Relation of the childhood autism rating scale-parent version to diagnosis,stress, and age

This study explored the relation of severity of functional impairment on the Childhood Autism Rating Scale-Parent version (CARS-P) to diagnosis, parenting stress, and child age. Twenty-two mothers of children with autism and 19 mothers of children with pervasive developmental disorder-not otherwise specified (PDD-NOS) completed the CARS-P and the Parenting Stress Index. The autism group received significantly higher (i.e., more severe impairment) CARS-P ratings that did the PDD-NOS group. For the total sample, severity of impairment was a significant predictor of child-related parenting stress. The CARS-P was inconsistently associated with age-significantly positive for the PDD-NOS group but nonsignificantly for the autism group. Implications for the use of the CARS-P in assessment of children and the evaluation of interventions are discussed.     

Pharmacotherapy of childhood anxiety disorders

Anxiety disorders are among the most common psychiatric disorders of childhood, yet limited data is available regarding the use of psychotropic medications for these conditions. Until recently, much of the data on the pharmacologic treatment of pediatric anxiety disorders has consisted of case reports and small open-label studies, with the exception of pediatric obsessive-compulsive disorder (OCD), which has had a comparatively rich literature consisting of several double blind trials. This void has been lessening, however, with four double blind, placebo-controlled studies published in the past year alone. Although the majority of pharmacologic studies of pediatric anxiety continue to focus on the treatment of OCD, additional reports on treatment of generalized anxiety disorder, panic disorder, social anxiety disorder, and separation anxiety disorder have recently been published. This article will review significant pharmacologic studies published in the prior year, and the role of pharmacotherapy in the treatment of pediatric anxiety disorders.     

Comorbidity among childhood anxiety disorders

This paper reports on 73 consecutive admissions to an outpatient anxiety disorder clinic for children and adolescents. Patients were evaluated with a structured diagnostic interview for primary and secondary disorders with DSM-III criteria in order to examine patterns of comorbidity. The most common primary diagnoses for the sample included separation anxiety disorder (33%), overanxious disorder (15%), social phobia of school (15%), and major depression (15%). Children with a primary diagnosis of separation anxiety disorders were most likely to receive a concurrent diagnosis of overanxious disorder. Alternatively, children with a primary diagnosis of overanxious disorder were most likely to receive an additional diagnosis indicative of a social anxiety problem, either social phobia or avoidant disorder. Children with a primary major depression most often exhibited social phobia and/or overanxious disorder. No clear-cut pattern of comorbidity emerged for the social phobic (school) group. These findings are discussed in terms of their comparability with results recently obtained from an adult anxiety clinic population.     

Pathophysiology of childhood anxiety disorders.

Prior reviews on the pathophysiology of anxiety consistently note the need for more research on biological aspects of childhood social phobia, separation anxiety disorder, and generalized anxiety disorder. The current review summarizes biological research that is relevant to these three disorders. In the first part of the review, barriers that have prevented progress in this area are delineated, and recent developments are discussed that set the stage for major advances in research on childhood anxiety disorders. In the second part of the review, studies are discussed that provide insights on the pathophysiology of childhood social phobia, separation anxiety disorder, and generalized anxiety disorder. Research on each specific disorder illustrates the manner in which recent developments in biological research facilitate novel research approaches uniquely suited for answering essential clinical questions in research on both childhood and adult anxiety disorders. For example, in research on social phobia, biological studies might enhance understandings of the longitudinal associations between individual childhood and adult disorders. In research on separation anxiety disorder, biological studies might enhance understanding on family-genetic associations between childhood and adult disorders. Finally, in research on generalized anxiety disorder, biological studies might enhance understandings of comorbidities among distinct childhood and adult disorders, particularly with respect to the relationship between anxiety and depressive disorders.     

Family-based treatment of childhood anxiety disorders

Recently attention has turned to family involvement in the treatment of childhood anxiety disorders. Theoretical models and research on parenting behaviour have identified specific targets for family intervention. A growing number of family-based treatment studies targeting these parenting behaviours and interactions suggest that this approach is effective. A review of the targets of treatment and intervention strategies are described in detail.     

Fluoxetine for the treatment of childhood anxiety disorders

OBJECTIVE: To assess the efficacy and tolerability of fluoxetine for the acute treatment of children and adolescents with generalized anxiety disorder, separation anxiety disorder, and/or social phobia. METHOD: Anxious youths (7-17 years old) who had significant functional impairment were randomized to fluoxetine (20 mg/day) (n = 37) or placebo (n = 37) for 12 weeks. RESULTS: Fluoxetine was effective in reducing the anxiety symptoms and improving functioning in all measures. Using intent-to-treat analysis, 61% of patients taking fluoxetine and 35% taking placebo showed much to very much improvement. Despite this improvement, a substantial group of patients remained symptomatic. Fluoxetine was well tolerated except for mild and transient headaches and gastrointestinal side effects. Youths with social phobia and generalized anxiety disorder responded better to fluoxetine than placebo, but only social phobia moderated the clinical and functional response. Severity of the anxiety at intake and positive family history for anxiety predicted poorer functioning at the end of the study. CONCLUSIONS: Fluoxetine is useful and well tolerated for the acute treatment of anxious youths. Investigations regarding the optimization of treatment to obtain full anxiety remission and the length of treatment necessary to prevent recurrences are warranted.     

Development, reliability, and validity of the children's aggression scale-parent version

OBJECTIVE: To provide preliminary psychometric data on the Children's Aggression Scale-Parent Version (CAS-P), which assesses severity, frequency, pervasiveness, and diversity of aggressive, as distinct from nonaggressive, disruptive behaviors. METHOD: The scale has 33 items representing five domains: Verbal Aggression, Aggression Against Objects and Animals, Provoked Physical Aggression, Unprovoked Physical Aggression, and Use of Weapons. The CAS-P was completed for 73 clinically referred children. Validity was evaluated dimensionally by examining the relationship of CAS-P scores to other parent and teacher rating scales, and categorically by comparing scores of children with attention-deficit hyperactivity disorder (ADHD) alone, oppositional defiant disorder, and conduct disorder. RESULTS: The scale as a whole had excellent internal consistency (alpha = .93). Children with conduct disorder were rated significantly higher than those with oppositional defiant disorder, who were rated significantly higher than those with ADHD alone. The CAS-P did not distinguish clinical control children from those with ADHD only. Correlations with other rating scales provide further support for the validity of the CAS-P. CONCLUSIONS: The CAS-P assesses distinct components of aggressive behavior and may fill a gap in that it distinguishes among various types and severity of aggressive behaviors, and the settings in which they take place.     

Cognitive-behavioral therapy with childhood anxiety disorders: functioning in adolescence

We examined anxiety symptoms, anxiety-related impairment, and further treatment in adolescents who received cognitive behavioral therapy (CBT) for childhood anxiety disorders 6-7 years previously. Forty-three adolescents and their parents (14 boys, 29 girls; mean age 16.7 years) participated in structured telephone interviews. Participants (68% of initial sample of 63) did not differ in age, diagnostic profile, socioeconomic status, or initial severity from nonparticipants but more girls than boys participated. Indices based on child- and parent-reported symptoms and impairment were calculated, and within-sample comparisons by age, gender, diagnosis, and initial severity were done using t tests. Predictors of symptoms and impairment were also examined. On average, adolescents reported modest levels of anxiety-related impairment. Further treatment for anxiety had occurred in 30% (13 of 43) of patients. Stepwise regressions found female gender and diagnosis other than generalized anxiety disorder predictive of increased symptoms by parent report, and initial severity predicted adolescent-reported impairment. Adolescents showed limited internalizing symptomatology and impairment but almost one third had required further treatment. Studies comparing treated and untreated samples are needed to clarify whether CBT alters the natural history of childhood anxiety disorders and to replicate our findings regarding predictors of symptomatology and impairment.     

Treatment of childhood anxiety disorders: a preliminary comparison between cognitive-behavioral group therapy and a psychological placebo intervention

The present study examined the efficacy of group cognitive-behavioral therapy (CBT) in the treatment of childhood anxiety disorders. Thirty high-anxious children (aged 9-12 years) were assigned to either (a) group CBT (n = 10), (b) a psychological placebo intervention (i.e., emotional disclosure [ED]; n = 10), or (c) a no-treatment control condition (n = 10). Therapy outcome measures (i.e., children's self-report of anxiety disorders symptoms, depression, and trait anxiety) were obtained three months before treatment, at pretreatment, and at posttreatment. Results showed that levels of psychopathological symptoms remained relatively stable during the three months preceding treatment. Most importantly, pretreatment-posttreatment comparisons indicated that CBT was superior to ED and the no-treatment control condition. That is, only in the CBT condition significant reductions of anxiety disorders symptoms, trait anxiety, and depression were observed. These findings can be taken as further evidence for the efficacy of CBT in the treatment of childhood anxiety disorders.     

Neurocognitive correlates of anxiety disorders in children: a preliminary report

Children with anxiety disorders have been suggested to possess a specific cognitive scheme that underscores negative information and leads to the formation of a negative view of themselves and of the world. The aim of the present study was to assess the neuropsychological processes of children and adolescents with anxiety disorders, as compared to healthy matched controls. Nineteen children (6-18 years) with anxiety disorders and 14 age-matched healthy controls participated in the study. Both groups scored within normal range on the Wechsler Intelligence Scale for Children-Revised (WISC-R). All children underwent neuropsychological assessment with the California Verbal Learning Test (CVLT) (Verbal Processing), the Rey-Osterrieth Complex Figure test (ROCF) (Nonverbal Processing), and the Wisconsin Card Sorting Test (WCST) (Executive Functions). The anxiety group scored lower than the control group on all measures of the CVLT and had a significantly greater number of errors, perseverative responses, and incorrect answers after negative feedback on the WCST. No differences were detected for the ROCF. We conclude that in children and adolescents, anxiety disorders may be associated with lowered linguistic abilities and cognitive flexibility, as measured by neuropsychological paradigms. Anxiety does not appear to be associated with nonverbal processes.     

Pregnancy complications associated with childhood anxiety disorders

To determine whether perinatal complications predict childhood anxiety disorders independently of parental psychopathology, we systematically assessed pregnancy and delivery complications and psychopathology in a sample of children (mean age=6.8 years) at high risk for anxiety disorders whose parents had panic disorder with (n=138) or without (n=26) major depression, and in contrast groups of offspring of parents with major depression alone (n=47), or no mood or anxiety disorders (n=95; total N=306). Psychopathology in the children was assessed by structured diagnostic interviews (K-SADS), and pregnancy and delivery complications were assessed using the developmental history module of the DICA-P. Number of pregnancy complications predicted multiple childhood anxiety disorders independently of parental diagnosis (odds ratio=1.6 [1.4-2.0]). This effect was accounted for by heavy bleeding requiring bed-rest, hypertension, illness requiring medical attention, and serious family problems. Associations remained significant when lifetime child mood and disruptive behavior disorders were covaried. Results suggest that prenatal stressors may increase a child's risk for anxiety disorders beyond the risk conferred by parental psychopathology alone.     

Familial predictors of treatment outcome in childhood anxiety disorders

OBJECTIVE: To determine whether family factors are predictive of outcome in children with anxiety disorders who are receiving cognitive-behavioral treatment. METHOD: Participants were 61 children aged 8 to 12 years (mean = 10.0, SD = 1.4) with Axis I anxiety disorders who had been referred to a large Toronto children's hospital. Parents and children completed measures assessing family functioning, parenting stress, parental frustration, and parental psychopathology before and after treatment. Outcome measures included clinician-rated functioning (Children's Global Assessment Scale) and self- and parent-rated anxiety (Revised Children's Manifest Anxiety Scale). RESULTS: Child ratings of family dysfunction and frustration predicted clinician-rated improvement (total R2 = 0.28, p < .001). Mother and father reports of family dysfunction, and maternal parenting stress, predicted mother-rated child improvement (total R2 = 0.18, p < .01). Father-rated somatization and child reports of family dysfunction and frustration predicted child-rated improvement (total R2 = 0.25, p < .001). Several family factors improved with treatment. CONCLUSION: Family dysfunction appears to be related to less favorable treatment outcome in children with anxiety disorders.     

Early childhood predictors of adult anxiety disorders.

This paper considers the influence of temperamental factors on the development of anxious symptoms in children and adolescents. About 20 percent of healthy children are born with a temperamental bias that predisposes them to be highly reactive to unfamiliar stimulation as infants and to be fearful of or avoidant to unfamiliar events and people as young children. Experiences act on this initial temperamental bias and, by adolescence, about one-third of this group is likely to show signs of serious social anxiety. These children are also likely to have one or more biological features, including a sympathetically more reactive cardiovascular system, asymmetry of cortical activation in EEG favoring a more active right frontal area, more power in the EEG in the higher frequency range, and a narrower facial skeleton. The data imply that this temperamental bias should be conceptualized as constraining the probability of developing a consistently fearless and spontaneous profile rather than as determining an anxious or introverted phenotype.     

Fluvoxamine pharmacotherapy of anxiety disorders in later life: preliminary open-trial data

The authors present data from an open trial of fluvoxamine (median daily dosage: 200 mg) in the treatment of generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder in 19 older outpatients (mean age = 66.8). Of the 12 subjects completing the 21-week trial, 8 achieved a good response (50% reduction in symptom measures) and 7 were rated as much or very much improved. Fluvoxamine pharmacotherapy also had a significant effect in reducing comorbid depressive symptoms and in increasing levels of functioning. These data support the effectiveness of fluvoxamine in older subjects with anxiety disorders (particularly generalized anxiety disorder) and warrant further double-blind, placebo-controlled evaluation.     

Pathological worry, anxiety disorders and the impact of co-occurrence with depressive and other anxiety disorders

The Penn State Worry Questionnaire (PSWQ) was administered to 123 outpatients with principal diagnoses of generalized anxiety disorder (GAD), social anxiety disorder (SAD), panic disorder with agoraphobia, and panic disorder without agoraphobia (PD) to examine the specificity of pathological worry for GAD. The mean PSWQ scores in patients with GAD and SAD were significantly higher than the mean PSWQ scores in patients with PD, while not differing significantly in the subgroups without any co-occurring depressive or anxiety disorders. Patients with any co-occurring depressive or anxiety disorder scored significantly higher on the PSWQ. In a logistic regression analysis, high PSWQ scores independently predicted only GAD and SAD diagnoses. The study suggests that pathological worry is specific not only for GAD, and indicates that a significant relationship exists between pathological worry, GAD and SAD, and that depressive and anxiety disorders co-occurrence increases levels of pathological worry in patients with anxiety disorders.     

Attentional bias towards angry faces in childhood anxiety disorders

Objective

To examine attentional bias towards angry and happy faces in 8-12 year old children with anxiety disorders (n = 29) and non-anxious controls (n = 24).

Method

Children completed a visual-probe task in which pairs of angry/neutral and happy/neutral faces were displayed for 500 ms and were replaced by a visual probe in the spatial location of one of the faces.

Results

Children with more severe anxiety showed an attentional bias towards angry relative to neutral faces, compared with anxious children who had milder anxiety and non-anxious control children, both of whom did not show an attentional bias for angry faces. Unexpectedly, all groups showed an attentional bias towards happy faces relative to neutral ones.

Conclusions

Anxiety symptom severity increases attention to threat stimuli in anxious children. This association may be due to differing threat appraisal processes or emotion regulation strategies.