A psychometric evaluation of the parent report form of the State-Trait Anxiety Inventory for Children--Trait Version

Genetic and environmental sources of familial resemblance in anxiety: a nuclear twin family design

BACKGROUND

A dominant feature of anxiety disorders is familial aggregation. However, the underlying mechanisms of between- and within-generational anxiety resemblance remain poorly understood. By disentangling the genetic v. environmental sources of familial resemblance in anxiety, we can help prevent within-family transmission of anxiety disorders. Therefore, data from both parents and twins are needed to obtain unbiased and detailed estimations of genetic and environmental sources of similarity between family members.

METHODS

We examined data from 991 families with same-sex twins. Trait anxiety in twins was assessed via self-report and parent report, while parental trait anxiety was assessed via self-report. We established a nuclear twin family model and estimated genetic and environmental variances using two survey waves.

RESULTS

The results suggested that additive genetic (A), dominant genetic (D), and non-shared environmental (E) influences significantly contributed to trait anxiety, whereas familial environmental influences (F) and passive gene-environment correlations (rGE) did not. Sibling environmental influences (S) were only found in self-report data, and increased when genetic influences decreased from Wave 1 to Wave 2.

CONCLUSIONS

Our study highlights the important role of broad heritability in intrafamilial trait anxiety similarity. Parent-child resemblance occurred primarily due to shared genetic makeup rather than direct environmental transmission. Sibling-specific environments, as the only source of shared environments, need further investigation. These findings have both theoretical and practical significance for anxiety disorders. Future research can expand our understanding by examining the gene-environment interplay and sex differences.

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

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

Mindfulness-based cognitive therapy for children and adolescents with anxiety disorders at-risk for bipolar disorder: A psychoeducation waitlist controlled pilot trial

AIM

Previous studies suggest that Mindfulness-Based Cognitive Therapy for Children (MBCT-C) is feasible and may improve anxiety and emotion regulation in youth with anxiety disorders at-risk for bipolar disorder. However, controlled studies are warranted to replicate and extend these findings.

METHODS

In the current study, 24 youth with anxiety disorders who have at least one parent with bipolar disorder participated in a MBCT-C treatment period (n = 24; M_age = 13.6, 75% girls, 79% White) with a subset also participating in a prior psychoeducation waitlist control period (n = 19 M_age = 13.8, 68% girls, 84% White). Participants in both the waitlist and MBCT-C periods completed independently-rated symptom scales at each time point. Participants in the waitlist period received educational materials 12 weeks prior to the beginning of MBCT-C.

RESULTS

There were significantly greater improvements in overall clinical severity in the MBCT-C period compared to the waitlist period, but not in clinician- and child-rated anxiety, emotion regulation or mindfulness. However, increases in mindfulness were associated with improvements in anxiety and emotion regulation in the MBCT-C period, but not the waitlist period.

CONCLUSIONS

Findings suggest that MBCT-C may be effective for improving overall clinical severity in youth with anxiety disorders who are at-risk for bipolar disorder. However, waitlist controlled designs may inflate effect sizes so interpret with caution. Larger studies utilizing prospective randomized controlled designs are warranted.

Predictors and Outcomes of Sudden Gains and Sudden Regressions in Cognitive Behavioral Therapy for Youth Anxiety

Sudden gains (SGs), referring to large, stable symptom improvement occurring between consecutive treatment sessions, have been associated with improved outcomes among adults with various psychological disorders. Little research exists on SGs or sudden symptom worsening (i.e., sudden regressions [SRs]) during treatment for youth disorders. The current study examined predictors and outcomes of SGs/SRs via multiple informants in youth anxiety treatment. Participants were 118 youth (age M = 11.6, SD = 2.5; 53.8% female) and their caregivers receiving a cognitive-behavioral therapy protocol for a principal anxiety disorder. Anxiety symptom severity was assessed weekly via the State-Trait Anxiety Inventory for Children-Trait-Child/Parent versions. SGs and SRs occurred in 45.8 and 31.3% of youth, respectively. SRs were more common among youth with comorbid mood or externalizing disorders, while SGs occurred more often among youth with greater pretreatment anxiety symptom severity. SGs were not associated with posttreatment outcomes, but SRs predicted significantly higher posttreatment internalizing symptoms based on child report (β = .23, p = .03) and externalizing symptoms based on child (β = .15, p = .04) and parent report (β = .16, p = .03), controlling for overall magnitude of symptom change. SRs among youth receiving cognitive-behavioral therapy for anxiety are associated with pretreatment clinical complexity and poorer posttreatment outcomes and may serve as a warning sign to clinicians of possible treatment failure.

Identifying the trauma recovery needs of maltreated children: An examination of child welfare workers' effectiveness in screening for traumatic stress

Children in the child welfare system comprise a group characterized by exposure to trauma via experiences of maltreatment, under circumstances presenting multiple risk factors for traumatic stress. High rates of posttraumatic stress have been observed in this population. However, there is currently no standard for the universal screening of children in child welfare for trauma exposure and traumatic stress. This study examined the trauma experiences of a sample of maltreated children and whether their child welfare workers were effective screeners of traumatic stress symptoms. Descriptive and correlational analyses were conducted regarding a sample of children (N = 131) with trauma screenings completed by their child welfare workers and clinical measures of traumatic stress symptoms. Four hierarchical regression models were also examined to determine whether workers' screening information regarding child age, trauma exposure history and symptoms of traumatic stress were predictive of outcomes on clinical measures. The analyses revealed complex trauma exposure histories and high rates of traumatic stress symptoms among this generally younger sample of maltreated children. Additionally, the models supported workers' efficacy in screening for symptoms of total posttraumatic stress and specific trauma symptoms of intrusion and avoidance. Workers were less effective in screening for the symptoms of arousal. These findings support the importance of identifying the trauma recovery needs of maltreated children and the utility of child protection workers in assisting with the trauma screening process. Implications are provided for related practice, policy and training efforts in child welfare.

Mindfulness-based cognitive therapy for youth with anxiety disorders at risk for bipolar disorder: a pilot trial

AIM

Children and adolescents with bipolar parents have an elevated risk for anxiety disorders. However, antidepressant medications commonly used to treat symptoms of anxiety may accelerate the onset of mania in these already at-risk youth. Therefore, studies evaluating innovative non-pharmacologic treatments for anxiety in this population are urgently needed.

METHODS

Subjects participated in 12 weekly sessions of mindfulness-based cognitive therapy for children (MBCT-C), a manualized group psychotherapeutic intervention utilizing cognitive behavioural principles and mindfulness exercises to increase regulation of attention and non-judgmental acceptance of present moment thoughts, emotions and experiences. Independent raters administered symptoms rating scales prior to each treatment session. Spearman correlations and paired-samples signed rank tests were used to examine outcomes. After-intervention surveys and session transcripts were reviewed to assess feasibility and acceptability of the intervention.

RESULTS

Participants included 10 youth (meanage  = 13.2; 80% girls; 40% biracial) with generalized, social and/or separation anxiety disorders, and a parent with bipolar disorder. Clinician-rated anxiety was significantly reduced after intervention (meanbefore  = 11.1; meanafter  = 4.3; P < 0.01), as well as youth-rated trait anxiety (P = 0.03). Parent-rated emotion regulation significantly increased from before to after intervention (P = 0.05). Increases in mindfulness were associated with decreases in anxiety (P = 0.03). Finally, children and parents/guardians reported high levels of feasibility, acceptability and usefulness of the intervention.

CONCLUSION

Findings support the feasibility, acceptability and preliminary efficacy of MBCT-C for treating anxiety in youth at risk for bipolar disorder. Future controlled and larger studies are needed to confirm these preliminary findings.

Adapting Manualized CBT for a Cognitively Delayed Child With Multiple Anxiety Disorders

This study examined the effectiveness of a modified cognitive-behavioral therapy (CBT) program for the treatment of a cognitively delayed 8-year-old girl presenting with social phobia, selective mutism, and generalized anxiety disorder (GAD). Multimethod assessment, at pretreatment and posttreatment, included a semistructured diagnostic interview, self-reports, and parent and teacher reports. Cognitive delays were apparent at the initial assessment and confirmed on review of previous evaluations. CBT for anxious youth was implemented in a modified fashion to ensure that the methods built on the child’s competencies and were compatible with her developmental capacities. Following 20 CBT sessions, posttreatment assessment indicated significant reduction in anxiety symptoms, as indicated by the diagnostic interview and self-report and other report of symptomatology. The child no longer met diagnostic criteria for GAD or selective mutism at posttreatment. The case study illustrates how CBT can be modified and applied flexibly in response to individual needs and limitations of the child.

Investigating Unique Environmental Influences of Parenting Practices on Youth Anxiety

The associations between parenting practices and adolescent anxiety symptoms were examined in both individual and monozygotic (MZ) twin differences levels. Participants were 804 pairs of Chinese MZ adolescent twins aged 10–18 years ( M = 13.57, SD = 2.67, 52% females). Twins’ anxiety symptoms were assessed by self- and parent-reports. Twins also reported their perceived parenting practices. On the individual level, parental warmth-reasoning was negatively, whereas harshness-hostility was positively, associated with both self- and parent-reported youth anxiety. On the MZ-twin differences level, the magnitudes of the associations between parenting practices and youth anxiety were decreased. MZ-twin difference in parental warmth-reasoning remained significantly associated with self- and parent-reported youth anxiety; MZ-twin difference in parental harsh-hostility was only significantly associated with self-reported youth anxiety. This study indicated that parental warmth-reasoning and harshness-hostility may be unique environmental experiences that influence youth anxiety, and illustrated the necessity of controlling for gene-environment correlations when examining the true environmental effects of parenting on child behavior.

Genetic and environmental contributions to anxiety among Chinese children and adolescents--a multi-informant twin study

BACKGROUND

Child and adolescent anxiety has become a major public health concern in China, but little was known about the etiology of anxiety in Chinese children and adolescents. The present study aimed to investigate genetic and environmental influences on trait anxiety among Chinese children and adolescents. Rater, sex, and age differences on these estimates were also examined.

METHODS

Self-reported and parent-reported child's trait anxiety was collected from 1,104 pairs of same-sex twins aged 9-18 years. Genetic models were fitted to data from each informant to determine the genetic (A), shared (C), and non-shared environmental (E) influences on trait anxiety.

RESULTS

The parameter estimates and 95% confidence intervals (CI) of A, C, E on self-reported trait anxiety were 50% [30%, 60%], 5% [0%, 24%], 45% [40%, 49%]. For parent-reported data, the corresponding parameter estimates were 63% [47%, 78%], 13% [1%, 28%], and 24% [22%, 27%], respectively. The heritability of anxiety was higher in girls for self-reported data, but higher in boys for parent-reported data. There was no significant age difference in genetic and environmental contributions for self-reported data, but a significant increase of heritability with age for parent-reported data.

CONCLUSIONS

The trait anxiety in Chinese children and adolescents was highly heritable. Non-shared environmental factors also played an important role. The estimates of genetic and environmental effects differed by rater, sex and age. Our findings largely suggest the cross-cultural generalizability of the etiological model of child and adolescent anxiety.

Positive and negative family emotional climate differentially predict youth anxiety and depression via distinct affective pathways

A socioaffective specificity model was tested in which positive and negative affect differentially mediated relations of family emotional climate to youth internalizing symptoms. Participants were 134 7(th)-9(th) grade adolescents (65 girls; 86 % Caucasian) and mothers who completed measures of emotion-related family processes, experienced affect, anxiety, and depression. Results suggested that a family environment characterized by maternal psychological control and family negative emotion expressiveness predicted greater anxiety and depression, and was mediated by experienced negative affect. Conversely, a family emotional environment characterized by low maternal warmth and low positive emotion expressiveness predicted only depression, and was mediated through lowered experienced positive affect. This study synthesizes a theoretical model of typical family emotion socialization with an extant affect-based model of shared and unique aspects of anxiety and depression symptom expression.

Impaired Facial Affect Perception in Unaffected Children at Familial Risk for Panic Disorder

Recent studies suggest that impaired processing of facial affect has a familial component and may reflect a marker of liability to psychopathology. This study investigated whether facial affect processing is impaired in offspring with parental panic disorder (PD). Psychiatrically healthy children with parental PD (n = 51) and age and sex matched control children with no parental psychopathology (n = 51) completed a standard facial recognition task. High-risk children made more errors recognizing fearful faces than controls and misattributed fear and angry facial affect as surprised. High-risk females also made more errors recognizing sad faces compared to low risk females and misattributed sadness as fear. No difference emerged for self-rated anxiety while viewing facial expressions. However, self-rated anxiety correlated moderately with misrecognition of fearful facial affect in high-risk children. Overall, our data suggest that the ability to correctly recognize negative facial emotions is impaired in children with parental PD. Further research is needed to confirm if these deficits represent a trait marker of liability for PD and elucidate the contribution of genetic and family environmental influences.

Anxiety in adolescents: Update on its diagnosis and treatment for primary care providers

Anxiety disorders are the most prevalent mental health concern facing adolescents today, yet they are largely undertreated. This is especially concerning given that there are fairly good data to support an evidence-based approach to the diagnosis and treatment of anxiety, and also that untreated, these problems can continue into adulthood, growing in severity. Thus, knowing how to recognize and respond to anxiety in adolescents is of the utmost importance in primary care settings. To that end, this article provides an up-to-date review of the diagnosis and treatment of anxiety disorders geared towards professionals in primary care settings. Topics covered include subtypes, clinical presentation, the etiology and biology, effective screening instruments, evidence-based treatments (both medication and therapy), and the long-term prognosis for adolescents with anxiety. Importantly, we focus on the most common types of anxiety disorders, often known as phobias, which include generalized anxiety disorder, social anxiety/social phobia, separation anxiety disorder, panic disorder, and specific phobias. In summary, anxiety is a common psychiatric problem for adolescents, but armed with the right tools, primary care providers can make a major impact.

Does cognitive behavioral therapy for youth anxiety outperform usual care in community clinics? An initial effectiveness test

OBJECTIVE

Most tests of cognitive behavioral therapy (CBT) for youth anxiety disorders have shown beneficial effects, but these have been efficacy trials with recruited youths treated by researcher-employed therapists. One previous (nonrandomized) trial in community clinics found that CBT did not outperform usual care (UC). The present study used a more stringent effectiveness design to test CBT versus UC in youths referred to community clinics, with all treatment provided by therapists employed in the clinics.

METHOD

A randomized controlled trial methodology was used. Therapists were randomized to training and supervision in the Coping Cat CBT program or UC. Forty-eight youths (56% girls, 8 to 15 years of age, 38% Caucasian, 33% Latino, 15% African-American) diagnosed with DSM-IV anxiety disorders were randomized to CBT or UC.

RESULTS

At the end of treatment more than half the youths no longer met criteria for their primary anxiety disorder, but the groups did not differ significantly on symptom (e.g., parent report, eta-square = 0.0001; child report, eta-square = 0.09; both differences favoring UC) or diagnostic (CBT, 66.7% without primary diagnosis; UC, 73.7%; odds ratio 0.71) outcomes. No differences were found with regard to outcomes of comorbid conditions, treatment duration, or costs. However, youths receiving CBT used fewer additional services than UC youths (χ(2)(1) = 8.82, p = .006).

CONCLUSIONS

CBT did not produce better clinical outcomes than usual community clinic care. This initial test involved a relatively modest sample size; more research is needed to clarify whether there are conditions under which CBT can produce better clinical outcomes than usual clinical care. CLINICAL TRIAL REGISTRY INFORMATION: Community Clinic Test of Youth Anxiety and Depression Study, URL: http://clinicaltrials.gov, unique identifier: NCT01005836.

Development of the Japanese version of the Pediatric Quality of Life Inventory Brain Tumor Module

Background

The Pediatric Quality of Life Inventory™ (PedsQL™) is a widely-used modular instrument for measuring health-related quality of life in children aged 2 to 18 years. The PedsQL™ Brain Tumor Module is comprised of six scales: Cognitive Problems, Pain and Hurt, Movement and Balance, Procedural Anxiety, Nausea, and Worry. In the present study, we developed the Japanese version of the PedsQL™ Brain Tumor Module and investigated its feasibility, reliability, and validity among Japanese children and their parents.

Methods

Translation equivalence and content validity were verified using the standard back-translation method and cognitive debriefing tests. Participants were recruited from 6 hospitals in Japan and the Children's Cancer Association of Japan, and questionnaires were completed by 137 children with brain tumors and 166 parents. Feasibility of the questionnaire was determined based on the amount of time required to complete the form and the percentage of missing values. Internal consistency was assessed using Cronbach's coefficient alpha. Test-retest reliability was assessed by retesting 22 children and 27 parents. Factorial validity was verified by exploratory factor analyses. Known-groups validity was described with regard to whole brain irradiation, developmental impairment, infratentorial tumors, paresis, and concurrent chemotherapy. Convergent and discriminant validity were determined using Generic Core Scales and State-Trait Anxiety Inventory for children.

Results

Internal consistency was relatively high for all scales (Cronbach's coefficient alpha > 0.70) except the Pain and Hurt scale for the child-report, and sufficient test-retest reliability was demonstrated for all scales (intraclass correlation coefficient = 0.45-0.95). Factorial validity was supported through exploratory factor analysis (factor-item correlation = 0.33-0.96 for children, 0.55-1.00 for parents). Evaluation of known-groups validity confirmed that the Cognitive Problems scale was sensitive for developmental impairment, the Movement and Balance scale for infratentorial tumors or paresis, and the Nausea scale for a patient currently undergoing chemotherapy. Convergent and discriminant validity with the PedsQL™ Generic Core Scales and State-Trait Anxiety Inventory for children were acceptable.

Conclusions

The Japanese version of the PedsQL™ Brain Tumor Module is suitable for assessing health-related quality of life in children with brain tumors in clinical trials and research studies.

Children with high-functioning autism spectrum disorders and co-occurring anxiety symptoms: implications for assessment and treatment

PURPOSE

The purpose of this article is to provide guidance and recommendations for children with high-functioning Autism Spectrum Disorders (ASD) and anxiety, including suggestions for assessment and intervention.

CONCLUSIONS

Children with ASD are at increased risk for developing clinical anxiety symptoms. Anxiety symptoms can impact school performance, peer relationships, and family functioning. Emerging clinical research has demonstrated the potential positive impact of modified cognitive behavioral therapy to reduce anxiety symptoms in children with ASD.

PRACTICE IMPLICATIONS

Modifications necessary to make cognitive behavioral therapy (CBT) protocols accessible to children with ASD are presented, along with specific suggestions for evaluating and treating anxiety symptoms.

Effects of videogame distraction using a virtual reality type head-mounted display helmet on cold pressor pain in children

OBJECTIVE

To test whether a head-mounted display helmet enhances the effectiveness of videogame distraction for children experiencing cold pressor pain.

METHOD

Forty-one children, aged 6-14 years, underwent one or two baseline cold pressor trials followed by two distraction trials in which they played the same videogame with and without the helmet in counterbalanced order. Pain threshold (elapsed time until the child reported pain) and pain tolerance (total time the child kept the hand submerged in the cold water) were measured for each cold pressor trial.

RESULTS

Both distraction conditions resulted in improved pain tolerance relative to baseline. Older children appeared to experience additional benefits from using the helmet, whereas younger children benefited equally from both conditions. The findings suggest that virtual reality technology can enhance the effects of distraction for some children. Research is needed to identify the characteristics of children for whom this technology is best suited.

Assessing anxiety with the Child Behavior Checklist and the Teacher Report Form

We evaluated the utility of Anxiety scales for the Child Behavior Checklist (CBCL) and the Teacher Report Form (TRF). The scales (CBCL-A; TRF-A) were examined using mothers and teachers of anxiety-disordered (AD; 157 mothers, 70 teachers) and non-anxiety-disordered (NAD; 100 mothers, 17 teachers) children. Separate samples of parents and teachers of AD (mothers=145, fathers=120, teachers=137) and NAD (mothers=35, fathers=29, teachers=27) children cross-validated the original findings. CBCL-A and TRF-A scores significantly discriminated AD children from NAD children and correlated significantly with other measures of child anxiety. The CBCL-A and TRF-A were sensitive to treatment changes. Relative to the CBCL/TRF Anxious/Depressed syndromes and Internalizing dimensions, the CBCL-A and TRF-A improved prediction of anxiety status. Relative to Achenbach, Demenci, and Rescorla's [Achenbach, T. M., Demenci, L., & Rescorla, L. A. (2003). DSM-oriented and empirically based approaches to constructing scales from the same item pools. Journal of Clinical Child and Adolescent Psychology, 32, 328-340] CBCL Anxiety subscale, the CBCL-A predicted comparably. Findings are discussed in terms of the CBCL-A and TRF-A as clinical tools.

Who is best at predicting children's anxiety in response to a social evaluative task? A comparison of child, parent, and teacher reports

The purpose of this preliminary study was to examine the validity of child, parent, and teacher reports of child social anxiety in predicting the child's responses to a social evaluative task. Children, parents, and teachers each completed a measure of social anxiety, as well as a measure that asked them to predict the child's anxiety during a behavioral approach task (BAT) of reading aloud in front of a video camera. Consistent with previous literature, analyses revealed poor agreement across informants. Importantly, children's reports predicted their own anxious feelings and, to some degree, their behaviors during the task, whereas other informants' reports did not. We recommend that further research examine the relative validity of multiple informants' reports in predicting children's real-life behavior.

Thai School-Age Children’s Perception of Fear

Information about how Thai school-age children perceive fear is necessary for the development of culturally appropriate anxiety or fear measures. The purpose of this study was to describe Thai school-age children’s perceptions of fear from their own perspective. Qualitative data from 13 Thai students in Grades 3 to 6 in three schools in Bangkok were obtained by semistructured, formal interviews, combined with drawings. The data were analyzed using content analysis within the frame of category development in the grounded theory method. Several culturally specific aspects of fear were revealed. This information is useful for health care providers caring for Thai children. The results of this study also illustrate the importance of carefully assessing children from culturally diverse backgrounds related to manifestations of anxiety or fear.

Evidence-Based Assessment of Anxiety and Its Disorders in Children and Adolescents

We provide an overview of where the field currently stands when it comes to having evidence-based methods and instruments available for use in assessing anxiety and its disorders in children and adolescents. Methods covered include diagnostic interview schedules, rating scales, observations, and self-monitoring forms. We also discuss the main purposes or goals of assessment and indicate which methods and instruments have the most evidence for accomplishing these goals. We also focus on several specific issues that need continued research attention for the field to move forward toward an evidence-based assessment approach. Finally, tentative recommendations are made for conducting an evidence-based assessment for anxiety and its disorders in children and adolescents. Directions for future research also are discussed.

Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up

Research suggests that the sequelae of childhood anxiety disorders, if left untreated, can include chronic anxiety, depression, and substance abuse. The current study evaluated the maintenance of outcomes of children who received a 16-week cognitive-behavioral treatment for primary anxiety disorders (generalized, separation, and social anxiety disorders) an average of 7.4 years earlier. The 86 participants (ages 15 to 22 years; 91% of the original sample) and their parents completed diagnostic interviews and self- and parent-report measures. According to the diagnostic interviews, a meaningful percentage of participants maintained significant improvements in anxiety at long-term follow-up. With regard to sequelae, positive responders to anxiety treatment, as compared with less positive responders, had a reduced amount of substance use involvement and related problems at long-term follow-up. The findings are discussed with regard to child anxiety and some of its sequelae.