Roma A. Vasa

Attention Bias toward Threat in Pediatric Anxiety Disorders.

OBJECTIVE To examine attention bias toward threat faces in a large sample of anxiety-disordered youths using a well-established visual probe task. METHOD Study participants included 101 children and adolescents (ages 7-18 years) with generalized anxiety disorder, social phobia, and/or separation anxiety disorder enrolled in a multisite anxiety treatment study. Nonanxious youths (n = 51; ages 9-18 years) were recruited separately. Participants were administered a computerized visual probe task that presents pairs of faces portraying threat (angry), positive (happy), and neutral expressions. They pressed a response key to indicate the spatial location of a probe that replaced one of the faces on each trial. Attention bias scores were calculated from response times to probes for each emotional face type. RESULTS Compared to healthy youths, anxious participants demonstrated a greater attention bias toward threat faces. This threat bias in anxious patients did not significantly vary across the anxiety disorders. There was no group difference in attention bias toward happy faces. CONCLUSIONS These results suggest that pediatric anxiety disorders are associated with an attention bias toward threat. Future research may examine the manner in which cognitive bias in anxious youths changes with treatment.

Premorbid Prevalence of ADHD and Development of Secondary ADHD After Closed Head Injury

OBJECTIVE To determine premorbid prevalence of attention-deficit hyperactivity disorder (ADHD) in children with moderate and severe closed head injury (CHI), to determine incidence of ADHD 1 year after injury, and to characterize children who develop ADHD by demographic, neuropsychiatric, and outcome variables. METHOD Ninety-nine children who had severe and moderate CHI were followed up for 1 year. Premorbid and 1-year postinjury psychiatric status were ascertained by parent and child structured interviews and questionnaires measuring affective lability, aggression, apathy, and social judgment. RESULTS Premorbid prevalence of ADHD was 0.20, significantly higher than in a reference population (0.045). Fifteen of the remaining 80 children (0.19) developed full ADHD criteria (except for age of onset) by the end of the first year. Children who developed secondary ADHD (S-ADHD) had significantly greater premorbid psychosocial adversity, posttraumatic affective lability and aggression, posttraumatic psychiatric comorbidity, and overall disability than children who did not develop S-ADHD. CONCLUSIONS There is an excess prevalence of premorbid ADHD among children who present with moderate and severe CHI. Children with high psychosocial adversity are more likely to develop S-ADHD after CHI. S-ADHD has criteria in common with personality change due to CHI, a deficit in behavioral inhibition being the major overlapping feature.

Performance on measures of executive function following pediatric traumatic brain injury.

Objective : To investigate the relationships among age at injury, neuroanatomic lesion location, and measures of executive function (EF) following paediatric traumatic brain injury (TBI). Methods : EF was assessed in 68 children (aged 7-15) with moderate-to-severe TBI 1 year post-injury. EF tests included: (1) Tower of Hanoi (TOH), a measure of problem solving ability, (2) Wisconsin Card Sorting Test (WCST), a measure of categorization and ability to shift cognitive strategies, (3) Letter Fluency (LF), a measure of novel lexical search and rule-governed word generation. EF variables included number of moves needed to achieve a 3-ring solution on the TOH, number of perseverative and non-perseverative errors on the WCST, and number of words generated on LF. Intellectual functioning was also assessed using the Verbal Intellectual Quotient (VIQ) from the Wechsler Intelligence Scale from Children-3rd edn (WISC-III). Data from standardized MRIs, performed at 3-months post-injury, were available for all subjects and were used to determine lesion location, lesion volumes, and total number of lesions. The relationships among EF, lesion variables (frontal lesion volume, extrafrontal lesion volume, total number of lesions) and age at injury were examined. Pre-injury special education services and attention deficit hyperactivity disorder (ADHD) were controlled for. Results : Younger age at injury was associated with more perseverative errors on the WCST and worse performance on LF. Frontal lesion volume was not predictive of performance on any measures of EF. Greater extrafrontal lesion volume and total number of lesions were predictive of worse performance on LF. When controlling for pre-injury special education placement and pre-injury ADHD, there was little change in the results. Conclusions : Younger age at injury places children at greater risk of impairment on measures of EF. Performance on measures of EF depends on brain variables other than frontal lobes including extrafrontal cortical brain areas and total number of lesions. The relationship between extrafrontal brain regions and EF suggests that domain-specific cognitive content (i.e. language or visuospatial analysis), mediated by the parietal or temporal lobes, may disrupt underlying cognitive processes necessary for successful performance on measures of EF. In addition, the association between total number of lesions and EF may be related to disconnections and disruption of frontal/subcortical systems.

Neuroimaging correlates of anxiety after pediatric traumatic brain injury

BACKGROUND Anxiety disorders are common after traumatic brain injury (TBI). Data on the neural correlates of these conditions are lacking. This study examines the relationship between brain damage, particularly to the orbitofrontal cortex (OFC) and temporal lobe, and anxiety symptoms and disorders. METHODS Ninety-five children and adolescents were followed for one year postinjury. Preinjury and one-year postinjury anxiety status were obtained from the parent. Magnetic resonance imaging was performed to evaluate brain lesions. The primary analysis used regression models to determine relationships between brain lesions and anxiety outcomes. As a secondary analysis, previously reported posttraumatic stress disorder (PTSD) data were reanalyzed using similar methods for purposes of comparison. RESULTS The primary analysis showed that greater volume and number of OFC lesions correlated with decreased risk for anxiety, whereas lesions in other brain areas did not correlate with anxiety. Consistent with prior data, the secondary analysis showed an inverse correlation between OFC damage and PTSD; temporal lobe damage was positively correlated with PTSD. CONCLUSIONS After pediatric TBI, greater damage to the OFC is associated with decreased risk for anxiety outcomes. Similar to adult data, these findings implicate OFC dysfunction in childhood anxiety. Temporal lobe damage did not correlate with anxiety, in contrast to the findings for PTSD.

Depth of lesion model in children and adolescents with moderate to severe traumatic brain injury: use of SPGR MRI to predict severity and outcome

OBJECTIVES The utility of a depth of lesion classification using an SPGR MRI sequence in children with moderate to severe traumatic brain injury (TBI) was examined. Clinical and depth of lesion classification measures of TBI severity were used to predict neurological and functional outcome after TBI. METHODS One hundred and six children, aged 4 to 19, with moderate to severe TBI admitted to a rehabilitation unit had an SPGR MRI sequence obtained 3 months afterTBI. Acquired images were analyzed for location, number, and size of lesions. The Glasgow coma scale (GCS) was the clinical indicator of severity. The deepest lesion present was used for depth of lesion classification. Speed of injury was inferred from the type of injury. The disability rating scale at the time of discharge from the rehabilitation unit (DRS1) and at 1 year follow up (DRS2) were functional outcome measures. RESULTS The depth of lesion classification was significantly correlated with GCS severity, number of lesions, and both functional measures, DRS1 and DRS2. This result was more robust for time 1, probably due to the greater number of psychosocial factors impacting on functioning at time 2. Lesion volume was not correlated with the depth of lesion model. In multivariate models, depth of lesion was most predictive of DRS1, whereas GCS was most predictive of DRS2. CONCLUSIONS A depth of lesion classification of TBI severity may have clinical utility in predicting functional outcome in children and adolescents with moderate to severe TBI.

Anxiety after severe pediatric closed head injury

OBJECTIVE To assess the frequency of anxiety symptoms and disorders 1 year after severe pediatric closed head injury (CHI) and to determine the risk factors associated with these postinjury outcomes. METHOD Ninety-seven subjects were prospectively followed for 1 year after severe CHI (Glasgow Coma Scale Score = 3-8). Assessments of preinjury and 1-year postinjury psychiatric status and psychosocial adversity were conducted. Frequency of anxiety symptoms and disorders 1 year after injury were the outcome measures. Data collection occurred between 1992 and 1996. RESULTS There was a significant increase in the total number of anxiety symptoms after injury compared with before injury. The most frequent symptoms were overanxious symptoms, followed by obsessive-compulsive symptoms, separation anxiety symptoms, and simple phobia symptoms. There was a trend toward an increase in the frequency of overanxious disorder after injury. Preinjury anxiety symptoms correlated positively with postinjury anxiety symptoms and disorders. Younger age at injury correlated positively with postinjury anxiety symptoms. CONCLUSIONS One year after severe CHI, children are at risk for a variety of anxiety symptoms and, possibly, overanxious disorder. Preinjury anxiety and younger age at injury are risk factors for these disturbances.

Clinical Predictors of Posttraumatic Stress Disorder After Closed Head Injury in Children

OBJECTIVE To describe injury, demographic, and neuropsychiatric characteristics of children who develop posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PTSS) after closed head injury (CHI). METHOD Ninety-five children with severe CHI and amnesia for the event were prospectively followed for 1 year. Structured interviews were administered twice to the parents: shortly after injury to cover the childs premorbid status, and 1 year after injury. The child was also interviewed twice: shortly after injury to cover current status, and 1 year after injury. Outcome measures were diagnostic status (PTSD by parent or child) and symptom severity (PTSS by parent or child). RESULTS Twelve children developed PTSD by 1 year after injury, 5 according to parent report, 5 according to child report, and 2 according to both parent and child report. Predictors of PTSD at 1 year post-CHI included female gender and early post-CHI anxiety symptoms. Predictors of PTSS at 1 year post-CHI were (1) premorbid psychosocial adversity, premorbid anxiety symptoms, and injury severity; and (2) early post-CHI depression symptoms and nonanxiety psychiatric diagnoses. CONCLUSIONS PTSD developed in 13% of children with severe CHI accompanied by traumatic amnesia. Predictors of PTSD and PTSS after CHI, according to parent and child report, are consistent with predictors of PTSD and PTSS that develop after non-head injury trauma.

A Systematic Review of Treatments for Anxiety in Youth with Autism Spectrum Disorders

This study systematically examined the efficacy and safety of psychopharmacological and non-psychopharmacological treatments for anxiety in youth with autism spectrum disorders (ASD). Four psychopharmacological, nine cognitive behavioral therapy (CBT), and two alternative treatment studies met inclusion criteria. Psychopharmacological studies were descriptive or open label, sometimes did not specify the anxiety phenotype, and reported behavioral activation. Citalopram and buspirone yielded some improvement, whereas fluvoxamine did not. Non-psychopharmacological studies were mainly randomized controlled trials (RCTs) with CBT demonstrating moderate efficacy for anxiety disorders in youth with high functioning ASD. Deep pressure and neurofeedback provided some benefit. All studies were short-term and included small sample sizes. Large scale and long term RCTs examining psychopharmacological and non-psychopharmacological treatments are sorely needed.

Psychiatric-related emergency department visits among children with an autism spectrum disorder.

Objective This study aimed to examine the prevalence and characteristics of psychiatry-related emergency department (ED) visits among children with an autism spectrum disorder (ASD), including the specific reason for visit, as well as the influence of insurance type. Methods Data used for this cross-sectional, observational study were obtained from the 2008 National Emergency Department Sample, the largest all-payer ED database in the United States. Psychiatry-related visits to the ED among children with ASD were identified using International Classification of Diseases, Ninth Revision, billing codes. A total of 3,974,332 visits (unweighted) were present for youth 3–17 years, of which 13,191 involved a child with ASD. Results Thirteen percent of visits among children with ASD were due to a psychiatric problem, as compared with 2% of all visits by youths without ASD. Results from the multivariate analyses revealed that the likelihood for a psychiatric ED visit was increased 9-fold (odds ratio [OR], 9.13; 95% confidence interval [CI], 8.61–9.70) among pediatric ASD visits, compared with non-ASD visits. Children with ASD who were covered by private insurance, compared with those with medical assistance, were at even greater risk for a psychiatric ED visit (OR, 1.58; 95% CI, 1.53–1.63). Visits among children with ASD were more likely to be due to externalizing (OR, 1.62; 95% CI, 1.44–1.83) and psychotic (OR, 1.93; 95% CI, 1.58–2.35) disorders compared with visits among non-ASD children. Conclusions This study highlights the need for improving community-based psychiatric systems of care for youths with ASD to divert psychiatry-related ED visits, particularly for those children with private insurance.

Differences in attention, executive functioning, and memory in children with and without ADHD after severe traumatic brain injury.

Although the development of Attention Deficit Hyperactivity Disorder (ADHD) after traumatic brain injury (TBI) has been described, it is unknown whether children with TBI and ADHD have greater neuropsychological impairments than children with TBI alone. This study examines attention, executive functioning, and memory in children with TBI-only and TBI + ADHD. Caregivers of 82 children with severe TBI completed structured psychiatric interviews at enrollment to diagnose premorbid ADHD and one-year after injury to diagnose post-injury ADHD. Children underwent neuropsychological testing one year after injury. One memory measure significantly differentiated children with TBI-only from children with newly developed ADHD [secondary ADHD (S-ADHD)] and those with premorbid ADHD that persisted after injury [persisting ADHD (P-ADHD)]. Compared with the TBI-only group, children with TBI + ADHD had worse performance on measures of attention, executive functioning, and memory. Results reveal that in children with severe TBI, the behavioral diagnosis of ADHD is associated with more difficulty in attention, executive functioning, and memory. Additionally, results suggest greater deficits in memory skills in the S-ADHD group compared with the P-ADHD group. Although findings provide preliminary support for distinguishing P-ADHD from S-ADHD, further research is needed to investigate neuropsychological differences between these subgroups of children with severe TBI.