Effects of Cognitive-Behavioral Therapy on Anxiety in Children with Autism Spectrum Disorders: A Randomized Controlled Trial

We compared the effects of a 16-week Cognitive-Behavioral Therapy (CBT) program and a Social Recreational (SR) program on anxiety in children with Autism Spectrum Disorders (ASD). Seventy children (9–16 years old) were randomly assigned to either of the programs (n _CBT = 36; n _SR = 34). Measures on child’s anxiety using the Spence Child Anxiety Scale—Child (SCAS-C) and the Clinical Global Impression—Severity scale (CGI-S) were administered at pre-, post-treatment, and follow-ups (3- and 6-month). Children in both programs showed significantly lower levels of generalized anxiety and total anxiety symptoms at 6-month follow-up on SCAS-C. Clinician ratings on the CGI-S demonstrated an increase in the percentage of participants rated as “Normal” and “Borderline” for both programs. Findings from the present study suggest factors such as regular sessions in a structured setting, consistent therapists, social exposure and the use of autism-friendly strategies are important components of an effective framework in the management of anxiety in children and adolescents with ASD.     

Is social anxiety disorder in childhood associated with developmental deficit/delay?

Children with social anxiety disorder (SAD) have been reported to display reduced social skills. Less attention has been paid to whether neurodevelopmental deficits/delays (NDD’s) in language and motor function may contribute to their impaired social skills. The present study aimed to assess the extent of language and motor impairment in children with SAD. A population-based screened sample consisting of 150 children (11–12 years) was assessed with a diagnostic interview (Kiddie-SADS), the Wechsler Abbreviated Scale of Intelligence (WASI) and the Motor Assessment Battery for Children (MABC). Test results were compared across five diagnostic groups: SAD (n = 29); ADHD (n = 23); SAD and ADHD (n = 6); “other disorder” (n = 44) and “no disorder” (n = 48). Delays in language and motor development as reported by mother were also investigated. Verbal IQ and motor skills were reduced and maternally reported delay was more frequent in the SAD group compared to the “other disorder” and “no disorder” group.     

Temperament and character among Korean children and adolescents with anxiety disorders

The purpose of this study was to evaluate the temperament and character of children and adolescents with anxiety disorders in samples from Korean community. The study subjects were children and adolescents diagnosed with social phobia (n = 66), separation anxiety disorder (n = 47), specific phobia (n = 415), and obsessive–compulsive disorder (n = 42) with the diagnostic interview schedule for children, version IV (DISC-IV) in representative community samples. Among these, we excluded other psychiatric disorder comorbid samples, with the exception of externalizing disorders. We assessed the subjects of each anxiety group using the junior temperament and character inventory (JTCI). Social phobias were significantly associated with high harm avoidance and low self-directedness on the JTCI. The association of specific phobias with high harm avoidance, and obsessive–compulsive disorder with low self-directedness was also significant. Separation anxiety disorder was not associated with any temperament and character on the JTCI. Children and adolescents with anxiety disorders have different temperaments and character profiles in accordance with diagnostic groups, which implies the specific pathophysiological mechanism of each anxiety disorder.     

Thought-Action Fusion in Childhood: Measurement,Development, and Association with Anxiety,Rituals and Other Compulsive-like Behaviors

A new inventory assessing thought-action fusion (TAF) in children is presented. We explore the psychometric properties of this instrument and examine the associations between TAF, ritualistic and compulsive-like behavior (CLB) and anxiety. Three hundred thirteen children ages 7–14 (M = 10.16, SD = 1.92) representing six grades (grouped into three grade levels (grades 2–3, 4–5, and 6–7) completed the Thought-action Fusion Inventory for Children (TAFIC) and the Child Revised Manifest Anxiety Scale. One hundred thirty-five parents or guardians completed the Childhood Routines Inventory. Results revealed high internal consistency in the TAFIC (Cronbach’s α = .92). TAF scores changed with age: Older children reported less TAF than younger children. Stepwise multiple regression analyses revealed that: (1) physiological anxiety predicted CLB in early childhood; (2) TAF predicted CLB in older children. Consistent with structural developmental theories, TAF changes throughout development, but plays a role in the normative regulation of affective states, as well as in the development of ritualistic compulsive like behavior in children.     

The direction of effects between perceived parental behavioral control and psychological control and adolescents’ self-reported GAD and SAD symptoms

This study examined the direction of effects and age and sex differences between adolescents’ perceptions of parental behavioral and psychological control and adolescents’ self-reports of generalized anxiety disorder (GAD) and separation anxiety disorder (SAD) symptoms. The study focused on 1,313 Dutch adolescents (early-to-middle cohort n = 923, 70.3%; middle-to-late cohort n = 390, 29.7%) from the general population. A multi-group, structural equation model was employed to analyze the direction of the effects between behavioral control, psychological control and GAD and SAD symptoms for the adolescent cohorts. The current study demonstrated that a unidirectional child effect model of the adolescents’ GAD and SAD symptoms predicting parental control best described the data. Additionally, adolescent GAD and SAD symptoms were stronger and more systematically related to psychological control than to behavioral control. With regard to age–sex differences, anxiety symptoms almost systematically predicted parental control over time for the early adolescent boys, whereas no significant differences were found between the late adolescent boys and girls.     

Separation Anxiety Avoidance Inventory-Child and Parent Version: Psychometric Properties and Clinical Utility in a Clinical and School Sample

The psychometric properties and clinical utility of the Separation Anxiety Avoidance Inventory, child and parent version (SAAI-C/P) were examined in two studies. The aim of the SAAI, a self- and parent-report measure, is to evaluate the avoidance relating to separation anxiety disorder (SAD) situations. In the first study, a school sample of 384 children and their parents (n = 279) participated. In the second study, 102 children with SAD and 35 children with other anxiety disorders (AD) were investigated. In addition, 93 parents of children with SAD, and 35 parents of children with other AD participated. A two-factor structure was confirmed by confirmatory factor analysis. The SAAI-C and SAAI-P demonstrated good internal consistency, test–retest reliability, as well as construct and discriminant validity. Furthermore, the SAAI was sensitive to treatment change. The parent–child agreement was substantial. Overall, these results provide support for the use of the SAAI-C/P version in clinical and research settings.     

A Multitrait–Multimethod Analysis of the Construct Validity of Child Anxiety Disorders in a Clinical Sample

The present study examines the construct validity of separation anxiety disorder (SAD), social phobia (SoP), panic disorder (PD), and generalized anxiety disorder (GAD) in a clinical sample of children. Participants were 174 children, 6 to 17 years old (94 boys) who had undergone a diagnostic evaluation at a university hospital based clinic. Parent and child ratings of symptom severity were assessed using the Multidimensional Anxiety Scale for Children (MASC). Diagnostician ratings were obtained from the Anxiety Disorders Interview Schedule for Children and Parents (ADIS: C/P). Discriminant and convergent validity were assessed using confirmatory factor analytic techniques to test a multitrait–multimethod model. Confirmatory factor analyses supported the current classification of these child anxiety disorders. The disorders demonstrated statistical independence from each other (discriminant validity of traits), the model fit better when the anxiety syndromes were specified than when no specific syndromes were specified (convergent validity), and the methods of assessment yielded distinguishable, unique types of information about child anxiety (discriminant validity of methods). Using a multi-informant approach, these findings support the distinctions between childhood anxiety disorders as delineated in the current classification system, suggesting that disagreement between informants in psychometric studies of child anxiety measures is not due to poor construct validity of these anxiety syndromes.     

Comparison of sleep problems in children with anxiety and attention deficit/hyperactivity disorders

This cross-sectional case–control study compared sleep problems in consecutively referred children aged 7–13 years meeting DSM-IV criteria for anxiety disorder, attention deficit/hyperactivity disorder (ADHD), comorbid anxiety disorder and ADHD, and a group of control children of similar age and gender. Diagnoses were assessed with the Kiddie-SADS PL interview, parent form, and the sleep problems with a standardized sleep questionnaire, the Children’s Sleep Habits Questionnaire (CSHQ), as reported by the mother. A total of 141 children were included (anxiety disorder (n = 41), ADHD (n = 39), comorbid condition (n = 25), controls (n = 36)). Children in the clinical groups had more sleep problems than controls. Children with anxiety disorders and children with comorbid condition were reported to have more sleep problems than children with ADHD alone. Night waking was associated with comorbid anxiety disorder and ADHD. Bedtime resistance was associated with anxiety disorder, while daytime sleepiness affected all clinical groups. Clinical management of children with ADHD and anxiety disorders needs to include assessment of sleep problems.     

Social anxiety disorder in 11–12-year-old children

Objective To investigate the level of diagnostic and discriminative accuracy of The Social Anxiety Scale for Children – Revised (SASC-R) for identifying social anxiety disorder (SAD) in a community-based sample of 11–12 year-old children. Parent–child diagnostic agreement was also examined. Method A questionnaire including SASC-R and items on impulsive behavior was sent to a population based sample of children, born in 1992. A total of 2568 parents returned their questionnaires (rr: 70%), and 1297 (51%) consented to further participation. An index group [50 high-scoring children on social anxiety (SA-group)] and two contrast groups [(50 high-scoring children on impulsive behavior (Imp-group) and 50 low-scoring children on SA and Imp, (Ls-group)] were selected for participation. Results SAD was assigned 35 (23%) of 150 children; 28 (80%) from the SA-group; 7 (20%) from the Imp- group and 0 from the Ls-group. The SASC-R showed relatively high discriminative accuracy for SAD, but was also influenced by other diagnoses. Mother–child agreement was fair (κ=0.46), and mother-only diagnoses were frequent. Both child and parent information are important when diagnosing SAD in this age group.     

Assessing Defense Structure in School-Age Children Using the Response Evaluation Measure-71-Youth Version (REM-Y-71)

This study used the Response Evaluation Measure-Youth (REM-Y-71), a self-report measure of 21 defense reactions, among school-age children. Participants were elementary and middle school students (n=290; grades 3–8; age range: 8–15; mean=11.73). Factor analysis revealed a 2-factor defense structure consistent with structure among high school and adult samples. The composite REM-Y defense scores for each factor were significant predictors of social desirability, using the Children’s Defensiveness Scale (CDS); anxiety, using the State-Trait Anxiety Inventory for Children (STAIC); and psychosocial functioning. This study represents the first cross-sectional empirical analysis of overall defense structure and use among children and early adolescents.     

The characteristics of the comorbidity between social anxiety and separation anxiety disorders in adult patients

Abstract

Objective: In the present study, we compared social anxiety disorder (SAD) patients with (n?=?31) and without childhood and adulthood separation anxiety disorder (SeAD) (n?=?50) with respect to suicidal behavior, avoidant personality disorder (AvPD), other anxiety disorders (ADs), and major depression as well as some sociodemographic variables.

Methods: In assessment of patients, we used Structured Clinical Interview for Separation Anxiety Symptoms, childhood and adulthood Separation Anxiety Symptom Inventories, Liebowitz Social Anxiety Scale, The SCID-II Avoidant Personality Disorder Module, Beck Depression Inventory, and Beck Scale for Suicidal Ideation.

Results: SAD patients with SeAD had higher comorbidity rates of AvPD, other lifetime ADs and panic disorder, and current major depression than those without SeAD. The current scores of SAD, depression, and suicide ideation and the mean number of AvPD symptoms were significantly higher in comorbid group compared to pure SAD subjects. The SAD and SeAD scores had significant associations with current depression, suicide ideations, and AvPD. The mean number of AvPD criteria and the current severity of depression were significantly associated with the comorbidity between SAD and SeAD.

Conclusion: Our findings might indicate that the comorbidity of SeAD with SAD may increase the risk of the severity of AvPD and current depression.     

What are the odds of anxiety disorders running in families? A family study of anxiety disorders in mothers,fathers, and siblings of children with anxiety disorders

This family study investigated (1) the prevalence of anxiety disorders (ADs) in parents and siblings of children (n = 144) aged 8–18 years with ADs compared to control children (n = 49), and (2) the specificity of relationships between child–mother, child–father, and child–sibling ADs. Clinical interviews were used to assess current DSM-IV-TR ADs in children and siblings, and lifetime and current ADs in parents. Results showed that children with ADs were two to three times more likely to have at least one parent with current and lifetime ADs than the control children (odds ratio (OR) = 2.04 and 3.14). Children with ADs were more likely to have mothers with current ADs (OR = 2.51), fathers with lifetime ADs (OR = 2.84), but not siblings with ADs (OR = 0.75). Specific relationships between mother–child ADs were found for Social Anxiety Disorder (SAD, OR = 3.69) and Generalized Anxiety Disorder (OR = 3.47). Interestingly, all fathers and siblings with SAD came from families of children with SAD. Fathers of children with SAD were more likely to have lifetime ADs themselves (OR = 2.86). Findings indicate that children with ADs more often have parents with ADs, and specifically SAD is more prevalent in families of children with SAD. Influence of parent’s (social) ADs should be considered when treating children with ADs.     

Do Youth with Separation Anxiety Disorder Differ in Anxiety Sensitivity From Youth with Other Anxiety Disorders?

Studies on the relationship between separation anxiety disorder (SAD) in childhood and panic disorder (PD) in adolescence and adulthood have yielded results which suggest a common underlying vulnerability for both disorders. In this study, we examined whether one such possible vulnerability—anxiety sensitivity—differed for youth diagnosed with SAD versus other anxiety disorders. Anxiety sensitivity was assessed using the Childhood Anxiety Sensitivity Index (CASI) in 315 clinic-referred youth (ages 6–17, 113 girls). 145 children (46%) were diagnosed with one or more primary anxiety disorder, including SAD (n?=?22), generalized anxiety (GAD) (n?=?79), social anxiety (SocA) (n?=?55), and specific phobia (SP) (n?=?45). Children with SAD reported higher levels of anxiety sensitivity and fears of physical symptoms than children with SP and SocA, but not children with GAD. We speculate that children who have SAD and GAD and high anxiety sensitivity may be more vulnerable to develop PD.     

Development and Preliminary Psychometric Evaluation of the Children’s Saving Inventory

This study reports on the development and initial psychometric properties of the Children’s Saving Inventory (CSI), a parent-rated measure designed to assess child hoarding behaviors. Subjects included 123 children and adolescents diagnosed with primary Obsessive–Compulsive Disorder (OCD) and their parents. Trained clinicians administered the Children’s Yale-Brown Obsessive–Compulsive Scale (CY-BOCS), items assessing Family Accommodation and the Clinical Global Impressions—Severity index. Parents completed the CSI, Child Obsessive–Compulsive Impact Scale (COIS)—Parent Version and Child Behavior Checklist. Youth completed the COIS—Child Version, Obsessive–Compulsive Inventory Child Version (OCI-CV), Multidimensional Anxiety Scale for Children, and Children’s Depression Inventory—Short Form. A four factor solution was identified; factors were named Discarding, Clutter, Acquisition, and Distress/Impairment. Internal consistency for the CSI Total and factor scores were good. One-week test–retest reliability (n = 31) from a random subsample was excellent. Known groups validity was supported vis-à-vis higher CSI scores for those endorsing hoarding on the CY-BOCS Symptom Checklist. Convergent and discriminant validity was evidenced by weak relationships with OCI-CV Checking and Contamination factors but strong relationships with the OCI-CV Hoarding factor and with hoarding obsession/compulsions on the CY-BOCS. These findings provide initial support for the reliability and validity of the CSI for the assessment of hoarding behaviors among youth with OCD. Future studies are needed to extend these findings to non-OCD samples of youth.     

Emotional Reasoning and Parent-Based Reasoning in Non-Clinical Children,and Their Prospective Relationships with Anxiety Symptoms

Emotional and parent-based reasoning refer to the tendency to rely on personal or parental anxiety response information rather than on objective danger information when estimating the dangerousness of a situation. This study investigated the prospective relationships of emotional and parent-based reasoning with anxiety symptoms in a sample of non-clinical children aged 8–14 years (n = 122). Children completed the anxiety subscales of the Revised Children’s Anxiety and Depression Scale (Muris et al. Clin Psychol Psychother 9:430–442, 2002) and provided danger ratings of scenarios that systematically combined objective danger and objective safety information with anxiety-response and positive-response information. These measurements were repeated 10 months later (range 8–11 months). Emotional and parent-based reasoning effects emerged on both occasions. In addition, both effects were modestly stable, but only in case of objective safety. Evidence was found that initial anxiety levels were positively related to emotional reasoning 10 months later. In addition, initial levels of emotional reasoning were positively related to anxiety at a later time, but only when age was taken into account. That is, this relationship changed with increasing age from positive to negative. No significant prospective relationships emerged between anxiety and parent-based reasoning. As yet the clinical implications of these findings are limited, although preliminary evidence indicates that interpretation bias can be modified to decrease anxiety.     

A Randomized Controlled Trial of the Child Anxiety Multi-Day Program (CAMP) for Separation Anxiety Disorder

While the efficacy of cognitive behavior therapy for childhood anxiety disorders, including separation anxiety disorder (SAD), has been established, tailoring such treatments to particular interests and needs may enhance uptake of evidence-based interventions. The current investigation evaluates the feasibility and preliminary efficacy of an intensive, cognitive-behavioral intervention for girls with SAD provided within the novel context of a 1-week camp-like setting, the Child Anxiety Multi-Day Program (CAMP). Twenty-nine female children aged 7–12 with a principal diagnosis of SAD were randomized to immediate CAMP treatment (n = 15) or waitlist (i.e., delayed treatment; n = 14) condition during the course of this randomized controlled trial. Children in the immediate treatment group evidenced significant reductions in SAD severity, functional impairment, and parent report of child anxiety symptoms relative to the waitlist condition. The intervention’s positive therapeutic response suggests one possible delivery model for surmounting difficulties faced in the dissemination of weekly treatments for SAD.     

Psychiatric disorders in children and adolescents presenting with unexplained chronic pain: what is the prevalence and clinical relevancy?

The prevalence of psychiatric disorders among children with unexplained chronic pain (UCP) is high in unselected populations and pain clinics, yet the clinical relevance of these disorders in children referred for unexplained pain is not known. This study assessed the prevalence of clinically relevant psychiatric disorders and their predictors in children referred to a children’s hospital for UCP. Psychiatry morbidity was assessed in 134 children, aged 8–17 years, using the Diagnostic Interview Schedule for Children–parent version (DISC-P) and the Semi-structured Clinical Interview for Children and Adolescents (SCICA). Clinical relevance was determined using a maladjustment criterion of 61 or lower on the Children’s Global Assessment Scale (CGAS). Pain parameters were measured with standardized questionnaires. Results were analysed by logistic regression. According to the DISC-P, 21% of the children had clinically relevant psychiatric disorders, predominantly anxiety disorders (18%). According to the SCICA, 28% of the children had clinically relevant psychiatric disorders, consisting of anxiety, affective, and disruptive disorders (12, 19, and 9%, respectively). Headache (compared to musculoskeletal pain) was an independent clinical predictor of psychiatric morbidity (OR = 3.10; 95% CI 1.07–8.92, p = 0.04/adjusted OR 2.99; 95% CI 1.02–8.74, p = 0.04). In conclusion, clinically relevant psychiatric disorders are common among children and adolescents referred for UCP. Adding a child psychiatrist assessment, treatable affective and disruptive disorders become identifiable. Children with an additional risk are those presenting with headache.     

Randomized Controlled Trial for Early Intervention for Autism: A Pilot Study of the Autism 1-2-3 Project

We piloted a 2-week “Autism-1-2-3” early intervention for children with autism and their parents immediately after diagnosis that targeted at (1) eye contact, (2) gesture and (3) vocalization/words. Seventeen children were randomized into the Intervention (n = 9) and Control (n = 8) groups. Outcome measures included the Autism Diagnostic Observation Schedule, Ritvo-Freeman Real Life Rating Scale, Symbolic Play Test, and Parenting Stress Index. Children with autism improved in language/communication, reciprocal social interaction, and symbolic play. Parents perceived significant improvement in their children’s language, social interaction, and their own stress level. This intervention can serve as short-term training on communication and social interaction for children with autism, and reduce the stress of their parents during the long waiting time for public health services.     

Social Anxiety Scale for Adolescents (SAS-A): Measuring Social Anxiety Among Finnish Adolescents

The aim of this study was to investigate symptoms of social anxiety and the psychometric properties of the Social Anxiety Scale for Adolescents (SAS-A) among Finnish adolescents, 13–16 years of age. Study 1 (n = 867) examined the distribution of SAS-A scores according to gender and age, and the internal consistency and factor structure of the SAS-A. In a subsample (n = 563; Study 2) concurrent and discriminant validity of the SAS-A were examined relative to the Social Phobia Inventory and the Beck Depression Inventory. Test–retest stability was examined over a 30-month period by repeated measures every 6 months in another subsample (n = 377; Study 3). Results mostly revealed no gender differences in social anxiety, except that boys reported more general social avoidance and distress than girls. Older adolescents (14–16-year-olds) reported higher social anxiety than younger adolescents (12–13-year-olds). Internal consistency for the SAS-A was acceptable for both genders and for all three SAS-A subscales. Confirmatory factor analysis replicated the original 18-item three-factor structure of the SAS-A, accounting for 61% of the variance between items. Evidence for concurrent and discriminant validity was found. Test–retest stability over 6 months was satisfactory. Results support the reliability and validity of the Finnish adaptation of the SAS-A, and further indicate that gender differences in adolescents’ social anxiety may vary across Western countries.     

The correlates and consequences of early appearing social anxiety in young children

Social anxiety is the fear of social situations and being negatively evaluated by others. Most previous studies of childhood social anxiety have employed clinical samples of children aged 10 years and older. The current study explored the correlates of social anxiety in an unselected sample of young children. Participants were n = 178 elementary school children in grade 2 (aged 7–8 years). Children were individually administered the Social Anxiety Scale for Children-Revised (SASC-R), as well as measures of socio-emotional adjustment. Teachers completed measures of children's socio-emotional problems and school adjustment. Results indicated that social anxiety was positively associated with self-reported loneliness, school avoidance, and internalizing coping, and negatively related to school liking. However, social anxiety was mostly unrelated to teacher-rated outcomes. Findings are discussed in terms of use of the SASC-R for this type of population and reasons for the disparity between child and teacher reports of adjustment outcomes.