Barbara Hoff Esbjørn

CBT for the treatment of child anxiety disorders: a review of why parental involvement has not enhanced outcomes.

Anxiety affects 10% of all children and disrupts educational, socio-emotional development and overall functioning of the child and family. Research has shown that parenting factors (i.e. intrusiveness, negativity, distorted cognitions) contribute to the development and maintenance of childhood anxiety. Recent studies have therefore investigated if the treatment effect of traditional cognitive behavioural therapy may be enhanced by adding a parental component. However, randomised controlled trials have not shown unequivocal support for this assumption. The results are inconsistent and ambiguous. This article investigates possible reasons for this inconsistency and in particular differences in methodology and the theoretical relevance of the applied parental components are highlighted as possible contributory factors. Another factor is that treatment effect is mainly measured by change in the childs diagnostic status rather than changes in parental or family functioning.

The Development of Anxiety Disorders: Considering the Contributions of Attachment and Emotion Regulation

Anxiety disorders are among the most common psychiatric disorders in childhood. Nonetheless, theoretical knowledge of the development and maintenance of childhood anxiety disorders is still in its infancy. Recently, research has begun to investigate the influence of emotion regulation on anxiety disorders. Although a relation between anxiety disorders and emotion regulation difficulties has been demonstrated, little attention has been given to the question of why anxious individuals have difficulties regulating their emotions. The present review examines the evidence of the link between emotion regulation and anxiety. It also explores the unique contributions of attachment style and dysfunctional emotion regulation to the development of anxiety disorders.

Prevalence and co-morbidity among anxiety disorders in a national cohort of psychiatrically referred children and adolescents☆

The paper provides prevalence estimates of anxiety disorders as well as homotypic (e.g., other anxiety disorders) and heterotypic (e.g., mood, externalizing) co-morbidity in a national sample of children and adolescents referred to the psychiatric system in Denmark. Data were gathered from a database containing 83% of all youth referred from 2004 to 2007 (N=13,241). A prevalence of 5.7% of anxiety disorder was found in the sample. Homotypic co-morbidity was found in only 2.8%, whereas heterotypic co-morbidity was found in 42.9% of the cohort. A total of 73.6% had a principal anxiety disorder as opposed to 26.4% who had other principal diagnoses and a secondary anxiety disorder. The national database not only provides a valuable prevalence estimate of anxiety disorders in every-day non-research psychiatric settings, but also highlights the importance of applying standardized screening instruments as routine to increase the precision in recognizing and reporting on childhood anxiety disorders.

Assessing the Revised Child Anxiety and Depression Scale (RCADS) in a National Sample of Danish Youth Aged 8–16 Years

Early identification of anxiety among youth is required to prevent them from going unrecognised and untreated by mental health professionals. A precise identification of the young person’s primary difficulty is also required to guide treatment programs. Availability of a valid and easily administrable assessment tool is crucial for identifying youth suffering from anxiety disorders. The purpose of the present study was therefore to examine the psychometric properties of the Danish version of the Revised Children’s Anxiety and Depression Scale (RCADS). A total of 667 youth from community schools (4th through 9th grade) across Denmark participated in the study. The psychometric properties of the RCADS-DAN resembled those reported in US and Europe. Within scale reliability was excellent with Chronbach’s alpha of.96. All subscales also showed good to excellent internal reliability. The study provides convincing evidence that the RCADS-DAN is a valid assessment tool for screening anxiety in Danish youth.

Anxiety in adolescents born preterm or with very low birthweight: a meta-analysis of case-control studies.

Aim  To determine if adolescents who are born very preterm (<32wks; of gestation) and/or with very low birthweight (VLBW; <1500g) have a higher risk of experiencing clinically significant anxiety problems.

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.

Anxiety levels in clinically referred children and their parents: Examining the unique influence of self‐reported attachment styles and interview‐based reflective functioning in mothers and fathers

OBJECTIVE Although much is known about childhood anxiety disorders, the differential contributions by mothers and fathers to child anxiety is poorly understood. This study examined the relation between child anxiety and parental level of psychopathology, attachment style, and reflective functioning (RF). DESIGN Thirty-eight clinically anxious children aged 7-12 years (55.3% female) referred for treatment and their parents (37 mothers, 34 fathers) participated in the study. METHOD Reflective functioning was coded based on Adult Attachment Interviews. Self-report questionnaires on attachment and psychopathology were administered. RESULTS Paternal psychopathology, attachment avoidance, and attachment anxiety as well as maternal attachment anxiety were associated with child anxiety. Mothers had higher RF abilities than fathers. Lower levels of RF in mothers and higher levels of attachment avoidance in fathers explained 42% of the variance in anxiety levels of the child. CONCLUSION Mothers and fathers may provide unique contributions to the development of child anxiety. The findings highlight the importance of considering fathers as well as mothers in research and treatment for childhood anxiety disorders.

Effects of Age and Anxiety on Processing Threat Cues in Healthy Children

This study investigated relationships between childhood anxiety, chronological age, and threat processing biases. It used a cross-sectional design comparing younger and older children, separated using a median-split on trait anxiety scores into low-anxious versus moderately-anxious groups. Participants were 67 schoolchildren, aged 7–14 years, who completed emotional Stroop and visual probe tasks with angry, happy, and neutral faces. Results from both tasks showed (i) a main effect of age on emotion processing, i.e., increased bias for emotional relative to neutral faces in younger than older children, and (ii) a moderating effect of age on anxiety-related bias for threat. That is, on the modified Stroop task, an enhanced processing bias for angry faces, relative to neutral faces, was found only in the group of moderately-anxious younger children. This bias appeared to be specific to angry faces, as it was not found for happy faces. On the visual probe task, moderately-anxious younger children also showed an enhanced attentional bias for angry faces, relative to neutral faces; in addition, they also showed a similar bias for happy relative to neutral faces. Taken together, findings suggest that moderately-anxious younger children show enhanced processing of threat, relative to neutral information, and that this anxiety-related threat bias lessens with age.

Exploring the Effect of Case Formulation Driven CBT for Children with Anxiety Disorders: A Feasibility Study

BACKGROUND Little is known about the effect of case-formulation based cognitive behaviour therapy (CBT) for anxious children. AIM The present study explores the feasibility of case-formulation driven CBT for anxious children. Parents were involved in treatment as either co-facilitators (involved only as the childs assistants, treatment being primarily directed at the child), or as co-clients (parents received therapy targeting theoretically established maintaining mechanisms; children received half of the sessions, parents the other half). METHOD Feasibility of the case-formulation driven CBT was established by comparing the completion rate and the percentage of children free of anxiety after treatment, with manualized treatments reported in existing meta-analyses. Children aged 7-12 years and their parents participated (n = 54). Families were assessed at pre- and posttreatment and at 6-month follow-up. RESULTS All families completed treatment and the percentage of recovery in the case-formulation driven approach was comparable to results obtained in manualized treatments. CONCLUSION The findings from this stage I study supports the notion that a case-formulation driven approach to CBT may be a feasible option when selecting treatment for anxious children; however, further studies must be conducted before firm conclusions can be drawn.

A structural assessment of the 30-item Metacognitions Questionnaire for Children and its relations to anxiety symptoms.

Theoretical models of anxiety have been developed in adult populations. The applicability of these models in child samples has been assessed using downward extensions of the questionnaires developed to assess the proposed theoretical mechanisms. This poses a challenge, as children are still in the process of developing the skills that are being assessed. Psychometrically sound assessment tools are therefore needed for this developing population, in order to ensure the early detection of mechanisms leading to anxiety disorders in children. This study examined if metacognitions, which play a key role in generalized anxiety disorder (GAD) in adults, can also be reliably assessed in childhood. The study investigated the psychometric properties of the 30-item Metacognitions Questionnaire for Children (MCQ-C₃₀; Gerlach, Adam, Marschke, & Melfsen, 2008) in a national sample of 974 children and adolescents (538 girls) ages 9-17 years. Confirmatory factor analysis supported the 5-factor subscale structure and a 2nd-order total scale factor, which corresponds with previous versions of the scale. MCQ-C₃₀ expectedly correlated significantly with anxiety symptoms and worry. Structural equation modeling revealed that both obsessive-compulsive disorder and generalized anxiety disorder symptoms regressed significantly onto the MCQ-C₃₀. We fitted separate models for children and adolescents, and no noticeable differences are suggested between the models. Female gender was, expectedly, associated with increased levels of general metacognitions. This gender effect was mediated by level of anxiety. Overall, the MCQ-C₃₀ exhibited acceptable psychometric properties in our community sample of children ages 9-17 years. Future studies should investigate the psychometric properties of the instrument in clinical samples and samples of younger children.