Familial predictors of treatment outcome in childhood anxiety disorders

Parental and Family Factors as Predictors of Threat Bias in Anxious Youth

The present study examined the relative predictive value of parental anxiety, parents' expectation of child threat bias, and family dysfunction on child's threat bias in a clinical sample of anxious youth. Participants (N = 488) were part of the Child/Adolescent Anxiety Multi-modal study (CAMS), ages 7-17 years (M = 10.69; SD = 2.80). Children met diagnostic criteria for generalized anxiety disorder, separation anxiety and/or social phobia. Children and caregivers completed questionnaires assessing child threat bias, child anxiety, parent anxiety and family functioning. Child age, child anxiety, parental anxiety, parents' expectation of child's threat bias and child-reported family dysfunction were significantly associated with child threat bias. Controlling for child's age and anxiety, regression analyses indicated that parents' expectation of child's threat bias and child-reported family dysfunction were significant positive predictors of child's self-reported threat bias. Findings build on previous literature by clarifying parent and family factors that appear to play a role in the development or maintenance of threat bias and may inform etiological models of child anxiety.

Youth anxiety and parent factors over time: directionality of change among youth treated for anxiety

The relationship between improvements in child anxiety and changes in parent factors (e.g., parental anxiety, parenting behaviors) is poorly understood. The present study investigated the directionality of change for child anxiety and parent factors among youth treated for anxiety disorders. Structural equation modeling examined these relationships pre- to posttreatment and at 1-year follow-up for 111 youth aged 7 to 14 (57% male, 84% Caucasian). Child anxiety was measured using the Anxiety Disorders Interview Schedule for Children and the Child Behavior Checklist. The State-Trait Anxiety Inventory, Children's Report of Parental Behavior Inventory, and Family Assessment Device were used to measure maternal anxiety, psychological control, behavior control, and family affective involvement. Findings suggest that decreases in mother-reported child anxiety led to decreases in maternal anxiety. Decreases in maternal psychological control and family affective involvement preceded decreases in clinician-rated child anxiety. Youth who showed the most reductions in anxiety over the course of treatment were those who tended to have lower family affective involvement, behavior control, and maternal anxiety at pretreatment. Stability of the parent factors and child anxiety over time suggest that stability was greater for behavior control and maternal anxiety relative to affective involvement and psychological control. The findings are consistent with previous research indicating the importance of these parent factors as they relate to anxiety in youth. Furthermore, results indicate that changes in child anxiety may precede changes in parent factors and suggest that parental psychological control and affective involvement are important treatment targets for youth with anxiety disorders.

Targeting parental psychopathology in child anxiety

The increased risk of anxiety in children of parents with psychopathology is a significant public health problem, as early-onset is associated with a variety of difficulties later in life. The aim of this article is to determine if treating parents is associated with improvements in child anxiety through the review of both top-down (parent identified for treatment) and family-focused child anxiety treatment studies. The authors present conclusions based on the state of the current literature, discuss implications for research and clinical practice, and propose utilizing a family-based model for treating parental psychopathology, parental behavior, and child anxiety.

Psychogenic movement disorders in children: characteristics and predictors of outcome

Psychogenic movement disorders are defined as hyperkinetic or hypokinetic movement disorders associated with underlying psychological disorders. Psychogenic movement disorders account for 1% to 9% of all neurologic diagnoses. The assessment and treatment of psychogenic movement disorders can be complex. We report patients seen over the past 5 years, diagnosed with psychogenic movement disorder. We discuss in this article some patient characteristics and some strategies that are effective in the management of this group of patients. The case examples presented in the current article demonstrate the importance of two factors, a multidisciplinary approach and engaging the family, that are essential components in the treatment of psychogenic movement disorders.

CBT for the treatment of child anxiety disorders: a review of why parental involvement has not enhanced outcomes

Anxiety affects 10% of all children and disrupts educational, socio-emotional development and overall functioning of the child and family. Research has shown that parenting factors (i.e. intrusiveness, negativity, distorted cognitions) contribute to the development and maintenance of childhood anxiety. Recent studies have therefore investigated if the treatment effect of traditional cognitive behavioural therapy may be enhanced by adding a parental component. However, randomised controlled trials have not shown unequivocal support for this assumption. The results are inconsistent and ambiguous. This article investigates possible reasons for this inconsistency and in particular differences in methodology and the theoretical relevance of the applied parental components are highlighted as possible contributory factors. Another factor is that treatment effect is mainly measured by change in the child's diagnostic status rather than changes in parental or family functioning.

Examining potential risk factors for anxiety in early childhood

Anxiety disorders are amongst the most prevalent psychiatric disorders in children and adolescents, with occurrence emerging early in the developmental trajectory. This study was one of the first to investigate potential risk factors for anxiety (i.e., behavioural inhibition, parental negative affect, parenting stress) in early childhood. Examination of risk factors was achieved through structural equation modelling and based on mothers' and fathers' report of 236 preschool aged children (4-6 years) in Brisbane, Australia. The structural model was found to fit the data well. All direct predictors of early childhood anxiety were significant and behavioural inhibition partially mediated parents' negative affectivity and mother's parenting stress. Results highlight the unique contribution of both parents in the aetiology of early childhood anxiety and assist in informing the development of intervention and prevention programs for young children.

Efficacy of Cognitive—Behavioural Therapy for Children and Adolescents With Anxiety Disorders

Support for the efficacy of cognitive—behavioural therapy (CBT) for anxious youth has accumulated. Significant treatment effects are observed and maintained over the long term for the majority of children receiving individual, family or group-based treatments. Nevertheless, all children do not improve. In fact, there is evidence to suggest that a significant percentage of children continue to experience anxiety following treatment and will seek additional treatment for their anxiety. This article will review the substantial evidence for CBT, the current information available on predictors of outcome and mechanisms of change. The article will also discuss the need for adequately powered randomised clinical trials that continue to refine and evaluate treatments for anxious children in an effort to improve outcomes for those children whose needs are not being met by our current treatments.

The Association Between Maternal Anxiety and Treatment Outcome for Childhood Anxiety Disorders

This study examined the influence of maternal anxiety on the treatment outcome of anxious children. Forty-eight clinically anxious children (aged 6–14 years) were classified into two groups based on the presence of an anxiety disorder diagnosis in their mother. Diagnostic data at posttreatment showed that children with anxious mothers responded significantly less favourably to cognitive behavioural therapy (CBT) than did children with nonanxious mothers (28% vs. 58% improved, respectively). At 12-month follow-up, 68% of children with anxious mothers improved, compared to 79% of children with nonanxious mothers. This difference was not significant. Findings were not consistent across outcome measures. This study also investigated the changes in maternal anxiety across child treatment. Prior to treatment, diagnostic data showed that 60% of mothers met criteria for an anxiety disorder. At posttreatment, 21% of these mothers were free of their primary diagnosis. There was also a significant reduction in self-reported maternal anxiety across treatment that was maintained at follow-up. Theoretical and clinical implications of the findings are discussed.

Predictors of outcome in a cognitive-behavioral group program for children and adolescents with social anxiety disorder

The present study examined predictors of treatment outcome among children and adolescents with social anxiety disorder (SAD). Seventy-five participants (8-13 years) participated in a 12-session cognitive behavioral group treatment (CBT). Potential predictors were the pre-treatment severity of anxious symptoms assessed from both the child's and parent's perspective as well as depressive symptoms (child report only) and general emotional distress in parent (parent self-report). Furthermore, the relationship between treatment outcome and child's self-reported pre-post changes in self-consciousness and maladaptive anxiety regulation was investigated. Pre-treatment level of social anxiety reported by the child was a significant predictor for outcome, i.e. children with higher levels of social anxiety at pretreatment reported a greater reduction in social anxiety at post-treatment. Reduction in self-consciousness and maladaptive anxiety regulation both predicted reduction in social anxiety, although not independently. The results suggest that tailoring intervention to include strategies for emotion regulation of anxiety may improve treatment outcome.

Failures in cognitive-behavior therapy for children

This article discusses treatment failures in child therapy, specifically cognitive-behavioral therapy (CBT) for anxiety and its disorders. The theoretical foundations and principles of CBT are discussed first, followed by a summary of the treatment outcome literature. Also discussed is how treatment failure is defined and gauged in CBT, as well as factors implicated in treatment failure. A case illustration highlights these factors, which resulted in the child not advancing positively in treatment. The article concludes with key practice recommendations.

CBT for childhood anxiety and substance use at 7.4-year follow-up: a reassessment controlling for known predictors

A previous report suggested that successful cognitive behavioral therapy (CBT) for child anxiety reduced substance use problems at 7.4-year follow-up, but that report did not include predictors of: (a) substance use disorder (SUD; e.g., attention deficit-hyperactivity disorder symptoms, negative life events, family substance abuse, additional treatment), or (b) treatment outcome (e.g., severity of internalizing pathology, age). Analyses incorporating these factors tested previously reported findings in 72 participants (ages 15-22 at follow-up; 84% of the 7.4-year follow-up sample), using parent and youth diagnostic interviews and report measures. The majority of previously reported associations between less successful treatment and later substance use problems remained significant after controlling for known predictors of SUD and treatment outcome. Our findings bolster previous conclusions that effective CBT for child anxiety may have ameliorative effects on the target disorder and later substance use problems.

Anxiety/stress among mothers living with HIV: effects on parenting skills and child outcomes

Parental HIV infection has been associated with negative outcomes for children, and parenting skills appear to be one mechanism operating in that association. The present study focuses on the relations between maternal stress, parenting, and child functioning among families where the mother is living with HIV. Sixty-nine mothers with at least one child between six and 12 years old completed questionnaires at the baseline assessment of an intervention designed to facilitate maternal disclosure of HIV status. Respondents were assessed using multiple measures of stress/anxiety, parenting skills, and child outcomes, including the Parenting Stress Index, the RAND Mental Health Inventory, the Family Routines Questionnaire, and the Child Behavior Checklist. Covariance structural modeling was used to assess the variable relationships, with latent constructs created for maternal anxiety/stress, parenting skills, and child problem behaviors (both direct and indirect effects were evaluated, with a model-based bootstrap used to verify model stability). Results demonstrated that maternal stress was negatively associated with a broad range of parenting skills, and that parenting skills were negatively associated with child problem behaviors. Mothers living with HIV who are anxious about their own health and functioning, and who were more stressed in their parental role, were more likely to exhibit poorer parenting skills - specifically to engage children less frequently in family routines (e.g., eating meals together, having a bedtime routine), poorer parent-child communication, and poorer and less consistent parenting discipline. Not uncommonly, mothers living with HIV experience a range of stressors above and beyond those related to their illness (e.g., poverty, residence in high risk and low resource communities, discrimination). Results demonstrate the need for interventions designed to decrease maternal stress and enhance parenting skills for families affected by HIV.

Comorbid depressive disorders in anxiety-disordered youth: demographic, clinical, and family characteristics

Research indicates that depression and anxiety are highly comorbid in youth. Little is known, however, about the clinical and family characteristics of youth with principal anxiety disorders and comorbid depressive diagnoses. The present study examined the demographic, clinical, and family characteristics of 200 anxiety-disordered children and adolescents (aged 7-17) with and without comorbid depressive disorders (major depressive disorder or dysthymic disorder), seeking treatment at a university-based anxiety clinic. All participants met DSM-IV diagnostic criteria for a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia). Of these, twelve percent (n = 24) also met criteria for a comorbid depressive disorder. Results suggest that anxiety-disordered youth with comorbid depressive disorders (AD-DD) were older at intake, had more severe anxious and depressive symptomatology, and were more impaired than anxiety-disordered youth without comorbid depressive disorders (AD-NDD). AD-DD youth also reported significantly more family dysfunction than AD-NDD youth. Future research should examine how this diagnostic and family profile may impact treatment for AD-DD youth.

Prospective community study of family stress and anxiety in (pre)adolescents: the TRAILS study

For prevention of anxiety in children and adolescents, it is important to know whether family stress is a predictor of anxiety. We studied this in 1,875 adolescents from the Tracking Adolescents' Individual Lives Survey (TRAILS) who were followed up for 2 years, from age 10-12 to 12-14 years. Adolescents reported anxiety and depression symptoms at both assessments, and parents reported family stress (family dysfunction and parenting stress) at the first assessment. Family dysfunction was not associated with future anxiety, whereas high parenting stress was. Furthermore, family dysfunction was more strongly associated with anxiety than with depression, whereas parenting stress was more strongly associated with depression. Level of parental psychopathology explained part of the association of family stress with anxiety. The associations were modest and the understanding of the origins of adolescents' anxiety will require identifying other factors than family stress that account for more of the variance.

Do parental psychopathology and unfavorable family environment predict the persistence of social phobia?

Parental psychopathology and unfavorable family environment are established risk factors for onset of offspring social phobia (SP), but their associations with the further course, e.g., persistence of the disorder, remain understudied. A community cohort of 1395 adolescents and their parents was followed-up over almost 10 years using the DIA-X/M-CIDI. Parental diagnostic interviews were supplemented by family history data. Parental rearing was retrospectively assessed by the Questionnaire of Recalled Parental Rearing Behavior in offspring, and family functioning by the Family Assessment Device in parents. Persistence measures (proportion of years affected since onset) were derived from diagnostic interviews, using age of onset, age of recency, and course information. Lack of emotional warmth and dysfunctional family functioning characteristics were associated with higher SP persistence, particularly in interaction with parental psychopathology. Predictors for SP persistence differ from those predicting SP onset. Unfavorable family environment alone and in interaction with parental disorders predict higher SP persistence.

Mediators and moderators of outcome in the behavioral treatment of childhood social phobia

OBJECTIVE

The current study examined mediators and moderators of treatment response among children and adolescents (ages 7-17 years) with a primary diagnosis of social phobia.

METHOD

Participants were 88 youths participating in one of two randomized controlled treatment trials of Social Effectiveness Therapy for Children. Potential mediators included changes in observer-rated social skill and child-reported loneliness after 12 weeks of Social Effectiveness Therapy for Children. Age and depressive symptoms were examined as potential moderators.

RESULTS

Loneliness scores and social effectiveness during a role-play task predicted changes in social anxiety and overall functioning at posttreatment. Changes in social anxiety were mediated by child-reported loneliness. Outcomes were not moderated by age or depressive symptoms.

CONCLUSIONS

Findings support the role of loneliness as an important mechanism of change during treatment for childhood social phobia.

Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents

The article reviews psychosocial treatments for phobic and anxiety disorders in youth. Using criteria from Nathan and Gorman (2002), 32 studies are evaluated along a continuum of methodological rigor. In addition, the treatments evaluated in each of the 32 studies are classified according to Chambless et al.'s (1996) and Chambless and Hollon's (1998) criteria. Findings from a series of meta-analyses of the studies that used waitlists also are reported. In accordance with Nathan and Gorman, the majority of the studies were either methodologically robust or fairly rigorous. In accordance with Chambless and colleagues, although no treatment was well-established, Individual Cognitive Behavior Therapy, Group Cognitive Behavior Therapy (GCBT), GCBT with Parents, GCBT for social phobia (SOP), and Social Effectiveness Training for children with SOP each met criteria for probably efficacious. The other treatments were either possibly efficacious or experimental. Meta-analytic results revealed no significant differences between individual and group treatments on diagnostic recovery rates and anxiety symptom reductions, as well as other youth symptoms (i.e., fear, depression, internalizing and externalizing problems). Parental involvement was similarly efficacious as parental noninvolvement in individual and group treatment formats. The article also provides a summary of the studies that have investigated mediators, moderators, and predictors of treatment outcome. The article concludes with a discussion of the clinical representativeness and generalizability of treatments, practice guidelines, and future research directions.

The unique impact of parent training for separation anxiety disorder in children

This investigation examined the preliminary efficacy of an integrated cognitive-behavioral parent-training protocol for six families of separation-anxious children (7 to 10 years of age) using a multiple baseline design across participants. Although families were assessed on child, parent, and clinician ratings at pre- and posttreatment as well as 6-month follow-up, only parents received education and training. Although the parent-training protocol was largely effective and treatment gains were maintained at 6-month follow-up, only those child participants whose parents experienced clinically significant improvement on parental process measures (i.e., enhanced efficacy or satisfaction, reduced stress) achieved high end-state functioning. Implications regarding the importance of individualized family-based interventions for treating anxious youth are discussed.

Parenting stress as a predictor of age upon admission to a child psychiatric inpatient facility

The current study examined child symptoms and parenting stress as predictors of children's age upon admission to a psychiatric inpatient facility. The children (N = 252) ranged from 6 to 12 years of age; most were male (71%) and over half were African American (59%). Externalizing behavior symptoms were associated with a younger age upon admission and internalizing behavior symptoms were associated with an older age. Parental social isolation was associated with a younger child's age upon admission, whereas difficulty with parental attachment was associated with an older age.

Maternal anxiety predicts favourable treatment outcomes in anxiety-disordered adolescents

OBJECTIVE

To determine the differential impact of maternal and paternal internalizing psychopathology on cognitive-behavioural treatment (CBT) outcome of anxiety-disordered children and adolescents.

METHOD

Participants consisted of 127 children and 51 adolescents with a primary anxiety diagnosis. Children were randomly assigned to a standardized group CBT or individual CBT; adolescents received individual CBT. Parents received four training sessions. Participants were evaluated at pre- and post-treatment with a clinical interview and with self- and parent-reported questionnaires. Lifetime anxiety and mood disorders in parents were obtained with a clinical interview.

RESULTS

For children, no associations were found between maternal and paternal anxiety or mood disorders and treatment outcome. For adolescents, however, maternal lifetime anxiety disorders were positively associated with pre-post-treatment improvement in clinician severity ratings and with treatment success.

CONCLUSION

Lifetime maternal anxiety disorders were significantly associated with favourable treatment outcomes in adolescents. Paternal disorders were not associated with treatment response.

Fathers' role in the etiology, prevention and treatment of child anxiety: A review and new model

Fathers have been neglected in investigations of the development, prevention, and treatment of anxiety and anxiety disorders in children and adolescents. This review provides a historical background of what is known about fathers' roles in the etiology of anxiety problems and provides evidence from bottom-up, top-down, and cross-sectional correlation studies of the connections between fathers' and their children's anxiety. Treatment and prevention programs are discussed in terms of the limited findings regarding fathers' involvement in treatment for children's and adolescents' anxiety problems. Finally, a model is presented to show the unique ways in which mothers and fathers are involved in the development of anxiety disorders in their children. Future directions for research in this area are highlighted.

Treatment Response in Child Anxiety is Differentially Related to the Form of Maternal Anxiety Disorder

An examination was made of the extent to which maternal anxiety predicted response to treatment of children presenting with an anxiety disorder. In a sample of 55 children referred to a local NHS CAMH service for treatment of an anxiety disorder, systematic mental state interview assessment was made of both mothers and children, and both completed self-report questionnaires to assess aspects of anxiety, both immediately before the children received treatment and following treatment. Children of mothers with anxiety disorder overall responded less well to treatment than children of mothers with no anxiety disorder. There was some diagnostic specificity in this in that children of mothers with GAD did as well in treatment as children whose mothers had no anxiety, whereas children of mothers with social phobia did poorly. The outcome for children with anxiety appears to be related to the presence and nature of maternal anxiety. It would seem prudent that treatment of children with anxiety involves assessment of maternal anxiety. It is important to establish in systematic investigation whether treatment of maternal anxiety improves the outcome for child anxiety.

Family Treatment of Child Anxiety: Outcomes, Limitations and Future Directions

Anxiety of childhood is a common and serious condition. The past decade has seen an increase in treatment-focussed research, with recent trials tending to give greater attention to parents in the treatment process. This review examines the efficacy of family-based cognitive behaviour therapy and attempts to delineate some of the factors that might have an impact on its efficacy. The choice and timing of outcome measure, age and gender of the child, level of parental anxiety, severity and type of child anxiety and treatment format and content are scrutinised. The main conclusions are necessarily tentative, but it seems likely that Family Cognitive Behaviour Therapy (FCBT) is superior to no treatment, and, for some outcome measures, also superior to Child Cognitive Behaviour Therapy (CCBT). Where FCBT is successful, the results are consistently maintained at follow-up. It appears that where a parent is anxious, and this is not addressed, outcomes are less good. However, for children of anxious parents, FCBT is probably more effective than CCBT. What is most clear is that large, well-designed studies, examining these factors alone and in combination, are now needed.

Psychotherapy of childhood anxiety disorders: A meta-analysis

BACKGROUND

The present study compared the efficacy of psychotherapy for childhood anxiety disorders (excluding trials solely treating post-traumatic stress disorder or obsessive-compulsive disorder).

METHODS

The meta-analysis included studies that met the basic CONSORT (consolidated standards of reporting trials) criteria. Several outcome variables (e.g. effect sizes, percentage of recovery) were analyzed using completer and intent-to-treat analyses during post-treatment and follow-up assessment. Twenty-four studies published by March 2005 were included in this meta-analysis.

RESULTS

In all the included studies, the active treatment condition was cognitive-behavioral. The overall mean effect of treatment was 0.86. No differences in outcome were found between individual and group treatments or child- and family-focused treatments. Follow-up data demonstrated that treatment gains were maintained up to several years after treatment.

CONCLUSIONS

These findings provide evidence that anxiety disorders in children can be treated efficaciously. The gathered data support the clinical utility of cognitive-behavioral therapy in this regard. Randomized controlled trial studies investigating treatments other than cognitive-behavioral therapy are missing.

Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders

This revised practice parameter reviews the evidence from research and clinical experience and highlights significant advancements in the assessment and treatment of anxiety disorders since the previous parameter was published. It highlights the importance of early assessment and intervention, gathering information from various sources, assessment of comorbid disorders, and evaluation of severity and impairment. It presents evidence to support treatment with psychotherapy, medications, and a combination of interventions in a multimodal approach.

Effects of perceived criticism on anxiety and depression during behavioral treatment of anxiety disorders

The present study explored the effect of perceived criticism (PC) on levels of anxiety and depression during behavioral treatment among patients diagnosed with obsessive-compulsive disorder (OCD) or panic disorder with agoraphobia (PDA). We posited that patients' perceptions of relatives' criticism and the degree to which they were upset by the criticism (UC) would be related to negative affect and discomfort during exposure. The sample included 75 patients with a primary diagnosis of OCD (n=43) or PDA (n=32) and their participating relatives. Measures of patients' weekly ratings of PC and upset about the criticism, anxious and depressed mood, and subjective discomfort during exposure treatment were analyzed using a mixed model regression approach (SAS Proc Mixed). Patients' anxious and depressed mood predicted greater discomfort during exposure. Patients who were more UC also had higher weekly ratings of anxiety and depression, and more discomfort during exposure sessions. Findings suggest that treatment outcome may be improved by attention to patients' reactions to their interpersonal environment.

Effects of parent and family characteristics on treatment outcome of anxious children

This study examines relations between family functioning, parenting stress, parental psychopathology, and treatment outcome. Participants included 61 children (ages 7-11 years) with features or diagnoses of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Treatment conditions included group cognitive behavioral therapy (CBT) and no-treatment control. Higher family cohesion at baseline was associated with significantly greater decreases in child anxiety at posttreatment for participants who received CBT, while no association was found for the no-treatment control participants. Parenting stress and parental psychopathology were not associated with treatment outcome for either condition. Post hoc analyses examining relations between family cohesion, parenting stress, and parental psychopathology showed that parents from families low in cohesion reported significantly higher levels of parenting stress and psychopathology compared to parents from families high in cohesion. These results will facilitate development and implementation of effective interventions with anxious children.

Client Similarities and Differences in Two Childhood Anxiety Disorders Research Clinics

Some evidence suggests that research and service clinics differ on treatment-relevant dimensions, but no study has examined whether research clinics (RCs) themselves differ. We compared 2 samples of children and adolescents (ages 7 to 17 years) with anxiety disorders treated in 2 different university-based child anxiety RCs, one in Philadelphia (n = 184) and one in Miami (n = 64), on child symptom and diagnostic measures, family characteristics (e.g., income), and level of maternal depression. The samples were not significantly different on any youth symptom and diagnostic measures except 1 (parent-reported diagnoses); further, the 2 samples were statistically equivalent on 3 of 6 youth symptom measures. Although the Miami sample had significantly more parent-reported diagnoses than the Philadelphia sample, the effect size was small (Cohen's d = .44). Statistically significant differences between the samples in ethnic background and family income were observed, though the former was not significant after controlling for population differences. Findings are discussed in terms of the implications of homogeneity of RCs for treatments tested there.

Maternal stress in nonverbal learning disorder: a comparison with reading disorder

Maternal stress was assessed in mothers of children ages 8 to 11 years with learning disorders (LD). Age-, gender-, and IQ-matched children with reading disorders (RD; n = 31), children with nonverbal learning disorders (NVLD; n = 21), and typically developing control participants (n = 23) participated. Mothers of children with LD reported higher levels of stress, although the specific nature of the stress appeared to vary by disorder subtype: Mothers of children with RD reported higher levels of general distress, whereas mothers of children with NVLD reported higher levels of dysfunctional interactions with their child. The severity of the LD was strongly associated with maternal stress in the sample of children with NVLD but not in the sample of children with RD. In the sample of children with NVLD, the best predictors of maternal stress were 2 variables associated with the child: The lower the child's Performance IQ, the higher the level of maternal stress. Furthermore, the level of the child's internalizing symptoms was also a strong predictor of maternal stress in the sample of children with NVLD. In our sample of children with RD, the 3 best predictors were all variables associated with the mother, including her age, her level of reported psychiatric symptoms, and her overall level of social support.

Should Parents Be Co-Clients in Cognitive-Behavioral Therapy for Anxious Youth?

Cognitive-behavioral therapy (CBT) for anxiety disorders in youth has been evaluated in randomized clinical trials (RCTs), and recent studies have sought to determine if the effects can be enhanced by an adjunctive parent component. The rationale for adding parents as active participants to treatment for anxious youth includes the notions that parenting factors (a) can contribute to the maintenance of anxiety, (b) could facilitate the generalization of treatment gains, and (c) have had favorable results in treatment of other childhood disorders. To date, there have been 9 CBT treatment outcome trials with anxious youth that included parents in treatment. This article (a) provides a critical review of the research on active parent involvement in CBT of anxious youth, (b) calculates and reports effect sizes emerging from these studies, and (c) recommends areas for future research.

Ten-year review of rating scales, VII: scales assessing functional impairment

OBJECTIVE

This is the seventh in a series of 10-year reviews of rating scales. Here the authors present scales measuring functional impairment, a sequela of mental illness. The measurement of functional impairment has assumed importance with the recognition that symptom resolution does not necessarily correlate with functional improvement.

METHOD

The authors reviewed functional impairment from multiple sources over the past 20 years. Thus, this article includes a variety of scales ranging from those that have been subject to critical review with strong psychometric support to those that have not been critically reviewed but are in widespread use to those that are still finding their niche.

RESULTS

These scales represent a continuum of constructs from symptoms to functional impairment to contextual factors that affect youths' functioning. Most older scales have focused on developmentally delayed youths. Newer scales strive to measure functional impairment separate from symptomatology. Some newer scales are also keyed to determination of level of service need.

CONCLUSIONS

Scales measuring functional impairment can elucidate the impact of illness on youths, identify targets for treatment, determine service needs, and monitor treatment effectiveness. These scales are widely used in community mental health and health service delivery. They can assist in providing evidence-based treatment.

Global assessment of psychosocial functioning in child and adolescent psychiatry. A review of three unidimensional scales (CGAS, GAF, GAPD)

Global assessment of functioning represents an important aspect of assessment in clinical practice and research. It can help identify persons in need of psychiatric treatment, have predictive value and measure change over time, including treatment effects. This review examines publications concerning development, psychometric properties and usefulness of three scales for children: Axis-VI in ICD-10 Global Assessment of Psychosocial Disability (GAPD), Children's Global Assessment Scale (CGAS) and Axis-V in DSM-IV Global Assessment of Functioning Scale (GAF). It is based on literature searches in PubMed and PsycInfo (1977-2003), and screening of Scandinavian and English textbooks on child psychiatry. The three scales differ in theoretical guidelines, descriptions of codes/anchor points and psychometric aspects. CGAS has been evaluated in 69 papers and 33 have been published on GAF used for children. The one paper comparing GAPD and CGAS found both scales sufficiently reliable for clinical practice. Reliability of CGAS and GAF has been found to vary from fair to substantial, depending on raters, training and diagnostic groups. International consensus for the use of one scale for global assessment of functioning for children 4-18 years would improve reliability in clinical practice and ease comparisons of studies across countries. A training programme would assist in this.

Medicated anxious children: characteristics and cognitive-behavioural treatment response

OBJECTIVE

To determine whether individual and family characteristics of children with anxiety disorders who take psychotropic medications differ from those that are unmedicated and whether there is a differential response to cognitive-behavioural therapy (CBT).

METHOD

Children ages 8 to 12 years (n = 102: 18 medicated, 84 unmedicated) were recruited in a specialized outpatient clinic over a 3-year period. All had a primary diagnosis of an anxiety disorder. Comparisons were done using t-tests for continuous measures and chi-square tests for discrete measures. Treatment-related changes were assessed using repeated measures analyses of variance.

RESULTS

Medicated and unmedicated groups did not differ by age, sex, socioeconomic status, or diagnostic profile. Initial ratings of anxiety symptoms, depressive symptoms, and global functioning were comparable. Greater family dysfunction and family frustration were reported in medicated children. With treatment, both groups improved symptomatically and showed improved family functioning. Families of medicated children showed a greater reduction in frustration than families of unmedicated children, whereas unmedicated children showed greater gains in global functioning.

CONCLUSIONS

Initial family functioning of medicated children seems to show more disturbances. Both medicated and unmedicated children can benefit from CBT. Further studies of differential treatment effects for medicated and unmedicated children are indicated.

Cumulative environmental risk in substance abusing women: early intervention, parenting stress, child abuse potential and child development

OBJECTIVE

To assess the relationship between cumulative environmental risks and early intervention, parenting attitudes, potential for child abuse and child development in substance abusing mothers.

METHOD

We studied 161 substance-abusing women, from a randomized longitudinal study of a home based early intervention, who had custody of their children through 18 months. The intervention group received weekly home visits in the first 6 months and biweekly visits from 6 to 18 months. Parenting stress and child abuse potential were assessed at 6 and 18 months postpartum. Children's mental and motor development (Bayley MDI and PDI) and language development (REEL) were assessed at 6, 12, and 18 months postpartum. Ten maternal risk factors were assessed: maternal depression, domestic violence, nondomestic violence, family size, incarceration, no significant other in home, negative life events, psychiatric problems, homelessness, and severity of drug use. Level of risk was recoded into four categories (2 or less, 3, 4, and 5 or more), which had adequate cell sizes for repeated measures analysis.

DATA ANALYSIS

Repeated measures analyses were run to examine how level of risk and group (intervention or control) were related to parenting stress, child abuse potential, and children's mental, motor and language development over time.

RESULTS

Parenting stress and child abuse potential were higher for women with five risks or more compared with women who had four or fewer risks; children's mental, motor, and language development were not related to level of risk. Children in the intervention group had significantly higher scores on the PDI at 6 and 18 months (107.4 vs. 103.6 and 101.1 vs. 97.2) and had marginally better scores on the MDI at 6 and 12 months (107.7 vs. 104.2 and 103.6 vs. 100.1), compared to the control group.

CONCLUSION

Compared to drug-abusing women with fewer than five risks, women with five or more risks found parenting more stressful and indicated greater inclination towards abusive and neglectful behavior, placing their infants at increased risk for poor parenting, abuse and neglect. Early home-based intervention in high-risk families may be beneficial to infant development.