.

METHODS

Ten adolescents with GAD and 10 healthy comparison subjects underwent fMRI while performing a continuous performance task with emotional and neutral distractors. Standard event-related voxel-wise fMRI and steady-state functional connectivity analyses were performed.

RESULTS

Increased activation was observed in the left medial prefrontal cortex and right ventrolateral prefrontal cortex (VLPFC) in response to emotional images compared to neutral imagines in youth with GAD. Connectivity analyses using the right VLPFC seed region suggested decreased connectivity between this region and the bilateral medial prefrontal cortex. Connectivity analyses using the right amygdala seed region revealed decreased correlation with the posterior cingulate cortex in adolescents with GAD. The left amygdala seed region demonstrated increased connectivity with the ipsilateral precuneus in youth with GAD compared to healthy subjects.

CONCLUSIONS

In addition to increased activation of the medial prefrontal cortex and right VLPFC, we observed altered connectivity between the amygdala or VLPFC and regions, which subserve mentalization (e.g. posterior cingulate cortex, precuneus, and medial prefrontal cortex). This suggests that structures that regulate emotion and affect interact abnormally with key structures that are involved in mentalization, a process known to be disrupted in GAD.

Bringing a developmental perspective to anxiety genetics

Despite substantial recent advancements in psychiatric genetic research, progress in identifying the genetic basis of anxiety disorders has been limited. We review the candidate gene and genome-wide literatures in anxiety, which have made limited progress to date. We discuss several reasons for this hindered progress, including small samples sizes, heterogeneity, complicated comorbidity profiles, and blurred lines between normative and pathological anxiety. To address many of these challenges, we suggest a developmental, multivariate framework that can inform and enhance anxiety phenotypes for genetic research. We review the psychiatric and genetic epidemiological evidence that supports such a framework, including the early onset and chronic course of anxiety disorders, shared genetic risk factors among disorders both within and across time, and developmentally dynamic genetic influences. We propose three strategies for developmentally sensitive phenotyping: examination of early temperamental risk factors, use of latent factors to model underlying anxiety liability, and use of developmental trajectories as phenotypes. Expanding the range of phenotypic approaches will be important for advancing studies of the genetic architecture of anxiety disorders.

Differentiating high-functioning autism and social phobia

Both high-functioning autism (HFA) and social phobia (SP) involve profound social interaction deficits. Although these disorders share some similar symptoms, they are conceptualized as distinct. Because both HFA and SP are defined behaviorally, the degree of overlap between the two disorders may result in misinterpretation of symptoms. However, the deficits in each disorder differ, particularly in areas of social interaction, emotion recognition and expression, and communication. This paper reviews the literature that informs our current understanding of the behavioral overlaps and differences in HFA and SP. The review also addresses the implications of our current knowledge of these two disorders for differential diagnosis, treatment, and future research. Interdisciplinary, developmentally-oriented research may help extend current approaches to HFA and SP.

Reduced dorsal anterior cingulate cortical activity during emotional regulation and top-down attentional control in generalized social phobia, generalized anxiety disorder, and comorbid generalized social phobia/generalized anxiety disorder

BACKGROUND

Generalized social phobia (GSP) and generalized anxiety disorder (GAD) are both associated with emotion dysregulation. Research implicates dorsal anterior cingulate cortex in both explicit emotion regulation (EER) and top-down attentional control (TAC). Although studies have examined these processes in GSP or GAD, no work compares findings across the two disorders or examines functioning in cases comorbid for both disorders (GSP/GAD). Here we compare the neural correlates of EER and TAC in GSP, GAD, and GSP/GAD.

METHODS

Medication-free adults with GSP (EER n = 19; TAC n = 18), GAD (EER n = 17; TAC n = 17), GSP/GAD (EER n = 17; TAC n = 15), and no psychopathology (EER n = 18; TAC n = 18) participated. During EER, individuals alternatively viewed and upregulated and downregulated responses to emotional pictures. During TAC, they performed an emotional Stroop task.

RESULTS

For both tasks, significant group × condition interactions emerged in dorsal anterior cingulate cortex and parietal cortices. Healthy adults showed significantly increased recruitment during emotion regulation, relative to emotion-picture viewing. GAD, GSP, and GSP/GAD subjects showed no such increases, with all groups differing from healthy adults but not from each other. Evidence of emotion-related disorder-specificity emerged in medial prefrontal cortex and amygdala. This disorder-specific responding varied as a function of emotion content but not emotion-regulatory demands.

CONCLUSIONS

GSP and GAD both involve reduced capacity for engaging emotion-regulation brain networks, whether explicitly or via TAC. A reduced ability to recruit regions implicated in top-down attention might represent a general risk factor for anxiety disorders.

Associations between household and neighborhood income and anxiety symptoms in young adolescents

BACKGROUND

A better understanding of the role of both family- and neighborhood-level socioeconomic characteristics in the development of anxiety disorders is important for identifying salient target populations for intervention efforts. Little research has examined the question of whether associations between anxiety and socioeconomic status (SES) differ depending upon the level at which SES is measured or way in which anxiety manifests. We studied associations between both household- and neighborhood-level income and four different manifestations of anxiety in a community sample of young adolescents.

METHODS

We conducted a cross-sectional analysis of data on 498 subjects aged 11-13 from a cohort study of Seattle-area middle school students. Generalized estimating equations were used to examine the association between both annual household income and neighborhood median income and each of four anxiety subscale scores from the multidimensional anxiety scale for children (MASC): physical symptoms, harm avoidance, social anxiety, and separation/panic anxiety.

RESULTS

A negative association was found between household income and scores on two of the four MASC subscales--physical symptoms and separation/panic anxiety. In contrast, at equivalent levels of household income, adolescents living in higher income neighborhoods reported higher physical and harm avoidance symptom scores.

CONCLUSION

The role that SES plays in the development of childhood anxiety appears to be complex and to differ depending on the specific type of anxiety that is manifest and whether income is evaluated at the household or neighborhood level.

[Prevalence of Depressive and Anxious Symptomatology in 14-18 ys-old Students from a Private School in Medellin]

OBJECTIVE

This study describes prevalence of depressive and anxious symptoms together with family, environmental and personal risk factors in a group of adolescents between 14 and 18 years of age in a private school of Medellín.

METHODS

An analytic observational cross sectional study was performed in 152 adolescents, evaluating sociodemographic aspects and prevalence of depressive and anxious symptomatology, as established through BDI-II and BAI.

RESULTS

Average age was 15.4 ± 0.9 years old, with a 25% prevalence of anxiety symptoms and 25.7% of depressive symptoms. From the 38 (25%) students with BAI positive, 26 (68.4%) were BDI positive, and from the 39 (25.6%) students with BDI positive, 26 (66.7%) were BAI positive.

CONCLUSIONS

the risk factors for anxiety and depressive symptomatology were: being a woman, being a victim of bullying and abuse. Having friends was the protective factors for depressive symptomatology. There was a statistical association between self-report of depressive and anxiety symptomatology; between the anxiety self-report and the depressive symptomatology; as well as between depressive and anxiety symptomatology and parents' perception of such symptoms.

Psychometric Properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C)

Reliable and valid self-report questionnaires could be useful as initial screening instruments for social phobia in both clinical settings and general populations. The present study investigates the factor structure and psychometric properties of the Social Phobia and Anxiety Inventory for Children (SPAI-C) in a sample of 228 children from the Italian general population aged 8 to 11. The children were asked to complete the Italian version of the SPAI-C and the Screen for Child Anxiety Related Emotional Disorders (SCARED) questionnaire. Confirmatory factor analyses revealed that social phobia can be conceptualized as a unitary construct consisting of five distinct but interrelated symptom clusters named Assertiveness, General Conversation, Physical/Cognitive Symptoms, Avoidance, and Public Performance. Internal consistency of the SPAI-C total scores and two subscales was good; correlations between SPAI-C total scores and SCARED total scores/subscales ranged from moderate to high (Generalized Anxiety Disorder, for social phobia), with the SCARED Social Phobia subscale as the best predictor of SPAI-C total scores. The results indicate that the SPAI-C is a reliable and sensitive instrument suitable for identifying Social Phobia in the young Italian general population.

Risky play and children's safety: balancing priorities for optimal child development

Injury prevention plays a key role in keeping children safe, but emerging research suggests that imposing too many restrictions on children’s outdoor risky play hinders their development. We explore the relationship between child development, play, and conceptions of risk taking with the aim of informing child injury prevention. Generational trends indicate children’s diminishing engagement in outdoor play is influenced by parental and societal concerns. We outline the importance of play as a necessary ingredient for healthy child development and review the evidence for arguments supporting the need for outdoor risky play, including: (1) children have a natural propensity towards risky play; and, (2) keeping children safe involves letting them take and manage risks. Literature from many disciplines supports the notion that safety efforts should be balanced with opportunities for child development through outdoor risky play. New avenues for investigation and action are emerging seeking optimal strategies for keeping children “as safe as necessary,” not “as safe as possible.” This paradigm shift represents a potential for epistemological growth as well as cross-disciplinary collaboration to foster optimal child development while preserving children’s safety.

Pre-adoption adversity and self-reported behavior problems in 7 year-old international adoptees

To further investigate the long-term impact of pre-adoption adversity on international adoptees, externalizing and internalizing symptoms were assessed using a self-report measure at school-age in addition to mothers' reports. The sample consisted of 95 adopted children and their mothers. Children's health and developmental status were assessed soon after arrival in their adoptive family. At age 7, the Dominic Interactive, a self-report measure, was used to evaluate externalizing and internalizing symptoms while mothers completed the CBCL. Children's self-reports were compared to their non-adopted peers'. Adopted children reported more symptoms of specific phobia than their peers. A significant correlation was found between mothers' and children's reports but only for externalizing symptoms. Self-reported symptoms were related to indices of nutritional and psychosocial deprivation at arrival, such as low height/age and weight/height ratios. Our results emphasize the importance of considering international adoptees' perception of their psychological adjustment and the long-term impact of early risk factors.

Developmental epidemiology of anxiety disorders

This review focuses on developmental aspects in the epidemiology of anxiety disorders including prevalence, onset, natural course, longitudinal outcome, and correlates and risk factors, with focus on childhood through young adulthood. Anxiety disorders are frequent and early-emerging conditions. They may remit spontaneously; however, the same or other mental disorders often recur. Although risk factors have been identified, more work is needed to identify the most powerful predictors for onset and the progression to more complex forms of psychopathology and to understand the underlying mechanisms and interactions. This identification is crucial to facilitate research prevention, early interventions, and treatment programs.

Panic disorder and school refusal

This article provides clinical and research information about panic disorder, agoraphobia, and school refusal. Proposed changes to the definition of panic disorder and agoraphobia for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition are outlined. Treatment of panic disorder, and school refusal in children and adolescents is also discussed.

Psychopharmacologic treatment of children and adolescents with anxiety disorders

Over the last decade, psychopharmacologic treatments for pediatric anxiety disorders have been developed and increasingly subjected to randomized, controlled trials. The authors summarize the data concerning the use of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), atypical anxiolytics, and benzodiazepines. The extant data suggest that SSRIs--both as monotherapy and when combined with psychotherapy--are effective in the treatment of pediatric anxiety disorders. In addition, some TCAs and SNRIs are effective. However, randomized controlled trials do not suggest efficacy for benzodiazepines or the atypical anxiolytic, buspirone, for children and adolescents with anxiety disorders.

Duplication of GTF2I results in separation anxiety in mice and humans

Duplication (dup7q11.23) and deletion (Williams syndrome) of chromosomal region 7q11.23 cause neurodevelopmental disorders with contrasting anxiety phenotypes. We found that 30% of 4- to 12-year-olds with dup7q11.23 but fewer than 5% of children with WS or in the general population met diagnostic criteria for a separation-anxiety disorder. To address the role of one commonly duplicated or deleted gene in separation anxiety, we compared mice that had varying numbers of Gtf2i copies. Relative to mouse pups with one or two Gtf2i copies, pups with additional Gtf2i copies showed significantly increased maternal separation-induced anxiety as measured by ultrasonic vocalizations. This study links the copy number of a single gene from 7q11.23 to separation anxiety in both mice and humans, highlighting the utility of mouse models in dissecting specific gene functions for genomic disorders that span many genes. This study also offers insight into molecular separation-anxiety pathways that might enable the development of targeted therapeutics.

Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder

Generalized anxiety disorder (GAD) is associated with significant morbidity in children and adolescents, yet only recently have the neuropharmacology and neurophysiology of this condition been studied in youth. Accumulating data suggest structural and functional abnormalities within the brain's fear networks in youth with GAD. Additionally, seven studies examined the efficacy of medications that modulate this system and, in some cases, the direct effects of these medications on structures within these networks (e.g. amygdala, ventrolateral prefrontal cortex [VLPFC]). In this review, we summarize the extant functional, functional connectivity, and structural neuroimaging data in children and adolescents with GAD. In addition, data concerning selective serotonin reuptake inhibitors (SSRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), atypical anxiolytics, benzodiazepines, and psychotherapy are reviewed in the context of the neurophysiology of pediatric GAD. The existing data suggest abnormal activity within the amygdala, VLPFC, and anterior cingulate cortex, as well as the possibility of impaired connectivity among these brain regions. In addition to numerous cognitive behavioral therapy (CBT) trials, five randomized, controlled psychopharmacologic trials primarily in youth with GAD suggest that SSRIs and SSNRIs are effective for this condition. These findings also raise the possibility that functional activity within the amygdala and VLPFC may be altered following successful treatment.

Anxiety disorder symptoms in children and adolescents: differences by age and gender in a community sample

INTRODUCTION

Anxiety symptoms in childhood and adolescence are an important risk factor for developing anxiety disorders in subsequent development stages. This study examines the frequency and characteristics of the symptoms of the principal anxiety disorders in children and adoloscents using a self-report questionnaire based on the diagnostic categories of the American Psychiatric Association (APA) manual.

MATERIAL AND METHODS

A cross-sectional, non-interventional study was conducted on 2522 children and adolescents form 8 to 17 years (49% males), enrolled from different schools in the Province of Alicante who completed the Spence Children's Anxiety Scale.

RESULTS

The mean score obtained on the scale (range: 0-114) was 25.15 (standard deviation (SD)=13.54). More than one in four (26.41%) of the children and adolescents showed high scores in any anxiety disorder. The anxiety symptoms due to separation were the most frequent in the sample (5.5%), followed by physical fears (5.1%). Girls scored significantly higher in all disorders (P<.001), except in obsessive-compulsive disorder. Differences were found as regards age in all disorders, except physical fears, but the effect sizes were only in anxiety due to separation, which decreased with age, and generalised anxiety, which was higher in adolescents than in children.

CONCLUSIONS

From the mental health perspective, it is important to be able to detect anxiety symptoms in children from 8 years onwards, in order to intervene early and prevent the development of anxiety disorders in later life.

Juvenile neurogenesis makes essential contributions to adult brain structure and plays a sex-dependent role in fear memories

Postnatal neurogenesis (PNN) contributes neurons to olfactory bulb (OB) and dentate gyrus (DG) throughout juvenile development, but the quantitative amount, temporal dynamics and functional roles of this contribution have not been defined. By using transgenic mouse models for cell lineage tracing and conditional cell ablation, we found that juvenile neurogenesis gradually increased the total number of granule neurons by approximately 40% in OB, and by 25% in DG, between 2 weeks and 2 months of age, and that total numbers remained stable thereafter. These findings indicate that the overwhelming majority of net postnatal neuronal addition in these regions occurs during the juvenile period and that adult neurogenesis contributes primarily to replacement of granule cells in both regions. Behavioral analysis in our conditional cell ablation mouse model showed that complete loss of PNN throughout both the juvenile and young adult period produced a specific set of sex-dependent cognitive changes. We observed normal hippocampus-independent delay fear conditioning, but excessive generalization of fear to a novel auditory stimulus, which is consistent with a role for PNN in psychopathology. Standard contextual fear conditioning was intact, however, pre-exposure dependent contextual fear was impaired suggesting a specific role for PNN in incidental contextual learning. Contextual discrimination between two highly similar contexts was enhanced; suggesting either enhanced contextual pattern separation or impaired temporal integration. We also observed a reduced reliance on olfactory cues, consistent with a role for OB PNN in the efficient processing of olfactory information. Thus, juvenile neurogenesis adds substantively to the total numbers of granule neurons in OB and DG during periods of critical juvenile behavioral development, including weaning, early social interactions and sexual maturation, and plays a sex-dependent role in fear memories.

Relationship of obsessive-compulsive disorder to age-related comorbidity in children and adolescents with Tourette syndrome

OBJECTIVE

Attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) are the 2 most frequent psychiatric disorders co-occurring with Tourette syndrome (TS). Both usually cause greater impairment in psychosocial functioning than the tics themselves. In a previous study, we examined the relationship of attention-deficit/hyperactivity disorder to other comorbid conditions in TS. The relationship of OCD to other comorbidities in TS still remains unclear and is the focus of the present study.

METHODS

Pearson's χ tests and logistic regressions (year-wise) were used to examine a cross-sectional sample of children and adolescents (n = 5060) diagnosed with TS, taken from the Tourette Syndrome International Database Consortium. We explored the relationship of OCD to other comorbid conditions in TS across different age groups.

RESULTS

In children (ages 5-10 y) with TS, higher rates of comorbidities were found in the presence compared with the absence of OCD. Adolescents (ages 11-17 y) with TS + OCD showed higher rates of internalizing (i.e., anxiety and mood) disorders when compared with those with TS - OCD. A year-wise increase of coexisting mood disorders was found for subjects with TS with and without OCD.

CONCLUSIONS

Overall, children and adolescents with TS + OCD showed higher rates of comorbid disorders compared with those with TS - OCD. This underlines the necessity for a comprehensive assessment of additional comorbidities even if the 2 disorders (TS + OCD) have already been diagnosed.

Parent and child perspectives on the nature of anxiety in children and young people with autism spectrum disorders: a focus group study

Anxiety disorders are common among children and young people with autism spectrum disorders (ASD). Despite growing knowledge about the prevalence, phenomenology and treatment of anxiety disorders, relatively little is understood about the nature and impact of anxiety in this group and little is known about autism-specific factors that may have a role in the increased prevalence of anxiety disorders. In this exploratory study, we report on a series of five focus groups with 17 parents of children and adolescents with ASD and anxiety. Across groups, parents gave strikingly similar descriptions of the triggers and behavioural signs associated with anxiety. Another consistent finding was that many parents reported that their children had great difficulty expressing their worries verbally and most showed their anxiety through changes in their behaviour. The impact of anxiety was reported to often be more substantial than the impact of ASD itself. The implications of the focus group findings are discussed in relation to existing literature.

Empirically derived subtypes of lifetime anxiety disorders: developmental and clinical correlates in U.S. adolescents

OBJECTIVE

The current study examined the sex- and age-specific structure and comorbidity of lifetime anxiety disorders among U.S. adolescents.

METHOD

The sample consisted of 2,539 adolescents (1,505 females and 1,034 males) from the National Comorbidity Survey-Adolescent Supplement who met criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR]) lifetime anxiety disorders (American Psychiatric Association, 2000). Adolescents ranged in age from 13 to 18 years (M = 15.2 years, SE = 0.08 years) and were 39% non-White. Multiple-group latent class analysis was conducted by adolescent sex and age to identify subgroups of adolescents with similar anxiety disorder profiles. Developmental and clinical correlates of empirically derived classes were also examined to assess the nomological validity of identified subgroups.

RESULTS

A 7-class solution provided the best fit to the data, with classes defined primarily by one rather than multiple anxiety disorders. Results also indicated that classes displayed similar diagnostic profiles across age, but varied by sex. Classes characterized by multiple anxiety disorders were consistently associated with a greater degree of persistence, clinical severity, impairment, and comorbidity with other DSM-IV-TR psychiatric disorders.

CONCLUSIONS

The presentation of lifetime anxiety disorders among adolescents and the observation of unique correlates of specific classes provide initial evidence for the utility of individual DSM-IV-TR anxiety disorder categories. Although findings of the present study should be considered preliminary, results emphasize the potential value of early intervention and gender-specific conceptualization and treatment of anxiety disorders.

Factors associated with the persistence and onset of new anxiety disorders in youth with bipolar spectrum disorders

OBJECTIVE

Anxiety disorders are among the most common comorbid conditions in youth with bipolar disorder, but, to our knowledge, no studies examined the course of anxiety disorders in youth and adults with bipolar disorder.

METHOD

As part of the Course and Outcome of Bipolar Youth study, 413 youth, ages 7 to 17 years who met criteria for Diagnostic and Statistical Manual, Fourth Edition (DSM-IV) bipolar I disorder (n = 244), bipolar II disorder (n = 28), and operationally defined bipolar disorder not otherwise specified (n = 141) were recruited primarily from outpatient clinics. Subjects were followed on average for 5 years using the Longitudinal Interval Follow-Up Evaluation. We examined factors associated with the persistence (> 50% of the follow-up time) and onset of new anxiety disorders in youth with bipolar disorder.

RESULTS

Of the 170 youth who had anxiety at intake, 80.6% had an anxiety disorder at any time during the follow-up. Most of the anxiety disorders during the follow-up were of the same type as those present at intake. About 50% of the youth had persistent anxiety, particularly generalized anxiety disorder (GAD). Persistence was associated with multiple anxiety disorders, less follow-up time in euthymia, less conduct disorder, and less treatment with antimanic and antidepressant medications (all P values ≤ .05). Twenty-five percent of the sample who did not have an anxiety disorder at intake developed new anxiety disorders during follow-up, most commonly GAD. The onset of new anxiety disorders was significantly associated with being female, lower socioeconomic status, presence of attention-deficit/hyperactivity disorder and substance use disorder, and more follow-up time with manic or hypomanic symptoms (all P values ≤ .05)

CONCLUSIONS

Anxiety disorders in youth with bipolar disorder tend to persist, and new-onset anxiety disorders developed in a substantial proportion of the sample. Early identification of factors associated with the persistence and onset of new anxiety disorders may enable the development of strategies for treatment and prevention.

[Guidelines of the Brazilian Medical Association for the diagnosis and differential diagnosis of social anxiety disorder]

OBJECTIVE

Social anxiety disorder is the most common anxiety disorder. The condition has a chronic course usually with no remission and is frequently associated with significant functional and psychosocial impairment. The Brazilian Medical Association, with the project named Diretrizes ('Guidelines', in English), endeavors to develop diagnostic and treatment protocols for the most common disorders. This work presents the most relevant findings regarding the guidelines of the Brazilian Medical Association concerning the diagnosis and differential diagnosis of social anxiety disorder.

METHOD

We used the methodology proposed by the Brazilian Medical Association for the Diretrizes project. The search was performed on the online databases Medline (PubMed), Scopus, Web of Science, and Lilacs, with no time restraints. Searchable questions were structured using PICO format (acronym for "patient or population"; "intervention, indicator or exposition"; "control or comparison" and; "outcome or ending").

RESULTS

We present data regarding the clinical manifestations of social anxiety disorder, impairments and implications related to the condition, differences between the generalized and specific subtypes, and the relationship with depression, drug dependence and abuse, and other anxiety disorders. Additionally, the main differential diagnoses are discussed.

CONCLUSION

The guidelines are intended to serve as references to the general practitioner and the specialist as well, facilitating the diagnosis of social anxiety disorder.

Caveats of chronic exogenous corticosterone treatments in adolescent rats and effects on anxiety-like and depressive behavior and hypothalamic-pituitary-adrenal (HPA) axis function

BACKGROUND

Administration of exogenous corticosterone is an effective preclinical model of depression, but its use has involved primarily adult rodents. Using two different procedures of administration drawn from the literature, we explored the possibility of exogenous corticosterone models in adolescence, a time of heightened risk for mood disorders in humans.

METHODS

In experiment 1, rats were injected with 40 mg/kg corticosterone or vehicle from postnatal days 30 to 45 and compared with no injection controls on behavior in the elevated plus maze (EPM) and the forced swim test (FST). Experiment 2 consisted of three treatments administered to rats from postnatal days 30 to 45 or as adults (days 70 to 85): either corticosterone (400 μg/ml) administered in the drinking water along with 2.5% ethanol, 2.5% ethanol or water only. In addition to testing on EPM, blood samples after the FST were obtained to measure plasma corticosterone. Analysis of variance (ANOVA) and alpha level of P < 0.05 were used to determine statistical significance.

RESULTS

In experiment 1, corticosterone treatment of adolescent rats increased anxiety in the EPM and decreased immobility in the FST compared to no injection control rats. However, vehicle injected rats were similar to corticosterone injected rats, suggesting that adolescent rats may be highly vulnerable to stress of injection. In experiment 2, the intake of treated water, and thus doses delivered, differed for adolescents and adults, but there were no effects of treatment on behavior in the EPM or FST. Rats that had ingested corticosterone had reduced corticosterone release after the FST. Ethanol vehicle also affected corticosterone release compared to those ingesting water only, but differently for adolescents than for adults.

CONCLUSIONS

The results indicate that several challenges must be overcome before the exogenous corticosterone model can be used effectively in adolescents.