Familial predictors of treatment outcome in childhood anxiety disorders.

OBJECTIVE: To determine whether family factors are predictive of outcome in children with anxiety disorders who are receiving cognitive-behavioral treatment. METHOD: Participants were 61 children aged 8 to 12 years (mean = 10.0, SD = 1.4) with Axis I anxiety disorders who had been referred to a large Toronto children's hospital. Parents and children completed measures assessing family functioning, parenting stress, parental frustration, and parental psychopathology before and after treatment. Outcome measures included clinician-rated functioning (Children's Global Assessment Scale) and self- and parent-rated anxiety (Revised Children's Manifest Anxiety Scale). RESULTS: Child ratings of family dysfunction and frustration predicted clinician-rated improvement (total R2 = 0.28, p < .001). Mother and father reports of family dysfunction, and maternal parenting stress, predicted mother-rated child improvement (total R2 = 0.18, p < .01). Father-rated somatization and child reports of family dysfunction and frustration predicted child-rated improvement (total R2 = 0.25, p < .001). Several family factors improved with treatment. CONCLUSION: Family dysfunction appears to be related to less favorable treatment outcome in children with anxiety disorders.

Childhood anxiety disorders: lessons from the literature.

Studies of childhood anxiety disorders have increased in recent years, but the clinical implications of the work are sometimes difficult to discern. This paper reviews salient findings (related to the assessment and management of anxious children) published in the last 5 years. The high comorbidity among disorders, the occurrence of different disorders in the same child over time, recent changes in diagnostic categories, the availability of new anxiety measures, and poor correspondence between parent and child reports of symptoms all underscore the need for thorough assessment. Increasing evidence supports cognitive-behavioural treatments for anxiety disorders, alone or in combination with pharmacotherapy. Other important aspects of management suggested by developmental studies of anxious children include psychoeducation about constitutional factors in the development of anxiety, interventions to address parental anxiety, parenting advice regarding behaviour management and reduction of family conflict, and treatment of child impairment to decrease the risk of depression. Questions requiring further research are identified.

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.

Perception of emotions in anxious and learning disabled children.

This study examined differences in the ability to perceive others' emotions in anxious and learning disabled children, as these differences may contribute to these children's unique socio-emotional difficulties and therapeutic needs. Forty-six children ages 8 to 12 with either anxiety disorders (ANX), language-based learning disabilities (LD), both conditions, or neither condition (clinical controls) were compared on the DANVA, a standardized measure of auditory and visual perception of emotion. Group results were then compared to normative data. Using multivariate analyses, significant group differences were found on the auditory portion of the DANVA but not on the visual portion. LD and comorbid children scored lower on several auditory stimuli, especially when presented at low emotional intensity, while ANX and comorbid children showed high accuracy for auditory sadness. Comorbid children also had lower auditory DANVA scores than the normative sample. No interactive effects between ANX and LD were found. ANX and LD each appear to have distinct effects on the auditory perception of others' emotions. Children with both conditions show both effects and differ from normal children in this domain. Replication using larger samples is required.

Cognitive-behavioral group treatments in childhood anxiety disorders: the role of parental involvement.

OBJECTIVES: This study examined (1) the effect of a cognitive-behavioral group intervention on anxiety, depression, and coping strategies in school-age children (aged 7-12 years) with Axis I anxiety disorders; and (2) the effect of parental involvement on treatment outcomes. METHOD: Parents and children (N = 62) were randomly assigned to one of three 12-week treatment conditions: parent and child intervention, child-only intervention, and parent-only intervention. Child anxiety, depression, and coping strategies were assessed before and after treatment. RESULTS: All treatment groups reported fewer symptoms of anxiety and depression posttreatment and changes in their use of coping strategies. Children in the parent and child intervention used more active coping strategies posttreatment compared with children in the other 2 treatment conditions. Parents in this treatment condition reported a significantly greater improvement in their children's emotional well-being than parents in the other treatment conditions. CONCLUSIONS: Cognitive-behavioral group interventions reduced symptoms of anxiety and depression in school-age children with anxiety disorders. Concurrent parental involvement enhanced the effect on coping strategies. Further investigation is needed to corroborate the effectiveness of such short-term interventions and the maintenance of treatment effects.

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.

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.

Child and parent reports of childhood anxiety: differences in coping styles.

This study compares children anxious only on parent report (PR) with those anxious on self-report (SR) and self- and parent report (SPR) to examine the reasons for the reporting differences. Sixty-five children aged 7-12 years who met criteria for one or more Axis I anxiety disorders (25% with comorbid nonanxiety diagnoses) completed standardized measures of anxiety, depression, and coping style. Parents completed measures of child psychopathology and adult coping style. Assessing clinicians completed the Global Assessment of Functioning. All parents endorsed anxiety in their children. Based on their responses on standardized self-report measures of anxiety, children were classified as endorsing anxiety (SPR group) or not endorsing anxiety (PR group). Multivariate analysis of variance revealed that children in the SPR group endorsed more depression and employed a greater variety of coping strategies than children in the PR group. The two groups did not differ on parent or clinician measures. These findings suggest that reporting differences may be related to differences in coping styles in anxious children. SPR children may over report anxiety symptoms due to feelings of decreased self-worth associated with depressive thinking, whereas PR children may be able to distract themselves from their anxieties. The lack of difference in functioning between the two groups suggests that self-report anxiety questionnaire scores are not necessarily indicative of severity.

Cognitive differences between anxious, normal, and ADHD children on a dichotic listening task.

To compare the performance of children with anxiety disorders with that of children with attention-deficit hyperactivity disorder (ADHD) and normal controls in the processing of emotional information. A total of 57 children ages 8 to 11 years (18 anxious, 20 ADHD, 19 normal control) were administered a dichotic listening task for the detection of words and emotions. Comparisons of overall performance, false alarms, and a sensitivity index (which took false alarms into account) were done using repeated measures analyses of variance. Anxious children made fewer false alarms for emotion targets compared to both ADHD children and normal controls, and fewer false alarms for words compared to normal controls. When controlling for false alarms, their performance exceeded that of both ADHD children and normal controls. There were no group differences in correct responses. Performance on a dichotic listening task differentiates anxious, ADHD, and normal children, particularly when listening for emotional targets. Further studies using this task may therefore elucidate differences in the processing of words and emotions between these three groups of 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 (Kagan's 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.

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 mother's 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.

Anorexia resulting from fear of vomiting in four adolescent girls.

Four adolescent girls were referred for psychiatric assessment because of suspected anorexia nervosa. Although all of them had lost at least 15% of their body weight, investigation showed that they did not meet the criteria for anorexia nervosa. In all cases, refusal to eat resulted from fear of vomiting following a viral illness and not from a desire to lose weight. Their family configurations and personal histories showed many similarities, including constricted range of affect and a notable lack of anger. With counseling and, in one case, psychotropic medication, the patients recovered promptly.

The effects of cultural differences on the physician-patient relationship.

Differences between patients' and physicians' perceptions of illness can result in poor communication and unsatisfactory treatment results. These differences are more likely when the patient's cultural background is different from the physician's. This article provides a case history of a cultural conflict between a patient, the patient's family, and the medical care system. The beliefs and practices of people unfamiliar with the North American health care system are discussed, and physicians' assumptions about how patients should behave are explored. Ways of preventing cultural conflict with patients are suggested.