PREVENTING CHILD AND ADOLESCENT ANXIETY DISORDERS: OVERVIEW OF SYSTEMATIC REVIEWS

Randomized controlled trial for selective preventive transdiagnostic intervention for adolescents at risk for emotional disorders

Significant evidence does exist on the effectiveness of transdiagnostic interventions to improve emotional problems in clinical populations, and their application as universal and indicated prevention programs. However, no randomized controlled trials (RCT) studying selective transdiagnostic prevention intervention have been published. This is the first known RCT to evaluate the efficacy/effectiveness of an evidence-based selective prevention transdiagnostic program for emotional problems in adolescents. The impact of three different interventions was evaluated: (1) PROCARE (Preventive transdiagnostic intervention for Adolescents at Risk for Emotional disorders), which is a group-based, abbreviated version of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A), along with adding a booster session to reduce risk of onset of anxiety and depression, (2) PROCARE + , which includes the PROCARE protocol along with personalized add-on modules tailored to match adolescents' risk factors, and (3) an active control condition (ACC) based on emotional psychoeducation. In total, 208 adolescents (48.5% girls) evidencing high risk and low protective factors were randomized and allocated to PROCARE, PROCARE + or ACC. Data from 153 adolescents who completed all assessments in the different phases of the study were analyzed. Self- and parent-reported measures were taken at baseline, as well as after the intervention, a 6 month follow-up was carried out, together with a 1 month follow-up after the booster session. Differences between conditions were significant on most of the outcome measures, with superior effect sizes for PROCARE + in the short and long term. Interventions were acceptable in terms of acceptability, with good satisfaction rates. Tailored targeted selective transdiagnostic interventions focused on mitigating risk factors and promoting protective factors in vulnerable adolescents are promising.

Effectiveness of Social Inclusion Interventions for Anxiety and Depression among Adolescents: A Systematic Review

BACKGROUND

Adolescents who are socially excluded are at increased risk of mental health problems such as depression and anxiety. Promoting social inclusion could be an effective strategy for preventing and treating adolescent depression and anxiety.

METHODS

We conducted a systematic review of intervention studies which aimed to prevent or treat adolescent depression and/or anxiety by promoting social inclusion. Throughout the review we engaged a youth advisory group of 13 young people (aged 21-24) from Uganda, Turkey, Syria, South Africa, and Egypt.

RESULTS

We identified 12 studies relevant to our review. The interventions tested use a range of different strategies to increase social inclusion and reduce depression and anxiety, including social skills training, psychoeducation, teaching life skills training, and cash transfers. Pooled standardised mean differences (SMDs) based on random-effects models showed medium-to-large benefits of interventions on improving depression and anxiety symptoms (n = 8; SMD = -0.62; 95% CI, -1.23 to -0.01, p < 0.05).

CONCLUSION

Although there are not many studies, those which have been done show promising results that strongly suggest that social inclusion could be an important component of programmes to promote adolescent mental health.

Randomized controlled trial for selective preventive transdiagnostic intervention for adolescents at risk for emotional disorders

Significant evidence does exist on the effectiveness of transdiagnostic interventions to improve emotional problems in clinical populations, and their application as universal and indicated prevention programs. However, no randomized controlled trials (RCT) studying selective transdiagnostic prevention intervention have been published. This is the first known RCT to evaluate the efficacy/effectiveness of an evidence-based selective prevention transdiagnostic program for emotional problems in adolescents. The impact of three different interventions was evaluated: (1) PROCARE (Preventive transdiagnostic intervention for Adolescents at Risk for Emotional disorders), which is a group-based, online-delivered, abbreviated version of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A), along with adding a booster session, to reduce risk of onset of anxiety and depression, (2) PROCARE + , which includes the PROCARE protocol along with personalized add-on modules tailored to match adolescents' risk factors, and (3) an active control condition (ACC) based on emotional psychoeducation. In total, 286 adolescents (53.3% girls) evidencing high risk and low protective factors were randomized and allocated to PROCARE, PROCARE + or ACC. Self- and parent-reported measures were taken at baseline, as well as after the intervention, a 6-month follow-up was carried out, together with a 1-month follow-up after the booster session. Differences between conditions were significant on most of the outcome measures, with superior effect sizes for PROCARE +. Interventions were excellent in terms of acceptability, with good satisfaction rates. Tailored selective transdiagnostic interventions focused on mitigating risk factors and promoting protective factors in vulnerable adolescents are promising.

Mental Health and Positive Development Prevention Interventions: Overview of Systematic Reviews

CONTEXT

Previous reviews of mental health interventions have focused on adolescents (10-19 years), with a paucity of comprehensive evidence syntheses on preventive interventions for school-aged children (5-10 years).

OBJECTIVE

To summarize and synthesize the available evidence from systematic reviews of mental health and positive development interventions for children aged 5-14.9 years in both high-income (HIC) and low- and middle-income countries (LMIC), with a focus on preventive and promotive strategies.

DATA SOURCES

This overview includes all relevant reviews from OVID Medline, The Cochrane Library, and Campbell Systematic Reviews through December 2020.

STUDY SELECTION

We included systematic reviews that synthesized empirical studies using experimental or quasi-experimental designs to evaluate the effectiveness of interventions in children aged 5-14.9 years.

DATA EXTRACTION

Data extraction and quality assessment were completed independently and in duplicate by two review authors. The AMSTAR2 tool was used to assess methodological quality.

RESULTS

We included 162 reviews. The greatest evidence was found in support of school-based universal and anti-bullying interventions in predominantly HIC. Moderate evidence was found for the use of substance abuse prevention, and early learning and positive development interventions in mixed settings. In LMIC-only contexts, the most promising evidence was found for positive youth development programs.

LIMITATIONS

The review was primarily limited by paucity of high-quality research due to methodological issues and high heterogeneity.

CONCLUSIONS

This overview of reviews highlights the need for further research to consolidate findings and understand the specific criteria involved in creating positive mental health and development outcomes from the various interventions considered.

Factors Influencing Adolescent Anxiety: The Roles of Mothers, Teachers and Peers

Grounded in social-ecological system theory, the present study tested the mediating effects of maternal psychological flexibility and mother-adolescent attachment on the relationship between maternal adult attachment and adolescent anxiety as well as the moderating effects of teacher support and peer support on the relationship between mother-adolescent attachment and adolescent anxiety. In total, 1139 Chinese mothers and adolescents completed a set of questionnaires, including the Experiences in Close Relationships Scale, Parental Psychological Flexibility Questionnaire, Inventory of Parent and Peer Attachment, Trait Anxiety Inventory, and Multidimensional Scale of Perceived Social Support. The results revealed that maternal adult attachment had a positive impact on adolescent anxiety. The relationship between maternal adult attachment and adolescent anxiety was chain mediated by maternal psychological flexibility and mother-adolescent attachment. In addition, teacher support and peer support had moderating effects on the relationship between mother-adolescent attachment and adolescent anxiety. These findings support the systematic social ecosystem perspective and highlight the differences in the effects of different maternal adult attachment styles, teacher support, and peer support on adolescent anxiety.

Regular swimming exercise improves metabolic syndrome risk factors: a quasi-experimental study

Background

In the past few decades, swimming became one of the most important physical activities within the health system and is considered a practical nonpharmacological approach to managing of type 2 diabetes (T2DM), hyperlipidemia, hypertension (HTN), and obesity. The current study aimed to assess the effect of long-term swimming sessions on glycemic and lipidemic parameters, hemodynamic responses, body fat percent, and body mass index for patients with metabolic risk factors from Palestine.

Methods

Forty participants from both genders with T2DM and HTN (aged 52.4 ± 5.5 yrs) agreed to participate in this quasi-experimental study and were divided into two groups. The first group included the participants who performed long-term swimming sessions and the second group served as the control. The first group exercised for 2 h, 3 times/week in 29–33 °C swimming pool temperature for 16 weeks. Simultaneously, the control group did not participate in any exercise and advised them to keep on with their everyday lifestyle. All the obtained metabolic syndrome risk factors data were analyzed using a two-way ANOVA analysis of variance (2*2) which was applied to determine the differences according group, time, and interaction.

Results

The results showed that there were statistically significant differences at p < 0.05 in the variables of Total Cholesterol (TC), High Density of Lipoprotein (HDL), Low Density of Lipoprotein (LDL), Triglycerides (TG), Blood Glucose (BG), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Body Mass Index (BMI), and body fat percent according to group, time, and interaction for the experimental group.

Conclusions

The findings of the current study suggested that the regular 16 weeks of swimming sessions could be considered nonpharmacological approaches in managing T2DM and HTN.

The school-led Preventure study: Protocol of a cluster-randomised controlled trial of effectiveness to prevent adolescent alcohol misuse, internalising problems, and externalising problems through a personality-targeted intervention delivered by school staff

Mental disorders and problematic alcohol use are common, co-occurring and cause significant harm to individuals and society. It is critical to intervene early to prevent chronic and debilitating trajectories. Existing prevention programs among adolescents are limited in effectiveness and implementation. This Australian-first study will examine the effectiveness and feasibility of a personality-targeted program called Preventure, in preventing the onset or escalation of alcohol use, internalising problems and externalising problems among young Australians, when delivered by school staff. A cluster randomised controlled trial (RCT) of effectiveness will be conducted from 2020 to 2022 with 12 schools in Sydney, Australia, with students aged 13 years at baseline. Schools will be randomly allocated to the Preventure intervention or a control condition who will receive their usual Health Education curriculum. Schools allocated to the intervention will deliver Preventure to students scoring one standard deviation above the population mean on one of four personality traits. Preventure consists of two 90-minute group sessions that incorporate cognitive-behavioural therapy and motivational interviewing to promote coping skills. Students will be invited to complete surveys at baseline, 6- and 12-months following the intervention. Primary outcomes include student alcohol use, internalising problems, and externalising problems. Implementation fidelity, feasibility and acceptability will also be examined through surveys with school staff and students. Ethical approval has been obtained from the University of Sydney Human Research Ethics Committee, and the State Education Research Applications Process for research in public schools in NSW. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000790943).

Unified Protocol for the Transdiagnostic Prevention of Emotional Disorders: Evaluation of a Brief, Online Course for College Freshmen

The transition to college represents a period of increased risk for developing a range of mental health conditions, highlighting the need for effective preventive interventions delivered in this setting. The purpose of the present study was to explore the feasibility, acceptability, and efficacy of a preventive version of the unified protocol for college students; this intervention, called emotions 101 was provided in a very brief, online course format. Unselected students (N = 243) were randomized to either the course (n = 120) or wait-list (n = 123) condition, and all participants were asked to complete self-report measures of stress, negative affectivity, and quality of life at baseline, 1-month, 6-month, and 8-month follow-up time points. Despite recruitment challenges, once participants enrolled in the course, they were likely to complete it and provide favorable satisfaction ratings and qualitative feedback. With regard to efficacy, there were no significant differences on our primary (emotional) outcomes (i.e., stress, negative affectivity, quality of life) as a function of condition, though individuals randomized to receive the course demonstrated significantly higher grade point averages at the end of their first college semester than those in the wait-list condition. Taken together, the findings from the present study suggest that a very brief, online prevention program for emotional disorders administered in a healthy sample does not significantly impact mental health variables.

Recognition of anxiety disorders in children: a cross-sectional vignette-based survey among general practitioners

OBJECTIVE

To quantify general practitioners' (GPs) sensitivity to anxiety disorders (ADs) when confronted with the range of symptoms common to children with ADs. Also, to explore GPs' conscious preferences and implicit tendencies for referral of children with ADs to mental healthcare.

DESIGN AND SETTING

In a cross-sectional vignette-based survey, all attendees of a Dutch continuing medical education conference for primary care physicians were presented with subtitled audio fragments of five vignettes that we constructed to mimic symptom presentation of children with ADs in general practice. We asked attendees to select per vignette the most plausible diagnoses and most adequate referral option, and for their general referral preferences when they suspect each of the most common mental health problems.

PARTICIPANTS

A sample of 229 GPs, resulting in a total of 1128 vignette evaluations.

MAIN OUTCOME MEASURE

GPs' selection rate of ADs in the five vignettes compared with a benchmark provided by mental health professionals (MHPs).

RESULTS

Overall, recognition of ADs was less likely in GPs compared with MHPs (OR=0.26, 95% CI 0.15 to 0.46). GPs varied in their recognition of anxiety, with 44.1% not once selecting anxiety as the probable presenting problem. When asked explicitly, 63.9% of the GPs reported that they would refer a child to mental healthcare when they suspect probable ADs. By contrast, only 12.0% of the GPs who recognised anxiety in the vignettes actually selected that referral option.

CONCLUSION

A significant fraction of GPs did not notice the depicted symptoms as anxiety. Despite the widespread prevalence of ADs, GPs seem to overlook anxiety already in their early diagnostic opinion. Improving GPs' familiarity with initial symptom presentation, ADs' base-rate, relevance and impact yields potential for timely recognition.

Physical Activity, Sleep, Body Mass Index, and Associated Risk of Behavioral and Emotional Problems in Childhood

OBJECTIVE

Cross-sectional data indicate that physical activity, longer sleep duration, and normal body weight are associated with better mental health in childhood. It is less clear whether these factors protect against future emotional and behavioral problems. We investigated whether physical activity, sleep duration, and body mass index (BMI) at the age of 7 years are associated with emotional and behavioral problems at the age of 11 years.

METHODS

Children born to European mothers enrolled in the prospective longitudinal Auckland Birthweight Collaborative Study (N = 871) were assessed at birth and ages 7 and 11 years. Physical activity and sleep duration were measured using accelerometer. BMI was calculated from height and weight measurement. Outcome variables assessed at the age of 11 years were parent and child self-report Strengths and Difficulties Questionnaire and parent and teacher Conners' Rating Scale scores.

RESULTS

Physical activity, sleep duration, and BMI at the age of 7 years were not significantly associated with emotional and behavioral problems at the age of 11 years. In cross-sectional analysis at the age of 11 years, there was no significant association between physical activity or sleep duration and emotional and behavioral problems. Children with a BMI in the overweight or obese range were significantly more likely to have teacher-rated behavior problems and parent-rated emotional or behavioral problems after adjustment for potential confounders.

CONCLUSION

Although physical activity and sleep have physical health benefits, they may not be protective against future emotional and behavioral problems in childhood in the general population. BMI in the obese or overweight range was significantly associated with current emotional and behavioral problems at the age of 11 years.

Physical Activity and Sports-Real Health Benefits: A Review with Insight into the Public Health of Sweden

Positive effects from sports are achieved primarily through physical activity, but secondary effects bring health benefits such as psychosocial and personal development and less alcohol consumption. Negative effects, such as the risk of failure, injuries, eating disorders, and burnout, are also apparent. Because physical activity is increasingly conducted in an organized manner, sport’s role in society has become increasingly important over the years, not only for the individual but also for public health. In this paper, we intend to describe sport’s physiological and psychosocial health benefits, stemming both from physical activity and from sport participation per se. This narrative review summarizes research and presents health-related data from Swedish authorities. It is discussed that our daily lives are becoming less physically active, while organized exercise and training increases. Average energy intake is increasing, creating an energy surplus, and thus, we are seeing an increasing number of people who are overweight, which is a strong contributor to health problems. Physical activity and exercise have significant positive effects in preventing or alleviating mental illness, including depressive symptoms and anxiety- or stress-related disease. In conclusion, sports can be evolving, if personal capacities, social situation, and biological and psychological maturation are taken into account. Evidence suggests a dose–response relationship such that being active, even to a modest level, is superior to being inactive or sedentary. Recommendations for healthy sports are summarized.

Emotional and Behavioral Health Needs in Elementary School Students in an Underserved Hispanic Community

High rates of mental health problems in adolescents have been well documented; less is known about elementary school children in disadvantaged communities. We examined emotional and behavioral health needs in 202 third and fourth graders enrolled in a charter school in a largely Hispanic community. The child-reported Revised Child Anxiety and Depression Scale-25 and Teacher's Report Form were used to evaluate mental health needs as perceived by these children and their teachers. The prevalence of teacher-reported depression and child self-reported anxiety was 7.0% and 6.67%, respectively. Living in a single parent household was found to be a specific risk factor in that those children had higher rates of emotional and behavioral problems than children living with both parents. Evidence of higher depression and anxiety identified in this sample compared to national representative data suggests the need for development of culturally sensitive early prevention and intervention in this underserved community.

Evaluating the Long-Term Effectiveness of School-Based Depression, Anxiety, and Substance Use Prevention Into Young Adulthood: Protocol for the Climate School Combined Study

Background

Mental health and substance use disorders are the leading causes of global disability in children and youth. Both tend to first onset or escalate in adolescence and young adulthood, calling for effective prevention during this time. The Climate Schools Combined (CSC) study was the first trial of a Web-based combined universal approach, delivered through school classes, to prevent both mental health and substance use problems in adolescence. There is also limited evidence for the cost-effectiveness of school-based prevention programs.

Objective

The aim of this protocol paper is to describe the CSC follow-up study, which aims to determine the long-term efficacy and cost-effectiveness of the CSC prevention program for depression, anxiety, and substance use (alcohol and cannabis use) up to 7 years post intervention.

Methods

A cluster randomized controlled trial (the CSC study) was conducted with 6386 participants aged approximately 13.5 years at baseline from 2014 to 2016. Participating schools were randomized to 1 of 4 conditions: (1) control (health education as usual), (2) Climate Substance Use (universal substance use prevention), (3) Climate Mental Health (universal mental health prevention), or (4) CSC (universal substance use and mental health prevention). It was hypothesized that the CSC program would be more effective than conditions (1) to (3) in reducing alcohol and cannabis use (and related harms), anxiety, and depression symptoms as well as increasing knowledge related to alcohol, cannabis, anxiety, and depression. This long-term study will invite follow-up participants to complete 3 additional Web-based assessments at approximately 5, 6, and 7 years post baseline using multiple sources of locator information already provided to the research team. The primary outcomes include alcohol and cannabis use (and related harms) and mental health symptoms. An economic evaluation of the program will also be conducted using both data linkage as well as self-report resource use and quality of life measures. Secondary outcomes include self-efficacy, social networks, peer substance use, emotion regulation, and perfectionism. Analyses will be conducted using multilevel mixed-effects models within an intention-to-treat framework.

Results

The CSC long-term follow-up study is funded from 2018 to 2022 by the Australian National Health and Medical Research Council (APP1143555). The first follow-up wave commences in August 2018, and the results are expected to be submitted for publication in 2022.

Conclusions

This is the first study to provide a long-term evaluation of combined universal substance use and mental health prevention up to 7 years post intervention. Evidence of sustained benefits into early adulthood would provide a scalable, easy-to-implement prevention strategy with the potential for widespread dissemination to reduce the considerable harms, burden of disease, injury, and social costs associated with youth substance use and mental disorders.

International Registered Report Identifier (IRRID)

PRR1-10.2196/11372

Anxiety-related disorders: An overview

Anxiety-related disorders are common in the child and adolescent population. They cause significant distress, which can affect social, emotional, family and academic functioning. They frequently present in general paediatric and primary care settings. Comprehensive assessment should include the child as well as parent and family functioning because anxiety-related disorders in other family members are common and, if untreated, can affect outcomes for the child. There are good evidence-based psychological interventions available, which should be the first line of treatment offered; accessing appropriate therapies for an adequate duration of treatment can, however, be challenging. Medication, particularly selective serotonin reuptake inhibitors, may have a role to play but should be used in the context of psychologically based therapies. Prevention of anxiety-related disorders in childhood is a major public health issue. Prevention programmes are available and should commence in the antenatal period through infancy, early childhood and adolescence, promoting positive attachments and resilience.

Effectiveness of Disease-Specific Cognitive Behavioral Therapy on Anxiety, Depression, and Quality of Life in Youth With Inflammatory Bowel Disease: A Randomized Controlled Trial

Objective

To evaluate the effectiveness of a disease-specific cognitive behavioral therapy (CBT) protocol on anxiety and depressive symptoms and health-related quality of life (HRQOL) in adolescents and young adults with inflammatory bowel disease (IBD).

Method

A parallel group randomized controlled trial was conducted in 6 centers of (pediatric) gastroenterology. Included were 70 patients and young adults (10-25 years) with IBD and subclinical anxiety and/or depressive symptoms. Patients were randomized into 2 groups, stratified by center: (a) standard medical care (care-as-usual [CAU]) plus disease-specific manualized CBT (Primary and Secondary Control Enhancement Training for Physical Illness; PASCET-PI), with 10 weekly sessions, 3 parent sessions, and 3 booster sessions (n = 37), or (b) CAU only (n = 33). Primary analysis concerned the reliable change in anxiety and depressive symptoms after 3 months (immediate posttreatment assessment). Exploratory analyses concerned (1) the course of anxiety and depressive symptoms and HRQOL in subgroups based on age, and (2) the influence of age, gender, and disease type on the effect of the PASCET-PI.

Results

Overall, all participants improved significantly in their anxiety and depressive symptoms and HRQOL, regardless of group, age, gender, and disease type. Primary chi-square tests and exploratory linear mixed models showed no difference in outcomes between the PASCET-PI (n = 35) and the CAU group (n = 33).

Conclusions

In youth with IBD and subclinical anxiety and/or depressive symptoms, preliminary results of immediate post-treatment assessment indicated that a disease-specific CBT added to standard medical care did not perform better than standard medical care in improving psychological symptoms or HRQOL. ClinicalTrials.gov: NCT02265588.

An appraisal of the trustworthiness of practice guidelines for depression and anxiety in children and youth

OBJECTIVE

Little is known about the trustworthiness of clinical practice guidelines (PGs) relevant to child and youth depression or anxiety. To address this gap, we used systematic review methods to identify all available relevant PGs, quality appraise them, and make recommendations regarding which PGs are trustworthy and should be used by clinicians.

METHODS

Prespecified inclusion criteria identified eligible PGs. Two independent trained reviewers applied the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Using three AGREE II domain scores (stakeholder involvement, rigor of development [clinical validity/trustworthiness], and editorial independence), PG quality was designated as (1) minimum (≥50%) and (2) high (≥70%).

RESULTS

Of 25 eligible PGs, five met minimum quality criteria (depression, n = 4; anxiety, n = 1); three out of five met high-quality criteria (depression, n = 2; anxiety, n = 1). Among the five minimum quality PGs, developers included government (n = 2), independent expert groups (n = 2), and other (n = 1). No PGs developed by specialty societies achieved minimum or high-quality ratings; eight of 25 PGs were up-to-date.

CONCLUSIONS

Trustworthy PGs are available to support clinical decisions about depression and anxiety in children and youth, but are few in number. Many existing PGs (up to 80%) may not be clinically valid. Clinicians who implement the high-quality PGs identified here can increase the number of children and youth who receive effective interventions for depression and anxiety, minimize harm, and avoid wasted resources. Clinicians, service planners, youth, and their families should encourage PG developers to increase the pool of high-quality PGs using internationally recognized PG development standards.

Development of a Single-Session, Transdiagnostic Preventive Intervention for Young Adults at Risk for Emotional Disorders

Cognitive-behavioral prevention programs have demonstrated efficacy in reducing subclinical symptoms of anxiety and depression, and there is some evidence to suggest that they can lower the risk of future disorder onset. However, existing interventions tend to be relatively lengthy and target specific disorders or problem areas, both of which limit their potential for widespread dissemination. To address these limitations, we aimed to develop a single-session, transdiagnostic preventive intervention based on the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for young adults at risk for developing anxiety and/or depressive disorders within a college setting. Results from this proof-of-concept study indicated that the intervention was viewed as highly satisfactory and acceptable. The intervention also was successful at delivering adaptive emotion management skills in its 2-hr workshop format. Future studies evaluating the efficacy of this novel transdiagnostic, emotion-focused prevention program are warranted.

Reducing Fear During Childhood to Prevent Anxiety Disorders Later: Insights From Developmental Psychobiology

Anxiety disorders are neurodevelopmental with the median age of onset 10 to 11 years, but developmental processes underlying fear and anxiety are rarely investigated. In the last decade, however, developmental rodent studies have increased our understanding of how to treat and prevent the persistence of anxiety. Behavioral findings from rodent studies match the observations in anxious children, and the neural and molecular findings help explain why anxiety disorders are indeed neurodevelopmental. Extinction processes that are involved in cognitive-behavioral therapy appear particularly effective in children compared with older populations. Policy should mandate school psychologists and government subsidies for therapy sessions to increase children’s mental-health-service utilization. Funding bodies also should challenge anxiety studies exclusively targeting adults to include younger people to investigate why anxiety disorders are developmental disorders and focus more on preventing their persistence later in life.

Feasibility of an emotional health curriculum for elementary school students in an underserved Hispanic community

PROBLEM

Hispanic children have greater mental health challenges but fewer received mental health services than other ethnic groups. A classroom-based Emotional Health Curriculum (EHC) was developed to address mental health disparities in an underserved Hispanic community.

METHODS

A quasi-experimental design with one group pre- and post-intervention was used to test the feasibility of an 8-week EHC for one hundred 3rd and 4th grade children in a dual-immersion Spanish-English elementary school. Limited efficacy was measured by changes in depression and anxiety scores reported by children and teachers. Acceptance was evaluated by a child-reported satisfaction survey and a focus group in which the four teachers shared their experiences. Implementation was measured by participation, retention, and fidelity rates.

FINDINGS

The child-reported depression and anxiety and teacher-reported depression were significantly decreased in at-risk children with the effect size ranging from 0.60 to 1.16 (ps < 0.05). The majority of children (89.7%) enjoyed the EHC and teachers observed that children had acquired skills to manage their emotional distress. The participation, retention, and fidelity rates were 98%, 94%, and 99.13%, respectively.

CONCLUSIONS

The results provide promising evidence that the EHC has the potential to improve depression and anxiety symptoms in at-risk children.

Evaluation of AMSTAR to assess the methodological quality of systematic reviews in overviews of reviews of healthcare interventions

BACKGROUND

Overviews of reviews (overviews) compile information from multiple systematic reviews (SRs) to provide a single synthesis of relevant evidence for decision-making. It is recommended that authors assess and report the methodological quality of SRs in overviews-for example, using A MeaSurement Tool to Assess systematic Reviews (AMSTAR). Currently, there is variation in whether and how overview authors assess and report SR quality, and limited guidance is available. Our objectives were to: examine methodological considerations involved in using AMSTAR to assess the quality of Cochrane and non-Cochrane SRs in overviews of healthcare interventions; identify challenges (and develop potential decision rules) when using AMSTAR in overviews; and examine the potential impact of considering methodological quality when making inclusion decisions in overviews.

METHODS

We selected seven overviews of healthcare interventions and included all SRs meeting each overview's inclusion criteria. For each SR, two reviewers independently conducted AMSTAR assessments with consensus and discussed challenges encountered. We also examined the correlation between AMSTAR assessments and SR results/conclusions.

RESULTS

Ninety-five SRs were included (30 Cochrane, 65 non-Cochrane). Mean AMSTAR assessments (9.6/11 vs. 5.5/11; p < 0.001) and inter-rater reliability (AC1 statistic: 0.84 vs. 0.69; "almost perfect" vs. "substantial" using the Landis & Koch criteria) were higher for Cochrane compared to non-Cochrane SRs. Four challenges were identified when applying AMSTAR in overviews: the scope of the SRs and overviews often differed; SRs examining similar topics sometimes made different methodological decisions; reporting of non-Cochrane SRs was sometimes poor; and some non-Cochrane SRs included other SRs as well as primary studies. Decision rules were developed to address each challenge. We found no evidence that AMSTAR assessments were correlated with SR results/conclusions.

CONCLUSIONS

Results indicate that the AMSTAR tool can be used successfully in overviews that include Cochrane and non-Cochrane SRs, though decision rules may be useful to circumvent common challenges. Findings support existing recommendations that quality assessments of SRs in overviews be conducted independently, in duplicate, with a process for consensus. Results also suggest that using methodological quality to guide inclusion decisions (e.g., to exclude poorly conducted and reported SRs) may not introduce bias into the overview process.

Development and validation of brief scales to measure emotional and behavioural problems among Chinese adolescents

OBJECTIVES

To develop and validate brief scales to measure common emotional and behavioural problems among adolescents in the examination-oriented education system and collectivistic culture of China.

SETTING

Middle schools in Hunan province.

PARTICIPANTS

5442 middle school students aged 11-19 years were sampled. 4727 valid questionnaires were collected and used for validation of the scales. The final sample included 2408 boys and 2319 girls.

PRIMARY AND SECONDARY OUTCOME MEASURES

The tools were assessed by the item response theory, classical test theory (reliability and construct validity) and differential item functioning.

RESULTS

Four scales to measure anxiety, depression, study problem and sociality problem were established. Exploratory factor analysis showed that each scale had two solutions. Confirmatory factor analysis showed acceptable to good model fit for each scale. Internal consistency and test-retest reliability of all scales were above 0.7. Item response theory showed that all items had acceptable discrimination parameters and most items had appropriate difficulty parameters. 10 items demonstrated differential item functioning with respect to gender.

CONCLUSIONS

Four brief scales were developed and validated among adolescents in middle schools of China. The scales have good psychometric properties with minor differential item functioning. They can be used in middle school settings, and will help school officials to assess the students' emotional/behavioural problems.

Treatment and Prevention of Depression and Anxiety in Youth: Test of Cross-Over Effects

Anxiety and depression are highly comorbid and share several common etiological processes. Therefore, it may be more efficient to develop interventions that treat or prevent these problems together rather than as separate entities. The present meta-analytic review examined whether interventions for children and adolescents that explicitly targeted either anxiety or depression showed treatment specificity or also impacted the other outcome (i.e. cross-over effects). We addressed this question both within the same type of study (i.e. treatment, prevention) and across study types. Only randomized controlled trials (RCTs) that assessed both constructs with dimensional measures were included in this review. For treatment studies, RCTs targeting anxiety (n = 18) showed significant effects on both anxious and depressive symptoms, although more strongly on anxiety than depression; similarly, RCTs treating depression (n = 9) yielded significant effects on both depressive and anxious symptoms, but stronger effects on depression than anxiety. Thus, there were cross-over effects in treatments purportedly targeting either anxiety or depression, and also treatment specificity, such that larger effects were seen for the target problem at which the treatment was aimed. Anxiety prevention studies (n = 14) significantly affected anxious, but not depressive symptoms, indicating no cross-over effect of anxiety prevention trials on depression. For depression prevention studies (n = 15), the effects were not significant for either depressive or anxiety symptoms, although the effect was significantly larger for depressive than for anxious symptoms. Post-hoc analyses revealed that the effect on depressive symptoms was significant in depression preventions trials of targeted but not universal samples. Implications for transdiagnostic interventions are discussed.

The neurobiology of dispositional negativity and attentional biases to threat: Implications for understanding anxiety disorders in adults and youth

When extreme, anxiety can become debilitating. Anxiety disorders, which often first emerge early in development, are common and challenging to treat, yet the neurocognitive mechanisms that confer increased risk have only recently begun to come into focus. Here we review recent work highlighting the importance of neural circuits centered on the amygdala. We begin by describing dispositional negativity, a core dimension of childhood temperament and adult personality and an important risk factor for the development of anxiety disorders and other kinds of stress-sensitive psychopathology. Converging lines of epidemiological, neurophysiological, and mechanistic evidence indicate that the amygdala supports stable individual differences in dispositional negativity across the lifespan and contributes to the etiology of anxiety disorders in adults and youth. Hyper-vigilance and attentional biases to threat are prominent features of the anxious phenotype and there is growing evidence that they contribute to the development of psychopathology. Anatomical studies show that the amygdala is a hub, poised to govern attention to threat via projections to sensory cortex and ascending neuromodulatory systems. Imaging and lesion studies demonstrate that the amygdala plays a key role in selecting and prioritizing the processing of threat-related cues. Collectively, these observations provide a neurobiologically-grounded framework for understanding the development and maintenance of anxiety disorders in adults and youth and set the stage for developing improved intervention strategies.