Colleen M. Cummings

Comorbidity of Anxiety and Depression in Children and Adolescents: 20 Years After

Brady and Kendall (1992) concluded that although anxiety and depression in youths are meaningfully linked, there are important distinctions, and additional research is needed. Since then, studies of anxiety-depression comorbidity in youths have increased exponentially. Following a discussion of comorbidity, we review existing conceptual models and propose a multiple pathways model to anxiety-depression comorbidity. Pathway 1 describes youths with a diathesis for anxiety, with subsequent comorbid depression resulting from anxiety-related impairment. Pathway 2 refers to youths with a shared diathesis for anxiety and depression, who may experience both disorders simultaneously. Pathway 3 describes youths with a diathesis for depression, with subsequent comorbid anxiety resulting from depression-related impairment. Additionally, shared and stratified risk factors contribute to the development of the comorbid disorder, either by interacting with disorder-related impairment or by predicting the simultaneous development of the disorders. Our review addresses descriptive and developmental factors, gender differences, suicidality, assessments, and treatment-outcome research as they relate to comorbid anxiety and depression and to our proposed pathways. Research since 1992 indicates that comorbidity varies depending on the specific anxiety disorder, with Pathway 1 describing youths with either social phobia or separation anxiety disorder and subsequent depression, Pathway 2 applying to youths with coprimary generalized anxiety disorder and depression, and Pathway 3 including depressed youths with subsequent social phobia. The need to test the proposed multiple pathways model and to examine (a) developmental change and (b) specific anxiety disorders is highlighted.

No need to worry: The promising future of child anxiety research.

Looking ahead, we review two themes concerning the treatment of youth anxiety: treatment personalization and its dissemination and implementation (DI). Anxious youth can be effectively treated, but not all youth respond, suggesting the need to further adapt, or personalize, interventions for nonresponders. Treatment personalization may benefit from increased knowledge of social phobia, modular and transdiagnostic treatments, and active mechanisms of change. Further, despite the availability of efficacious treatments, they remain underutilized in the community. DI needs to overcome concerns regarding treatment manuals, social and organizational factors, therapist training, and reaching underserved populations. Finally, computer-based programs can facilitate dissemination through both treating anxious youth and training therapists.

Computers and psychosocial treatment for child anxiety: recent advances and ongoing efforts.

Building on the empirical data supporting the efficacy of cognitive–behavioral therapy (CBT) for child anxiety, researchers are working on the development and evaluation of cost‐effective and transportable CBT approaches. Related to this, a widely endorsed goal is to disseminate evidence‐based treatments from research settings to community settings. Computer‐assisted treatments have emerged as a means to provide cost‐effective and efficient service to an increased number of anxious youth for whom a CBT treatment would be otherwise unavailable. We offer a rationale for the development and evaluation of computer‐assisted psychosocial treatments for anxiety in youth, offer illustrative advances made in this area, and describe our efforts in using computers to enhance dissemination of CBT for child anxiety. Specifically, our illustrations include a description of (a) Camp‐Cope‐A‐Lot (CCAL), a computer‐assisted CBT for the treatment of anxiety disorders in youth ages 7–12, and (b) CBT4CBT: Computer‐based training in CBT for anxious youth. Findings from evaluations of these programs are summarized, and further advances are proposed and discussed. Depression and Anxiety, 2011.  © 2010 Wiley‐Liss, Inc.

Mediators of change in the Child/Adolescent Anxiety Multimodal Treatment Study.

OBJECTIVE Test changes in (a) coping efficacy and (b) anxious self-talk as potential mediators of treatment gains at 3-month follow-up in the Child/Adolescent Anxiety Multimodal Treatment Study (CAMS). METHOD Participants were 488 youth (ages 7-17; 50.4% male) randomized to cognitive-behavioral therapy (CBT; Coping cat program), pharmacotherapy (sertraline), their combination, or pill placebo. Participants met Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) criteria for generalized anxiety disorder, social phobia, and/or separation anxiety disorder. Coping efficacy (reported ability to manage anxiety provoking situations) was measured by youth and parent reports on the Coping Questionnaire, and anxious self-talk was measured by youth report on the Negative Affectivity Self-Statement Questionnaire. Outcome was measured using the Pediatric Anxiety Rating Scale (completed by Independent Evaluators blind to condition). For temporal precedence, residualized treatment gains were assessed at 3-month follow-up. RESULTS Residualized gains in coping efficacy mediated gains in the CBT, sertraline, and combination conditions. In the combination condition, some unique effect of treatment remained. Treatment assignment was not associated with a reduction in anxious self-talk, nor did anxious self-talk predict changes in anxiety symptoms. CONCLUSIONS The findings suggest that improvements in coping efficacy are a mediator of treatment gains. Anxious self-talk did not emerge as a mediator.

The Therapeutic Relationship in Cognitive-Behavioral Therapy and Pharmacotherapy for Anxious Youth

OBJECTIVE We examined the therapeutic relationship with cognitive-behavioral therapists and with pharmacotherapists for youth from the Child/Adolescent Anxiety Multimodal Study (Walkup et al., 2008). The therapeutic relationship was examined in relation to treatment outcomes. METHOD Participants were 488 youth (ages 7-17 years; 50% male) randomized to cognitive-behavioral therapy (CBT; Coping Cat), pharmacotherapy (sertraline), their combination, or placebo pill. Participants met criteria for generalized anxiety disorder, social phobia, and/or separation anxiety disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994). The therapeutic relationship was assessed by youth report at Weeks 6 and 12 of treatment using the Childs Perception of Therapeutic Relationship scale (Kendall et al., 1997). Outcome measures (Pediatric Anxiety Rating Scale; Research Units on Pediatric Psychopharmacology Anxiety Study Group, 2002; and Clinical Global Impressions Scales; Guy, 1976) were completed by independent evaluators blind to condition. RESULTS For youth who received CBT only, a stronger therapeutic relationship predicted positive treatment outcome. In contrast, the therapeutic relationship did not predict outcome for youth receiving sertraline, combined treatment, or placebo. CONCLUSION A therapeutic relationship may be important for anxious youth who receive CBT alone.

A probabilistic and individualized approach for predicting treatment gains: an extension and application to anxiety disordered youth.

The objective of this study was to extend the probability of treatment benefit method by adding treatment condition as a stratifying variable, and illustrate this extension of the methodology using the Child and Adolescent Anxiety Multimodal Study data. The probability of treatment benefit method produces a simple and practical way to predict individualized treatment benefit based on pretreatment patient characteristics. Two pretreatment patient characteristics were selected in the production of the probability of treatment benefit charts: baseline anxiety severity, measured by the Pediatric Anxiety Rating Scale, and treatment condition (cognitive-behavioral therapy, sertraline, their combination, and placebo). We produced two charts as exemplars which provide individualized and probabilistic information for treatment response and outcome to treatments for child anxiety. We discuss the implications of the use of the probability of treatment benefit method, particularly with regard to patient-centered outcomes and individualized decision-making in psychology and psychiatry.

Anxious youth in research and service clinics

With the current focus on increasing utilization of empirically supported treatments, knowledge of sample differences and similarities has increasing importance. The present study compared anxiety-disordered youth (age 7-13) from (a) five Norwegian service clinics (SC, N = 111) to (b) a university research clinic (RC) in Philadelphia, USA (N = 144) on pre-treatment characteristics measured by the Multidimensional Anxiety Scale for Children, Child Behavior Checklist, Teacher Report Form, Anxiety Disorders Interview Schedule, and Childrens Global Assessment Scale (CGAS). SC youth demonstrated higher levels of anxiety based on child- (d = 0.42-1.04) and parent-report (d = 0.53) and conduct problems based on parent-report (d = 0.43) compared to RC youth. SC youth was more functionally impaired on the CGAS (d = 0.97), whereas RC youth evidenced a greater number of diagnoses (d = 0.63). The two samples were equivalent regarding parent-reported symptoms of affective, somatic, attention-deficit/hyperactivity, and oppositional problems. Future directions and clinical implications are discussed.

Parenting behaviors and anxious self-talk in youth and parents.

The present study examined the association between parental anxious self-talk, parenting behaviors, and youth anxious self-talk. Parents and youth ages 7 to 14 (M = 10.17; N = 208; 53% male) seeking treatment for anxiety were evaluated for anxiety symptoms, youth anxious self-talk, parental anxious self-talk, and youth-perceived parenting behavior. Youth and parental anxious self-talk were assessed by both child and parent self-reports; youth-perceived parenting behaviors were assessed by youth-reports. Parenting behaviors included separate ratings of paternal and maternal (a) acceptance, (b) psychological control, and (c) firm/behavioral control. Correlational analyses revealed that maternal anxious self-talk, but not paternal anxious self-talk, was significantly associated with youths anxious self-talk. Maternal anxious self-talk had an inverse association with youth-perceived maternal acceptance, but was not associated with youth-perceived maternal psychological or behavioral control. Higher youth-perceived maternal acceptance was significantly associated with lower youth anxious self-talk. Youth-perceived maternal acceptance partially mediated the association between mothers anxious self-talk and youths anxious self-talk. However, this mediation effect disappeared when taking into account youth depressive symptoms. Results are discussed in relation to clinical implications and future directions in research.

Pediatric bipolar disorder: recognition in primary care.

Purpose of review Bipolar disorder (BPD) is increasingly diagnosed in youth in both outpatient and inpatient settings. Research on BPD in youth has also increased dramatically; this paper summarizes issues of clinical relevance in primary care, advancements in the last year, and areas in which more research is needed. Recent findings Key issues and new developments are summarized in the following areas such as epidemiology and relevance, assessment and differential diagnosis, patient and family decision support, shared decision making and triage, treatment, and monitoring and collaboration with mental health professionals. Recent practice guidelines have important implications for diagnosis and treatment. Summary Early-onset BPD appears to have a more severe course and more comorbidity than later life onset, as well as longer delays in treatment seeking. Affected children show differences in cognitive functioning and neuroanatomy compared with the general population. Assessment of BPD in children needs to be comprehensive and longitudinal, as diagnosis remains a debated topic. Medications are a primary part of treatment, but more double-blind, placebo-controlled trials are needed. Psychosocial adjunctive treatment is important. Children with a family history of BPD are at risk for impaired functioning and psychopathology; high-risk studies will increase our understanding of the onset and course of BPD.

Emotional reactivity to daily events in youth with anxiety disorders

ABSTRACT Background: Although research supports associations between anxiety and emotional reactivity in adults (Cisler, J. M., Olatunji, B. O., Feldner, M. T., & Forsyth, J. P. (2010). Emotion regulation and the anxiety disorders: an integrative review. Journal of Psychopathology and Behavioral Assessment, 32(1), 68–82.), few studies have examined emotional reactivity in anxious youth (e.g., Carthy et al., 2010; Tan, P. Z., Forbes, E. E., Dahl, R. E., Ryan, N. D., Siegle, G. J., Ladouceur, C. D., & Silk, J. S. (2012). Emotional reactivity and regulation in anxious and nonanxious youth: a cell-phone ecological momentary assessment study. Journal of Child Psychology and Psychiatry, 53(2), 197–206.). Methods: Using daily diary methodology, this study examined both negative affect (NA) and positive affect (PA) reactivity to daily events in youth diagnosed with anxiety (N = 68; 60% female; 78% non-Hispanic White; M age = 11.18 years, SD = 3.17). We also examined whether parent-reported emotion regulation would predict emotional reactivity. Results: Participants reported more NA on days they experienced more negative parent and teacher events and less PA on days that they experienced more negative peer events. Additionally, better emotion regulation was associated with less NA reactivity to negative teacher events and to both negative and positive academic events. Conclusions: Interpersonal events have a salient effect on daily affect for anxious youth. Youth anxiety therapists should target emotion regulation associated with negative events involving adults and address barriers to developing and maintaining positive peer relationships.