Discriminant and concurrent validity of a simplified DSM-based structured diagnostic instrument for the assessment of autism spectrum disorders in youth and young adults.

BACKGROUND: To evaluate the concurrent and discriminant validity of a brief DSM-based structured diagnostic interview for referred individuals with autism spectrum disorders (ASDs). METHODS: To test concurrent validity, we assessed the structured interview's agreement in 123 youth with the expert clinician assessment and the Social Responsiveness Scale (SRS). Discriminant validity was examined using 1563 clinic-referred youth. RESULTS: The structured diagnostic interview and SRS were highly sensitive indicators of the expert clinician assessment. Equally strong was the agreement between the structured interview and SRS. We found evidence for high specificity for the structured interview. CONCLUSIONS: A simplified DSM-based ASD structured diagnostic interview could serve as a useful diagnostic aid in the assessment of subjects with ASDs in clinical and research settings.

Executive functioning in offspring at risk for depression and anxiety.

BACKGROUND: Executive functioning deficits (EFDs) have been found in adults with major depression and some anxiety disorders, yet it is unknown whether these deficits predate onset of disorder, or whether they reflect acute symptoms. Studies of at-risk offspring can shed light on this question by examining whether EFDs characterize children at high risk for depression and anxiety who are not yet symptomatic. METHODS: This study examined neuropsychological functioning in a sample of 147 children, ages 6-17 years (M age=9.16, SD=1.82), of parents with major depression (MDD) and/or panic disorder (PD) and of controls with neither disorder. Children were assessed via structured diagnostic interviews and neuropsychological measures. RESULTS: Although parental MDD and PD were not associated with neuropsychological impairments, presence of current offspring MDD was associated with poorer performance on several executive functioning and processing speed measures. Children with current generalized anxiety showed poorer verbal memory, whereas children with social phobia had more omissions on a continuous performance task. CONCLUSIONS: Findings suggest that EFDs do not serve as trait markers for developing anxiety or depression but appear to be symptomatic of current disorder.

Assessment of relevant parenting factors in families of clinically anxious children: the Family Assessment Clinician-rated Interview (FACI).

OBJECTIVE: Research on child and adolescent anxiety disorders has seen a surge in investigations of parenting factors potentially associated with their etiology. However, many of the well-established parenting measures are limited by over-reliance on self-report or lengthy behavioral observation procedures. Such measures may not assess factors most salient to anxiety etiology, since most family functioning measures were not originally developed for this purpose. The Family Assessment Clinician Interview (FACI) was developed as a clinician-administered interview of parent and family factors associated with child and adolescent anxiety. The present study is the first to investigate the psychometric properties of the FACI. METHOD: Using a clinical sample of 65 children with various anxiety disorders, and their parents, inter-rater reliability, convergent validity and associations with child-reported and clinician-evaluated anxiety severity were examined. RESULTS: suggest that the FACI has good to excellent inter-rater reliability with kappas ranging from 0.79 to 1.0 across FACI scales and subscales. Some evidence of convergent validity with relevant portions of the Family Environment Scale was observed, although the latter findings varied by respondent (mother versus father). The Family Warmth/Closeness subscale of the FACI was consistently associated with increased child anxiety symptoms. Contrary to expectations, higher levels of parental expectations were associated with lower levels of child anxiety. CONCLUSION: Results suggest that the FACI is a promising measure of family anxiety constructs that may be useful in both research and clinical settings.

High risk studies and developmental antecedents of anxiety disorders.

The past two decades have witnessed significant growth in our understanding of the developmental antecedents of anxiety disorders. In this article, we review studies of offspring at risk for anxiety disorders, longitudinal studies of the course of anxiety disorders in clinical, epidemiologic, and at-risk samples, studies of hypothesized temperamental risk factors for anxiety, and give a brief overview of the literature on environmental risk factors. Clear developmental antecedents to anxiety disorders identified include (1) childhood anxiety disorders [in particular, separation anxiety and overanxious disorder/general anxiety disorder (GAD)], (2) behavioral inhibition which predicts later social phobia, (3) anxiety sensitivity which predicts later panic disorder, and (4) negative affectivity, which predicts a spectrum of psychopathology including anxiety disorders. Further prospective studies are needed to examine the roles of environmental factors such as parenting practices, peer influences, stressful life events, and perinatal stressors. Future studies could benefit from (1) beginning earlier in development and following individuals into adulthood, (2) assessing the overlap between multiple temperamental constructs, (3) greater use of observational measures of temperament and of parent-child and peer interactions, (4) greater attention to parental psychopathology which may confound associations noted, (5) exploration of other features of anxiety disorders (neurofunctional correlates, cognitive features, other aspects of emotional regulation) as potential precursors, and (6) intervention studies exploring whether modifying developmental antecedents can alter the course of anxiety disorders.

Disruptive behavior disorders in offspring of parents with major depression: associations with parental behavior disorders.

OBJECTIVE: Although the offspring of parents with major depressive disorder (MDD) are at increased risk to develop disruptive behavior disorders (DBD) in addition to MDD, it remains unclear whether this heightened risk is due to MDD or to comorbid DBD in the parents. METHOD: In a secondary analysis of longitudinal data from offspring at risk for MDD and panic disorder and comparison children, we stratified 169 children of parents who had been treated for MDD based upon presence (n=50) or absence (n=119) of parental history of DBD (ADHD, oppositional disorder, and conduct disorder) and contrasted them with children of parents with DBD but without MDD (n=19) and children whose parents had neither MDD nor DBD (n=106). The children had been assessed in middle childhood using structured diagnostic interviews. RESULTS: Offspring of parents with MDD + DBD had significantly higher rates of MDD, DBD in general, and ADHD in particular, compared with offspring of parents with MDD alone. Offspring of parents with MDD + DBD also had higher rates of mania than controls. Both parental MDD and DBD conferred independent risk for MDD and DBD in the offspring. However, only parental DBD conferred independent risk for conduct disorder and ADHD and only parental MDD conferred independent risk for oppositional defiant disorder. CONCLUSION: Elevated rates of DBD in the offspring of parents with MDD appear to be due in part to the presence of DBD in the parents. Further studies of samples not selected on the basis of parental panic disorder are needed to confirm these results.

Children's interpretation and avoidant response biases in response to non-salient and salient situations: relationships with mothers' threat perception and coping expectations.

This study examined the effect of situation salience on interpretation and avoidant response biases in clinically anxious and non-clinical children. The relationship between mothers' threat perception and expectations of their children's coping, and children's threat perception and coping expectations was also assessed. Forty clinically anxious and 40 non-clinical children (ages 7-14) participated with their mothers. In response to hypothetical situations, children described their likely thoughts and actions; mothers listed a typical child's thoughts and what their child would do. Consistent with information processing theories of anxiety, anxious children displayed amplified cognitive biases in response to personally salient situations, compared to non-clinical children. Mothers of anxious children had lower expectations for their children's coping than mothers of non-anxious children, mirroring differences between the groups of children. Mothers' expectations of their children's coping predicted children's coping expectations in non-salient and salient situations and threat perception in salient situations. Implications of findings are discussed.

Clinical outcomes of laboratory-observed preschool behavioral disinhibition at five-year follow-up.

BACKGROUND: Behavioral disinhibition refers to a temperamental tendency to exhibit boldness, approach, and spontaneity in unfamiliar situations. We previously found it to be associated with childhood disruptive behavior and mood disorders, as well as with parental bipolar disorder. In the present study, our objective was to examine the diagnostic outcome in middle childhood of behavioral disinhibition assessed at preschool age among offspring at risk for anxiety and mood disorders. METHODS: The sample consisted of 284 children, including offspring of parents with panic disorder or major depression and comparison offspring of parents without these disorders, who had been assessed with laboratory observations of temperament at ages 21 months to 6 years. We reassessed 215 of the children (77%) at 5-year follow-up (mean age 9.6 years) with structured diagnostic interviews. RESULTS: Compared with noninhibited, nondisinhibited control subjects, behaviorally disinhibited children had higher lifetime rates of comorbid mood plus disruptive behavior disorders and higher current rates of any disruptive behavior disorder and of oppositional defiant disorder. CONCLUSIONS: Behavioral disinhibition appears to be a temperamental antecedent of disruptive behavior disorders and their comorbidity with mood disorders in middle childhood, which may be targeted for preventive intervention.

Information-Processing Biases in Children and Adolescents:An Introduction to the Special Issue.

This special issue focuses on new developments in research on information-processing biases in children and adolescents. Prior research suggests that attention and interpretation biases in response to emotional stimuli may be associated with the etiology and maintenance of anxiety and depression in youth. Although our understanding of youth biases has burgeoned over the past decade, questions remain regarding mixed findings across studies, heterogeneity of biases across individuals, specific factors that contribute to and maintain biases, and how best to maximize the efficacy of interventions designed to modify biases. Through the use of innovative methods and technology, the articles in this special issue illustrate progress being made toward filling these gaps in our knowledge and showcase some of the exciting new developments in this area of research.

Efficacy of Interpretation Bias Modification in Depressed Adolescents and Young Adults.

This study evaluated the efficacy of a four-session Cognitive Bias Modification-Interpretation program for 45 depressed adolescents and young adults (14-21 years old; 12 males, 33 females; Beck Depressive Inventory, Second Edition ≥ 14) randomized to an active intervention condition (repeated exposure to positive outcomes of depression-relevant ambiguous scenarios; n=23) or a control condition (n=22). Both conditions experienced reductions on a Test of Interpretation Bias at post-treatment, with no significant between-group differences. When limited to those with negative bias at baseline, the intervention group showed greater improvement in interpretation bias at mid- and post-treatment. In addition, the intervention group overall had greater improvements in self-reported negative cognitions than the control group at post-intervention and two-week follow-up. However, there were no differences between groups in depression or anxiety symptom change. Potential factors contributing to mixed findings are discussed.

Psychopathology in adolescent offspring of parents with panic disorder, major depression, or both: a 10-year follow-up.

OBJECTIVE: The authors examined the specificity and course of psychiatric disorders from early childhood through adolescence in offspring of parents with confirmed panic disorder and major depressive disorder. METHOD: The authors examined rates of psychiatric disorders at 10-year-follow-up (mean age, 14 years) in four groups: offspring of referred parents with panic and depression (N=137), offspring of referred parents with panic without depression (N=26), offspring of referred parents with depression without panic (N=48), and offspring of nonreferred parents with neither disorder (N=80). Follow-up assessments relied on structured interviews with the adolescents and their mothers; diagnoses were rated present if endorsed by either. RESULTS: Parental panic disorder, independently of parental depression, predicted lifetime rates in offspring of multiple anxiety disorders, panic disorder, agoraphobia, social phobia, and obsessive-compulsive disorder. Parental depression independently predicted offspring bipolar, drug use, and disruptive behavior disorders. Parental panic and depression interacted to predict specific phobia and major depressive disorder. Phobias were elevated in all at-risk groups, and depression was elevated in both offspring groups of parents with depression (with or without panic disorder), with the highest rates in the offspring of parents with depression only. Parental depression independently predicted new onset of depression, parental panic disorder independently predicted new onset of social phobia, and the two interacted to predict new onset of specific phobia and generalized anxiety disorder. CONCLUSIONS: At-risk offspring continue to develop new disorders as they progress through adolescence. These results support the need to screen and monitor the offspring of adults presenting for treatment of panic disorder or major depressive disorder.

Applying cognitive-behavioral therapy for anxiety to the younger child.

Cognitive-behavioral therapy (CBT) protocols for anxiety disorders have been shown to have efficacy with older children and adolescents; however, only recently have investigators begun to adapt and pilot such interventions for younger children. This article reviews data suggesting that even very young children can benefit from CBT for anxiety, discusses some of the necessary developmental adaptations when working with children of preschool and early elementary school age, and reviews studies that have implemented CBT for anxiety disorders with youngsters in this age range. The authors conclude with recommendations for future directions for research in this area.

A preliminary study of D-cycloserine augmentation of cognitive-behavioral therapy in pediatric obsessive-compulsive disorder.

BACKGROUND: Research on the neural circuitry underlying fear extinction has led to the examination of D-cycloserine (DCS), a partial agonist at the N-methyl-D-aspartate receptor in the amygdala, as a method to enhance exposure therapy outcome. Preliminary results have supported the use of DCS to augment exposure therapy in adult anxiety disorders; however, no data have been reported in any childhood anxiety disorder. Thus, we sought to preliminarily examine whether weight-adjusted DCS doses (25 or 50 mg) enhanced the overall efficacy of cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD). METHOD: Participants were 30 youth (aged 8-17) with a primary diagnosis of OCD. The study design was a randomized, double-blinded, placebo-controlled augmentation trial examining CBT + DCS versus CBT + Placebo (15 youth per group). All patients received seven exposure and response prevention sessions paired with DCS or placebo taken 1 hour before sessions. RESULTS: Although not significantly different, compared with the CBT + Placebo group, youth in the CBT + DCS arm showed small-to-moderate treatment effects (d = .31-.47 on primary outcomes). No adverse events were recorded. CONCLUSIONS: These results complement findings in adult OCD and non-OCD anxiety disorders and provide initial support for a more extensive study of DCS augmentation of CBT among youth with OCD.

Child behavior checklist clinical scales discriminate referred youth with autism spectrum disorder: a preliminary study.

OBJECTIVE: To evaluate the properties of clinical scales of the Child Behavior Checklist in discriminating referred children with autism spectrum disorders (ASDs) (autistic disorder, Asperger's disorder, and pervasive developmental disorder not otherwise specified) from psychiatrically referred children without ASDs. METHOD: Comparisons were made between children with ASDs (n = 65) with intelligence quotient >70 and children without ASDs (N = 83) on the clinical scales of the Child Behavior Checklist. Stepwise logistic regression was used to identify those scales that best predicted ASDs when compared with the non-ASD comparison group. Receiver operating characteristic curves examined the ability of the significant predictor T-scores to identify ASDs versus the non-ASD subjects. RESULTS: Withdrawn, Social Problems, and Thought Problems T-scores were the best independent predictors of ASD status. The Withdrawn + Social + Thought Problems T-scores yielded an area under the curve of 0.86, indicating an 86% chance that a randomly selected sample of ASD subject will have abnormal scores on these scales than a randomly selected sample of non-ASD subjects. CONCLUSION: These findings suggest that a new Child Behavior Checklist-ASD profile consisting of the Child Behavior Checklist-Withdrawn, Social, and Thought Problems scales could serve as a rapid and cost-effective screening instrument to help identify cases likely to meet clinical criteria for ASDs in the clinical setting.

Anxiety and depressive disorders in offspring at high risk for anxiety: a meta-analysis.

This paper presents a meta-analysis of studies examining prevalence of psychopathology among offspring of anxiety-disordered parents, with the purpose of determining overall risk among these offspring for developing anxiety and depressive disorders. Pooled odds ratios for these disorders among high-risk offspring, compared to offspring of psychiatric and non-psychiatric controls, were calculated. Sixteen papers (including three follow-up studies) were identified, encompassing 1892 offspring (ages 4-25 years). Results revealed that: (1) offspring of parents with anxiety disorders have greater risk for anxiety and depressive disorders than offspring of non-psychiatric controls (ORs=3.91 and 2.67, respectively) and greater risk for anxiety disorders than offspring of psychiatric controls (OR=1.84); (2) offspring of anxious parents have significantly greater odds of having each type of anxiety disorder and MDD compared to offspring of non-psychiatric controls (ORs range from 1.96 to 8.69); and (3) offspring of parents with anxiety only, anxiety plus MDD, and MDD only have similar odds of having anxiety and depressive disorders but significantly higher odds than offspring of parents without disorder. Results suggest that parental anxiety disorders confer significant risk for anxiety and depression in offspring. Additional studies are needed to examine whether there are differences among specific parental anxiety disorders.

Is psychopharmacologic treatment associated with neuropsychological deficits in bipolar youth?

OBJECTIVE: To evaluate the impact of psychopharmacologic treatments on neuropsychological functioning in bipolar youth. METHOD: Participants were 173 children (aged 6-17 years) with DSM-IV bipolar disorder. Participants were comprehensively assessed using structured diagnostic interviews (Schedule for Affective Disorders and Schizophrenia for School-Age Children) and neuropsychological measures (eg, subtests of the Wechsler Intelligence Scale for Children-III and Wechsler Adult Intelligence Scale-III) during the years 2001-2006. Comparisons were made in neuropsychological functioning between medicated and unmedicated youth with bipolar disorder. RESULTS: Children who were treated with mood stabilizers performed significantly (P < .05) more poorly than untreated children on measures of processing speed and working memory. Treatment with other classes of medication, including second-generation antipsychotics, was not significantly associated with neuropsychological impairments. CONCLUSIONS: Treatment with mood stabilizers may be associated with specific neuropsychological impairments. Cognitive side effects may need to be considered in selecting particular psychopharmacologic treatments for children with bipolar disorder.