Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample

The Relationship Between Social Anxiety Disorder and ADHD in Adolescents and Adults: A Systematic Review

OBJECTIVE

This review aimed to systematically gather empirical data on the link between social anxiety disorder and ADHD in both clinical and non-clinical populations among adolescents and adults.

METHOD

Literature searches were conducted in PsycInfo, PubMed, Scopus, and Web of Science, resulting in 1,739 articles. After screening, 41 articles were included. Results were summarized using a narrative approach.

RESULTS

The prevalence of ADHD in adolescents and adults with SAD ranged from 1.1% to 72.3%, while the prevalence of SAD in those with ADHD ranged from 0.04% to 49.5%. Studies indicate that individuals with both SAD and ADHD exhibit greater impairments. All studies were judged to be of weak quality, except for two studies which were rated moderate quality.

DISCUSSION

Individuals with SAD should be screened for ADHD and vice versa, to identify this common comorbidity earlier. Further research is needed to better understand the prevalence of comorbid ADHD and SAD in adolescents.

Decoding the effects of varied peer victimization forms on depression and anxiety among Chinese adolescents: An exploration through latent transition analysis

This study aims to examine co-occurrence patterns of depression and anxiety among Chinese adolescents and their associations with various forms of peer victimization. We collected longitudinal data from 1005 middle school students using the Multidimensional Peer Victimization Scale, Center for Epidemiological Studies Depression Scale, and State-Trait Anxiety Inventory. Then we conducted latent profile analysis, latent transition analysis, and logistic regression analysis. The results reveal the presence of three depression-anxiety profiles among participants: low depression-anxiety group, moderate depression-anxiety group, and high depression-anxiety group. As verbal and relational victimization increase, adolescents are more likely to transition to a higher level of depression-anxiety profile. However, an increase in physical and property victimization predicts a transition to a lower level of depression-anxiety profile. The diverse effects resulting from different forms of victimization exhibit gender differences. For boys, an increase in relational victimization made participants in the moderate depression-anxiety group more likely to transition to the high depression-anxiety group, whereas this effect was not significant among girls. This study is theoretically significant for understanding the link between depression, anxiety, and their influencing factors. It suggests that educators, while addressing verbal and relational harm in adolescents, should reconsider the potential impact of physical and property harm. Opportunities to transform negative events into positive ones should be explored. Educators should tailor their focus based on gender, with a particular emphasis on addressing relational harm among male students. This underscores the need for differentiated approaches to effectively support students.

Obstructive sleep apnea affects the psychological and behavioural development of children-a case-control study

This study aims to investigate the effects of obstructive sleep apnea on paediatric psychological and behavioural abnormalities. A total of 1086 paediatric patients with obstructive sleep apnea and 728 sample snoring controls were enrolled in the study. Patients with obstructive sleep apnea underwent bilateral tonsillectomy plus adenoidectomy or adenoidectomy alone. Repeated Autism Behaviour Checklist, Spence Children's Anxiety Scale, and Children's Depression Inventory were performed to assess the autism symptoms, anxiety level and depressive symptoms before and after surgery. The score of Autism Behaviour Checklist in preschool children with obstructive sleep apnea was higher than that in control. In school children with obstructive sleep apnea, the score of Spence Children's Anxiety Scale was also higher. School children with obstructive sleep apnea with depressive symptoms were significantly higher than that in control. The scores of Autism Behaviour Checklist, Spence Children's Anxiety Scale, and Children's Depression Inventory in the obstructive sleep apnea group after surgery were significantly lower than that before surgery. Our study showed that the score of Spence Children's Anxiety Scale and Children's Depression Inventory had a close correlation with the illness course and hypoxia duration. The Spence Children's Anxiety Scale and Children's Depression Inventory scores are also closely associated with the Autism Behaviour Checklist score. These results suggest that obstructive sleep apnea may have a significant impact on autism symptoms, anxiety levels and depressive symptoms in children. We found that the longer the duration of the obstructive sleep apnea course and hypoxia, the greater the impact on anxiety level and depressive symptoms. The suspected autism symptoms, anxiety level and depressive symptoms in children with obstructive sleep apnea were also significantly correlated. Thus, early detection and timely treatment may often reverse the psychological and behavioural abnormalities caused by obstructive sleep apnea.

Tracking perceived stress, anxiety, and depression in daily life: a double-downward spiral process

Introduction

Previous studies using retrospective questionnaires have suggested a complex relationship between perceived stress and related negative emotions and emphasized their importance in mental health. However, how daily perceived stress, anxiety, and depression interact dynamically in a natural context remains largely unexplored.

Methods

This study conducted a longitudinal survey that applied experience sampling methodology to data from 141 Chinese college students (58% women, mean age = 20.1 ± 1.63 years).

Results

The hierarchical linear models confirmed that daily perceived stress and negative emotions (i.e., perceived depression and anxiety) could reciprocally reinforce one another with the characteristic dynamics of a cognitive-emotional downward spiral. Additionally, anxiety and depression could further circularly aggravate each other imminently. These two intertwined downward-spiral processes constitute a double-downward-spiral model.

Discussion

The findings contribute to a better understanding of the interactive mechanisms underlying perceived stress and its related negative emotions in everyday life and highlight the significance of early emotion regulation and stress relief in healthy people.

School attendance problems in adolescent with attention deficit hyperactivity disorder

Introduction: A link between having a neurodevelopmental disorder, such as attention deficit hyperactivity disorder (ADHD) and school absenteeism, has been found in previous studies. Why ADHD poses a risk for absenteeism remains unclear, and insight into the mechanisms of the association is needed. The aim of the present study was to investigate school attendance problems (SAP) and both the symptoms related and the perceived reasons for them, as reported by adolescents with ADHD (n = 95), compared with neurotypical adolescents (n = 1,474). Method: The current study (N = 1,569) was part of the School absence in Finland-project. SAPs were measured with the Inventory of School Attendance Problems (ISAP). The ISAP questionnaire contains a symptom scale (ISAP S) and a function scale (ISAP F), which shows if and how the symptoms impacts school attendance. A linear mixed effects model was used to analyze outcomes on the ISAP factors, controlling for background variables living status, gender, other diagnoses, highest level of education for the parent and age. Results: Results show that adolescents with ADHD had been more absent from school compared to neurotypical adolescents during the prior 12-weeks. Adolescents with ADHD showed significantly more symptoms of agoraphobia/panic, problems within the family and problems with parents than neurotypical peers. The symptoms separation anxiety, agoraphobia/panic, aggression, problems within the family and problems with parents more often were perceived as the reason for SAP (ISAP F). Discussion: The results are in line with our initial hypotheses and previous studies. Because of the low response rate on the ISAP F scale, the results regarding reasons for SAPs should be interpreted with caution. Future research could examine specific preventive actions of SAPs for adolescents with ADHD, and different subtypes of ADHD.

Social anxiety disorder with comorbid major depression - why fearful attachment style is relevant

Individuals with social anxiety disorder (SAD) often suffer from comorbid major depressive disorder (MDD), which goes along with increased clinical and functional impairment. There has been little research on underlying differences regarding childhood adversities and attachment styles between individuals with SAD with and without comorbid MDD. In the present study, the consecutive sample comprised 612 SCID-diagnosed participants. Of these, n = 472 (62.3% women, 40.7 ± 13.8 years) showed SAD and comorbid MDD (SAD-MDD group) and n = 140 (47.9% women, 43.7 ± 14.7 years) showed just SAD (SAD group). The two groups were compared regarding SAD symptom severity (Social Phobia Inventory; SPIN), childhood adversities (Adverse Childhood Experience Questionnaire; ACE) and attachment styles (Attachment Style Questionnaire, ASQ). The SAD-MDD group reported significantly more severe SAD symptoms (p = .002, d = 0.30), more childhood adversities (p < .001, d = 0.35) and a higher level of fearful attachment style (p < .001, d = 0.30). Group significantly moderated the association between fearful attachment style and SAD symptom severity (β = .292, p < .05) but not between preoccupied attachment style and SAD symptom severity (β = -.184, p = .124; R²_adj = .168, p < .05). Fearful attachment style mediated the association between childhood adversities and SAD symptom severity in the SAD-MDD group. Our study could identify a specific significance of fearful attachment style for the association between negative childhood experiences and social anxiety symptoms in SAD-MDD. Findings have specific implications for the therapeutic relationship.

Prevalence and associated factors of depression, anxiety and suicidality among Chinese high school E-learning students during the COVID-19 lockdown

BACKGROUND

The outbreak of Coronavirus disease (COVID-19) in 2019 and the resulting quarantine may have increased the prevalence of mental health problems in adolescents. The aim of this study was to explore the association between the effects of home-based learning during the pandemic and the risks of depression, anxiety, and suicidality among junior and senior high school students.

METHODS

An online survey using Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) was conducted between 12 to 30 April 2020, on a total of 39,751 students. Multivariable logistic regression analysis was used to analyze the risk factors of associated depression, anxiety and suicidality during the pandemic.

RESULTS

Prevalence of depression, anxiety symptoms and suicidality found was 16.3% (95% CI: 16.0, 16.7), 10.3% (95% CI: 10.0, 10.6) and 20.3% (95% CI: 19.9, 20.7), respectively. Participants with female gender and in junior high school, with poor overall sleep quality and poor academic performance and very worried about being infected during COVID-19 were highly associated with the risk of depression, anxiety symptoms and suicidal ideation (all P<0.001).

CONCLUSIONS

Prevalence of self-reported mental health problems for adolescents using home-based distance learning was high. Implementing measures (e.g., wearing face masks) and spending only moderate time focusing on COVID-19-related information could be protective factors for mental health. These results provide suggestions for teachers and policy makers regarding adolescent improving sleep quality (sufficient sleep) and academic performance and reducing worry about pandemic during quarantine to prevent mental health problems.

Empathy in Social Anxiety Disorder: The Association with Attention Deficit Hyperactivity Disorder

Objectives: Our main hypothesis in this study was that patients with social anxiety disorder (SAD) and comorbid attention deficit hyperactivity disorder (ADHD) had lower empathy levels than those without ADHD. Also, after controlling for the severity of SAD and depression, we hypothesized that ADHD symptoms contributed to lower levels of empathy in SAD patients.Methods: 72 patients (46 females, 32 males) with SAD between the ages of 18-65 years were divided into two groups as those with (n = 32) and those without ADHD (n = 40). Participants were evaluated using the Liebowitz Social Anxiety Scale (LSAS), Turgay's Adult Attention-Deficit/Hyperactivity Disorder, Beck Depression Inventory (BDI), and Empathy Quotient. In this study, Mann Whitney-U test, Spearman correlation test, logistic and multiple regression analysis were used.Results: Education level (U = 371.5, p = .002) and empathy scores (U = 259.5, p < .0001) of SAD patients with ADHD were significantly lower than those without ADHD. BDI (U = 206.5, p < .0001), LSAS total (U = 454.5, p = .036), fear (U = 457.0, p = .038), and avoidance scores (U = 453.0, p = .034) were higher in SAD patients with ADHD than those without ADHD. Low levels of empathy (B = - 0.119, Exp(B) = 0.895, p = .014) and high severity of current depression (B = 0.119, Exp(B) = 1.127, p = .001) were significantly associated with comorbidity between SAD and ADHD. ADHD-inattention (β = -0.369, Exp(B) = -0.541, p = .004), and depression (β = -0.262, Exp(B) = -0.212, p = .036) negatively predicted empathy levels.Conclusions: Our findings may provide some evidence for the contribution of ADHD-inattention and depression to poor empathy in SAD patients. Therefore, it is recommended that symptoms of ADHD-inattention and depression should be carefully evaluated in SAD patients with low empathy.

The Heterogeneity of Selective Mutism: A Primer for a More Refined Approach

Selective mutism is a persistent and debilitating psychiatric disorder in which a child fails to speak in situations where speaking is expected. Although listed as an anxiety disorder, the multifaceted and heterogeneous nature of selective mutism indicates that a more accurate conceptualization may be as a neurodevelopmental disorder. This article serves as a primer of historical and clinical presentations, empirical clinical profiles, clinical distinctions, assessment, and treatment related to the complexity of selective mutism. The article includes a brief discussion of selective mutism within a developmental psychopathology perspective with an eye toward reformed efforts for prevention, assessment, and treatment regarding this population.

Long-term Service Use Among Youths Previously Treated for Anxiety Disorder

OBJECTIVE

(1) To describe rates of long-term service use among subjects previously enrolled in a landmark study of youth anxiety disorder treatment and followed into early adulthood; (2) to examine predictors of long-term service use; and (3) to examine the relationship between anxiety diagnosis and service use over time.

METHOD

The Child/Adolescent Anxiety Multimodal Extended Long-term Study prospectively assessed youths treated through the Child/Adolescent Anxiety Multimodal Study at ages 7-17 years into early adulthood. A total of 319 youths (mean age 17.7, 55.2% female) previously randomized to cognitive-behavioral therapy, sertraline, combination, or placebo for the treatment of anxiety participated; 318 had service use data. Four annual clinic assessments were conducted along with telephone check-ins every 6 months.

RESULTS

Overall, 65.1% of participants endorsed receiving some form of anxiety treatment over the course of the follow-up period, with more subjects reporting medication use than psychotherapy; 35.2% reported consistent use of services over the course of the study. Overall, service use declined over time in subjects with less severe anxiety but remained more steady in those with recurrent/chronic symptoms. Levels of life stress and depressive symptoms were associated with amount of service use over time whereas treatment-related variables (type of initial intervention, acute response, remission) were not. A subset of youths remained chronically anxious despite consistent service use.

CONCLUSION

These findings point to the need to develop models of care that approach anxiety disorders as chronic health conditions in need of active long-term management.

The proportion and associated factors of anxiety in Chinese adolescents with depression during the COVID-19 outbreak

BACKGROUND

Given the serious impact of the COVID-19 outbreak on the mental health of Chinese adolescents, this study aimed to examine the proportion of anxiety and its correlates among Chinese adolescents with depression during the pandemic.

METHODS

This cross-sectional online survey was conducted from February 20th to February 27, 2020 in China. Symptoms of depression and anxiety were assessed by the 20-item Center for Epidemiological Studies-Depression (CES-D) and 7-item Generalized Anxiety Disorder (GAD-7), respectively.

RESULTS

In this study, 3,498 adolescents with depression were identified. Of them, the proportion of anxiety was 45.1% (95% confidence interval [CI]=43.5%-46.8%). Multiple logistic regression analysis revealed that being concerned about graduation (OR=1.25, P=0.002, 95% CI=1.09-1.43), sleep duration <6hr/day (OR=1.80, P<0.001, 95% CI=1.38-2.34), study duration >8hr/day (OR=1.21, P=0.02, 95% CI=1.03-1.42), and quantity of homework higher than before (OR=1.68, P<0.001, 95% CI=1.40-2.02) were positively associated with anxiety; the number of confirmed COVID-19 cases at a provincial level of 100-999 (OR=0.70, P<0.001, 95% CI=0.59-0.83) and 1,000-9,999 (OR=0.69, P=0.001, 95% CI=0.55-0.87) were negatively related to anxiety in adolescents with depression.

LIMITATIONS

Because this was a cross-sectional online study, the causality between variables and anxiety could not be examined among depressed adolescents. The use of self-reported scales may lead to an underestimation of the proportion of anxiety among adolescents with depression.

CONCLUSIONS

The symptoms of anxiety were common in adolescents with depression during the COVID-19 outbreak. Timing screening and targeted interventions are necessary to mitigate the risks of mental illness of adolescents.

Clinical Effects of ADHD Subtypes in Patients With Social Anxiety Disorder

Objective: Our aim in this study is to evaluate the impacts of inattentive and combined types of childhood ADHD (ADHD-I, ADHD-C) in patients with social anxiety disorder (SAD). Methods: A total of 142 adult outpatients with a primary diagnosis of SAD were included. All patients were assessed by using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL), ADHD module and a clinical and sociodemographic data form and scales were filled out. Results: Childhood ADHD comorbidity rates was found to be 88 (62%) in patients with SAD, and 63 of these patients had the diagnosis of ADHD-I. ADHD-I group had higher scores of social anxiety and avoidance and had earlier onset of SAD than the ADHD-C group. Conclusion: The inattentive subtype of ADHD may have a more specific relationship with SAD than ADHD-C.

The importance of avoidant personality in social anxiety disorder with and without attention-deficit/hyperactivity disorder

In the present study, our primary aim was to compare the generalized social anxiety (GSAD) patients with and without attention-deficit/hyperactivity disorder (ADHD) in terms of avoidant personality disorder (AVPD), and some clinical variables. We also investigated the relationship of AVPD and depression with ADHD and GSAD. We hypothesized that ADHD may be associated with AVPD in patients with GSAD. Seventy-six patients with GSAD were evaluated for depression, AVPD, and childhood and adulthood diagnoses of ADHD. The GSAD patients with (n = 34) and without adulthood ADHD (n = 30) were compared with respect to some sociodemographic and clinical variables. GSAD patients with adulthood ADHD had significantly higher comorbid diagnosis of AVPD, more avoidant personality and depression symptoms than those without ADHD. Pearson's correlation coefficient in total sample (n = 76) showed that the mean number of AVPD criteria was significantly associated with the severity of Beck Depression Inventory, Wender Utah Rating Scale (WURS), and inattention symptoms of ADHD. There were no correlations between the total and subscale scores of Liebowitz Social Anxiety Scale and the mean number of AVPD criteria. The scores of WURS significantly predicted the mean number of AVPD criteria (β = 0.305, p= 0.007). The severity of current depression (β = 0.143, p = 0.30) and inattention symptoms of adulthood ADHD (β = 0.112, p = 0.46) were not associated with the severity of AVPD symptoms. These results might demonstrate that comorbid AVPD in adult SAD patients was related to a childhood ADHD independent from depression, and inattention symptoms of ADHD in adulthood.

Cyberbullying and depression among Chinese college students: A moderated mediation model of social anxiety and neuroticism

BACKGROUND

Cyberbullying is a serious social issue that can cause a number of psychological and behavioral problems for perpetrators and victims. Previous studies have shown that adolescent victims of cyberbullying are more likely to exhibit depressive symptoms. However, few studies have investigated the relationship between the perpetration of cyberbullying and depression, or the mediating and moderating mechanisms underlying this relationship.

METHODS

A questionnaire survey was conducted among 476 college students to investigate the relationships between cyberbullying perpetration and depression, the mediating role of social anxiety, and the moderating role of neuroticism.

RESULTS

The results showed that cyberbullying perpetration had a significant and positive predictive effect on depression. Social anxiety partially mediated this relationship. The direct predictive effect of cyberbullying perpetration on depression, and the relation between social anxiety and depression, were both moderated by neuroticism. Cyberbullying perpetration had a greater impact on depression for college students with lower levels of neuroticism and the predictive function of social anxiety on depression was stronger for individuals with low levels of neuroticism too. But neuroticism did not moderate the association between cyberbullying perpetration and social anxiety.

LIMITATIONS

This study focused only on the individual variables influencing the relationship between cyberbullying perpetration and depression, and did not examine interpersonal or environmental variables. Also, the cross-sectional research design means that causality cannot be deduced from the results.

CONCLUSIONS

Cyberbullying perpetration can predict depression directly, and also indirectly via the mediating role of social anxiety. Neuroticism moderates the relation both between cyberbullying and depression, and between social anxiety and depression. These findings provide new perspectives for the treatment and prevention of depression among college students.

Somatic Symptoms of Anxiety and Suicide Ideation Among Treatment-Seeking Youth With Anxiety Disorders

OBJECTIVE

The severity of anxiety, in general, has been associated with suicide ideation (SI) among youth, but research has yet to examine the specific anxiety symptoms that may contribute to SI among youth. This study examined the severity of specific anxiety symptom clusters (i.e., tense/restless, somatic/autonomic symptoms, humiliation/rejection, performing in public, separation anxiety, perfectionism, and anxious coping) and SI in youth who met diagnostic criteria for an anxiety disorder.

METHOD

Participants (N = 87) were treatment-seeking children and adolescents ages 6-17 (M = 11.1 years, SD = 3.06; 52.9% male) diagnosed with a principal anxiety disorder. Youth and their parents completed measures of youth anxiety symptom severity, depression, and SI.

RESULTS

Hierarchical linear regressions revealed that when anxiety symptom clusters were entered simultaneously, only youth self-reported (and not parent-reported) somatic/autonomic symptoms of anxiety significantly predicted SI, after controlling for depression and sex. Importantly, the relationship between somatic/autonomic symptoms of anxiety and SI was stronger than that between depression and SI.

CONCLUSIONS

These results suggest that assessing somatic symptoms of anxiety is especially important when quantifying suicide risk among anxiety-disordered youth.

Impacts of cognitive-behavioral intervention on anxiety and depression among social science education students: A randomized controlled trial

BACKGROUND

Anxiety is a common disorder which refers to a significant and persistent fear of one or more social or performance situations. This study investigated the impacts of cognitive-behavioral intervention on anxiety and depression among undergraduate students enrolled in social science education programs at public universities in the Southeast Nigeria.

METHODS

Participants were 55 undergraduate students enrolled in social science education programs at public universities in the Southeast Nigeria. The adequacy of the sample size used was determined using GPower software. Cognitive-behavioral treatment manuals on anxiety and depression were used to deliver the intervention. Data analyses were completed using repeated measures analysis of variance.

RESULTS

Results indicated a significant positive impact of cognitive-behavioral intervention on anxiety and depression among social science education students exposed to the cognitive-behavioral intervention when compared to the waitlisted group. Results also showed that there was a significant time × group interaction for anxiety and depression. Follow-up tests showed that significant reduction in anxiety and depression persisted after 3 months for the cognitive-behavioral intervention group in comparison to the waitlisted control group.

CONCLUSION

We concluded that cognitive-behavioral intervention was a successful intervention which decreased the symptoms of anxiety and depression in social science education students who participated in the study. Additional studies are recommended to further corroborate the influence of cognitive-behavioral intervention in the reduction of anxiety and depressive symptoms in the Nigerian undergraduate student population.

Latent Class Symptom Profiles of Selective Mutism: Identification and Linkage to Temperamental and Social Constructs

Selective mutism (SM) is a stable, debilitating psychiatric disorder in which a child fails to speak in most public situations. Considerable debate exists as to the typology of this population, with empirically-based studies pointing to possible dimensions of anxiety, oppositionality, and communication problems, among other aspects. Little work has juxtaposed identified symptom profiles with key temperamental and social constructs often implicated in SM. The present study examined a large, diverse, non-clinical, international sample of children aged 6-10 years with SM to empirically identify symptom profiles and to link these profiles to key aspects of temperament (i.e., emotionality, shyness, sociability, activity) and social functioning (i.e., social problems, social competence). Exploratory and confirmatory factor analysis revealed anxiety/distress, oppositionality, and inattention domains. In addition, latent class analysis revealed nuanced profiles labeled as (1) moderately anxious, oppositional, and inattentive, (2) highly anxious, and moderately oppositional and inattentive, and (3) mildly to moderately anxious, and mildly oppositional and inattentive. Class 2 was the most impaired group and was associated with greater emotionality, shyness, and social problems. Class 3 was the least impaired group and was associated with better sociability and social competence and activity. Class 1 was largely between the other classes, demonstrating less shyness and social problems than Class 2. The results help confirm previous findings of anxiety and oppositional profiles among children with SM but that nuanced classes may indicate subtle variations in impairment. The results have implications not only for subtyping this population but also for refining assessment and case conceptualization strategies and pursuing personalized and perhaps less lengthy treatment.

A dimensional approach to determine common and specific neurofunctional markers for depression and social anxiety during emotional face processing

Major depression disorder (MDD) and anxiety disorder are both prevalent and debilitating. High rates of comorbidity between MDD and social anxiety disorder (SAD) suggest common pathological pathways, including aberrant neural processing of interpersonal signals. In patient populations, the determination of common and distinct neurofunctional markers of MDD and SAD is often hampered by confounding factors, such as generally elevated anxiety levels and disorder-specific brain structural alterations. This study employed a dimensional disorder approach to map neurofunctional markers associated with levels of depression and social anxiety symptoms in a cohort of 91 healthy subjects using an emotional face processing paradigm. Examining linear associations between levels of depression and social anxiety, while controlling for trait anxiety revealed that both were associated with exaggerated dorsal striatal reactivity to fearful and sad expression faces respectively. Exploratory analysis revealed that depression scores were positively correlated with dorsal striatal functional connectivity during processing of fearful faces, whereas those of social anxiety showed a negative association during processing of sad faces. No linear relationships between levels of depression and social anxiety were observed during a facial-identity matching task or with brain structure. Together, the present findings indicate that dorsal striatal neurofunctional alterations might underlie aberrant interpersonal processing associated with both increased levels of depression and social anxiety.

Extended-release methylphenidate monotherapy in patients with comorbid social anxiety disorder and adult attention-deficit/hyperactivity disorder: retrospective case series

BACKGROUND

The relationship between social anxiety disorder (SAD) and attention-deficit/hyperactivity disorder (ADHD) is a subject which has recently become a topic of interest for research.

METHODS

In this study, 20 patients with comorbid SAD and adult ADHD who were treated with extended-release methylphenidate monotherapy were evaluated retrospectively.

RESULTS

Clinical response for both ADHD and SAD symptoms was observed in 17 of 20 patients. Overall, one patient did not respond to treatment and two patients dropped out of treatment at the beginning due to adverse effects.

CONCLUSION

Extended-release methylphenidate improved both SAD and ADHD symptoms and was generally well tolerated. Further studies are required to investigate the relationship between SAD and ADHD.

Parent-child interactions in children with asthma and anxiety

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

The relationship of social anxiety disorder symptoms with probable attention deficit hyperactivity disorder in Turkish university students; impact of negative affect and personality traits of neuroticism and extraversion

The aim of the present study was to evaluate relationship of social anxiety disorder symptoms with probable attention deficit hyperactivity disorder (ADHD) while controlling the personality traits of neuroticism and extraversion, anxiety and depression symptoms in a sample of Turkish university students (n=455). Participants were evaluated with the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Eysenck Personality Questionnaire Revised-Abbreviated Form (EPQR-A), the Adult ADHD Self-Report Scale (ASRS-v1.1) and the Liebowitz Social Anxiety Scale (LSAS). Severity of social anxiety, depression, anxiety and neuroticism were higher among those with probable ADHD, whereas extraversion score did not differ between the groups. The severity of ADHD score, particularly hyperactivity/impulsivity score, was related with the "fear or anxiety" together with low extraversion (introversion) and high neuroticism dimensions of personality, whereas the severity of ADHD score, both inatentiveness and hyperactivity/impulsivity scores, was related with "avoidence" together with low extraversion (introversion) dimension of personality. These findings suggest that probable ADHD and severity of ADHD symptoms are related with both "fear or anxiety" and "avoidance" of social anxiety, while personality dimensions of low extraversion (introversion) and high neuroticism may have an effect on this relationships among young adults.

Emotion Regulation and the Transdiagnostic Role of Repetitive Negative Thinking in Adolescents with Social Anxiety and Depression

Social anxiety and depression are common mental health problems among adolescents and are frequently comorbid. Primary aims of this study were to (1) elucidate the nature of individual differences in specific emotion regulation deficits among adolescents with symptoms of social anxiety and depression, and (2) determine whether repetitive negative thinking (RNT) functions as a transdiagnostic factor. A diverse sample of adolescents (N = 1065) completed measures assessing emotion regulation and symptoms of social anxiety and depression. Results indicated that adolescents with high levels of social anxiety and depression symptoms reported decreased emotional awareness, dysregulated emotion expression, and reduced use of emotion management strategies. The hypothesized structural model in which RNT functions as a transdiagnostic factor exhibited a better fit than an alternative model in which worry and rumination function as separate predictors of symptomatology. Findings implicate emotion regulation deficits and RNT in the developmental psychopathology of youth anxiety and mood disorders.

When social anxiety and depression go together: A population study of comorbidity and associated consequences

BACKGROUND

Despite several studies suggesting higher depression severity and dysfunction occurring in individuals with major depressive disorder (MDD) comorbid with social anxiety disorder (SAD), a clear understanding of the specific risks associated with this comorbidity is lacking. In this study we compared the disease characteristics and level of disability of individuals with MDD-SAD with other comorbidities between depression and anxiety.

METHODS

Data from the Collaborative Psychiatric Epidemiology Surveys (CPES) (N=20,013) were used. Individuals were divided in four groups comparing MDD-SAD with MDD alone, as well as other comorbidities between MDD and one anxiety (MDD-1ANX) or more than two anxiety disorders (MDD≥2ANX), with respect to several clinical, demographic, and functional characteristics.

RESULTS

MDD-SAD comorbidity in the general population occurred in younger people, particularly men, and seemed to have an earlier onset of MDD. Occupational and social dysfunction was similar between individuals with MDD-SAD and those with MDD-1ANX. However, individuals with MDD≥2ANX had significantly higher severity as measured by suicidality as well as substance abuse and social and occupational dysfunction. SAD was the most prevalent comorbid anxiety in this group.

LIMITATIONS

The findings of this study were derived from the cross-sectional data.

CONCLUSION

Our results suggest that the particular risks associated with MDD-SAD are the early onset and likelihood of additional anxiety, leading to higher severity and disability levels. Clinicians should increase the screening and treatment of SAD and other anxiety disorders in individuals with MDD given the higher associated health risk and functional impairment.

Mütterliches Expressed Emotion und elterliche Angst vor negativer Bewertung bei Kindern mit sozialer Angststörung

Zusammenfassung. Theoretischer Hintergrund: Ziel dieser Studie ist die Untersuchung von Expressed Emotion (EE) als Faktor des familiären Klimas sowie elterlicher Angst vor negativer Bewertung des Kindes als potentieller Mediator für den Zusammenhang von sozialer Angst der Eltern und Kinder. Methode: Kinder mit Sozialer Angststörung (SAS; n = 64) und ohne SAS (healthy control, HC, n = 52) sowie deren Eltern (Mütter und Väter) berichteten über eigene soziale Ängste und ihre Angst vor negativer Bewertung des Kindes. Mütter nahmen zudem am Five Minute Speech Sample (FMSS) zur Erhebung von EE teil. Ergebnisse: Berichte von Müttern von Kindern mit einer SAS wurden häufiger als High Expressed Emotion (HEE) eingestuft als Berichte von Müttern von HC Kindern. Es zeigte sich ein Zusammenhang von EE und sozialer Angst der Mutter wie auch mütterlicher Angst vor negativer Bewertung des Kindes. Zudem wurde der Zusammenhang zwischen kindlicher und mütterlicher sozialer Angst partiell durch die Angst vor negativer Bewertung des Kindes mediiert. Schlussfolgerungen: Es konnte ein Zusammenhang von kindlicher SAS und gleichzeitig erhöhtem EE der Mütter gezeigt werden. Erhöhte Angst vor negativer Bewertung des Kindes stellt einen potenziellen Mechanismus dar, wie mütterliche, nicht aber väterliche, soziale Angst an das Kind vermittelt werden kann.

Amplitude variability over trials in hemodynamic responses in adolescents with ADHD: The role of the anterior default mode network and the non-specific role of the striatum

It has been suggested that intra-individual variability (IIV) in performance on attention and other cognitive tasks might be a cognitive endophenotype in individuals with ADHD. Despite robust IIV findings in behavioral data, only sparse data exist on how what type of brain dysfunction underlies variable response times. In this study, we asked whether ADHD IIV in reaction time on a commonly-used test of attention might be related to variation in hemodynamic responses (HRs) observed trial-to-trial. Based on previous studies linking IIV to regions within the “default mode” network (DMN), we predicted that adolescents with ADHD would have higher HR variability in the DMN compared with controls, and this in turn would be related to behavioral IIV. We also explored the influence of social anxiety on HR variability in ADHD as means to test whether higher arousal associated with high trait anxiety would affect the neural abnormalities. We assessed single-trial variability of HRs, estimated from fMRI event-related responses elicited during an auditory oddball paradigm in adolescents with ADHD and healthy controls (11–18 years old; N = 46). Adolescents with ADHD had higher HR variability compared with controls in anterior regions of the DMN. This effect was specific to ADHD and not associated with traits of age, IQ and anxiety. However, an ADHD effect of higher HR variability also appeared in a basal ganglia network, but for these brain regions the relationships of HR variability and social anxiety levels were more complex. Performance IIV correlated significantly with variability of HRs in both networks. These results suggest that assessment of trial-to-trial HR variability in ADHD provides information beyond that detectable through analysis of behavioral data and average brain activation levels, revealing specific neural correlates of a possible ADHD IIV endophenotype.

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We studied if the behavioral variability in ADHD is also found on a neuronal level.

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Independent component analysis was combined with BOLD amplitude variability.

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Adolescents with ADHD had higher amplitude variability than healthy controls.

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Higher amplitude variability was shown in an anterior default mode network.

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Social anxiety in ADHD associated with high amplitude variability in the striatum

Dysregulation in Youth with Anxiety Disorders: Relationship to Acute and 7- to 19- Year Follow-Up Outcomes of Cognitive-Behavioral Therapy

This study evaluated the impact of dysregulation across cognitive, affective, and behavioral domains on acute and 7- to 19-year follow-up outcomes of cognitive-behavioral therapy (CBT) for anxiety, and explored dysregulation as a predictor of psychopathology and impairment in young adulthood among individuals who received anxiety treatment as youth. Participants (N = 64; 50 % female, 83 % non-Hispanic White) from two randomized clinical trials completed a follow-up assessment 7-19 years later. Latent profile analysis identified dysregulation based on Anxious/Depressed, Attention Problems, and Aggressive Behavior scores on the Child Behavior Checklist. Although pretreatment dysregulation was not related to acute or follow-up outcomes for anxiety diagnoses that were the focus of treatment, dysregulation predicted an array of non-targeted psychopathology at follow-up. Among youth with a principal anxiety disorder, the effects of CBT (Coping Cat) appear to be robust against broad impairments in self-regulation. However, youth with a pretreatment dysregulation profile likely need follow-up to monitor for the emergence of other disorders.

Parental Attitudes, Beliefs, and Understanding of Anxiety (PABUA): Development and psychometric properties of a measure

The Parental Attitudes, Beliefs, and Understanding of Anxiety (PABUA) was developed to assess parental beliefs about their child's anxiety, parents' perceived ability to cope with their child's anxiety and to help their child manage anxious symptoms, and to evaluate parents' understanding of various parenting strategies in response to their child's anxiety. The study evaluated the PABUA in mother-child dyads (N=192) seeking treatment for youth anxiety. Exploratory factor analysis yielded a three-factor solution and identified PABUA scales of Overprotection, Distress, and Approach (with Cronbach's alpha ranging from .67 to .83). Convergent and divergent validity of PABUA scales was supported by the pattern of associations with measures of experiential avoidance, beliefs related to children's anxiety, empathy, trait anxiety, and depressive symptoms; parent-reported family functioning; parent- and youth-reported anxiety severity; and parent-reported functional impairment (n=83). Results provide preliminary support for the PABUA as a measure of parental attitudes and beliefs about anxiety, and future studies that investigate this measure with large and diverse samples are encouraged.

Mediators of change in the Child/Adolescent Anxiety Multimodal Treatment Study

OBJECTIVE

Test changes in (a) coping efficacy and (b) anxious self-talk as potential mediators of treatment gains at 3-month follow-up in the Child/Adolescent Anxiety Multimodal Treatment Study (CAMS).

METHOD

Participants were 488 youth (ages 7-17; 50.4% male) randomized to cognitive-behavioral therapy (CBT; Coping cat program), pharmacotherapy (sertraline), their combination, or pill placebo. Participants met Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) criteria for generalized anxiety disorder, social phobia, and/or separation anxiety disorder. Coping efficacy (reported ability to manage anxiety provoking situations) was measured by youth and parent reports on the Coping Questionnaire, and anxious self-talk was measured by youth report on the Negative Affectivity Self-Statement Questionnaire. Outcome was measured using the Pediatric Anxiety Rating Scale (completed by Independent Evaluators blind to condition). For temporal precedence, residualized treatment gains were assessed at 3-month follow-up.

RESULTS

Residualized gains in coping efficacy mediated gains in the CBT, sertraline, and combination conditions. In the combination condition, some unique effect of treatment remained. Treatment assignment was not associated with a reduction in anxious self-talk, nor did anxious self-talk predict changes in anxiety symptoms.

CONCLUSIONS

The findings suggest that improvements in coping efficacy are a mediator of treatment gains. Anxious self-talk did not emerge as a mediator.

Developmental Differences in Functioning in Youth With Social Phobia

Social phobia (SoP) in youth may manifest differently across development as parent involvement in their social lives changes and social and academic expectations increase. This cross-sectional study investigated whether self-reported and parent-reported functioning in youth with SoP changes with age in social, academic, and home/family domains. Baseline anxiety impairment data from 488 treatment-seeking anxiety-disordered youth (ages 7-17, N = 400 with a SoP diagnosis) and their parents were gathered using the Child Anxiety Impact Scale and were analyzed using generalized estimating equations. According to youth with SoP and their parents, overall difficulties, social difficulties, and academic difficulties increased with age, even when controlling for SoP severity. These effects significantly differed for youth with anxiety disorders other than SoP. Adolescents may avoid social situations as parental involvement in their social lives decreases, and their withdrawn behavior may result in increasing difficulty in the social domain. Their avoidance of class participation and oral presentations may increasingly impact their academic performance as school becomes more demanding. Implications are discussed for the early detection and intervention of SoP to prevent increased impairment over the course of development.

Predominantly Inattentive Type of ADHD is Associated With Social Anxiety Disorder

OBJECTIVE

The aim of this study was to determine the frequency of childhood ADHD comorbidity in patients with social anxiety disorder (SAD), and the influence of this comorbidity on various demographic and clinical variables in SAD.

METHOD

A total of 130 patients with SAD were assessed with K-SADS-PL's (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version) behavioral disorders module to determine the childhood diagnosis of ADHD. Patients with or without a comorbid childhood ADHD were compared in terms of clinical characteristics and rating scores.

RESULTS

The mean age at onset of SAD was lower, and lifetime major depressive disorder and bipolar disorder (BD) comorbidity were higher in the SAD-ADHD group than in the SAD-without ADHD group.

CONCLUSION

We have found high ADHD comorbidity in patients with SAD. Presence of comorbid ADHD was associated with increased severity, functional impairment, and BD comorbidity.

Extended-release Methylphenidate Treatment and Outcomes in Comorbid Social Anxiety Disorder and Attention-deficit/Hyperactivity Disorder: 2 Case Reports

Social anxiety disorder is frequently comorbid with attention-deficit/hyperactivity disorder (ADHD). However, treatment recommendations are not clear in the presence of such comorbidity. A few studies in the literature have reported improvement in symptoms of both disorders with treatment specific for ADHD (ie, stimulants and atomoxetine). In this report, we present cases of 2 adults with social anxiety disorder and ADHD who were treated with methylphenidate monotherapy. Both cases responded well in terms of not only their ADHD symptoms but also the social anxiety disorder symptoms. Methylphenidate was well tolerated with no significant side effects. More studies are needed to better establish the potential of ADHD medications to be effective for comorbid social anxiety disorder symptoms.

Low perceived social support predicts later depression but not social phobia in middle adolescence

Social phobia and depression are common and highly comorbid disorders in adolescence. There is a lack of studies on possible psychosocial shared risk factors for these disorders. The current study examined if low social support is a shared risk factor for both disorders among adolescent girls and boys. This study is a part of the Adolescent Mental Health Cohort Study's two-year follow-up. We studied cross-sectional and longitudinal associations of perceived social support with social phobia, depression, and comorbid social phobia and depression among girls and boys. The study sample consisted of 2070 15-year-old adolescents at baseline. Depression was measured by the 13-item Beck Depression Inventory, social phobia by the Social Phobia Inventory (SPIN), and perceived social support by the Perceived Social Support Scale-Revised (PSSS-R). Girls reported higher scores on the PSSS-R than boys in total scores and in friend and significant other subscales. Cross-sectional PSSS-R scores were lower among adolescents with social phobia, depression, and comorbid disorder than among those without these disorders. Low PSSS-R total score and significant other subscale were risk factors for depression among both genders, and low support from friends among girls only. Low perceived social support from any source was not a risk factor for social phobia or comorbid social phobia and depression. As conclusion of the study, low perceived social support was a risk factor for depression, but not a shared risk factor for depression and social phobia. Interventions enhancing perceived social support should be an important issue in treatment of depression.

Comorbidity of anxiety and depression in children and adolescents: 20 years after

Brady and Kendall (1992) concluded that although anxiety and depression in youths are meaningfully linked, there are important distinctions, and additional research is needed. Since then, studies of anxiety-depression comorbidity in youths have increased exponentially. Following a discussion of comorbidity, we review existing conceptual models and propose a multiple pathways model to anxiety-depression comorbidity. Pathway 1 describes youths with a diathesis for anxiety, with subsequent comorbid depression resulting from anxiety-related impairment. Pathway 2 refers to youths with a shared diathesis for anxiety and depression, who may experience both disorders simultaneously. Pathway 3 describes youths with a diathesis for depression, with subsequent comorbid anxiety resulting from depression-related impairment. Additionally, shared and stratified risk factors contribute to the development of the comorbid disorder, either by interacting with disorder-related impairment or by predicting the simultaneous development of the disorders. Our review addresses descriptive and developmental factors, gender differences, suicidality, assessments, and treatment-outcome research as they relate to comorbid anxiety and depression and to our proposed pathways. Research since 1992 indicates that comorbidity varies depending on the specific anxiety disorder, with Pathway 1 describing youths with either social phobia or separation anxiety disorder and subsequent depression, Pathway 2 applying to youths with coprimary generalized anxiety disorder and depression, and Pathway 3 including depressed youths with subsequent social phobia. The need to test the proposed multiple pathways model and to examine (a) developmental change and (b) specific anxiety disorders is highlighted.

Selective Mutism in Early Childhood

Selective mutism (SM) is a relatively uncommon disorder in childhood, occurring in only 0.3 to 1.8 children per thousand. In early childhood, diagnosing SM can be particularly challenging, and the condition often goes unrecognized until the school years. Given the potential comorbidity of anxiety and communication deficits, treatment can be challenging and attendance in early childhood educational programs allows intervention in a contextually sensitive way that may also help address comorbidities and promote generalization. Thus, this case study of an African American preschool boy highlights the unique obstacles and opportunities of assessment and treatment in a preschool setting. Furthermore, we describe a three-step behavioral approach to addressing SM in collaboration with educators over a 3-month period. Substantive research indicates that early intervention with SM is associated with decreased likelihood of developing an anxiety-related disorder later in childhood; therefore, tailored assessment and intervention in early childhood within a community-based setting may be extremely useful.

Der Einfluss von situativer Angst auf die soziale Performanz und Selbstbewertung von Kindern mit sozialen Ängsten

Theoretischer Hintergrund: Studien zu sozialen Fertigkeiten und der Selbstbewertung von Kindern mit sozialen Ängsten zeigen ein heterogenes Bild. Fragestellung: Als ein möglicherweise wichtiger, jedoch bisher unbeachteter Einflussfaktor für die Erklärung dieser inkonsistenten Befunde wird die situative Angst während sozialer Situationen untersucht. Methode: Kinder mit hoher/niedriger sozialer Angst (HSA/NSA, je n=20) absolvierten zwei sozial-evaluative Aufgaben. Soziale Performanz, Selbsteinschätzungen sowie situative Angst wurden erfasst. Ergebnisse: HSA-Kinder zeigten eine verminderte soziale Performanz im Vergleich zur NSA-Gruppe in beiden Aufgaben (ηp2=.234). In beiden Gruppen verringerte sich die situative Angst über die Aufgaben hinweg (ηp2=.143), während sich die Selbstbewertungen parallel verbesserten (ηp2=.376) und einen hohen Zusammenhang zur situativen Angst zeigten. Schlussfolgerungen: Angstexposition und -habituation haben somit möglicherweise einen direkten positiven Einfluss auf die Selbstbewertungen von HSA Kindern. Für den Aufbau sozialer Fertigkeiten bei HSA-Kindern sind wahrscheinlich gezielte Interventionen nötig.

Assessing anxiety in youth with the multidimensional anxiety scale for children

The present study examined the psychometric properties, including discriminant validity and clinical utility, of the youth self-report and parent-report forms of the Multidimensional Anxiety Scale for Children (MASC) among youth with anxiety disorders. The sample included parents and youth (N = 488, 49.6% male) ages 7 to 17 who participated in the Child/Adolescent Anxiety Multimodal Study. Although the typical low agreement between parent and youth self-reports was found, the MASC evidenced good internal reliability across MASC subscales and informants. The main MASC subscales (i.e., Physical Symptoms, Harm Avoidance, Social Anxiety, and Separation/Panic) were examined. The Social Anxiety and Separation/Panic subscales were found to be significantly predictive of the presence and severity of social phobia and separation anxiety disorder, respectively. Using multiple informants improved the accuracy of prediction. The MASC subscales demonstrated good psychometric properties and clinical utilities in identifying youth with anxiety disorders.

Two Cases of Early Childhood Selective Mutism

Selective Mutism (SM) is a highly impairing disorder which typically presents upon entry to school and affects approximately 0.7% of children. Despite its impact on social and academic development, it is a difficult disorder to treat and there is a small evidence base for behavioral treatment. Preliminary evidence suggests that behavioral treatment focused on exposure to social interactions, social skill building, and involvement of caregivers in treatment may be promising. This article presents two cases of early childhood SM to demonstrate the importance of tailored treatment implementation to meet the individual needs of each family and help children resume typical social development.

Cognitive behavioral therapy for youth with social anxiety: differential short and long-term treatment outcomes

This study examined social anxiety symptoms and/or diagnosis as a predictor of differential short- and long-term cognitive-behavioral treatment (CBT) outcomes. Ninety-one anxiety-disordered youth participated in a randomized clinical trial of CBT. Semi-structured interviews provided dimensional clinical severity ratings (CSRs) for children's principal anxiety disorder at pretreatment, posttreatment, 1-year and 7.4-year follow-up assessments for youth with versus without pretreatment social anxiety. Thirty-nine youth presented with either principal (n=17), secondary (n=11), or tertiary social phobia diagnoses (n=7) or subclinical social anxiety symptoms (n=4). Hierarchal linear modeling (HLM) indicated that youth made similar gains from pretreatment to posttreatment and 1-year follow-up regardless of their social anxiety symptoms or diagnosis; however, youth with social anxiety symptoms or diagnosis were significantly less improved at 7.4-year follow-up. This pattern was distinct from that of youth with the most severe (CSR=4) principal anxiety disorders at pretreatment. Though initially responsive to CBT, children who present with social anxiety diagnoses or symptoms may require an enhanced or extended treatment to maintain their gains into young adulthood whether or not social anxiety is considered their principal childhood difficulty.

Social functioning in youth with anxiety disorders: association with anxiety severity and outcomes from cognitive-behavioral therapy

Social functioning was assessed using the Child Behavior Checklist and Teacher Report Form for children with anxiety disorders who participated in a randomized clinical trial (N = 161, aged 7-14). Significant relationships were found between severity of children's principal anxiety disorder and most measures of social functioning, such that poorer social functioning was associated with more severe anxiety. Among youth who received cognitive-behavioral therapy (n = 111), significant associations were found between parent-reported social competence and both absence of principal anxiety disorder and lower anxiety severity at posttreatment and 1-year follow-up, controlling for the severity of the child's principal anxiety disorder at pretreatment. Findings support a relationship between anxiety severity and social difficulties, and suggest the importance of social competence for a favorable treatment response.