Worry in normal children

Annual Research Review: Health anxiety in children and adolescents-developmental aspects and cross-generational influences

Health anxiety involves excessive worries about one's health along with beliefs one has an illness or may contract a serious disease. Concerning evidence suggests that health anxiety is on the rise in society, possibly further fueled by the COVID-19 pandemic. Recent classification systems acknowledge that impairing health-related worries and beliefs can emerge in early childhood with significant levels of symptoms persisting throughout childhood, and possibly continuous with diagnostic considerations in adulthood. This narrative review summarizes recent research advances in health anxiety in children and adolescents, focusing on various developmental aspects of health anxiety and related concepts in youths. Findings suggest that health anxiety symptoms in young age groups are associated with impairment, distress, and increased healthcare use, as well as substantial comorbidity with mainly other emotional problems and disorders. Furthermore, longitudinal studies suggest that childhood health anxiety can persist across adolescence, perhaps with links to chronic courses in adulthood. The growing literature was further reviewed, thus extending our understanding of early risk factors, including the potential role of exposure to serious illness and transgenerational transmission of health anxiety. Learning more about developmental trajectories will be highly relevant to inform strategies for early detection and prevention. While modified cognitive behavioral therapies in adults are successful in treating health anxiety, specific interventions have not yet been tested in youths. Given substantial overlaps with other psychopathology, it could be important to develop and explore more transdiagnostic and scalable approaches that take advantage of common factors in psychotherapy, while also including a wider perspective on potential familiar maladaptive illness cognitions and behaviors.

Prevalence of anxiety, sleep bruxism and temporomandibular disorders during COVID-19 in Qatari children and adolescents: a cross-sectional study

PURPOSE

Understanding the impact of coronavirus disease-2019 (COVID-19) pandemic social restrictions on the lives of children and adolescents is of utmost importance to enable timely diagnosis and treatment. Therefore, the aim of this study was to explore the prevalence of anxiety, sleep bruxism, temporomandibular disorders (TMD) and change in dietary and brushing habits and their association with COVID-19 social restrictions.

METHODS

Parents of fit and healthy Qatari children and adolescents were recruited and interviewed by the research team, whereby validated questioners were used to assess the prevalence of children's/adolescents' anxiety, sleep bruxism and TMD. Furthermore, changes in dietary and brushing habits were also evaluated.

RESULTS

A total of 199 parents of children and adolescents (mean age = 9.3 ± 3.2 years old) were included. Overall anxiety symptoms, sleep bruxism and TMD were evident in 29.6%, 5.7% and 23.1%, respectively. An increased consumption of food, sweets and worsening of brushing habits were evident in 51.8%, 62.8% and 31.2%, respectively.

CONCLUSION

Within the limitations of this study, pandemic-related social restrictions could result in elevated levels of anxiety, specifically, social phobia, amongst children and adolescents, which could inevitably lead to unwanted dental consequences.

Anxiety symptoms among children visiting a pediatric emergency center in Qatar during the COVID-19 pandemic: A cross-sectional study

Although the evidence base regarding the impact of the COVID-19 pandemic on children has been growing, descriptions of their experiences remain scarce. In this cross-sectional study, the authors used the Child-Reported Spence Children's Anxiety Scale to collect data from 91 children visiting a pediatric emergency center in Qatar during the pandemic. Around 25% of the children reported elevated levels of overall anxiety. Obsessive-compulsive symptoms were the most common, with 59.3% of children reporting elevated symptoms. The mean score of physical injury fears was significantly affected by gender, with females having higher scores. Overall rates for elevated anxiety symptoms were similar in natives and expatriate children. The findings suggest that the effects of the pandemic on children may depend on several vulnerability factors, including developmental age and gender. This study highlights the need to plan multidisciplinary strategies to enhance children's access to mental health services during and after the current health crisis.

Maternal Worry Socialization and Toddler Inhibited Temperament: Transactional Associations and Stability across Time

Caregiver socialization of child emotions has consequences for both typical development and anxiety risk, with caregivers' non-supportive responses to worry perhaps especially salient to children's anxiety development. Children, in turn, impact the caregiving environment they receive through their temperament. We investigated transactional relations between maternal non-supportive responses to child worry (mother-reported) and two differently-measured child inhibited temperament indices (i.e., mother-perceived child inhibition to novelty, laboratory-observed child dysregulated fear) in a sample of 136 predominantly non-Hispanic, White mother-toddler dyads. Worry socialization and mother-reported inhibition to novelty were measured at each of three time points (toddler age 2, 3, 4 years), and dysregulated fear was measured at ages 2 and 3. Constructs showed stability across time, with effect sizes ranging from medium to large. Child inhibited temperament measures positively correlated within time point at ages 2 and 3, and laboratory-observed child dysregulated fear predicted mothers' later perceptions of their children's inhibition to novelty. At toddler age 2, mothers of children showing more dysregulated fear reported responding more non-supportively to worry. However, when controlling for one another, more mother-perceived child inhibition to novelty and less laboratory-observed child dysregulated fear at age 3 predicted mothers' greater non-supportive worry responses at child age 4. There was an indirect effect across time, such that children's greater laboratory-observed dysregulated fear predicted their mothers' heightened perceptions of inhibited temperament, which in turn predicted mothers' greater non-supportive worry responses. Findings lend support to anxiety-relevant construct stability in toddlerhood, as well as child-elicited, rather than parent-elicited, associations across time.

A randomised controlled dismantling trial of sleep restriction therapies for chronic insomnia disorder in middle childhood: effects on sleep and anxiety, and possible contraindications

Sleep restriction therapies likely drive improvement in insomnia in middle childhood via increases in homeostatic sleep pressure (e.g., evening sleepiness). Increased evening sleepiness may also dampen comorbid anxiety symptoms; and reduced wakefulness in bed may reduce worry. However, sleep restriction therapies have never been evaluated as a standalone intervention in this population. The mechanism of action needs testing, as do effects on anxiety, and cognitive performance and parasomnias (possible contraindications). This randomised controlled trial evaluated the efficacy of two "doses" of sleep restriction therapy (sleep restriction therapy, bedtime restriction therapy), compared to a control condition (time in bed regularisation). A total of 61 children (mean [SD, range] age 9.1 [2.1, 6-14] years; 54% female) with chronic insomnia disorder received two weekly 60-min treatment sessions with a psychologist. Sleep, sleepiness, anxiety, worry, cognitive performance, and parasomnias were measured pre-treatment, across treatment, and at 4-weeks post-treatment. Both the sleep and bedtime restriction groups experienced reductions in total sleep time (d = 1.38-2.27) and increases in evening sleepiness (d = 1.01-1.47) during the 2-week treatment, and improvements in insomnia (i.e., sleep onset latency; d = 1.10-1.21), relative to the control group. All groups reported improved anxiety and worry, yet there were no differences between the control and restriction groups (all p > 0.658). Time in bed increased at the 1-month follow-up, and benefits to sleep and insomnia were maintained. There were no adverse effects on cognitive functioning (all p > 0.259), nor parasomnia occurrence (all p > 0.740). These results suggest that sleep restriction therapies are brief, yet effective, standalone interventions for insomnia in middle childhood, and improvements are likely due to increased sleepiness, not sleep regularisation.

Repetitive Negative Thinking Processes Account for Gender Differences in Depression and Anxiety During Adolescence

Rumination and worry are vulnerability factors involved in the early development of depression and anxiety during adolescence, particularly in girls. Current views conceptualize rumination and worry as transdiagnostic forms of repetitive negative thinking (RNT). However, most of research has analyzed them separately, without considering gender differences. We analyzed common and specific roles of rumination and worry in accounting for depressive and anxiety symptom levels overall and as a function of gender in adolescents (N = 159). Rumination and worry items were loaded into separate RNT factors. Girls showed a higher use of rumination and worry and higher levels of depression and anxiety than boys. Structural equation modeling supported that both RNT factors accounted for gender differences in symptom levels: rumination was the strongest mediator for depression and worry the strongest mediator for anxiety. Our findings support both general and specific contributions of RNT to account for affective symptomatology during adolescence, particularly in girls.

Longitudinal Links among Mother and Child Emotion Regulation, Maternal Emotion Socialization, and Child Anxiety

Models of transdiagnostic family emotion processes recognize parents' emotion-related characteristics and behaviors as key contributors to child emotional development and psychological functioning. One such psychological outcome, child anxiety, is prevalent and early emerging, underscoring the importance of identifying early family- and emotion-related mechanisms involved in anxiety risk. We investigated the extent to which mother and child emotion-related traits and behaviors related to child anxiety in a community sample of 175 mother-child dyads. Using three time-points (child ages 2-4 years, assessments 1 year apart), we examined how mothers' emotion dysregulation predicted their emotion socialization practices (either supportive or non-supportive) and children's emotion regulation (ER; either attention- or caregiver-focused) over time, in relation to later child anxiety. Models controlled for child inhibited temperament and also tested the role of maternal anxiety in these trajectories. Mothers reported on their emotion dysregulation, emotion socialization, and their own and their child's anxiety, whereas child ER and inhibited temperament were measured using laboratory observation. In supportive emotion socialization models, maternal emotion dysregulation predicted child anxiety 2 years later. An indirect effect emerged, such that greater maternal emotion dysregulation predicted greater non-supportive emotion socialization, which in turn related to children's greater caregiver-focused ER. Maternal emotion dysregulation, maternal anxiety, and child inhibited temperament each predicted child anxiety above and beyond other variables, although their shared variance likely accounted for some of the results. Findings lend partial support to current theoretical models of transdiagnostic family emotion processes and child anxiety development, suggesting promising avenues of future research.

Prevalence of elevated anxiety symptoms among children in quarantine with COVID-19 infection in the State of Qatar: A cross-sectional study

Background

Children are particularly vulnerable to the psychological effects of the COVID-19 pandemic. The disruption in daily life has impacted children significantly. Moreover, the increased worrying associated with the probability of getting infected or becoming seriously unwell due to infection can potentially precipitate anxiety disorders among children.

Objective

This study aimed to determine rates of elevated anxiety symptoms in children with COVID-19 infection. It also explored whether there were any differences in terms of age, gender, and residency status.

Method

A cross-sectional, questionnaire-based study with 88 participants (children aged 7-13 years, 54.5% males, 45.5% females) from two institutional quarantine centers. The Spence Children's Anxiety Scale and its validated Arabic version (self-reported questionnaires) were used to measure anxiety symptoms.

Results

36.3% children reported elevated anxiety symptoms. A lower rate of 32.8% was reported in younger children (7-11 years) compared to 45.8% in older children (12 and 13 years). 70.4% and 57.9% children reported physical injury fears and separation anxiety respectively. A higher prevalence of overall anxiety was reported in children from expatriate families (40.6%) compared to native children (25%). The difference in the mean scores between the expatriate and native group of children was found statistically significant for obsessive-compulsive symptoms.

Conclusions

The prevalence of elevated anxiety symptoms among children in quarantine with COVID-19 infection can be much higher than that reported in the general population. Older children can have elevated anxiety symptoms more commonly than their younger counterparts can. Expatriate children are likely to be more vulnerable to the psychological impact of the pandemic compared to children from local families. Our results suggest the crucial need of focusing on the psychological impact of COVID-19 pandemic on children. The prioritization and effective management of the mental health needs of children should be a vital component of the overall, global response to the pandemic.

Elucidating the neural correlates of emotion recognition in children with sub-clinical anxiety

BACKGROUND

The pervasiveness of subclinical anxiety in children, highlights the need to identify its neurobiological underpinnings to better inform interventions. Given the now well-established link between aberrant emotion processing and anxiety disorders and yet limited neurobiologically-informed research in this area, this study examined the neural correlates of emotion recognition (ER) in children with sub-clinical anxiety.

METHOD

Ninety children (aged 9-11 years) with sub-clinical anxiety, completed an emotion recognition task whilst undergoing functional magnetic resonance imaging. The ER task required participants to match shapes and match emotional faces in the context of shape distractors. Participants also completed the Spence Children's Anxiety Scale (SCAS).

RESULTS

Greater blood oxygenation level dependent (BOLD) changes associated with ER were observed in the lateral occipital cortex, middle frontal gyrus, superior middle frontal gyrus, inferior frontal gyrus, superior parietal lobule, inferior parietal lobule, superior temporal gyrus, and middle temporal gyrus symmetrically. The clusters also included posterior cingulate cortex, insula, hippocampus, amygdala and cerebellum during matching emotions than those matching shapes. Females showed greater BOLD changes associated with ER than males in the right middle frontal gyrus. The BOLD changes associated with ER in the right middle frontal gyrus and right insula were greater in children with SCAS subscale (physical injury fear) scores in the normal range than those with elevated scores.

DISCUSSION

The findings in this study implicate the right middle frontal gyrus and insula as key regions in the neurobiological underpinnings of sub-clinical anxiety as they relate to attention impairments in anxious children.

CONCLUSION

The results of this study indicate there are gender differences in young participants during emotion processing and provides a neurobiological target for attention impairments in anxious children.

Children's Expressions of Worry During the COVID-19 Pandemic in Sweden

Objective

Sweden is an international exception in its public health response to the COVID-19 pandemic, with a higher number of deaths, albeit not pediatric, compared with other Nordic countries. The objective of this study was to investigate what worries children and adolescents living in Sweden expressed in relation to the pandemic.

Methods

Using an anonymous web-survey, 1,047 children (4–12 years; N = 717) and adolescents (13–18 years; N = 330) responded to five background and four open-ended questions, one of which was: Is there anything that you are worried about when it comes to ‘Corona’? The responses were coded using manifest content analysis. Interrater reliability was .95, assessed on the code level.

Results

Worry was common (77%); mostly (60%) related to disease or death of elderly relatives, parents, the child him/herself or general worry for the elderly/risk groups. Existential worry (15%) comprised worries about the future, including economy and worries about the world perishing or the contagion becoming uncontrollable. A developmental trajectory was evident in the nature of responses. Adolescents’ worries about the future included missing out on their youth and employment. They also worried about society (6%), for example, the future of democracy and the world economy. There was no indication of socioeconomic status or geographic area (urban vs. rural) affecting the presence of worrisome thoughts.

Conclusions

Worry about “Corona” was common. Universal preventative mental health intervention is warranted and could be conducted in the school setting. Intervention could be tailored by age, covering discussion on financial aspects with adolescents.

Repetitive Negative Thinking and Eating Disorders: A Meta-Analysis of the Role of Worry and Rumination

The role of worry and rumination in eating disorders (EDs) is controversial. This meta-analysis of the literature is aimed at clarifying the relationship between repetitive negative thinking (RNT) and EDs. In accordance with the PRISMA criteria, a comprehensive search of the literature was conducted on PubMed and PsycInfo from inception to March 2021. Search terms: “eating disorder/anorexia/bulimia/binge eating disorder” AND “worry/rumination/brooding/repetitive thinking”. A manual search of reference lists was also run. Forty-three studies were included. RNT was found to be associated with anorexia, bulimia, and binge eating disorder. A moderating effect was found for “presence/absence ED diagnosis” and “subtype of ED symptom”. ED patients showed higher RNT than the general population. No differences were observed for age or between worry and rumination in the magnitude of their association with EDs.

Experiences of online exposure-based treatment with parental support for teenagers with excessive worry

Worry is a common symptom that can become excessive and is related to several negative health outcomes. Our research group recently developed an online treatment for teenagers with excessive worry with a parallel programme for their parents. The treatment is characterized by a specific focus on exposure to uncertainty and other avoided stimuli, and includes a substantial amount of parental involvement. The aim of this study was to explore how teenagers and their parents experienced the treatment, especially how they perceived working independently with exposure tasks, parental involvement in the treatment programme, and a fixed treatment format. An experienced, independent clinical psychologist interviewed eight teenagers and nine parents in total. The verbatim transcripts were analysed with thematic analysis and two main themes emerged: ‘Seeing the worry in a new light’ and ‘Changing within a set format’, which both consisted of three subthemes. Based on the analysis, we concluded that teenagers can work actively with exposure and experience it as helpful even though it can be difficult and strange at first, and that parental involvement can be perceived as beneficial by both teenagers and their parents. While the online format placed a substantial responsibility on the families, and some would have wanted additional therapist support, working independently with one’s difficulties was acceptable.

Key learning aims

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Maternal Anxiety and Toddler Inhibited Temperament Predict Maternal Socialization of Worry

Parent emotion socialization refers to the process by which parents impart their values and beliefs about emotion expressivity to their children. Parent emotion socialization requires attention as a construct that develops in its own right. The socialization of child worry, in particular, has implications for children's typical socioemotional development, as well as their maladaptive development towards anxiety outcomes. Existing theories on emotion socialization, anxiety, and parent-child relationships guided our investigation of both maternal anxiety and toddler inhibited temperament as predictors of change in mothers' unsupportive (i.e., distress, punitive, and minimizing) responses to toddler worry across 1 year of toddlerhood. Participants included 139 mother-toddler dyads. Mothers reported on their own anxiety and their emotion socialization responses to toddler worry. We assessed toddler inhibited temperament through a mother-report survey of shyness and observational coding of dysregulated fear. Maternal anxiety but not child inhibited temperament predicted distress reactions and punitive responses, whereas maternal anxiety and toddler dysregulated fear both uniquely predicted minimizing responses. These results support continued investigation of worry socialization as a developmental outcome of both parent and child characteristics.

A Cognitive Model of Pathological Worry in Children and Adolescents: A Systematic Review

Worry is common in children and adolescents, yet some youth experience excessive worries that persist over time and cause significant distress. Whilst the literature on worry and generalised anxiety disorder (GAD) in adults is well established, relatively less is known about the cognitive mechanisms underlying child and adolescent worry. An influential cognitive model of adult pathological worry (Hirsch and Matthews in Behav Res Therapy 50:636–646, 10.1016/j.brat.2012.06.007, 2012) proposes that negative information-processing biases, reduced executive functions, and verbal worry are critical in the aetiology of GAD in adults. The current systematic review investigated whether this cognitive model of worry could be extended to understand child and adolescent worry. Following a systematic search of the literature and screening for eligibility, 30 studies were identified. Evidence indicates that negative information-processing biases and reduced executive functions play an important role in worry and GAD in children and adolescents. However, evidence that children and adolescents experience verbal worry is inconclusive. Building upon Hirsch and Matthews' cognitive model (Behav Res Therapy 50:636–646, 10.1016/j.brat.2012.06.007, 2012), we propose a model of child and adolescent worry to provide a guiding framework for future research. We conclude that cognitive models of worry should incorporate a developmental framework in order to provide greater insight into the mechanisms uniquely associated with worry in children and adolescents and help to identify the cognitive processes to target for early interventions and treatments.

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.

Trends in adolescent mental health during economic upturns and downturns: a multilevel analysis of Swedish data 1988-2008

Background

A long-term trend of increasing mental health problems among adolescents in many Western countries indicates a great need to investigate if and how societal changes have contributed to the reported increase. Using seven waves of repeated cross-sectional data collected between 1988 and 2008 in Sweden, the current study examined if economic factors at the societal level (municipality unemployment rate) and at the individual level (worry about family finances), and their interaction could explain a secular trend in mental health problems.

Methods

Participants were 17 533 students of age 15–16 years (49.3% girls), from 14 municipalities in a county of Sweden. Data on adolescents’ mental health (psychosomatic problems) and worry about family finances were obtained using a self-report questionnaire. A series of multilevel regression analyses were conducted in order to explain the trends in adolescents’ mental health.

Results

The results indicated that the individual-level predictor (worry about family finances) significantly explained the increasing rates of adolescents’ psychosomatic problems. This was particularly the case during the mid-1990s, which was characterised by a severe recession in Sweden with high unemployment rates. For example, after accounting for adolescents’ worry, a significant increase in psychosomatic symptoms between 1988 and 1998 among girls (b=0.112, P<0.05) disappeared (b=0.018, P>0.05) and a non-significant decrease between 1988 and 1995 among boys (b=−0.017, P>0.05) became significant (b=−0.142, P<0.05). Neither municipality unemployment rate nor its interaction with adolescents’ worry explained psychosomatic problems.

Conclusions

The findings demonstrate the effects of adolescents’ worry about family finances on a secular trend in mental health problems during an economically bleak period of time. The study highlights the need for repeated measurements including a large number of time points over a long time period in order to analyse time-specific putative explanatory factors for trends in adolescent mental health problems.

Endocrinological and subjective stress responses in children with depressive, anxiety, or externalizing disorders

In this study, we used a stress test to investigate endocrinological and subjective stress responses of 8- to 14-year-old children with internalizing or externalizing disorders and healthy controls. The sample (N = 170) consisted of clinical and community children. Parents were given a diagnostic interview to diagnose their children's psychiatric condition. We measured saliva cortisol and subjectively experienced arousal in children before and after the Trier Social Stress Test for Children. Children also rated their performance immediately after the stress test, and 1 hr later they rated their positive and negative thoughts about this stressful event. Children with internalizing or externalizing disorders exhibited a blunted cortisol response compared to healthy controls. Depressed children rated their test performance lower and reported more negative thoughts after the test in comparison to healthy controls, anxious children reported more arousal before and after the task, and children with externalizing disorders reported more positive thoughts. In regression analyses, cortisol and subjective stress responses were both predictive of psychiatric disorders. The study extends previous work on the relation between psychiatric disorders and children's stress responses to an experimentally induced stress task by including a broad range of psychiatric disorders and by integrating endocrinological and subjective stress responses.

The pathogenesis of childhood anxiety disorders: Considerations from a developmental psychopathology perspective

Anxiety disorders are among the most prevalent psychiatric problems in children and adolescents. The present article summarizes the main evidence that has accumulated on the pathogenesis of childhood anxiety disorders during the past two decades. Various risk and vulnerability factors (e.g., genetics, behavioral inhibition, disgust sensitivity, negative life events, family influences), protective factors (e.g., effortful control, perceived control), and maintaining factors (e.g., avoidance, cognitive biases) will be discussed. The information will be described in terms of a developmental psychopathology perspective, which assumes that (a) most forms of psychopathology are the result of multiple causal influences; (b) both successful and unsuccessful adaptation are important for understanding the origins of psychopathology; and (c) psychopathology occurs in a developing organism.

Developing Positive Attitudes for Life in the Twenty-First Century

Amodified version of Chapman's 'Thought Power' programme was used with regular Hong Kong secondary school students. A randomly selected group of students took part in a ten session 'Thought Power' programme organized in their school. The programme focused on stress identification, awareness of the role of thoughts in creating feelings, relaxation, awareness of automatic thoughts that are harmful and helpful, emotional versus physical pain, modification of automatic thoughts, problem-solving and alternative goal setting. Data on harmful thoughts, helpful thoughts, stress, general well-being and locus of control all revealed positive benefits for involvement in the 'Thought Power' programme. These benefits were evident in pre-test post-test comparisons for the project group, as well as in post-test comparisons between the project group and a comparison group. Several comparisons of each type were statistically significant. The findings suggest a role for such programmes in the regular school, and with regular (nonproblem) students.

Treatment of Attention-Deficit/Hyperactivity Disorder in Preschool-Age Children: Child and Adolescent Psychiatrists' Adherence to Clinical Practice Guidelines

OBJECTIVES

To compare child and adolescent psychiatrists' (CAPs) practices in the treatment of preschool children with attention-deficit/hyperactivity disorder (P-ADHD) with published guidelines, and to determine which clinical factors most influence physicians' decisions to initiate pharmacotherapy for P-ADHD.

METHODS

We developed and mailed the Preschool ADHD Treatment Questionnaire (PATQ) to a randomly selected national sample of ∼2200 CAPs trained in the management of ADHD. The PATQ asked CAPs about their approach to clinical management of children ages 4-5 years with ADHD-specifically, how often they recommend parent training in behavior management, medication as a first- or second-line treatment, and which medication they typically choose first. CAPs also rated the perceived importance of 19 different clinical factors in their decision to initiate pharmacotherapy. These 19 factors reflected five child-centered areas of concern: ADHD risk factors, education concerns, social issues (SI), emotional stress, and physical safety (PS). The physicians were asked to rate each factor on a 4-point Likert scale from "not important" to "very important."

RESULTS

The final sample consisted of 339 board-certified CAPs. When adherence to the Academy of Child and Adolescent Psychiatry (AACAP) guidelines was defined as initial treatment with behavior management (not medication) and pharmacotherapy specifically with methylphenidate as second-line treatment, only 7.4% of CAPs followed clinical guidelines. Most physicians identified PS as an important or very important factor when initiating pharmacotherapy for P-ADHD (93.4%), followed by educational concerns (EC) (79.9%), emotional stress (69.6%), SI (52.8%), and the presence of risk factors for ADHD (32.7%).

CONCLUSIONS

The overwhelming majority of CAPs do not follow current AACAP guidelines for treatment of P-ADHD, especially regarding medication initiation and selection. When deciding whether to prescribe medication for P-ADHD, safety and EC were the most important and historical risk factors for ADHD were the least important clinical factors.

An exploratory study of fears among adolescent students from an urban cohort in India

BACKGROUND

Normal fear is an adaptive response to a real or imagined threat. Fears occur in children and adolescents at varying levels while they negotiate different developmental phases.

OBJECTIVE

The present study aimed at assessing the types of fears in children and adolescents between the ages of 11 and 19 years. Age and gender based differences in these fears were also studied.

MATERIALS AND METHODS

The study sample consisted of 2010 adolescents from an urban setting between the ages of 11 and 19 who filled in a proforma questionnaire for socio-demographic details and also filled in the Fear Survey Schedule for Children-Revised (FSSC-R). Statistical analysis of the data was done along with the use of descriptive statistics.

RESULTS

The prevalence of fears among adolescents was found to be 85.17% in the total sample. Girls reported a significantly greater number of fears (p<0.0001) and greater levels of fear (p<0.0001) than boys. Age however, did not affect the number of fears reported. Girls scored significantly higher on all the subscales of the FSSC-R. 'Failing a test' emerged as the most common fear expressed by the sample. Girls expressed a greater fear for snakes and earthquakes than boys.

CONCLUSION

Girls expressed fears to a greater extent than boys and adolescents demonstrated a high level of fears in general. There is a need for further studies in this direction to elucidate the nature of fears in this population.

The development of worry throughout childhood: Avon Longitudinal Study of Parents and Children data

OBJECTIVES

Anxiety is a normal part of childhood and adolescence; however, longitudinal research investigating the development of worrisome thoughts throughout childhood is lacking. This study investigated mothers' perspectives on their child's normal development of worry as the cognitive component of anxiety and its impact on child functioning in a longitudinal population-based cohort.

METHODS

The data for this study were extracted from the Avon Longitudinal Study of Parents and Children. Mothers (N = 2,227) reported on their child's worry content, frequency, control, emotional disruption, and interference when their child was 7, 10, and 13 years old using the parent component of the Development and Well-being Assessment. At age 10 and 13, pubertal status was assessed using children's self-report of pubic hair developmental progress.

RESULTS

Mothers reported a peak of worrisome thoughts at 10. Emotional disruption was highest at 10, and the highest level of interference in daily life was observed at 13, especially for girls. Advanced pubertal status and worry frequency were positively associated for boys at 10 and girls at 13. Advanced puberty at 10 was also associated with overall higher worry frequency and emotional disruption.

CONCLUSIONS

Findings are discussed within a developmental framework outlining the normal development of worrisome thoughts, associated distress, and interference throughout early adolescence. Increased knowledge of normative worry could be informative to further our understanding of adolescence as a vulnerable period for the development of mental health problems, such as generalized anxiety disorder.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Worrying is a normal part of childhood, making distinguishing between normal and pathological worrying challenging. Worry content remains consistent between age 4 and 7, but only for boys. The complexity and elaboration of worrisome thoughts increase from 8 years onwards. What does this study add? Worry frequency peaks at 10 and a low ability to control those worries can be observed at this age. The highest level of interference in performing daily activities due to worries is observed at age 13. Child sex and pubertal status play a role in understanding how normal worry patterns develop from age 10 onwards.

Adapting Metacognitive Therapy to Children with Generalised Anxiety Disorder: Suggestions for a Manual

The metacognitive model and therapy has proven to be a promising theory and intervention for emotional disorders in adults. The model has also received empirical support in normal and clinical child samples. The purpose of the present study was to adapt metacognitive therapy to children (MCT-c) with generalised anxiety disorder (GAD) and create suggestions for an adapted manual. The adaptation was based on the structure and techniques used in MCT for adults with GAD. However, the developmental limitations of children were taken into account. For instance, therapy was aided with worksheets, practical exercises and delivered in a group format. Overall, the intervention relied heavily on practising MCT techniques in vivo with therapist assistance. A detailed description of how the manual was adapted for this age group is given, and examples from a group of four children are presented in a case series. Findings indicate that the adapted version of the metacognitive techniques and manual for children is feasible.

Parental changes after involvement in their anxious child's cognitive behavior therapy

OBJECTIVE

Specific parental behaviors and cognitions are associated with child anxiety. Studies informing us of the directionality of the associations are lacking. We investigated the effect of parental involvement in children's anxiety treatment on parental behaviors and cognitions.

METHOD

Children (N=54, 7-12 years) and parents were randomly allocated to different treatment groups (involved, not involved). Observed behavior, self-reported behavior and cognitions were assessed separately for mothers and fathers at pre-, posttreatment and follow-up.

RESULTS

There were no differences over time for self-reported parental efficacy and observed negativity, but self-reported autonomy granting increased for both groups over time. Differential effects were found between groups for observed paternal over-involvement (fathers involved in treatment showed a more rapid decrease) and self-reported maternal autonomy-granting (non-involved mothers showed a greater increase).

CONCLUSION

Our findings suggest that child anxiety significantly influences parental behaviors and cognitions. Child therapy may successfully change the family system.

Worry in adolescents with visual impairment

We assessed worries of 162 German adolescents with visual impairment. Most adolescents reported low levels of worry. Nonetheless, about 25% showed moderate to high levels of worry related to a further decline of vision and not finding the right romantic partner. While adolescents with visual impairment reported lower levels of worry than an age- and gender-matched sample of sighted adolescents, adolescents with stronger visual impairment worried more than those with lower levels of visual impairment. In addition, higher levels of worry were associated with more depressive symptoms and, in part, with less optimism, negative changes of vision in recent years, higher age, and worse grades at school. Possible reasons for the inconsistent associations of visual impairment with levels of worry are discussed.

Meta-worry, worry, and anxiety in children and adolescents: relationships and interactions

The metacognitive model has increased our understanding of the development and maintenance of generalized anxiety disorders in adults. It states that the combination of positive and negative beliefs about worry creates and sustains anxiety. A recent review argues that the model can be applied to children, but empirical support is lacking. The aim of the 2 presented studies was to explore the applicability of the model in a childhood sample. The first study employed a Danish community sample of youth (n = 587) ages 7 to 17 and investigated the relationship between metacognitions, worry and anxiety. Two multiple regression analyses were performed using worry and metacognitive processes as outcome variables. The second study sampled Danish children ages 7 to 12, and compared the metacognitions of children with a GAD diagnosis (n = 22) to children with a non-GAD anxiety diagnosis (n = 19) and nonanxious children (n = 14). In Study 1, metacognitive processes accounted for an additional 14% of the variance in worry, beyond age, gender, and anxiety, and an extra 11% of the variance in anxiety beyond age, gender, and worry. The Negative Beliefs about Worry scale emerged as the strongest predictor of worry and a stronger predictor of anxiety than the other metacognitive processes and age. In Study 2, children with GAD have significantly higher levels of deleterious metacognitions than anxious children without GAD and nonanxious children. The results offer partial support for the downward extension of the metacognitive model of generalized anxiety disorders to children.

Lasting associations between early-childhood temperament and late-adolescent reward-circuitry response to peer feedback

Behavioral inhibition, a temperament identifiable in infancy, is associated with heightened withdrawal from social encounters. Prior studies raise particular interest in the striatum, which responds uniquely to monetary gains in behaviorally inhibited children followed into adolescence. Although behavioral manifestations of inhibition are expressed primarily in the social domain, it remains unclear whether observed striatal alterations to monetary incentives also extend to social contexts. In the current study, imaging data were acquired from 39 participants (17 males, 22 females; ages 16-18 years) characterized since infancy on measures of behavioral inhibition. A social evaluation task was used to assess neural response to anticipation and receipt of positive and negative feedback from novel peers, classified by participants as being of high or low interest. As with monetary rewards, striatal response patterns differed during both anticipation and receipt of social reward between behaviorally inhibited and noninhibited adolescents. The current results, when combined with prior findings, suggest that early-life temperament predicts altered striatal response in both social and nonsocial contexts and provide support for continuity between temperament measured in early childhood and neural response to social signals measured in late adolescence and early adulthood.

Reduced error-related activation of dorsolateral prefrontal cortex across pediatric anxiety disorders

OBJECTIVE

Abnormalities of cognitive control functions, such as conflict and error monitoring, have been theorized to underlie obsessive-compulsive symptoms but only recently have been considered a potentially relevant psychological construct for understanding other forms of anxiety. The authors sought to determine whether these cognitive control processes elicit the same abnormalities of brain function in patients with pediatric obsessive-compulsive disorder (OCD) as in those with non-OCD anxiety disorders.

METHOD

Functional magnetic resonance imaging of the Multisource Interference Task was used to measure conflict- and error-related activations in youth (8-18 years) with OCD (n = 21) and non-OCD anxiety disorders (generalized anxiety disorder, social phobia, separation anxiety disorder; n = 23) compared with age-matched healthy controls (n = 25).

RESULTS

There were no differences in performance (accuracy, response times) among groups. However, a significant effect of group was observed in the dorsolateral prefrontal cortex (dlPFC) during error processing, driven by decreased activation in patients with OCD and those with non-OCD anxiety compared with healthy youth. Between patient groups, there was no difference in error-related dlPFC activation.

CONCLUSIONS

Hypoactive dlPFC response to errors occurs in pediatric patients with OCD and those with non-OCD anxiety. These findings suggest that insufficient error-related engagement of the dlPFC associates with anxiety across traditional diagnostic boundaries and appears during the early stages of illness.

Validation of a clinically useful measure of children's state anxiety before medical procedures

PURPOSE

Assessment of children's anxiety in busy clinic settings is an important step in developing tailored interventions. This article describes the construct validation of the Children's Anxiety Meter-State (CAM-S), a brief measure of state anxiety.

DESIGN AND METHODS

Existing data were used to investigate the associations between child self-reports of anxiety, parent reports of child anxiety, and observed child distress during an intravenous procedure.

RESULTS

Children's (n = 421) CAM-S scores were significantly associated with all parent measures and observed distress ratings.

PRACTICE IMPLICATIONS

Findings support the use of the CAM-S for assessment of child anxiety in clinical settings.

Cognitive behavior therapy for the anxiety triad

This article presents an overview of the existing, as well as newly developed, cognitive behavior therapy methods for treating the child anxiety triad (separation anxiety disorder, generalized anxiety disorder, and social phobia). For each disorder of the triad, the authors review diagnostic criteria, clinical presentation, disorder-specific treatment methods and innovations, and future directions for research.

The mediating effect of cognitive development on children's worry elaboration

The present study investigated how developmentally determined cognitive mechanisms, holding theoretical links to the worry process, mediate the relationship between Age and Worry Elaboration in children. Sixty-four children aged 3-7 (M = 5.58, SD = 1.28) were presented with a Conservation of Liquid task assessing their Cognitive Development (specifically Concrete Operational Skills), a false-belief task to measure possession of Belief-Desire Theory of Mind, and a task measuring the ability to acknowledge multiple possibilities. The ability to elaborate on potential negative outcomes was assessed using a Worry Elaboration task. Mediation analysis revealed that all three variables significantly mediated the relationship between Age and Worry Elaboration. A multiple mediation model is presented in which Concrete Operational Skills, Belief-Desire Theory of Mind and Multiple Possibilities understanding mediate the relationship between Age and Worry Elaboration.

Worry, General Self-Efficacy and School Achievement: An Exploratory Study With Chinese Adolescents

This study identified issues in school – and in life outside school – that caused significant worry for 120 Chinese adolescents (72 males, 48 females) attending a secondary school in Hong Kong. The study explored relationships existing among 3 variables comprising degree of worry, students' general self-efficacy, and their academic achievement. Findings indicated that the students' principal worries centred on school-related matters such as examinations, promotion to higher classes, and getting a job after graduation. Students also worried significantly about the health status of family members, and family finances. Differences in patterns of worry and in self-efficacy beliefs were found between lower- and higher-achieving students. No significant correlations were found among students' degree of worry, general self-efficacy, and achievement. Results are discussed from the perspective of Chinese culture, the Hong Kong education system, and support for students.

Do Children Differentiate Worry From Fear?

Worry has been defined as a primarily cognitive process closely related to fear or anxiety. This definition is widely accepted by clinicians and researchers investigating worry and is often provided to research participants, especially to children. The present study aimed to empirically test the proposition that both adults and children conceptualise worry as a cognitive process, and that they differentiate it from fear on the basis of worry's relatively stronger association with thinking. Groups of 45 adults and 70 children completed three versions of a worry list questionnaire, reporting on the extent to which they worry about, are afraid of, and think about a list of negative outcomes. Regression analyses showed that in adults, thinking about a negative outcome had a significant unique association with worrying. In children, however, worrying was more strongly associated with fear ratings, especially in the case of physical outcomes. The data suggest that adults and children report on different concepts when they rate their worries via questionnaires. This difference may reflect developmental changes in the worry process itself, or developmental changes in the way individuals interpret and respond to worry list questionnaires. Follow-up studies using alternative methodologies are now needed to further clarify the results.

Worry, beliefs about worry and problem solving in young children

BACKGROUND

Childhood worry is common, and yet little is known about why some children develop pathological worry and others do not. Two theories of adult worry that are particularly relevant to children are Davey's problem-solving model in which perseverative worry occurs as a result of thwarted problem-solving attempts, and Wells' metacognitive model, in which positive and negative beliefs about worry interact to produce pathological worry.

AIMS

The present study aimed to test hypotheses that levels of worry in young children are associated with poor or avoidant solution generation for social problems, and poor problem-solving confidence. It also aimed to explore beliefs about worry in this age group, and to examine their relationships with worry, anxiety and age.

METHOD

Fifty-seven young children (6-10 years) responded to open ended questions about social problem-solving situations and beliefs about worry, and completed measures of worry, anxiety and problem-solving confidence.

RESULTS

Children with higher levels of worry and anxiety reported using more avoidant solutions in social problem situations and children's low confidence in problem solving was associated with high levels of worry. Children as young as 6 years old reported both positive and negative beliefs about worry, but neither were associated with age, gender, or level of anxiety or worry.

CONCLUSIONS

RESULTS indicate similarities between adults and children in the relationships between problem-solving variables and worry, but not in relationships between beliefs about worry and worry. This may be due to developmental factors, or may be the result of measurement issues.

Neural circuitry underlying affective response to peer feedback in adolescence

Peer feedback affects adolescents' behaviors, cognitions and emotions. We examined neural circuitry underlying adolescents' emotional response to peer feedback using a functional neuroimaging paradigm whereby, 36 adolescents (aged 9-17 years) believed they would interact with unknown peers postscan. Neural activity was expected to vary based on adolescents' perceptions of peers and feedback type. Ventrolateral prefrontal cortex (vlPFC) activity was found when adolescents indicated how they felt following feedback (acceptance or rejection) from peers of low vs high interest. Greater activation in both cortical (e.g. superior temporal gyrus, insula, anterior cingulate) and subcortical (e.g. striatum, thalamus) regions emerged in response to acceptance vs rejection feedback. Response to acceptance also varied by age and gender in similar regions (e.g. superior temporal gyrus, fusiform, insula), with greater age-related increases in activation to acceptance vs rejection for females than males. Affective response to rejection vs acceptance did not yield significantly greater neural activity in any region. vlPFC response suggests cognitive flexibility in reappraising initial perceptions of peers following feedback. Striatal response suggests that acceptance is a potent social reward for adolescents, an interpretation supported by more positive self-reported affective response to acceptance than rejection from high- but not low-interest peers.

Children's expressions of negative emotions and adults' responses during routine cardiac consultations

OBJECTIVE

One function of expressing emotion is to receive support. The aim of this study was to assess how children with heart disease express negative emotions during routine consultations, and examine the interaction between children's expressions and adults' responses.

METHODS

Seventy children, aged 7-13 years, completed measures of anxiety and were videotaped during cardiology visits. Adult-child interactions were analyzed using the Verona Definitions of Emotional Sequences.

RESULTS

Children expressed negative emotion, mainly in subtle ways; however, adults rarely recognized and responded to these expressions. The frequency of children's expressions and adults' responses were related to the child's age, level of anxiety, and verbal participation.

CONCLUSION

Children do not openly express negative emotions frequently during routine cardiac consultations; they are more likely to provide subtle cues of negative emotion. When expression of negative emotions does occur, adults may consider using the opportunity to explore the child's emotional experiences.

Preschool onset attention-deficit/hyperactivity disorder: course and predictors of stability over 24 months

OBJECTIVE

The present study examined the course of ADHD over 24 months in a preschool population.

METHOD

n=48 preschoolers with ADHD, aged 3.0-5.11 years, subjects included in a larger sample of preschoolers with depression and other disorders (n=306) were comprehensively assessed at 3 annual time points over 24 months in a prospective longitudinal follow-up study.

RESULTS

Baseline diagnoses of preschool MDD, ODD, and CD were risk factors for ADHD diagnosis over 24 months in this preschool population. Among older preschoolers and after controlling for key demographic variables, ADHD predicted later ADHD diagnosis, along with other significant risk factors - baseline diagnosis of ODD, and/or family history of disruptive disorders, and stressful life events.

CONCLUSIONS

ADHD showed greater homotypic continuity at later rather than earlier preschool ages. Other disruptive comorbidities also emerged as key predictors of stable ADHD course. Study findings may help to inform which preschool ADHD populations to target for early intervention. Larger sample sizes are needed to confirm these findings and to further explore the stability, course, and predictors of outcome of preschool onset ADHD.

The metacognitive model of generalized anxiety disorder in children and adolescents

Worry is a common phenomenon in children and adolescents, with some experiencing excessive worries that cause significant distress and interference. The metacognitive model of generalized anxiety disorder (Wells 1995, 2009) was developed to explain cognitive processes associated with pathological worry in adults, particularly the role of positive and negative beliefs about worry. This review evaluates the application of the model in understanding child and adolescent worry. Other key issues reviewed include the link between cognitive and metacognitive development and worry, and the measurement of worry and metacognitive worry in young people. Implications of these findings and directions for future research are discussed.