Family dimensions in anxious-depressed school refusers

Chinese clients' experiences throughout family therapy for school-refusing adolescents: A multiperspectival interpretative phenomenological analysis

OBJECTIVE

This study aimed to explore Chinese clients' experiences with family dynamic change throughout family therapy for school refusal and the interventions adolescents and their parents identified as useful during family therapy.

METHODS

A multiperspective interpretative phenomenology analysis (IPA) was adopted. Thirty-two participants from 11 Chinese families with school-refusing adolescents were recruited after completing family therapy at the hospitals. Semistructured interviews were conducted with the families, and the transcripts were analyzed.

RESULTS

Four main superordinate themes emerged: reshaping healthy family boundaries, building a harmonious family atmosphere, learning to cooperate and fight against stress, and achieving individual growth.

CONCLUSION

Our analysis suggested that changes in school-refusing adolescents through family therapy consisted of multilevel factors. These factors influence the reversal of adolescents' school refusal. Some targeted interventions for Chinese adolescents who refuse school are discussed and suggested.

Modifiable Parent Factors Associated with Child and Adolescent School Refusal: A Systematic Review

School refusal is a complex problem that refers to difficulty attending/remaining at school due to emotional distress about attendance. Despite its occurrence being associated with negative outcomes, many are unresponsive to the current treatment options. While parent factors have a key role to play in school refusal, they are not adequately addressed in existing treatments. Further research is needed to consolidate understanding and implement new treatments. Employing the PRISMA method, this review aims to identify modifiable parent factors associated with child and/or adolescent school refusal. Eight studies met inclusion criteria from which nine factors were identified. Factors found to be associated with school refusal included: parent psychopathology, family functioning and maternal overprotection (communication subdomain). Other factors such as maternal overprotection (affection, assistance and travel subdomains) and parental self-efficacy had weak or inconsistent results warranting further investigation. Overall, findings call for action in this field that has sparse and dated literature.

Practitioner Review: Signposts for Enhancing Cognitive-Behavioral Therapy for School Refusal in Adolescence

Factors associated with adolescent development influence the occurrence and presentation of school refusal (SR). Cognitive-behavioral therapy (CBT) manuals for the treatment of SR account for these developmental issues to varying degrees. Some multimodal treatments aim to address the complexity of adolescent SR by incorporating interventions alongside CBT, such as medication, inpatient treatment, and educational support in a special setting. However, CBT manuals and multimodal treatments appear to fail to help approximately one-third to two-thirds of adolescents, with respect to achieving regular school attendance. This paper provides an overview of suggestions in the literature for improving treatment for SR, with a focus on adolescent SR. Seven signposts emerge from the literature, namely, increased number or frequency of sessions, greater attention to social anxiety disorder and social functioning, greater attention to depression, greater attention to emotion regulation, careful consideration of the role of parents, greater attention to parent-adolescent communication and problem-solving, and the use of alternative educational settings. Professionals may find these signposts helpful when planning and delivering treatment for SR in adolescents. Research is needed to determine the benefit of including one or more of these adaptations alongside an existing SR treatment.

Developmental Issues Associated with Adolescent School Refusal and Cognitive-Behavioral Therapy Manuals

It is important to consider developmental issues when addressing school refusal (SR) in adolescence. Referral rates appear to be higher among adolescents relative to children, and treatment appears to be less effective among adolescents. This paper provides an in-depth review of developmental issues associated with adolescent SR and treatment via cognitive-behavioral therapy (CBT). It begins by considering the reasons for the higher referral and poorer treatment outcomes, including the higher level of absenteeism in adolescence, higher rates of concurrent social anxiety disorder and depressive disorder, and the developmental challenges inherent to adolescence. Such challenges include increased academic and social demands in the secondary-school environment, and increasing autonomy which may contribute to family conflict. These developmental issues may potentiate and exacerbate an adolescent's difficulty attending school, make it difficult for families to cope, and complicate practitioners' efforts to provide effective treatment for SR. Further, the review describes CBT manuals for SR and the extent to which they are developmentally sensitive. There are five CBT manuals, which vary in their sensitivity to developmental issues. Various multimodal treatments employ interventions in addition to CBT, such as medication or inpatient treatment, to address the complexity of SR in adolescence. Nevertheless, nonresponse to treatment for adolescent SR ranges from one-third to two-thirds of youths. Attention thus needs to be given to ways of improving treatment outcomes.

A Systematic Review of Somatic Symptoms in School Refusal

OBJECTIVE

School refusers often display somatic symptoms that are temporally related to school attendance. The aim of this systematic review is to summarize characteristics and causes of somatic symptoms and their management in the context of school refusal. Findings of this review may help clinicians in their daily practice.

METHODS

PubMed and PsycINFO databases were systematically searched (according to PRISMA guidelines) for articles mentioning somatic symptoms in school refusal by May 2020. Among 1025 identified studies, 148 were included.

RESULTS

Unspecific somatic symptoms were frequently the first complaints in school refusal. Abdominal pain, headache, nausea, vomiting, muscular or joint ache, diarrhea, dizziness, fatigue, and palpitation were the most commonly encountered symptoms and were usually not accounted for by an identifiable physical disease. Anxiety was the most recurrent etiology found, but physicians' lack of awareness about psychological comorbidities often delayed psychological/psychiatric referral. Successful therapies consisted of dialectical behavior therapy, anxiety management through relaxation/breathing training, and ignoring the somatic symptoms.

CONCLUSIONS

Somatic symptoms in school refusal are frequent but poorly understood. Their management could include interventions targeting anxiety, psychotherapies such as emotional awareness and expression therapy, third-wave behavioral therapies, and psychoeducation. A multidisciplinary approach through strengthened collaboration between school staff, physicians, and psychologists/psychiatrists is needed to improve well-being in children who experience somatic symptoms as related to school avoidance.

Individuals at ultra-high risk of psychosis and first-degree relatives of patients with schizophreniaexperience impaired family functionality and social support deficit in comparison to healthy controls

AIM

The present study was designed to assess the role of family function and social support in the context of different phases of schizophrenia.

METHODS

First-episode patients with experiences of schizophrenia (FEP), ultra-high risk for psychosis (UHR), first-degree relatives (FDR) of patients with experiences of schizophrenia, and healthy controls (HC) (40 per group) were subjected to in-person clinical interviews. The results of these interviews were then used to gauge social support and family function using the Perceived Social Support Scale (PSSS) and the Family Adaptability and Cohesion Scales (FACESII-CV). Data were analyzed through ANCOVA, correlation analysis and logistic regression analyses.

RESULTS

We found that family function and social support showed a approximately gradual downward trend through the HC, FDR, UHR, and FEP groups but no significant differences were found in the family function of the FDR, UHR and FDR group. Logistic regression analyses indicated that UHR group patients exhibited decreased family support and family cohesion relative to members of the HC group, but had greater perceived social support than did members of the FEP group. Results for members of the FDR group were in line with those of members of the UHR group.

CONCLUSIONS

These findings suggested that both UHR and FDR individuals experience impaired family functionality and social support which expanded the understanding of the psychological characteristics of the prodromal period of schizophrenia. Further explorations are warranted to develop optimal psychosocial interventions.

Family Environment Variables as Predictors of School Absenteeism Severity at Multiple Levels: Ensemble and Classification and Regression Tree Analysis

School attendance problems, including school absenteeism, are common to many students worldwide, and frameworks to better understand these heterogeneous students include multiple classes or tiers of intertwined risk factors as well as interventions. Recent studies have thus examined risk factors at varying levels of absenteeism severity to demarcate distinctions among these tiers. Prior studies in this regard have focused more on demographic and academic variables and less on family environment risk factors that are endemic to this population. The present study utilized ensemble and classification and regression tree analysis to identify potential family environment risk factors among youth (i.e., children and adolescents) at different levels of school absenteeism severity (i.e., 1 + %, 3 + %, 5 + %, 10 + %). Higher levels of absenteeism were also examined on an exploratory basis. Participants included 341 youth aged 5-17 years (M = 12.2; SD = 3.3) and their families from an outpatient therapy clinic (68.3%) and community (31.7%) setting, the latter from a family court and truancy diversion program cohort. Family environment risk factors tended to be more circumscribed and informative at higher levels of absenteeism, with greater diversity at lower levels. Higher levels of absenteeism appear more closely related to lower achievement orientation, active-recreational orientation, cohesion, and expressiveness, though several nuanced results were found as well. Absenteeism severity levels of 10-15% may be associated more with qualitative changes in family functioning. These data may support a Tier 2-Tier 3 distinction in this regard and may indicate the need for specific family-based intervention goals at higher levels of absenteeism severity.

Identifying Risk Profiles of School Refusal Behavior: Differences in Social Anxiety and Family Functioning Among Spanish Adolescents

School attendance problems negatively affect students' development. This study attempted to identify different school refusal behavior profiles and to examine their relationship with three dimensions of social anxiety (fear of negative evaluation, social avoidance and distress in new situations, and social avoidance and distress that is experienced more generally in the company of peers) and the perception of family functioning. Participants included 1842 Spanish adolescents (53% girls) aged 15-18 years (M = 16.43; SD = 1.05). The School Refusal Assessment Scale-Revised (SRAS-R), the Social Anxiety Scale for Adolescents (SAS-A), and the Family APGAR Scale (APGAR: Adaptation, Partnership, Growth, Affection, and Resolve) were administered. Latent class analysis revealed four school refusal behavior profiles: non-school refusal behavior, high school refusal behavior, moderately low school refusal behavior, and moderately high school refusal behavior. Analyses of variance (ANOVA) indicated that adolescents' with the profile of high school refusal behavior showed higher scores in all the subscales of social anxiety. In contrast, the non-school refusal behavior group revealed higher scores in the perception of good family functioning, whereas the high school refusal behavior profile obtained the lowest scores in this scale. These findings suggest that students who reject school are at a higher risk of developing social anxiety problems and manifesting family conflicts. These students should be prioritized in order to attend to their needs, promoting self-help to overcome social anxiety and family problems with the purpose of preventing school refusal behaviors.

School Refusal Behavior in Indian Children: Analysis of Clinical Profile, Psychopathology and Development of a Best-Fit Risk Assessment Model

OBJECTIVES

School refusal is seen as an emergency in child psychiatry and various risk factors have been analyzed. Children who present with school refusal have been shown to have several associated psychiatric comorbidities. However, risk assessment of psychiatric comorbidities is lacking, particularly in the Indian context. The authors aimed to study the sociodemographic profile and associated psychopathology in children with school refusal. They compared the prevalence rates of psychiatric illnesses to that of the community. A best-fit model for risk assessment of psychopathology was formulated.

METHODS

Past records of children aged 5-16 y, who presented with school refusal in the period from June 2013 through June 2015 to authors' Child Guidance Clinic were studied and their sociodemographic details, symptoms and diagnoses were obtained. Chi square test of proportion was used to compare the prevalence rates between the study population and community. Multinomial analysis was used to elucidate a best-fit model of risk assessment.

RESULTS

School refusal was seen in 3.6% of children. 77.8% of the children had a psychiatric diagnosis, most common being depression (26.7%), followed by anxiety (17.7%). Prevalence of psychiatric disorders was significantly higher in the study population than community (p < 0.05). A best-fit model of 4 factors: academic difficulties, adjustment problems at school, behavioral problems and parental conflicts is suggested (p < 0.05).

CONCLUSIONS

School refusal is associated with significant psychopathology, most commonly depression, followed by anxiety. The best-fit model for risk assessment can predict the likelihood of psychopathology and help in early diagnosis.

Familienstrukturen in Familien von Kindern mit einer Störung mit Trennungsangst

Zusammenfassung. Theoretischer Hintergrund: Die Störung mit Trennungsangst ist eine der häufigsten psychischen Erkrankung im Kindesalter, bei der das Familiensystem in besonderem Ausmaß mit betroffen ist. Untersuchungen mit Kindern mit Schulverweigerung und komorbider Trennungsangst weisen darauf hin, dass in Familien dieser Kinder häufiger dysfunktionale Familienkonstellationen vorliegen. Fragestellung: Die vorliegende Studie hat das Ziel zu überprüfen, ob Familien mit Trennungsangst häufiger dysfunktionale Familienstrukturen aufweisen als Familien von Kindern mit anderen Angststörungen oder ohne psychische Störung. Methode: 71 Familien von Kindern mit Trennungsangst, 25 Familien mit Kindern mit anderen Angststörungen und 21 Familien mit Kindern ohne psychische Störungen wurden mit dem Familiensystemtest (FAST) untersucht. Ergebnisse: Die Gruppen unterscheiden sich nicht signifikant in der Häufigkeit dysfunktionaler Familienstrukturen. Diskussion: Dysfunktionale (verstrickte) Familienstruktur und Trennungsangst zeigen keinen Zusammenhang. Weitere vertiefende Untersuchungen sind notwendig, um den möglichen Zusammenhang von dysfunktionalen Familienstrukturen und Angststörungen zu prüfen.

Family process and youth internalizing problems: A triadic model of etiology and intervention

Despite major advances in the development of interventions for youth anxiety and depression, approximately 30% of youths with anxiety do not respond to cognitive behavioral treatment, and youth depression treatments yield modest symptom decreases overall. Identifying networks of modifiable risk and maintenance factors that contribute to both youth anxiety and depression (i.e., internalizing problems) may enhance and broaden treatment benefits by informing the development of mechanism-targeted interventions. A particularly powerful network is the rich array of family processes linked to internalizing problems (e.g., parenting styles, parental mental health problems, and sibling relationships). Here, we propose a new theoretical model, the triadic modelof family process, to organize theory and evidence around modifiable, transdiagnostic family factors that may contribute to youth internalizing problems. We describe the model's implications for intervention, and we propose strategies for testing the model in future research. The model provides a framework for studying associations among family processes, their relation to youth internalizing problems, and family-based strategies for strengthening prevention and treatment.

Comorbid Anxiety and Depressive Symptoms in Children and Adolescents: A Systematic Review and Analysis

BACKGROUND

A large and extensive body of research has examined comorbid anxiety and depression in adults. Children and adolescents also frequently present with comorbid anxiety and depression; however, research and treatment require unique environmental and neurodevelopmental considerations in children. As a result, our understanding of comorbid anxiety and depression in children and adolescents is limited.

OBJECTIVE

The goal of this systematic review was to examine the current literature focused on comorbid anxiety and depression in children and adolescents. The review included theoretical conceptualizations as well as diagnostic, neurobiological, prevention, and treatment considerations. In addition, a proposed algorithm for the treatment of comorbid anxiety and depression in children/adolescents is provided.

METHODS

This systematic literature review included 3 discrete searches in Ovid SP Medline, PsycInfo, and PubMed.

RESULTS

The review included and synthesized 115 articles published between 1987 and 2015. The available evidence suggests that anxiety and depression are common in clinical populations of children and adolescents, and that comorbidity is likely underestimated in children and adolescents. Children and adolescents with comorbid anxiety and depression have unique presentations, greater symptom severity, and treatment resistance compared with those who have either disease in isolation. A dimensional approach may be necessary for the future development of diagnostic strategies and treatments for this population. Nascent neuroimaging work suggests that anxiety and depression each represents a distinct neurobiological phenotype.

CONCLUSIONS

The literature that is currently available suggests that comorbid anxiety and depression is a common presentation in children and adolescents. This diagnostic picture underscores the importance of comprehensive dimensional assessments and multimodal evidence-based approaches given the high disease severity. Future research on the neurobiology and the treatment of these common clinical conditions is warranted.

Prevention and Intervention for Anxiety Disorders in Children and Adolescents: A Whole School Approach

This paper explores a whole school approach to the prevention and intervention for anxiety disorders in children and adolescents. Anxiety disorders are the most prevalent psychopathology in childhood and adolescence. In addition to having serious consequences for academic, social and family life, anxiety has also been shown to be a precursor to depression, substance abuse and eating disorders. School counsellors are well placed to identify students with anxiety disorders, instigate prevention programs and treat or refer anxious students. Prevention and early intervention for anxiety disorders needs to be coordinated and integrated into the regular curriculum as well as into the life of the classroom and the school. Barriers to schools working well in this area are identified and discussed.

Developmentally sensitive cognitive behavioral therapy for adolescent school refusal: rationale and case illustration

School refusal can be difficult to treat and the poorest treatment response is observed among older school refusers. This poor response may be explained, in part, by the impact of developmental transitions and tasks upon the young person, their family, and the treatment process. This paper describes and illustrates the @school program, a cognitive behavioral therapy (CBT) designed to promote developmental sensitivity when planning and delivering treatment for adolescent school refusal. Treatment is modularized and it incorporates progress reviews, fostering a planned yet flexible approach to CBT. The treatment is illustrated in the case of Allison, a 16-year-old female presenting with major depressive disorder and generalized anxiety disorder. A case formulation guided the selection, sequencing, and pacing of modules targeting predisposing, precipitating, perpetuating, and protective factors. Treatment comprised 16 sessions with Allison (interventions addressing depression, anxiety, and school attendance) and 15 concurrent sessions with her mother (strategies to facilitate an adolescent's school attendance), including two sessions with Allison and mother together (family communication and problem solving to reduce parent-adolescent conflict). Two treatment-related consultations were also conducted with Allison's homeroom teacher. Allison's school attendance improved during the course of treatment. By post-treatment, there was a decrease in internalizing behavior, an increase in self-efficacy, and remission of depressive disorder and anxiety disorder. Clinically significant treatment gains were maintained at 2-month follow-up. Factors influencing outcome may include those inherent to the @school program together with less specific factors. Special consideration is given to parents' use of both authoritative and autonomy-granting approaches when helping an adolescent to attend school.

Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents

BACKGROUND

Depressive disorders are common in children and adolescents and, if left untreated, are likely to recur in adulthood. Depression is highly debilitating, affecting psychosocial, family and academic functioning.

OBJECTIVES

To evaluate the effectiveness of psychological therapies and antidepressant medication, alone and in combination, for the treatment of depressive disorder in children and adolescents. We have examined clinical outcomes including remission, clinician and self reported depression measures, and suicide-related outcomes.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 11 June 2014. The register contains reports of relevant randomised controlled trials (RCTs) from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

RCTs were eligible for inclusion if they compared i) any psychological therapy with any antidepressant medication, or ii) a combination of psychological therapy and antidepressant medication with a psychological therapy alone, or an antidepressant medication alone, or iii) a combination of psychological therapy and antidepressant medication with a placebo or'treatment as usual', or (iv) a combination of psychological therapy and antidepressant medication with a psychological therapy or antidepressant medication plus a placebo.We included studies if they involved participants aged between 6 and 18 years, diagnosed by a clinician as having Major Depressive Disorder (MDD) based on Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the quality of the studies. We applied a random-effects meta-analysis, using the odds ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe continuous outcomes when the same measures were used, and standard mean difference (SMD) when outcomes were measured on different scales.

MAIN RESULTS

We included eleven studies, involving 1307 participants in this review. We also identified one ongoing study, and two additional ongoing studies that may be eligible for inclusion. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results. Regarding the risk of bias in studies, just under half the studies had adequate allocation concealment (there was insufficient information to determine allocation concealment in the remainder), outcome assessors were blind to the participants' intervention in six studies, and in general, studies reported on incomplete data analysis methods, mainly using intention-to-treat (ITT) analyses. For the majority of outcomes there were no statistically significant differences between the interventions compared. There was limited evidence (based on two studies involving 220 participants) that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.27 to 0.98), with 67.8% of participants in the medication group and 53.7% in the psychotherapy group rated as being in remission. There was limited evidence (based on three studies involving 378 participants) that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention (OR 1.56, 95% CI 0.98 to 2.47), with 65.9% of participants treated with combination therapy and 57.8% of participants treated with medication, rated as being in remission. There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention (OR 1.82, 95% CI 0.38 to 8.68).Suicide-related Serious Adverse Events (SAEs) were reported in various ways across studies and could not be combined in meta-analyses. However, some trials measured suicidal ideation using standardised assessment tools suitable for meta-analysis. In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%) (OR 0.26, 95% CI 0.09 to 0.72) and this effect appeared to remain at six to nine months (OR 0.26, 95% CI 0.07 to 0.98), with 13.6% of participants in the medication group and 3.9% of participants in the psychological therapy group reporting suicidal ideation. It was unclear what the effect of combination therapy was compared with either antidepressant medication alone or psychological therapy alone on rates of suicidal ideation. The impact of any of the assigned treatment packages on drop out was also mostly unclear across the various comparisons in the review.Limited data and conflicting results based on other outcome measures make it difficult to draw conclusions regarding the effectiveness of any specific intervention based on these outcomes.

AUTHORS' CONCLUSIONS

There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.

Tricyclic drugs for depression in children and adolescents

BACKGROUND

There is a need to identify effective and safe treatments for depression in children and adolescents. While tricyclic drugs are effective in treating depression in adults, individual studies involving children and adolescents have been equivocal. Prescribing of tricyclic drugs for depression in children and adolescents is now uncommon, but an accurate estimate of their efficacy is helpful as a comparator for other drug treatments for depression in this age group. This is an update of a Cochrane review first published in 2000 and updated in 2002, 2006 and 2010.

OBJECTIVES

To assess the effects of tricyclic drugs compared with placebo for depression in children and adolescents and to determine whether there are differential responses to tricyclic drugs between child and adolescent patient populations.

SEARCH METHODS

We conducted a search of the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 12 April 2013), which includes relevant randomised controlled trials from the following bibliographic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (all years), EMBASE (1974-), MEDLINE (1950-) and PsycINFO (1967-). The bibliographies of previously published reviews and papers describing original research were cross-checked. We contacted authors of relevant abstracts in conference proceedings of the American Academy of Child and Adolescent Psychiatry, and we handsearched the Journal of the American Academy of Child and Adolescent Psychiatry (1978 to 1999).

SELECTION CRITERIA

Randomised controlled trials comparing the efficacy of orally administered tricyclic drugs with placebo in depressed people aged 6 to 18 years.

DATA COLLECTION AND ANALYSIS

One of two review authors selected the trials, assessed their quality, and extracted trial and outcome data. A second review author assessed quality and checked accuracy of extracted data. Most studies reported multiple outcome measures including depression scales and clinical global impression scales. For each study, we took the best available depression measure as the index measure of depression outcome. We established predetermined criteria to assist in the ranking of measures. Where study authors reported categorical outcomes, we calculated individual and pooled risk ratios for non-improvement in treated compared with control subjects. For continuous outcomes, we calculated pooled effect sizes as the number of standard deviations by which the change in depression scores for the treatment group exceeded those for the control group.

MAIN RESULTS

Fourteen trials (590 participants) were included. No overall difference was found for the primary outcome of response to treatment compared with placebo (risk ratio (RR) 1.07, 95% confidence interval (CI) 0.91 to 1.26; 9 trials, N = 454). There was a small reduction in depression symptoms (standardised mean difference (SMD) -0.32, 95% CI -0.59 to -0.04; 13 trials, N = 533), but the evidence was of low quality. Subgroup analyses suggested a small reduction in depression symptoms among adolescents (SMD -0.45, 95% CI -0.83 to -0.007), and negligible change among children (SMD 0.15, 95% CI -0.34 to 0.64). Treatment with a tricyclic antidepressant caused more vertigo (RR 2.76, 95% CI 1.73 to 4.43; 5 trials, N = 324), orthostatic hypotension (RR 4.86, 95% CI 1.69 to 13.97; 5 trials, N = 324), tremor (RR 5.43, 95% CI 1.64 to 17.98; 4 trials, N = 308) and dry mouth (RR 3.35, 95% CI 1.98 to 5.64; 5 trials, N = 324) than did placebo, but no differences were found for other possible adverse effects. Wide CIs and the probability of selective reporting mean that there was very low-quality evidence for adverse events.There was heterogeneity across the studies in the age of participants, treatment setting, tricyclic drug administered and outcome measures. Statistical heterogeneity was identified for reduction in depressive symptoms, but not for rates of remission or response. As such, the findings from analyses of pooled data should be interpreted with caution.We judged none of these trials to be at low risk of bias, with limited information about many aspects of risk of bias, high dropout rates, and issues regarding measurement instruments and the clinical usefulness of outcomes, which were often variously defined across trials.

AUTHORS' CONCLUSIONS

Data suggest tricyclic drugs are not useful in treating depression in children. There is marginal evidence to support the use of tricyclic drugs in the treatment of depression in adolescents.

Psychological therapies versus antidepressant medication, alone and in combination for depression in children and adolescents

BACKGROUND

Depressive disorders are common in children and adolescents and, if left untreated, are likely to recur in adulthood. Depression is highly debilitating, affecting psychosocial, family and academic functioning.

OBJECTIVES

To evaluate the effectiveness of psychological therapies and antidepressant medication, alone and in combination, for the treatment of depressive disorder in children and adolescents. We have examined clinical outcomes including remission, clinician and self reported depression measures, and suicide-related outcomes.

SEARCH METHODS

We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) to 11 November 2011. This register contains reports of relevant randomised controlled trials (RCTs) from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).

SELECTION CRITERIA

RCTs were eligible for inclusion if they compared i) any psychological therapy with any antidepressant medication, or ii) a combination of psychological therapy and antidepressant medication with a psychological therapy alone, or an antidepressant medication alone, or iii) a combination of psychological therapy and antidepressant medication with a placebo or 'treatment as usual', or (iv) a combination of psychological therapy and antidepressant medication with a psychological therapy or antidepressant medication plus a placebo.We included studies if they involved participants aged between 6 and 18 years, diagnosed by a clinician as having Major Depressive Disorder (MDD) based on Diagnostic and Statistical Manual (DSM) or International Classification of Diseases (ICD) criteria.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the quality of the studies. We applied a random-effects meta-analysis, using the odds ratio (OR) to describe dichotomous outcomes, mean difference (MD) to describe continuous outcomes when the same measures were used, and standard mean difference (SMD) when outcomes were measured on different scales.

MAIN RESULTS

We included ten studies, involving 1235 participants in this review. Studies recruited participants with different severities of disorder and with a variety of comorbid disorders, including anxiety and substance use disorder, therefore limiting the comparability of the results. Regarding the risk of bias in studies, half the studies had adequate allocation concealment (there was insufficient information to determine allocation concealment in the remainder), outcome assessors were blind to the participants' intervention in six studies, and in general, studies reported on incomplete data analysis methods, mainly using intention-to-treat (ITT) analyses. For the majority of outcomes there were no statistically significant differences between the interventions compared. There was limited evidence (based on two studies involving 220 participants) that antidepressant medication was more effective than psychotherapy on measures of clinician defined remission immediately post-intervention (odds ratio (OR) 0.52, 95% confidence interval (CI) 0.27 to 0.98), with 67.8% of participants in the medication group and 53.7% in the psychotherapy group rated as being in remission. There was limited evidence (based on three studies involving 378 participants) that combination therapy was more effective than antidepressant medication alone in achieving higher remission from a depressive episode immediately post-intervention (OR 1.56, 95% CI 0.98 to 2.47), with 65.9% of participants treated with combination therapy and 57.8% of participants treated with medication, rated as being in remission. There was no evidence to suggest that combination therapy was more effective than psychological therapy alone, based on clinician rated remission immediately post-intervention (OR 1.82, 95% CI 0.38 to 8.68).Suicide-related Serious Adverse Events (SAEs) were reported in various ways across studies and could not be combined in meta-analyses. However suicidal ideation specifically was generally measured and reported using standardised assessment tools suitable for meta-analysis. In one study involving 188 participants, rates of suicidal ideation were significantly higher in the antidepressant medication group (18.6%) compared with the psychological therapy group (5.4%) (OR 0.26, 95% CI 0.09 to 0.72) and this effect appeared to remain at six to nine months (OR 1.27, 95% CI 0.68 to 2.36), with 13.6% of participants in the medication group and 3.9% of participants in the psychological therapy group reporting suicidal ideation. It was unclear what the effect of combination therapy was compared with either antidepressant medication alone or psychological therapy alone on rates of suicidal ideation. The impact of any of the assigned treatment packages on drop out was also mostly unclear across the various comparisons in the review.Limited data and conflicting results based on other outcome measures make it difficult to draw conclusions regarding the effectiveness of any specific intervention based on these outcomes.

AUTHORS' CONCLUSIONS

There is very limited evidence upon which to base conclusions about the relative effectiveness of psychological interventions, antidepressant medication and a combination of these interventions. On the basis of the available evidence, the effectiveness of these interventions for treating depressive disorders in children and adolescents cannot be established. Further appropriately powered RCTs are required.

Adolescent school absenteeism: modelling social and individual risk factors

BACKGROUND

  School absenteeism is a complex problem that includes risk factors associated with individual traits, socio-economic conditions, family structure, the school and society. The consequences of extensive school absenteeism can be detrimental for the youth.

METHOD

  In this exploratory study we aimed to investigate the relative importance of different risk factors on school absenteeism. We assessed 865 Norwegian high school students testing a model of school absenteeism using Exploratory Structural Equation Modelling (ESEM).

RESULTS

  Analysis show that on the individual level most of the measured risk factors were significantly associated with absenteeism. School absenteeism was predicted by externalising behaviour, family work and health, and school environment directly.

CONCLUSION

  The implications of the findings on school absenteeism are that it will be important to focus more on the context and co-occurrence of these problems in order to fully understand them.

Family processes in the development of youth depression: translating the evidence to treatment

There is strong evidence that family factors play a role in the development, maintenance and course of youth depression. However, to date few clinical trials of psychotherapy for youth depression employ family therapy interventions or target the known family risk factors. This is surprising given recent meta-analytic findings showing only modest effect sizes for psychotherapy for youth depression, and that cognitive therapies do not outperform non-cognitive therapies. The aim of this review is to 1) use a developmental systems approach to review empirical evidence on family risk factors for youth depression to identify potential targets for treatment, 2) examine the extent to which these family risk factors have been targeted in clinical trials for youth depression, and 3) provide a road map for the development of empirically validated family-based interventions for youth depression. Strong evidence was found supporting a relationship between family factors at multiple system levels and depressive symptoms or disorders. Support for several different hypothesized causal mechanisms as well as bidirectional effects was found. A comparison of the identified risk factors and psychotherapy trials for youth depression indicated that few RCT's target family factors; among those that do, only a few of the family risk factors are targeted. Recommendations for translation of empirical knowledge of family risk factors and mechanisms to develop empirically valid family-based interventions to enhance existing treatments for youth depression are provided.

Body image in patients with eating disorders and their mothers, and the role of family functioning

OBJECTIVE

Little is known about body images of mothers of patients with eating disorders. In this study we investigated body image in patients with eating disorders and in their mothers, and the relationship of their body images with family functioning.

METHODS

A computer program was used that allows modeling perceived and desired body images of patients and their mothers. Patients and mothers estimated their own body images and mothers estimated the images they have of their daughters with eating disorders. The selected images were compared to anthropometric data and family functioning according to the Family Assessment Measure. Data from 29 patients with the diagnosis of anorexia nervosa and 20 patients with bulimia nervosa are presented.

RESULTS

Both in patients with anorexia and in patients with bulimia, aspects of family functioning were associated with mothers' and daughters' perceptual body size distortion and body dissatisfaction. Mothers' perception of family functioning predicted daughters' perceptual body size distortion and body dissatisfaction in the total sample of 49 patients.

CONCLUSION

Body images of mothers and mothers' perceptions of family functioning may provide additional information for the treatment of patients with eating disorders.

Effects of parent and family characteristics on treatment outcome of anxious children

This study examines relations between family functioning, parenting stress, parental psychopathology, and treatment outcome. Participants included 61 children (ages 7-11 years) with features or diagnoses of separation anxiety disorder, generalized anxiety disorder, and/or social phobia. Treatment conditions included group cognitive behavioral therapy (CBT) and no-treatment control. Higher family cohesion at baseline was associated with significantly greater decreases in child anxiety at posttreatment for participants who received CBT, while no association was found for the no-treatment control participants. Parenting stress and parental psychopathology were not associated with treatment outcome for either condition. Post hoc analyses examining relations between family cohesion, parenting stress, and parental psychopathology showed that parents from families low in cohesion reported significantly higher levels of parenting stress and psychopathology compared to parents from families high in cohesion. These results will facilitate development and implementation of effective interventions with anxious children.

Separation anxiety disorder, panic disorder, and school refusal

Studies attest to the chronic nature of anxiety in youth. Consequently, there is a growing literature examining causative pathways to these disorders and efficacious treatments for them. This review examines separation anxiety disorder, a commonly occurring childhood anxiety disorder, and panic disorder, a more rare anxiety disorder in youth. Finally, school refusal, which may be tied to an internalizing or externalizing disorder or no disorder at all, is examined.

Are somatic symptoms and related distress more prevalent in Hispanic/Latino youth? Some methodological considerations

This article comments on the current status of the anxiety literature involving Latino children and adolescents. As the 2 articles that focus on Hispanic/Latino youth in this special section independently found somatic symptoms to be more prevalent in Latino youth than other racial/ethnic groups (Pina & Silverman, this issue; Varela et al., this issue), this commentary discusses methodological considerations for guiding future anxiety research and makes suggestions for clinicians who treat Latino children and adolescents.

School refusal and psychiatric disorders: a community study

OBJECTIVE

To examine the association between anxious school refusal and truancy and psychiatric disorders in a community sample of children and adolescents using a descriptive rather than etiological definition of school refusal.

METHOD

Data from eight annual waves of structured psychiatric interviews with 9- to 16-year-olds and their parents from the Great Smoky Mountains Study were analyzed.

RESULTS

Pure anxious school refusal was associated with depression (odds ratio [OR] = 13, 95% confidence interval [CI] 3.4, 42) and separation anxiety disorder (OR = 8.7, 95% CI 4.1, 19). Pure truancy was associated with oppositional defiant disorder (OR = 2.2, 95% CI 1.2, 4.2), conduct disorder (OR = 7.4, 95% CI 3.9, 14), and depression (OR = 2.6, 95% CI 1.2, 56). Of mixed school refusers (children with both anxious school refusal and truancy), 88.2% had a psychiatric disorder. They had increased rates of both emotional and behavior disorders. Specific fears, sleep difficulties, somatic complaints, difficulties in peer relationships, and adverse psychosocial variables had different associations with the three types of school refusal.

CONCLUSIONS

Anxious school refusal and truancy are distinct but not mutually exclusive and are significantly associated with psychopathology, as well as adverse experiences at home and school. Implications of these findings for assessment, identification, and intervention for school refusal are discussed.

School refusal in children and adolescents: a review of the past 10 years

OBJECTIVE

To critically review the past 10 years of research on school refusal in children and adolescents.

METHOD

Literature on school refusal published from 1990 onward was reviewed following a systematic search of PsycINFO. The review focuses on definitional issues, epidemiology and school refusal identification, diagnostic considerations, family functioning, assessment, treatment, and follow-up studies.

RESULTS

While definitional and conceptual issues are still evident, promising developments have occurred in relation to assessment and treatment practices and understanding of the family context of school refusal.

CONCLUSIONS

From a clinical viewpoint, school refusal cases require comprehensive assessment and treatment. Advances have been made in the treatment of school refusal. However, additional controlled studies evaluating interventions for school refusal are needed.