Practitioner Review: Anxiety disorders in children and young people - assessment and treatment

Pediatric anxiety disorders: Basic concepts for primary care

Anxiety disorders in children and adolescents often present in primary care, and many clinicians will need to guide families on treatment. The purpose of this article is to give a brief overview of assessment and treatment principles for clinicians in primary care. Anxiety and its expression are heavily influenced by children's developmental progression and capabilities. Anxiety disorders have multiple underlying etiologies including temperament, environmental exposure to stressors, and childhood trauma. All anxiety disorders are strengthened by an operant process known as escape conditioning. The most effective treatments for child and adolescent anxiety begin with behavioral-based interventions including exposure with response prevention (ERP) and cognitive behavioral therapy (CBT). Medication can be effective in combination with CBT and ERP, or as a standalone treatment when behavioral interventions are not available. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors have been evaluated by randomized clinical trials for the treatment of childhood anxiety, but most are not approved by the Food and Drug Administration. When anxiety is severe and functional impairment is high, referral for psychiatric care and multimodal treatment reduces the likelihood of poor outcomes.

Discrepancies in Parent-Child Perception of Parental Control and Associations with Children's Anxiety: The Buffering Effect of Parent-Child Closeness

Previous research has predominantly relied on single-informant reports to establish the association between parental control and children's anxiety. However, there remains ambiguity regarding the extent to which discrepancies in parent-child reports of parental control are related to children anxiety. This study examined parent-child perceived discrepancies in parental control and their association with children's anxiety, along with the moderated effect of parent-child closeness through cross-sectional and prospective analysis. The sample consisted of 790 children (Mage = 11.34, SD = 6.73, 45.60% for girls), with 741 father-child dyads and 760 mother-child dyads included. Data were analyzed using polynomial regressions with response surface analysis. The results indicated that children tended to perceive higher levels of parental psychological control and lower levels of behavioral control compared to their parents' perceptions. In the cross-sectional analysis, a significant association between greater incongruence in psychological/behavioral control and higher levels of children's anxiety at T1 was observed exclusively in father-child dyads. In prospective analysis, for both father-child and mother-child dyads, congruence in higher levels of psychological control was associated with higher levels of children's anxiety at T2, while congruence in higher levels of behavioral control was associated with lower levels of children's anxiety at T2. Additionally, greater incongruence in psychological/behavioral control was linked to higher levels of children's anxiety at T2. Furthermore, mother-child closeness emerged as a significant moderator such that perceived incongruence in psychological/behavioral control could not affect children's anxiety at T2 in the high mother-child closeness condition. These findings highlight the significance of considering parent-child congruence and incongruence when examining the impact of parental control on children's anxiety.

The Role of Executive Function at 6 Years in the Association between Behavioral Inhibition at 5 Years and Anxiety at 7 Years

EF skills play a central role in the etiology and maintenance of anxiety, but it is unclear whether they act as moderators or mediators in the relation between early behavioral inhibition (BI) and later anxiety. The current study tested two models by examining whether two executive functions (EF) skills (cognitive flexibility and working memory) assessed at age 6 acted as moderators or mediators in the relation between BI at 5 years and anxiety symptoms at 7 years. The sample consisted of 422 children from the Quebec Longitudinal Study of Child Development. We tested the moderation model, main and interaction effects using hierarchical multiple regression analyses and the mediation model with the product of coefficients test. Results showed that higher BI at 5 years predicted high anxiety at 7 years only at low levels of cognitive flexibility or working memory at 6 years. This suggests that high levels of cognitive flexibility or working memory at 6 years may act as protective factors. In contrast, neither cognitive flexibility nor working memory at age 6 acted as mediators in the association between BI at 5 years and anxiety at 7 years. Results support the hypothesis that goal-driven cognitive control processes act as moderators and promote adaptive functioning by dampening the effect of early BI on later anxiety.

Patterns of sub-optimal change following CBT for childhood anxiety

BACKGROUND

Children and adolescents demonstrate diverse patterns of symptom change and disorder remission following cognitive behavioural therapy (CBT) for anxiety disorders. To better understand children who respond sub-optimally to CBT, this study investigated youths (N = 1,483) who continued to meet criteria for one or more clinical anxiety diagnosis immediately following treatment or at any point during the 12 months following treatment.

METHODS

Data were collected from 10 clinical sites with assessments at pre-and post-treatment and at least once more at 3, 6 or 12-month follow-up. Participants were assigned to one of three groups based on diagnostic status for youths who: (a) retained an anxiety diagnosis from post to end point (minimal responders); (b) remitted anxiety diagnoses at post but relapsed by end point (relapsed responders); and (c) retained a diagnosis at post but remitted to be diagnosis free at end point (delayed responders). Growth curve models assessed patterns of change over time for the three groups and examined predictors associated with these patterns including demographic, clinical and parental factors, as well as treatment factors.

RESULTS

Higher primary disorder severity, being older, having a greater number of anxiety disorders, having social anxiety disorder, as well as higher maternal psychopathology differentiated the minimal responders from the delayed and relapsed responders at the baseline. Results from the growth curve models showed that severity of the primary disorder and treatment modality differentiated patterns of linear change only. Higher severity was associated with significantly less improvement over time for the minimal and relapsed response groups, as was receiving group CBT, when compared to the delayed response group.

CONCLUSIONS

Sub-optimal response patterns can be partially differentiated using variables assessed at pre-treatment. Increased understanding of different patterns of change following treatment may provide direction for clinical decision-making and for tailoring treatments to specific groups of clinically anxious youth. Future research may benefit from assessing progress during treatment to detect emerging response patterns earlier.

Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review

Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.

Physiological correlates of anxiety in childhood and adolescence: A systematic review and meta-analysis

Anxiety is one of the most prevalent problems that affects children and adolescents. The vast majority of diagnostic tools for anxiety depend on written or verbal reports from children and adolescents or their significant others. The validity and reliability of such reports can be compromised by their subjective nature. Thus, there is growing interest in whether anxiety can be indexed with objective physiological measures. The key aim of this systematic review and meta-analysis was to determine which physiological measures are most reliably associated with elevated levels of anxiety amongst children and adolescents. Online databases (e.g., PsycINFO, Embase, Medline) were searched for relevant studies according to pre-determined criteria. Twenty-five studies comprising 2502 participants (N = 1160 with high anxiety) met inclusion, identifying 11 groups of physiological measures. Our meta-analysis revealed that skin conductance level is the most sensitive measure of anxiety (d = 0.83), followed by electromyography (EMG) measures (d = 0.71) and skin conductance response (d = 0.58). However, the included studies varied in terms of subjective measures, study designs, experimental task measures, and physiological measures. Consideration of these differences in methodology offer potential directions for future research.

Addressing School Connectedness, Belonging, and Culturally Appropriate Care for Newly Immigrated Students and Families

School connectedness is the degree to which students experience acceptance, inclusion, and care by school personnel and peers. A sense of belonging incorporates an emotional connection to the community. School connectedness and belonging are protective factors that promote student engagement, accomplishment, and community performance. Despite the rise in students from immigrant families in the United States, belonging and connectedness for youth from diverse cultural and linguistic experiences are understudied. School-based nurses, our term, is inclusive of advanced practice pediatric, family, and psychiatric nurse practitioners, are well-positioned to support school connectedness for youth who may encounter hurdles to health care because of cultural and linguistic differences. We present practice suggestions for language, culture, and inclusion using three health conditions experienced by youth: anxiety, asthma, and obesity. School-based nurses and other school personnel who provide linguistic and culturally appropriate care can support students in feeling connected and included in their school communities.

Adolescent internet use predicts higher levels of generalized and social anxiety symptoms for girls but not boys

Past research suggests that internet use can increase the risks of internalizing symptoms in adolescents. However, bidirectional relationships between adolescent internet use and anxiety symptoms have received very little attention. Furthermore, few studies have examined these links according to sex. The present study attempts to fill this gap by investigating longitudinal associations between Canadian boys' and girls' internet use and symptoms of generalized anxiety and social anxiety using data from the Quebec longitudinal Study of Child Development. A sample of 1324 adolescents (698 girls, 626 boys) self-reported the number of hours per week they spent on the internet and their symptoms of generalized and social anxiety at ages 15 and 17. We estimated two cross-lagged panel models with social or generalized anxiety symptoms and internet use at age 15 predicting those same variables at age 17. Sex was used as a grouping variable and socioeconomic status was included as a control variable. Internet use at 15 predicted generalized and social anxiety symptoms at age 17 in girls, but not boys. Social and generalized anxiety symptoms at age 15 did not predict internet use at age 17 for both boys and girls. These results suggest that internet use can be a significant risk factor for the development of anxiety symptoms in adolescent girls. Girls may be more vulnerable to the negative effects of internet use due to increased sensitivity to social comparisons. Thus, helping girls develop healthier internet use habits should be a target for promoting their mental health.

Short Research Article: Changes in life functioning in a self-help, online program for child and adolescent anxiety

BACKGROUND

Anxiety-related functional impairment, as reflected by life interference, is a lesser explored but highly relevant treatment outcome, and it is crucial that it be included and examined in the evaluation of treatment outcomes of internet-delivered Cognitive Behavioural Therapy (iCBT).

METHODS

This single group, pre-post study examined changes in life interference and anxiety symptoms in a sample of children (n = 1198; mean age 9.66 years) and adolescents (n = 721; mean age 13.66 years) participating in the BRAVE Self-Help program in Australia.

RESULTS

Results demonstrated that both children and adolescents showed improvements in anxiety symptoms, with effect sizes ranging from ηp 2  = .194-.318. Reductions in life interference were evident for children (ηp 2  = .008-.044), particularly later in the programme, but adolescents did not show such effects. Adolescents in the low completer group (completing 3-5 sessions) showed increases in at-home interference (ηp 2  = .038).

CONCLUSIONS

Adolescents in particular may require more sessions before entrenched life interference, such as that resulting from avoidance behaviours, can be overcome.

Parent-led cognitive behaviour therapy for child anxiety problems: overcoming challenges to increase access to effective treatment

BACKGROUND

Anxiety problems have a particularly early age of onset and are common among children. As we celebrate the anniversary of the BABCP, it is important to recognise the huge contribution that cognitive behavioural therapy (CBT) has made to the treatment of anxiety problems in children. CBT remains the only psychological intervention for child anxiety problems with a robust evidence base, but despite this, very few children with anxiety problems access CBT. Creative solutions are urgently needed to ensure that effective treatments can be delivered at scale. Here we focus on parent-led CBT as this offers a potential solution that is brief and can be delivered by clinicians without highly specialised training. Over the last decade there has been a substantial increase in randomised controlled trials evaluating this approach with consistent evidence of effectiveness. Nonetheless clinicians, and parents, often have concerns about trying the approach and can face challenges in its delivery.

METHOD

We draw on empirical evidence and our clinical experience to address some of these common concerns and challenges, with particular emphasis on the key principles of empowering parents and working with them to provide opportunities for new learning for their children.

CONCLUSIONS

We conclude by highlighting some important directions for future research and practice, including further evaluation of who does and does not currently benefit from the approach, determining how it should be adapted to optimise outcomes among groups that may not currently get maximum benefits and across cultures, and capitalising on recent technological developments to increase engagement and widen access.

Exploring Sociodemographic Characteristics, Adverse Childhood Experience, and Mental Health History as Predictors of Anxiety and Depression among Adolescents and Young Adults: Findings from the MoreGoodDays Support Program in Alberta, Canada

BACKGROUND

The COVID-19 pandemic has increased psychological disorders among adolescents and young adults.

METHODS

This study used a cross-sectional design. An online survey questionnaire was used to collect sociodemographic and clinical information from subscribers of MoreGoodDays program, a daily supportive text message program co-designed with adolescents and young adults for their peers in Alberta. Validated instruments, the Generalized Anxiety Disorder GAD-7 scale and Patient Health Questionnaire-9 PHQ-9 were used to collect information on likely GAD and likely major depressive disorder (MDD). Data was analyzed with SPSS version 25 using chi-squared tests and binary logistic regression analysis.

RESULTS

343 subscribers of MoreGoodDays participated in the survey. Overall, 117 (56.0%) respondents had a likely MDD and 97 (46.6%) had a likely GAD. Participants who would like to receive mental health counselling were 27 times more likely to experience GAD (OR = 27; 95% CI: 3.09-250.00) and 40 times more likely to experience MDD (OR = 40.03; 95% CI: 4.43-361.51) than those who did not. Respondents who had received mental health counselling in the past were 18.5 times more likely to experience MDD compared with those who had not (OR = 18.52; 95% CI: 1.55-200.00). Demographic variables, including age, education, employment, and relationship status, and clinical variables, such as history of anxiety, depression, obsessive-compulsive disorder, ADHD, and adverse childhood experience, did not independently the predict presence of likely GAD or MDD in subscribers of MoreGoodDays.

CONCLUSION

The prevalence of anxiety and depression was relatively high among subscribers of MoreGoodDays, indicating the long-term effect of the COVID-19 pandemic. This finding has significant implications in the broader contextof mental health research and emphasizes the need for more research into innovative mental health support for this cohort. The desire to receive counselling was predictive of both anxiety and depression and is a positive sign of the openness of this cohort to receive psychological intervention. Since this group is mostly adapted to mobile text technology, government agencies and policymakers should prioritize and implement readily accessible interventions such as supportive text messages to support their psychological well-being.

Prevention and Treatment of Social Anxiety Disorder in Adolescents: Protocol for a Randomized Controlled Trial of the Online Guided Self-Help Intervention SOPHIE

BACKGROUND

Social anxiety symptoms are highly prevalent among adolescents and are associated with poor quality of life and low psychosocial functioning. If untreated, social anxiety often persists into adulthood and increases the risk for comorbid disorders. Therefore, early interventions for social anxiety to prevent negative long-term consequences are critical. However, adolescents rarely seek help and often avoid face-to-face psychotherapeutic interventions due to the perceived lack of autonomy and anonymity. Thus, online interventions represent a promising opportunity to reach adolescents who have social anxiety but do not seek help yet.

OBJECTIVE

This study aims to evaluate the efficacy, moderators, and mediators of an online intervention developed to reduce social anxiety in adolescents.

METHODS

A total of 222 adolescents aged 11-17 years with subclinical social anxiety (N=166) or with a diagnosis of social anxiety disorder (N=56) are randomly assigned to the online intervention or a care-as-usual control group. The 8-week guided online intervention is based on the Cognitive Model of Social Phobia and evidence-based online interventions for social anxiety adapted to the specific needs of adolescents. The care-as-usual group will be given access to the online intervention after the follow-up assessment. Participants are assessed at baseline, at 4 and 8 weeks post intervention, and at 3-month follow-up assessment on the primary outcome, that is, social anxiety, on secondary outcomes (eg, level of functioning, fear and avoidance, general anxiety, depression, quality of life, self-esteem, and negative effects of the intervention), on potential moderators (eg, therapy motivation, therapy expectancy, and satisfaction with the intervention), and potential mediators (eg, therapeutic alliance and adherence to the intervention). Data will be analyzed based on an intention-to-treat approach and both groups (intervention and care-as-usual) will be compared at each assessment time point. Furthermore, potential mechanisms of change and generalization of intervention effects on daily life are assessed using an ecological momentary assessment procedure that includes items on maintaining mechanisms of social anxiety, social context, and affect. Participants are prompted 3 times a day during the first 8 weeks of the study and again for 2 weeks following the follow-up assessment.

RESULTS

Recruitment is ongoing; initial results are expected in 2024.

CONCLUSIONS

Results are discussed considering the potential of online interventions as a low-threshold prevention and treatment option for adolescents with social anxiety and in light of current advances in dynamic modeling of change processes and mechanisms in early intervention and psychotherapy in adolescents.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04782102; https://clinicaltrials.gov/ct2/show/NCT04782102.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44346.

Understanding parental knowledge, attitudes and self-efficacy in professional help-seeking for child anxiety

BACKGROUND

Child anxiety disorders are highly prevalent yet undertreated. As parents are often 'gatekeepers' to children receiving treatment and support, this study aimed to investigate modifiable parental factors affecting professional help-seeking for their children from general practitioners (GPs), psychologists, and paediatricians.

METHODS

In this study, 257 Australian parents of children aged 5-12 years with elevated anxiety symptoms completed a cross-sectional online survey. The survey assessed help-seeking from a GP, psychologist, and paediatrician (General Help Seeking Questionnaire), as well as anxiety knowledge (Anxiety Literacy Scale), help-seeking attitudes (Attitudes Toward Seeking Professional Psychological Help), personal stigma (Generalised Anxiety Stigma Scale) and self-efficacy (Self-Efficacy in Seeking Mental Health Care).

RESULTS

66.9 % of participants had sought help from a GP, 61.1 % from a psychologist, and 33.9 % from a paediatrician. Help-seeking from a GP or psychologist was associated with lower personal stigma (p = .02 and p = .03 respectively). Participants who sought help from a psychologist also had more positive attitudes toward seeking professional support (p = .01). Conversely, knowledge of anxiety disorders and self-efficacy were not associated with help-seeking from any source.

LIMITATIONS

Limitations of the study include the representativeness of our sample (female gender, higher education level); unexplained variance potentially accounted for by other factors (e.g., structural barriers); lack of prior validation of measures in a parent sample.

CONCLUSIONS

This research will inform the development of public health policy and psychoeducation interventions for parents, to reduce personal stigma and increase positive attitudes toward professional help-seeking, in turn improving help-seeking for child anxiety.

Saudi Arabian Perceptions of Childhood Anxiety, Parental Communication, and Parenting Style

Parenting communication and parenting style, including expressions of fear, worry, and threat, may contribute to children's anxiety and apprehension. This study examined the degree to which perceptions of parental communication (both verbal and nonverbal) and parenting style are linked with childhood anxiety. This is among the first studies to investigate these relationships in a Saudi Arabian context. We employed a sample of 121 Saudi adults who completed questionnaires measuring perceptions of 2 parenting styles (authoritative and authoritarian), parental anxiety, and childhood anxiety. Parental communication elements such as shouting, criticism, facial expression, and body expressions were included among assessments of perceived parental anxiety, authoritative style, and authoritarian style. The results indicated that perceptions of childhood anxiety were positively associated with parental anxiety but not consistently associated with other assessed variables. This research addressed perceptions of parental communication and parenting style in the development of childhood anxiety, extending upon previous research on Western samples to a Middle Eastern sample residing in Saudi Arabia.

Parental anxiety and offspring development: A systematic review

BACKGROUND

Parental anxiety has been associated with increased risk of emotional and behavioural problems for offspring, yet the differing impact of each parent is unclear. As emotional disorders continue to present a significant challenge to the health system and with the role of mothers and fathers changing over the past two decades, we sought to systematically review the available literature for an association between parental anxiety and offspring suboptimal outcomes.

METHODS

A systematic review was conducted using the following databases: Ovid MEDLINE, Embase; PsycINFO and Google Scholar. Reference lists of the included papers were also searched. Data was analysed and grouped based on offspring age.

RESULTS

Eighteen studies were included in this review. Results suggest that both parents' mental health can impact negatively on the functioning of offspring, during infancy, childhood, and adolescence. This association is weak in infancy, with equivocal results, however the association in childhood appears robust for both mothers and fathers. In adolescence, the findings suggest that maternal anxiety may be more influential than paternal anxiety.

LIMITATIONS

As the methodology of the included studies was heterogenous, and the timing of assessment varied across the papers, drawing concrete conclusions from the existing research is somewhat impaired.

CONCLUSIONS

Both mothers' and fathers' anxiety have the propensity to negatively impact on their child's development. Implementing preventative interventions, which include both parents, as well as systemic interventions, which include the whole family, are essential in stemming the intergenerational transmission of mental health problems within families.

The Integrated Behavior Therapy for Children with Selective Mutism: Findings from an open pilot study in a naturalistic setting

To test the hypothesis that the Integrated Behavior Therapy for Children with Selective Mutism (IBTSM), administered in a naturalistic setting, is (a) a feasible and acceptable treatment, (b) effective in reducing children's selective mutism (SM) and social anxiety (SA) symptoms, and (c) effective in reducing parents' accommodation behaviors to their children's anxiety. This was an open, uncontrolled trial with assessments at baseline, first session, and post-treatment. The study treated 30 children aged 4-13, using the IBTSM protocol. The diagnosis of SM was established by psychologists using a structured interview. The parents reported levels of SM, SA, and parental accommodation on questionnaires, and the level of children's global functioning was rated by clinicians. Feasibility and acceptability of the IBTSM were assessed using dropout rates, protocol adherence, adverse events, and therapist's acceptability ratings. The IBTSM had acceptable dropout rates, with no adverse events and high acceptability rates. Following IBTSM, children's SM and SA levels, and parents' accommodation, significantly decreased. 75% of children were rated by clinicians as treatment responders. IBTSM is a feasible, acceptable, and efficacious treatment for children with SM, utilized in clinical settings. The results of this open trial must be replicated in randomized controlled studies.

Mental health symptoms in children and adolescents during COVID-19 in Australia

OBJECTIVE

COVID-19 has led to disruptions to the lives of Australian families through social distancing, school closures, a temporary move to home-based online learning, and effective lockdown. Understanding the effects on child and adolescent mental health is important to inform policies to support communities as they continue to face the pandemic and future crises. This paper sought to report on mental health symptoms in Australian children and adolescents during the initial stages of the pandemic (May to November 2020) and to examine their association with child/family characteristics and exposure to the broad COVID-19 environment.

METHODS

An online baseline survey was completed by 1327 parents and carers of Australian children aged 4 to 17 years. Parents/carers reported on their child's mental health using five measures, including emotional symptoms, conduct problems, hyperactivity/inattention, anxiety symptoms and depressive symptoms. Child/family characteristics and COVID-related variables were measured.

RESULTS

Overall, 30.5%, 26.3% and 9.5% of our sample scored in the high to very high range for emotional symptoms, conduct problems and hyperactivity/inattention, respectively. Similarly, 20.2% and 20.4% of our sample scored in the clinical range for anxiety symptoms and depressive symptoms, respectively. A child's pre-existing mental health diagnosis, neurodevelopmental condition and chronic illness significantly predicted parent-reported child and adolescent mental health symptoms. Parental mental health symptoms, having a close contact with COVID-19 and applying for government financial assistance during COVID-19, were significantly associated with child and adolescent mental health symptoms.

CONCLUSION

Our findings show that Australian children and adolescents experienced considerable levels of mental health symptoms during the initial phase of COVID-19. This highlights the need for targeted and effective support for affected youth, particularly for those with pre-existing vulnerabilities.

Development of social anxiety cognition scale for college students: Basing on Hofmann's model of social anxiety disorder

Introduction

To develop the Chinese version of the Social Anxiety Cognition Scale for College Students (SACS-CS) based on Hofmann's model of social anxiety disorder and examine its reliability and validity.

Methods

Based on literature analysis and structured interviews, a theoretical model was constructed and behavioral examples were collected. According to the results of participants' and experts' evaluations, the initial SACS-CS was developed. The study data were collected from a total of 500 valid participants, randomly divided into two samples. Sample 1 (n = 200) and sample 2 (n = 300) were considered for exploratory factor analysis and confirmatory factor analysis (CFA), respectively. Internal reliability and validity were examined using all 500 participants, and temporal reliability was established using sample 3 (n = 70), who completed the scale again after 4 weeks.

Results

The SACS-CS consists of 21 items, grouped under four factors: self-perception, social skills, emotional control, and cost estimation. The four-factor model fits well. The internal consistency coefficient of the scale and the four factors ranged from 0.87 to 0.96, and the test-retest reliability ranged from 0.76 to 0.84. The scores of the scale and the four factors were significantly correlated with the score of the Interaction Anxiousness Scale (r = 0.54-0.64).

Discussion

The SACS-CS possesses good reliability and validity and can be applied in the cognitive assessment of college students' social anxiety. The scale could help people with different social anxiety disorder conditions receive more personalized interventions.

Theory-Guided Remote Cooperative Learning-Based Preventive Dental Education as Part of the School Curriculum

BACKGROUND

Oral health is fundamental to overall well-being. As teens are at high risk for tooth decay, we require a unique approach to motivate them to maintain oral health.

METHODS

Sixty-four adolescents (10-13 years) were recruited from 2 schools. Oral health education was based on cooperative learning guided by the social determination theory (SDT) principles. Students' oral health knowledge and oral self-care skills were assessed at baseline (before education), 3 weeks, and 6 months after the education.

RESULTS

Complete data were available for 51 students (follow-up rate 79.7%). There were significant (p < 0.001) changes in the mean (SD) toothbrushing score from 10.1 (±6.3) (baseline) to 26.5 (±6.0) (follow-up 1) and to 28.1 (±5.3) (follow-up 2). The mean (SD) tooth brushing time significantly (p < 0.001) increased from the baseline of 84.0 (±43.5) to the first follow-up to 107.0 (±39.8) and to 102.3 (±33.1) at the second follow-up. The mean (SD) diet knowledge scores significantly (p < 0.001) increased from 8.2 (±2.1) at the baseline to 10.2 (±2.7) at the first follow-up and remained the same at the second follow-up.

CONCLUSION

Social determination theory-guided cooperative learning was efficient in improving student oral health-related knowledge and oral self-care skills, and this improvement was maintained for 6 months after the discontinued education.

Extinction Learning Across Development: Neurodevelopmental Changes and Implications for Pediatric Anxiety Disorders

Alterations in extinction learning relate to the development and maintenance of anxiety disorders across the lifespan. While exposure therapy, based on principles of extinction, can be highly effective for treating anxiety, many patients do not show sufficient improvement following treatment. In particular, evidence suggests that exposure therapy does not work sufficiently for up to 40% of children who receive this evidence-based treatment.Importantly, fear learning and extinction, as well as the neural circuitry supporting these processes, undergo dynamic changes across development. An improved understanding of developmental changes in extinction learning and the associated neural circuitry may help to identify targets to improve treatment response in clinically anxious children and adolescents. In this chapter, we provide a brief overview of methods used to study fear learning and extinction in developmental populations. We then review what is currently known about the developmental changes that occur in extinction learning and related neural circuitry. We end this chapter with a discussion of the implications of these neurodevelopmental changes for the characterization and treatment of pediatric anxiety disorders.

Parent-Led Cognitive Behavioural Therapy for Children with Autism Spectrum Conditions. A Pilot Study

This article reports on a pilot study of a parent-only cognitive behavioural therapy (CBT) programme for parents of children with autism spectrum disorders (ASD) and anxiety difficulties. Twenty-one parents of anxious children with ASD (5-11 of age) completed the From Timid to Tiger intervention. Parent outcome measures were assessed at post-intervention and at 3-month follow-up. Analysis indicated significant reductions in both parent and clinician reports of child anxiety symptoms. Specifically, 38% of children were free of their primary diagnosis at treatment end and this increased to 57% when measured at 3-month follow-up. Positive gains were evidenced regarding parents' ability to manage their child's anxiety without accommodating to it. The results provide preliminary evidence of parent-only CBT programs for children with ASD.

The effect of anxiety on working memory and language abilities in elementary schoolchildren with and without Additional Health and Developmental Needs

Although excessive childhood anxiety is recognised as a significant public health, education and socioeconomic concern, the specific effects of such anxiety on language development and working memory, particularly visual working memory, are relatively unknown. Thus, this study aimed to examine parent-reported trait anxiety, parent-reported functional language (daily communication skills) and clinical measures of non-verbal intelligence, receptive and expressive vocabulary, phonological awareness, and visual and auditory-verbal short-term and working memory in elementary schoolchildren. The final sample included 41 children categorised as Additional Health and Developmental Needs (AHDN) due to medical, neurodevelopmental or educational concerns and 41 age- and IQ-matched neurotypical (NT) children, aged 5- to 9-years. Results showed that 26% of all children in our entire sample (AHDN and NT) experienced moderate, sub-clinical anxiety (as reported by parents), and that AHDN children were 10.5 times more likely to experience high anxiety than the NT group (odds ratio). Parents of AHDN children reported lower functional language in their children than parents of NT children. Cognitive testing indicated that the AHDN group also had poorer visual and auditory-verbal working memory than the NT group. Further, High Anxiety children (drawn from both AHDN and NT groups) showed poorer parent-reported functional language skills, and lower visual and auditory-verbal working memory capacities. Our findings are amongst the first to confirm that the presence of high parent-rated trait anxiety is associated with reduced visual working memory in children, which is consistent with biological and theoretical expectations of the impact of anxiety on visually driven, goal-directed attention and working memory. Our results regarding the high prevalence of sub-clinical anxiety in both ADHD and neurotypical children highlight the need for early assessment of anxiety in all schoolchildren, especially those classified as AHDN.

Receipt of evidence-based care for children and adolescents with anxiety in Australia

OBJECTIVE

Cognitive-behavioural therapy is recommended as the first-line treatment for children and adolescents with anxiety. Despite its efficacy, a recent United Kingdom study indicated that few children with anxiety disorders receive cognitive-behavioural therapy. The primary aim of this study was to examine the receipt of cognitive-behavioural therapy for children and adolescents with elevated anxiety symptoms in Australia. Second, this study also examined whether there was a difference in the type of treatment received based on socioeconomic status and geographical location.

METHOD

Using self-reported questionnaires, parents of children aged 4-18 years and children aged 12-18 years (N = 784; elevated anxiety symptom sample n = 169) were recruited from four samples: community (n = 164), school (n = 177), clinic (n = 16) and online panel provider (n = 427). Participants reported on the child's anxiety symptoms and the type of treatment (if any) the child received for their anxiety symptoms.

RESULTS

Results indicated that 19.5% of children and adolescents with elevated anxiety symptoms received evidence-based treatment (e.g. cognitive-behavioural therapy). Of those families who did seek help for anxiety in Australia, the majority (66.3%) did not receive cognitive-behavioural therapy. In addition, neither socioeconomic status (which was based on the Australian Index of Community Socio-Educational Advantage [ICSEA]) nor location (metropolitan vs regional/remote) affected whether individuals received evidence-based care or non-evidence-based care.

CONCLUSION

Overall, children and adolescents in this study seeking support for their anxiety symptoms were not receiving adequate evidence-based care, regardless of socioeconomic status and location. These findings indicate there is a need to increase the receipt of cognitive-behavioural therapy for children and adolescents with anxiety symptoms. The findings should tentatively be interpreted, given data were collected during the COVID-19 pandemic.

Anxiety among Adolescents and Young Adults during COVID-19 Pandemic: A Multi-Country Survey

(1) Background: Adolescents-and-young-adults (AYA) are prone to anxiety. This study assessed AYA's level of anxiety during the COVID-19 pandemic; and determined if anxiety levels were associated with country-income and region, socio-demographic profile and medical history of individuals. (2) Methods: A survey collected data from participants in 25 countries. Dependent-variables included general-anxiety level, and independent-variables included medical problems, COVID-19 infection, age, sex, education, and country-income-level and region. A multilevel-multinomial-logistic regression analysis was conducted to determine the association between dependent, and independent-variables. (3) Results: Of the 6989 respondents, 2964 (42.4%) had normal-anxiety, and 2621 (37.5%), 900 (12.9%) and 504 (7.2%) had mild, moderate and severe-anxiety, respectively. Participants from the African region (AFR) had lower odds of mild, moderate and severe than normal-anxiety compared to those from the Eastern-Mediterranean-region (EMR). Also, participants from lower-middle-income-countries (LMICs) had higher odds of mild and moderate than normal-anxiety compared to those from low-income-countries (LICs). Females, older-adolescents, with medical-problems, suspected-but-not-tested-for-COVID-19, and those with friends/family-infected with COVID-19 had significantly greater odds of different anxiety-levels. (4) Conclusions: One-in-five AYA had moderate to severe-anxiety during the COVID-19-pandemic. There were differences in anxiety-levels among AYAs by region and income-level, emphasizing the need for targeted public health interventions based on nationally-identified priorities.

Identifying Child Anxiety Through Schools-identification to intervention (iCATS-i2i): protocol for single-arm feasibility trial

Background

Anxiety disorders are common among primary-school aged children, but few affected children receive evidence-based treatment. Identifying and supporting children who experience anxiety problems through schools would address substantial treatment access barriers that families and school staff often face. We have worked with families and school staff to co-design procedures that incorporate screening, feedback for parents, and the offer of a brief intervention in primary schools. This study sets out to assess the feasibility of a subsequent school-based cluster randomised controlled trial to evaluate these procedures. Our objectives are to ensure our procedures for identifying and supporting children with anxiety difficulties through primary schools are acceptable and there are no negative impacts, to estimate recruitment and retention rates, and to identify any changes needed to study procedures or measures.

Methods

We will recruit six primary/junior schools in England (2 classes per school), and invite all children (aged 8–9) (n = 360) and their parent/carer and class teacher in participating classes to take part. Children, parents and class teachers will complete questionnaires at baseline and 12-week follow-up. Children who ‘screen positive’ on a 2-item parent-report child anxiety screen at baseline will be the target population (expected n = 43). Parents receive feedback on screening questionnaire responses, and where the child screens positive the family is offered support (OSI: Online Support and Intervention for child anxiety). OSI is a brief, parent-led online intervention, supported by short telephone sessions with a Children’s Wellbeing Practitioner. Participants’ experiences of study procedures will be assessed through qualitative interviews/discussion groups.

Discussion

Evidence-based procedures for identifying and supporting children with anxiety difficulties through primary schools would improve children’s access to timely, effective intervention for anxiety difficulties.

Trial registration

ISRCTN registry: ISRCTN30032471. Retrospectively registered on 18 May 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01140-x.

The Neurobiology of Infant Attachment-Trauma and Disruption of Parent-Infant Interactions

Current clinical literature and supporting animal literature have shown that repeated and profound early-life adversity, especially when experienced within the caregiver-infant dyad, disrupts the trajectory of brain development to induce later-life expression of maladaptive behavior and pathology. What is less well understood is the immediate impact of repeated adversity during early life with the caregiver, especially since attachment to the caregiver occurs regardless of the quality of care the infant received including experiences of trauma. The focus of the present manuscript is to review the current literature on infant trauma within attachment, with an emphasis on animal research to define mechanisms and translate developmental child research. Across species, the effects of repeated trauma with the attachment figure, are subtle in early life, but the presence of acute stress can uncover some pathology, as was highlighted by Bowlby and Ainsworth in the 1950s. Through rodent neurobehavioral literature we discuss the important role of repeated elevations in stress hormone corticosterone (CORT) in infancy, especially if paired with the mother (not when pups are alone) as targeting the amygdala and causal in infant pathology. We also show that following induced alterations, at baseline infants appear stable, although acute stress hormone elevation uncovers pathology in brain circuits important in emotion, social behavior, and fear. We suggest that a comprehensive understanding of the role of stress hormones during infant typical development and elevated CORT disruption of this typical development will provide insight into age-specific identification of trauma effects, as well as a better understanding of early markers of later-life pathology.

Childhood-onset versus adolescent-onset anxiety and depression: Epidemiological and neurodevelopmental aspects

Anxiety and depression are common in youth and are frequently accompanied by attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). However, it is unclear how common ADHD, ASD, and other neurodevelopmental disorders (NDDs, i.e., ADHD, ASD, developmental coordination disorder, learning disorder, and tic disorders) are in children versus adolescents with anxiety and depression. We aimed to delineate whether different anxiety/depression age-of-onset groups show distinguishable NDD patterns. The study was based on 4492 twins born in Sweden between 1998 and 2003 from the nation-wide population-based Child and Adolescent Twin Study in Sweden. Prevalence and odds ratios were calculated using screening measures of anxiety and depression at ages 9 and 15, and NDDs at age 9. Individuals with childhood-onset anxiety/depression had a substantially higher NDD prevalence compared to individuals with adolescent-onset anxiety/depression. Highest prevalence was found for individuals with anxiety/depression both in childhood and adolescence. In this group, individuals also had substantially higher odds of having at least one NDD (14.7, 95% CI 6.3 - 34.0) compared to individuals without anxiety/depression. This emphasizes the need to further investigate the etiology of childhood and adolescent anxiety/depression, as they most likely represent different constructs depending on age-of-onset, lending support for possibly different treatment approaches.

Enhanced Cognitive-Behavioral Treatment for Anxiety Disorders in Children of Clinically Anxious Parents: Two Case Studies

Children with anxiety disorders are significantly less likely to recover following cognitive-behavioral therapy (CBT) if they have a parent with clinical anxiety. Despite this, prior research which has adapted CBT treatments to cater for this vulnerable clinical cohort of children is limited. In response to the identified need to optimize treatment outcomes for this particular group of children with anxiety disorders, an enhanced CBT intervention was recently developed, specifically to target anxiety maintenance factors in clinically anxious child–parent dyads. This dual case study presents the implementation of the enhanced intervention with two children with complex clinical presentations. Prior to treatment, both children met criteria for multiple anxiety disorders, as did their mothers. The presented case studies describe session-by-session treatment accounts, with a particular focus on the children’s experiences of individual and joint-observational exposure treatment components. Outcome data is provided for both children and their mothers, based on assessment measures collected at pre- and post-treatment, and during the intervention. At post-treatment, both children demonstrated symptom reduction and improved functioning across all diagnoses, including remission on a secondary diagnosis, although both still met criteria for their primary diagnoses. Additionally, self-reported outcomes on intervention acceptability measures were favorable. Results implied that the enhanced intervention provided a viable alternative treatment approach for children and their parents with co-occurring anxiety disorders. Recommendations are provided for clinicians delivering CBT to clinically anxious child–parent dyads.

Internalizing symptoms in adolescence are modestly affected by symptoms of anxiety, depression, and neurodevelopmental disorders in childhood

BACKGROUND

Internalizing disorders, such as anxiety and depressive disorders, are common mental disorders in young people, but a detailed understanding of the symptom continuity from childhood to adolescence that additionally includes a variety of neurodevelopmental disorder (NDD) symptoms is lacking. We therefore aimed to assess the extent to which parent-reported anxiety, depression, and NDD symptoms in childhood predict parent-reported internalizing symptoms in adolescence.

METHODS

We used the nation-wide population-based Child and Adolescent Twin Study in Sweden, comprising 4492 twins born in Sweden between 1998 and 2003 that were assessed at age 9, and then again at age 15. Linear regression in a structural equation modelling framework was used to analyze the data.

RESULTS

Overall, our results indicate that 15.9% of the variance in internalizing symptoms at age 15 can be predicted by anxiety, depression, and NDD symptoms at age 9. Anxiety and NDD symptoms in childhood predicted the largest amount of internalizing symptoms in adolescence.

CONCLUSIONS

Adolescent internalizing symptoms are modestly affected by childhood symptoms of anxiety, depression, and NDDs, suggesting that they may represent different constructs across age. Future studies should further empirically investigate differences in etiology and trajectories of childhood versus adolescent internalizing symptoms.

Does Training Parents in Reinforcement Skills or Relationship Skills Enhance Individual Youths' Cognitive Behavioral Therapy for Anxiety? Outcome, Specificity, and Mediation

We conducted a dismantling design treatment study comparing individual CBT, CBT targeting parents' reinforcement skills (CBT+Reinf), and CBT targeting parents' relationship skills (CBT+ Relat) in 341 youths with primary anxiety diagnoses. At posttreatment, youths in CBTs with parent involvement had lower anxiety than youths in CBT. At 12-month follow-up, youths in CBT+Relat maintained lower anxiety relative to CBT. At posttreatment, negative reinforcement was significantly lower in CBT+Reinf than CBT+Relat and CBT; negative reinforcement partially mediated youth anxiety reduction. Reducing parental negative reinforcement in CBT+Reinf was associated with lower parental psychological control which also partially mediated youth anxiety reduction. Some of these mediational dynamics continued through follow-up. Targeting concrete behavioral parenting skills, especially negative reinforcement, produced treatment specificity and partial mediation relative to less concrete targeting, and enhanced CBT. Findings highlight complexities in identifying mechanisms through which targeting of parenting skills produces youth anxiety reduction and suggest avenues for future research.

Using the Child Sheehan Disability Scale to Differentiate Severity Level in Youth With Anxiety Disorders and Obsessive Compulsive Disorder

The current study extends the psychometric support for the Child Sheehan Disability Scale (CSDS) as a measure of impairment associated with childhood anxiety disorders, including obsessive compulsive disorder. The CSDS was completed by 1,481 predominately Caucasian youth (55.4% female) ages 8 to 17 (M = 12.68, SD = 2.78) from primarily two-parent households and a parent across community, outpatient, intensive outpatient treatment, and residential settings. The results replicated and extended the previously found strong convergent validity, discriminant validity, and treatment sensitivity with a revised parent-report item in the larger sample. Moreover, the CSDS successfully differentiated between patients receiving treatment of different levels of intensity. These data were used to develop preliminary qualitative descriptors associating individual scores with a likely level of indicated treatment to enhance the clinical applicability of the CSDS. This study establishes the CSDS as one of the briefest and most rigorously evaluated measures of impairment associated with child anxiety. However, the performance of the CSDS must be examined in more representative samples before being applied to diverse populations.

Family socio-economic status and Chinese Preschoolers' anxious symptoms during the COVID-19 pandemic: the roles of parental investment, parenting style, home quarantine length, and regional pandemic risk

Using data from 16,161 families with target child of 3-6 years old in Hubei, China during COVID-19 pandemic, this study examined the association between family socio-economic status (SES) and preschoolers' anxious symptoms (PAS). Parental investment and parenting style were tested as mediators for this association. Home quarantine length was tested as a moderator for this direct association and for the associations between family SES and parenting processes, whereas regional pandemic risk was tested as a moderator for the entire model. Results support the utility of Family Stress and Family Investment Models in a Chinese context by identifying unique roles of parental investment and parenting style in mediating the link between family SES and PAS. Quarantine length moderated the link between family SES and authoritarian parenting: Strength of this negative association was stronger for families with longer quarantine than for those with shorter quarantine. Further, family SES was negatively associated with PAS through its negative association with authoritarian parenting, regardless of the quarantine length. Model comparison analyses between high-risk region versus low/medium-risk region groups indicated that the pandemic risk for living regions did not alter any pathway in the model. Such findings inform the designs of targeted interventions to help families cope with pandemic-related challenges. Promoting parental investment and adaptive patenting style represents an avenue to diminish consequences of family economic hardship for young children's mental health, regardless of macrolevel pandemic risk. Interventions should attend to home quarantine duration, as it contextualizes the links among family SES, parenting, and child well-being.

Development and Preliminary Validation of the Child & Adolescent Social Cognitions Questionnaire

Negative cognitions play a central role in adolescent social anxiety, and yet there is a lack of empirically validated measures assessing these in detail. This study describes the adaptation of the Child & Adolescent Social Cognitions Questionnaire (CASCQ) from the adult version of the scale and its preliminary validation in a general adolescent school sample (N = 671). Exploratory and confirmatory factor analysis on split halves of the data indicated two factors, labelled 'negative self-concept' and 'anxious appearance', provided the best fit. Totals and subscales possessed good internal consistency and convergent validity. Findings suggest that the CASCQ is a reliable and valid measure of social anxiety-related cognitions in youth and may be useful for research and clinical purposes. Further examination of the scale with pre-adolescents and clinical samples is warranted.

Paternal Feelings and Child's Anxiety: The Mediating Role of Father-Child Insecure Attachment and Child's Emotional Regulation

The study introduces a path model that links between paternal feelings and child’s anxiety symptoms, aiming to test the mediational role of father–child insecure attachment and the child’s difficulties in emotional regulation in the occurrence of anxiety disorders among a sample of 148 fathers and their children (65 boys and 83 girls aged 8–18) attending the child psychiatric center of a public hospital. Participants completed a battery of diagnostical and research questionnaires, including the Parental Feelings Inventory (PFI), the Difficulties in Emotion Regulation Scale (DERS), the Screen for Child Anxiety–Related Emotional Disorders (SCARED), and the Experiences in Close Relationships Scale–Revised Child version (ECR-RC). Using structural equation modeling, we found father’s anger to be associated with father–child anxiety attachment, while the latter simultaneously mediated the link to the child’s anxiety both directly and indirectly (through emotion regulation [ER]). Consistent with previous evidence, we found insecure attachment and emotional regulation to be uniquely associated with the child’s anxiety. The current findings are among the first to demonstrate the interrelations between these variables in the context of father–child relations, suggesting that the child’s exposure to paternal anger might contribute to developing difficulties in ER and elevated anxiety due to a father–child insecure-anxious attachment relationship. The theoretical and practical implications of the findings are discussed in light of parental gender.

Time-Out with Young Children: A Parent-Child Interaction Therapy (PCIT) Practitioner Review

Time-out is a component of many evidence-based parent training programmes for the treatment of childhood conduct problems. Existing comprehensive reviews suggest that time-out is both safe and effective when used predictably, infrequently, calmly and as one component of a collection of parenting strategies-i.e., when utilised in the manner advocated by most parent training programmes. However, this research evidence has been largely oriented towards the academic community and is often in conflict with the widespread misinformation about time-out within communities of parents, and within groups of treatment practitioners. This dissonance has the potential to undermine the dissemination and implementation of an effective suite of treatments for common and disabling childhood conditions. The parent-practitioner relationship is integral to the success of Parent-Child Interaction Therapy (PCIT), an evidence-based treatment which involves live coaching of parent(s) with their young child(ren). Yet this relationship, and practitioner perspectives, attitudes and values as they relate to time-out, are often overlooked. This practitioner review explores the dynamics of the parent-practitioner relationship as they apply to the teaching and coaching of time-out to parents. It also acknowledges factors within the clinical setting that impact on time-out's use, such as the views of administrators and professional colleagues. The paper is oriented toward practitioners of PCIT but is of relevance to all providers of parent training interventions for young children.

The Ecology of Youth Psychological Wellbeing in the COVID-19 Pandemic

The consequences of profound disruption to everyday life caused by the COVID-19 pandemic will only emerge over time. Guided by ecological systems (Pitchik et al., 2021) and developmental psychopathology (Masten & Cicchetti, 2010) frameworks, I review evidence that points to parents at home with children as particularly vulnerable to increased psychological difficulties, particularly in contexts of poverty. Resultant compromised parenting may reduce children's opportunities for the kinds of everyday interactions that promote cognitive and socioemotional development and expose them to increases in coercive, avoidant, and other problematic caregiving behaviours. I discuss three evidence-based strategies that parents could adopt to buffer their child's mental health: building positive discipline strategies, talking with the child about the pandemic and its consequences, and conversing about the past. I conclude, however, that approaches to supporting parents and their children at this time must also address multisystem factors that compromise caregivers' ability to provide nurturing care.

Validation of the brief version of the Spence Children's Anxiety Scale for Spanish children (SCAS-C-8)

OBJECTIVE

This study aimed to validate the self-reported brief version of the Spence Children's Anxiety Scale-Children (SCAS-C-8) in pre-adolescent Spanish children.

METHOD

Participants were 824 children aged 8-12 from a community sample. The results revealed a good fit to the one-factor structure, adequate internal consistency (α = 0.75), and evidence of test-retest reliability (α = 0.77).

RESULTS

The strong relationship between the SCAS-C-8 and emotional problems provided evidence of convergent validity. Also, the results showed factorial gender invariance.

CONCLUSION

The SCAS-C-8 is a suitable instrument for pre-adolescent Spanish children. The brevity and simplicity of this scale may facilitate early detection and help to narrow the existent gap between the presence of anxiety problems and psychological assistance-seeking.

The Limited Effect of Mindfulness-Based Interventions on Anxiety in Children and Adolescents: A Meta-Analysis

Anxiety disorders are common mental health problems amongst youth with harmful impacts often extending into adulthood. Mindfulness-based interventions (MBIs) have become increasingly popular for addressing mental health issues, particularly in schools; however, it remains unclear how effective they are for reducing youth anxiety. This meta-analysis aimed to evaluate the efficacy and effect moderators of MBIs on anxiety outcomes in children and adolescents. Eligible studies were published randomised controlled trials (RCTs) of MBIs conducted with participants aged 18 years or younger, investigating anxiety outcomes using a well-validated anxiety scale. A systematic search of RCTs published through to February 2019 identified 20 studies for inclusion (n = 1582). A random effects model was used to synthesise MBI effects. Stratified meta-analyses as well as individual, random effects meta-regressions were performed to examine how effects varied by age group, intervention setting, control type, research location, and intervention dosage. Although, across all studies, there was a small beneficial effect of MBIs on anxiety post treatment (d = 0.26), this was significantly moderated by research location, with RCTs conducted in Iran producing large effects (d = 1.25), and RCTs conducted in Western countries demonstrating no significant beneficial effect compared to controls (very small, d = 0.05). Effects were non-significant at follow-up assessment points. Post-treatment effects were significant for MBIs conducted with children (d = 0.41) and for MBIs when compared to passive controls (d = 0.33), but non-significant for adolescents (d = 0.21), for MBIs conducted in schools (d = 0.30) and in clinics (d = 0.13), and when MBIs were compared to active controls (d = 0.12). Results suggest that MBIs are likely to have a small to medium, yet temporary effect in reducing anxiety symptoms in children (not adolescents), but amongst Western youth populations the most likely outcome, from RCTs to date, is that MBIs produce no beneficial effect in anxiety reduction. Results revealed a lack of evidence to support investment in school-based MBIs to address youth anxiety.

Evaluation of a parent-led cognitive behaviour therapy programme in routine clinical practice: A controlled trial

Parent-led cognitive behavioural therapy for child anxiety disorders have garnered a growing evidence base. However, it is unclear how such approaches translate into routine clinical practice. The current study aims to evaluate the effectiveness of an 8-session treatment (From Timid to Tiger) in reducing child anxiety and behavioural difficulties, as well as family accommodation. The parents of 71 children (aged 4-11) were assigned to the treatment or a waitlist control. Parent report measures were completed pre-treatment, at treatment-end, and at 3-month follow-up. Parents assigned to the waitlist were assessed 8 weeks after the initial assessment. Findings indicated that parents who attended the group reported significant reductions in child anxiety and behavioural difficulties. In addition, the parents in the treatment group reported a reduction in family accommodation compared to those in the waitlist. The current control trial provides tentative evidence of the use and effectiveness of such parent-led approaches in addressing child anxiety difficulties commonly seen in routine clinical practice. PRACTITIONER POINTS: Parent-led approaches are effective treatments in managing child anxiety difficulties. Very little research to date has assessed the effectiveness of such approaches in routine clinical practice. The From Timid to Tiger program is a brief parent-led CBT intervention. The programme was effective in reducing child anxiety and behavioural difficulties. Parents also reported a reduction in behaviours related to family accommodation. Such programmes show promise and can be used in routine clinical practice.

Neurobiology of Infant Fear and Anxiety: Impacts of Delayed Amygdala Development and Attachment Figure Quality

Anxiety disorders are the most common form of mental illness and are more likely to emerge during childhood compared with most other psychiatric disorders. While research on children is the gold standard for understanding the behavioral expression of anxiety and its neural circuitry, the ethical and technical limitations in exploring neural underpinnings limit our understanding of the child's developing brain. Instead, we must rely on animal models to build strong methodological bridges for bidirectional translation to child development research. Using the caregiver-infant context, we review the rodent literature on early-life fear development to characterize developmental transitions in amygdala function underlying age-specific behavioral transitions. We then describe how this system can be perturbed by early-life adversity, including reduced efficacy of the caregiver as a safe haven. We suggest that greater integration of clinically informed animal research enhances bidirectional translation to permit new approaches to therapeutics for children with early onset anxiety disorders.

Practitioner review: health anxiety in children and young people in the context of the COVID-19 pandemic

Health-related fear is a normal and common response in the face of the global pandemic of COVID-19. Children and young people are frequently being exposed to messages about the threat to health, including from the media and authorities. Whilst for most, their anxiety will be proportionate to the threat, for some, existing pre-occupation with physical symptoms and illness will become more problematic. There is a growing body of evidence that health anxiety may occur in childhood, however much of the literature is taken from research using adult samples. This practitioner review aims to give an overview of the assessment and treatment of health-related worries in children and young people in the context of the COVID-19 pandemic. This review is based on the limited existing evidence in this population and the more substantial evidence base for treating health anxiety in adults. We consider the adaptations needed to ensure such interventions are developmentally appropriate.

Delivering cognitive therapy for adolescent social anxiety disorder in NHS CAMHS: a clinical and cost analysis

BACKGROUND

Cognitive therapy, based on the Clark and Wells (1995) model, is a first-line treatment for adults with social anxiety disorder (SAD), and findings from research settings suggest it has promise for use with adolescents (Cognitive Therapy for Social Anxiety Disorder in Adolescents; CT-SAD-A). However, for the treatment to be suitable for delivery in routine clinical care, two questions need to be addressed.

AIMS

Can therapists be trained to achieve good outcomes in routine Child and Adolescent Mental Health Services (CAMHS), and what are the costs associated with training and treatment?

METHOD

CAMHS therapists working in two NHS trusts received training in CT-SAD-A. They delivered the treatment to adolescents with SAD during a period of supervised practice. We examined the clinical outcomes for the 12 patients treated during this period, and estimated costs associated with treatment and training.

RESULTS

Treatment produced significant improvements in social anxiety symptoms, general anxiety and depression symptoms, and reductions in putative process measures. Seventy-five per cent (9 out of 12) patients showed a reliable and clinically significant improvement in social anxiety symptoms, and 64% (7/11) lost their primary diagnosis of SAD. The total cost to the NHS of the CT-SAD-A treatment was £4047 (SD = £1003) per adolescent treated, of which £1861 (SD = £358) referred to the specific estimated cost of face-to-face delivery; the remaining cost was for training and supervising therapists who were not previously familiar with the treatment.

CONCLUSIONS

This study provides preliminary evidence that clinicians can deliver good patient outcomes for adolescents with SAD in routine CAMHS during a period of supervised practice after receiving a 2-day training workshop. Furthermore, the cost of delivering CT-SAD-A with adolescents appeared to be no more than the cost of delivering CT-SAD with adults.

The use of acceptance and commitment therapy (ACT) in addressing family accommodation (FA) for child anxiety

Many parents of children with anxiety tend to engage in varying levels of family accommodation (FA) in order to alleviate anxiety symptoms. This can exacerbate anxiety symptoms and have adverse effects for psychological treatments. A small number of general and specific interventions have been developed for FA but treatment research is at a nascent stage. Acceptance and commitment therapy (ACT) may be an effective treatment for FA. This article reviews the potential advantages and uses of ACT and how ACT’s six core processes can help target particular features of FA. The theoretical support for ACT is reviewed relevant to FA. The article concludes by conjecturing how ACT may be a useful and adaptive treatment in targeting FA.

Key learning aims

(1)

Comparing neural correlates of conditioned inhibition between children with and without anxiety disorders - A preliminary study

Cognitive-behavioral therapy (CBT), a first-line treatment for pediatric anxiety disorders, is based on principles of threat learning and extinction. However, CBT does not work sufficiently for up to 40% of clinically anxious youth. The neural and behavioral correlates of conditioned inhibition might provide promising targets for attempts to improve CBT response. During conditioned inhibition, threat and safety cues appear together, forming a safety compound. Here, we test whether this safety compound elicits a reduced fear response compared to pairing the threat cue with a novel cue (novel compound). The current pilot study compares behavioral, physiological, and neural correlates of conditioned inhibition between children with (n = 17, Mage = 13.09, SDage = 3.05) and without (n = 18, Mage = 14.49, SDage = 2.38) anxiety disorders. Behavioral and physiological measures did not differ between children with and without anxiety disorders during fear acquisition. During testing, children with anxiety disorders showed overall higher skin conductance response and expected to hear the aversive sound following the novel compound more often than children without anxiety disorders. Children with anxiety disorders showed more activity in the right ventromedial prefrontal cortex (vmPFC) to the safety versus novel compound. Children without anxiety disorders showed the opposite pattern - more right vmPFC activity to the novel versus safety compound (F(1,31) = 5.40, p = 0.03). No group differences manifested within the amygdala, dorsal anterior cingulate cortex, or hippocampus. These pilot findings suggest a feasible approach for examining conditioned inhibition in pediatric anxiety disorders. If replicated in larger samples, findings may implicate perturbed conditioned inhibition in pediatric anxiety disorders and provide targets for CBT.

Learning About Safety: Conditioned Inhibition as a Novel Approach to Fear Reduction Targeting the Developing Brain

Adolescence is a peak time for the onset of psychiatric disorders, with anxiety disorders being the most common and affecting as many as 30% of youths. A core feature of anxiety disorders is difficulty regulating fear, with evidence suggesting deficits in extinction learning and corresponding alterations in frontolimbic circuitry. Despite marked changes in this neural circuitry and extinction learning throughout development, interventions for anxious youths are largely based on principles of extinction learning studied in adulthood. Safety signal learning, based on conditioned inhibition of fear in the presence of a cue that indicates safety, has been shown to effectively reduce anxiety-like behavior in animal models and attenuate fear responses in healthy adults. Cross-species evidence suggests that safety signal learning involves connections between the ventral hippocampus and the prelimbic cortex in rodents or the dorsal anterior cingulate cortex in humans. Particularly because this pathway follows a different developmental trajectory than fronto-amygdala circuitry involved in traditional extinction learning, safety cues may provide a novel approach to reducing fear in youths. In this review, the authors leverage a translational framework to bring together findings from studies in animal models and humans and to bridge the gap between research on basic neuroscience and clinical treatment. The authors consider the potential application of safety signal learning for optimizing interventions for anxious youths by targeting the biological state of the developing brain. Based on the existing cross-species literature on safety signal learning, they propose that the judicious use of safety cues may be an effective and neurodevelopmentally optimized approach to enhancing treatment outcomes for youths with anxiety disorders.