Social anxiety disorder in children: investigating the relative contribution of automatic thoughts, repetitive negative thinking and metacognitions.

BACKGROUND: Social anxiety disorder (SAD) is common in youths. However, our understanding of SAD in children is inferior to that of SAD in adolescents or adults, and it is unclear if known adult SAD maintenance mechanisms may also operate in children with SAD. AIM: The paper sets out to investigate the specificity of positive automatic thoughts, social threat negative automatic thoughts, repetitive negative thinking, positive and negative metacognitions in predicting SAD symptoms and diagnoses in clinically anxious children. METHOD: We enrolled 122 clinically anxious children aged 7-13 years; of these, 33 had an SAD diagnosis. RESULTS: SAD symptoms correlated positively with social threat negative automatic thoughts, repetitive negative thinking, and negative metacognitions, and negatively with positive automatic thoughts. Linear regression indicated that, of these variables, only social threat negative automatic thoughts predicted social anxiety symptoms. Logistic regression indicated that social threat negative automatic thoughts, a higher number of diagnoses and negative metacognitive beliefs specifically predicted the presence of SAD diagnosis. CONCLUSIONS: Our findings suggest that content-specific social threat negative automatic thoughts was the only variable that specifically distinguished both higher levels of social anxiety symptoms and diagnoses.

Mothers' and children's metacognitions and the development of childhood anxiety: a longitudinal investigation of transmission.

Theory and preliminary evidence suggests that parental beliefs and cognitions may be transmitted to their offspring. Transmission of maladaptive cognitions may play a role in the development of anxiety disorders in childhood. However, few studies have investigated such transmission using longitudinal designs. The objective of this study was to investigate the interaction between maternal and child metacognitions and their role in the development of childhood anxiety. We used a longitudinal design with self-report measures of maternal and child anxiety symptoms and metacognitions. Participants were 107 mothers and their children who were assessed when the children were between 7 and 12 years old and again 3 years later. Child metacognitions at baseline did not predict later child anxiety symptoms. Baseline maternal metacognitions approached significance in predicting anxiety symptoms in children at the follow-up, when controlling for known risk factors, including female gender and higher levels of anxiety in mother and child at baseline. Mediation analyses revealed that child metacognitions at baseline, as well as at follow-up fully mediated the relationship between maternal baseline metacognitions and child anxiety 3 years later. Examinations of how child and maternal metacognitions affect child anxiety levels after three years revealed that current levels of child metacognitions play a greater role in predicting child anxiety than child and maternal metacognitions at baseline.

Assessment of the cognitive attentional syndrome in children: an adaptation of the CAS-1.

BACKGROUND: Research suggests that the metacognitive model is applicable to clinical child populations. However, few measures related to the model are available for younger age groups. A key concept of the model is the cognitive attentional syndrome (CAS), which encompasses the individual's worry and rumination, maladaptive coping strategies, and metacognitive beliefs. While the CAS has been successfully measured in adults, this has not yet been attempted in children. AIMS: The aim of this study was to adapt a measure of the CAS for use with children and investigate the measure's associations with anxiety, worry, depression and metacognitions. METHODS: Our study included 127 children with anxiety disorders aged 7-13 years. The adult measure of CAS was adapted for use with children and administered at pre- and post-treatment. We examined the correlations between variables and the ability of the CAS measure to explain variance in anxious symptomatology, as well as the measure's sensitivity to treatment change. RESULTS: The adapted measure, CAS-1C, displayed strong associations with overall anxiety, depression, worry and metacognitions. The CAS-1C explained an additional small amount of variance in anxiety and worry symptoms after accounting for metacognitions, which may be due to the measure also assessing thinking styles and coping strategies. Furthermore, the measure displayed sensitivity to treatment change. CONCLUSIONS: The child measure of the CAS is a brief tool for collecting information on metacognitive beliefs and strategies that maintain psychopathology according to the metacognitive model, and it can be used to monitor treatment changes in these components.

How do anxious children attempt to regulate worry? Results from a qualitative study with an experimental manipulation.

OBJECTIVE: The objective of this study was to explore how anxiety-disordered children attempt to regulate their worry. DESIGN: An experimental manipulation was applied, followed by a qualitative interview. METHODS: Thirty children aged 7-13 were enrolled in this study. Each child was presented with a black mystery box, was told that shortly he/she would have to feel what was inside the box, and was then left alone for 4 min, prior to commencing the task. The purpose of the experimental manipulation was to induce slight levels of worry in the child, so that he/she could better report on worry regulation strategies. Afterwards, an interview about how the child had regulated worry during the experimental manipulation and in everyday life was undertaken. The interviews were coded using thematic analysis. RESULTS: Five main themes were uncovered. These were (1) internal regulation of worry, for example, thinking about something else and self-reassurance talk, (2) external regulation of worry, for example, behavioural avoidance and distraction, (3) perceived effect of strategies, (4) shifting between strategies, and (5) absence of a strategy. CONCLUSIONS: Our results demonstrate that anxious children use a variety of behavioural and cognitive strategies to regulate worry. They use these strategies in combination, they generally perceive them as ineffective, and they sometimes do not report any strategy for attempting to regulate their worry. These results indicate that clinicians should be curious about which strategies anxious children use to regulate their worry, how these strategies interact with each other, and how they are implemented by the child. PRACTITIONER POINTS: Using an experimental manipulation followed by an interview, this study sought to investigate how anxious children seek to regulate their worries. Anxious children attempt to regulate their worry with use of behavioural regulation strategies, such as avoidance and distraction, and with use of cognitive regulation strategies, including thinking about something else, self-reassurance talk, and thought suppression. Sometimes, however, anxious children are not able to report a regulation strategy for a specific worry episode, suggesting that they may not always have a strategy or that they lack the introspective ability to report what they did. Clinicians should be aware that anxious children may use internal (cognitive) regulation strategies while at the same time using behavioural regulation strategies, such as avoidance.

The Puzzle of Emotion Regulation: Development and Evaluation of the Tangram Emotion Coding Manual for Children.

The ability to regulate one's emotions is crucial to engaging successfully in social contexts. Difficulties in emotion regulation are seen in multiple psychiatric disorders, prompting an increased interest in the concept. Suitable methods for assessing emotion regulation, however, are lacking. In this study, we investigated the interrater and intrarater reliability, construct validity, and content validity of a new observational method for evaluating children's emotion regulation abilities (a complex puzzle task) in a sample of 62 children without psychiatric disorders and 23 children with attention-deficit/hyperactivity disorder (ADHD) aged 7-12, using intra-class correlation coefficients for the reliability analyses and Spearman's rank-order correlations for analyses of convergent and discriminant validity. A panel of experts examined the content validity of the test, and Mann-Whitney U-tests were used to investigate the ability of the test to differentiate the non-clinical group from the ADHD group. Results showed a high level of interrater and intrarater reliability of the test. There was mixed evidence for convergent and discriminant validity as expected due to the novelty and experimental nature of the test, making it difficult to compare with questionnaire-based measures. Content validity analysis was satisfactory, and the group comparison showed that the test differentiated the groups on the primary outcome measure. Overall, the measure demonstrated high feasibility and satisfactory psychometric properties. The generic nature of the test makes it suitable for use across psychiatric disorders and age groups with potential relevance in both research and clinical settings.

Modeling the Relationships Between Metacognitive Beliefs, Attention Control and Symptoms in Children With and Without Anxiety Disorders: A Test of the S-REF Model.

In the metacognitive model, attentional control and metacognitive beliefs are key transdiagnostic mechanisms contributing to psychological disorder. The aim of the current study was to investigate the relative contribution of these mechanisms to symptoms of anxiety and depression in children with anxiety disorders and in non-clinical controls. In a cross-sectional design, 351 children (169 children diagnosed with a primary anxiety disorder and 182 community children) between 7 and 14 years of age completed self-report measures of symptoms, attention control and metacognitive beliefs. Clinically anxious children reported significantly higher levels of anxiety, lower levels of attention control and higher levels of maladaptive metacognitive beliefs than controls. Across groups, lower attention control and higher levels of maladaptive metacognitive beliefs were associated with stronger symptoms, and metacognitions were negatively associated with attention control. Domains of attention control and metacognitions explained unique variance in symptoms when these were entered in the same model within groups, and an interaction effect between metacognitions and attention control was found in the community group that explained additional variance in symptoms. In conclusion, the findings are consistent with predictions of the metacognitive model; metacognitive beliefs and individual differences in self-report attention control both contributed to psychological dysfunction in children and metacognitive beliefs appeared to be the strongest factor.

Increasing access to low-intensity interventions for childhood anxiety: A pilot study of a guided self-help program for Scandinavian parents.

Cognitive Behavior Therapy (CBT) is an effective treatment for child anxiety. However, access to treatment is limited. It has been suggested that low-intensity formats of parent-delivered CBT may improve access to treatment. Our aim was to develop and pilot-test the acceptability and effect of a low-intensity therapist-guided parent-delivered group program for anxious children (age 7-12 years) adjusted to the Scandinavian culture. The program required 1.5 hours of therapist-time per family. Mothers, fathers and children reported on revised child anxiety and depression scale (RCADS) at referral, pre- and post-treatment. Mothers and fathers also gave a qualitative account of their experiences. Thirty-one families were enrolled and only one family dropped out. Mean age of the children was 9 years. Intent-to-treat analyses revealed significant reductions in anxiety and depressive symptoms from pre- to post-treatment for all informants. Large effect sizes were found for child anxiety symptoms as reported by mothers and fathers, and for child depressive symptoms as reported by mothers. Medium to large effect sizes was found for the self-reported anxiety symptoms by the children, and for depressive symptoms reported by both children and fathers. More than 93% of the parents would recommend the program. Results suggest that our program may provide a new approach to improve access to treatment for anxious children in Scandinavia; however, further research must be conducted before firm conclusions can be drawn.

The direct and indirect effect of attachment insecurity and negative parental behavior on anxiety in clinically anxious children: it's down to dad.

BACKGROUND: Theoretically, insecure attachment and negative parental behaviors are risk factors for childhood anxiety. However, few empirical studies have examined their relative contribution including differences between mothers and fathers. To date, only one study has examined a mediational model including these factors, albeit in a nonclinical sample. METHOD: This study ameliorates this limitation by investigating direct and indirect relations between maternal and paternal attachment and behaviors, and clinical anxiety in children (mean age 9.6 years). The study recruited 54 families. Anxiety symptoms were measured by the Spielberger State-trait Inventory for Children, attachment relationships by the Security Scale, and parental behaviors using the Rearing Behavior Questionnaire. RESULTS: Neither insecure attachment relationship with mother nor maternal negative behavior was a significant predictor of anxiety in children. However, insecure attachment to father accounted for a significant proportion of variance in anxiety, and also fully mediated the relationship between paternal rejection and anxiety. CONCLUSIONS: Our findings highlight the importance of assessing the relative contribution of risk factors and the importance of including fathers when investigating the development and maintenance of childhood anxiety.

Cognitive Behavior Therapy and Metacognitive Therapy: Moderators of Treatment Outcomes for Children with Generalized Anxiety Disorder.

Although cognitive behavioral therapy (CBT) is effective for childhood anxiety disorders, approximately 40% of youth remain anxious after treatment. Metacognitive therapy (MCT-c) for children with generalized anxiety disorder (GAD) has shown promising effects. The present study aimed to examine if CBT and MCT-c show differential effects in children with primary GAD based on baseline characteristics, in a quasi-experimental design. To investigate which treatment is most beneficial for whom, three potential moderators: age, symptom severity, and comorbid social anxiety were examined. Sixty-three children aged 7-14 completed CBT or MCT-c. Participants were assessed before and after treatment. Both CBT and MCT-c were highly effective in treatment of childhood GAD. None of the selected variables significantly moderated treatment outcomes. Subgroups of children with high symptom severity and social anxiety comorbidity showed trends of responding better to CBT. Methodologically stronger studies are needed to facilitate a better adaptation of treatment for children with GAD.

OK-432 Treatment of Early Fetal Chylothorax: Pregnancy Outcome and Long-Term Follow-Up of 14 Cases.

BACKGROUND: The treatment options for fetal chylothorax include thoracocentesis, thoracoamniotic shunting, and pleurodesis using OK-432. Knowledge on the long-term outcomes after treatment with OK-432 is limited. OBJECTIVE: The aim of this study was to assess the long-term outcomes of children treated in utero with OK-432. METHODS: We performed follow-up on pregnancies and children treated in utero with OK-432 between 2003 and 2009 at Copenhagen University Hospital Rigshospitalet for pleural effusions at gestational age (GA) 16+0-21+6 weeks. Anamnestic information, physical examination, pulmonary function test, neuropediatric examination, and intelligence testing using the Wechsler Intelligence Scale were used for evaluation. RESULTS: Fourteen cases, all chylothorax, were treated with OK-432. None had preterm premature rupture of membranes (PPROM), and the median GA at delivery was 38+5 (24+4-41+5) weeks. Twelve children were eligible for follow-up. The median age at follow-up was 11.4 (7.8-13.8) years. Pulmonary function was normal in all children and the mean full-scale IQ did not differ from that of normal children. Four children had a diagnosed medical condition, attention deficit disorder, or genetic syndrome. The remaining children had normal follow-up. CONCLUSION: Children treated with OK-432 have comparable survival rates and long-term neurodevelopmental outcomes to those treated with thoracoamniotic shunts. There seems to be a lower risk of procedure-related PPROM.

Does comorbidity predict poorer treatment outcome in pediatric anxiety disorders? An updated 10-year review.

The aim of the present review was to provide an updated investigation of literature from the past ten years that examined the effects of comorbid problems on treatment outcomes, and/or explored if cognitive behavioral treatments (CBT) targeting anxiety disorders also affected comorbid disorders. A search of the literature resulted in a total of 33 publications, based on 28 randomized controlled trials that met predefined inclusion criteria. An analysis of studies that examined whether comorbidity affects treatment outcome yielded mixed results for different types of comorbidities. The inconsistent results were largely due to methodological heterogeneity in the identified studies. Support for negative effects of comorbidity on treatment outcomes was usually found in studies that investigated comorbidity as a categorical diagnosis, rather than symptom levels, and those that analyzed specific comorbid diagnoses, rather than grouping them together. Overall, our findings suggest that comorbid disorders may have a more negative impact on treatment outcomes than proposed in previous reviews, particularly in the cases of comorbid social anxiety and mood disorders. Furthermore, CBT for anxiety disorders in children was found to ameliorate comorbid problems.

The efficacy of group metacognitive therapy for children (MCT-c) with generalized anxiety disorder: An open trial.

Metacognitive therapy is an effective treatment for anxiety disorders in adults. Studies have demonstrated that the underlying theoretical model is also supported in children. It has therefore been suggested that metacognitive therapy for children may be effective. Our study is an open trial of metacognitive therapy for children with generalized anxiety as their primary disorder. Therapy was provided in groups. Families were interviewed with the Anxiety Disorders Interview Schedule - child/parent versions. They reported on the child's anxiety levels using the Revised Childrens Anxiety and Depression Scale - child/parent versions. Children reported on metacognitive beliefs using the Metacognitions Questionnaire for Children - 30 item version. Fourty-four children aged 7-13 years (50% girls) were enrolled, and one family dropped out during treatment. Fifty percent of the children had received counseling or psychological treatment for their anxiety disorder previously. Following treatment, 86.4% of the children were free of their primary disorder and 72.7% were free of all anxiety disorders, the corresponding figures were 75% and 65.9% at 6-months follow-up. The effect sizes were large for all measures and clinically significant improvements were obtained for 70% of the children at posttest and 77% at follow-up. Our study suggests that metacognitive therapy for children with generalized anxiety disorder may be a highly promising treatment approach.

Attachment as a predictor of non response to CBT treatment in children with anxiety disorders.

Children's and parents' attachment patterns have been linked with the presence of pediatric anxiety disorders. The present study examined the role of attachment in predicting cognitive behavior therapy (CBT) treatment outcomes. A total of 69 children aged 7-13 years were assessed using a semi-structured interview, and treated with CBT. Differences between responders and nonresponders with regard to pretreatment characteristics were explored, and the predictive power of factors significantly different between groups was assessed using binominal logistic regression. Responders and nonresponders did not significantly differ with regard to child's attachment to parent. Maternal attachment anxiety was found to be the strongest predictor of treatment outcome, remaining significant after controlling for symptoms severity. Results suggest that clinicians should pay more attention to how the relationships formed between anxious children and their anxiously attached mothers may prohibit a positive treatment response, and augment treatment appropriately.

Exploring the relationships between maternal and child metacognitions and child anxiety.

Research has shown that anxiety may be transmitted through verbal information pathways, for example, when parents share their anxious cognitions with their child. Less is known about the influence of parental metacognitions, that is, beliefs regarding thoughts, on child anxiety. We explored the relations between metacognitions in mothers and their children and anxiety in the children. Our study included 111 non-clinical children aged 8 to 12 years and their mothers. Children rated their metacognitions, worry and anxiety, and mothers rated their metacognitions. Results indicated agreement between maternal and child metacognitions. Maternal metacognitions were positively associated with children's anxiety symptoms and worry, and this relation was mediated by the children's metacognitions. Our results warrant further examination of the role of parental metacognitions in child anxiety.

Can attachment and peer relation constructs predict anxiety in ethnic minority youths? A longitudinal exploratory study.

Anxiety is the most prevalent psychiatric disturbance in childhood effecting typically 15-20% of all youth. It has been associated with attachment insecurity and reduced competence in peer relations. Prior work has been limited by including mainly White samples, relying on questionnaires, and applying a cross-sectional design. The present study addressed these limitations by considering how at-risk non-White youth (n = 34) responded to the Friends and Family Interview (FFI) in middle childhood and how this linked up with anxiety symptoms and an anxiety diagnosis three years later in early adolescence. Five dimensions of secure attachment, namely, (i) to mother, (ii) to father, (iii) coherence, (iv) developmental understanding, and (v) social competence and quality of contact with best friend in middle childhood, were found to correlate significantly (and negatively) with self-reported anxiety symptoms. Linear regression results showed independent influences of female gender, and (low) quality of best friend contact as the most efficient model predicting anxiety symptoms. Logistic regression results suggested a model that included female gender, low social competence, and immature developmental understanding as efficient predictors of an anxiety diagnosis, evident in only 18% of the sample. These results point to the usefulness of after-school programs for at-risk minority youth in promoting peer competence, developmental awareness, and minimizing anxiety difficulties.

Identifying the Best-Fitting Factor Structure of the Experience of Close Relations - Revised in a Scandinavian Example.

The aim of this study was to enhance the understanding of cultural and sample differences in the assessment of attachment by examining the factor structure of the Experiences in Close Relationships-Revised (ECR-R). The ECR-R is a self-report measure of adult romantic attachment dimensions. The present study used a Danish sample with the purpose of addressing limitations in previous studies, such as the lack of diversity in cultural background, restricted sample characteristics, and poorly fitting structure models. Participants consisted of 253 parents of children between the ages of 7 and 12 years, 53% being mothers. The parents completed the paper version of the questionnaire. Confirmatory Factor Analyses were carried out to determine whether theoretically and empirically established models including one and two factors would also provide adequate fits in a Danish sample. A previous study using the original ECR suggested that Scandinavian samples may best be described using a five-factor solution. Our results indicated that the one- and two-factor models of the ECR-R did not fit the data well. Exploratory Factor Analysis revealed a five-factor model. Our study provides evidence that further investigation is needed to establish which model may provide the best model fit in the Scandinavian countries.

Adapting Metacognitive Therapy to Children with Generalised Anxiety Disorder: Suggestions for a Manual.

The metacognitive model and therapy has proven to be a promising theory and intervention for emotional disorders in adults. The model has also received empirical support in normal and clinical child samples. The purpose of the present study was to adapt metacognitive therapy to children (MCT-c) with generalised anxiety disorder (GAD) and create suggestions for an adapted manual. The adaptation was based on the structure and techniques used in MCT for adults with GAD. However, the developmental limitations of children were taken into account. For instance, therapy was aided with worksheets, practical exercises and delivered in a group format. Overall, the intervention relied heavily on practising MCT techniques in vivo with therapist assistance. A detailed description of how the manual was adapted for this age group is given, and examples from a group of four children are presented in a case series. Findings indicate that the adapted version of the metacognitive techniques and manual for children is feasible.

Parental changes after involvement in their anxious child's cognitive behavior therapy.

OBJECTIVE: Specific parental behaviors and cognitions are associated with child anxiety. Studies informing us of the directionality of the associations are lacking. We investigated the effect of parental involvement in children's anxiety treatment on parental behaviors and cognitions. METHOD: Children (N=54, 7-12 years) and parents were randomly allocated to different treatment groups (involved, not involved). Observed behavior, self-reported behavior and cognitions were assessed separately for mothers and fathers at pre-, posttreatment and follow-up. RESULTS: There were no differences over time for self-reported parental efficacy and observed negativity, but self-reported autonomy granting increased for both groups over time. Differential effects were found between groups for observed paternal over-involvement (fathers involved in treatment showed a more rapid decrease) and self-reported maternal autonomy-granting (non-involved mothers showed a greater increase). CONCLUSION: Our findings suggest that child anxiety significantly influences parental behaviors and cognitions. Child therapy may successfully change the family system.

Assessing the Revised Child Anxiety and Depression Scale (RCADS) in a national sample of Danish youth aged 8-16 years.

Early identification of anxiety among youth is required to prevent them from going unrecognised and untreated by mental health professionals. A precise identification of the young person's primary difficulty is also required to guide treatment programs. Availability of a valid and easily administrable assessment tool is crucial for identifying youth suffering from anxiety disorders. The purpose of the present study was therefore to examine the psychometric properties of the Danish version of the Revised Children's Anxiety and Depression Scale (RCADS). A total of 667 youth from community schools (4(th) through 9(th) grade) across Denmark participated in the study. The psychometric properties of the RCADS-(DAN) resembled those reported in US and Europe. Within scale reliability was excellent with Chronbach's alpha of.96. All subscales also showed good to excellent internal reliability. The study provides convincing evidence that the RCADS-(DAN) is a valid assessment tool for screening anxiety in Danish youth.

Prevalence and co-morbidity among anxiety disorders in a national cohort of psychiatrically referred children and adolescents.

The paper provides prevalence estimates of anxiety disorders as well as homotypic (e.g., other anxiety disorders) and heterotypic (e.g., mood, externalizing) co-morbidity in a national sample of children and adolescents referred to the psychiatric system in Denmark. Data were gathered from a database containing 83% of all youth referred from 2004 to 2007 (N=13,241). A prevalence of 5.7% of anxiety disorder was found in the sample. Homotypic co-morbidity was found in only 2.8%, whereas heterotypic co-morbidity was found in 42.9% of the cohort. A total of 73.6% had a principal anxiety disorder as opposed to 26.4% who had other principal diagnoses and a secondary anxiety disorder. The national database not only provides a valuable prevalence estimate of anxiety disorders in every-day non-research psychiatric settings, but also highlights the importance of applying standardized screening instruments as routine to increase the precision in recognizing and reporting on childhood anxiety disorders.