Assessing Anxiety-Related Impairment in Children and Adolescents.

Anxiety disorders (ADs) frequently lead to significant impairment across important domains of youth functioning. Yet until recently, clinical research and assessment have largely neglected the measurement of anxiety-related impairment. In this article, we review the evidence for five extant rating scales of youth anxiety-related impairment, guided by widely used evaluative criteria. Emerging psychometric data show the potential utility of these rating scales for achieving different assessment functions. Of the five scales, the Child Anxiety Impact Scale, particularly the parent-report version, has been the most researched one. Promising psychometric data support its use for assessing anxiety-related impairment in school, social, and family/home domains of functioning. We conclude with recommendations for growing this research base and for incorporating these rating scales into the youth AD clinical and research assessment process.

Does Cognitive-Behavioral Therapy for Youth Anxiety Disorders Improve Social Functioning and Peer Relationships?

Child and adolescent anxiety disorders (ADs) contribute to impairment in social functioning and peer relationships, exacerbating anxiety and related difficulties. The extent to which the AD treatment with the strongest evidence-base, cognitive-behavioral therapy (CBT), improves social functioning and peer relationships is unclear. In this article, we report results of the first systematic narrative review of this topic. Randomized clinical trials of CBT for child and/or adolescent ADs were included if they used at least one measure of social functioning or peer relationships as a treatment outcome. Sixteen studies met our inclusion criteria. From each study, we extracted the sample characteristics, treatment arms, social and/or peer outcome measures, and statistical findings. Results show that social functioning and/or peer relationships improved over time in the majority of studies, highlighting an important aspect of treatment efficacy beyond anxiety reduction. There were also several treatment-specific effects, but considerable variability across studies' samples, methods, and findings, makes it difficult to draw firm conclusions about which specific treatments improve specific outcomes. We recommend next steps for research to reconcile these findings, including improved operationalization and standardization of social and peer outcomes, and research on treatment specificity and mechanisms.

Bidirectional Associations Between Friend Overprotection and Psychosocial Adjustment During Adolescence.

As friends increase in closeness and influence during adolescence, some friends may become overprotective, or excessively and intrusively protective. Engaging in overprotective behavior, and being the recipient of such behavior, may have positive and negative adjustment trade-offs. The current study examines, for the first time, bidirectional associations between friend overprotection and several adjustment trade-offs, including internalizing problems (i.e., depressive and anxiety symptoms), peer difficulties (i.e., rejection and physical and relational victimization), and positive friendship quality (i.e., closeness, help, and security) during early adolescence. Participants were 269 young adolescents (140 boys; Mage = 11.46, SD = 0.41) who completed self-report and peer nomination measures in their schools at two time points 4 months apart (Fall and Spring of the school year). Structural equation models revealed that being overprotected by a friend predicted decreases in friendship quality and was predicted by peer difficulties and internalizing problems (negatively). Being overprotective of friends predicted increases in internalizing symptoms and was predicted by peer difficulties. Findings are novel as they suggest that friend overprotection may be risky (and not beneficial) for both the overprotector and the overprotectee, setting the stage for future inquiry in this new area of peer relations research.

Clinical Update: The Role of Family Accommodation in Youth Anxiety Treatment Outcomes.

Over the past several years, family accommodation (FA) has gained increasing recognition for its role in child and adolescent anxiety disorders. Recent clinical trials highlight the importance of assessing and addressing FA within the context of treatment, with findings showing that FA is a significant predictor of treatment success. This clinical update was prompted by such findings, and specifically findings from a study by Zilcha-Mano and colleagues (2020) which suggest that the level of agreement between child- and parent-reports of FA has differential effects on outcomes for child- and parent-based treatments. In this article we aim to provide (1) a brief overview of the research pointing to the reduction of FA as a critical ingredient of youth anxiety treatment, and (2) a summary and in-depth discussion of the study by Zilcha-Mano et al. (2020) that speaks to the potential importance of leveraging multi-informant reports of FA. With regard to the latter aim, we offer preliminary suggestions for how clinicians might incorporate measures of FA into their practice to maximize benefits for anxious youth and their families. We also offer suggestions for how future research can build on these novel findings, advance methods of FA assessment, and promote its clinical utility.

Youth social functioning interacts with treatment arm, diagnosis, and gender to predict anxiety treatment outcome.

Research has uncovered a wide range of predictors of youth anxiety treatment outcome (i.e., symptom severity and diagnostic remission). Youth's social functioning is one predictor that has been rarely studied, however, which is a significant gap given its importance to development and clinical functioning. We address this gap by examining two aspects of youth's social functioning as predictors of anxiety treatment outcome: (1) positive social interactions and (2) social skills. We further examined the moderating roles of treatment arm (child- or parent-based treatment), diagnosis (presence or absence of social anxiety disorder), and youth gender, between each of the two predictors and treatment response and remission. Participants were 96 youths with anxiety disorders (6-16 years; 54% girls) and their mothers, who completed diagnostic interviews and questionnaires at baseline and posttreatment. Multiple regression models revealed that higher baseline parent-reports of their child's social skills predicted lower posttreatment anxiety symptom severity for youth with social anxiety disorder. Modified linear probability models revealed that baseline youth-reports of their social skills predicted remission from anxiety diagnoses for youths assigned to the parent-based treatment. Baseline youth-reports of their positive social interactions and parent-reports of youth social skills predicted remission from anxiety diagnoses for girls. Results contribute to the predictor literature by highlighting the importance of youth social functioning to anxiety treatment outcome.

Anxiety and Social Functioning: The Moderating Roles of Family Accommodation and Youth Characteristics.

It is well established that anxiety can contribute to social functioning difficulties during childhood and adolescence. It is less clear which anxious youth are most likely to struggle socially, and what types of difficulties they are likely to experience, limiting the extent of identification and intervention efforts. In this study, we aim to improve specification of the linkages between youth anxiety severity and social functioning by examining several potential moderators of these associations. Specifically, we examine whether family accommodation of youth anxiety, in addition to youth age, sex, and the presence of a social anxiety disorder diagnosis, influence associations between anxiety severity and social functioning among youth with anxiety disorders. Youth (N = 158, Mage = 9.99 years, SD = 2.74) and their mothers completed diagnostic interviews and questionnaires assessing anxiety and depression symptoms, family accommodation, and a range of social functioning variables. In a series of hierarchical linear regressions, we found that youth anxiety severity was most strongly associated with social impairment at high levels of family accommodation for adolescents and for youth without social anxiety disorder (mother-report). We also found several direct effects of anxiety severity, family accommodation, and youth age, sex, and diagnosis on different facets of youth social functioning (youth- and/or mother-report). We discuss clinical implications and future research directions focused on specifying the nature of associations between youth anxiety and their social functioning.

Friend Overprotection in Emerging Adulthood: Associations with Autonomy Support and Psychosocial Adjustment.

Overprotection is a known risk factor in parent-child relationships, but has received little attention in the context of friendships. No studies have examined overprotection in emerging-adult friendships. Yet, overprotection may be especially significant during this developmental period given the prevalence of autonomy-seeking and risk-taking behaviors. In this study, we thus investigated whether overprotection is a feature of emerging-adult friendships that is meaningfully associated with psychosocial adjustment. We also examined whether friend autonomy support is one mechanism by which friend overprotection impacts outcomes. University students (N = 363) completed a new self-report measure of friend overprotection developed for this study, and previously validated measures of relationship qualities (friendship quality, helicopter parenting) and internalizing symptoms (social anxiety, depression). We found initial support for the reliability and validity of the new friend overprotection measure. A path analysis revealed positive associations between friend overprotection and friendship quality and internalizing symptoms, with friend autonomy support as an explanatory mechanism of these associations. Findings are novel as they suggest that overprotection is a salient feature of many friendships during emerging adulthood that may impact psychosocial adjustment in both helpful and harmful ways.

Using Evaluative Criteria to Review Youth Anxiety Measures, Part II: Parent-Report.

This Evidence Base Update of parent-report measures of youth anxiety symptoms is a companion piece to our update on youth self-report anxiety symptom measures (Etkin et al., 2021). We rate the psychometric properties of the parent-report measures as Adequate, Good, or Excellent using criteria developed by Hunsley and Mash (2008) and Youngstrom et al. (2017). Our review reveals that the evidence base for parent-report measures is considerably less developed compared with the evidence base for youth self-report measures. Nevertheless, several measures, the parent-report Screen for Child Anxiety-Related Emotional Disorders, Multidimensional Anxiety Scale for Children, and Spence Children's Anxiety Scale, were found to have Good to Excellent psychometric properties. We conclude our review with suggestions about which parent-report youth anxiety measures are best suited to perform different assessment functions and directions for additional research to expand and strengthen the evidence base.

Using Evaluative Criteria to Review Youth Anxiety Measures, Part I: Self-Report.

Evidence-based assessment serves several critical functions in clinical child psychological science, including being a foundation for evidence-based treatment delivery. In this Evidence Base Update, we provide an evaluative review of the most widely used youth self-report measures assessing anxiety and its disorders. Guided by a set of evaluative criteria (De Los Reyes & Langer, 2018), we rate the measures as Excellent, Good, or Adequate across their psychometric properties (e.g., construct validity). For the eight measures evaluated, most ratings assigned were Good followed by Excellent, and the minority of ratings were Adequate. We view these results overall as positive and encouraging, as they show that these youth anxiety self-report measures can be used with relatively high confidence to accomplish key assessment functions. Recommendations and future directions for further advancements to the evidence base are discussed.

Receiving Prosocial Behavior: Examining the Reciprocal Associations between Positive Peer Treatment and Psychosocial and Behavioral Outcomes.

This study investigates the prospective and reciprocal associations between positive peer treatment and psychosocial (popularity, preference, psychological distress) and behavioral (prosocial behavior) outcomes during early adolescence. Participants were 270 young adolescents (52% boys; Mage  = 11.84 years) who completed peer nomination and self-report measures as part of a 7-month longitudinal study (Wave 1; Feb. Grade 6; Wave 2: May, Grade 6; Wave 3: Sept., Grade 7). Cross-lagged autoregressive path models revealed reciprocal associations between positive peer treatment and prosocial behavior, such that Wave 1 positive peer treatment predicted increases in Wave 2 prosocial behavior and vice versa. Findings are novel, highlight the importance of considering positive peer treatment during adolescence, and set the stage for future work in this area.

Severe Social Withdrawal: Cultural Variation in Past Hikikomori Experiences of University Students in Nigeria, Singapore, and the United States.

Hikikomori (social withdrawal that lasts six months or longer) is a growing problem among Japanese adolescents and young adults, with recent estimates that approximately 1% of Japanese youths will suffer from an episode of hikikomori in their lifetimes. What remains unclear is whether hikikomori is a culture-bound syndrome or a condition impacting youths around the globe. Hence, the self-reported prevalence and psychosocial correlates of past experiences with hikikomori were examined in cross-sectional samples of university students from Singapore (n = 147), Nigeria (n = 151), and the United States (n = 301). Following tests of measurement invariance, comparisons showed that past experiences with hikikomori were related to elevated levels of current loneliness and depressive symptoms in each sample. However, analyses also revealed evidence of cultural variation in both the prevalence and the psychosocial correlates associated with past experiences of hikikomori, which taken together, provide preliminary evidence that the culture-bound characterization of hikikomori may not be appropriate.

Evaluating the Psychological Concomitants of Other-Sex Crush Experiences During Early Adolescence.

Very little empirical attention has been paid to other-sex crush experiences during adolescence. As a result, it is not known whether such experiences, which appear to be relatively common, impact psychological adjustment outcomes. This two-wave (3 month interval) longitudinal study of 268 young adolescents (48 % girls; M age at Time 1 = 11.84 years) examined the psychological concomitants of other-sex crush experiences (having and being viewed by others as a crush). Anxious-withdrawal and gender were evaluated as moderators. Peer nomination measures at Time 1 assessed both types of crush experiences and mutual friendship involvement, and participants completed self-report measures of loneliness and depressive symptoms at Times 1 and 2. The results from regression analyses revealed significant associations between having an other-sex crush and depressive symptoms at Time 1 and loneliness at Time 2, after accounting for the effects of mutual friendship. Two interaction effects also revealed that crush status was a risk factor for depressive symptoms at low levels of anxious-withdrawal but a protective factor at high levels. The findings provide the first empirical evidence that other-sex crush experiences are developmentally significant during early adolescence.

Mixed-grade rejection and its association with overt aggression, relational aggression, anxious-withdrawal, and psychological maladjustment.

The authors examined the associations between mixed-grade rejection (rejection by peers in a different school grade), anxious-withdrawal, aggression, and psychological adjustment in a middle school setting. Participants were 181 seventh-grade and 180 eighth-grade students (M age = 13.20 years, SD = 0.68 years) who completed peer nomination and self-report measures in their classes. Analyses indicated that in general, same- and mixed-grade rejection were related to overt and relational aggression, but neither type was related to anxious-withdrawal. Mixed-grade rejection was associated uniquely and negatively with self-esteem for seventh-grade boys, while increasing the loneliness associated with anxious-withdrawal. The results suggest that school-wide models of peer relations may be promising for understanding the ways in which different peer contexts contribute to adjustment in middle school settings.

The differential impact of parental warmth on externalizing problems among triangulated adolescents.

Triangulation is a family-wide process in which children are inappropriately involved in interparental conflict, placing them at heightened risk for adjustment problems. A common form of triangulation occurs by parents pressuring their children to take sides, which may result in feelings of being torn between parents. Externalizing behaviors in particular may develop as adolescents feel caught in the middle of conflict and forced to choose a side. However, the nature of the triadic process of triangulation may be impacted by dyadic-level relationships within the family. The authors thus explored how positive parenting processes may alter the relations between triangulation and adolescent externalizing problems. Mothers, fathers, and adolescents (n = 301 families) provided assessments of adolescent externalizing problems, triangulation, and maternal and paternal warmth. Analyses revealed a 3-way interaction among triangulation and maternal and paternal warmth predicting adolescent externalizing problems; child gender also moderated these relations. Among highly triangulated youth, boys displayed increased externalizing problems when both parents exhibited low or high warmth, whereas girls showed increased behavior problems in the context of low maternal but high paternal warmth. These findings indicate the importance of examining the broader family context and gender when considering the impact of triangulation during adolescence.

Does humor explain why relationally aggressive adolescents are popular?

The association between relational aggression and popularity during early adolescence is well established. Yet, little is known about why, exactly, relationally aggressive young adolescents are able to achieve and maintain high popular status among peers. The present study investigated the mediating role of humor in the association between relational aggression and popularity during early adolescence. Also considered was whether the association between relational aggression and humor varies according to adolescents' gender and their friends' levels of relational aggression. Participants were 265 sixth-grade students (48% female; 41% racial/ethnic minority; M age = 12.04 years) who completed peer nomination and friendship measures in their classrooms at two time points (Wave 1: February; Wave 2: May). The results indicated that Wave 1 relational aggression was related to Wave 1 and 2 popularity indirectly through Wave 1 humor, after accounting for the effects of Wave 1 physical aggression, ethnicity, and gender. Additional analyses showed that relational aggression and humor were related significantly only for boys and for young adolescents with highly relationally aggressive friends. The results support the need for further research on humor and aggression during early adolescence and other mechanisms by which relationally aggressive youth achieve high popular status.