Cost-Effectiveness of the Mindfulness-Based Childbirth and Parenting Program for Pregnant Women With Fear of Childbirth.

OBJECTIVE: To examine the cost-effectiveness of the Mindfulness-Based Childbirth and Parenting (MBCP) program compared with enhanced care as usual (ECAU). DESIGN: Randomized controlled trial. SETTING: Midwifery settings in the Netherlands, April 2014 to July 2017. PARTICIPANTS: Subset of pregnant women with high levels of fear of childbirth (N = 54: randomized to MBCP, n = 32, or to ECAU, n = 22) who were selected from the parent study because they completed all four cost questionnaires. METHODS: We measured self-reported health care and non-health care costs. A subset of participants from the parent study completed the questionnaires at all four assessment points. We used the Wijma Delivery Expectancy Questionnaire to measure fear of childbirth and used the EuroQol-5D to measure quality of life. We used these measures of effect together with societal costs in the primary cost-effectiveness analyses. In the secondary cost-effectiveness analyses, we used different estimates of effects and costs to test the robustness of the primary analyses. RESULTS: In all but one scenario, MBCP was more effective and cost less than ECAU. As indicated by the acceptability curves, the likelihood of MBCP being cost-effective varied within a range of 70% to 98%. CONCLUSION: Our findings indicate that MBCP is a cost-effective intervention to reduce fear of childbirth in pregnant women. Important next steps are to replicate the study in countries with different health care systems and to explore the potential for further integration of MBCP into midwifery care.

Effectiveness of an innovative treatment protocol for misophonia in children and adolescents: Design of a randomized controlled trial.

Background: Misophonia is a recently identified disorder in which individuals experience intense, uncontrollable and disproportional irritation, anger or disgust when confronted with specific sounds or stimuli associated with these sounds. Prevalence rates in children and adolescents are currently still to be investigated. The reported average age of onset is around 13 years, in clinical practice children from 8 years old are referred.Misophonia is associated with avoidance and anticipation anxiety, possibly leading to serious educational and social consequences for children and families. Worldwide, no evidence-based treatment exists specifically for children and adolescents with misophonia.This article presents the design of a randomized controlled trial testing the effectiveness of cognitive behavioral therapy (CBT) combined with psychomotor therapy (PMT) for misophonia in children and adolescents (aged 8-18). Methods: In total, 82 patients will be randomly assigned to a treatment condition or waiting list condition of 3 months (WCG). Treatment consists of 7 weekly group therapy sessions (1.5 h CBT plus 1.5 h PMT) and a follow-up after 3 weeks. Pre and post treatment assessments will be conducted during a baseline assessment, after 3 and 6 months. The primary outcome will be assessed by the Amsterdam Misophonia Scale - Youth (AMISOS-Y) and secondary outcomes (e.g. quality of life) and putative predictors (e.g. parenting burden) will be studied. Conclusion: This trial is the first study worldwide testing the effectiveness of a combined CBT plus PMT protocol for misophonia in children and adolescents. If proven effective, this protocol provides an innovation to improve care for youth with misophonia.

The Development and Validation of a Subscale for the School-Age Child Behavior CheckList to Screen for Autism Spectrum Disorder.

The first aim of this study was to construct/validate a subscale-with cut-offs considering gender/age differences-for the school-age Child Behavior CheckList (CBCL) to screen for Autism Spectrum Disorder (ASD) applying both data-driven (N = 1666) and clinician-expert (N = 15) approaches. Further, we compared these to previously established CBCL ASD profiles/subscales and DSM-oriented subscales. The second aim was to cross-validate results in two truly independent samples (N = 2445 and 886). Despite relatively low discriminative power of all subscales in the cross-validation samples, results indicated that the data-driven subscale had the best potential to screen for ASD and a similar screening potential as the DSM-oriented subscales. Given beneficial implications for pediatric/clinical practice, we encourage colleagues to continue the validation of this CBCL ASD subscale.

BOAM: A Visual, Explanatory Diagnostic and Psychoeducation System Used in Collaboration with Families-Feasibility and Acceptability for Children Who Are Non-Responsive to Treatment as Usual.

Many children referred to mental health services have neurodevelopmental problems, which are not always recognized because the resulting emotional and behavioral problems dominate diagnosis and treatment. BOAM (Basic needs, Order, Autonomy and Meaning) is a new diagnostic system consisting of imaginative models that explain the complexity of symptoms and underlying neuropsychological problems in a simple way. It is designed to be used in a transparent, collaborative process with families, so that family members can better understand the nature of mental health problems, thus increasing self-knowledge and mutual understanding. In this study, the feasibility of the BOAM diagnostic trajectory and subsequent treatment informed by this trajectory are evaluated clinically in 34 children who have not responded to or relapsed after treatment as usual (TAU). Parents completed questionnaires pre-test, post-test and at a 3-month follow-up. The treatment drop-out rate was 2.9%. Post-test, parents rated the BOAM trajectory positively. The questionnaires (measuring child psychopathology, attention, executive functioning, family functioning, partner relationships and parenting stress) demonstrated sensitivity to change, and therefore, seems appropriate for a future effectiveness study. A limitation was the high percentage of missing measurements both post-test (41%) and at the follow-up (41%). The BOAM diagnostic trajectory and subsequent treatment may be a feasible alternative for children who do not respond to or relapse after TAU.

Modular CBT for Childhood Anxiety Disorders: Evaluating Clinical Outcomes and its Predictors.

This study examined clinical outcomes of a modular individual CBT for children with anxiety disorders (AD), and predictors of outcomes, in usual clinical practice. Participants were 106 children with ADs (7-17 years), and parents. Assessments were pre-, mid-, post-test, and 10 weeks after CBT (follow-up). Predictors (measured pre-treatment) were child characteristics (gender, age, type of AD, comorbid disorders), fathers' and mothers' anxious/depressive symptoms, and parental involvement (based on parents' presence during treatment sessions and the use of a parent module in treatment). At follow-up, 59% (intent-to-treat analyses) to 70% (completer analysis) of the children were free from their primary anxiety disorder. A significant decrease in anxiety symptoms was found. Higher parental involvement was related to lower child anxiety at follow-up, but only for children with comorbid disorders. Findings suggest that it is beneficial to treat anxiety with modular CBT. Future steps involve comparisons of modularized CBT with control conditions.

Fear of childbirth, nonurgent obstetric interventions, and newborn outcomes: A randomized controlled trial comparing mindfulness-based childbirth and parenting with enhanced care as usual.

OBJECTIVE: To investigate whether mindfulness-based childbirth and parenting (MBCP) or enhanced care as usual (ECAU) for expectant couples decreases fear of childbirth (FOC) and nonurgent obstetric interventions during labor and improves newborn outcomes. DESIGN: Randomized controlled trial. SETTING: Midwifery settings, the Netherlands, April 2014-July 2017. POPULATION: Pregnant women with high FOC (n = 141) and partners. METHODS: Allocation to MBCP or ECAU. Hierarchical multilevel and intention-to-treat (ITT) and per-protocol (PP) analyses. MAIN OUTCOME MEASURES: Primary: pre-/postintervention FOC, labor anxiety disorder, labor pain (catastrophizing and acceptance), and preferences for nonurgent obstetric interventions. Secondary: rates of epidural analgesia (EA), self-requested cesarean birth (sCB), unmedicated childbirth, and 1- and 5-minute newborn's Apgar scores. RESULTS: MBCP was significantly superior to ECAU in decreasing FOC, catastrophizing of labor pain, preference for nonurgent obstetric interventions, and increasing acceptance of labor pain. MBCP participants were 36% less likely to undergo EA (RR 0.64, 95% CI [0.43-0.96]), 51% less likely to undergo sCB (RR 0.49, 95% CI [0.36-0.67]), and twice as likely to have unmedicated childbirth relative to ECAU (RR 2.00, 95% CI [1.23-3.20]). Newborn's 1-minute Apgar scores were higher in MBCP (DM -0.39, 95% CI [-0.74 to -0.03]). After correction for multiple testing, results remained significant in ITT and PP analyses, except EA in ITT analyses and 1-minute Apgar. CONCLUSIONS: MBCP for pregnant couples reduces mothers' fear of childbirth, nonurgent obstetric interventions during childbirth and may improve childbirth outcomes. MBCP adapted for pregnant women with high FOC and their partners appears an acceptable and effective intervention for midwifery care.

Can a simple assessment of fear of childbirth in pregnant women predict requests and use of non-urgent obstetric interventions during labour?

OBJECTIVE: To examine whether the Wijma Delivery Expectation Questionnaire (W-DEQ-A) and the one-item Fear of Childbirth-Postpartum-Visual Analogue Scale (FOCP-VAS) - measuring high FOC - are useful tools in predicting requested and received non-urgent obstetric interventions in pregnant women. DESIGN: A prospective cohort study. POPULATION AND SETTING: Self-selected pregnant women from midwifery care settings (n=401). METHODS: W-DEQ-A and FOCP-VAS were assessed at two timepoints in pregnancy. Measures of non-urgent obstetric interventions which were derived from medical files were: induction of labour, epidural analgesia, augmentation with oxytocin due to failure to progress and self-requested caesarean section. Hierarchical logistics regression models were used. MAIN OUTCOME MEASURES: The change in the Nagelkerke R2 was examined for three models predicting two outcome measures: (1) explicitly requested non-urgent obstetric interventions during pregnancy and (2) received non-urgent obstetric interventions during labour. The first model only included participants' characteristics, the second model also included FOCP-VAS ≥5, and in the third model the W-DEQ-A ≥66 was added. RESULTS: High FOC measured with FOCP-VAS≥5 predicted requested (pseudo-R2=0.33, X2=59.82, P<0.001) and received non-urgent obstetric interventions (pseudo-R2=0.19, X2=32.81, P<0.001) better than high FOC measured with W-DEQ-A≥66. CONCLUSION: This study is the first evaluating self-reported FOC and postpartum based on VAS (subjective outcome) in relation to actual pregnancy and childbirth outcomes derived from medical files (objective outcome). Non-urgent obstetric interventions could already be predicted in the first half of pregnancy by means of a simple FOC assessment with the one-item FOCP-VAS. Implementing this easy to use one-item screening tool in midwifery care is suggested.

Social anxiety and perceptions of likeability by peers in children.

The current study aimed to investigate the discrepancy between self-reported and peer-reported likeability among children, and the relation with social anxiety, depression, and social support. In total, 532 children between 7 and 12 years completed questionnaires about social anxiety symptoms, depressive symptoms, and social support, estimated their own likeability, and indicated how much they liked their classmates. Children with higher levels of social anxiety or depression overestimated their likeability less or even underestimated their likeability. Social anxiety symptoms, but not depressive symptoms, were significant predictors of the discrepancy. Social support was positively related to likeability and negatively related to social anxiety, but did not moderate the association between social anxiety symptoms and perception accuracy of likeability. These results are in line with cognitive theories of childhood social anxiety, and they stress the importance of using multi-informant measures when studying the relation between social anxiety and social functioning in children.

Fathers' and Mothers' Early Mind-Mindedness Predicts Social Competence and Behavior Problems in Childhood.

Parental mind-mindedness, the parent's propensity to treat the child as an intentional agent, has repeatedly shown to promote children's development of social understanding and secure attachment. Less is known about whether the impact of maternal and paternal mind-mindedness extends to children's social and behavior problems. We investigated the combined effect of mothers' and fathers' (N = 104) mind-mindedness at 4, 12, and 30 months on children's social competence and externalizing and internalizing behavior problems at 4.5 years. Besides, we examined the stability, continuity, parental concordance, and inter-parental differences in the use of mind-related comments. Appropriate mind-mindedness (i.e., correct interpretations of the child's mental states) and nonattuned mind-mindedness (i.e., misinterpretations of the child's mental states) were observed during parent-child free-play interactions. Social competence, internalizing and externalizing behavior problems were assessed using both parents' reports. Hierarchical multiple regression analyses showed that, at 12 months, infrequent use of appropriate mind-related comments of both parents predicted children's externalizing problems, while their frequent use of nonattuned comments predicted children's low social competence. Furthermore, mothers' frequent use of nonattuned comments at 12 and 30 months and fathers' nonattuned comments at 30 months predicted children's externalizing behavior. The findings suggest that both parents' low use of mind-related comments, and frequent misinterpretations of their child's mind, may act as risk factors for later social and behavior problems of their child.

Do Parental Psychiatric Symptoms Predict Outcome in Children With Psychiatric Disorders? A Naturalistic Clinical Study.

OBJECTIVE: Parental psychiatric symptoms can negatively affect the outcome of children's psychopathology. Studies thus far have mainly shown a negative effect of maternal depression. This study examined the associations between a broad range of psychiatric symptoms in mothers and fathers and the child's outcome. METHOD: Internalizing and externalizing psychiatric symptoms were assessed in 742 mothers, 440 fathers, and their 811 children at the first evaluation in 3 child and adolescent psychiatric outpatient clinics and at follow-up (on average 1.7 years later). Predictions of child's symptoms scores were tested at follow-up by parental symptom scores at baseline, parental scores at follow-up, and offspring scores at baseline. RESULTS: Children whose mother or father scored above the (sub)clinical threshold for psychiatric symptoms at baseline had higher symptom scores at baseline and at follow-up. Offspring follow-up scores were most strongly predicted by offspring baseline scores, in addition to parental psychiatric symptoms at follow-up. Offspring symptom scores at follow-up generally were not predicted by parental scores at baseline. Maternal and paternal associations were of similar magnitude. CONCLUSION: Higher symptom scores at follow-up in children of parents with psychopathology were mainly explained by higher symptom scores at baseline. Continuing parent-offspring associations could be a result of reciprocal effects, ie, parental symptoms influencing offspring symptoms and offspring symptoms influencing parental symptoms. Nevertheless, the results show that these children are at risk for persisting symptoms, possibly indicating the need to treat maternal and paternal psychopathology.

Cost-effectiveness of Family Group Conferencing in child welfare: a controlled study.

BACKGROUND: This study aimed to examine the short- and long term (cost-) effectiveness of Family Group Conferencing (FGC) compared to care as usual (CAU) in terms of improved child safety, empowerment and social support. METHODS: A subgroup of a larger randomized controlled trial, comprising 69 families in child welfare (experimental group: n = 46; control group: n = 23), was included. RESULTS: No additional effects of FGC on child safety, social support and only short-term positive effects on empowerment were found. There were no differences in costs between FGC and CAU. The chance for FGC to be cost-effective was small. For families who refused FGC, the FGC approach was more cost-effective than CAU, whereas it was less cost-effective for families that prepared or completed FGC. CONCLUSIONS: Overall, FGC is not (cost-)effective in improving child safety, empowerment and social support, but cost-effectiveness varies at different levels of FGC-completion. TRIAL REGISTRATION: Dutch Trial Register number NTR4320 . Registered 17 December 2013.

Parental Involvement in CBT for Anxiety-Disordered Youth Revisited: Family CBT Outperforms Child CBT in the Long Term for Children With Comorbid ADHD Symptoms.

OBJECTIVE: The objective of this study was to examine the efficacy of child cognitive-behavioral therapy (CCBT) versus family CBT (FCBT) in anxiety-disordered youth with high and low comorbid ADHD symptoms. METHOD: Youth with anxiety disorders ( n = 123, aged 8-18) were classified in four groups according to (a) the type of CBT received (child vs. family) and (b) their comorbid ADHD symptoms, measured with the Child Behavior Checklist (CBCL) Attention Problems syndrome scale level (normal vs. [sub]clinical). Severity of anxiety disorders was assessed with Anxiety Disorders Interview Schedule-Child and Parent (ADIS-C/P) version and anxiety symptoms via a 71-item anxiety symptom questionnaire, the Screen for Child Anxiety and Related Emotional Disorders (SCARED-71), before and after CBT, and at 3 months and 1-year follow-ups. RESULTS: Based on the severity of anxiety disorders, children with high ADHD symptoms profit more from FCBT than CCBT in the long term. For children low on ADHD symptoms, and for anxiety symptoms and attention problems, no differences between CCBT and FCBT occurred. CONCLUSION: Family involvement seems a valuable addition to CBT for children with comorbid anxiety and ADHD symptoms.

What are the odds of anxiety disorders running in families? A family study of anxiety disorders in mothers, fathers, and siblings of children with anxiety disorders.

This family study investigated (1) the prevalence of anxiety disorders (ADs) in parents and siblings of children (n = 144) aged 8-18 years with ADs compared to control children (n = 49), and (2) the specificity of relationships between child-mother, child-father, and child-sibling ADs. Clinical interviews were used to assess current DSM-IV-TR ADs in children and siblings, and lifetime and current ADs in parents. Results showed that children with ADs were two to three times more likely to have at least one parent with current and lifetime ADs than the control children (odds ratio (OR) = 2.04 and 3.14). Children with ADs were more likely to have mothers with current ADs (OR = 2.51), fathers with lifetime ADs (OR = 2.84), but not siblings with ADs (OR = 0.75). Specific relationships between mother-child ADs were found for Social Anxiety Disorder (SAD, OR = 3.69) and Generalized Anxiety Disorder (OR = 3.47). Interestingly, all fathers and siblings with SAD came from families of children with SAD. Fathers of children with SAD were more likely to have lifetime ADs themselves (OR = 2.86). Findings indicate that children with ADs more often have parents with ADs, and specifically SAD is more prevalent in families of children with SAD. Influence of parent's (social) ADs should be considered when treating children with ADs.

Anxiety Levels in Children with Autism Spectrum Disorder: A Meta-Analysis.

The aim of the current study was to meta-analytically examine whether anxiety levels in children with autism spectrum disorders (ASD) are elevated. A total of 83 articles were selected from a systematic literature search and were included in the meta-analyses. Results demonstrated that children with ASD had higher anxiety levels compared to typically developing children, and this difference increased with IQ. Youth with ASD also tended to have higher anxiety levels compared to clinically referred children, and this difference increased with age. Children with ASD had higher anxiety levels compared to youth with externalizing or developmental problems, but not when compared to youth with internalizing problems. The study findings highlight the importance of more research in order to fully understand the nature and development of anxiety in children with ASD. More specifically, the results suggest that especially high-functioning adolescents with ASD may be at risk for developing anxiety disorders. Therefore, it seems important to carefully follow and monitor children with ASD transcending to adolescence.

Are Anxiety Disorders in Children and Adolescents Less Impairing Than ADHD and Autism Spectrum Disorders? Associations with Child Quality of Life and Parental Stress and Psychopathology.

We compared clinically referred children with anxiety disorders (AD; n = 63) to children with autism spectrum disorder (ASD; n = 39), ADHD Combined (ADHD-C; n = 62), ADHD Predominantly Inattentive (ADHD-I; n = 64), and typically developing children (n = 42) on child quality of life (QOL), paternal and maternal psychopathology and parental stress. Diagnoses were based on DSM-IV-TR criteria. Multilevel analyses showed that QOL in AD was higher on school and social functioning, compared to respectively ADHD and ASD, and lower compared to normal controls on all five domains. Fathers reported their AD children higher QOL than mothers. Also, AD appeared to be associated with less parental stress and parental psychopathology than other child psychopathology. Therefore, parental factors may need to be considered more in treatment of children with ADHD/ASD than AD.

'I've Changed My Mind', Mindfulness-Based Childbirth and Parenting (MBCP) for pregnant women with a high level of fear of childbirth and their partners: study protocol of the quasi-experimental controlled trial.

BACKGROUND: Approximately 25 % of pregnant women suffer from a high level of Fear of Childbirth (FoC), as assessed by the Wijma Delivery Expectancy Questionnaire (W-DEQ-A, score ≥66). FoC negatively affects pregnant women's mental health and adaptation to the perinatal period. Mindfulness-Based Childbirth and Parenting (MBCP) seems to be potentially effective in decreasing pregnancy-related anxiety and stress. We propose a theoretical model of Avoidance and Participation in Pregnancy, Birth and the Postpartum Period in order to explore FoC and to evaluate the underlying mechanisms of change of MBCP. METHODS/DESIGN: The 'I've Changed My Mind' study is a quasi-experimental controlled trial among 128 pregnant women (week 16-26) with a high level of FoC, and their partners. Women will be allocated to MBCP (intervention group) or to Fear of Childbirth Consultation (FoCC; comparison group). Primary outcomes are FoC, labour pain, and willingness to accept obstetrical interventions. Secondary outcomes are anxiety, depression, general stress, parental stress, quality of life, sleep quality, fatigue, satisfaction with childbirth, birth outcome, breastfeeding self-efficacy and cost-effectiveness. The total study duration for women is six months with four assessment waves: pre- and post-intervention, following the birth and closing the maternity leave period. DISCUSSION: Given the high prevalence and severe negative impact of FoC this study can be of major importance if statistically and clinically meaningful benefits are found. Among the strengths of this study are the clinical-based experimental design, the extensive cognitive-emotional and behavioural measurements in pregnant women and their partners during the entire perinatal period, and the representativeness of study sample as well as generalizability of the study's results. The complex and innovative measurements of FoC in this study are an important strength in clinical research on FoC not only in pregnant women but also in their partners. TRIAL REGISTRATION: Dutch Trial Register (NTR): NTR4302 , registration date the 3rd of December 2013.

Cost-Effectiveness of Group and Internet Cognitive Behavioral Therapy for Insomnia in Adolescents: Results from a Randomized Controlled Trial.

STUDY OBJECTIVES: To investigate cost-effectiveness of adolescent cognitive behavioral therapy for insomnia (CBTI) in group- and Internet-delivered formats, from a societal perspective with a time horizon of 1 y. METHODS: Costs and effects data up to 1-y follow-up were obtained from a randomized controlled trial (RCT) comparing Internet CBTI to face-to-face group CBTI. The study was conducted at the laboratory of the Research Institute of Child Development and Education at the University of Amsterdam, and the academic youth mental health care center UvAMinds in Amsterdam. Sixty-two participants meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for insomnia were randomized to face-to-face group CBTI (GT; n = 31, age = 15.6 y ± 1.8, 71.0% girls) or individual Internet CBTI (IT; n = 31, age = 15.4 y ± 1.5, 83.9% girls). The intervention consisted of six weekly sessions and a 2-mo follow up booster-session of CBTI, consisting of psychoeducation, sleep hygiene, restriction of time in bed, stimulus control, cognitive therapy, and relaxation techniques. GT sessions were held in groups of six to eight adolescents guided by two trained sleep therapists. IT consisted of individual Internet therapy with preprogrammed content similar to GT, and guided by trained sleep therapists. RESULTS: Outcome measures were subjective sleep efficiency (SE) ≥ 85%, and quality-adjusted life-years (QALY). Analyses were conducted from a societal perspective. Incremental cost-effectiveness ratios (ICERs) were calculated using bootstrap sampling, and presented in cost-effectiveness planes. Primary analysis showed costs over 1 y were higher for GT but effects were similar for IT and GT. Bootstrapped ICERs demonstrated there is a high probability of IT being cost-effective compared to GT. Secondary analyses confirmed robustness of results. CONCLUSIONS: Internet CBTI is a cost-effective treatment compared to group CBTI for adolescents, although effects were largely similar for both formats. Further studies in a clinical setting are warranted. CLINICAL TRIAL REGISTRATION: ID: ISRCTN33922163; trial name: Effectiveness of cognitive behavioral therapy for sleeplessness in adolescents; URL: http://www.isrctn.com/ISRCTN33922163.

Parenting and Children's Internalizing Symptoms: How Important are Parents?

Parenting behaviors are associated with children's internalizing symptoms, however, it is not often examined which factors could possibly influence this relationship. The goals of this study were twofold. One goal was to examine whether the association between parenting and children's internalizing symptoms would increase if parenting behaviors were assessed behaviorally and in a context where the child displayed specific anxious behaviors. Another goal was to examine whether this relationship was influenced by the age and gender of the child, and by possible parenting differences between mothers and fathers. These questions were examined in a sample of 211 children aged 4-12 years; 140 community children and 71 clinically referred anxious children. Parents completed questionnaires regarding children's internalizing symptoms and parenting behaviors (positive reinforcement, punishment, force, reinforcement of dependency, and modeling/reassurance). In line with expectations, more punishment and less modeling/reassurance by parents were related to more internalizing symptoms in children. Child gender, child age, parent gender and clinical anxiety status were not found to influence the relationship between parenting and children's internalizing symptoms. Our results suggest that paternal parenting is as important as maternal parenting with respect to children's internalizing symptoms, and therefore, fathers could be included in child treatment as well.

A cost of illness study of children with high-functioning autism spectrum disorders and comorbid anxiety disorders as compared to clinically anxious and typically developing children.

The study's aim was to estimate the societal costs of children with high-functioning ASD and comorbid anxiety disorder(s) (ASD + AD-group; n = 73), and to compare these costs to children with anxiety disorders (AD-group; n = 34), and typically developing children (controls; n = 87). Mean total costs for the ASD + AD-group amounted 17,380 per year. Societal costs were estimated at almost 142 million euro per year. Costs in the ASD + AD-group were four times higher compared to the AD-group, and 27 times higher compared to controls. ASD-related costs were higher in the ASD + AD-group; anxiety-related costs did not differ between the ASD + AD- and AD-group; costs due to physical or other reasons did not differ across groups. The findings suggest that costs can be decreased if effective treatment options for treating anxiety in ASD are established, however, the remaining costs associated with ASD would still be large. A limitation of the study is that a group of children with ASD without anxiety disorders is lacking.