Anxiety Disorders During Childhood and Adolescence: Origins and Treatment

The Structure of Challenging Parenting Behavior and Associations With Anxiety in Dutch and Australian Children

Challenging parenting behavior (CPB), a novel construct involving active physical and verbal behaviors that encourage children to push their limits, has been identified as a potential buffer against child anxiety. This study aimed to (a) evaluate the measurement invariance of the Challenging Parenting Behavior Questionnaire (CPBQ4-6) across Dutch and Australian mothers and fathers of preschoolers, (b) examine differences in levels of CPB across mothers and fathers and across countries, and (c) examine whether parents' CPB predicts less child anxiety symptoms and disorders. Participants were 312 families-146 Dutch and 166 Australian-with their 3- to 4-year-old child (55.8% girls). Fathers' and mothers' CPB was measured using the CPBQ4-6, and child anxiety symptoms and presence of anxiety disorders were assessed using maternal reports. Multigroup confirmatory factor analyses revealed equivalence of factor structure and factor loadings (all significant) of the CPBQ4-6 across mothers and fathers and across countries. Evidence of partial scalar invariance indicated that the groups differed on some subscales of the CPBQ4-6. Australian mothers scored lower on the CPB factor than Australian fathers and Dutch parents. Structural equation models showed that CPB predicted fewer child anxiety symptoms and anxiety disorders for all groups. The study confirms that the CPBQ4-6 is appropriate for use with Dutch and Australian parents of preschool-age children and identifies CPB as a multifaceted and coherent construct. The negative relations between CPB and child anxiety suggest that CPB has a protective role in childhood anxiety and is important to examine in future research and interventions.

Comparison of Stepped Care Delivery Against a Single, Empirically Validated Cognitive-Behavioral Therapy Program for Youth With Anxiety: A Randomized Clinical Trial

OBJECTIVE

Stepped care is embraced as an ideal model of service delivery but is minimally evaluated. The aim of this study was to evaluate the efficacy of cognitive-behavioral therapy (CBT) for child anxiety delivered via a stepped-care framework compared against a single, empirically validated program.

METHOD

A total of 281 youth with anxiety disorders (6-17 years of age) were randomly allocated to receive either empirically validated treatment or stepped care involving the following: (1) low intensity; (2) standard CBT; and (3) individually tailored treatment. Therapist qualifications increased at each step.

RESULTS

Interventions did not differ significantly on any outcome measures. Total therapist time per child was significantly shorter to deliver stepped care (774 minutes) compared with best practice (897 minutes). Within stepped care, the first 2 steps returned the strongest treatment gains.

CONCLUSION

Stepped care and a single empirically validated program for youth with anxiety produced similar efficacy, but stepped care required slightly less therapist time. Restricting stepped care to only steps 1 and 2 would have led to considerable time saving with modest loss in efficacy. Clinical trial registration information-A Randomised Controlled Trial of Standard Care Versus Stepped Care for Children and Adolescents With Anxiety Disorders; http://anzctr.org.au/; ACTRN12612000351819.

Combining child social skills training with a parent early intervention program for inhibited preschool children

BACKGROUND

Previous studies have demonstrated the efficacy of early intervention for anxiety in preschoolers through parent-education. The current study evaluated a six-session early intervention program for preschoolers at high risk of anxiety disorders in which a standard educational program for parents was supplemented by direct training of social skills to the children.

METHODS

Seventy-two children aged 3-5 years were selected based on high behavioural inhibition levels and concurrently having a parent with high emotional distress. Families were randomly assigned to either the intervention group, which consisted of six parent-education group sessions and six child social skills training sessions, or waitlist. After six months, families on waitlist were offered treatment consisting of parent-education only.

RESULTS

Relative to waitlist, children in the combined condition showed significantly fewer clinician-rated anxiety disorders and diagnostic severity and maternal (but not paternal) reported anxiety symptoms and life interference at six months. Mothers also reported less overprotection. These gains were maintained at 12-month follow-up. Parent only education following waitlist produced similar improvements among children. Quasi-experimental comparison between combined and parent-only interventions indicated greater reductions from combined intervention according to clinician reports, but no significant differences on maternal reports.

CONCLUSIONS

Results suggest that this brief early intervention program for preschoolers with both parent and child components significantly reduces risk and disorder in vulnerable children. The inclusion of a child component might have the potential to increase effects over parent-only intervention. However, future support for this conclusion through long-term, randomised controlled trials is needed.

The Parenting to Reduce Adolescent Depression and Anxiety Scale: Assessing parental concordance with parenting guidelines for the prevention of adolescent depression and anxiety disorders

Background

Despite substantial evidence demonstrating numerous parental risk and protective factors for the development of adolescent depression and anxiety disorders, there is currently no single measure that assesses these parenting factors. To address this gap, we developed the Parenting to Reduce Adolescent Depression and Anxiety Scale (PRADAS) as a criterion-referenced measure of parental concordance with a set of evidence-based parenting guidelines for the prevention of adolescent depression and anxiety disorders. In this paper, we used a sample of Australian parents of adolescents to: (1) validate the PRADAS as a criterion-referenced measure; (2) examine parental concordance with the guidelines in the sample; and (3) examine correlates of parental concordance with the guidelines.

Methods

Seven hundred eleven parents completed the PRADAS, as well as two established parenting measures, and parent-report measures of adolescent depression and anxiety symptoms. Six hundred sixty adolescent participants (aged 12–15) also completed the symptom measures. Concordance with the guidelines was assessed via nine subscale scores and a total score. Reliability of the scores was assessed with an estimate of the agreement coefficient, as well as 1-month test-retest reliability. Convergent validity was examined via correlations between the scale and two established parenting measures.

Results

One proposed subscale was removed from the final version of the scale, resulting in a total of eight subscales. Reliability was high for the total score, and acceptable to high for seven of the eight subscales. One-month test-retest reliability was acceptable to high for the total score. Convergent validity was supported by moderate to high correlations with two established measures of parenting. Overall, rates of parental concordance with the guidelines were low in our sample. Higher scores were associated with being female and higher levels of parental education. Greater parental concordance with the guidelines was associated with fewer symptoms of depression and anxiety in adolescent participants.

Discussion

This initial validation study provides preliminary support for the reliability and validity of the PRADAS. The scale has potential for use in both clinical and research settings. It may be used to identify parents’ strengths and potential targets for intervention, and as an outcome measure in studies of preventive parenting interventions.

Social anxiety in pre-adolescent children: What do we know about maintenance?

The cognitive theory of social anxiety disorder (SAD) is one of the most widely accepted accounts of the maintenance of the disorder in adults, yet it remains unknown if, or to what extent, the same cognitive and behavioral maintenance mechanisms that occur in adult SAD also apply to SAD among pre-adolescent children. In contrast to the adult literature, current models of SAD in children mostly account for etiology and maintenance processes are given limited attention. Consequently, their clinical utility for the treatment of SAD in children may be limited. This narrative review, first, critically examines the different theoretical conceptualizations of the maintenance of social anxiety in the child and adult literature and illustrates how these have resulted in different treatment approaches and clinical understanding. Second, it reviews the available evidence relating to hypotheses about the maintenance of SAD in children as derived from adult cognitive and etiological models. Third, it highlights the need to attend directly to child specific maintenance mechanisms in SAD, to draw on cognitive theory, and to account for the influence of childhood-specific contextual (e.g. family and school-based interactions) and developmental factors on children's social experiences.

Anxiety in youth with asthma: A meta-analysis

OBJECTIVES

Anxiety often presents comorbidly with asthma in youth under 18; however, prevalence rates are unclear. The aim of this review was to provide an up-to-date analysis of the literature investigating the prevalence of anxiety disorders, and comparisons of anxiety disorders and symptomatology in youth with asthma, compared to those without.

METHODS

A systematic search was conducted using the databases PsycINFO, MEDLINE, EMBASE, and CINAHL.

RESULTS

The search process produced 15 studies (n = 7443) reporting data on youth with asthma and anxiety disorders, 11 studies (n = 10 332) reporting data on youth with and without asthma and anxiety disorders, and 28 studies (n = 5848) reporting data on youth with and without asthma and anxiety symptomatology. Youth with asthma had an anxiety disorder prevalence rate of 22.7%. Youth with asthma also had a greater number of anxiety disorders, compared to those without asthma (d = 0.37, 95%CI: 0.24-0.50, P < 0.001), and higher levels of anxiety symptomatology than youth without asthma (d = 0.29, 95%CI: 0.19-0.39, P < 0.001).

CONCLUSIONS

Youth with asthma display a prevalence rate for anxiety disorders that is more than three times higher than the prevalence in healthy youth. For the specific anxiety disorders investigated, elevated prevalence rates for youth with asthma were also found. Future research needs to focus on the factors that mediate or predict the development and maintenance of anxiety in youth with asthma and the development of clinically efficacious treatments.

Parent-child interactions in children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the parenting factors that may underlie this relationship. The aim of the current study was to examine observed parenting behaviours - involvement and negativity - associated with asthma and anxiety in children using the tangram task and the Five Minute Speech Sample (FMSS). Eighty-nine parent-child dyads were included across four groups of children (8-13 years old): asthma and anxiety, anxiety only, asthma only and healthy controls. Overall, results from both tasks showed that parenting behaviours of children with and without asthma did not differ significantly. Results from a subcomponent of the FMSS indicated that parents of children with asthma were more overprotective, or self-sacrificing, or non-objective than parents of children without asthma, and this difference was greater in the non-anxious groups. The results suggest that some parenting strategies developed for parents of children with anxiety may be useful for parents of children with asthma and anxiety (e.g. strategies targeting involvement), however, others may not be necessary (e.g. those targeting negativity).

Evaluation of the PAI-A Anxiety and Depression Scales: Evidence of Construct Validity

Against the background of a dearth of studies examining the properties of the scale scores of the Personality Assessment Inventory-Adolescent (PAI-A; Morey, 2007), this study was conducted to evaluate evidence of construct validity for the Anxiety (ANX) and Depression (DEP) scales of the PAI-A. Convergent and discriminant validity of the ANX and DEP scale scores were investigated using a sample of adolescents admitted to the adolescent program of a private tertiary care inpatient treatment facility. Multiple methods assessing anxious and depressive symptomology and diagnoses were included. Construct validity of the ANX and DEP scales was mostly supported. Advantages of using the PAI-A for the assessment of anxiety and depression were discussed.

Eclectic approach to anxiety disorders among rural children

Introduction

Anxiety disorders in primary school-aged children negatively affect their mental health and psychological development. Available non-medical treatments for these conditions are time-consuming and expensive. In this context, eclectic therapy is a therapeutic approach that incorporates some therapeutic techniques and philosophies to create the ideal treatment. In this study, eclectic therapy consisted of art therapy and cognitive-behavioral therapy designed for children suffering from high level of anxiety in their middle childhood years. The therapy also included group guidance sessions for their mothers. The effectiveness of this intervention was examined in the study.

Methods

61 students aged 9-12 years with high levels of anxiety participated in the study. Intervention A (n = 20) consisted of 9-hour eclectic therapy for children with 3-hour group guidance sessions for their mothers. Intervention B (n = 20) consisted of 9-hour eclectic therapy for children. There was also a control group (n = 21).

Results

Teacher ratings of children's mental health difficulties and self-report ratings of anxiety disorders indicated a significant difference from pretest to posttest, revealing a large effect size between the two interventions. Higher levels of pretest scores significantly predicted higher posttest scores for all domains of anxiety and mental health difficulties. Furthermore, age, gender, mothers working a 15-hour day, mother's educational level, parental divorce rates, parental death, and family monthly income predicted therapy outcomes.

Conclusion

Results provide support for the effectiveness of eclectic art and CBT to improve children's mental health and reduce anxiety through changing thoughts, beliefs, emotions, and behaviors that may cause fear and anxiety.

Depression and Anxiety Prevention Based on Cognitive Behavioral Therapy for At-Risk Adolescents: A Meta-Analytic Review

Depression and anxiety disorders are among the most common mental disorders during adolescence. During this life phase, the incidence of these clinical disorders rises dramatically, and even more adolescents suffer from symptoms of depression or anxiety that are just below the clinical threshold. Both clinical and subclinical levels of depression or anxiety symptoms are related to decreased functioning in various areas, such as social and academic functioning. Prevention of depression and anxiety in adolescents is therefore imperative. We conducted a meta-analytic review of the effects of school-based and community-based prevention programs that are based on cognitive behavioral therapy with the primary goal preventing depression, anxiety, or both in high risk adolescents. Articles were obtained by searching databases and hand searching reference lists of relevant articles and reviews. The selection process yielded 32 articles in the meta-analyses. One article reported on two studies and three articles reported on both depression and anxiety. This resulted in a total of 36 studies, 23 on depression and 13 on anxiety. For depression prevention aimed at high risk adolescents, meta-analysis showed a small effect of prevention programs directly after the intervention, but no effect at 3-6 months and at 12 months follow-up. For anxiety prevention aimed at high risk adolescents, no short-term effect was found, nor at 12 months follow-up. Three to six months after the preventive intervention, symptoms of anxiety were significantly decreased. Although effects on depression and anxiety symptoms were small and temporary, current findings cautiously suggest that depression and anxiety prevention programs based on CBT might have small effects on mental health of adolescents. However, it also indicates that there is still much to be gained for prevention programs. Current findings and possibilities for future research are discussed in order to further improve the effectiveness of targeted prevention on internalizing disorders.

Factors affecting improvement of children and adolescents who were treated in the child and adolescent psychiatry inpatient unit

Objective

This study aimed to assess the correlates and predictors of improvement in general functioning of children and adolescents who are treated in the child and adolescent psychiatry (CAMHS) inpatient unit.

Methods

Hospital records of 308 children and adolescents who were treated for at least 1 month in the CAMHS inpatient unit from 2005–2016 were included. Associations with individual, familial, and clinical variables and the difference in Children’s Global Assessment Scale (ΔCGAS) scores at admission and discharge were evaluated.

Results

Positive predictors of ΔCGAS were older age and lower CGAS scores at admission, whereas high familial risk scores at admission and diagnosis of early-onset schizophrenia negatively predicted ΔCGAS (B = 0.698, p = 0002; B = −0.620, p < 0.001; B = −0.842, p = 0.002; B =−9.184, p = 0.000, respectively). Familial risk scores were significantly and negatively correlated with ΔCGAS (p = 0.004, Spearman’s rho = −0.2).

Conclusions

This study indicates that improvement in general functioning during inpatient treatment in CAMHS is better at an older age and with lower general functioning at admission. However, high familial risks and diagnosis of early-onset schizophrenia weakens this improvement.

Predictors of clinician use of exposure therapy in community mental health settings

Exposure therapy is recognized as the key component of cognitive-behavioral treatment for anxiety. However, exposure is the least used evidence-based treatment in community mental health settings and is the most challenging technique for clinicians to adopt within the context of effectiveness and implementation trials. Little work has examined clinician and organizational characteristics that predict use of exposure, which is important for identifying implementation strategies that may increase its use. In a large sample of community health clinicians (N=335) across 31 clinical practice sites, this study characterized clinician and organizational predictors of exposure use and relaxation for anxiety. Mixed effects regression analyses indicated that both clinician attitudes and an organization's implementation climate may be important levers for interventions seeking to increase clinician exposure use. Greater clinician use of relaxation strategies was also associated with less exposure use. Results point to important implications for implementing cognitive-behavioral therapy for anxiety, including de-emphasizing relaxation and attending to organizational climate.

Factors Associated With Parental Consent to use D-Cycloserine for Child Anxiety

This study examined factors influencing parent willingness to use D-Cycloserine (DCS) for treating child anxiety. N = 222 parents were given information about using DCS to treat anxiety. They were then asked to rate their willingness to allow their child to take DCS/antibiotics for mild anxiety, severe anxiety, or an infection. The associations between willingness to use DCS and parental trait anxiety, demographics, as well as specific concerns regarding the medication, were examined. Parents could also provide written responses regarding their attitudes to DCS, which were analysed for themes. Parents reported concerns regarding potential side-effects from DCS. More severe anxiety was associated with more willingness to consent; however, parents were more willing to use antibiotics to treat an infection than DCS to treat their child's anxiety. The degree of perceived benefit from DCS was most strongly associated with parents’ willingness to use it. Overall, parents expressed mixed views, reporting they would consider using DCS to treat their child; however, they had significant concerns about it. Results suggest providing parents with information explaining how DCS works, its risks and potential benefits may increase its acceptability.

Student–Teacher Relationships and Student Anxiety: Moderating Effects of Sex and Academic Achievement

This study examined the influence of student–teacher relationships on children’s anxiety and its differential association according to children’s sex and academic achievement. The sample included 350 third- and fourth-grade students and their elementary school teachers. Results of multiple regression analysis indicated that student–teacher conflict at the beginning of the school year was associated with higher anxiety in students at the end of the year. The influence of conflict with teachers also varied for boys and girls, according to their academic achievement. Indeed, high-achieving girls reporting conflict with teachers presented more anxiety compared with boys and their low-achieving peers. This study highlights the influence of teachers on student anxiety, and brings attention to high-achieving girls, a group rarely considered at risk.

Anxiety disorders

Anxiety disorders constitute the largest group of mental disorders in most western societies and are a leading cause of disability. The essential features of anxiety disorders are excessive and enduring fear, anxiety or avoidance of perceived threats, and can also include panic attacks. Although the neurobiology of individual anxiety disorders is largely unknown, some generalizations have been identified for most disorders, such as alterations in the limbic system, dysfunction of the hypothalamic-pituitary-adrenal axis and genetic factors. In addition, general risk factors for anxiety disorders include female sex and a family history of anxiety, although disorder-specific risk factors have also been identified. The diagnostic criteria for anxiety disorders varies for the individual disorders, but are generally similar across the two most common classification systems: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, Tenth Edition (ICD-10). Despite their public health significance, the vast majority of anxiety disorders remain undetected and untreated by health care systems, even in economically advanced countries. If untreated, these disorders are usually chronic with waxing and waning symptoms. Impairments associated with anxiety disorders range from limitations in role functioning to severe disabilities, such as the patient being unable to leave their home.

Internet-Delivered Parenting Program for Prevention and Early Intervention of Anxiety Problems in Young Children: Randomized Controlled Trial

OBJECTIVE

The Cool Little Kids parenting group program is an effective intervention for preventing anxiety disorders in young children who are at risk because of inhibited temperament. The program has six group sessions delivered by trained psychologists to parents of 3- to 6-year-old children. An online adaptation (Cool Little Kids Online) has been developed to overcome barriers to its wide dissemination in the community. This study tested the efficacy of Cool Little Kids Online in a randomized controlled trial.

METHOD

A total of 433 parents of a child aged 3 to 6 years with an inhibited temperament were randomized to the online parenting program or to a 24-week waitlist. The online program has 8 interactive modules providing strategies that parents can implement with their child to manage their child's avoidant coping, reduce parental overprotection, and encourage child independence. Parents were provided telephone consultation support with a psychologist when requested. Parents completed self-report questionnaires at baseline and at 12 and 24 weeks after baseline.

RESULTS

The intervention group showed significantly greater improvement over time in child anxiety symptoms compared to the control group (d = 0.38). The intervention group also showed greater reductions in anxiety life interference (ds = 0.33-0.35) and lower rates of anxiety disorders than the control group (40% versus 54%), but there were minimal effects on broader internalizing symptoms or overprotective parenting.

CONCLUSION

Results provide empirical support for the efficacy of online delivery of the Cool Little Kids program. Online dissemination may improve access to an evidence-based prevention program for child anxiety disorders. Clinical trial registration information-Randomised Controlled Trial of Cool Little Kids Online: A Parenting Program to Prevent Anxiety Problems in Young Children; http://www.anzctr.org.au/; 12615000217505.

Negative Life Events, Social Support, and Self-Efficacy in Anxious Adolescents

PURPOSE

To examine the prevalence and correlates of anxiety in a community sample of adolescents. Knowing the prevalence and characteristics of anxious adolescents is valuable to improve anxiety prevention strategies and interventions.

DESIGN

Cross-sectional data about anxiety were collected via a school survey from a community sample of Norwegian adolescents aged 12-17 (N = 1719).

METHODS

Based on scores from the Spence Children's Anxiety Scale, the adolescents were categorized as not anxious or anxious. Logistic regression analysis was performed to access the impact of each factor on the likelihood that participants would report an elevated level of anxiety.

RESULTS

A total of 22% of the adolescents were categorized as anxious. Female gender, experienced negative life events, low social support, and low self-efficacy were associated with elevated level of anxiety.

CONCLUSIONS

The high prevalence of anxiety in adolescents demonstrates the importance of improved prevention interventions targeting anxious adolescents. We argue that addressing is the responsibility of not only the individual adolescents and their families but also schools, school health services, and policy makers. School-based interventions that increase social support and self-efficacy would probably be particularly beneficial for anxious adolescents.

School-based cognitive behavioral interventions for anxious youth: study protocol for a randomized controlled trial

Background

Anxiety disorders are prevalent among adolescents and may have long-lasting negative consequences for the individual, the family and society. Cognitive behavioral therapy (CBT) is an effective treatment. However, many anxious youth do not seek treatment. Low-intensity CBT in schools may improve access to evidence-based services. We aim to investigate the efficacy of two CBT youth anxiety programs with different intensities (i.e., number and length of sessions), both group-based and administered as early interventions in a school setting. The objectives of the study are to examine the effects of school-based interventions for youth anxiety and to determine whether a less intensive intervention is non-inferior to a more intensive intervention.

Methods/design

The present study is a randomized controlled trial comparing two CBT interventions to a waitlist control group. A total of 18 schools participate and we aim to recruit 323 adolescents (12-16 years). Youth who score above a cutoff on an anxiety symptom scale will be included in the study. School nurses recruit participants and deliver the interventions, with mental health workers as co-therapists and/or supervisors. Primary outcomes are level of anxiety symptoms and anxiety-related functional impairments. Secondary outcomes are level of depressive symptoms, quality of life and general psychosocial functioning. Non-inferiority between the two active interventions will be declared if a difference of 1.4 or less is found on the anxiety symptom measure post-intervention and a difference of 0.8 on the interference scale. Effects will be analyzed by mixed effect models, applying an intention to treat procedure.

Discussion

The present study extends previous research by comparing two programs with different intensity. A brief intervention, if effective, could more easily be subject to large-scale implementation in school health services.

Trial registration

ClinicalTrials.gov, NCT02279251. Registered on 15 October 2014. Retrospectively registered.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1831-9) contains supplementary material, which is available to authorized users.

The influence of patient, caregiver, and family factors on symptoms of anxiety and depression in children and adolescents with intractable epilepsy

OBJECTIVE

The objective was to evaluate the association of caregiver and family factors with symptoms of anxiety and depression in children and adolescents with medically refractory localization-related epilepsy (i.e., failed at least two epilepsy medications).

METHOD

Forty-four children (ages 6-11years) and 65 adolescents (ages 12-18years) and their parents participated in this multicentered, observational, cross-sectional study. Univariable and multivariable linear regressions were used to evaluate the influence of multiple patient, caregiver, and family characteristics on self-reported symptoms of anxiety and depression in the children and adolescents.

RESULTS

Among children, depressive symptoms were associated with a lower proportion of life with seizures (β=.344, p=.022), caregiver depression (β=.462, p=.002), poorer family relationships (β=.384, p=.010), and poorer family mastery and social support (β=.337, p=.025); in multivariable analysis, proportion of life with epilepsy and parental depression remained significant. No significant predictors of anxiety were found among children. Among adolescents, depressive symptoms were associated with caregiver unemployment (β=.345, p=.005) and anxiety (β=.359, p=.003), low household income (β=.321, p=.012), poorer family mastery and social support (β=.334, p=.007), and greater family demands (β=.326, p=.008); in multivariable analysis, caregiver unemployment and anxiety remained significant. Greater anxiety symptoms among adolescents were associated with females (β=.320, p=.009) and caregiver depression (β=.246, p=.048) and anxiety (β=.392, p=.001) and poorer family mastery and social support (β=.247, p=.047); in multivariable analysis, female sex and caregiver anxiety remained significant.

SIGNIFICANCE

These findings highlight the central role of caregiver psychopathology, which is amenable to intervention, on children and adolescents' symptoms of anxiety and depression. Addressing caregiver psychopathology may improve children and adolescents' quality of life even if seizure control is not attained.

Adapting Cognitive Behavioral Therapy for Anxious Children and Adolescents

This article discusses considerations for adapting cognitive behavioral therapy (CBT) techniques and processes with anxious children and adolescents. To successfully deliver CBT with this population, the therapist must take into consideration the child's developmental level and other contextual factors that may affect treatment outcome. Suggested adaptions to CBT include the use of rewards, technology, and interactive activities to increase child motivation and engagement. Moreover, dependent on the child's or adolescent's cognitive capacity, cognitive techniques will need to be simplified and concrete examples provided to increase children's understanding. It may be beneficial to have parents and/or schools involved in children's treatment to assist them to implement CBT strategies outside of the therapy setting. A case example is presented to illustrate the implementation of CBT with a child.

Shaping emotion regulation: attunement, symptomatology, and stress recovery within mother-infant dyads

The foundations of emotion regulation are organized, in part, through repeated interactions with one's caregiver in infancy. Less is known about how stress physiology covaries between a mother and her infant within these interactions, leaving a gap in our understanding of how the biological basis of emotion regulation develops. This study investigated physiological attunement between mothers and their 5-month-old infants, as well as the influence of maternal depression and anxiety, during stress recovery. During the reengagement phase of the Still Face Paradigm, mother-infant dyads exhibited negative attunement, as measured by inverse covariation of respiratory sinus arrhythmia (RSA). Increases in maternal RSA corresponded to decreases in infant RSA, underscoring dyadic adjustment during recovery. Moreover, infant regulation differed as a function of maternal anxiety, with more anxious mothers having infants with higher RSA during reengagement. Implications for the consolidation of regulatory capabilities within the context of the early caregiving relationship are discussed.

A Parent-Mediated, Cognitive Behavioral Therapy Group Treatment for Young Children With High-Functioning Autism Spectrum Disorder and Comorbid Anxiety: Development and Case Illustration of the Fun With Feelings Program

Comorbid anxiety is increasingly being recognized as a significant concern in children with high-functioning autism spectrum disorder (HFASD; Selles & Storch, 2013). Given the significant short and long term impact of anxiety on the functioning of a child with autism spectrum disorder (ASD; e.g., Bellini, 2004; Ben-Sasson et al., 2008), it is imperative that children with HFASD and comorbid anxiety receive intervention as early as is possible. Despite this need, there is a currently a dearth of research examining anxiety management programs for young children with HFASD. This article describes the development of a parent-mediated, cognitive behavioral therapy, group program for anxiety in 4- to 6-year-old children with HFASD. It provides a detailed discussion of the strategies taught to parents and children and highlights some of the challenges involved. A case study is also presented to illustrate progression and outcomes brought about through the program.

Do pharmaceuticals reach and affect the aquatic ecosystems in Brazil? A critical review of current studies in a developing country

Pharmaceutical residues are not completely removed in wastewater treatment plants (WWTPs) becoming contaminants in aquatic ecosystems. Thereby, it is important to investigate their concentrations in the environment and the possible consequences of their occurrence, including for human health. Here, we briefly reviewed the paths of pharmaceuticals to reach the environment, their behavior and fate in the environment, and the possible consequences of their occurrence. Moreover, we synthetized all the studies about the detection of pharmaceuticals in Brazilian water bodies and the available ecotoxicological knowledge on their effects. In this study, when we compare the data found on these compounds worldwide, we observed that Brazilian surface waters present considerable concentrations of 17α-ethinylestradiol, 17β-estradiol, and caffeine. In general, concentrations found in aquatic systems worldwide seems to be low; however, ecotoxicological tests showed that even these low concentrations can cause sublethal effects in biota. The knowledge about the effects of continuous exposure and mixtures is sparse. In summary, new research is urgently required about the effects of these compounds in biota-including long-term exposition and mixture tests-and on specific technologies to remove these compounds in water bodies and WWTPs, besides the introduction of new policies for pharmaceutical use.

Cross-sectional study of anxiety symptoms in students in preexamination period

BACKGROUND

Preexamination period is an exceptionally stressful time for schoolgoing children and adolescents, and the propensity of having anxiety symptoms increases.

AIM

This study aimed to assess the presence of anxiety symptoms in students in preexamination period.

MATERIALS AND METHODS

The study was carried on 619 children from Class VIII to XI. All of them were given a structured questionnaire for sociodemographic profile and Screen for Child Anxiety Related Emotional Disorders questionnaire. Association of various variables with presence of anxiety symptoms was assessed. Statistics was analyzed with SPSS version 17.0 software.

RESULTS

Totally 170 children (27.5%) had anxiety symptoms, similarly the various subgroups had increased frequency compared to the known prevalence in this age group. Age, years spent in the current school, living with parents, presence of domestic stressors, and grade deterioration, all were significantly associated with increased frequency of these symptoms. Similarly, association with various subgroups is described.

CONCLUSION

This study attempts to give evidence of increased anxiety symptoms, during preexamination phase, compared to the reported prevalence in this age group, and thus to address this becomes imperative which will improve their performance and also the mental health preventing distress along with psychological and behavioral problems.

Anxiety

Anxiety disorders (separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalised anxiety disorder) are common and disabling conditions that mostly begin during childhood, adolescence, and early adulthood. They differ from developmentally normative or stress-induced transient anxiety by being marked (ie, out of proportion to the actual threat present) and persistent, and by impairing daily functioning. Most anxiety disorders affect almost twice as many women as men. They often co-occur with major depression, alcohol and other substance-use disorders, and personality disorders. Differential diagnosis from physical conditions-including thyroid, cardiac, and respiratory disorders, and substance intoxication and withdrawal-is imperative. If untreated, anxiety disorders tend to recur chronically. Psychological treatments, particularly cognitive behavioural therapy, and pharmacological treatments, particularly selective serotonin-reuptake inhibitors and serotonin-noradrenaline-reuptake inhibitors, are effective, and their combination could be more effective than is treatment with either individually. More research is needed to increase access to and to develop personalised treatments.

Children Who are Anxious in Silence: A Review on Selective Mutism, the New Anxiety Disorder in DSM-5

Selective mutism (SM) is a relatively rare childhood disorder characterized by a consistent failure to speak in specific settings (e.g., school, social situations) despite speaking normally in other settings (e.g., at home). The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) lists SM among the anxiety disorders. This makes sense as the current review of the literature confirms that anxiety is a prominent symptom in many children suffering from this condition. Further, research on the etiology and treatment of SM also corroborates the conceptualization of SM as an anxiety disorder. At the same time, critical points can be raised regarding the classification of SM as an anxiety disorder. We explore a number of such issues in this review. Recommendations for dealing with this diagnostic conundrum are made for psychologists, psychiatrists, and other mental health workers who face children with SM in clinical practice, and directions for future research are highlighted.

Threat interpretation and parental influences for children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the cognitive and parent factors that may underpin this relationship. The present study investigated interpretation biases in children with asthma and anxiety and their parents, and whether parent-child discussions influenced children's interpretations. Eighty-nine parent-child dyads were included across four groups: children with asthma and anxiety, children with anxiety only, children with asthma only and healthy children (aged between 8 and 13 years old). Interpretation bias was assessed using ambiguous scenarios. Children with anxiety showed an interpretation bias in the general threat scenarios, whereas children with asthma showed an interpretation bias in the asthma threat scenarios. Parental predictions of their child's responses showed similar results. Parent-child discussions increased avoidance for children with anxiety and no asthma across all scenarios, but only for children with asthma and anxiety in the asthma threat scenarios. The results provide partial support for a cognitive theory of asthma and anxiety in children and suggest that parents play a role in influencing children's thinking styles. Treatment programs could thus aim to target and modify interpretation biases in children with anxiety, and include parents as part of treatment.

Patterns of Comorbidity Among Girls With ADHD: A Meta-analysis

CONTEXT

Although children with attention-deficit/hyperactivity disorder (ADHD) are at elevated risk for comorbid psychopathology, the clinical correlates of ADHD in girls are far less understood relative to boys, despite ADHD being one of the most common childhood disorders in girls.

OBJECTIVE

To meta-analytically summarize rates of comorbid internalizing (anxiety, depression) and externalizing (oppositional defiant disorder [ODD], conduct disorder [CD]) psychopathology among girls with and without ADHD.

DATA SOURCES

Literature searches (PubMed, Google Scholar) identified published studies examining comorbid psychopathology in girls with and without ADHD.

STUDY SELECTION

Eighteen studies (1997 participants) met inclusion criteria and had sufficient data for the meta-analysis.

DATA EXTRACTION

Odds ratios for each comorbid disorder were calculated from available data. Demographic (eg, age, race/ethnicity) and study characteristics (eg, referral source, diagnostic method) were also coded.

RESULTS

Compared with girls without ADHD, girls with ADHD were significantly more likely to meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for each comorbid disorder assessed. Relative odds were higher for externalizing (ODD: 5.6×; CD: 9.4×) relative to internalizing disorders (anxiety: 3.2×; depression: 4.2×). Meta-regression revealed larger effect sizes of ADHD on anxiety for studies using multiple diagnostic methods, featuring younger children, and including clinic-referred (versus community-referred) girls; the effect of ADHD on ODD varied based on diagnostic informant.

LIMITATIONS

Findings were derived from cross-sectional studies, precluding causal inferences.

CONCLUSIONS

Girls with ADHD frequently exhibit comorbid externalizing and internalizing disorders. We discuss future research priorities and consider intervention implications for ADHD and comorbid psychopathology in girls.

Prevalence of anxiety disorders among children who stutter

PURPOSE

Stuttering during adulthood is associated with a heightened rate of anxiety disorders, especially social anxiety disorder. Given the early onset of both anxiety and stuttering, this comorbidity could be present among stuttering children.

METHOD

Participants were 75 stuttering children 7-12 years and 150 matched non-stuttering control children. Multinomial and binary logistic regression models were used to estimate odds ratios for anxiety disorders, and two-sample t-tests compared scores on measures of anxiety and psycho-social difficulties.

RESULTS

Compared to non-stuttering controls, the stuttering group had six-fold increased odds for social anxiety disorder, seven-fold increased odds for subclinical generalized anxiety disorder, and four-fold increased odds for any anxiety disorder.

CONCLUSION

These results show that, as is the case during adulthood, stuttering during childhood is associated with a significantly heightened rate of anxiety disorders. Future research is needed to determine the impact of those disorders on speech treatment outcomes.

The effect of targeting tolerance of children's negative emotions among anxious parents of children with anxiety disorders: A pilot randomised controlled trial

Following cognitive behavioural therapy for child anxiety a significant minority of children fail to lose their diagnosis status. One potential barrier is high parental anxiety. We designed a pilot RCT to test claims that parental intolerance of the child's negative emotions may impact treatment outcomes. Parents of 60 children with an anxiety disorder, who were themselves highly anxious, received either brief parent-delivered treatment for child anxiety or the same treatment with strategies specifically targeting parental tolerance of their child's negative emotions. Consistent with predictions, parental tolerance of the child's negative emotions significantly improved from pre- to post-treatment. However, there was no evidence to inform the direction of this association as improvements were substantial in both groups. Moreover, while there were significant improvements in child anxiety in both conditions, there was little evidence that this was associated with the improvement in parental tolerance. Nevertheless, findings provide important clinical insight, including that parent-led treatments are appropriate even when the parent is highly anxious and that it may not be necessary to adjust interventions for many families.

Parental Involvement in Infant Sleep Routines Predicts Differential Sleep Patterns in Children With and Without Anxiety Disorders

This study compared parents' retrospective reports of their involvement in infant settling strategies and their relation to current sleep patterns among children (N = 84, ages 7-11) with generalized anxiety disorder (GAD) and healthy controls. Parents of children with GAD were significantly more likely to report rocking their infants to sleep and putting infants down when they were already asleep than parents of healthy controls, even when accounting for infant health-related factors and parental anxiety. Greater involvement in infant sleep routines also predicted sleep patterns (measured via actigraphy) during childhood, though opposite relationships were observed in the two groups. Early involvement was related to poorer sleep in control children but better sleep for children with GAD even after controlling for current parenting practices. Findings suggest differential effects of early sleep-related parenting for children with and without later anxiety disorders with possible implications for early intervention.

Co-Occurrence of ADHD and Anxiety in Preschool Children

OBJECTIVE

The objective of this study was to examine co-occurrence of ADHD and anxiety in preschool children.

METHOD

The data collection was part of the Norwegian Mother and Child Cohort Study (MoBa) at the Norwegian Institute of Public Health. After a screening for ADHD symptoms at 36 months, participants were clinically assessed at age 36 to 44 months. Psychiatric symptoms of ADHD and anxiety were derived from the Preschool Age Psychiatric Assessment (PAPA) interview.

RESULTS

In preschoolers with ADHD symptoms, 33% were reported to have symptoms of anxiety. Children with symptoms of ADHD and anxiety had more severe ADHD symptomatology, and particularly more inattentive symptoms compared with children with ADHD symptoms and no anxiety.

CONCLUSION

Clinicians should be aware of the frequent overlap between symptoms of anxiety and ADHD in preschoolers as different intervention strategies may be required.

Evaluating differences in Pavlovian fear acquisition and extinction as predictors of outcome from cognitive behavioural therapy for anxious children

BACKGROUND

Extinction is a key theoretical model of exposure-based treatments, such as cognitive behavioural therapy (CBT). This study examined whether individual differences in physiological responses and subjective stimulus evaluations as indices of fear extinction predicted response to CBT.

METHODS

Thirty-two nonanxious comparisons and 44 anxious, 7-to-13-year-old children completed a Pavlovian conditioning and extinction task. Anxious children then completed group-based CBT. Skin conductance responses (SCRs) as well as subjective arousal and valence evaluations were measured in response to a conditioned stimulus paired with an aversive tone (CS+) and another conditioned stimulus presented alone (CS-). Both stimuli were presented alone during extinction. Diagnostic and symptom measures were completed before and after treatment.

RESULTS

Like nonanxious comparisons, treatment responders did not acquire conditioned negative stimulus evaluations and displayed elevated SCRs that declined significantly across extinction trials. Nonresponders, by contrast, showed elevated negative stimulus evaluations of both CSs that were sensitive to extinction trials but showed no change in SCRs during extinction. Change in physiological but not evaluative indices of fear extinction predicted better treatment outcomes.

CONCLUSIONS

Individual differences in evaluative and physiological indices of fear extinction might moderate response to CBT.

Early Nonparental Care and Social Behavior in Elementary School: Support for a Social Group Adaptation Hypothesis

This study examined the contribution of nonparental child-care services received during the preschool years to the development of social behavior between kindergarten and the end of elementary school with a birth cohort from Québec, Canada (N = 1,544). Mothers reported on the use of child-care services, while elementary school teachers rated children's shyness, social withdrawal, prosociality, opposition, and aggression. Children who received nonparental child-care services were less shy, less socially withdrawn, more oppositional, and more aggressive at school entry (age 6 years). However, these differences disappeared during elementary school as children who received exclusive parental care caught up with those who received nonparental care services. This "catch-up" effect from the perspective of children's adaptation to the social group is discussed.

Emergent patterns of risk for psychopathology: The influence of infant avoidance and maternal caregiving on trajectories of social reticence

The current study investigated the influential role of infant avoidance on links between maternal caregiving behavior and trajectories at risk for psychopathology. A sample of 153 children, selected for temperamental reactivity to novelty, was followed from infancy through early childhood. At 9 months, infant avoidance of fear-eliciting stimuli in the laboratory and maternal sensitivity at home were assessed. At 36 months, maternal gentle discipline was assessed at home. Children were repeatedly observed in the lab with an unfamiliar peer across early childhood. A latent class growth analysis yielded three longitudinal risk trajectories of social reticence behavior: a high-stable trajectory, a high-decreasing trajectory, and a low-increasing trajectory. For infants displaying greater avoidance, 9-month maternal sensitivity and 36-month maternal gentle discipline were both positively associated with membership in the high-stable social reticence trajectory, compared to the high-decreasing social reticence trajectory. For infants displaying lower avoidance, maternal sensitivity was positively associated with membership in the high-decreasing social reticence trajectory, compared to the low-increasing trajectory. Maternal sensitivity was positively associated with the high-stable social reticence trajectory when maternal gentle discipline was lower. These results illustrate the complex interplay of infant and maternal behavior in early childhood trajectories at risk for emerging psychopathology.

Aetiological influences on stability and change in emotional and behavioural problems across development: a systematic review

Emotional and behavioural problems in childhood and adolescence can be chronic and are predictive of future psychiatric problems. Understanding what factors drive the development and maintenance of these problems is therefore crucial. Longitudinal behavioural genetic studies using twin, sibling or adoption data can be used to explore the developmental aetiology of stability and change in childhood and adolescent psychopathology. We present a systematic review of longitudinal, behavioural genetic analyses of emotional and behavioural problems between ages 0 to 18 years. We identified 58 studies, of which 19 examined emotional problems, 30 examined behavioural problems, and 9 examined both. In the majority of studies, stability in emotional and behavioural problems was primarily genetically influenced. Stable environmental factors were also widely found, although these typically played a smaller role. Both genetic and environmental factors were involved in change across development. We discuss the findings in the context of the wider developmental literature and make recommendations for future research.

Prevention and early intervention of anxiety problems in young children: A pilot evaluation of Cool Little Kids Online

Anxiety disorders are common, debilitating, and begin early in life. Early intervention to prevent anxiety disorders in children who are at risk could have long-term impact. The 'Cool Little Kids' parenting group program has previously been shown to be efficacious in preventing anxiety disorders in temperamentally inhibited young children. Wider dissemination of the program could be achieved with an internet-based delivery platform, affording greater accessibility and convenience for parents. The aim of this study was to evaluate 'Cool Little Kids Online', a newly developed online version of the existing parenting group program. Fifty-one parents of children aged 3-6 years were recruited to evaluate the online program's acceptability and preliminary efficacy in reducing inhibited young children's anxiety problems. Parents were randomized to receive either a clinician-supported version or an unsupported version of the program. Parents had 10 weeks to access the program and completed questionnaires at baseline and post-intervention. Both groups showed medium-to-large reductions in children's anxiety symptoms, emotional symptoms, number of child anxiety diagnoses, and improvements in life interference from anxiety. The effect of clinician support was inconsistent and difficult to interpret. Parents reported high levels of satisfaction with the program. These encouraging results indicate that the online version is acceptable and useful for parents with temperamentally inhibited young children. Cool Little Kids Online may be a promising direction for improving access to an evidence-based prevention and early intervention program for child anxiety problems. A large randomized trial is warranted to further evaluate efficacy.