Assessment and treatment of anxiety disorders in children and adolescents

Parents' Perspectives of an Arts Engagement Program Supporting Children with Anxiety

Arts engagement programs (AEPs) are non-clinical, structured programs led by artists and educators to support mental health and wellbeing. While evidence demonstrates positive mental health outcomes in adult AEPs, studies of childhood AEPs remain sparse. We created a gallery-based AEP (Culture Dose for Kids) for children with anxiety based on a successful arts engagement pilot for adults with depression. We questioned whether our tailored-for-children adult program would effectively and feasibly support children's mental health. Through parents' perspectives and feedback, this study tested the program's acceptability, feasibility, and effectiveness with children with anxiety. Quantitative and qualitative measures were used to determine whether the program was an effective and acceptable mental health support for children with anxiety. Our findings revealed that the program positively and significantly impacted parental perceptions of their child's anxiety. Our findings illustrate depictions of improved mood, confidence, and sense of empowerment in the child, qualities associated with resilience and mental wellbeing. Open-ended activities provided opportunities for connection, creativity, and experimentation-sources of strength for improving mental health. This study adds to the small but growing evidence base supporting the role of arts-based community care in youth mental health and wellbeing.

Using evidence-based psychological approaches to accommodation anomalies

INTRODUCTION

Accommodation anomalies are frequently caused or exacerbated by psychological problems such as anxiety. Patients share many features with those with other anxiety based somatic symptoms such as stomach-ache, palpitations and headaches. They can be difficult to treat, and the ophthalmic literature rarely goes beyond diagnosis and ocular treatment. This study reports characteristics and outcomes of a short case series of patients with accommodation spasms and weaknesses assessed objectively, and outlines a psychological approach to treatment.

METHODS

23 patients (13 severe accommodative weakness or "paralysis," 10 accommodative spasm) aged between 8-30 years, were referred to our laboratory after diagnosis by their referring clinician and exclusion of pathology or drug-related causes. Their accommodation and convergence were assessed objectively with a laboratory photorefractive method, as well as by conventional orthoptic testing and dynamic retinoscopy. All interactions with the patients used an evidence-based psychological approach, to give them insight into how stress and anxiety can cause or exacerbate eye symptoms and help them to break a vicious cycle of anxiety and risk of deterioration.

RESULTS

83% were female and 57% had previously diagnosed anxiety or dyslexia (with many more acknowledging being "worriers"). Inconsistency of responses was the rule and all showed normal responses at some time during their visit. Responses were poorly related to the visual stimuli presented and objective responses often differed from subjective. Dissociation between convergence and accommodation was more common, compared to our large, previously reported, control groups. No participant had true paralysis of accommodation. Responses often improved dramatically within one session after discussion and explanation of the strong relationship between anxiety and accommodative anomalies. None have returned for further advice or treatment.

CONCLUSIONS

Our approach explicitly addresses psychological factors in causing, or worsening, accommodation (and co-existing convergence) anomalies. Many of these patients do not realize that a certain amount of blur is normal in everyday life. Ocular symptoms are often a sign of anxiety, not the primary problem. By recognizing this, patients can be helped to address the triggering issues and symptoms often subside or resolve spontaneously. Well-meaning professionals, offering only ocular treatments, can deflect attention away from the real cause and can unwittingly be making things worse.

Screening for Anxiety in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Anxiety disorder, a common mental health condition in the US, comprises a group of related conditions characterized by excessive fear or worry that present as emotional and physical symptoms. The 2018-2019 National Survey of Children's Health found that 7.8% of children and adolescents aged 3 to 17 years had a current anxiety disorder. Anxiety disorders in childhood and adolescence are associated with an increased likelihood of a future anxiety disorder or depression.

OBJECTIVE

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for anxiety disorders in children and adolescents. This is a new recommendation.

POPULATION

Children and adolescents 18 years or younger who do not have a diagnosed anxiety disorder or are not showing recognized signs or symptoms of anxiety.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that screening for anxiety in children and adolescents aged 8 to 18 years has a moderate net benefit. The USPSTF concludes that the evidence is insufficient on screening for anxiety in children 7 years or younger.

RECOMMENDATION

The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in children 7 years or younger. (I statement).

Initiation of antidepressant use among refugee and Swedish-born youth after diagnosis of a common mental disorder: findings from the REMAIN study

PURPOSE

The objective of this study was to compare the initiation and type of antidepressant use between refugees and matched Swedish-born youth after a diagnosis of a common mental disorder (CMD) and assess sociodemographic and clinical factors associated with the initiation.

METHODS

The study cohort included youth aged 16-25 years, with an incident diagnosis of CMD based on specialized health care registers in Sweden 2006-2016, without prior antidepressant use during 1 year. One Swedish-born person was matched for each identified refugee youth (N = 3936 in both groups). Initiation of antidepressant use and factors associated with the initiation, were investigated with logistic regression yielding Odds ratios, OR, and 95% Confidence Intervals, CI.

RESULTS

Refugees were less likely to initiate antidepressant use compared with Swedish-born (40.5% vs. 59.6%, adjusted OR 0.43, 95% CI 0.39-0.48). Selective serotonin reuptake inhibitors (SSRIs) were less frequently initiated for refugees than Swedish-born (71.2% vs. 81.3% of initiations, p < 0.0001). Sertraline was the most commonly initiated antidepressant both for refugees (34.3%) and Swedish-born individuals (40.3%). Among refugees, factors associated with increased odds of antidepressant initiation were previous use of anxiolytics or hypnotics, previous sickness absence of < 90 days, cancer and older age (OR range 1.07-2.72), and less than 5 years duration of residency in Sweden was associated with decreased odds (OR 0.76, 95% CI 0.63-0.92).

CONCLUSION

Young refugees with a CMD seem to initiate antidepressants in general and those most effective considerably less often than their Swedish-born counterparts.

Variations in Parent and Teacher Ratings of Internalizing, Externalizing, Adaptive Skills, and Behavioral Symptoms in Children with Selective Mutism

Selective mutism (SM) is an anxiety disorder that impacts communication. Children with SM present concerns to parents and teachers as they consistently do not speak in situations where there is an expectation to speak, such as at school, but speak in other settings where they feel more comfortable, such as at home. The purpose of this study was to investigate the relationship between parents’ and teachers’ perceptions of children with SM on behavioral rating scales and language measures. Forty-two children (22 boys and 20 girls, ranging from 2.4 to 13.8 years, with a mean age of 7.1 years) took part in this study. Parents and teachers completed the Behavior Assessment System for Children (BASC-3) measuring internalizing behaviors, externalizing behaviors, adaptive skills, and behavioral symptoms. Frequency of speaking and language abilities were also measured. Parents and teachers both identified withdrawal as the most prominent feature of SM but parents saw children as significantly more withdrawn than did their teachers. Both rated children similarly at-risk on scales of functional communication and social skills. Higher adaptive skills (including functional communication and social skills) were positively correlated with vocabulary, narrative language, and auditory serial memory according to teachers. Parent and teacher rating scales provide valuable information for diagnosis and progress monitoring. Children with SM can benefit from mental health practitioners who can identify and enhance their emotional well-being.

Collaborative care model for treatment of persistent symptoms after concussion among youth (CARE4PCS-II): Study protocol for a randomized, controlled trial

Background

Currently, there is limited evidence to guide intervention and service delivery coordination for youth who suffer a concussion and subsequently experience persistent post-concussive symptoms (PCS) (Lumba-Brown et al. JAMA Pediatr 172(11):e182853, 2018; Lumba-Brown A et al. JAMA Pediatr 172(11):e182847, 2018). We have developed a collaborative care intervention with embedded cognitive-behavioral therapy, care management, and stepped-up psychotropic medication consultation to address persistent PCS and related psychological comorbidities. The CARE4PCS-II study was designed to assess whether adolescents with persistent symptoms after sports-related concussion will demonstrate better outcomes when receiving this collaborative care intervention compared to a usual care (control) condition.

Methods/design

This investigation is a randomized comparative effectiveness trial to receive intervention (collaborative care) or control (usual care). Two hundred sports-injured male and female adolescents aged 11–18 years with three or more post-concussive symptoms that persist for at least 1 month but less than 9 months after injury will be recruited and randomized into the study. The trial focuses on the effects of the intervention on post-concussive, depressive, and anxiety symptoms measured 3, 6, and 12 months after baseline.

Discussion

The CARE4PCS II study is a large comparative effectiveness trial targeting symptomatic improvements in sports injured adolescents after concussion. The study is unique in its adaptation of the collaborative care model to a broad spectrum of primary care, sports medicine, and school settings. The investigation incorporates novel elements such as the delivery of CBT through HIPAA complaint video conferenceing technology and has excellent widespread dissemination potential should effectiveness be demonstrated.

Trial registration

ClinicalTrials.gov, NCT03034720. Registered on January 27, 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3662-3) contains supplementary material, which is available to authorized users.

Increasing Access to Mental Health Care With Breathe, an Internet-Based Program for Anxious Adolescents: Study Protocol for a Pilot Randomized Controlled Trial

Background

There is a demand to make first-line treatments, including cognitive behavioural therapy (CBT) for adolescent anxiety disorders, more widely available. Internet-based CBT is proposed to circumvent access and availability barriers and reduce health care system costs. Recent reviews suggest more evidence is needed to establish the treatment effects of Internet-based CBT in children and adolescents and to determine related economic impacts.

Objective

This pilot trial aims to collect the necessary data to inform the planning of a full-scale RCT to test the effectiveness of the Internet-based CBT program Breathe (Being Real, Easing Anxiety: Tools Helping Electronically).

Methods

We are conducting a 27-month, 2-arm parallel-group, pilot randomized controlled trial (RCT). Outcomes will inform the planning of a full-scale RCT aimed to test the effectiveness of Internet-based CBT with a population of adolescents with moderate to mild anxiety problems. In the pilot RCT we will: (1) define a minimal clinically important difference (MCID) for the primary outcome measure (total anxiety score using the Multidimensional Anxiety Scale for Children); (2) determine a sample size for the full-scale RCT; (3) estimate recruitment and retention rates; (4) measure intervention acceptability to inform critical intervention changes; (5) determine the use of co-interventions; and (6) conduct a cost-consequence analysis to inform a cost-effectiveness analysis in the full-scale RCT. Adolescents aged 13-17 years seeking care for an anxiety complaint from a participating emergency department, mobile or school-based crisis team, or primary care clinic are being screened for interest and eligibility. Enrolled adolescents are being randomly allocated to either 8 weeks of Internet-based CBT with limited telephone and e-mail support, or a control group with access to a static webpage listing anxiety resources. Adolescents are randomly assigned using a computer generated allocation sequence. Data are being collected at baseline, treatment completion, and at a 3-month follow-up.

Results

Currently, adolescents are being enrolled in the study. Enrolment is taking place between March 2014 and February 2016; data collection will conclude May 2016. We expect that analysis and results will be available by August 2016.

Conclusions

In many communities, the resources available for front-line anxiety treatment are outweighed by the need for care. This pilot RCT is an essential step to designing a robust RCT to evaluate the effectiveness of an Internet-based CBT program for adolescents with moderate to mild anxiety problems.

Trial Registration

Clinicaltrials.gov NCT02059226; http://clinicaltrials.gov/ct2/show/NCT02059226 (Archived by WebCite at http://www.webcitation.org/6epF8v7k4)

Substance use and mental health disorders are linked to different forms of intimate partner violence victimisation

BACKGROUND

Substance and mental health disorders convey significant health burdens and impair interpersonal relationships. We tested associations between comorbid substance and mental health disorders and different forms of intimate partner violence (IPV) experienced by young adults.

METHOD

Mothers (n = 6703) were recruited during pregnancy to the longitudinal Mater-University of Queensland Study of Pregnancy. Mother/offspring dyads were followed up from birth to 21 years. Offspring with complete psychiatric data at 21 years who reported having had an intimate partnership were included (n = 1781). Participants' experiences of psychological, physical and severe combined IPV were assessed at 21 years using a summarised form of the Composite Abuse Scale. We used the Composite International Diagnostic Interview to obtain lifetime diagnoses of mental health and substance disorders. Multivariable logistic regression models of each IPV form were adjusted for individual, family and neighbourhood factors during adolescence, and for other forms of IPV.

RESULTS

We have shown specific links between different forms of IPV experienced and individual substance and mental health disorders. Mental health disorders were related to all three forms of IPV, while alcohol disorders were linked to psychological IPV (ORAUD = 1.86; 1.21-2.86) and illicit substance disorders to physical IPV (ORSUD = 2.07; 1.25-3.43). The co-occurrence of related disorders was strongly linked to psychological and physical IPV.

CONCLUSIONS

Intimate partner violence was experienced by both men and women. Substance and mental health disorders were associated with specific forms of IPV victimisation, suggesting that screening IPV clients and mental health/substance disorder patients for the converse problems may be important for intervention planning.

Beyond butterflies: generalized anxiety disorder in adolescents

A generalized anxiety disorder diagnosis must include thorough history-taking, the use of age-appropriate screening tools, and physical assessment. Research and development into the use of screening tools and effectiveness of treatment strategies for generalized anxiety disorder is needed to better manage adolescents with the disorder.

Familial factors associated with development of alcohol and mental health comorbidity

BACKGROUND AND AIMS

Co-occurring mental health and alcohol problems appear to be associated with greater health burdens than either single disorder. This study compares familial and individual contributions to development of comorbid alcohol/mental problems and tests whether these differ from single disorders.

DESIGN

Women (n = 6703) were recruited during pregnancy to the longitudinal Mater-University of Queensland Study of Pregnancy (MUSP). Mother/offspring dyads were followed over 21 years.

SETTING

Mater-Misericordiae Public Hospital, Brisbane, Australia.

PARTICIPANTS

Primary offspring from the MUSP with full psychiatric information at 21 years and maternal information at age 14 (n = 1755).

MEASUREMENTS

Structured interviews at age 21 yielded a four-category outcome using mental health and alcohol modules of the Composite International Diagnostic Interview (no disorder, alcohol only, mental health only and comorbid alcohol/mental health). Multinomial logistic regression models were adjusted for gender, maternal mental health and substance use, family environment and adolescent behaviour.

FINDINGS

Maternal smoking [odds ratio (OR) = 1.56; 95% confidence interval (CI) = 1.09-2.22 versus no-disorder] and low mother-offspring warmth (OR = 3.19; 95% CI = 1.99-5.13) were associated with mental health/alcohol comorbidity in young adults, as were adolescent drinking (OR = 2.22; 95% CI = 1.25-3.96), smoking (OR = 2.24; 95% CI = 1.33-3.77) and attention/thought problems (OR = 2.04; 95% CI = 1.18-3.52). Some differences were seen from single disorders. In a subsample with paternal data, fathers' drinking problems (OR = 2.41; 95% CI = 1.10-5.29) were more associated strongly with offspring mental health/alcohol comorbidity than both single disorders (P < 0.05).

CONCLUSIONS

Maternal smoking and low mother-child warmth appear to be related to alcohol, mental health and comorbid disorders at age 21, possibly via constituent alcohol and mental health disorders. Adolescent drinking and attention/thought problems appear to be associated with comorbid disorders but not with individual alcohol and mental health disorders.

Does early socio-economic disadvantage predict comorbid alcohol and mental health disorders?

BACKGROUND

Alcohol and mental health disorders are highly prevalent in the general population, with co-occurrence recognised as a major public health issue. Socio-economic factors are frequently associated with both disorders but their temporal association is unclear. This paper examines the association between prenatal socio-economic disadvantage and comorbid alcohol and mental health disorders at young adulthood.

METHODS

An unselected cohort of women was enrolled during early pregnancy in the large longitudinal Mater-University of Queensland Study of Pregnancy (MUSP), at the Mater Misericordiae Public Hospital in Brisbane, Australia. The mothers and their offspring were followed over a 21 year period. Offspring from the MUSP birth cohort who provided full psychiatric information at age 21 and whose mothers provided socioeconomic information at baseline were included (n=2399). Participants were grouped into no-disorder, mental health disorder only, alcohol disorder only or comorbid alcohol and mental health disorders according to DSM-IV diagnoses at age 21 as assessed by the Composite International Diagnostic Interview. We used multivariate logistic regression analysis to compare associations of disorder group with single measures of prenatal socio-economic disadvantage including family income, parental education and employment, and then created a cumulative scale of socioeconomic disadvantage.

RESULTS

Greater socio-economic disadvantage was more strongly associated with comorbidity (OR 3.36; CI95 1.37, 8.24) than with single disorders. This relationship was not fully accounted for by maternal mental health, smoking and drinking during pregnancy.

CONCLUSION

Multiple domains of socio-economic disadvantage in early life are associated with comorbid alcohol and mental health disorders.

Pediatric anxiety disorders: from neuroscience to evidence-based clinical practice

The objective of this narrative review of the literature is to describe the epidemiology, etiology, pathophysiology, diagnosis, and treatment of pediatric anxiety disorders. We aim to guide clinicians in understanding the biology of anxiety disorders and to provide general guidelines for the proper diagnoses and treatment of these conditions early in life. Anxiety disorders are prevalent, associated with a number of negative life outcomes, and currently under-recognized and under-treated. The etiology involves both genes and environmental influences modifying the neural substrate in a complex interplay. Research on pathophysiology is still in its infancy, but some brain regions, such as the amygdala and the prefrontal cortex, have been implicated in fear and anxiety. Current practice is to establish diagnosis based purely on clinical features, derived from clinical interviews with the child, parents, and teachers. Treatment is effective using medication, cognitive behavioral therapy, or a combination of both. An introduction to the neuroscience behind anxiety disorders combined with an evidence-based approach may help clinicians to understand these disorders and treat them properly in childhood.

Comparison of behavioral profiles for anxiety-related comorbidities including ADHD and selective mutism in children

BACKGROUND

Elucidating differences in social-behavioral profiles of children with comorbid presentations, utilizing caregiver as well as teacher reports, will refine our understanding of how contextual symptoms vary across anxiety-related disorders.

METHODS

In our pediatric anxiety clinic, the most frequent diagnoses and comorbidities were mixed anxiety (MA; ≥ 1 anxiety disorder; N = 155), anxiety with comorbid attention-deficit hyperactivity disorder (MA/ADHD, N = 47) and selective mutism (SM, N = 48). Behavioral measures (CPRS, CTRS) were analyzed using multiple one-way multivariate analyses of covariance tests. Differences between the three diagnostic groups were examined using completed parent and teacher reports (N = 135, 46, and 48 for MA, MA/ADHD, and SM groups, respectively).

RESULTS

Comparisons across the MA, MA/ADHD, and SM groups indicate a significant multivariate main effect of group for caregiver and teacher responses (P < 0.01). Caregivers reported that children with SM are similar in profile to those with MA, and both groups were significantly different from the MA/ADHD group. Teachers reported that children with SM had more problems with social behaviors than with the MA or MA/ADHD groups. Further comparison indicates a significant main effect of group (P < 0.001), such that children with SM have the greatest differences in behavior observed by teachers versus caregivers.

CONCLUSIONS

Clinical profiles between MA/ADHD, MA, and SM groups varied, illustrating the importance of multi-rater assessment scales to capture subtle distinctions and to inform treatment planning given that comorbidities occur frequently in children who present with anxiety.

Psychopharmacologic treatment for pediatric anxiety disorders

Anxiety is an innate emotion that all humans experience, especially during early childhood in periods of significant growth and development. Treatment strategies exist for anxiety disorders that cause significant dysfunction and impairment in youth. This article provides a current overview of the literature on psychopharmacologic management of pediatric anxiety disorders. Potential side effects and complications of psychotropic medications are reviewed. The treatment of anxiety disorders in patients with comorbid conditions is explored, addressing the impact on treatment course and pharmacologic recommendations. A clinical vignette describing a 10-year-old boy with increasing anxiety is presented describing in-hospital and outpatient treatment and therapies.

Duplication of GTF2I results in separation anxiety in mice and humans

Duplication (dup7q11.23) and deletion (Williams syndrome) of chromosomal region 7q11.23 cause neurodevelopmental disorders with contrasting anxiety phenotypes. We found that 30% of 4- to 12-year-olds with dup7q11.23 but fewer than 5% of children with WS or in the general population met diagnostic criteria for a separation-anxiety disorder. To address the role of one commonly duplicated or deleted gene in separation anxiety, we compared mice that had varying numbers of Gtf2i copies. Relative to mouse pups with one or two Gtf2i copies, pups with additional Gtf2i copies showed significantly increased maternal separation-induced anxiety as measured by ultrasonic vocalizations. This study links the copy number of a single gene from 7q11.23 to separation anxiety in both mice and humans, highlighting the utility of mouse models in dissecting specific gene functions for genomic disorders that span many genes. This study also offers insight into molecular separation-anxiety pathways that might enable the development of targeted therapeutics.

Treatment and outcomes for anxiety disorders among children and adolescents: a review of coping strategies and parental behaviors

This article reviews the current literature on the treatment of anxiety disorders in children and adolescents and describes the factors that are essential to address in treatment. Coping deficits and parental behaviors are highlighted as factors that contribute to anxiety in youth. Interventions for anxious youth are described, with particular emphasis on cognitive-behavioral therapy for anxiety disorders. Finally, a review of the longitudinal course of anxiety and suggestions for future directions in treatment and research are provided.