ABSTRACT
Although cognitive-behavioral psychotherapy (CBT) and pharmacotherapy are evidence-based treatments for pediatric anxiety, many youth with anxiety disorders fail to respond to these treatments. Given limitations of clinical measures in predicting treatment response, identifying neural predictors is timely. In this study, 35 anxious youth (ages 7-19 years) completed an emotional face-matching task during which the late positive potential (LPP), an event-related potential (ERP) component that indexes sustained attention towards emotional stimuli, was measured. Following the ERP measurement, youth received CBT or selective serotonin reuptake inhibitor (SSRI) treatment, and the LPP was examined as a predictor of treatment response. Findings indicated that, accounting for pre-treatment anxiety severity, neural reactivity to emotional faces predicted anxiety severity post- CBT and SSRI treatment such that enhanced electrocortical response to angry faces was associated with better treatment response. An enhanced LPP to angry faces may predict treatment response insofar as it may reflect greater emotion dysregulation or less avoidance and/or enhanced engagement with environmental stimuli in general, including with treatment.
Subject(s)
Anger/physiology , Anxiety/physiopathology , Anxiety/therapy , Cognitive Behavioral Therapy/methods , Evoked Potentials/physiology , Facial Expression , Facial Recognition/physiology , Outcome Assessment, Health Care , Selective Serotonin Reuptake Inhibitors/pharmacology , Adolescent , Adult , Anger/drug effects , Anxiety/drug therapy , Child , Evoked Potentials/drug effects , Facial Recognition/drug effects , Female , Humans , Male , Young AdultABSTRACT
Neuroimaging has shown promise as a tool to predict likelihood of treatment response in adult anxiety disorders, with potential implications for clinical decision-making. Despite the relatively high prevalence and emergence of anxiety disorders in youth, very little work has evaluated neural predictors of response to treatment. The goal of the current study was to examine brain function during emotional face processing as a predictor of response to treatment in children and adolescents (age 7-19 years; N=41) with generalized, social, and/or separation anxiety disorder. Prior to beginning treatment with the selective serotonin reuptake inhibitor (SSRI) sertraline or cognitive behavior therapy (CBT), participants completed an emotional faces matching task during functional magnetic resonance imaging (fMRI). Whole brain responses to threatening (ie, angry and fearful) and happy faces were examined as predictors of change in anxiety severity following treatment. Greater activation in inferior and superior frontal gyri, including dorsolateral prefrontal cortex and ventrolateral prefrontal cortex, as well as precentral/postcentral gyri during processing of threatening faces predicted greater response to CBT and SSRI treatment. For processing of happy faces, activation in postcentral gyrus was a significant predictor of treatment response. Post-hoc analyses indicated that effects were not significantly moderated by type of treatment. Findings suggest that greater activation in prefrontal regions involved in appraising and regulating responses to social signals of threat predict better response to SSRI and CBT treatment in anxious youth and that neuroimaging may be a useful tool for predicting how youth will respond to treatment.
Subject(s)
Anger , Anxiety, Separation/physiopathology , Anxiety, Separation/therapy , Fear , Phobia, Social/physiopathology , Phobia, Social/therapy , Prefrontal Cortex/physiopathology , Social Perception , Adolescent , Brain/physiopathology , Brain Mapping , Child , Cognitive Behavioral Therapy , Facial Expression , Facial Recognition , Female , Humans , Magnetic Resonance Imaging , Male , Selective Serotonin Reuptake Inhibitors/therapeutic use , Sertraline/therapeutic use , Treatment Outcome , Young AdultABSTRACT
Recent advances in the developmental epidemiology, neurobiology, and treatment of pediatric anxiety disorders have increased our understanding of these conditions and herald improved outcomes for affected children and adolescents. This article reviews the current epidemiology, longitudinal trajectory, and neurobiology of anxiety disorders in youth. Additionally, we summarize the current evidence for both psychotherapeutic and psychopharmacologic treatments of fear-based anxiety disorders (e.g., generalized, social, and separation anxiety disorders) in children and adolescents. Current data suggest that these disorders begin in childhood and adolescence, exhibit homotypic continuity, and increase the risk of secondary anxiety and mood disorders. Psychopharmacologic trials involving selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SSNRIs) are effective in pediatric patients with anxiety disorders and have generally demonstrated moderate effect sizes. Additionally, current data support cognitive behavioral therapy (CBT) for the treatment of these conditions in youth and suggest that the combination of psychotherapy + an SSRI may be associated with greater improvement than would be expected with either treatment as monotherapy.
Subject(s)
Anti-Anxiety Agents/therapeutic use , Antidepressive Agents/therapeutic use , Anxiety Disorders/diagnosis , Anxiety Disorders/therapy , Cognitive Behavioral Therapy , Psychotherapy, Psychodynamic , Adolescent , Anxiety/diagnosis , Anxiety/therapy , Child , Combined Modality Therapy , Humans , Mass Screening , Mindfulness , Mood Disorders/drug therapy , Phobic Disorders/diagnosis , Phobic Disorders/therapy , Randomized Controlled Trials as Topic , Selective Serotonin Reuptake Inhibitors/therapeutic use , Treatment OutcomeABSTRACT
BACKGROUND: Elucidating differences in social-behavioral profiles of children with comorbid presentations, utilizing caregiver as well as teacher reports, will refine our understanding of how contextual symptoms vary across anxiety-related disorders. METHODS: In our pediatric anxiety clinic, the most frequent diagnoses and comorbidities were mixed anxiety (MA; ≥ 1 anxiety disorder; N = 155), anxiety with comorbid attention-deficit hyperactivity disorder (MA/ADHD, N = 47) and selective mutism (SM, N = 48). Behavioral measures (CPRS, CTRS) were analyzed using multiple one-way multivariate analyses of covariance tests. Differences between the three diagnostic groups were examined using completed parent and teacher reports (N = 135, 46, and 48 for MA, MA/ADHD, and SM groups, respectively). RESULTS: Comparisons across the MA, MA/ADHD, and SM groups indicate a significant multivariate main effect of group for caregiver and teacher responses (P < 0.01). Caregivers reported that children with SM are similar in profile to those with MA, and both groups were significantly different from the MA/ADHD group. Teachers reported that children with SM had more problems with social behaviors than with the MA or MA/ADHD groups. Further comparison indicates a significant main effect of group (P < 0.001), such that children with SM have the greatest differences in behavior observed by teachers versus caregivers. CONCLUSIONS: Clinical profiles between MA/ADHD, MA, and SM groups varied, illustrating the importance of multi-rater assessment scales to capture subtle distinctions and to inform treatment planning given that comorbidities occur frequently in children who present with anxiety.
Subject(s)
Anxiety Disorders/psychology , Attention Deficit Disorder with Hyperactivity/psychology , Mutism/psychology , Social Behavior , Adolescent , Anxiety Disorders/epidemiology , Attention Deficit Disorder with Hyperactivity/epidemiology , Child , Child, Preschool , Comorbidity , Female , Humans , Male , Multivariate Analysis , Mutism/epidemiologyABSTRACT
Anxiety is an innate emotion that all humans experience, especially during early childhood in periods of significant growth and development. Treatment strategies exist for anxiety disorders that cause significant dysfunction and impairment in youth. This article provides a current overview of the literature on psychopharmacologic management of pediatric anxiety disorders. Potential side effects and complications of psychotropic medications are reviewed. The treatment of anxiety disorders in patients with comorbid conditions is explored, addressing the impact on treatment course and pharmacologic recommendations. A clinical vignette describing a 10-year-old boy with increasing anxiety is presented describing in-hospital and outpatient treatment and therapies.
Subject(s)
Anxiety Disorders/drug therapy , Psychotropic Drugs/therapeutic use , Adolescent , Anxiety Disorders/psychology , Child , Humans , Psychotherapy/methodsABSTRACT
The current study compared ethnic minority and European American clinically-referred anxious youth (N=686; 2-19 years) on internalizing symptoms (i.e., primary anxiety and comorbid depression) and neighborhood context. Data were provided from multiple informants including youth, parents, and teachers. Internalizing symptoms were measured by the Multidimensional Anxiety Scale for Children, Child Depression Inventory, Child Behavior Checklist and Teacher Report Form. Diagnoses were based on the Anxiety Disorders Interview Schedule for Children. Neighborhood context was measured using Census tract data (i.e., owner-occupied housing, education level, poverty level, and median home value). Ethnic minority and European American youth showed differential patterns of diagnosis and severity of anxiety disorders. Further, ethnic minority youth lived in more disadvantaged neighborhoods. Ethnicity and neighborhood context appear to have an additive influence on internalizing symptoms in clinically-referred anxious youth. Implications for evidence-based treatments are discussed.
Subject(s)
Anxiety Disorders/ethnology , Minority Groups/psychology , White People/psychology , Adolescent , Black or African American/psychology , Anxiety Disorders/psychology , Anxiety Disorders/therapy , Asian/psychology , Chicago/epidemiology , Child , Child, Preschool , Female , Hispanic or Latino/psychology , Humans , Male , Philadelphia/epidemiology , Psychiatric Status Rating Scales , Residence Characteristics/statistics & numerical data , School Health Services/statistics & numerical data , Student Health Services/statistics & numerical data , Students/psychology , Young AdultABSTRACT
Cardiovascular response patterns to laboratory-based social and physical exercise challenges were evaluated in 69 children and adolescents, 20 with selective mutism (SM), to identify possible neurophysiological mechanisms that may mediate the behavioral features of SM. Results suggest that SM is associated with a dampened response of the vagal brake to physical exercise that is manifested as reduced reactivity in heart rate and respiration. Polyvagal theory proposes that the regulation of the vagal brake is a neurophysiological component of an integrated social engagement system that includes the neural regulation of the laryngeal and pharyngeal muscles. Within this theoretical framework, sluggish vagal brake reactivity may parallel an inability to recruit efficiently the structures involved in speech. Thus, the findings suggest that dampened autonomic reactivity during mobilization behaviors may be a biomarker of SM that can be assessed independent of the social stimuli that elicit mutism.
Subject(s)
Autonomic Nervous System/physiopathology , Exercise/physiology , Heart Rate/physiology , Mutism/physiopathology , Vagus Nerve/physiopathology , Adolescent , Child , Child, Preschool , Female , Humans , Male , RespirationABSTRACT
This article reviews the current literature on the treatment of anxiety disorders in children and adolescents and describes the factors that are essential to address in treatment. Coping deficits and parental behaviors are highlighted as factors that contribute to anxiety in youth. Interventions for anxious youth are described, with particular emphasis on cognitive-behavioral therapy for anxiety disorders. Finally, a review of the longitudinal course of anxiety and suggestions for future directions in treatment and research are provided.
Subject(s)
Adaptation, Physiological , Anxiety Disorders/therapy , Cognitive Behavioral Therapy/methods , Parent-Child Relations , Parenting/psychology , Adolescent , Child , Child, Preschool , Family Therapy , Female , Humans , Male , Treatment OutcomeABSTRACT
This article reviews the current screening and assessment tools for anxiety disorders in children and adolescents, as well as evidence-based treatment interventions for these disorders. The following anxiety disorders are discussed: separation anxiety disorder, generalized anxiety disorder, specific phobia, panic disorder, social anxiety disorder (social phobia), and selective mutism. There are several well-studied screening and assessment tools to identify childhood anxiety disorders early and differentiate the various anxiety disorders. Evaluations of baseline somatic symptoms, severity, and impairment ratings of the anxiety disorders, and collecting ratings from several sources is clinically helpful in assessment and treatment follow-up. Cognitive-behavioral therapy (CBT) has been extensively studied and has shown good efficacy in treatment of childhood anxiety disorders. A combination of CBT and medication may be required for moderate to severely impairing anxiety disorders and may improve functioning better than either intervention alone. Selective serotonin reuptake inhibitors are currently the only medications that have consistently shown efficacy in treatment of anxiety disorders in children and adolescents. Despite proven efficacy, the availability of CBT in the community is limited. Current research is focusing on early identification of anxiety disorders in community settings, increasing the availability of evidence-based interventions, and modification of interventions for specific populations.
Subject(s)
Anxiety Disorders/diagnosis , Anxiety Disorders/therapy , Cognitive Behavioral Therapy , Adolescent , Anti-Anxiety Agents/therapeutic use , Anxiety Disorders/psychology , Child , Humans , Severity of Illness IndexABSTRACT
This revised practice parameter reviews the evidence from research and clinical experience and highlights significant advancements in the assessment and treatment of anxiety disorders since the previous parameter was published. It highlights the importance of early assessment and intervention, gathering information from various sources, assessment of comorbid disorders, and evaluation of severity and impairment. It presents evidence to support treatment with psychotherapy, medications, and a combination of interventions in a multimodal approach.
