The Role of Parental Beliefs About Anxiety and Attachment on Parental Accommodation of Child Anxiety.

This study examined: 1) the relationship between negative parental beliefs about child anxiety (i.e., it is harmful), insecure parental attachment and parental accommodation of child anxiety; 2) whether parental attachment insecurity moderates the effect of negative beliefs about anxiety on parent accommodation; and 3) a path model of parental factors affecting accommodation and child anxiety severity. Participants were 139 parents of children (6-18 years) with a primary anxiety disorder. Parents completed measures of parental accommodation of their child's anxiety, beliefs about child anxiety, and attachment security. Child anxiety diagnosis and severity was determined using semi-structured clinical interviews. Negative beliefs about child anxiety were directly associated with levels of parental accommodation. There was no direct relationship between insecure attachment and accommodation; however anxious attachment moderated the effect of parental beliefs about anxiety on parental accommodation. Among parents with more secure attachment, negative beliefs about anxiety were associated with greater parental accommodation. However, among parents with less secure attachment, accommodation was high regardless of beliefs about anxiety. A path model suggested that negative beliefs about anxiety was related to increased parental accommodation, which in turn was related to increased child anxiety severity. Psychoeducation about the nature of anxiety is likely to be beneficial in helping to reduce accommodation among parents with more secure attachment styles. However, among those with greater anxious attachment, psychoeducation may need to be tailored to focus on corrective information about the impact of treatment processes on the parent-child relationship.

Stakeholder selected strategies for obesity prevention in childcare: results from a small-scale cluster randomized hybrid type III trial.

BACKGROUND: Together, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children's exposure to and intake of fruits and vegetables. WISE emphasizes 4 evidence-based practices (EBPs): (1) use of a mascot; (2) educators' role modeling; (3) positive feeding practices; and (4) hands-on exposures. The current study reports on a small-scale implementation trial aimed at improving the use of WISE EBPs by teachers. METHODS: A Hybrid Type III Cluster Randomized Design compared a Basic and Enhanced implementation strategy. The Basic Strategy included training and reminders only; the Enhanced strategy was a multi-faceted package of stakeholder-selected strategies including a leadership commitment, an implementation blueprint, a local champion, an environmental reminder of the EBPs, facilitation, and tailored educational resources and incentives. All study sites were Head Starts. Sites were randomized using a balancing technique that considered site characteristics; 4 sites (20 classrooms, 39 educators, 305 children) received Enhanced support; 5 sites (18 classrooms, 36 educators, 316 children) received Basic support. RE-AIM guided the evaluation, and implementation fidelity was the primary outcome. Strategies were assessed using examination of data distributions and unadjusted comparisons (t tests) as well as general linear and mixed effects models controlling for covariates. RESULTS: For the primary outcome of fidelity, the Enhanced group had significantly higher means for 3 of 4 EBPs. Multivariate models explained a significant portion of variance for both mascot use and hands-on exposure with a significant positive effect observed for treatment condition. The Enhanced group also had higher rates of Appropriateness and Organizational Readiness for Implementing Change (as indicators of implementation and adoption, respectively). There was no significant difference between groups for indicators of Reach, Effectiveness or Maintenance. Formative interviews indicated key targets for iteration and potential mechanisms. Key events were catalogued to provide context for interpretation (e.g., 61% of classrooms with turnover). CONCLUSIONS: Findings were mixed but suggested promise for the Enhanced strategy, especially considering key events of the study. Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes. TRIAL REGISTRATION: NCT03075085 Registered 20 February 2017.

Prevalence, severity, and clinical correlates of food neophobia in Salvadorian youth.

Food neophobia (FN) describes problematic fear-based avoidance/restriction of novel foods. Using the novel parent-reported Measure of Food Neophobia (MFN), the authors examined FN symptoms and impairment in 305 Salvadorian children and explored clinical correlates. Factor analysis supported the MFN's designed structure to inquire about FN symptoms and FN impairment. At least one FN symptom was observed in 91% of the sample; however, only 9% were rated as having moderate or greater impairment. Demographic variables were not associated with FN; however, FN was positively correlated with internalizing, externalizing, inattention, health anxiety, and obsessive-compulsive symptoms. Inattention symptoms and health anxiety emerged as significant predictors of FN symptoms, while FN symptoms were the only significant predictor of FN impairment. The present study supports the MFN and provides information about FN in a general population, including the prevalence of clinically significant symptoms and association with psychological domains. Continued investigation of FN is still needed.

Table Talk: revision of an observational tool to characterize the feeding environment in early care and education settings.

OBJECTIVE: The Table Talk tool is an observational assessment of early care and education teacher (ECET) mealtime practices. The Table Talk Revised (TT-R) tool incorporates new constructs that emerged from qualitative research and teases apart existing categories to improve nuance of data capture. The objective of this study was to evaluate the TT-R, document interrater reliability for the TT-R, and report on ECET feeding communications in broader settings than previously studied (i.e., beyond a single Lunch and Head Start only). METHODS: Trained observers conducted mealtime observations in classrooms (Nclassroms = 63, 10 sites) during Breakfast and two Lunches for both Lead and Assistant ECETs (N = 126). Classrooms were spread across Head Start in an urban area (60%), Head Starts in a rural area (24%), and a state-funded preschool (16%). RESULTS: On average, there were 22.17 (SD = 10.92) total verbal feeding communications at Breakfast, 37.72 (SD = 15.83) at Lunch1, and 34.39 (SD = 15.05) at Lunch2 with meals averaging 25 min. The most commonly observed supportive statement category was Exploring Foods for Lead (Breakfast = 1.61, Lunch1 = 3.23, Lunch2 = 2.70) and Assistant ECETs (Breakfast = .89, Lunch1 = 2.03) except for Lunch2 which was Encourages Trying in a Positive Way (Lunch2 = 1.30). The most commonly observed unsupportive statement category was Firm Behavioral Control for both Lead (Breakfast = 3.61, Lunch1 = 5.84, Lunch2 = 5.51) and Assistants ECETs (Breakfast = 3.11, Lunch1 = 6.38, Lunch2 = 4.32). The majority of Interclass Correlation Coefficients indicating interrater reliability were in the excellent range (64%) for commonly occurring statement categories, and 14 of the 19 low frequency statement categories had > 80% agreement. CONCLUSIONS AND IMPLICATIONS: Overall, items added to the Table Talk tool performed well, and interrater reliability was favorable. Our study also documented differences between Lead and Assistant teachers in mealtime practices and illustrated differing patterns of interaction between lunches and breakfast, important findings to inform future research and practice. The TT-R may be a useful measurement tool for monitoring and evaluating ECET practices in mealtime environments as well as informing intervention.

Parental accommodation of symptoms in adolescents with chronic pain.

Chronic pain in adolescents can be highly impairing. Parental reactions to their child's pain are important factors influencing pain perception and pain-related impairment in children and adolescents. The present study aimed to examine parental accommodation of pain symptoms using the Inventory of Parent Accommodations of Children's Symptoms (IPACS) to provide empirical support for the utility of this measure in parents of adolescents with chronic pain. We examined the prevalence, nature, and correlates of accommodation behaviors in 66 adolescents with chronic pain and their parents using the IPACS. All parents reported some level of accommodation of their child's pain symptoms. After controlling for pain severity, parental accommodation was associated with functional impairment. In addition, parental accommodation mediated the link between parental catastrophizing reactions to pain and child impairment and between child anxiety and depressive symptoms and child impairment. The IPACS appears to be a useful measure of parental accommodation of pain. Parental accommodation should be included as an intervention target when necessary. It is important to educate families about the negative consequences that can be related to excessive accommodation of pain symptoms and to provide effective resources to manage the impact of chronic pain and replace accommodation with more adaptive pain coping strategies.

Pester Power: Examining Children's Influence as an Active Intervention Ingredient.

OBJECTIVE: To determine if children's pester power related to a classroom-based nutrition program, Together, We Inspire Smart Eating (WISE), is related to familial dietary habits and parental food purchases and practices. METHODS: Classroom teachers delivered weekly WISE lessons at 7 Head Start sites across 2 states in the southern US. Before and after the intervention, parents were interviewed on the consumption of WISE fruits and vegetables, intake of nutrient-poor foods, parenting practices related to food, and exposure to WISE through the child's pester power. RESULTS: After controlling for baseline levels of outcome variables, child willingness to try new foods at baseline, and the effect of state, pester power predicated significant variance in the outcomes of consumption of WISE foods (F3, 229 = 34.7, P < .001, ΔR2 = 0.03, P = .002) and parenting practices that support healthy dietary intake and attitudes for young children (F2, 264 = 77.2, P < .001, ΔR2 = 0.02, P = .006). CONCLUSIONS AND IMPLICATIONS: The findings of this study highlight the potential for children's influence on food consumption and habits at home.

The Impact of Comorbidity on Cognitive-Behavioral Therapy Response in Youth with Anxiety and Autism Spectrum Disorder.

The impact of externalizing comorbidity on treatment outcome was examined in 104 youth ages 7-16 (M = 11.09 years) with autism spectrum disorder and primary anxiety/obsessive compulsive disorder who completed modular cognitive behavioral therapy (CBT) for anxiety/OCD. Three comorbidity profiles were utilized for group comparisons: participants with oppositional defiant or conduct disorder with attention-deficit hyperactivity disorder (ODD; CD; ADHD; group EXT, n = 25); those without ODD/CD and only ADHD (group ADHD, n = 46); and those without externalizing comorbidity (NO-EXT, n = 33). Post-treatment outcomes were measured continuously (Pediatric Anxiety Rating Scale, Clinical Global Impression-Severity) and categorically (treatment response, remission). The ADHD group was four times more likely of being a treatment responder compared to NO-EXT (OR 4.05). Comorbidity group did not impact remission. After controlling for pre-treatment scores, there was a significantly greater reduction of the CGI-S for ADHD versus NO-EXT and EXT versus NO-EXT, but results did not significantly differ for the PARS. Results suggest that a modular CBT approach yields positive impact for treatment outcomes in youth with comorbid externalizing problems, particularly among those with comorbid ADHD.

A Pilot Study of Family-Based Exposure-Focused Treatment for Youth with Autism Spectrum Disorder and Anxiety.

Anxiety is a common and impairing condition in youth with autism spectrum disorders (ASD). Evidence supports the use of cognitive behavioral therapy for treating anxiety in this population; however, available treatment protocols may be difficult to implement outside of research settings. The present study examined the efficacy of family-based exposure-focused treatment (FET) compared to a treatment as usual (TAU) control in 32 youth aged 6-17 years with ASD and co-occurring anxiety. Fourteen youth were randomized to FET, which included 12 face-to-face weekly therapy sessions lasing 45-55 min, while 18 youth completed the TAU control where engagement in psychotherapy or pharmacotherapy was at the discretion of the families. Results strongly supported FET with a 79% (versus 0% in TAU) response rate, 86% (versus 0% in TAU) remission in primary anxiety diagnosis, and large between-group effects on clinician-rated anxiety severity and most parent-rated domains of anxiety-related impairment. Among treatment responders, 2-month follow-up supported maintenance of gains. Overall, the study supported FET as a relatively brief intervention for the treatment of anxiety in youth with ASD, although further research is needed to replicate these findings and compare FET outcomes to more comprehensive interventions.

Symptom Profiles Specific to Trauma in a Child Inpatient Unit.

Adverse childhood experiences (ACE) score showing 4 or more types of trauma have been shown to be a strong predictor of deleterious outcomes.1 We report here on the relationship between ACE or number of trauma types, and symptom profile as measured by the Child Behavior Checklist (CBCL) of children on an inpatient unit. Previous work has been limited to samples preselected for trauma, thus limiting the ability to identify whether the clinical presentation of trauma has unique attributes when compared to a clinical sample of comparable severity.

Open Trial of Modular Cognitive-Behavioral Therapy in the Treatment of Anxiety Among Late Adolescents with Autism Spectrum Disorder.

Given the high rates of comorbid anxiety and autism spectrum disorder (ASD) in the adolescent and young adult population, effective treatment protocols to address anxiety symptoms are of importance to help promote greater independence across settings. While research supports the use of cognitive-behavioral therapy (CBT) across younger age groups with ASD, the literature is limited on interventions benefitting adolescents and young adults with comorbid anxiety disorders and ASD. Therefore, this open trial utilized a modified CBT manual for seven participants between the ages of 16 and 20 years, consisting of a 16-week modularized CBT treatment, including psychoeducation, cognitive therapy, and exposure therapy. Measures of anxiety and depression were completed at baseline and post-treatment. Findings demonstrated significant reductions on clinician-rated measures of anxiety. While findings are encouraging, additional studies examining the efficacy of CBT for this population with ASD and clinical anxiety are necessary to further identify beneficial treatment components.

Presentation and Correlates of Hoarding Behaviors in Children with Autism Spectrum Disorders and Comorbid Anxiety or Obsessive-Compulsive Symptoms.

We investigated the presentation and correlates of hoarding behaviors in 204 children aged 7-13 with autism spectrum disorder (ASD) and comorbid anxiety or obsessive-compulsive disorder (OCD) symptoms. Approximately 34% of the sample presented at least moderate levels, and with 7% presenting severe to extreme levels of hoarding. Child gender predicted hoarding severity. In addition, child ASD-related social difficulties together with attention-deficit and hyperactivity disorder symptom severity positively predicted hoarding controlling for child gender and restricted and repetitive behaviors. Finally, child anxiety/OCD symptoms positively predicted hoarding, controlling for all other factors. These results suggest hoarding behaviors may constitute a common feature of pediatric ASD with comorbid anxiety/OCD, particularly in girls and children with greater social difficulties and comorbid psychiatric symptom severity.

Quality and Correlates of Peer Relationships in Youths with Chronic Pain.

Youths with chronic pain may experience difficulties with peer relationships. We investigated the quality and correlates of peer relationships in a sample of 181 youths with chronic pain. A majority of youths were satisfied with their relationships with peers; however, levels were highly variable. Higher functional impairment and depression levels predicted lower peer relationship quality, controlling for demographic and other pain-related factors. In addition, peer relationship quality and pain severity predicted child depression and anxiety symptoms, whereas peer relationship quality only predicted anger symptoms. Relationship quality moderated the association between pain severity and functional impairment, suggesting that strong relationships with peers may buffer the effects of pain on functioning. Peer relationships seem particularly important for the adjustment and psychological well-being of youths with chronic pain. Particular attention should be given to functionally impaired and depressed children, who may be at higher risk of peer difficulties.

Initial psychometrics, outcomes, and correlates of the Repetitive Body Focused Behavior Scale: Examination in a sample of youth with anxiety and/or obsessive-compulsive disorder.

BACKGROUND: Body-Focused Repetitive Behaviors (BFRBs), including skin-picking, hair-pulling, and nail-biting, commonly occur in youth, even at elevated/problematic levels, and are associated with a number of other psychiatric symptoms. The present study examined the internal consistency of a brief screening tool for BFRBs as well as the prevalence, severity, and correlates of BFRBs in a sample of youth with a primary anxiety or obsessive-compulsive disorder (OCD). METHODS: Ninety-three youth-parent dyads presenting for treatment for anxiety or OCD completed study measures including the Repetitive Body Focused Behavior Scale - Parent (RBFBS), which includes subscales for skin-picking, hair-pulling, and nail-biting, as well as a number of additional clinician-, parent-, and child-rated scales. RESULTS: The RBFBS demonstrated good to excellent internal consistency. BFRBs were endorsed in 55% of youths, with elevated levels in 27%. Skin-picking was the most common BFRB (38%), followed by nail-biting (34%) and hair-pulling (4%). Youth with BFRBs, as compared to those without, were rated as more avoidant by their parents. Among those with BFRBs, more avoidant tendencies, anxiety sensitivity, and child-rated panic, separation, and generalized anxiety symptoms were associated with elevated BFRB severity. BFRBs were equally common but more likely to be elevated among youth with a primary anxiety, than OCD, diagnosis. DISCUSSION: Results provide initial support for the RBFBS as a brief screening tool for the three common BFRBs. In addition, the results suggest avoidant tendencies and physical manifestations of distress may be particularly relevant to the escalation of BFRB symptoms in youth.

Outpatient Treatment Patterns of Pediatric Obsessive-Compulsive Disorder.

INTRODUCTION: Little is known about community physician treatment practices for children with obsessive-compulsive disorder (OCD). This study is the first to describe the treatment of pediatric OCD in office-based and outpatient department-based physicians in the United States. METHODS: Data from the 2003-2011 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were used. We provided descriptive statistics for sample characteristics and treatments administered during the visit, and examined differences in treatment by comorbid conditions and settings using logistic regression. RESULTS: Psychotherapy was provided in 46% of visits in children with OCD overall, while serotonin reuptake inhibitor (SRI) medication was prescribed to 55% overall, atypical antipsychotics were prescribed to 22% of youth either alone or in combination with another medication; 11% received no psychotherapy or pharmacotherapy. Psychotherapy and at least one pharmacotherapy were provided to 36% of patients. There were no significant differences in characteristics of patients receiving each class of medication. CONCLUSION: Among children and adolescents, OCD was primarily treated by physicians using SRI medication and/or psychotherapy. A sizeable proportion of children were given atypical antipsychotic medications. Wider dissemination of evidence-based psychological treatments and continued monitoring of adherence to guidelines is warranted.

The Treatment Worries Questionnaire: Conjoined measures for evaluating worries about psychosocial treatment in youth and their parents.

Treatment worries, which surround requirements and results of obtaining treatment, may represent an important construct; however, previous measures were limited by their specificity, format, and lack of parent report. Therefore the present study examined the initial outcomes and psychometrics of corresponding measures of treatment worries in youth (Treatment Worries Questionnaire - Child; TWQ-C) and their parents (Treatment Worries Questionnaire - Parent; TWQ-P). Participants were 94 youth (7-17-years old) and parent dyads presenting for treatment of an anxiety disorder. Dyads completed the TWQ-C and TWQ-P along with additional measures prior to initiating treatment. Treatment worries were endorsed in the mild-moderate range by youth and the TWQ-C demonstrated good-excellent internal consistency, a three-factor structure, and consistent convergent and divergent relationships. Treatment worries were endorsed in the low-mild range by parents and the TWQ-P demonstrated fair-good internal consistency, a four-factor structure, and consistent divergent relationships, but variable (by factor) convergent relationships. The results provide information on treatment worries and support the use of the TWQ-C and TWQ-P as broad assessments of the concept. Low endorsement of worries among parents likely relates to the treatment-seeking nature of the sample. Future investigations using the TWQ-C and TWQ-P in a variety of samples is warranted.

An initial study of family accommodation in children and adolescents with chronic tic disorders.

This initial study examined the nature, incidence, and clinical correlates of family accommodation in youth with tic disorders, and validated a brief self-report measure of tic-related family accommodation, the Tic Family Accommodation Scale (TFAS). Seventy-five youth aged 6-18 who were diagnosed with a tic disorder and their parent completed a diagnostic clinical interview, and clinician and parent-report measures of tic severity, depressive symptoms, anxiety symptoms, behavioral problems, family accommodation and impairment. An exploratory factor analysis of the TFAS showed a two-factor structure, with good internal consistency for the Total score, Modification of Child Environment and Modification of Parent Environment subscales (α = 0.88, 0.86, and 0.81, respectively). Family accommodation was not associated with tic severity. Family accommodation was associated with increased anxiety and depressive symptoms, higher externalizing, rule breaking, aggressive behaviors and social problems, and with greater tic-related functional impairment. Anxiety and externalizing problems (but not depressive symptoms) predicted family accommodation when controlling for tic severity. Family accommodation predicted high levels of functional impairment over and above the effect of tic severity, anxiety, depression and externalizing problems. Family accommodation is a common phenomenon for youth with tic disorders, with modifications typically encompassing changes to the child and/or parent environments. Accommodation was not associated with tic severity, but was related to higher levels of anxiety, depressive symptoms, externalizing symptoms, aggression, and rule breaking behaviors. Results suggest that other emotional symptoms are more likely to drive accommodation practices than the tic symptoms per se.

Prevalence and Clinical Differences of Suicidal Thoughts and Behaviors in a Community Sample of Youth Receiving Cognitive-Behavioral Therapy for Anxiety.

This study examined the incidence of suicidal thoughts and behaviors in youth with anxiety before initiating cognitive behavioral therapy, as well as the emergence of suicidal thoughts and behaviors during treatment. Overall, 30% of youth experienced suicidal thoughts and behaviors. Prior to treatment, 24% reported suicidal thoughts and behaviors, and 13.1% endorsed suicidal thoughts and behaviors during treatment. More than half who endorsed suicidal thoughts and behaviors during treatment were newly identified cases not detected prior to treatment. Disagreement among parent- and child-report measures of suicidality was found at baseline. Youth who experienced suicidal thoughts and behaviors had higher levels of loneliness, depressive symptoms, overt peer victimization, functional impairment, and externalizing symptoms. Findings suggest that the assessment of suicidality at a single time-point and from one informant is not sufficient to identify at-risk youth. Ongoing assessment of suicidal risk during treatment is important in this population.

Examination of the Phenomenology and Clinical Correlates of Emetophobia in a Sample of Salvadorian Youths.

Emetophobia is an under-researched disorder characterized by a specific fear of vomiting. There is a paucity of research on this impairing condition, with extant examinations being largely limited to adult samples and online communities. The present study examined the incidence, phenomenology, and correlates of emetophobia in 305 Salvadorian youths. Caregivers completed a battery of questionnaires regarding the youth's symptoms of emetophobia, internalizing/externalizing symptoms, health anxiety, and obsessive-compulsive symptoms. Approximately 7.5 % of the sample was elevated on emetophobia symptoms, and higher levels of emetophobia symptoms were correlated with higher levels of internalizing, externalizing, health anxiety, and obsessive-compulsive symptoms, and lower levels of adaptive functioning. Youths meeting the cutoff for elevated emetophobia symptoms versus those who did not demonstrated significantly higher levels of externalizing behaviors, as well as general obsessive-compulsive symptoms, especially doubting/checking and neutralizing behaviors. These findings are hoped to help improve the conceptualization and treatment of this poorly understood disorder.

Predictors of parent-child agreement on child anxiety diagnoses on the ADIS-IV-C/P.

Diagnostic agreement between parents' and children's reports on children's anxiety problems is notoriously poor; however, very few investigations have examined specific predictors of inter-rater agreement on child anxiety diagnoses. This study examined predictors of categories of parent and child diagnostic endorsement on the Anxiety Disorders Interview Schedule for Children-IV. One hundred eight children (ages 7-13) and their parents completed structured diagnostic interviews for non-OCD/PTSD anxiety diagnoses and paper and pencil measures of functioning and impairment in a variety of domains. Parent-child agreement was statistically significant for social phobia and separation anxiety disorder, but was overall poor for all anxiety diagnoses. Externalizing disorder status, family accommodation frequency, and child rated impairment in various domains differentially predicted informant discrepancies for different anxiety disorders. These data are among the first to suggest variables that may explain parent-child concordance.

Suicidal ideation in youth with tic disorders.

BACKGROUND: This study examined the incidence and clinical correlates of suicidal ideation (SI) in youth with tic disorders (TD). The independent contribution of tics, anxiety, depressive and externalizing symptoms on SI severity in youth with TD was assessed. METHOD: Participants were 75 treatment-seeking youth with a TD (N=75) aged 6-18. Participants completed diagnostic assessments, clinician-ratings, self- and parent-report measures of emotional functioning and the presence and/or severity of suicidal ideation. RESULTS: Based on youth-report, 61% of youth endorsed at least some symptoms of SI, and 8% endorsed symptoms that exceeded the clinically significant cut-off. Parents reported SI in 11% of cases, with generally poor agreement between parent- and youth-report. Suicidal ideation correlated with higher anxiety, depressive and externalizing symptoms, affective lability, and with poorer distress tolerance and overall functioning. Anxiety, depressive and externalizing symptoms showed an independent relationship with SI. Tic severity was not associated with SI. Rather, higher tic severity was associated with an increase in anxiety symptoms, which in turn, was associated with greater SI severity. LIMITATIONS: Cross-sectional data limits causal conclusions. Diagnosis was based on unstructured assessments by expert clinicians, including consensus diagnosis, rather than structured clinical interviews. CONCLUSIONS: Around 8-11% of youth with TD experienced SI. Tic severity did not have any direct influence on SI, however the presence of comorbid anxiety and depressive symptoms significantly increases this risk. Results suggest that it is psychiatric comorbidity, rather than tics themselves, that predispose youth with tic disorders to increased risk of suicidality.