Development of a scale to evaluate young children's responses to uncertainty and low environmental structure

A pilot, single-arm feasibility study of an integrated cognitive-behavioral treatment for anxiety in young autistic children

OBJECTIVE

Anxiety is prevalent in young autistic children under 7 years of age. Yet there is a paucity of empirically based interventions for this age group. DINO Strategies for Anxiety and Uncertainty Reduction (DINOSAUR) is an innovative cognitive behavioral intervention that seeks to optimize treatment response in young autistic children by targeting anxiety and the contributing mechanisms of intolerance of uncertainty and parental accommodation using a telehealth delivery model. This pilot, single-arm study examines the preliminary feasibility of DINOSAUR.

METHODS

Fourteen autistic children ages 4-6 years with average language and cognitive skills and their parents received the intervention. Quantitative and qualitative data pertaining to parent satisfaction and treatment outcomes were collected.

RESULTS

Attendance, retention, and parent satisfaction ratings offer preliminary support for the feasibility of the treatment model. Change in clinical severity ratings on a semi-structured parent interview of anxiety and parents' qualitative report suggests the potential to benefit young autistic children.

CONCLUSIONS

Results support future study of the DINOSAUR model in a larger, randomized controlled trial.

Anxiety in autistic preschool children: Phenomenology and a network analysis of correlates

Anxiety disorders in autistic children are associated with significant functional impairment. Few studies have examined impairing anxiety presentations in autistic preschool children (i.e., 3-5 years old). This cross-sectional study examined the phenomenology of impairing anxiety and the strongest correlates of anxiety in 75 autistic preschool children. Parents completed a diagnostic interview that assesses two anxiety types, DSM-5 anxiety disorders and impairing distinct anxiety presentations, and measures of anxiety correlates. An exploratory network analysis examined connections between anxiety and its correlates. Forty percent of children had impairing anxiety. Specific phobia followed by 'other social fear,' a type of distinct anxiety, were the most common anxiety types. Child intolerance of uncertainty (IU) was the only correlate that was associated with anxiety in a network analysis framework. Child IU linked anxiety to two other correlates, sensory over-responsivity and somatic symptoms. Findings emphasize the need for early intervention for anxiety and further research on its correlates.

The assessment of Intolerance of uncertainty in youth: An examination of the Intolerance of Uncertainty Scale-Revised in Italian nonclinical boys and girls

Intolerance of Uncertainty (IU) is a transdiagnostic factor involved in several psychological disorders. Adolescence is characterized by elevated uncertainty and psychopathological vulnerability, but insufficient attention has been paid to IU at this age. This study aimed to investigate the factor structure and psychometric properties of the Intolerance of Uncertainty Scale-Revised (IUS-R) in Italian preadolescents and adolescents. 862 Italian students (57.3% girls) aged 11-17 (M = 14.8 ± 1.91) completed the IUS-R and measures of internalizing and externalizing symptoms, and psychological well-being. To test the factor structure of the IUS-R, one-factor, two-factor, and bifactor models were compared; measurement invariance, reliability, and validity were also addressed. Results showed that the bifactor model outperformed alternative factor models, and a general factor was needed to model the IUS-R. Bifactor model indices supported using the total score to assess IU reliably. Configural and metric invariance by age and sex were fully supported, while the IUS-R achieved partial scalar invariance. Significant correlations emerged for the IUS-R total score with psychopathological constructs, while no relationships with psychological well-being were found. Compared to adult normative data, higher total IUS-R scores were detected, suggesting that IU may be a phase-specific characteristic of adolescence. Our findings support using the IUS-R to measure IU across the lifespan. The recommended use of the total score and its associations with psychopathological dimensions highlight the transdiagnostic nature of IU in adolescence. Therefore, including IU when implementing interventions to prevent maladaptive outcomes in teenagers would be beneficial.

Minimising Young Children's Anxiety through Schools (MY-CATS): statistical analysis plan for a cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of an online parent-led intervention compared with usual school practice for young children identified as at risk for anxiety disorders

BACKGROUND

The Minimising Young Children's Anxiety through Schools (MY-CATS) trial is being conducted to determine whether an online evidence-based parent-guided cognitive behavioural therapy intervention in addition to usual school practice is effective and cost-effective compared with usual school practice in reducing anxiety disorders in children aged 4-7 deemed 'at risk' of anxiety disorders. This update article describes the detailed statistical analysis plan for the MY-CATS trial and reports a review of the underpinning sample size assumptions.

METHODS AND DESIGN

The MY-CATS study is a two-arm, definitive superiority pragmatic parallel group cluster randomised controlled trial in which schools will be randomised 1:1 to receive either the intervention (in addition to usual school practice) or the usual school practice only. This update to the (published) protocol provides a detailed description of the study methods, the statistical principles, the trial population and the planned statistical analyses, including additional analyses comprising instrumental variable regression and mediation analysis.

TRIAL REGISTRATION

ISRCTN82398107 . Prospectively registered on 14 January 2021.

Minimising young children's anxiety through schools (MY-CATS): protocol for a cluster randomised controlled trial to evaluate the effectiveness and cost-effectiveness of an online parent-led intervention compared with usual school practice for young children identified as at risk for anxiety disorders

BACKGROUND

Identifying and supporting young children who are at risk of developing anxiety disorders would benefit children, families, and wider society. Elevated anxiety symptoms, inhibited temperament, and high parental anxiety are established risk factors for later anxiety disorders, but it remains unclear who is most likely to benefit from prevention and early intervention programmes. Delivering an online intervention through schools to parents of young children who have one or more of these risks could maximise reach. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of delivering an online parent-led intervention, compared with usual school provision only, for children (aged 4-7) identified as at risk for anxiety disorders on the basis of at least one risk factor. We also aim to identify the characteristics of children who do and do not benefit from intervention and mechanisms of change from the intervention.

METHODS

The design will be a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to intervention or usual school practice arms in a 1:1 ratio stratified according to level of deprivation within the school. The study will recruit and randomise at least 60 primary/infant schools in England, and on the basis of recruiting 60 schools, we will recruit 1080 trial participants (540 per arm). Parents of all children (aged 4-7) in sampled Reception, Year 1, and Year 2 classes will be invited to complete screening questionnaires. Children who screen positive on the basis of anxiety symptoms, and/or behavioural inhibition, and/or parent anxiety symptoms will be eligible for the trial. Parents/carers of children in schools allocated to the intervention arm will be offered a brief online intervention; schools in both arms will continue to provide any usual support for children and parents throughout the trial. Assessments will be completed at screening, baseline (before randomisation), 6 weeks, 12 weeks, and 12 months post-randomisation. The primary outcome will be the absence/presence of an anxiety disorder diagnosis at 12 months.

DISCUSSION

The trial will determine if delivering an online intervention for parents of young children at risk of anxiety disorders identified through screening in schools is effective and cost-effective.

TRIAL REGISTRATION

ISRCTN 82398107 . Prospectively registered on Jan. 14, 2021.

DINOSAUR: an integrated cognitive-behavioral treatment for anxiety in young children with ASD

Background

Anxiety disorders are highly prevalent in children and adolescents with autism spectrum disorder and often emerge before the age of 6 years. Yet, only a few studies have examined anxiety treatment for this group. Preliminary evidence from these studies suggests that utilizing cognitive behavioral therapy (CBT) as well as strategies to target intolerance of uncertainty (IU) and parental accommodation, known mechanistic and maintaining factors of anxiety may improve anxiety and optimize outcomes in this age group.

Main body

To meet this need, we developed an integrated treatment called DINO Strategies for Anxiety and intolerance of Uncertainty Reduction (DINOSAUR), a 12-week group telehealth treatment for 4- to 6-year-old children with ASD. DINOSAUR works with young children and their parents to deliver CBT along with interventions targeting IU and parental accommodation. In this paper, we first discuss the rationale for developing this treatment and then describe a pilot study of its feasibility and preliminary efficacy.

Conclusions

There is a great need to develop anxiety treatments for young children with ASD. We proposed a novel integrated treatment approach that aims to alter the way young children and parents respond to fear, which could potentially improve short- and long-term mental health outcomes for this age group.

Trial registration

ClinicalTrials.govNCT04432077 on June 03, 2020

Protocol for a longitudinal study investigating the role of anxiety on academic outcomes in children on the autism spectrum

BACKGROUND

Children on the autism spectrum are consistently reported to underachieve compared to ability. In typically developing children, anxiety is a strong predictor of poor school performance. Despite the high prevalence of anxiety disorders among children on the spectrum, the impact of their anxiety on academic achievement is under-researched. The main aim of this project is to determine the moderating role anxiety may have in the development of academic learning behaviours (academic enablers) in children on the spectrum. This project addresses a gap in knowledge about the possible associations between anxiety and academic achievement in children on the spectrum. Understanding these associations opens up the possibility of new intervention pathways to enhance academic outcomes through anxiety reduction/prevention.

METHODS

This longitudinal study will aim to recruit 64 children on the spectrum aged 4-5 years and their parents. Information will be gathered from children, parents and teachers. Children will be randomly assigned to one of two conditions in order to experimentally manipulate anxiety levels in the sample: experimental (to receive an anxiety reduction/prevention program, N = 32) or control (no intervention/treatment as usual, N = 32). The primary outcome measures are child academic skills and enabling behaviours assessed using the Academic Competence Evaluation Scales and the WIAT-II. Anxiety will be assessed through parent and teacher report. Assessments will be conducted at baseline, post-experimental manipulation of anxiety, and within the first year of formal schooling. It is hypothesised that anxiety will moderate the relationship between autism characteristics and academic enablers.

DISSEMINATION

Results will be disseminated through peer-reviewed manuscripts and conference presentations. Lay summaries will be provided to all participants and available on the research centre website.

The relationship between sensory reactivity, intolerance of uncertainty and anxiety subtypes in preschool-age autistic children

LAY ABSTRACT

This study found links between greater sensory hyperreactivity (e.g., over-sensitive to sensory input), intolerance of uncertainty and anxiety, including separation anxiety, in autistic pre-schoolers. Sensory hyperreactivity may predict both anxiety and intolerance of uncertainty, and anxiety and intolerance of uncertainty may both be mutually important, mediating factors. These findings have implications for early anxiety interventions. But there is a pressing need for objective assessments that can be used with preschool-age autistic children.

Psychometric Evaluation of the Intolerance of Uncertainty Scale for Children (IUSC): Findings From Clinical and Community Samples in Iran

OBJECTIVE

The present study examined the psychometric properties of a Persian version of the Intolerance of Uncertainty Scale for Children (IUSC; Comer et al, 2009).

METHOD

Participating youth (n = 346) 8 to 18 years of age were nonreferred community youth (n = 279) or youth who met diagnostic criteria for an anxiety disorder (n = 67) and their parents.

RESULTS

Across child- and parent-report data, confirmatory factor analysis supported a shortened 12-item version of the IUSC, and the confirmatory factor analysis also confirmed a theory-driven correlated two-factor structure of the IUSC-12. (i.e., prospective/inhibitory IU). Results further supported reliability and validity of parent- and child-reports of the Persian IUSC-12 via evidence of internal consistency, 4-week retest, significant associations with established measures of internalizing problems, and the ability of the measure to reliably distinguish the clinical sample from the community sample.

CONCLUSION

Findings demonstrate sound psychometric properties of the Persian version of the IUSC-12 and provide additional support for the reliability and validity of the measure and its use in non-Western cultures. Findings are discussed in terms of implications for assessment, treatment, and study of anxiety and related internalizing problems in Iranian youth.

Intolerance of uncertainty in youth: Psychometrics of the Intolerance of Uncertainty Index-A for Children

Intolerance of uncertainty (IU) is a cognitive vulnerability for pathological anxiety. The current study adapted the Intolerance of Uncertainty Index-A for Children (IUI-A-C), and created a single-item Intolerance of Uncertainty Clinician-Rated Index (IUCR), both of which assess a youth's general inability to endure uncertainty. Psychometric properties of these two measures were evaluated. Participants were 146 youth aged 7-17 years seeking treatment for anxiety. The IUI-A-C evidenced individual item performance (i.e., correlations between each item and the total remainder score > .40, ps <.001), internal consistency, convergent validity with the IUCR and self-report measures of anxiety and functional impairment, divergent validity with ADHD severity, and retest reliability with a mean interval of over four weeks. The IUCR also evidenced convergent validity with the IUI-A-C and self-report measures of anxiety and functional impairment and divergent validity with ADHD severity. The IUI-A-C predicted composite principal diagnosis severity but did not predict composite GAD diagnosis severity. The IUI-A-C and IUCR have utility as measures of IU in youth. The role of IU in specific anxiety disorders and future research are discussed.

A Preliminary Investigation of Cognitive Features Associated With Worry Among African American Youth

Although knowledge of the cognitive factors that place children at risk for worry has grown, little is known about these processes within African American youth. The present study investigated cognitive factors associated with worry in a sample of 47 African American children, ages 8 to 13. Participants completed self-report measures of worry, intolerance of uncertainty, positive and negative beliefs about worry, and negative problem orientation. Results supported the hypothesis that cognitive factors demonstrated significant positive associations with worry. Based on a model predicting worry from all cognitive factors, negative beliefs about worry emerged as the only individual predictor. This is the first study to examine cognitive factors associated with worry in an African American sample of children and provides initial support for the applicability of these cognitive factors in future examinations of worry within this population. Future research should continue to explore cognitive as well as other factors that predispose African America children to worry.

Intolerance of Uncertainty, anxiety, and worry in children and adolescents: A meta-analysis

BACKGROUND

Intolerance of uncertainty (IU) has been implicated in the development and maintenance of worry and anxiety in adults and there is an increasing interest in the role that IU may play in anxiety and worry in children and adolescents.

METHOD

We conducted a systematic review and meta-analysis to summarize existing research on IU with regard to anxiety and worry in young people, and to provide a context for considering future directions in this area of research. The systematic review yielded 31 studies that investigated the association of IU with either anxiety or worry in children and adolescents.

RESULTS

The meta-analysis showed that IU accounted for 36.00% of the variance in anxiety and 39.69% in worry. Due to the low number of studies and methodological factors, examination of potential moderators was limited; and of those we were able to examine, none were significant moderators of either association. Most studies relied on questionnaire measures of IU, anxiety, and worry; all studies except one were cross-sectional and the majority of the studies were with community samples.

LIMITATIONS

The inclusion of eligible studies was limited to studies published in English that focus on typically developing children.

CONCLUSIONS

There is a strong association between IU and both anxiety and worry in young people therefore IU may be a relevant construct to target in treatment. To extend the existing literature, future research should incorporate longitudinal and experimental designs, and include samples of young people who have a range of anxiety disorders.

Factor structure of the intolerance of uncertainty scale for children

Intolerance of uncertainty (IU), a dispositional negative orientation toward uncertainty and its consequences, has been studied in adults, but research has only recently examined IU in youth. Despite some advances, little is known about the factor structure of measures of IU in youth. The present study used confirmatory factor analysis to examine the structure of IU as measured by the Intolerance of Uncertainty Scale for Children (IUSC; Comer et al., 2009) in a sample of youth (N=368) 9-18 years of age (M_age=12.47) with and without anxiety disorders and their mothers. Findings demonstrated multiple acceptable factor structures: a correlated factors 2-factor structure and a bifactor model where a general factor underlies all items. While the bifactor model provides better fit and reliability to the data, multivariate analyses indicated that the 2-factor structure distinguishes apprehensive anxiety regarding future events (prospective IU) from present-focused inhibition of behavior due to uncertainty and negative reactions to the presence of uncertainty (inhibitory IU); a total IU score predicted all anxiety domains for self- and parent-reports except for parent-report harm avoidance. Findings are discussed in terms of consistency of IU across adult and youth samples, and how results can inform treatment efforts and etiologic models of IU and anxiety.