Imipramine plus cognitive-behavioral therapy in the treatment of school refusal.

OBJECTIVE: To investigate the efficacy of 8 weeks of imipramine versus placebo in combination with cognitive-behavioral therapy (CBT) for the treatment of school-refusing adolescents with comorbid anxiety and major depressive disorders. METHOD: This was a randomized, double-blind trial with 63 subjects entering the study and 47 completing. Outcome measures were weekly school attendance rates based on percentage of hours attended and anxiety and depression rating scales. RESULTS: Over the course of treatment, school attendance improved significantly for the imipramine group (z = 4.36, p < .001) but not for the placebo group (z = 1.26, not significant). School attendance of the imipramine group improved at a significantly faster rate than did that of the placebo group (z = 2.39, p = .017). Over the 8 weeks of treatment, there was a significant difference between groups on attendance after controlling for baseline attendance; mean attendance rate in the final week was 70.1% +/- 30.6% for the imipramine group and 27.6% +/- 36.1% for the placebo group (p < .001). Defining remission as 75% school attendance, 54.2% of the imipramine group met this criterion after treatment compared with only 16.7% from the placebo group (p = .007). Anxiety and depression rating scales decreased significantly across treatment for both groups, with depression on the Children's Depression Rating Scale-Revised decreasing at a significantly faster rate in the imipramine group compared with the placebo group (z = 2.08, p = .037). CONCLUSIONS: Imipramine plus CBT is significantly more efficacious than placebo plus CBT in improving school attendance and decreasing symptoms of depression in school-refusing adolescents with comorbid anxiety and depression.

ADHD boys in young adulthood: psychosocial adjustment.

OBJECTIVE: To prospectively examine psychosocial functioning in young adulthood in children with attention-deficit/hyperactivity disorder (ADHD). METHOD: This 10-year prospective study compared psychosocial functioning in 18 young adult men in whom ADHD had been diagnosed in childhood and 18 male controls who had never been psychiatrically ill. Subjects' average age was 21 years at follow-up. Interviews assessed subjects' educational, occupational, residential, and marital status; utilization of mental health services; and psychological status. RESULTS: Young adults with ADHD were significantly more likely than controls to be using mental health services, to report psychological problems, and to have fathered children. In addition, a trend indicated that young men with ADHD were more likely to have dropped out of high school but subsequently attained a graduate equivalency diploma. There was also a trend for young adults with ADHD to report a greater history of trouble with the law; however, the groups did not differ on current legal problems. CONCLUSIONS: Overall, these young adults with ADHD appear to have overcome educational and legal difficulties experienced during high school. However, continued problems in psychological functioning appear to persist into young adulthood.

Predictors of severity of absenteeism in children with anxiety-based school refusal.

Examined possible relations among sociodemographic, clinical, and familial variables and level of school absenteeism in children with anxiety-based school refusal. These children exhibit a great deal of variability in the severity of school refusal, with some youngsters missing only an occasional day of school, whereas other exhibit pervasive school absenteeism. Participants were 76 children referred for treatment of anxiety-based school refusal. Children and a parent completed a structured clinical interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children) and self-report measures that assess children's levels of fear (Fear Survey Schedule for Children-Revised), trait and somatic anxiety (Modified State-Trait Anxiety Inventory for Children), and depressive symptomatology (Children's Depression Inventory), as well as family environment characteristics (Family Environment Scale). Regression analyses revealed that older age, lower levels of fear, and less active families were primary predictors of greater levels of school absenteeism.

Cognitive-behavioral treatment of school phobia.

OBJECTIVE: To conduct a controlled group outcome investigation of the efficacy of cognitive-behavioral treatment for school phobia. METHOD: Fifty-six children with school phobia were randomly assigned to 12 weeks of cognitive-behavioral therapy or an attention-placebo control condition. Pre- and posttreatment school attendance, self-reported anxiety and depression, and diagnostic status were compared. RESULTS: Both the experimental and control treatments were equally effective at returning children to school. Both treatments also were effective in reducing children's anxiety and depressive symptoms. Follow-up revealed no differences between groups when the children reentered school the next school year. CONCLUSIONS: Overall, results suggest that psychosocial treatments are effective at returning school-phobic children to school and that the highly structured cognitive-behavioral approach may not be superior to more traditional educational and supportive treatment methods.

Worrisome thoughts in children clinically referred for anxiety disorder.

Administered a 31-item worry measure, based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) for anxiety disorders, to referred children with anxiety disorders (n = 72) or attention deficit hyperactivity disorder (ADHD; n = 50), and to nonreferred, never psychiatrically ill controls (n = 55). Anxiety and ADHD groups did not differ for self-reported worries. Anxious children did report more "intense" worries about separation and social evaluation than controls. ADHD children reported more intense worries about friends and school than controls. Separation worries were most prevalent in children with separation anxiety disorder, thus distinguishing this subgroup from both control groups. Results suggest that intense worries specific to one's anxiety disorder are more clinically relevant than the overall level of worry. Implications for assessment of worry are discussed.

Anxious children in adulthood: a prospective study of adjustment.

OBJECTIVE: To prospectively examine psychosocial functioning in young adulthood for children and adolescents with anxiety disorders. METHOD: This 8-year prospective study compared psychosocial functioning in young adults (mean age 22 years) who had histories of early-onset anxiety disorders, comorbid anxiety and depressive disorders, or no history of psychiatric illness (NPI). Follow-up interviews assessed subjects' residential, educational, occupational, and marital status; utilization of mental health services; and psychological status RESULTS: Anxious subjects without histories of depression were less likely than NPI controls to be living independently. Anxious-depressed subjects were less likely than controls to be working or in school; more likely than purely anxious subjects to utilize mental health services; and more likely than both anxious and control subjects to report psychological problems, most frequently depression. CONCLUSIONS: Overall, results suggest that children with anxiety disorders are relatively well adjusted in young adulthood. However, a history of comorbid depression is prognostic of a more negative outcome.

A prospective study of childhood anxiety disorders.

OBJECTIVE: To evaluate course and outcome of DSM-III-R anxiety disorders prospectively in clinically referred children. METHOD: Children were blindly and repeatedly assessed with a structured diagnostic interview over a 3- to 4-year period to determine recovery from anxiety disorder and development of new psychiatric disorders. Both psychopathological (attention-deficit hyperactivity disorder, n = 50) and never psychiatrically ill (NPI, n = 83) controls served as comparison groups for children with anxiety disorders (n = 84). RESULTS: The majority of children (82%) were free from their intake anxiety disorders by the end of the follow-up. Relapse of these anxiety disorders after remission was rare (8%). During follow-up, anxious children were more likely to develop new psychiatric disorders (30%), primarily new anxiety disorders (16%), than were NPI children (11% and 2%, respectively), but not psychopathological controls (42% and 10%, respectively). CONCLUSIONS: Overall, results suggest a favorable outcome with respect to diagnostic status for clinically referred children with anxiety disorders. However, these children may be at risk for new psychiatric disorders over time.

Relationship between ADHD and anxiety in boys: results from a family study.

OBJECTIVE: Recent studies have found an increased risk for both anxiety disorder and attention-deficit hyperactivity disorder (ADHD) in the adult relatives of children with ADHD in comparison with adult relatives of normal controls. Such findings may account for the high rates of comorbid anxiety found in children with ADHD, and they suggest a relationship between the two disorders. However, additional studies are needed to address this relationship that include both anxiety disorder and normal control groups. METHOD: The first- (n = 239) and second-degree relatives (n = 1,266) of clinically referred boys with ADHD (n = 49), clinically referred boys with anxiety disorder (n = 46), and controls who have never been psychiatrically ill (NPI controls) (n = 37) were assessed with structured interview and diagnosed according to DSM-III-R criteria. Lifetime rates of ADHD and anxiety disorder were then compared for relatives in the three proband groups. RESULTS: Female relatives of ADHD probands had significantly higher rates of anxiety disorder than female relatives of NPI controls. However, relatives of anxious probands and NPI controls did not differ for ADHD. Furthermore, no evidence of cosegregation of anxiety disorder with ADHD was found in the relatives of probands in the two patient groups. CONCLUSIONS: ADHD and anxiety may share common risk factors but appear to be independently transmitted in families. The high rate of anxiety in female relatives of ADHD probands was comparable with that found in relatives of anxious probands and warrants further investigation.

Anxiety disorders in African-American and white children.

There are little available data on African-American children with anxiety disorders. Treatment-seeking African-American (n = 30) and white children (n = 139), with a current DSM-III-R anxiety disorder, were compared on sociodemographic background variables, clinical characteristics, and lifetime rates of specific DSM-III-R anxiety disorders. Overall, results suggested that the anxiety-disordered African-American and white children who sought treatment from an outpatient mental health facility were more similar than different. The two groups did, however, differ somewhat on several variables (trend only), including rates of school refusal, severity of primary anxiety disorder, lifetime prevalence of posttraumatic stress disorder, and total scores on the Fear Survey Schedule for Children-Revised. More specifically, white children were more likely to present with school refusal and higher severity ratings, while African American children were more likely to have a history of posttraumatic stress disorder and score higher on the FSSC-R. The impact of these findings and the need for additional research are discussed.

Do childhood anxiety measures measure anxiety?

The Fear Survey Schedule for Children-Revised (FSSC-R), Revised-Children's Manifest Anxiety Scale (RCMAS), and the Modified State-Trait Anxiety Inventory for Children (STAIC-M) are three widely used self-report measures of childhood anxiety. While previous studies have established the reliability of these measures, their validity in discriminating anxious from non-anxious youngsters remains to be established. The present study examines the discriminant validity of the three measures by comparing clinic referred samples of boys with an anxiety disorder (n = 105) or ADHD (n = 59) with a community sample of never-psychiatrically-ill boys (n = 49). Results indicated that the two patient groups differed significantly from the never-psychiatrically-ill group on the RCMAS and STAIC-M, but the anxious and ADHD groups did not differ from each other. None of the three groups differed on the FSSC-R. The implications of these findings for the assessment of childhood anxiety disorders are discussed.

DSM-III-R anxiety disorders in children: sociodemographic and clinical characteristics.

This study investigated the characteristics of each of the specific DSM-III-R (American Psychiatric Association, 1987) anxiety disorders in a clinic sample of 188 anxiety disordered children. Characteristics examined included sociodemographic variables (age-at-intake, gender, and race of the child, and family marital and socioeconomic status) and clinical variables (disorder age-at-onset and severity, and history of additional disorders). Findings are discussed in light of the contemporary literature on childhood anxiety disorders.

Avoidant disorder and social phobia in children and adolescents.

The diagnoses of avoidant disorder and social phobia in children have received little research attention. Although DSM-III-R describes avoidant disorder and social phobia as data are available to support this notion. The current study examined characteristics of avoidant disorder and social phobia by comparing outpatient youngsters with avoidant disorder, social phobia, and avoidant disorder plus social phobia on demographic variables and patterns of comorbidity. The psychiatric groups were compared with matched normal controls on symptom measures of depression and fear. Findings indicated that the three psychiatric groups were strikingly similar on all but one variable, age at intake. These findings question the notion of avoidant disorder and social phobia as distinct disorders in children and adolescents.

Anxiety disorders in children and their families.

The first- and second-degree relatives of children with anxiety disorders were compared with relatives of children with attention deficit-hyperactivity disorder and children who had never been psychiatrically ill for lifetime rates of psychopathological conditions, particularly anxiety disorders. Results from blind, diagnostic interviews indicated an increased prevalence of anxiety disorders in the first-degree relatives of children with anxiety disorder compared with relatives of both children with attention deficit-hyperactivity disorder and never psychiatrically ill children. Relationships between specific anxiety disorders in children and their relatives revealed an increased rate of panic disorder among the first-degree relatives of children with over-anxious disorder, compared with the relatives of children with separation anxiety disorder and children with other types of anxiety disorders. There also was a trend for panic disorder to be more prevalent among relatives of children with panic disorder than among relatives of children with anxiety disorder without panic. Obsessive-compulsive disorder was the only other anxiety disorder that appeared to show a similar specific relationship between children and their relatives. In general, the findings from this study suggest that there is a familial component involved in the pathogenesis of childhood anxiety disorders. The specificity of this relationship varies among individual anxiety disorders.

Symptoms of anxiety disorders in normal children.

The present study examined prevalence, expression, and developmental patterns of DSM-III-R anxiety disorder symptoms in 62 never-psychiatrically-ill children. Subclinical phobias and overanxious disorder symptoms were fairly common, while symptoms of other anxiety disorders were less common. Direction of sex and age differences was generally consistent with previous literature, but few reached statistical significance. Nonanxious and subclinically anxious subsamples of never-psychiatrically-ill subjects were compared on individual and family psychopathology. Subclinically anxious children showed greater individual and family psychopathology than nonanxious children, though differences decreased at 12-month follow-up. Anxiety as a normal developmental phenomenon is discussed.

School refusal in anxiety-disordered children and adolescents.

The characteristics of anxiety-based school refusal were examined in 63 school refusing children and adolescents referred to an outpatient anxiety disorder clinic. Patients were assessed on sociodemographic, diagnostic, and personality variables, as well as familial history of school refusal. Results suggest that there are two primary diagnostic "subgroups" of school refusers--separation anxious and phobic. Phobic school refusers had a later age of onset and showed more pervasive (severe) school refusal than separation anxious school refusers. By contrast, separation anxious school refusers were more likely than phobic school refusers to have mothers who had a history of school refusal problems. The implications of these findings are discussed.

Overanxious disorder: an examination of developmental differences.

Differences between a clinical sample of younger (ages 5 to 11) and older (ages 12 to 19) children meeting DSM-III criteria for overanxious disorder (OAD) were examined. Younger and older children were compared in terms of (1) the rates of OAD diagnoses occurring in the two age groups, (2) sociodemographic characteristics, (3) symptom expression, (4) association with other forms of maladjustment, and (5) self-reported anxiety and depression. The prevalence of OAD diagnoses and sociodemographic characteristics did not differ. Although younger and older OAD children showed similar rates of most specific DSM-III OAD symptoms, older children presented with a higher total number of overanxious symptoms than younger children. Older children more frequently exhibited a concurrent major depression or simple phobia, whereas younger OAD children more commonly had coexisting separation anxiety or attention deficit disorders. Older OAD children reported significantly higher levels of anxiety and depression on self-report measures. Findings indicated that the expression of OAD varies by developmental level.

Association between anxiety and depression in children and adolescents with anxiety disorders.

The relationship between anxiety and depression was examined in a sample of 106 children and adolescents referred to an outpatient anxiety disorder clinic for children. Twenty-eight percent of patients with DSM-III diagnoses of anxiety disorders displayed a concurrent major depression. Children with anxiety disorders plus major depression were found (1) to be older, (2) to demonstrate more severe anxiety symptomatology, and (3) to be diagnosed with different rates of certain anxiety-disorder subtypes, when compared to anxious patients without major depression. Nondepressed anxious children and adolescents did not differ from a psychopathological control group in severity of either anxiety or depression symptoms.

Psychiatric illness in the mothers of anxious children.

The authors compared maternal lifetime psychiatric illness for children with separation anxiety disorder and/or overanxious disorder (N = 58) and for children who were psychiatrically disturbed but did not manifest an anxiety or affective disorder (N = 15). The vast majority (83%) of mothers of children with separation anxiety disorder and/or overanxious disorder had a lifetime history of an anxiety disorder. Moreover, over one-half (57%) of the mothers presented with an anxiety disorder at the same time at which their children were seen for similar problems. Both of these rates significantly differed from those obtained for control subjects.

Comorbidity among childhood anxiety disorders.

This paper reports on 73 consecutive admissions to an outpatient anxiety disorder clinic for children and adolescents. Patients were evaluated with a structured diagnostic interview for primary and secondary disorders with DSM-III criteria in order to examine patterns of comorbidity. The most common primary diagnoses for the sample included separation anxiety disorder (33%), overanxious disorder (15%), social phobia of school (15%), and major depression (15%). Children with a primary diagnosis of separation anxiety disorders were most likely to receive a concurrent diagnosis of overanxious disorder. Alternatively, children with a primary diagnosis of overanxious disorder were most likely to receive an additional diagnosis indicative of a social anxiety problem, either social phobia or avoidant disorder. Children with a primary major depression most often exhibited social phobia and/or overanxious disorder. No clear-cut pattern of comorbidity emerged for the social phobic (school) group. These findings are discussed in terms of their comparability with results recently obtained from an adult anxiety clinic population.