Amy R. Perwien

Anxiety Disorders in Children and Adolescents: A Review of the Past 10 Years

OBJECTIVE To critically review the research on anxiety disorders in children and adolescents, focusing on new developments in the past 10 years. METHOD This review includes recent articles which contribute to the conceptualization, assessment, and treatment of childhood anxiety disorders. RESULTS Information was organized into a developmental framework. Anxiety disorders research has shown steady progress. CONCLUSIONS More research is needed, particularly in the areas of neurobiological basis of anxiety disorders, longitudinal studies, and treatment.

Knowledge and information about ADHD: Evidence of cultural differences among African-American and white parents

Attention deficit hyperactivity disorder (ADHD) is considered the most common child psychiatric disorder in the United States of America. Despite the high prevalence (estimated at 3-5%), little is known about the level and source of knowledge about ADHD among those affected by the disease, and about cultural and ethnic variations in knowledge levels and information sources. This represents a serious deficit, because health behavior, including demand for health services, is thought to be strongly influenced by knowledge or beliefs held by individuals and their networks. Furthermore, recent research suggested minority children may be less likely to receive services for ADHD. To examine possible differences in ADHD knowledge and information source, a sample of 486 African-American and white parents of children at high risk for ADHD were surveyed by telephone and subsequently participated in face-to-face interviews addressing their explanatory models of ADHD. Results revealed significant ethnic differences in knowledge and sources of information about ADHD. Fewer African-American parents than white parents indicated that they had ever heard of ADHD (69% compared to 95%, P < 0.001), or that they knew some or a lot about it (36% compared to 70%, P < 0.001) African-American parents were more likely to attribute ADHD to excessive sugar in the diet than whites (59% compared to 30.0%, P < 0.001). Finally, even though the physician was listed as the most preferred information source for both groups, only 17.5% of African-American parents reported they had received information about ADHD from the physician compared to 29% of whites (P < 0.01). African American parents reported less use of and less preference for written informational materials (newspapers, journals, library) than white parents. We conclude that substantially more research should be undertaken to examine the relationship between ethnicity and ADHD knowledge, to inform culturally appropriate education campaigns and to improve access to services for this important treatable child mental health condition.

Imipramine Plus Cognitive-Behavioral Therapy in the Treatment of School Refusal

OBJECTIVE To investigate the efficacy of 8 weeks of imipramine versus placebo in combination with cognitive-behavioral therapy (CBT) for the treatment of school-refusing adolescents with comorbid anxiety and major depressive disorders. METHOD This was a randomized, double-blind trial with 63 subjects entering the study and 47 completing. Outcome measures were weekly school attendance rates based on percentage of hours attended and anxiety and depression rating scales. RESULTS Over the course of treatment, school attendance improved significantly for the imipramine group (z = 4.36, p < .001) but not for the placebo group (z = 1.26, not significant). School attendance of the imipramine group improved at a significantly faster rate than did that of the placebo group (z = 2.39, p = .017). Over the 8 weeks of treatment, there was a significant difference between groups on attendance after controlling for baseline attendance; mean attendance rate in the final week was 70.1% +/- 30.6% for the imipramine group and 27.6% +/- 36.1% for the placebo group (p < .001). Defining remission as 75% school attendance, 54.2% of the imipramine group met this criterion after treatment compared with only 16.7% from the placebo group (p = .007). Anxiety and depression rating scales decreased significantly across treatment for both groups, with depression on the Childrens Depression Rating Scale-Revised decreasing at a significantly faster rate in the imipramine group compared with the placebo group (z = 2.08, p = .037). CONCLUSIONS Imipramine plus CBT is significantly more efficacious than placebo plus CBT in improving school attendance and decreasing symptoms of depression in school-refusing adolescents with comorbid anxiety and depression.

Somatic symptoms in anxious-depressed school refusers

OBJECTIVE To identify the most common physical complaints in a sample of adolescent school refusers with comorbid anxiety and depressive disorders. Whether somatic symptoms are more likely to be associated with high levels of anxiety or high levels of depression was also explored. METHOD Forty-four adolescents in a treatment study were evaluated at baseline with structured psychiatric interviews and measures of anxiety, depression, and somatization. RESULTS The most common somatic complaints were in the autonomic and gastrointestinal categories. In simple regression analyses, anxiety level as measured with the Revised Childrens Manifest Anxiety Scale and depression level as measured with the Beck Depression Inventory each significantly predicted the severity of somatic symptoms. The correlation between percentage of days absent from school and severity of somatic symptoms approached significance (r = .27, p = .074). CONCLUSIONS Knowledge that somatic complaints are commonly an expression of underlying anxiety and depression may facilitate more rapid referral for psychiatric assessment and treatment and thereby help avoid unnecessary medical workups and sequelae from school refusal.

Caffeine Withdrawal in Normal School-Age Children

OBJECTIVE Caffeine is widely consumed by children around the world. The purpose of this study was to determine whether children manifest withdrawal effects after cessation of caffeine intake. METHOD Thirty normal children completed the single-blind, within-subjects, repeated-measures study with weekly sessions. Subjects were tested four times: (1) baseline (on regular caffeine diet); (2) on caffeine (approximately 120 to 145 mg/day); (3) during withdrawal (24 hours after discontinuation of caffeine taken for 13 consecutive days); and (4) at return to baseline. Subjects were evaluated with self-report measures of symptoms and objective measures of attention, motor performance, processing speed, and memory. RESULTS During caffeine withdrawal, there was a significant deterioration on response time of a visual continuous performance test of attention. This finding is consistent with caffeine withdrawal. The deterioration in response time appeared to persist for 1 week. CONCLUSIONS Twenty-four hours after children discontinued caffeine, there was a decrease in performance on reaction time of a task requiring sustained attention. Further work is indicated to determine whether children manifest caffeine withdrawal effects after cessation of caffeine intake.

Diagnostic utility of two commonly used ADHD screening measures among special education students.

OBJECTIVE To examine the diagnostic utility of two commonly used attention-deficit hyperactivity disorder (ADHD) screening measures in a population of special education students and address whether screener performance is affected by demographic characteristics. METHOD A school district population of special education students was screened for ADHD risk using two parent questionnaires, the 46-item Attention Deficit Disorders Evaluation Scale (ADDES) and the 10-item Conners Abbreviated Symptom Questionnaire (ASQ). All high-risk children and a random sample of low-risk children subsequently underwent DSM-IV-based diagnostic assessment through parental diagnostic interviews (Diagnostic Interview Schedule for Children Version 3.0). Diagnostic utility was summarized by sensitivity, specificity, predictive utilities of positive and negative tests, and efficiency, all of which were estimated using an approach that accounted for the sampling design. RESULTS Overall efficiency scores ranged between 70% and 74%. Sensitivity estimates were below 70% even at low screener cutoff scores. The ADDES did not perform significantly better than the ASQ. Significant gender and ethnicity effects emerged. CONCLUSIONS Overall, both the ASQ and the ADDES yielded substantial numbers of false positives and false negatives among this population of children, indicating that alternative approaches will be required to accurately and efficiently identify children in need of services for ADHD. Child psychiatrists can play a valuable consulting role as school districts and primary care settings struggle to implement appropriate identification procedures for ADHD.

Anxiety Rating for Children — Revised: Reliability and validity

Abstract The purpose of this investigation was to define the psychometric properties of the Anxiety Rating for Children — Revised (ARC-R), a clinician rating scale for the assessment of anxiety symptoms in children and adolescents. The ARC-R is comprised of an Anxiety subscale and a Physiological subscale. In a clinical sample ( N = 22), the test-retest reliability and interrater reliability were investigated. In a nonoverlapping clinic sample of school refusers ( N = 199), the internal reliability and convergent, divergent, and discriminant validity were evaluated. Test-retest ( r = .93) and interrater reliability ( r = .95) were excellent. There was good internal reliability of items (Cronbachs alpha = .80). The Anxiety subscale of the ARC-R correlated somewhat higher with self-report anxiety instruments ( r = .62) than with self-report depression instruments ( r = .54–.56). The Anxiety subscale of the instrument discriminated between children with and without an anxiety disorder. This new instrument was shown to be a reliable measure of clinician-rated anxiety. The validity of the ARC-R Anxiety subscale was demonstrated. The potential uses of this instrument for clinical and research purposes are highlighted.