Katharina Manassis

Group and Individual Cognitive-Behavioral Therapy for Childhood Anxiety Disorders: A Randomized Trial

OBJECTIVE To compare the efficacy of group and individual cognitive-behavioral therapy (CBT) in children with Axis I anxiety disorders. It was hypothesized that certain subgroups would respond preferentially to one modality. METHOD Seventy-eight children aged 8-12 years with diagnosed anxiety disorders were randomly assigned to a 12-week, manual-based program of group or individual CBT, both with parental involvement. Outcomes included child anxiety (child and parent report) and global functioning as estimated by clinicians. Repeated-measures analyses of variance (ANOVAs) were done. The sample was then dichotomized by self-reported social anxiety (high/low) and parent-reported hyperactivity (high/low) using median splits, and diagnostically by generalized anxiety disorder versus phobic disorders. ANOVAs were repeated. RESULTS Children and parents reported significantly decreased anxiety and clinicians reported significantly improved global functioning regardless of treatment modality. Children reporting high social anxiety reported greater gains in individual treatment than in group treatment (p <.01). Parent reports of hyperactivity and diagnostic differences were not associated with differential treatment response by modality. CONCLUSIONS Children with anxiety disorders appear to improve with CBT, whether administered in a group or individual format. A subgroup of children reporting high social anxiety may respond preferentially to individual treatment. Replication of these findings is indicated.

Attachment in Mothers with Anxiety Disorders and Their Children

OBJECTIVE This study examined adult attachment in mothers diagnosed with anxiety disorders and child-mother attachment in their children. METHOD Eighteen mothers with Axis I anxiety disorders completed the Adult Attachment Interview and standardized questionnaires. These mothers and their preschool children (n = 20) then participated in the Strange Situation Procedure. RESULTS All mothers were classified as nonautonomous with respect to attachment, with 78% judged unresolved. When those judged unresolved were reassigned to their alternate categories, the proportion of nonautonomous mothers was 61%. Eighty percent of the children were classified as insecurely attached, with 65% judged disorganized. When those judged disorganized were reassigned to their alternate categories, the proportion of insecurely attached children was 55%. Sixty-five percent of the children matched their mothers attachment classification. Mothers of securely attached children reported fewer recent life events, fewer depressive symptoms, and a greater sense of parenting competence than mothers of insecurely attached children. CONCLUSIONS These results suggest that attachment measures can be applied to anxious populations. The high rate of insecurity among offspring of anxious mothers indicates a need for longitudinal studies of these children.

Behavioural inhibition, attachment and anxiety in children of mothers with anxiety disorders.

Objective This study examined the relationship between behavioural inhibition, insecure mother-child attachment and evidence of anxiety in the offspring of mothers with anxiety disorders. Method Twenty children aged 18 to 59 months who were born to 18 mothers with diagnosed anxiety disorders were examined for behavioural inhibition (Kagans measures) and mother-child attachment (Strange Situation Procedure). Child anxiety was assessed using DSM-III-R criteria and the Child Behavior Checklist (CBCL). Results Sixty-five percent of the children were behaviourally inhibited. They showed more somatic problems and fewer destructive behaviours than those who were not inhibited. Eighty percent of the children were insecurely attached. They had higher CBCL internalizing scores than secure children and three of them met diagnostic criteria for anxiety disorders. Conclusion Though preliminary, this work suggests a need to identify children of anxious mothers as being at risk for anxiety, especially in the presence of inhibited temperament or attachment difficulties.

Dichotic Listening and Response Inhibition in Children With Comorbid Anxiety Disorders and ADHD

OBJECTIVE To compare children with comorbid anxiety disorders (ANX) and attention-deficit hyperactivity disorder (ADHD) with children with either pure disorder and normal controls on 2 cognitive measures to elucidate the cognitive basis of this comorbidity. METHOD Four groups of children aged 8 to 12 years (n = 64 total) were assessed: ANX, ADHD, both conditions (comorbid group), and neither condition (normal control group). Groups were compared on 2 cognitive measures: a measure of auditory emotional perception (dichotic listening task) and a measure of response inhibition (stop task), chosen for their relative specificity for ANX and ADHD, respectively, in previous studies. RESULTS Multivariate analyses of variance revealed significant group differences on the dichotic listening task (p < .05), with the comorbid group differing from the control group on emotion targets (p < .01) and the ADHD group differing from the control group on word targets (p < .05). On the stop task, the ADHD group appeared slower than the other diagnostic groups on both go and stop-signal reaction times, but differences were not significant. CONCLUSIONS In this study, children with comorbid ANX and ADHD showed reduced auditory emotion recognition relative to controls but did not show response inhibition deficits. Thus they appeared cognitively distinct from children with either pure disorder.

Individual and familial predictors of impairment in childhood anxiety disorders.

OBJECTIVE To determine which correlates of childhood anxiety disorders are predictive of impaired functioning as judged by clinicians. METHOD Seventy-four families of children with anxiety disorders attending a hospital outpatient clinic completed questionnaires measuring child symptoms of anxiety and depression, maternal psychopathology, maternal ratings of child psychopathology, and developmental and environmental difficulties. Clinicians completed the Global Assessment of Functioning (GAF) for each child, and correlations between it and the other measures were ascertained. RESULTS Maternal ratings of child conduct problems, child symptoms of depression, maternal phobic anxiety, developmental difficulties, and psychosocial adversity were significantly correlated with GAF. Results of a multiple regression analysis revealed that these variables accounted for 25% of the variance in GAF scores. The first four variables were significant predictors of impairment in children with phobic disorders. Psychosocial adversity was the only significant predictor of impairment in children with generalized anxiety disorder. CONCLUSIONS In addition to child depression and developmental or psychosocial adversity, impairment in childhood anxiety disorders appears to be related to parental anxiety and behavior management difficulties, particularly in phobic disorders. Addressing the latter factors may enhance treatment efficacy.

Types of parental involvement in CBT with anxious youth: A preliminary meta-analysis

OBJECTIVE Meta-analytic studies have not confirmed that involving parents in cognitive behavior therapy (CBT) for anxious children is therapeutically beneficial. There is also great heterogeneity in the type of parental involvement included. We investigated parental involvement focused on contingency management (CM) and transfer of control (TC) as a potential outcome moderator using a meta-analysis with individual patient data. METHOD Investigators of randomized controlled trials (RCTs) of CBT for anxious children, identified systematically, were invited to submit their data. Conditions in each RCT were coded based on type of parental involvement in CBT (i.e., low involvement, active involvement without emphasis on CM or TC, active involvement with emphasis on CM or TC). Treatment outcomes were compared using a 1-stage meta-analysis. RESULTS All cases involved in active treatment (894 of 1,618) were included for subgroup analyses. Across all CBT groups, means of clinical severity, anxiety, and internalizing symptoms significantly decreased posttreatment and were comparable across groups. The group without emphasis on CM or TC showed a higher proportion with posttreatment anxiety diagnoses than the low-involvement group. Between posttreatment and 1-year follow-up, the proportion with anxiety diagnoses significantly decreased in CBT with active parental involvement with emphasis on CM or TC, whereas treatment gains were merely maintained in the other 2 groups. CONCLUSIONS CBT for anxious children is an effective treatment with or without active parental involvement. However, CBT with active parental involvement emphasizing CM or TC may support long-term maintenance of treatment gains. RESULTS should be replicated as additional RCTs are published.

Assessing attachment: convergent validity of the adult attachment interview and the parental bonding instrument

OBJECTIVE The aim of this study was to determine whether or not the Parental Bonding Instrument (PBI) can provide information about parent-child attachment that is comparable to information obtained from the Adult Attachment Interview (AAI), a more complex measure of attachment. METHOD One hundred and thirty emotionally and/or behaviourally disturbed adolescents (73 male, 57 female; ages 13-19 years, x = 15.3 +/- 1.47 years) participating in a study of attachment and suicidality completed the PBI and the AAI. Data from these measures were compared within participants. RESULTS Maternal care and overprotection on the PBI differed significantly by AAI attachment classification (F3,122 = 2.79, p = 0.012), with autonomous participants showing the most optimal and unresolved participants the least optimal PBI results. Maternal love and maternal involvement/role reversal on the AAI were significant predictors of maternal care and maternal overprotection, respectively, on the PBI (R2 = 0.15; R2 = 0.16). These predictions improved when AAI scales measuring idealisation and involving anger towards the mother were included in the regression analyses (R2 = 0.35; R2 = 0.20). Autonomous participants on AAI showed the highest scale correlations across instruments. CONCLUSIONS Attachment information obtained from the PBI and the AAI is comparable in participants with optimal attachment histories, but not in participants showing idealisation or anger towards their mothers. Caution is, therefore, advisable when using the PBI to obtain attachment information in clinical samples where suboptimal attachment histories are likely.

Cognitive Behavioral Therapy Age Effects in Child and Adolescent Anxiety: An Individual Patient Data Metaanalysis

Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap.

Neuropsychological performance in childhood OCD: A preliminary study

Background: Neuropsychological deficits have often been found in studies of adults with obsessive compulsive disorder (OCD). However, few studies have examined such impairment in children with OCD and of those studies published, the results are mixed. Methods: In the present study, 14 OCD children were compared to 24 healthy developing children of similar age and intellectual ability on a series of neuropsychological tests that assess response inhibition, abstract reasoning and problem solving, planning ability, verbal and nonverbal fluency, working memory, attention and information processing speed, and visual and verbal memory and learning. Results: No significant differences emerged between the children with OCD and healthy controls for working memory, verbal fluency, attention, information processing speed, concept formation/abstraction, and response inhibition. We observed some deficits and a trend toward performance differences between the groups for psychomotor speed and attention, cognitive flexibility, nonverbal fluency, planning ability, and verbal memory and learning. Results are partially consistent with those found in adults with OCD. Findings were not related to depressive symptoms or self‐report feeling of anxiety. Conclusions: This preliminary survey indicates that OCD children may have deficits for cognitive flexibility and planning ability and differ from adults with OCD in not presenting with poor response inhibition or memory deficits. Larger, multi‐site studies are warranted to help delineate the neurocognitive deficits associated with childhood OCD. Depression and Anxiety, 2010.

Beyond behavioral inhibition: Etiological factors in childhood anxiety

Theoretical models of childhood anxiety have emphasized temperamental vulnerability, principally behavioral inhibition, and its interaction with various environmental factors promoting anxiety (for example, overprotective parenting, insecure attachment, life stress). Although clearly establishing the importance of both nature and nurture in anxious psychopathology, these models have not adequately explained the diversity of anxiety disorders presenting in childhood, the fact that some childrens diagnoses change over time, and the progression (in some children) from highly comorbid presentations in middle childhood to one predominant disorder in adolescence. This article presents additional factors that may be helpful to consider when trying to understand these findings and describes applications to promote healthy adjustment in anxious youngsters. Such factors include specific risks for certain disorders, developmental changes and cultural factors affecting the intensity and expression of anxiety, and the emergence of various more or less adaptive coping styles.