Elucidating risk mechanisms of gene-environment interactions on pediatric anxiety: integrating findings from neuroscience

Early Life Maltreatment and Adolescent Interpretations of Ambiguous Social Situations: Investigating Interpersonal Cognitions and Emotional Symptoms

In the general population, negative interpretations of social situations have been associated with risk of developing emotional disorders such as anxiety and depression. Given that childhood maltreatment poses risk for later emotional disorders, this study examined whether interpersonal cognitive style differentiated maltreated adolescents from their non-maltreated peers and correlated with emotional symptoms across each group. Forty-seven maltreated and 28 non-maltreated adolescents were recruited from New South Wales, Australia to complete a battery of questionnaires that assessed interpersonal cognitions and levels of anxiety and depression. Comparable endorsement of threatening interpretations of social situations between maltreated adolescents and their non-maltreated peers across measures was found. Furthermore, an association between anxiety and depressive symptoms and interpretation bias was found within the non-maltreatment group but not the maltreated group. Unlike general population samples, negative cognitions do not associate with emotional symptoms in victims of early maltreatment. More research is needed to investigate the cognitive factors maintaining emotional symptoms in adolescent victims of maltreatment.

Impact of ADCYAP1R1 genotype on longitudinal fear conditioning in children: interaction with trauma and sex

Dysregulated fear conditioned responses have been associated with PTSD in adults, with increased fear-potentiated startle (FPS) serving as a potential intermediate phenotype for PTSD risk. This phenotype has also been associated with stress-related ADCYAP1R1 gene variants in adult women. However, FPS and genotype have not yet been examined during development. The aim of this study was to examine developmental changes in fear conditioning, and to see whether these changes were impacted by genotype and trauma. Differential fear conditioning using FPS was tested in n = 63 children ages 8-13 at two visits (V1, V2) 1 year apart. Startle response was measured using electromyograph recordings of the eyeblink muscle. The rs2267735 SNP of the ADCYAP1R1 gene was extracted from genome-wide (GWAS) analyses. Trauma exposure was assessed using the Violence Exposure Scale-Revised (VEX-R). We found significant Visit by Genotype interactions, with CC genotype increasing FPS from V1 to V2. At V2 there was a Genotype by Violence interaction, with higher FPS in the CC vs G allele groups among those with higher violence exposure (F = 17.46, p = 0.0002). Females with the CC genotype had higher FPS compared to G allele females (F = 12.09, p = 0.002); there were no effects of genotype in males. This study showed Gene × Environment × Development and Gene × Sex effects of ADCYAP1R1 in a high-risk pediatric population. Those with the CC genotype and high levels of violence exposure, as well as females with the CC genotype, showed the greatest conditioned fear responses in adolescence.

ADad 6: the predictive factors for Anxiety Disorders among adolescents in a rural community population in India

OBJECTIVE

Development of Anxiety Disorders (AD) among adolescents is the interplay of risk and protective factors that have a biological and environmental basis. This study documents the predictive factors associated with the presence of AD among adolescents in India.

METHODS

The authors prospectively collected data for 500 adolescents in a community with independent, trained raters. Data on the dependent variable of AD and its subtypes was collected with Screen for Child Anxiety Related Emotional Disorders (SCARED), Socio-economic status with Modified Kuppuswamy Scale, depression with Beck Depression Inventory and the other independent variables with a specially designed proforma. The predictive factors for the presence of AD were analyzed with univariate and multivariate regression analyses appropriately, and a parsimonious predictive model was built.

RESULTS

Gender (adjusted OR = 1.96), and presence of Depressive Disorder (adjusted OR = 24.14) emerged as independent risk factors. Level of education came-out as a protective factor (adjusted OR = 0.66). Adolescent girls were at risk of developing Separation Anxiety Disorder (SeAD) (adjusted OR = 3.51) and Social Anxiety Disorder (SoAD) (adjusted OR = 1.69). Level of education had a protective influence on SeAD (adjusted OR = 0.39) and SoAD (adjusted OR = 0.59) among those doing high school. This protective effect increased if they were in higher-secondary school for SeAD (adjusted OR = 0.21) and SoAD (adjusted OR = 0.22). In the multivariate model age of the adolescent also gained significance and the 3-factor model had a good model fit. Panic Disorder and Generalized Anxiety Disorder were not related to any specific variable.

CONCLUSIONS

Identifying the factors associated with AD and the subtypes can be used to predict, prevent or treat these disorders in this population. Educating adolescent girls to higher-secondary school level seem to be an important step in this direction.

Current status on behavioral and biological markers of PTSD: a search for clarity in a conflicting literature

Extensive research has identified stereotypic behavioral and biological abnormalities in post-traumatic stress disorder (PTSD), such as heightened autonomic activity, an exaggerated startle response, reduced basal cortisol levels and cognitive impairments. We have reviewed primary research in this area, noting that factors involved in the susceptibility and expression of PTSD symptoms are more complex and heterogeneous than is commonly stated, with extensive findings which are inconsistent with the stereotypic behavioral and biological profile of the PTSD patient. A thorough assessment of the literature indicates that interactions among myriad susceptibility factors, including social support, early life stress, sex, age, peri- and post-traumatic dissociation, cognitive appraisal of trauma, neuroendocrine abnormalities and gene polymorphisms, in conjunction with the inconsistent expression of the disorder across studies, confounds attempts to characterize PTSD as a monolithic disorder. Overall, our assessment of the literature addresses the great challenge in developing a behavioral and biomarker-based diagnosis of PTSD.

Preventive intervention for anxious preschoolers and their parents: strengthening early emotional development

The high prevalence and early onset of anxiety disorders have inspired innovative prevention efforts targeting young at-risk children. With parent-child prevention models showing success for older children and adolescents, the goal of this study was to evaluate a parent-child indicated preventive intervention for preschoolers with mild to moderate anxiety symptoms. Sixteen children (ages 3-5) and at least one of their parents participated in Strengthening Early Emotional Development (SEED), a new 10-week intervention with concurrent groups for parents and children. Outcome measures included clinician-rated and parent-rated assessments of anxiety symptoms, as well as measures of emotion knowledge, parent anxiety, and parental attitudes about children's anxiety. Participation in SEED was associated with reduced child anxiety symptoms and improved emotion understanding skills. Parents reported decreases in their own anxiety, along with attitudes reflecting enhanced confidence in their children's ability to cope with anxiety. Reductions in child and parent anxiety were maintained at 3-month follow-up. Findings suggest that a parent-child cognitive-behavioral preventive intervention may hold promise for young children with mild to moderate anxiety. Improvements in parent anxiety and parental attitudes may support the utility of intervening with parents. Fostering increased willingness to encourage their children to engage in new and anxiety-provoking situations may help promote continued mastery of new skills and successful coping with anxiety.

Impaired neuroendocrine and immune response to acute stress in medication-naive patients with a first episode of psychosis

Little is known about how the biological stress response systems--the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal (HPA) axis, and the immune system--function during psychosis. Results of studies on the effect of stress on the immune and autonomic system in patients with schizophrenia are inconsistent. The present study investigates whether the stress response is impaired in medication-naive patients with a first episode of psychosis. Ten male patients with a first episode of psychosis and 15 controls were exposed to the stress of public speaking. Parameters of the ANS (heart rate and catecholamines), the HPA axis (plasma adrenocorticotropic hormone [ACTH] and cortisol), and the immune system (number and activity of natural killer [NK] cells) were measured. Peak responses were calculated to examine the relationship between stress-induced activation of the different systems. Subjective stress and anxiety before and during the task were assessed. Patients and controls displayed similar autonomic responses to acute stress. However, there was an impaired HPA axis response, slow onset and return of ACTH, and flattened cortisol response and a reduced increase in number NK cells and NK cell activity in patients with a first episode of psychosis. Furthermore, in patients, the relationship between the different stress response systems was weaker or absent compared with controls. These findings indicate that impairments in stress processing are associated with the endophenotype of psychosis and are not a result of illness progression or antipsychotic medication.

Anxiety disorders in adolescence are associated with impaired facial expression recognition to negative valence

OBJECTIVE

The aim of the present study was to test the ability of adolescents with a current anxiety diagnosis to recognize facial affective expressions, compared to those without an anxiety disorder.

METHODS

Forty cases and 27 controls were selected from a larger cross sectional community sample of adolescents, aged from 10 to 17 years old. Adolescent's facial recognition of six human emotions (sadness, anger, disgust, happy, surprise and fear) and neutral faces was assessed through a facial labeling test using Ekman's Pictures of Facial Affect (POFA).

RESULTS

Adolescents with anxiety disorders had a higher mean number of errors in angry faces as compared to controls: 3.1 (SD=1.13) vs. 2.5 (SD=2.5), OR=1.72 (CI95% 1.02 to 2.89; p=0.040). However, they named neutral faces more accurately than adolescents without anxiety diagnosis: 15% of cases vs. 37.1% of controls presented at least one error in neutral faces, OR=3.46 (CI95% 1.02 to 11.7; p=0.047). No differences were found considering other human emotions or on the distribution of errors in each emotional face between the groups.

CONCLUSION

Our findings support an anxiety-mediated influence on the recognition of facial expressions in adolescence. These difficulty in recognizing angry faces and more accuracy in naming neutral faces may lead to misinterpretation of social clues and can explain some aspects of the impairment in social interactions in adolescents with anxiety disorders.

Transition to adulthood: the critical period for pre-emptive, disease-modifying care for schizophrenia and related disorders

There is an urgent need and a global opportunity to rethink not only the dominant research paradigms in etiological research but also to invest in less constrained strategies which cut across the existing diagnostic silos to seek out common risk factors, late as well as early neurodevelopmental processes, pathophysiologies, and novel treatment strategies. The high-quality research presented in this special issue of Schizophrenia Bulletin makes a compelling case for such a rethink. While there is still a genuine disconnect between our understanding of the complex and dramatic brain changes that occur during the transition to adulthood and the concurrent surge in incidence of mental ill-health, there is no doubt that a much more serious focus on the perionset stage of clinical disorders in young people with their rapidly evolving brains, social environments, and life trajectories could be extremely productive. Research access to these early stages of illness would be catalyzed by the widespread construction of engaging stigma-free portals and clinical scaffolding appropriate for young people in the 21st century. The latter are urgently required to supersede traditional models of care, which have served both patients and families so poorly, and equally have failed to unlock a deeper understanding of the origins and progression of potentially serious mental disorders.

Normal gut microbiota modulates brain development and behavior

Microbial colonization of mammals is an evolution-driven process that modulate host physiology, many of which are associated with immunity and nutrient intake. Here, we report that colonization by gut microbiota impacts mammalian brain development and subsequent adult behavior. Using measures of motor activity and anxiety-like behavior, we demonstrate that germ free (GF) mice display increased motor activity and reduced anxiety, compared with specific pathogen free (SPF) mice with a normal gut microbiota. This behavioral phenotype is associated with altered expression of genes known to be involved in second messenger pathways and synaptic long-term potentiation in brain regions implicated in motor control and anxiety-like behavior. GF mice exposed to gut microbiota early in life display similar characteristics as SPF mice, including reduced expression of PSD-95 and synaptophysin in the striatum. Hence, our results suggest that the microbial colonization process initiates signaling mechanisms that affect neuronal circuits involved in motor control and anxiety behavior.

Selective attention to affective stimuli and clinical depression among youths: role of anxiety and specificity of emotion

Cognitive models of psychopathology posit that the content or focus of information-processing biases (e.g., attentional biases) is disorder specific: Depression is hypothesized to be characterized by attentional biases specifically for depression-relevant stimuli (e.g., sad facial expressions), whereas anxiety should relate particularly to attentional biases to threat-relevant stimuli (e.g., angry faces). However, little research has investigated this specificity hypothesis and none with a sample of youths. The present study examined attentional biases to emotional faces (sad, angry, and happy compared with neutral) in groups of pure depressed, pure anxious, comorbid depressed and anxious, and control youths (ages 9-17 years; N = 161). Consistent with cognitive models, pure depressed and pure anxious youths exhibited attentional biases specifically to sad and angry faces, respectively, whereas comorbid youths exhibited attentional biases to both facial expressions. In addition, control youths exhibited attentional avoidance of sad faces, and comorbid boys avoided happy faces. Overall, findings suggest that cognitive biases and processing of particular emotional information are specific to pure clinical depression and anxiety, and results inform etiological models of potentially specific processes that are associated with internalizing disorders among youths.

Attentional bias, emotion recognition, and emotion regulation in anorexia: state or trait?

BACKGROUND

Anorexia nervosa (AN) is associated with difficulties in emotion recognition and regulation and with attentional biases to social affective stimuli. This study aimed to examine these factors in a group of women following long-term recovery from AN.

METHODS

The Reading the Mind in the Eyes task, Difficulties in Emotion Regulation Scale, and a computerized pictorial Stroop task (angry and neutral faces) were administered to 175 women: 50 with acute AN, 35 recovered from AN, and 90 healthy control subjects (HCs).

RESULTS

The recovered group had a significantly higher social and angry-threat attentional bias than HCs, with medium effect sizes, and significantly lower scores on the emotion recognition measure than HCs, with a medium effect size. On the other hand, the recovered group did not significantly differ from the HC group in terms of emotion regulation.

CONCLUSIONS

Attentional biases to social affective pictorial stimuli and difficulties with emotion recognition appear to be traits associated with a lifetime history of AN, whereas emotion regulation difficulties appear to remit when the individual successfully recovers from the illness.

CBT for childhood anxiety disorders: differential changes in selective attention between treatment responders and non-responders

BACKGROUND

This study examined whether treatment response to stepped-care cognitive-behavioural treatment (CBT) is associated with changes in threat-related selective attention and its specific components in a large clinical sample of anxiety-disordered children.

METHODS

Ninety-one children with an anxiety disorder were included in the present study. Children received a standardized stepped-care CBT. Three treatment response groups were distinguished: initial responders (anxiety disorder free after phase one: child-focused CBT), secondary responders (anxiety disorder free after phase two: child-parent-focused CBT), and treatment non-responders. Treatment response was determined using a semi-structured clinical interview. Children performed a pictorial dot-probe task before and after stepped-care CBT (i.e., before phase one and after phase two CBT).

RESULTS

Changes in selective attention to severely threatening pictures, but not to mildly threatening pictures, were significantly associated with treatment success. At pre-treatment assessment, initial responders selectively attended away from severely threatening pictures, whereas secondary responders selectively attended toward severely threatening pictures. After stepped-care CBT, initial and secondary responders did not show any selectivity in the attentional processing of severely threatening pictures. Treatment non-responders did not show any changes in selective attention due to CBT.

CONCLUSIONS

Initial and secondary treatment responders showed a reduction of their predisposition to selectively attend away or toward severely threatening pictures, respectively. Treatment non-responders did not show any changes in selective attention. The pictorial dot-probe task can be considered a potentially valuable tool in assigning children to appropriate treatment formats as well as for monitoring changes in selective attention during the course of CBT.

Children's attentional biases and 5-HTTLPR genotype: potential mechanisms linking mother and child depression

In this study, we examined the roles of specific cognitive (attentional bias) and genetic (5-HTTLPR) risk factors in the intergenerational transmission of depression. Focusing first on the link between maternal history of major depressive disorder (MDD) and children's attentional biases, we found that children of mothers with a history of MDD during their children's lives, compared to children of mothers with no depression history, exhibited greater attentional avoidance of sad faces. This attention bias was specific to sad, rather than happy or angry, faces. There was also preliminary evidence that this relation is stronger among children carrying the 5-HTTLPR S or L(G) allele than among those homozygous for the L(A) allele. Next, conceptualizing mothers' levels of depressive symptoms during the multi-wave prospective follow-up within a vulnerability-stress framework, we found evidence for a three-way child 5-HTTLPR x attentional bias x mother depressive symptom interaction predicting children's depressive symptoms. Specifically, the relation between mother and child depressive symptom levels over time was strongest among children carrying the 5-HTTLR S or L(G) allele who also exhibited attentional avoidance of sad faces. These findings provide initial support for role of children's 5-HTTLPR genotype and attentional biases for sad faces in the intergenerational transmission of depression.

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

This review summarizes findings on the epidemiology and etiology of anxiety disorders among children and adolescents including separation anxiety disorder, specific phobia, social phobia, agoraphobia, panic disorder, and generalized anxiety disorder, also highlighting critical aspects of diagnosis, assessment, and treatment. Childhood and adolescence is the core risk phase for the development of anxiety symptoms and syndromes, ranging from transient mild symptoms to full-blown anxiety disorders. This article critically reviews epidemiological evidence covering prevalence, incidence, course, and risk factors. The core challenge in this age span is the derivation of developmentally more sensitive assessment methods. Identification of characteristics that could serve as solid predictors for onset, course, and outcome will require prospective designs that assess a wide range of putative vulnerability and risk factors. This type of information is important for improved early recognition and differential diagnosis as well as prevention and treatment in this age span.

Startle response in behaviorally inhibited adolescents with a lifetime occurrence of anxiety disorders

OBJECTIVE

Behaviorally inhibited children face increased risk for anxiety disorders, although factors that predict which children develop a disorder remain poorly specified. The current study examines whether the startle reflex response may be used to differentiate between behaviorally inhibited adolescents with and without a history of anxiety.

METHOD

Participants were assessed for behavioral inhibition during toddlerhood and early childhood. They returned to the laboratory as adolescents and completed a fear-potentiated startle paradigm and a clinical diagnostic interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version). Magnitude of the startle reflex was examined at baseline and during cues associated with safety and threat.

RESULTS

Only adolescents who showed high levels of behavioral inhibition and had a lifetime occurrence of anxiety disorders showed increased startle reactivity in the presence of safety cues. Neither behavioral inhibition nor diagnosis was related to startle reactivity during threat cues.

CONCLUSIONS

These results suggest that neurobiological measures, such as the startle reflex, may be a potential risk marker for the development of anxiety disorders among behaviorally inhibited adolescents. These methods may enhance our ability to identify vulnerable individuals before the development of anxious psychopathology.

Pharmacogenetics of selective serotonin reuptake inhibitors in pediatric depression and anxiety

Selective serotonin reuptake inhibitors (SSRIs) are now an accepted and widely used first-line treatment for pediatric depression and anxiety. However, the data indicate that SSRI treatment achieves a clinical response in only 55-60% of children, and some may develop drug-induced suicidal behavior. Clinicians have no reliable tools to help them identify in advance those youths who are not likely to respond to an SSRI, or who are likely to develop SSRI-induced suicidality. Pharmacogenetic research attempts to identify genetic markers that are associated with response and side-effect profile. This review covers all the pharmacogenetic studies conducted as yet on pediatric samples and compares them with available data on adult samples. An emphasis is put on serotonergic genes such as the serotonin transporter (5-HTT) and additional genes known to be active in the CNS.