Anxiety and depressive disorders in fathers and mothers of anxious school-refusing children

A Systematic Review of Somatic Symptoms in School Refusal

OBJECTIVE

School refusers often display somatic symptoms that are temporally related to school attendance. The aim of this systematic review is to summarize characteristics and causes of somatic symptoms and their management in the context of school refusal. Findings of this review may help clinicians in their daily practice.

METHODS

PubMed and PsycINFO databases were systematically searched (according to PRISMA guidelines) for articles mentioning somatic symptoms in school refusal by May 2020. Among 1025 identified studies, 148 were included.

RESULTS

Unspecific somatic symptoms were frequently the first complaints in school refusal. Abdominal pain, headache, nausea, vomiting, muscular or joint ache, diarrhea, dizziness, fatigue, and palpitation were the most commonly encountered symptoms and were usually not accounted for by an identifiable physical disease. Anxiety was the most recurrent etiology found, but physicians' lack of awareness about psychological comorbidities often delayed psychological/psychiatric referral. Successful therapies consisted of dialectical behavior therapy, anxiety management through relaxation/breathing training, and ignoring the somatic symptoms.

CONCLUSIONS

Somatic symptoms in school refusal are frequent but poorly understood. Their management could include interventions targeting anxiety, psychotherapies such as emotional awareness and expression therapy, third-wave behavioral therapies, and psychoeducation. A multidisciplinary approach through strengthened collaboration between school staff, physicians, and psychologists/psychiatrists is needed to improve well-being in children who experience somatic symptoms as related to school avoidance.

Family Features of Social Withdrawal Syndrome (Hikikomori)

Background: Family may play an important role in the origin, maintenance, and treatment of people with social withdrawal. The aim of this study is to analyze family factors related to social withdrawal syndrome. Methods: Socio-demographic, clinical, and family data, including family psychiatric history, dysfunctional family dynamics, and history of family abuse were analyzed in 190 cases of social withdrawal with a minimum duration of 6 months that started an at-home treatment program. Data were analyzed at baseline and at 12 months. Results: In 36 cases (18%) neither the patient nor the family allowed at home evaluation and treatment by the Crisis Resolution Home Treatment (CRHT) team. Patients had high rates of dysfunctional family dynamics (n = 115, 61.5%), and family psychiatric history (n = 113, 59.3%), especially maternal affective (n = 22, 42.9%), and anxiety disorders (n = 11 20.4%). There was a non-negligible percentage of family maltreatment in childhood (n = 35, 20.7%) and single-parent families (n = 66, 37.8%). Most of the cases lived with their families (n = 135, 86%), had higher family collaboration in the therapeutic plan (n = 97, 51.9%) and families were the ones to detect patient isolation and call for help (n = 140, 73.7%). Higher social withdrawal severity (as defined by at least one of: early age of onset, no family collaboration, lack of insight, higher CGSI score, and higher Zarit score), was associated with family psychiatric history, dysfunctional family dynamics, and family abuse history. All of these predictive variables were highly correlated one to each other. Conclusions: There is a high frequency of family psychiatric history, dysfunctional family dynamics, and traumatic events in childhood (family maltreatment), and these factors are closely interrelated, highlighting the potential role of family in the development and maintenance of social withdrawal.

Psychopathology among parents of children and adolescents with separation anxiety disorder

OBJECTIVE

To examine psychopathology among parents of children and adolescents with separation anxiety disorder (SAD).

METHOD

A case-control design was applied: parents of children and adolescents suffering from SAD (n = 30; age: 10.7 ± 1.8 a) were compared with parents of youth without any psychiatric disease (n = 30; age: 11.2 ± 1.8 a). The SCID-I, a structured clinical interview to assess psychopathology, was applied among the parents group.

RESULTS

Parents of children and adolescents suffering from SAD exhibited a significantly higher prevalence of psychopathology, mainly anxiety disorders and mood disorders, in comparison with the control group. Within anxiety disorders, mothers predominantly suffered from social phobia and specific phobia. Fathers most frequently suffered from obsessive-compulsive disorder and social phobia. Maternal anxiety disorder (current and lifetime) and maternal affective disorder (lifetime) proved to be significant predictors of SAD in youth.

CONCLUSIONS

The associations between parents' psychopathology and the development of SAD in their children are discussed in the light of clinical implications, both in terms of psychotherapeutic care as well as treatment outcome.

Responses to voluntary hyperventilation in children with separation anxiety disorder: implications for the link to panic disorder

BACKGROUND

Biological theories on respiratory regulation have linked separation anxiety disorder (SAD) to panic disorder (PD). We tested if SAD children show similarly increased anxious and psychophysiological responding to voluntary hyperventilation and compromised recovery thereafter as has been observed in PD patients.

METHODS

Participants were 49 children (5-14 years old) with SAD, 21 clinical controls with other anxiety disorders, and 39 healthy controls. We assessed cardiac sympathetic and parasympathetic, respiratory (including pCO2), electrodermal, electromyographic, and self-report variables during baseline, paced hyperventilation, and recovery.

RESULTS

SAD children did not react with increased anxiety or panic symptoms and did not show signs of slowed recovery. However, during hyperventilation they exhibited elevated reactivity in respiratory variability, heart rate, and musculus corrugator supercilii activity indicating difficulty with respiratory regulation.

CONCLUSIONS

Reactions to hyperventilation are much less pronounced in children with SAD than in PD patients. SAD children showed voluntary breathing regulation deficits.

Association of childhood family environments with the risk of social withdrawal ('hikikomori') in the community population in Japan

AIMS

Hikikomori is a form of social withdrawal among those who retreat from social interaction for protracted periods of time. This study examines family-related childhood factors for hikikomori using the retrospective data derived from a population-based survey.

METHODS

We derived data from World Mental Health Survey Japan. The subjects of this study were community residents aged 20-49 years (n=708). Multiple logistic regression was applied to examine the association between the lifetime experience of hikikomori and childhood family environment, adjusting for sex, age, and respondents' history of common mental disorders.

RESULTS

Father's high educational level (odds ratio [OR]=6.0, 95% confidence interval [CI]=1.6-22.9), mother's common mental disorders (OR=5.9, 95%CI=1.1-33.3), and mother's panic disorders (OR=6.6, 95%CI=1.1-39.1) were significantly and positively associated with hikikomori after controlling for respondents' sex, age, and history of mental disorders.

CONCLUSIONS

Our findings suggest that hikikomori cases are more likely to occur in families where the parents have high levels of education. Maternal panic disorder may be another risk factor for children to develop hikikomori.

Anxiety, mood, and substance use disorders in parents of children with anxiety disorders

Examined the prevalence of anxiety, mood, and substance use disorders in the parents of anxiety disordered (AD) children relative to children with no psychological disorder (NPD). The specificity of relationships between child and parent anxiety disorders was also investigated. Results revealed higher prevalence rates of anxiety disorders in parents of AD children relative to NPD children. Specific child-mother relationships were found between child separation anxiety and panic disorder and maternal panic disorder, as were child and maternal social phobia, obsessive compulsive disorder, and specific phobias. Findings are discussed with reference to theory, clinical implications, and future research needs.

Family correlates of comorbid anxiety disorders in children with attention deficit/hyperactivity disorder

This study evaluated parental anxiety and parenting practices associated with comorbid Anxiety Disorders among children with Attention Deficit/Hyperactivity Disorder. Clinic-referred families (n=143) were diagnosed using DSM criteria. Parents and children completed measures of parenting practices. Comorbid anxiety in children was significantly associated with maternal anxiety, overprotectiveness, and a lack of positive parenting. The relative odds of comorbid anxiety appeared to be especially high when all three factors were present. These findings are consistent with theory linking those three family factors to the development of anxiety in all children. Implications for adjunctive treatment of anxiety that is comorbid with ADHD are discussed.

Le refus scolaire

Pediatrician are often questioned by school refusal which relies on a wide range of psychopathological features and necessitates specific approaches. This disabling condition remains underestimated and is still increasing. A poor prognosis associated with a prolonged school absence is the common hallmark of school refusals, regardless of its heterogeneity. Its seriousness warrants early identification and prompt intervention by childhood healthcare professionals, teachers and social workers. A specialized treatment is needed, closely linked with families and school. Promising developments come from a functional rather than symptomatic concept of school refusal. They offer tailored interventions which fit the clinical diversity of school refusals. After a brief historical summary and current definitions of school refusal, the authors review the main clinical features and comorbidity before taking up treatment modalities.

Childhood social anxiety disorder: from understanding to treatment

Childhood social anxiety disorder is a condition of complex origins. Longitudinal studies of shyness and behavioral inhibition, and twin and family history studies, support a genetic component, but experiences such as family environment, parenting, and traumatic conditioning also are observed. Many children with significant shyness and behavioral inhibition do not develop social anxiety disorder, reinforcing the need for longitudinal studies exploring resiliency and risk factors that can be incorporated into diathesis stress models. Efficacy data regarding cognitive and behavioral therapies and pharmacotherapy are promising, and their effectiveness awaits further research. These studies will need to incorporate a multiplicity of perspectives to ensure the long-term sustainability of interventions for social anxiety disorder in children and adolescents.

Neurobiologie et pharmacothérapie de la phobie sociale

Social phobia (also known as social anxiety disorder) is still not clearly understood. It was not established as an authentic psychiatric entity until the diagnostic nomenclature of the American Psychiatric Association DSM III in 1980. In recent years, increasing attention among researchers has contributed to provide important information about the genetic, familial and temperamental bases of social phobia and its neurochemical, neuroendocrinological and neuroanatomical substrates, which remain to be further investigated. Up to date, there have been several findings about the possible influence of variables, including particularly genetic, socio-familial and early temperamental (eg behavioral inhibition) factors that represent risk for the later development of social phobia. Clinical neurobiological studies, based on the use of exogenous compounds such as lactate, CO2, caffeine, epinephrine, flumazenil or cholecystokinin/pentagastrin to reproduce naturally occurring phobic anxiety, have shown that patients with social phobia appear to exhibit an intermediate sensitivity between patients with panic disorder and control subjects. No difference in the rate of panic attacks in response to lactate, low concentrations of CO2 (5%), epinephrine or flumazenil was observed between patients with social phobia and normal healthy subjects, both being less reactive compared to patients with panic disorder. However, patients with social phobia had similar anxiety reactions to high concentrations of CO2 (35%), caffeine or cholecystokinin/pentagastrin than those seen in patients with panic disorder, both being more intensive than in controls. Several lines of evidence suggest specific neurotransmitter system alterations in social phobia, especially with regard to the serotoninergic, noradrenergic and dopaminergic systems. Although no abnormality in platelet serotonin transporter density has been found, patients with social phobia appear to show an enhanced sensitivity of both post-synaptic 5HT1A and 5HT2 serotonin receptor subtypes, as reflected by increased anxiety and hormonal responses to serotoninergic probes. Platelet 5HT2 receptor density has also been reported to be positively correlated to symptom severity in patients with social phobia. During anticipation of public speaking, heart rate was elevated in patients with social phobia compared to controls. Norepinephrine response to the orthostatic challenge test or to the Valsalva maneuver was also greater in patients with social phobia. While normal beta-adrenergic receptor number was observed in lymphocytes, a blunted response of growth hormone to clonidine, an a2-adrenergic agonist, was reported. This suggests reduced post-synaptic a2-adrenergic receptor functioning related to norepinephrine overactivity in social phobia. Decreased cerebrospinal fluid levels of the dopamine metabolite homovanillic acid have also been observed. There are relatively few reports of involvement of the adrenal and thyroid functions in social phobia, and all that has been noted is that patients with social phobia show an exaggerated adrenocortical response to a psychological stressor. Recent advances in neuro-imaging have contributed to find low striatal dopamine D2 receptor binding or low dopamine transporter site density in patients with social phobia. They have also demonstrated the involvement of the cortico-limbic pathways, including the prefrontal cortex, hippocampus and amygdala, which show an increased activity in different experimental conditions. These brain regions have extensively been reported to play an important role in the cognitive appraisal in determining the significance of environmental stimuli, in the emotional and mnemonic integration of information, and in the expression of contextual fear-conditioned behaviors, which might be disrupted in the light of the phenomelogical aspects of social phobia. A substantial body of literature based on case reports, open and placebo-controlled trials, has now clearly examined the efficacy of major classes of psychotropic agents including monoamine oxidase inhibitors, beta-blockers, selective serotonin reuptake inhibitors and benzodiazepines in social phobia. Until recently, irreversible non-selective monoamine oxidase inhibitors, of which phenelzine was the most extensively evaluated, were considered as the most efficacious treatment in reducing the symptomatology associated with social phobia in 50-70% of cases after 4 to 6 weeks. However, side effects and dietary restrictions limit their use. This led to the development of reversible inhibitors of monoamine oxidase A, for which careful dietary monitoring is not required. Moclobemide has been the most widely studied but produced unconvincingly therapeutic effects on social phobic symptoms. To date, selective serotonin reuptake inhibitors may be considered as a reasonable first-line pharmacotherapy for social phobia. There is growing evidence for the efficacy of the selective serotonin reuptake inhibitors fluvoxamine, fluoxetine, citalopram, paroxetine and sertraline. They have beneficial effects with response rates ranging from 50 to 80% in social phobia. It has been recommended that the treatment period should be extended at least 6 months beyond the early improvement achieved within the first 4 to 6 weeks. The overall advantages include tolerability with a low risk of adverse events. The benzodiazepines clonazepam and alprazolam have also been proposed for the treatment of social phobia. Symptomatic relief occurred in 40 to 80% of the cases with a relatively rapid onset of action within the first two weeks. Untoward effects, discontinuation-related withdrawal symptoms and abuse or dependence liability constitute major concerns about the use of benzodiazepines, so they should be reserved for cases unresponsive to the safer medications cited above. Beta-blockers such as atenolol and propanolol have commonly been employed in performance anxiety, decreasing autonomic symptoms (eg, tachycardia, sweating and dry mouth). However, they are not effective in the generalized form of social phobia. Other pharmacologic alternatives seem helpful for the management of social phobia, including venlafaxine, gabapentin, bupropion, nefazodone or augmentation with buspirone. Preliminary studies point to promising effects of these agents. Larger controlled clinical trials are now needed to confirm their potential role in the treatment of social phobia.

Separation anxiety disorder in young children: a longitudinal and family analysis

We conducted a longitudinal study of young children with clinical, subclinical, or nonclinical levels of separation anxiety to evaluate the diagnostic stability and concomitant parent and family variables of separation anxiety disorder (SAD). Youngsters were assessed at age 3 years (n = 60) and 3.5 years later (n = 44). Data were collected from children, parents, teachers, and clinicians. Results revealed that most diagnoses of SAD were not stable during this developmental period, as many children drifted toward subclinical or nonclinical status. In addition, children with clinical SAD, compared to those with subclinical SAD or no symptoms of SAD, had a disproportionately higher number of comorbid diagnoses and experienced significantly greater somatic concerns, anxiety, and general internalizing behavior. In addition, their parents experienced greater depression, obsessive-compulsive behavior, phobic anxiety, and general distress. The results preliminarily support prior findings that most children experience a dissipation of SAD symptoms in young childhood but that some children continue to experience stable, significant distress. The results are consistent with prior research on older children that SAD remits for many but not all youth and suggest that parent and family variables may have much to do with cases of poor remission in this population.

Is childhood separation anxiety disorder a predictor of adult panic disorder and agoraphobia? A seven-year longitudinal study

OBJECTIVE

To examine whether separation anxiety disorder (SAD) in childhood is a risk factor for panic disorder and agoraphobia in adulthood.

METHOD

Patients (n = 85) who had completed treatment for SAD, generalized anxiety disorder, and/or social phobia 7.42 years earlier (on average) were reassessed using structured diagnostic interviews.

RESULTS

Subjects with a childhood diagnosis of SAD did not display a greater risk for developing panic disorder and agoraphobia in young adulthood than those with other childhood anxiety diagnoses. Subjects with a childhood diagnosis of SAD did not more frequently meet full diagnostic criteria for panic disorder and agoraphobia, generalized anxiety disorder, social phobia, or major depressive disorder in adulthood than subjects with childhood diagnoses of generalized anxiety disorder or social phobia, but were more likely to meet criteria for other anxiety disorders (i.e., specific phobia, obsessive compulsive disorder, posttraumatic stress disorder, and acute stress disorder).

CONCLUSIONS

These results argue against the hypothesis that childhood SAD is a specific risk factor for adult panic disorder and agoraphobia.

Parenting behaviors in parents with anxiety disorders

Anxiety disorders are familial, and although considerable evidence supports the role of genetic/biological parameters in their development, these alone do not entirely explain their etiology. In this study, the role of parenting behavior as a possible factor in the transmission of anxiety from parent to child was examined. Using interview, self-report, and direct behavioral observation, behaviors of parents with an anxiety disorder were compared to those of parents without an anxiety disorder on a number of dimensions, but particularly with respect to whether anxious parents actively inhibited their children from engaging in normal age appropriate activities. These behaviors were assessed during routine activities and in a structured non-conflictual play task. Although anxious parents did not overtly restrict their child's behavior in either type of activity, they reported higher levels of distress when their children were engaged in these activities. Similarly, the "emotional climate" in families with an anxious parent differed significantly from families without an anxious parent. The results are discussed in terms of how parenting behaviors might influence the development of maladaptive anxiety via social learning and information transfer, and their heuristic implications.

Predictors of treatment response in anxious-depressed adolescents with school refusal

OBJECTIVE

To identify predictors of treatment response to 8 weeks of cognitive-behavioral therapy (CBT) among anxious-depressed adolescents with school refusal, half of whom received imipramine plus CBT and half of whom received placebo plus CBT.

METHOD

A hierarchical multiple regression analysis was used to evaluate the following variables as potential predictors of treatment response as measured by school attendance at the end of treatment: baseline severity (school attendance at baseline), drug group (imipramine versus placebo), presence of separation anxiety disorder (SAD), and presence of avoidant disorder (AD).

RESULTS

Baseline attendance, CBT plus imipramine, SAD, and AD were significant predictors of treatment response and accounted for 51% of the variance in outcome. Specifically, a higher rate of attendance at baseline and receiving imipramine predicted a better response to treatment whereas the presence of SAD and AD predicted a poorer response to treatment. The relationship between sociodemographic variables and treatment outcome was also evaluated. Age and socioeconomic status were unrelated to school attendance after treatment. Males had significantly higher rates of attendance after treatment than females.

CONCLUSIONS

Adolescents with school refusal are a heterogeneous population and require individualized treatment planning. Variables such as diagnosis and severity at the start of treatment should be taken into consideration when planning treatment.

Separation anxiety disorder in children and adolescents: epidemiology, diagnosis and management

This paper provides an overview of the phenomenology, longitudinal outcome data, assessment and management of separation anxiety disorder (SAD) in children and adolescents. SAD is qualitatively different from early worries, and is characterised by an abnormal reactivity to real or imagined separation from attachment figures, which significantly interferes with daily activities and developmental tasks. Different epidemiological studies indicate a prevalence of 4 to 5% in children and adolescents. In contrast to other anxiety disorders, 50 to 75% of children with SAD come from homes of low socioeconomic status. The severity of symptomatology ranges from anticipatory uneasiness to full-blown anxiety about separation, but children are usually brought to the clinician when SAD results in school refusal or somatic symptoms. School refusal is reported in about 75% of children with SAD, and SAD is reported to occur in up to 80% of children with school refusal. Longitudinal studies have suggested that childhood SAD may be a risk factor for other anxiety disorders, but whether this link is specific to, for example, panic disorder and agoraphobia, or whether SAD represents a general factor of vulnerability for a broad range of anxiety disorders is still debated. Most relevant data are reported on nonpharmacological treatments (psychoeducational, behavioural, cognitive-behavioural, family and psychodynamic), and these are the first choice approach in SAD. Controlled studies show efficacy of cognitive-behavioural therapy in children with anxiety disorders and specifically in SAD-school phobia, supporting this approach as the best proven treatment. Pharmacotherapy should be used in addition to behavioural or psychotherapeutic intervention when the child's symptoms have failed to respond to those treatments, and he/she is significantly impaired by the symptoms. Selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRI) have a good adverse effect profile and may be considered as first choice drugs in SAD. When different SSRIs fail to improve symptomatology, a trial with a tricyclic antidepressant (TCA) is indicated, with careful monitoring of cardiac functioning. Because of the adverse effect profile and the potential for abuse and dependence, benzodiazepines should be used only when a rapid reduction of symptomatology is needed, until the SSRI or the TCA have begun to be effective (few weeks). Buspirone should be considered in children who have not responded to other treatments. Further research is needed to confirm efficacy of newer antidepressants (venlafaxine, mirtazapine, nefazodone) in childhood anxiety disorders.

Bringing up bashful baby. Developmental pathways to social phobia

Shyness is a risk factor for, or an early manifestation of, more enduring problems with social anxiety. But the majority of shy children do not develop social phobia, and factors that further increase risk are poorly understood, underscoring the complexity of this relationship. Studies uniformly show that social phobia (particularly the generalized subtype) runs in families, and twin studies suggest that a moderate component of this familial tendency is genetic in origin. Understanding the genetic etiology of other neuropsychiatric disorders characterized by abnormal social interest, social communication (e.g., autism), or both may prove informative for social phobia. The contribution of unique experiences to the development of social phobia is clear from genetic studies, but studies to date have failed to elucidate what kinds of experiences might be involved. Given patient reports that socially traumatic conditioning experiences have often occurred, detailed evaluation of these kinds of experiences in monozygotic twins discordant for social phobia would be a particularly informative research strategy. Nongenetic familial factors probably have more limited effects on the development of social phobia, although the impact of parental modeling of, and acquiescence to, childhood social fears deserves to be further investigated. These factors may be particularly salient for the expression of social phobia in children whose genes render them susceptible. If so, it should be possible to design early interventions to prevent the progression from phobia proneness (e.g., designated on the basis of family history) to phobic disorder.

Separation anxiety and actual separation experiences during childhood in patients with panic disorder

OBJECTIVE

The association between separation anxiety in childhood and actual separation experiences during childhood has not yet been investigated in patients with panic disorder.

METHODS

In 115 patients with panic disorder with or without agoraphobia and in 124 control subjects without a history of psychiatric illness, we assessed separation anxiety during childhood, retrospectively, using DSM-IV and ICD-10 criteria and the Separation Anxiety Symptom Inventory (SASI). In addition, actual separation experiences from age 0 to 15 years were assessed, retrospectively.

RESULTS

A total of 22.6% of the patients and 4.8% of the control subjects fulfilled both DSM-IV and ICD-10 criteria for childhood separation anxiety (chi 2 = 11.8; P < 0.0001). Further, 57.4% of the patients and 37.9% of the control subjects reported actual separation experiences during their childhood (chi 2 = 9.09, P < 0.003). Separation anxiety and actual separation experiences, however, were independent of each other.

CONCLUSION

These results suggest that separation anxiety during childhood is not a consequence of actual traumatic separation experiences in panic disorder patients.

School refusal in children and adolescents: a review of the past 10 years

OBJECTIVE

To critically review the past 10 years of research on school refusal in children and adolescents.

METHOD

Literature on school refusal published from 1990 onward was reviewed following a systematic search of PsycINFO. The review focuses on definitional issues, epidemiology and school refusal identification, diagnostic considerations, family functioning, assessment, treatment, and follow-up studies.

RESULTS

While definitional and conceptual issues are still evident, promising developments have occurred in relation to assessment and treatment practices and understanding of the family context of school refusal.

CONCLUSIONS

From a clinical viewpoint, school refusal cases require comprehensive assessment and treatment. Advances have been made in the treatment of school refusal. However, additional controlled studies evaluating interventions for school refusal are needed.

Childhood anxiety disorders: lessons from the literature

Studies of childhood anxiety disorders have increased in recent years, but the clinical implications of the work are sometimes difficult to discern. This paper reviews salient findings (related to the assessment and management of anxious children) published in the last 5 years. The high comorbidity among disorders, the occurrence of different disorders in the same child over time, recent changes in diagnostic categories, the availability of new anxiety measures, and poor correspondence between parent and child reports of symptoms all underscore the need for thorough assessment. Increasing evidence supports cognitive-behavioural treatments for anxiety disorders, alone or in combination with pharmacotherapy. Other important aspects of management suggested by developmental studies of anxious children include psychoeducation about constitutional factors in the development of anxiety, interventions to address parental anxiety, parenting advice regarding behaviour management and reduction of family conflict, and treatment of child impairment to decrease the risk of depression. Questions requiring further research are identified.