Using Evaluative Criteria to Review Youth Anxiety Measures, Part II: Parent-Report

Oxytocin as a Biomarker of Differential Effects to SPACE vs. CBT Treatment of Child Anxiety Disorders

OBJECTIVE

Two lines of research, on outcome moderators and on novel treatment targets, seek to improve the overall efficacy of child anxiety treatment, with mixed results. We propose that an integration of both lines of research can lead to improved treatment efficacy. In a first proof of concept of this approach, we studied whether the interaction between baseline levels and targeted changes in peripheral oxytocin (OT) can predict differential responses to two childhood anxiety treatments.

METHOD

A total of 124 mother-child dyads participated in the study. Children's salivary OT levels were measured at baseline and again, immediately after an experimental dyadic interaction in the lab. Dyads were subsequently randomized to receive one of two treatments, differing in their targets: SPACE (Supportive Parenting for Anxious Childhood Emotions) and CBT (cognitive-behavioral therapy). Treatment outcomes were assessed using the Childhood Anxiety Related Emotional Disorders scale, reported by both mother and child.

RESULTS

The findings suggest that in SPACE, where the mother is the main agent of change, higher baseline levels of child OT, coupled with increases in OT following a positive mother-child interaction, predicted greater treatment efficacy. By contrast, in CBT, where the child is the main agent of change, higher baseline levels of child OT, coupled with a decrease in OT following the interaction, predicted greater treatment efficacy.

CONCLUSIONS

The findings highlight the importance of the integration between moderators and targets of treatments for progress toward improving treatment efficacy through precision medicine.

The Role of Pediatric Sensory Over-responsivity and Anxiety Symptoms in the Development of Family Accommodations

Sensory over-responsivity (SOR) is linked with elevated anxiety and reduced family wellbeing. Family accommodation of anxiety relates with greater symptom severity and reduced intervention outcome. This study examined the contribution of child SOR and co-occurring anxiety symptoms to family accommodation and its consequences. Ninety families of typically developing children (ages 4-13 years), completed an online survey including the Sensory Profile 2, Screen for Child Anxiety Related Emotional Disorders (SCARED), and Family Accommodation Sensory Scale (FASENS). FASENS scores include frequency of accommodation, child impact, and family impact.Children with elevated anxiety symptoms had significantly higher sensory and FASENS scores. Stepwise linear regression indicated that only SOR symptoms significantly predicted the frequency of sensory family accommodation, while both SOR and anxiety symptoms predicted the impact of family accommodation upon child and family well-being.Both SOR and anxiety symptoms in children predict the impact of sensory family accommodations on child and family well-being.

Boundaries on Parent Involvement in Their Child's Anxiety Cognitive-Behavioral-Treatment Outcome: Parent Reinforcement and Relationship Behaviors Moderate Outcome

Extending a recent parent mediation efficacy trial, we identified parent reinforcement and relationship behaviors as setting boundary conditions, or moderators, of youth anxiety outcome in 254 youths and their parents, who were randomized to: (1) Cognitive Behavioral Treatment (CBT) with parent reinforcement behavior training (CBT + Reinf); (2) CBT with parent relationship behavior training (CBT + Relat); or (3) individual youth CBT - a comparator control arm. Findings revealed that parents with high baseline negative reinforcement levels and acceptance levels (i.e., above the mean) report their children as having lower anxiety at outcome, when assigned to CBT + Reinf, and CBT + Relat, respectively, versus CBT. No moderation effects were found for either parent positive reinforcement or parent psychological control. Implications for treating anxiety disorders and moving toward precision treatment approaches in youth are discussed, and the importance of research replication and extension.

Attention Training for Child Anxiety and Its Disorders: Moving from Research to Clinical Implementation

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training's anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

Family Accommodation and Separation Anxiety: The Moderating Role of Child Attachment

Family accommodation, or changes in parental behavior aimed at avoiding or alleviating child anxiety-related distress, contributes to the severity of anxiety symptoms, and is most strongly associated with separation anxiety. This study examined whether child attachment security, characterized as the degree to which children perceive their parents to be reliable, available, and communicative, moderates the association between family accommodation and separation anxiety symptoms, and whether this moderation is specific to separation anxiety among other anxiety symptoms. In a sample of clinically anxious children (N = 243, 6-12 years), family accommodation was significantly positively associated with separation anxiety symptoms across levels of attachment security. Family accommodation was more strongly associated with parent-reported separation anxiety symptoms in children with lower attachment security compared with those with higher attachment security. No significant moderation effect emerged for other anxiety symptoms. Findings enhance understanding of the role of attachment within family accommodation of child anxiety.

Responding to threat: Associations between neural reactivity to and behavioral avoidance of threat in pediatric anxiety

BACKGROUND

Despite broad recognition of the central role of avoidance in anxiety, a lack of specificity in its operationalization has hindered progress in understanding this clinically significant construct. The current study uses a multimodal approach to investigate how specific measures of avoidance relate to neural reactivity to threat in youth with anxiety disorders.

METHODS

Children with anxiety disorders (ages 6-12 years; n = 65 for primary analyses) completed laboratory task- and clinician-based measures of avoidance, as well as a functional magnetic resonance imaging task probing neural reactivity to threat. Primary analyses examined the ventral anterior insula (vAI), amygdala, and ventromedial prefrontal cortex (vmPFC).

RESULTS

Significant but distinct patterns of association with task- versus clinician-based measures of avoidance emerged. Clinician-rated avoidance was negatively associated with right and left vAI reactivity to threat, whereas laboratory-based avoidance was positively associated with right vAI reactivity to threat. Moreover, left vAI-right amygdala and bilateral vmPFC-right amygdala functional connectivity were negatively associated with clinician-rated avoidance but not laboratory-based avoidance.

LIMITATIONS

These results should be considered in the context of the restricted range of our treatment-seeking sample, which limits the ability to draw conclusions about these associations across children with a broader range of symptomatology. In addition, the limited racial and ethnic diversity of our sample may limit the generalizability of findings.

CONCLUSION

These findings mark an important step towards bridging neural findings and behavioral patterns using a multimodal approach. Advancing understanding of behavioral avoidance in pediatric anxiety may guide future treatment optimization by identifying individual-specific targets for treatment.

Evidence Base Update on the Assessment of Irritability, Anger, and Aggression in Youth

OBJECTIVE

Irritability, anger, and aggression have garnered significant attention from youth mental health researchers and clinicians; however, fundamental challenges of conceptualization and measurement persist. This article reviews the evidence base for assessing these transdiagnostic constructs in children and adolescents.

METHOD

We conducted a preregistered systematic review of the evidence behind instruments used to measure irritability, anger, aggression, and related problems in youth. Searches were conducted in PsycINFO and PubMed, identifying 4,664 unique articles. Eligibility criteria focused on self- and proxy-report measures with peer-reviewed psychometric evidence from studies in English with youths ages 3-18. Additional measures were found through ancillary search strategies (e.g. book chapters, review articles, test publishers). Measures were screened and coded by multiple raters with acceptable reliability.

RESULTS

Overall, 68 instruments met criteria for inclusion, with scales covering irritability (n = 15), anger (n = 19), aggression (n = 45), and/or general overt externalizing problems (n = 27). Regarding overall psychometric support, 6 measures (8.8%) were classified as Excellent, 46 (67.6%) were Good, and 16 (23.5%) were Adequate. Descriptive information (e.g. informants, scales, availability, translations) and psychometric properties (e.g. reliability, validity, norms) are summarized.

CONCLUSIONS

Numerous instruments for youth irritability, anger, and aggression exist with varying degrees of empirical support for specific applications. Although some measures were especially strong, none had uniformly excellent properties across all dimensions, signaling the need for further research in particular areas. Findings promote conceptual clarity while also producing a well-characterized toolkit for researchers and clinicians addressing transdiagnostic problems affecting youth.

Measurement-Based Care for Depression in Youth: Practical Considerations for Selecting Measures to Assess Depression, Associated Features and Functioning

Identification and management of major depressive disorder (MDD) in children and adolescents remains a significant area of public health need. The process for identifying depression (e.g. screening) and management (e.g. measurement based care [MBC]) is substantially enhanced by utilization of clinical measures and rating scales. Measures can be self- or caregiver reported or clinician rated. They can aid recognition of at-risk individuals for future assessment and assist in clinical diagnosis and management of depression. In addition to assessing symptoms of depression, rating scales can be used to assess important associated features (e.g. anxiety, trauma) and functional outcomes (e.g. quality of life, performance/productivity). In this manuscript, we discuss practical considerations for clinicians and researchers when selecting rating instruments for assessing depression, associated factors, functioning, and treatment outcomes (i.e. adherence and side effects) as part of MBC in youth and provide a summary of rating scales commonly used in research and clinical settings.

Assessing Anxiety-Related Impairment in Children and Adolescents

Anxiety disorders (ADs) frequently lead to significant impairment across important domains of youth functioning. Yet until recently, clinical research and assessment have largely neglected the measurement of anxiety-related impairment. In this article, we review the evidence for five extant rating scales of youth anxiety-related impairment, guided by widely used evaluative criteria. Emerging psychometric data show the potential utility of these rating scales for achieving different assessment functions. Of the five scales, the Child Anxiety Impact Scale, particularly the parent-report version, has been the most researched one. Promising psychometric data support its use for assessing anxiety-related impairment in school, social, and family/home domains of functioning. We conclude with recommendations for growing this research base and for incorporating these rating scales into the youth AD clinical and research assessment process.

Parent involvement enhances CBTs for anxiety disorders in Hispanic/Latino youth: Acculturation as a moderator

OBJECTIVE

Although cognitive behavioral treatments (CBTs) are well-established evidence-based interventions for anxiety disorders in youth, there is long-standing underrepresentation of Hispanic/Latino (H/L) families in youth anxiety clinical trials research. The impact of such underrepresentation is that clinicians who work with H/L youth have minimal evidence-based guidance on best practices. The present study moves toward informing best practices for working with H/L youth with anxiety disorders by examining H/L parents' acculturation and enculturation as moderators of youth anxiety outcomes following CBTs.

METHOD

Two hundred eleven H/L youths ages 6-16 (M = 9.41 years, SD = 2.39 years; 43.8% female) and their parents were assigned to individual-youth CBT or one of two parent involvement CBTs: one targeted decreasing parent psychological control, the other targeted decreasing parent use of negative reinforcement. Parent acculturation and enculturation were measured at pretreatment; youth anxiety severity was measured at pretreatment, posttreatment, and 12-month follow-up evaluations.

RESULTS

Youth anxiety outcomes were enhanced in both parent involvement CBTs compared with individual-youth CBT. Parent acculturation, but not enculturation, significantly moderated outcomes. At lower levels of parent acculturation, youth anxiety outcomes were enhanced in the parent involvement CBT that targeted negative reinforcement. At higher levels of parent acculturation, youth anxiety outcomes were enhanced in the parent involvement CBT that targeted psychological control.

CONCLUSIONS

These findings further support the efficacy of CBTs for anxiety disorders in H/L youth and suggest guidance for tailoring parent involvement treatments based on parent acculturation levels. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Youth social functioning interacts with treatment arm, diagnosis, and gender to predict anxiety treatment outcome

Research has uncovered a wide range of predictors of youth anxiety treatment outcome (i.e., symptom severity and diagnostic remission). Youth's social functioning is one predictor that has been rarely studied, however, which is a significant gap given its importance to development and clinical functioning. We address this gap by examining two aspects of youth's social functioning as predictors of anxiety treatment outcome: (1) positive social interactions and (2) social skills. We further examined the moderating roles of treatment arm (child- or parent-based treatment), diagnosis (presence or absence of social anxiety disorder), and youth gender, between each of the two predictors and treatment response and remission. Participants were 96 youths with anxiety disorders (6-16 years; 54% girls) and their mothers, who completed diagnostic interviews and questionnaires at baseline and posttreatment. Multiple regression models revealed that higher baseline parent-reports of their child's social skills predicted lower posttreatment anxiety symptom severity for youth with social anxiety disorder. Modified linear probability models revealed that baseline youth-reports of their social skills predicted remission from anxiety diagnoses for youths assigned to the parent-based treatment. Baseline youth-reports of their positive social interactions and parent-reports of youth social skills predicted remission from anxiety diagnoses for girls. Results contribute to the predictor literature by highlighting the importance of youth social functioning to anxiety treatment outcome.

Anxiety and Social Functioning: The Moderating Roles of Family Accommodation and Youth Characteristics

It is well established that anxiety can contribute to social functioning difficulties during childhood and adolescence. It is less clear which anxious youth are most likely to struggle socially, and what types of difficulties they are likely to experience, limiting the extent of identification and intervention efforts. In this study, we aim to improve specification of the linkages between youth anxiety severity and social functioning by examining several potential moderators of these associations. Specifically, we examine whether family accommodation of youth anxiety, in addition to youth age, sex, and the presence of a social anxiety disorder diagnosis, influence associations between anxiety severity and social functioning among youth with anxiety disorders. Youth (N = 158, M_age = 9.99 years, SD = 2.74) and their mothers completed diagnostic interviews and questionnaires assessing anxiety and depression symptoms, family accommodation, and a range of social functioning variables. In a series of hierarchical linear regressions, we found that youth anxiety severity was most strongly associated with social impairment at high levels of family accommodation for adolescents and for youth without social anxiety disorder (mother-report). We also found several direct effects of anxiety severity, family accommodation, and youth age, sex, and diagnosis on different facets of youth social functioning (youth- and/or mother-report). We discuss clinical implications and future research directions focused on specifying the nature of associations between youth anxiety and their social functioning.