Establishing Clinical Cutoffs for Response and Remission on the Screen for Child Anxiety Related Emotional Disorders (SCARED)

What is the role of screening instruments in the management of psychiatric comorbidities in epilepsy? Tools and practical tips for the most common comorbidities: Depression and anxiety

Depression and anxiety are the most common psychiatric comorbidities in epilepsy and are known to increase healthcare utilization, the risk of refractory epilepsy, and anti-seizure medication intolerability. Despite this, depression and anxiety continue to be underrecognized and undertreated in people with epilepsy (PWE). Several barriers to the identification of depression and anxiety in PWE exist, including reliance on unstructured interviews rather than standardized, validated instruments. Moreover, there is a dearth of behavioral health providers to manage these comorbidities once identified. The use of validated screening instruments in epilepsy clinics can assist with both the identification of psychiatric symptoms and monitoring of treatment response by the epilepsy clinician for PWE with comorbid depression and/or anxiety. While screening instruments can identify psychiatric symptoms occurring within a specified time, they are not definitively diagnostic. Screeners can be time efficient tools to identify patients requiring further evaluation for diagnostic confirmation. This article reviews recent literature on the utility of depression and anxiety screening instruments in epilepsy care, including commonly used screening instruments, and provides solutions for potential barriers to clinical implementation. Validated depression and anxiety screening instruments can increase identification of depression and anxiety and guide epilepsy clinician management of these comorbidities which has the potential to positively impact patient care.

The implications of the COVID-19 pandemic on eating disorder features and comorbid psychopathology among adolescents with anorexia nervosa and matched controls: a comparative cohort design study

PURPOSE

To examine implications of the COVID-19 pandemic on eating disorder (ED) features and psychopathology in female adolescents with anorexia nervosa (AN).

METHOD

In total 79 females with first-onset AN (aged 12-22 years) were included and were followed up across a period of 1 year. We assessed AN participants recruited pre-pandemic (n = 49) to those recruited peri-pandemic (n = 30). Pre- (n = 37) and peri-pandemic (n = 38) age-, and education-matched typically developing (TD) girls (n = 75) were used as a reference cohort. ED features and psychopathology were assessed at baseline. After 1 year of follow-up the association between pandemic timing and clinical course was assessed. Analyses of covariance were used to examine differences in ED features and psychopathology.

RESULTS

Peri-pandemic AN participants experienced less ED symptoms at baseline compared to pre-pandemic AN participants. In particular, they were less dissatisfied with their body shape, and experienced less interpersonal insecurity. In addition, the peri-pandemic AN group met fewer DSM-IV criteria for comorbid disorders, especially anxiety disorders. In contrast, peri-pandemic AN participants had a smaller BMI increase over time. In TD girls, there were no differences at baseline in ED features and psychopathology between the pre- and peri-pandemic group.

CONCLUSION

Overall, peri-pandemic AN participants were less severely ill, compared to pre-pandemic AN participants, which may be explained by less social pressure and peer contact, and a more protective parenting style during the pandemic. Conversely, peri-pandemic AN participants had a less favorable clinical course, which may be explained by reduced access to health care facilities during the pandemic.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Evaluating the development and well-being assessment (DAWBA) in pediatric anxiety and depression

Enhancing screening practices and developing scalable diagnostic tools are imperative in response to the increasing prevalence of youth mental health challenges. Structured lay psychiatric interviews have emerged as one such promising tool. However, there remains limited research evaluating structured psychiatric interviews, specifically their characterization of internalizing disorders in treatment-seeking youth. This study evaluates the relationship between the Development and Well-Being Assessment (DAWBA), a structured psychiatric interview, and established measures of pediatric anxiety and depression, including the Screen for Child Anxiety Related Disorders (SCARED), the Pediatric Anxiety Rating Scale (PARS), and the Mood and Feelings Questionnaire (MFQ). The study comprised two independent clinical samples of treatment-seeking youth: sample one included 55 youth with anxiety and 29 healthy volunteers (HV), while sample two included 127 youth with Major Depressive Disorder and 73 HVs. We examined the association between the DAWBA band scores, indicating predicted risk for diagnosis, the SCARED and PARS (sample one), and the MFQ (sample two). An exploratory analysis was conducted in a subset of participants to test whether DAWBA band scores predicted the change in anxiety symptoms (SCARED, PARS) across a 12-week course of cognitive behavioral therapy. The results revealed that the DAWBA significantly predicted the SCARED, PARS and MFQ measures at baseline; however, it did not predict changes in anxiety symptoms across treatment. These findings suggest that the DAWBA may be a helpful screening tool for indexing anxiety and depression in treatment-seeking youth but is not especially predictive of longitudinal trajectories in symptomatology across psychotherapy.

Immersive Virtual Reality Exposures for the Treatment of Childhood Anxiety

Exposure-based cognitive behavior therapy (CBT) has demonstrated efficacy and is recommended as a front-line treatment for childhood anxiety. Unfortunately, challenges exist that impact the effective implementation of exposure-based CBT in clinical practice. One of the primary challenges is the accessibility and availability of exposure stimuli (e.g., spiders, storms, heights) in CBT sessions. Immersive virtual reality (VR) has shown promise as a scalable and sustainable solution to address this clinical need, but remains largely untested in youth with anxiety disorders. Here, we examine the use of VR exposures in the treatment of youth with an anxiety disorder (i.e., specific phobias). We aimed to investigate: (1) the feasibility and clinical benefit of VR exposures; (2) whether VR exposures elicit changes in physiological arousal and/or subjective distress; and (3) whether habituation serves as a mechanism across physiological and subjective outcomes for VR exposures. Three youth and their parents completed a clinical evaluation, which was followed by a one session treatment (OST) with VR exposures. Afterward, youth and parents completed clinical assessments one-week and 1-month after treatment. Immersive VR exposures were found to be feasible and demonstrated clinical benefit for reducing anxiety severity. Additionally, VR exposures elicited changes in both physiological and subjective outcomes. Finally, physiological habituation to VR exposures was observed among participants who exhibited treatment response at follow-up. Collectively, these findings demonstrate preliminary evidence that VR exposures are feasible, tolerable, and show some therapeutic benefit for treating youth with anxiety.

Pediatric anxiety: An update for primary care NPs

ABSTRACT

New guidelines for identifying anxiety in pediatric patients constitute important changes in screening for primary care providers, including primary care NPs. This article seeks to guide NPs in both following the screening guidelines and providing strategic care for patients and their families.

Anxiety in children and youth: Part 1-Diagnosis

Anxiety disorders are the most common mental health concerns affecting Canadian children and adolescents. The Canadian Paediatric Society has developed two position statements that summarize current evidence regarding the diagnosis and management of anxiety disorders. Both statements offer evidence-informed guidance to support paediatric health care providers (HCPs) making decisions around the care of children and adolescents with these conditions. The objectives of Part 1, which focuses on assessment and diagnosis, are to: (1) review the epidemiology and clinical characteristics of anxiety disorders and (2) describe a process for assessment of anxiety disorders. Specific topics are reviewed, including prevalence, differential diagnosis, co-occurring conditions, and the process of assessment. Approaches are offered for standardized screening, history-taking, and observation. Associated features and indicators that distinguish anxiety disorders from developmentally appropriate fears, worries, and anxious feelings are considered. Note that when the word 'parent' (singular or plural) is used, it includes any primary caregiver and every configuration of family.

Anxiety in children and youth: Part 1-Diagnosis

Anxiety disorders are the most common mental health concerns affecting Canadian children and adolescents. The Canadian Paediatric Society has developed two position statements that summarize current evidence regarding the diagnosis and management of anxiety disorders. Both statements offer evidence-informed guidance to support paediatric health care providers (HCPs) making decisions around the care of children and adolescents with these conditions. The objectives of Part 1, which focuses on assessment and diagnosis, are to: (1) review the epidemiology and clinical characteristics of anxiety disorders and (2) describe a process for assessment of anxiety disorders. Specific topics are reviewed, including prevalence, differential diagnosis, co-occurring conditions, and the process of assessment. Approaches are offered for standardized screening, history-taking, and observation. Associated features and indicators that distinguish anxiety disorders from developmentally appropriate fears, worries, and anxious feelings are considered. Note that when the word 'parent' (singular or plural) is used, it includes any primary caregiver and every configuration of family.

Early exposure to flame retardants is prospectively associated with anxiety symptoms in adolescents: A prospective birth cohort study

BACKGROUND

Anxiety disorders emerge during childhood and adolescence and are frequently preceded by subsyndromal anxiety symptoms. Environmental toxicants, including gestational polybrominated diphenyl ether (PBDE) exposure, are associated with neuropsychiatric sequelae; however, the role of PBDEs as risk factors for anxiety in adolescence is unclear.

METHODS

Using data from the Health Outcomes and Measures of the Environment (HOME) Study, a prospective pregnancy and birth cohort enrolled from 2003 to 2006, we investigated the relationship between gestational serum PBDE concentrations and anxiety symptoms in adolescents (N = 236). We measured five PBDE congeners (PBDE-28, -47, -99, -100, and -153) at 16 ± 3 weeks of gestation and calculated their sum (∑PBDE). We assessed self-reported anxiety symptoms using the Screen for Child Anxiety Related Emotional Disorders (SCARED) and depressive symptoms using the Children's Depression Inventory (CDI-2) at age 12 years. We estimated the associations of maternal PBDE concentrations with child anxiety and depressive symptoms using multivariable linear regression and modified Poisson regression. Covariates included child sex, maternal race, maternal age at delivery, maternal marital status, maternal education, and household income at the 12-year study visit as well as maternal depressive and anxiety symptoms. Sensitivity analyses were performed to control for maternal lead and mercury at delivery.

RESULTS

After adjusting for predetermined covariates, each doubling in maternal PBDE concentrations was associated with increased SCARED scores (e.g., for ∑PBDE, SCARED total score, β = 1.6 95% confidence interval [CI]: 0.3-2.9, p = .019) and a nonsignificant increase in depressive symptoms (e.g., for CDI total score, β = .8, 95% CI: -0.2-1.8, p = .11).

CONCLUSIONS

Gestational serum PBDE concentrations just before mid-pregnancy and during a period of active cortical and limbic neurogenesis, synaptogenesis and myelogenesis may be a risk factor for developing anxiety symptoms in early adolescence.

Psychometric evaluation of a caregiver-report adaptation of the Overall Anxiety Severity and Impairment Scale (OASIS) for use with youth populations

Background Despite progress in youth anxiety assessment, there is need for a measure that is simultaneously (a) free, (b) brief, (c) focused broadly on anxiety and avoidance severity, frequency, and interference, and (d) concerned with the past week. The adult overall anxiety severity and impairment scale (OASIS) was adapted to yield a caregiver-report of past week youth anxiety and interference (OASIS-Y). Methods In a sample of diverse youth seeking anxiety services (N = 132; 67% racial/ethnic minority) and their caregivers, analyses examined the OASIS-Y factor structure, internal consistency, and convergent and divergent validity. Hierarchical linear modeling in a participant subset examined OASIS-Y sensitivity to treatment-related change. Results OASIS-Y internal consistency was high and confirmatory factor analysis supported a single-factor structure similar to that found in adults. OASIS-Y convergent validity was supported by a medium-sized association with an established, commercially available measure of youth anxiety, and divergent validity was supported by the absence of unique associations with measures of youth attention and externalizing problems. In a sample subset, session-by-session OASIS-Y scores significantly declined across treatment, and declined at a steeper rate among treatment "responders" versus "non-responders," providing evidence of OASIS-Y sensitivity to treatment-related change. Limitations This study focused on a clinical sample and cannot speak to OASIS-Y performance in community settings. Shared method-variance may have also influenced findings. Conclusions This study offers the first psychometric evaluation of the OASIS-Y, and underscores the promising clinical utility of the measure for assessing past week youth anxiety and impairment and for supporting routine outcome monitoring.

Transdermal Electrical Neuromodulation for Anxiety and Sleep Problems in High-Functioning Autism Spectrum Disorder: Feasibility and Preliminary Findings

BACKGROUND

Autism spectrum disorder (ASD) is associated with anxiety and sleep problems. We investigated transdermal electrical neuromodulation (TEN) of the cervical nerves in the neck as a safe, effective, comfortable and non-pharmacological therapy for decreasing anxiety and enhancing sleep quality in ASD.

METHODS

In this blinded, sham-controlled study, seven adolescents and young adults with high-functioning ASD underwent five consecutive treatment days, one day of the sham followed by four days of subthreshold TEN for 20 min. Anxiety-provoking cognitive tasks were performed after the sham/TEN. Measures of autonomic nervous system activity, including saliva α-amylase and cortisol, electrodermal activity, and heart rate variability, were collected from six participants.

RESULTS

Self-rated and caretaker-rated measures of anxiety were significantly improved with TEN treatment as compared to the sham, with effect sizes ranging from medium to large depending on the rating scale. Sleep scores from caretaker questionnaires also improved, but not significantly. Performance on two of the three anxiety-provoking cognitive tasks and heart rate variability significantly improved with TEN stimulation as compared to the sham. Four of the seven (57%) participants were responders, defined as a ≥ 30% improvement in self-reported anxiety. Salivary α-amylase decreased with more TEN sessions and decreased from the beginning to the end of the session on TEN days for responders. TEN was well-tolerated without significant adverse events.

CONCLUSIONS

This study provides preliminary evidence that TEN is well-tolerated in individuals with ASD and can improve anxiety.

Pharmacogenetically Guided Escitalopram Treatment for Pediatric Anxiety Disorders: Protocol for a Double-Blind Randomized Trial

Current pharmacologic treatments for pediatric anxiety disorders (e.g., selective serotonin reuptake inhibitors (SSRIs)) frequently use "one size fits all" dosing strategies based on average responses in clinical trials. However, for some SSRIs, including escitalopram, variation in CYP2C19 activity produces substantial variation in medication exposure (i.e., blood medication concentrations). This raises an important question: would refining current SSRI dosing strategies based on CYP2C19 phenotypes increase response and reduce side effect burden? To answer this question, we designed a randomized, double-blind trial of adolescents 12-17 years of age with generalized, separation, and/or social anxiety disorders (N = 132). Patients are randomized (1:1) to standard escitalopram dosing or dosing based on validated CYP2C19 phenotypes for escitalopram metabolism. Using this approach, we will determine whether pharmacogenetically-guided treatment-compared to standard dosing-produces faster and greater reduction in anxiety symptoms (i.e., response) and improves tolerability (e.g., decreased risk of treatment-related activation and weight gain). Secondarily, we will examine pharmacodynamic variants associated with treatment outcomes, thus enhancing clinicians' ability to predict response and tolerability. Ultimately, developing a strategy to optimize dosing for individual patients could accelerate response while decreasing side effects-an immediate benefit to patients and their families. ClinicalTrials.gov Identifier: NCT04623099.

Using Evaluative Criteria to Review Youth Anxiety Measures, Part II: Parent-Report

This Evidence Base Update of parent-report measures of youth anxiety symptoms is a companion piece to our update on youth self-report anxiety symptom measures (Etkin et al., 2021). We rate the psychometric properties of the parent-report measures as Adequate, Good, or Excellent using criteria developed by Hunsley and Mash (2008) and Youngstrom et al. (2017). Our review reveals that the evidence base for parent-report measures is considerably less developed compared with the evidence base for youth self-report measures. Nevertheless, several measures, the parent-report Screen for Child Anxiety-Related Emotional Disorders, Multidimensional Anxiety Scale for Children, and Spence Children's Anxiety Scale, were found to have Good to Excellent psychometric properties. We conclude our review with suggestions about which parent-report youth anxiety measures are best suited to perform different assessment functions and directions for additional research to expand and strengthen the evidence base.

Cognitive Behavior Therapy Tailored to Anxiety Symptoms Improves Pediatric Functional Abdominal Pain Outcomes: A Randomized Clinical Trial

OBJECTIVES

To evaluate the feasibility of a stepped care model, and establish the effect of a tailored cognitive behavioral therapy, the Aim to Decrease Anxiety and Pain Treatment (ADAPT), compared with standard medical treatment as usual on pain-related outcomes and anxiety.

STUDY DESIGN

Eligible patients between the ages of 9 and 14 years with functional abdominal pain disorders (n = 139) received enhanced usual care during their medical visit to a gastroenterologist. Those that failed to respond to enhanced usual care were randomized to receive either a tailored cognitive behavioral therapy (ADAPT) plus medical treatment as usual, or medical treatment as usual only. ADAPT dose (4 sessions of pain management or 6 sessions of pain and anxiety management) was based on presence of clinically significant anxiety. Outcomes included feasibility, based on recruitment and retention rates. Response to ADAPT plus medical treatment as usual vs medical treatment as usual on pain-related outcomes and anxiety measures was also investigated using a structural equation modeling equivalent of a MANCOVA. Anxiety levels and ADAPT dose as moderators of treatment effects were also explored.

RESULTS

Based on recruitment and retention rates, stepped care was feasible. Enhanced usual care was effective for only 8% of youth. Participants randomized to ADAPT plus medical treatment as usual showed significantly greater improvements in pain-related disability, but not pain levels, and greater improvements in anxiety symptoms compared with those randomized to medical treatment as usual only. Anxiety and ADAPT treatment dose did not moderate the effect of treatment on disability nor pain.

CONCLUSIONS

Tailoring care based on patient need may be optimal for maximizing the use of limited psychotherapeutic resources while enhancing care.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03134950.

Research Review: Pediatric anxiety disorders - what have we learnt in the last 10 years?

BACKGROUND

Anxiety disorders first emerge during the critical developmental periods of childhood and adolescence. This review synthesizes recent findings on the prevalence, risk factors, and course of the anxiety disorders; and their neurobiology and treatment.

METHODS

For this review, searches were conducted using PubMed, PsycINFO, and clinicaltrials.gov. Findings related to the epidemiology, neurobiology, risk factors, and treatment of pediatric anxiety disorders were then summarized.

FINDINGS

Anxiety disorders are high prevalence, and early-onset conditions associated with multiple risk factors including early inhibited temperament, environment stress, and structural and functional abnormalities in the prefrontal-amygdala circuitry as well as the default mode and salience networks. The anxiety disorders are effectively treated with cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

CONCLUSIONS

Anxiety disorders are high prevalence, early-onset conditions associated with a distinct neurobiological fingerprint, and are consistently responsive to treatment. Questions remain regarding who is at risk of developing anxiety disorders as well as the way in which neurobiology predicts treatment response.

Using Evaluative Criteria to Review Youth Anxiety Measures, Part I: Self-Report

Evidence-based assessment serves several critical functions in clinical child psychological science, including being a foundation for evidence-based treatment delivery. In this Evidence Base Update, we provide an evaluative review of the most widely used youth self-report measures assessing anxiety and its disorders. Guided by a set of evaluative criteria (De Los Reyes & Langer, 2018), we rate the measures as Excellent, Good, or Adequate across their psychometric properties (e.g., construct validity). For the eight measures evaluated, most ratings assigned were Good followed by Excellent, and the minority of ratings were Adequate. We view these results overall as positive and encouraging, as they show that these youth anxiety self-report measures can be used with relatively high confidence to accomplish key assessment functions. Recommendations and future directions for further advancements to the evidence base are discussed.

Using Yoga to Reduce Anxiety in Children: Exploring School-Based Yoga Among Rural Third- and Fourth-Grade Students

INTRODUCTION

Anxiety is becoming more common in children and can negatively affect social and academic performance. The purpose of this study was to explore the impact of 10 min of yoga on anxiety in third- and fourth-graders over 8 weeks.

METHOD

Participants completed 10 min of yoga daily during the school week. Participants completed the Screen for Child Anxiety Related Emotional Disorders anxiety screening tool at the beginning and after the program.

RESULTS

Paired sample t test noted a significant difference between pretest and posttest raw scores in the category of generalized anxiety disorder. On average, participants had significantly decreased raw anxiety scores after completing the program (mean = -0.0308), t₍₆₀₎ = -3.137, p < .05.

DISCUSSION

This study demonstrates that yoga practiced as little as 10 min a day over 8 weeks can have a significant impact on decreasing anxiety in children aged 8-10 years.

Self-Report Rating Scales to Guide Measurement-Based Care in Child and Adolescent Psychiatry

Measurement-based care involves the practice of systematically administrating rating scales to patients in order to use the collected information to enhance clinical evaluation, monitor treatment progress, and directly inform decisions relating to each patient's treatment. Rating scales must be psychometrically validated and efficiently administered within the practice setting. Brief rating scales that are available within the public domain may help to optimize workflows and prevent response fatigue. Clinicians should also have a sufficient understanding of the underlying psychometric properties of rating scales to accurately interpret changes in scores over time and use these results to appropriately direct care.

Clinical Reference Points for the Screen for Child Anxiety-related Disorders in 2 Investigations of Youth With Chronic Pain

OBJECTIVE

Anxiety is common in pediatric chronic pain and is related to a higher risk for poor outcomes; thus, there is a need for effective clinical screening methods to identify youth with chronic pain and co-occurring anxiety. The Screen for Child Anxiety-related Disorders (SCARED) is a validated measure that defines clinically significant anxiety using the traditional clinical cut-off, but in pain populations, may fail to screen in youth with subclinical anxiety that may also be at increased risk. Two studies aimed to devise a clinically meaningful approach to capture anxiety severity in pediatric chronic pain.

MATERIALS AND METHODS

Study 1 (n=959) and Study 2 (n=207) were completed at 2 separate pediatric pain clinics, where the SCARED was administered along with measures of disability, activity limitations, pain intensity, quality of life, and pain catastrophizing. Groups with different levels of anxiety were compared on clinical outcomes via multivariate analyses of variance or independent samples t tests.

RESULTS

A tertile solution suggested the following anxiety groupings based on the SCARED: minimal (0 to 12), subclinical (13 to 24), and clinical (≥25). Across both studies, the tertile solution was generally superior in classifying different levels of pain-related outcomes.

DISCUSSION

Future directions include testing the utility of this anxiety classification system to identify youth with subclinical levels of anxiety for early intervention focused on both pain and anxiety management.

Parent-Child Agreement on Family Accommodation Differentially Predicts Outcomes of Child-Based and Parent-Based Child Anxiety Treatment

Objectives: Family accommodation is linked to poor treatment outcomes for childhood anxiety. Progress in research on the role of accommodation in treatment has been hindered by the relatively weak association between child and parent reports on accommodation. In this study, we suggest that parent-child agreement on family accommodation may provide a dependable estimation of this construct, and investigated whether the level of parent-child agreement on family accommodation predicts subsequent treatment outcome. We further examined whether the effect was greater in Supportive Parenting for Anxious Childhood Emotions (SPACE), which directly targets family accommodation, than in individual child-focused cognitive behavioral therapy (CBT).Methods: Participants were 104 children (aged 6-15) with anxiety disorders, and their mothers, randomized to SPACE or CBT. Accommodation was rated by mothers and children before treatment, halfway through treatment, and at treatment end, using respective versions of Family Accommodation Scale-Anxiety. To accurately estimate agreement, we conducted multilevel response surface analysis by polynomial regression, with agreement on accommodation at each time point predicting subsequent child anxiety severity, over the course of treatment.Results: Parent-child agreement and disagreement on accommodation were significant predictors of subsequent anxiety symptom severity. Different results were obtained for SPACE and CBT, suggesting potentially distinct underlying mechanisms.Conclusions: The findings suggest treatment-specific roles of accommodation in SPACE vs. CBT. Multiple-informant assessment of accommodation provides important information, which may have important implications for optimal treatment personalization.

Suicidal Ideation Among Anxious Youth: A Preliminary Investigation of the Role of Neural Processing of Social Rejection in Interaction with Real World Negative Social Experiences

Suicidal ideation increases in adolescence, especially for anxious youth, and is a frequent precursor to suicide. This study examined whether neural processing of social rejection interacted with negative social experiences to predict suicidal ideation. Thus, to our knowledge this is the first study to examine how brain function may interact with the environment to contribute to suicidal ideation in youth, consistent with a developmental psychopathology perspective. Thirty-six anxious youth (ages 11 to 16) completed diagnostic interviews and questionnaires, an ecological momentary assessment (EMA) protocol, and a functional magnetic resonance imaging paradigm. Results showed that youth experienced greater severity of suicidal ideation when they exhibited heightened activation to social rejection in the right anterior insula and also experienced high levels of peer victimization or EMA-measured daily negative social experiences. Findings provide preliminary evidence that alterations in neural processing of social rejection interacts with exposure to negative social experiences to contribute to suicidal ideation.

Psychometric properties and factor structure of the Korean version of the screen for child anxiety related emotional disorders (SCARED)

BACKGROUND

The aim of this study was to examine the psychometric properties of the Korean version of Screen for Child Anxiety Related Emotional Disorders (SCARED) on a sample of Korean youths and to examine the cross-cultural differences in adolescents' anxiety.

METHODS

Our study included 147 adolescents (ages 12-17, 92 girls), 93 with major depressive disorder and 54 as controls. Participants were evaluated using the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL), SCARED, Child Behavior Checklist (CBCL), Disruptive Behavioral Disorder Scale (DBD) and Attention Deficit Hyperactivity Disorder Rating Scale (ADHD-RS). Pearson's r and Cronbach's α values of the SCARED were calculated, and exploratory factor analysis was conducted.

RESULTS

The Korean SCARED scores were correlated with the total anxiety scores of K-SADS-PL (r = 0.74) and the CBCL anxious/depressed subscale scores (r = 0.35). Results showed a five-factor structure with good internal consistency, in which some items were loaded on different factors compared to previous studies.

CONCLUSIONS

The Korean SCARED demonstrated promising psychometric properties, and could be a valid scale for screening anxiety symptoms in primary care. The fact that different items comprised the factors may reflect the cultural difference between United States and Korea in experiencing anxiety.

Integrating evidence-based assessment into clinical practice for pediatric anxiety disorders

BACKGROUND

Although evidence-based assessments are the cornerstone of evidence-based treatments, it remains unknown whether incorporating evidence-based assessments into clinical practice enhances therapists' judgment of therapeutic improvement. This study examined whether the inclusion of youth- and parent-reported anxiety rating scales improved therapists' judgment of treatment response and remission compared to the judgment of treatment-masked independent evaluators (IEs) after (a) weekly/biweekly acute treatment and (b) monthly follow-up care.

METHODS

Four hundred thirty six youth received cognitive-behavioral therapy (CBT), medication, CBT with medication, or pill placebo through the Child/Adolescent Anxiety Multimodal Study. Participants and parents completed the following anxiety scales at pretreatment, posttreatment, and follow-up: Screen for Childhood Anxiety and Related Disorders (SCARED) and Multidimensional Anxiety Scale for Children (MASC). IEs rated anxiety on the Clinical Global Impression of Severity (CGI-S) and Improvement (CGI-I) at posttreatment and follow-up. Therapists rated anxiety severity and improvement using scales that paralleled IE measures.

RESULTS

Fair-to-moderate agreement was found between therapists and IEs after acute treatment (κ = 0.38-0.48), with only slight-to-fair agreement found after follow-up care (κ = 0.07-0.33). Optimal algorithms for determining treatment response and remission included the combination of therapists' ratings and the parent-reported SCARED after acute (κ = 0.52-0.54) and follow-up care (κ = 0.43-0.48), with significant improvement in the precision of judgments after follow-up care (p < .02-.001).

CONCLUSION

Therapists are good at detecting treatment response and remission, but the inclusion of the parent-report SCARED optimized agreement with IE rating-especially when contact was less frequent. Findings suggest that utilizing parent-report measures of anxiety in clinical practice improves the precision of therapists' judgment.

Parent-Based Treatment as Efficacious as Cognitive-Behavioral Therapy for Childhood Anxiety: A Randomized Noninferiority Study of Supportive Parenting for Anxious Childhood Emotions

OBJECTIVE

Treatment for childhood anxiety disorders is insufficient in many cases. Parent involvement has been examined to augment child-based cognitive-behavioral therapy (CBT), but no studies have compared the efficacy of stand-alone parent-based treatment to CBT. Research implicates family accommodation in the maintenance and course of childhood anxiety. Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based treatment that reduces accommodation of childhood anxiety. This study compared SPACE to CBT in a noninferiority trial.

METHOD

Participants were children with primary anxiety disorders (N = 124; 7-14 years of age; 53% female participants; 83% white), randomly assigned to either SPACE (n = 64) with no direct child-therapist contact, or CBT (n = 60) with no parent treatment. A total of 97 participants (78%) completed all treatment sessions and assessments. Attrition did not differ significantly between groups. Primary anxiety outcomes included diagnostic interview and clinician-rated scales. Secondary outcomes included parent and child ratings of anxiety severity, family accommodation, and parenting stress. Noninferiority margins were determined based on statistical and clinical considerations. Change in family accommodation and parenting stress were examined using mixed models analyses.

RESULTS

SPACE was noninferior, relative to CBT, on primary and secondary anxiety outcomes, and based on ratings provided by independent evaluators, parents, and children. Family accommodation and parenting stress were significantly reduced in both treatments, with significantly greater reduction in family accommodation following SPACE compared to CBT. Treatment credibility and satisfaction were high.

CONCLUSION

SPACE is an acceptable and efficacious treatment for childhood anxiety disorders, is noninferior to CBT, and provides an alternative strategy for treating anxiety in children.

CLINICAL TRIAL REGISTRATION INFORMATION

Explanatory Clinical Trial of a Novel Parent Intervention for Childhood Anxiety (SPACE); https://clinicaltrials.gov; NCT02310152.

Defining Treatment Outcomes in Pediatric Obsessive-Compulsive Disorder Using a Self-Report Scale

This study examined benchmarks of treatment response and clinical remission on the Obsessive Compulsive Inventory-Child Version (OCI-CV) for youth with obsessive-compulsive disorder (OCD). Participants were 91 youth who enrolled in a randomized controlled trial that examined the benefit of augmenting cognitive behavior therapy (CBT) with either d-cycloserine or placebo. Youth completed the OCI-CV at baseline, Week 4 (prior to initiating exposure therapy), and posttreatment. Receiver operator curve (ROC) analyses examined optimal benchmarks for treatment response and clinical remission as identified by independent evaluators at the posttreatment assessment using the Clinical Global Impression (CGI) scales of Improvement (CGI-Improvement), Severity (CGI-Severity), and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Optimal benchmarks for treatment response were a 20%-25% reduction in the OCI-CV total score. Meanwhile, optimal benchmarks for remission were a 55%-65% reduction in the OCI-CV total score and a posttreatment total score ≤6-8. OCI-CV benchmarks exhibited moderate agreement with the CY-BOCS for treatment response and clinical remission. Meanwhile, fair agreement was observed for response and remission with CGI scales. A lower pretreatment OCI-CV total score was associated with less agreement between classification approaches. Findings provide benchmarks for classifying treatment response and clinical remission in an efficient manner. Given the moderate agreement between the CY-BOCS and OCI-CV benchmarks, the OCI-CV may serve as a useful alternative when clinician-rated scales cannot be administered due to limited resources (e.g., time, training). Thus, evidence-based measurement can be incorporated to monitor therapeutic response and remission in clinical practice.

Assessing anxiety disorders in children and adolescents

BACKGROUND

Given the relatively high prevalence of anxiety problems among young people and their adverse consequences if left untreated, it is important that clinicians and researchers have access to reliable and valid assessment tools to facilitate early detection, case formulation, treatment design and evaluation of outcomes.

METHOD

This paper presents the findings of a pragmatic review of the literature regarding the assessment of anxiety in young people in multiple contexts, including mental health services, school-based screening and research trials.

RESULTS

Commonly used diagnostic interviews, questionnaire measures and alternative assessment methods are described, along with psychometric properties and practical issues. The review indicates the complexities of assessing anxiety problems given the high level of comorbidity between anxiety disorders and with depression. It also highlights the different approaches required for assessment across different age groups, the need for multiple informants and issues relating to the lack of agreement between reporters. There is a strong evidence-base for several diagnostic instruments and anxiety scales, although the accuracy of youth and parent report scales in forming clinical diagnoses is not sufficiently strong to justify their use in isolation for diagnostic purposes.

CONCLUSIONS

The assessment of youth anxiety should ideally include a multiinformant, multimethod approach, with measures tailored to the age of the child, and the purpose of the evaluation. There is now a sufficiently strong research base to enable clinicians and researchers to ensure that they select evidence-based instruments.

Defining Treatment Response and Remission in Youth Anxiety: A Signal Detection Analysis With the Multidimensional Anxiety Scale for Children

OBJECTIVE

To determine the percent reduction cutoffs on the Multidimensional Anxiety Scale for Children (MASC) that optimally predict treatment response and remission in youth with anxiety disorders.

METHOD

Youths and their parents completed the MASC-C/P before and after treatment, and the Anxiety Disorders Interview Schedule for DSM-IV-Child and Parent Versions (ADIS-IV-C/P) and the Clinical Global Impression-Improvement Scale (CGI-I) were administered by independent evaluators. Treatment response and remission were defined by post-treatment ratings on the CGI-I and the ADIS-IV-C/P, respectively. Quality receiver operating characteristic methods determined the optimal cutoff on the MASC-P for predicting overall remission (loss of all study entry diagnoses) and optimal percent reductions on the MASC-P for predicting treatment response and remission of separation anxiety, social anxiety, and generalized anxiety.

RESULTS

A post-treatment raw score of 42 optimally predicted remission. A reduction of 35% on the total MASC-P predicted treatment response. A reduction of 30% on the Separation Anxiety/Panic subscale of the MASC-P predicted separation anxiety remission. A reduction of 35% on the Social Anxiety subscale of the MASC-P predicted social anxiety remission. The MASC did not evidence a cutoff for remission of generalized anxiety disorder.

CONCLUSION

MASC cutoffs can facilitate comparison across studies and guide practice, aiding clinicians in assessing progress and informing treatment plans.