Patterns of anxiety symptoms in toddlers and preschool-age children: evidence of early differentiation

Anxiety and Disruptive Behavior Symptoms and Disorders in Preschool-Age Offspring of Parents With and Without Bipolar Disorder: Associations With Parental Comorbidity

OBJECTIVE

We examined the relative contribution of parental bipolar disorder (BPD) and psychiatric comorbidities (disruptive behavior disorders [DBD] and anxiety disorders) in predicting psychiatric symptoms and disorders in 2-5-year-old offspring.

METHODS

Participants were 60 families with a parent with BPD and 78 offspring and 70 comparison families in which neither parent had a mood disorder and 91 offspring. Parent and offspring diagnoses and symptoms were assessed using standardized diagnostic interviews and measures, with offspring assessors masked to parental diagnoses.

RESULTS

Offspring of parents with BPD had significant elevations in behavioral, mood and anxiety disorders and symptoms. Both parental BPD and DBD contributed to elevations in child disruptive behavioral symptoms, whereas child anxiety symptoms were more strongly predicted by comorbid parental anxiety. Parental BPD was a stronger predictor than comorbid DBD of child DBDs.

CONCLUSION

Some of the elevated risk for disorders in preschoolers is accounted for by parental comorbidity.

What do neuroanatomical networks reveal about the ontology of human cognitive abilities?

Over the last decades, cognitive psychology has come to a fair consensus about the human intelligence ontological structure. However, it remains an open question whether anatomical properties of the brain support the same ontology. The present study explored the ontological structure derived from neuroanatomical networks associated with performance on 15 cognitive tasks indicating various abilities. Results suggest that the brain-derived (neurometric) ontology partly agrees with the cognitive performance-derived (psychometric) ontology complemented with interpretable differences. Moreover, the cortical areas associated with different inferred abilities are segregated, with little or no overlap. Nevertheless, these spatially segregated cortical areas are integrated via denser white matter structural connections as compared with the general brain connectome. The integration of ability-related cortical networks constitutes a neural counterpart to the psychometric construct of general intelligence, while the consistency and difference between psychometric and neurometric ontologies represent crucial pieces of knowledge for theory building, clinical diagnostics, and treatment.

•

Psychometric and neurometric cognitive ontologies are partly equivalent

•

Ability-related brain areas are ontologically segregated with little to no overlap

•

However, ability-related brain areas are densely interconnected by fiber tracts

The role of temperament and parenting on anxiety problems among toddlers: Moderating role of parenting and mediating role of attachment

Anxiety problems are seen as early as 1-2 years of age. Among others, parenting and child temperament are considered as the most important factors affecting anxiety in early childhood. In the current study, the unique roles of parenting (maternal overprotectiveness and warmth) and temperament (behavioral inhibition and negative emotionality), parenting-temperament interactions, and mediating role of ambivalent attachment between behavioral inhibition and anxiety were investigated. One-hundred mother-child (18-36-month-old) dyads participated in this study. Children's anxiety and temperament were measured through mother-reported scales, attachment was measured by observation via home visits, and parenting dimensions were measured via both mother-reported scales and observation. The results revealed that behavioral inhibition and overprotectiveness were positively associated with toddlers' anxiety, whereas there were no significant direct associations of negative emotionality and warmth with anxiety. However, the interaction between behavioral inhibition and warmth predicted toddler's anxiety; that is, if behaviorally inhibited children had mothers who were low on warmth, those children were more likely to exhibit anxiety symptoms compared to children with low behavioral inhibition, whereas anxiety levels did not change for children of warm mothers. Ambivalent attachment mediated the relationship between behavioral inhibition and anxiety. The nature of parent-child interactions is discussed based on toddlerhood anxiety.

Attention Bias and Prodromal Anxiety Symptoms in Toddlers With Fragile X Syndrome and Down Syndrome

Early identification of behavioral risk markers for anxiety is essential to optimize long-term outcomes in children with neurodevelopmental disorders. This study analyzed attentional avoidance and its relation to anxiety and autism spectrum disorder (ASD) symptomatology during social and nonsocial fear conditions in toddlers with fragile X syndrome (FXS) and Down syndrome (DS). Toddlers with FXS and DS exhibited increased nonsocial attentional avoidance relative to typically developing (TD) toddlers. Attentional avoidance was not related to anxiety symptom severity in any group; however, higher ASD symptom severity was related to more social attentional avoidance in the FXS and TD groups. Findings suggest that there may be different underlying mechanisms driving attentional avoidance across neurodevelopmental disorders.

Very early family-based intervention for anxiety: two case studies with toddlers

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive-behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent-child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

Cognitive Behavioural Therapy for Anxiety Disorders in Young Children: A Dutch Open Trial of the Fun FRIENDS Program

Anxiety disorders in young children are highly prevalent and increase the risk of social, school, and familial problems, and also of psychiatric disorders in adolescence and adulthood. Nevertheless, effective interventions for this age group are lacking. One of the few available interventions is the Fun FRIENDS program. We examined whether young children with anxiety disorders showed less anxiety after participating in Fun FRIENDS. Twenty-eight clinically anxious children (4–8 years old) participated in the cognitive behavioural Fun FRIENDS program. The program consists of 12 weekly 1.5-hour sessions and was provided in groups of 3 to 5 children. At preintervention and direct postintervention, parents completed the Anxiety Disorders Interview Schedule for Children and Child Behavior Checklist. Clinically and statistically significant decreases were found in number of anxiety disorders, symptom interference, emotional and behavioural problems, internalising problems, and anxiety problems. The decrease in anxious/depressed problems and externalising problems was not significant. Furthermore, higher preintervention anxiety levels predicted more treatment progress, whereas sex and age did not. The Dutch version of Fun FRIENDS is promising in treating anxiety disorders in young children. Randomised controlled trials are needed to draw definite conclusions on the effectiveness of Fun FRIENDS in a clinical setting.

Classification of postoperative behavior disturbances in preschool children: A qualitative study

BACKGROUND/AIM

Negative postoperative changes in children are frequent and have been described for decades. However, there is currently no theoretical framework, nor any consensual operational criteria for identifying them. This study aims at characterizing the many dimensions involved in postoperative behavioral disturbances in early childhood, using a qualitative analysis applied for the first time to these symptoms.

METHOD

Fifty-seven parents of preschool children (1-5 years old; 38 boys), who underwent general anesthesia, were interviewed 10 days after surgery. Semi-structured interviews investigated behavioral disturbances classically described in preschool children. Qualitative analysis of the transcripts allied both deductive and inductive reasoning, and inductive coding was carried out using constant comparison method with dedicated qualitative software.

RESULTS

Parents reported both positive and negative postoperative changes. Negative changes were classified in four main categories: (a) Externalizing and (b) Internalizing problems behaviors, (c) Feeding sleeping disruption and (d) Somatic problems, each comprising different sub-categories. Importantly within these categories, the symptoms distribution changed in 5 years old children, compared to younger children. Finally, our method allowed defining whether these (negative or positive) changes were significant or not, that is, the importance of postoperative behavioral changes.

CONCLUSION

The results of this study highlight the heterogeneity of postoperative disturbances in preschool children. These results are of primary importance for the definition and measurement of postoperative behavioral disturbances.

What are the validity and reliability of the modified Yale Preoperative Anxiety Scale-Short Form in children less than 2 years old?

BACKGROUND

Accurate measurement of preoperative anxiety is important for pediatric surgical patients' care as well as for monitoring anxiety-reducing interventions. The modified Yale Preoperative Anxiety Scale-short form is well validated for this purpose in children aged 2 years and above, but not in younger children.

AIMS

We aimed to validate the Dutch version of the modified Yale Preoperative Anxiety Scale-short form for measuring preoperative anxiety in children less than 2 years old.

METHODS

Two investigators independently assessed infants' anxiety at the holding area and during induction of anesthesia with the modified Yale Preoperative Anxiety Scale-short form and the COMFORT-Behavior scale-live and from video observations. Construct validity and responsiveness of both scales were tested with Pearson correlation coefficient. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was assessed using Cronbach's α, and inter-rater reliability and intra-rater reliability were tested using the intraclass correlation coefficient and Cohen's linearly weighted kappa. Hypotheses for sufficient inter-rater reliability (r > 0.60) and validity (r > 0.65) had been formulated a priori in line with the COSMIN guidelines.

RESULTS

Behavior of 129 infants (89.1% male) with a median age of 6.5 months (range 0.9-16.5 months) was observed. The correlations between the modified Yale Preoperative Anxiety Scale-short form and COMFORT-Behavioral scale were strong at the holding area and at induction of anesthesia, as were the correlation of change scores between the holding area and induction. Internal consistency of the modified Yale Preoperative Anxiety Scale-short form was excellent at both the holding area and at induction of anesthesia. Inter-rater reliability was good to excellent on scale level and moderate to good on item level.

CONCLUSION

These findings support the validity and reliability of the Dutch version of the modified Yale Preoperative Anxiety Scale-short form in children less than 2-years-old.

Generalized Anxiety Disorder in Very Young Children: First Case Reports on Stability and Developmental Considerations

Generalized anxiety disorder (GAD) is purported to start in early childhood but concerns about attenuation of anxiety symptoms over time and the development of emerging cognitive and emotional processing capabilities pose multiple challenges for accurate detection. This paper presents the first known case reports of very young children with GAD to examine these developmental challenges at the item level. Three children, five-to-six years of age, were assessed with the Diagnostic Infant and Preschool Assessment twice in a test-retest reliability study. One case appeared to show attenuation of the worries during the test-retest period based on caregiver report but not when followed over two years. The other two cases showed stability of the full complement of diagnostic criteria. The cases were useful for demonstrating that the current diagnostic criteria appear adequate for this developmental period. The challenges of accurate assessment of young children that might cause missed diagnoses are discussed. Future research on the underlying dysregulation of negative emotionality and long-term follow-ups are needed to better understand the etiology, treatment, and course of GAD in this age group.

Efficacy and Acceptability of Psychotherapy for Anxious Young Children: A Meta-analysis of Randomized Controlled Trials

We aimed to provide an overview of psychotherapy in young anxious children (mean age, <7 years). Seven electronic databases, including PubMed, EMBASE, Cochrane, Web of Science, PsycINFO, CINAHL, and ProQuest Dissertations, were searched. Randomized controlled trials that compared psychotherapies with control conditions were included. Efficacy (score change on an anxiety rating scale and rate of being freed from anxiety) and acceptability (discontinuations due to any event) were evaluated. Six of the total seven studies included in our study adopted cognitive behavioral therapy (CBT), with only one adopting behavior therapy (BT). Psychotherapy effectively reduced anxiety symptoms (standardized mean difference = -0.83; 95% confidence interval [CI], -1.08 to -0.57), and its rate of freeing patients from anxiety was high (risk ratio [RR] = 0.30; 95% CI, 0.19 to 0.47). No remarkable difference for acceptability was found between the two therapy types (RR = 0.54; 95% CI, 0.25 to 1.18). Psychotherapy, both CBT and BT, benefits young anxious children.

Infant stranger fear trajectories predict anxious behaviors and diurnal cortisol rhythm during childhood

Although a robust literature has linked stable, high levels of fear across childhood to increased risk for anxiety problems, less is known about alternative pathways to anxiety. We tested two putatively normative developmental pathways of early fearfulness for their distinct associations with behavioral (anxiety-related behaviors and symptoms) and biological (diurnal cortisol) markers of anxiety risk in middle childhood in a community-based sample (n = 107). Steeper increases in fear from 6 to 36 months predicted more parent-reported anxiety symptoms at age 8 years. In addition, children who exhibited steep increases in fear during infancy were overrepresented among children with diagnoses of separation anxiety disorder at age 8 years. Finally, we showed that steeper increases in fearfulness in infancy predicted flatter slopes of diurnal cortisol at age 8 years for girls. Thus, differences in stranger fear across infancy may indicate varying degrees of risk for anxious behaviors in later childhood.

A hierarchical causal taxonomy of psychopathology across the life span

We propose a taxonomy of psychopathology based on patterns of shared causal influences identified in a review of multivariate behavior genetic studies that distinguish genetic and environmental influences that are either common to multiple dimensions of psychopathology or unique to each dimension. At the phenotypic level, first-order dimensions are defined by correlations among symptoms; correlations among first-order dimensions similarly define higher-order domains (e.g., internalizing or externalizing psychopathology). We hypothesize that the robust phenotypic correlations among first-order dimensions reflect a hierarchy of increasingly specific etiologic influences. Some nonspecific etiologic factors increase risk for all first-order dimensions of psychopathology to varying degrees through a general factor of psychopathology. Other nonspecific etiologic factors increase risk only for all first-order dimensions within a more specific higher-order domain. Furthermore, each first-order dimension has its own unique causal influences. Genetic and environmental influences common to family members tend to be nonspecific, whereas environmental influences unique to each individual are more dimension-specific. We posit that these causal influences on psychopathology are moderated by sex and developmental processes. This causal taxonomy also provides a novel framework for understanding the heterogeneity of each first-order dimension: Different persons exhibiting similar symptoms may be influenced by different combinations of etiologic influences from each of the 3 levels of the etiologic hierarchy. Furthermore, we relate the proposed causal taxonomy to transdimensional psychobiological processes, which also impact the heterogeneity of each psychopathology dimension. This causal taxonomy implies the need for changes in strategies for studying the etiology, psychobiology, prevention, and treatment of psychopathology. (PsycINFO Database Record

Feasibility of Screening for Preschool Behavioral and Emotional Problems in Primary Care Using the Early Childhood Screening Assessment

The American Academy of Pediatrics recommends screening young children for behavioral and emotional problems (BEP) during primary care visits. Because of time constraints, few primary care providers (PCPs) use standardized screening tools to detect BEP. The Early Childhood Screening Assessment (ECSA) is a brief screening tool developed specifically to meet the needs of pediatric primary care providers (PCPs). The ECSA has established psychometric properties, but the feasibility and acceptability of the ECSA have not been established. This study examines the degree to which PCPs would incorporate ECSA screening and how PCPs value the ECSA as a tool to detect children with BEP. Twenty-seven pediatric PCPs were trained to implement ECSA screening. Six months after training, 96% of PCPs reported that the ECSA was practical for use at well-visits, 70% were still screening and 89% agreed that it helped detect more cases of BEP than by routine history-taking alone.

Prevention Services for Externalizing and Anxiety Symptoms in Low-Income Children: the Role of Parent Preferences in Early Childhood

Dissemination of prevention programs targeting young children is impeded by challenges with parent engagement. Matching program characteristics to parent preferences is associated with increased retention in clinical/intervention settings, but little is known about the types of prevention programs that interest parents. The objectives of this study were to better understand parents' preferences for services designed to prevent externalizing and anxiety disorders and to identify factors associated with preferences. Ethnically diverse, low-income caregivers (n = 485) of young children (11-60 months) completed surveys on child anxiety and externalizing symptoms, parental worry about their children, parent anxiety symptoms, and preferences for prevention group topics. Parents were more likely to prefer a group targeting externalizing behaviors compared to anxiety. Cluster analysis revealed four groups of children: low symptoms, moderate anxiety-low externalizing, moderate externalizing-low anxiety, and high anxiety and externalizing. Parents' preferences varied according to co-occurrence of child anxiety and externalizing symptoms; interest in a program targeting externalizing problems was associated with elevated externalizing problems (regardless of anxiety symptom level), parent anxiety symptoms, and parent worry about their child. Only parent anxiety symptoms predicted parents' interest in an anxiety-focused program, and preference for an anxiety-focused program was actually reduced if children had co-occurring anxiety and externalizing symptoms versus only anxiety symptoms. Results suggest that parents' interest in a program to prevent externalizing problems was well-aligned with the presenting problem, whereas preferences for anxiety programming suggest a more complex interplay among factors. Parent preferences for targeted programming are discussed within a broader framework of parent engagement.

[Attachment Patterns and their Relation to the Development of Anxiety Symptoms in Childhood and Adolescence]

From the perspective of attachment theory, insecure attachment can be seen as a key risk factor for the development of anxiety symptoms and anxiety disorders. This systematic review addresses the current state of empirical research on the relationship between attachment status and anxiety symptoms respective anxiety disorders in childhood and adolescence. 21 current international studies published between 2010 and 2014 were included in this systematic review. These studies were heterogeneous in target populations, methods and study design. The majority of studies supported the assumed correlation between insecure attachment and anxiety symptoms or anxiety disorders. These findings are more evident in studies with school-age children than with preschool children or adolescents. Furthermore, the disorganized-disoriented type of attachment seems to be a particular risk factor for the development of anxiety symptoms and anxiety disorders. Results were discussed in relation to attachment theory and with reference to the results of previous relevant reviews.

Development of a novel observational measure for anxiety in young children: The Anxiety Dimensional Observation Scale

BACKGROUND

Identifying anxiety disorders in preschool-age children represents an important clinical challenge. Observation is essential to clinical assessment and can help differentiate normative variation from clinically significant anxiety. Yet, most anxiety assessment methods for young children rely on parent-reports. The goal of this article is to present and preliminarily test the reliability and validity of a novel observational paradigm for assessing a range of fearful and anxious behaviors in young children, the Anxiety Dimensional Observation Schedule (Anx-DOS).

METHODS

A diverse sample of 403 children, aged 3 to 6 years, and their mothers was studied. Reliability and validity in relation to parent reports (Preschool Age Psychiatric Assessment) and known risk factors, including indicators of behavioral inhibition (latency to touch novel objects) and attention bias to threat (in the dot-probe task) were investigated.

RESULTS

The Anx-DOS demonstrated good inter-rater reliability and internal consistency. Evidence for convergent validity was demonstrated relative to mother-reported separation anxiety, social anxiety, phobic avoidance, trauma symptoms, and past service use. Finally, fearfulness was associated with observed latency and attention bias toward threat.

CONCLUSIONS

Findings support the Anx-DOS as a method for capturing early manifestations of fearfulness and anxiety in young children. Multimethod assessments incorporating standardized methods for assessing discrete, observable manifestations of anxiety may be beneficial for early identification and clinical intervention efforts.

Preschool anxiety disorders predict different patterns of amygdala-prefrontal connectivity at school-age

Objective

In this prospective, longitudinal study of young children, we examined whether a history of preschool generalized anxiety, separation anxiety, and/or social phobia is associated with amygdala-prefrontal dysregulation at school-age. As an exploratory analysis, we investigated whether distinct anxiety disorders differ in the patterns of this amygdala-prefrontal dysregulation.

Methods

Participants were children taking part in a 5-year study of early childhood brain development and anxiety disorders. Preschool symptoms of generalized anxiety, separation anxiety, and social phobia were assessed with the Preschool Age Psychiatric Assessment (PAPA) in the first wave of the study when the children were between 2 and 5 years old. The PAPA was repeated at age 6. We conducted functional MRIs when the children were 5.5 to 9.5 year old to assess neural responses to viewing of angry and fearful faces.

Results

A history of preschool social phobia predicted less school-age functional connectivity between the amygdala and the ventral prefrontal cortices to angry faces. Preschool generalized anxiety predicted less functional connectivity between the amygdala and dorsal prefrontal cortices in response to fearful faces. Finally, a history of preschool separation anxiety predicted less school-age functional connectivity between the amygdala and the ventral prefrontal cortices to angry faces and greater school-age functional connectivity between the amygdala and dorsal prefrontal cortices to angry faces.

Conclusions

Our results suggest that there are enduring neurobiological effects associated with a history of preschool anxiety, which occur over-and-above the effect of subsequent emotional symptoms. Our results also provide preliminary evidence for the neurobiological differentiation of specific preschool anxiety disorders.

The relationships among separation anxiety disorder, adult attachment style and agoraphobia in patients with panic disorder

Epidemiological studies indicate that separation anxiety disorder occurs more frequently in adults than children. It is unclear whether the presence of adult separation anxiety disorder (ASAD) is a manifestation of anxious attachment, or a form of agoraphobia, or a specific condition with clinically significant consequences. We conducted a study to examine these questions. A sample of 141 adult outpatients with panic disorder participated in the study. Participants completed standardized measures of separation anxiety, attachment style, agoraphobia, panic disorder severity and quality of life. Patients with ASAD (49.5% of our sample) had greater panic symptom severity and more impairment in quality of life than those without separation anxiety. We found a greater rate of symptoms suggestive of anxious attachment among panic patients with ASAD compared to those without ASAD. However, the relationship between ASAD and attachment style is not strong, and adult ASAD occurs in some patients who report secure attachment style. Similarly, there is little evidence for the idea that separation anxiety disorder is a form of agoraphobia. Factor analysis shows clear differentiation of agoraphobic and separation anxiety symptoms. Our data corroborate the notion that ASAD is a distinct condition associated with impairment in quality of life and needs to be better recognized and treated in patients with panic disorder.

The diagnostic utility of separation anxiety disorder symptoms: an item response theory analysis

At present, it is not clear whether the current definition of separation anxiety disorder (SAD) is the optimal classification of developmentally inappropriate, severe, and interfering separation anxiety in youth. Much remains to be learned about the relative contributions of individual SAD symptoms for informing diagnosis. Two-parameter logistic Item Response Theory analyses were conducted on the eight core SAD symptoms in an outpatient anxiety sample of treatment-seeking children (N = 359, 59.3 % female, M Age = 11.2) and their parents to determine the diagnostic utility of each of these symptoms. Analyses considered values of item threshold, which characterize the SAD severity level at which each symptom has a 50 % chance of being endorsed, and item discrimination, which characterize how well each symptom distinguishes individuals with higher and lower levels of SAD. Distress related to separation and fear of being alone without major attachment figures showed the strongest discrimination properties and the lowest thresholds for being endorsed. In contrast, worry about harm befalling attachment figures showed the poorest discrimination properties, and nightmares about separation showed the highest threshold for being endorsed. Distress related to separation demonstrated crossing differential item functioning associated with age-at lower separation anxiety levels excessive fear at separation was more likely to be endorsed for children ≥9 years, whereas at higher levels this symptom was more likely to be endorsed by children <9 years. Implications are discussed for optimizing the taxonomy of SAD in youth.

Perceived family impact of preschool anxiety disorders

OBJECTIVE

We examined the perceived impact of child anxiety disorders on family functioning, because such impact is a key predictor of mental health service receipt. In addition, we examined the relative impact of preschool anxiety compared to that of other early childhood disorders, and whether this impact persisted after accounting for the effects of comorbidity, or varied by child age and sex.

METHOD

Drawing from a pediatric primary-care clinic and oversampling for children at risk for anxiety, 917 parents of preschoolers (aged 2-5 years) completed a diagnostic interview and reported on child psychiatric symptom impact on family finances, relationships, activities, and well-being.

RESULTS

After accounting for comorbid disorders, families of children with anxiety were 3.5 times more likely to report a negative impact of their child's behavior on the family relative to nondisordered children. Generalized and separation anxiety had an impact on family functioning similar to that of attention-deficit/hyperactivity disorder and disruptive disorders. There was a significant family impact for girls with social phobia, whereas there was no impact for boys.

CONCLUSIONS

Preschool anxiety has a significant, unique impact on family functioning, particularly parental adjustment, highlighting the family impairment linked with early anxiety, and the need for further research on barriers to care for these disorders.

Continuity in features of anxiety and attention deficit/hyperactivity disorder in young preschool children

Anxiety disorders and attention deficit/hyperactivity disorder (ADHD) develop before school age, but little is known about early developmental pathways. Here we test two hypotheses: first, that early signs of anxiety and ADHD at 18 months predict symptoms of anxiety and ADHD at age 3½ years; second, that emotional dysregulation at 18 months predicts the outcome of co-occurring anxiety and ADHD at age 3½ years. The study was part of the prospective Norwegian Mother and Child Cohort Study (MoBa) at the Norwegian Institute of Public Health. The 628 participants were clinically assessed at 3½ years. Questionnaire data collected at 18 months were categorized into early behavioural scales of anxiety, ADHD, and emotional dysregulation. We investigated continuity in features of anxiety and ADHD from 18 months to 3½ years of age through logistic regression analyses. Anxiety symptoms at 3½ years were predicted by early signs of anxiety (Odds ratio (OR) = 1.41, CI = 1.15-1.73) and emotional dysregulation (OR = 1.33, CI = 1.15-1.54). ADHD symptoms at 3½ years were predicted by early signs of ADHD (OR = 1.51, CI = 1.30-1.76) and emotional dysregulation (OR = 1.31, CI = 1.13-1.51). Co-occurring anxiety and ADHD symptoms at 3½ years were predicted by early signs of anxiety (OR = 1.43, CI = 1.13-1.84), ADHD (OR = 1.30, CI = 1.11-1.54), and emotional dysregulation (OR = 1.34, CI = 1.13-1.58). We conclude that there were modest continuities in features of anxiety and ADHD through early preschool years, while emotional dysregulation at age 18 months was associated with symptoms of anxiety, ADHD, and co-occurring anxiety and ADHD at age 3½ years.

Preschool anxiety disorders in pediatric primary care: prevalence and comorbidity

OBJECTIVE

We sought to establish prevalence rates and detail patterns of comorbidity for generalized anxiety disorder, separation anxiety disorder, and social phobia in preschool-aged children.

METHOD

The Duke Preschool Anxiety Study, a screen-stratified, cross-sectional study, drew from pediatric primary care and oversampled for children at risk for anxiety. A total of 917 parents of preschool children (aged 2-5 years) completed the Preschool Age Psychiatric Assessment.

RESULTS

Generalized anxiety disorder, separation anxiety disorder, and social phobia are common in preschool-aged children attending pediatric primary care. Three-fourths of preschoolers with an anxiety disorder only had a single anxiety disorder. Generalized anxiety disorder displayed the greatest degree of comorbidity: with separation anxiety disorder (odds ratio [OR] = 4.1, 95% CI = 2.0-8.5), social phobia (OR = 6.4, 95% CI = 3.1-13.4), disruptive behavior disorders (OR = 5.1, 95% CI = 1.6-15.8), and depression (OR = 3.7, 95% CI = 1.1-12.4).

CONCLUSIONS

The weakness of association between generalized anxiety disorder and depression stands in contrast to substantial associations between these 2 disorders reported in older individuals. Attenuated associations in preschool-aged children could translate into clinical opportunities for targeted early interventions, aimed at modifying the developmental trajectory of anxiety disorders.

Biobehavioral indicators of social fear in young children with fragile X syndrome

Anxiety is among the most impairing conditions associated with Fragile X syndrome (FXS) and is putatively linked to atypical physiological arousal. However, few studies have examined this association in young children with FXS. The authors examined whether patterns of arousal and behavior during an experimental stranger approach paradigm differ between a cross-sectional sample of 21 young children with FXS and 19 controls (12-58 months old). Groups did not differ in mean levels of behavioral fear. Unlike the control group, however, the FXS group demonstrated increased facial fear at older ages, as well as age-dependent changes in associations between heart activity and distress vocalizations. These findings may inform theoretical models of anxiety etiology in FXS and early detection efforts.

Treatment of anxiety and depression in the preschool period

OBJECTIVE

Empirical studies have established that clinical anxiety and depressive disorders may arise in preschool children as young as 3.0 years. Because empirical studies validating and characterizing these disorders in preschoolers are relatively recent, less work has been done on the development and testing of age-appropriate treatments.

METHOD

A comprehensive literature search yielded several small randomized controlled trials of psychotherapeutic treatments for preschool anxiety and depression. The literature also contained case series of behavioral and psychopharmacologic interventions for specific anxiety disorders. However, to date, no large-scale randomized controlled trials of treatment for any anxiety or depressive disorder specifically targeting preschool populations have been published.

RESULTS

Several age-adapted forms of cognitive-behavioral therapy have been developed and preliminarily tested in small randomized controlled trials and appear promising for different forms of preschool anxiety disorders. Notably, these adaptations centrally involve primary caregivers and use age-adjusted methodology such as cartoon-based materials and co-constructed drawing or narratives. Modified forms of parent child interaction therapy have been tested and appear promising for anxiety and depression. Although preventive interventions that target parenting have shown significant promise in anxiety, these methods have not been explored in early childhood depression. Studies of the impact of parental treatment on infants suggest that direct treatment of the youngest children may be necessary to affect long-term change.

CONCLUSIONS

Recommendations are made for the clinical treatment of these disorders when psychotherapy is the first line of intervention.

Bringing a developmental perspective to anxiety genetics

Despite substantial recent advancements in psychiatric genetic research, progress in identifying the genetic basis of anxiety disorders has been limited. We review the candidate gene and genome-wide literatures in anxiety, which have made limited progress to date. We discuss several reasons for this hindered progress, including small samples sizes, heterogeneity, complicated comorbidity profiles, and blurred lines between normative and pathological anxiety. To address many of these challenges, we suggest a developmental, multivariate framework that can inform and enhance anxiety phenotypes for genetic research. We review the psychiatric and genetic epidemiological evidence that supports such a framework, including the early onset and chronic course of anxiety disorders, shared genetic risk factors among disorders both within and across time, and developmentally dynamic genetic influences. We propose three strategies for developmentally sensitive phenotyping: examination of early temperamental risk factors, use of latent factors to model underlying anxiety liability, and use of developmental trajectories as phenotypes. Expanding the range of phenotypic approaches will be important for advancing studies of the genetic architecture of anxiety disorders.