Stimulant Treatment Effect on Anxiety Domains in Children with Attention-Deficit/Hyperactivity Disorder With and Without Anxiety Disorders: A 12-Week Open-Label Prospective Study.

Objectives: The effect of stimulants on anxiety domains has not been systematically studied. We assessed prospectively the impact of stimulant treatment in children with attention-deficit/hyperactivity disorder (ADHD) on the severity of anxiety domains and on ADHD with comorbid anxiety disorders. Methods: Children with ADHD (n = 57, aged 6-15 years) started a stimulant or were switched from one stimulant to another. Assessments were conducted at four time points (baseline and weeks 2, 6, and 12) and consisted of parental questionnaires (ADHD rating scale, screen for child anxiety related disorders [SCARED]), and side effect questionnaire completed by a child psychiatrist. Results: A significant improvement in total SCARED scores was obtained after 12 weeks stimulant treatment in children both with and without anxiety disorders. Significant reductions were detected in generalized anxiety, separation anxiety, and school avoidance SCARED subscales, but not in panic and social anxiety subscales. ADHD symptoms significantly improved both in children with and without anxiety comorbidities. Conclusion: We found specific effects of stimulants on anxiety domains. Stimulant treatment, even for ADHD children diagnosed with comorbid anxiety disorders, is relatively safe regarding the risk of anxiety exacerbation. Moreover, the presence of anxiety symptoms or disorders does not interfere with the beneficial effect of the stimulants on the ADHD core symptoms. Clinical trial regestration number: IRB SMC-6893-20.

The association between sleep disturbances of children with anxiety disorders and those of their mothers.

OBJECTIVE: Previous research has demonstrated a link between childhood anxiety and sleep problems, but little is known about the link between these difficulties and parental sleep disturbances. The purpose of the current study was to explore the association between anxious children's sleep difficulties and those of their mothers. METHOD: A total of 101 children aged 8-18 years and their mothers participated in this study. The clinical group included 66 children (mean age = 11.45 years, standard deviation = 2.79 years) diagnosed with anxiety disorders, and the control group included 35 age- and sex-matched normal healthy controls. Mothers completed questionnaires assessing their child's anxiety and sleep, as well as their own sleep. Children completed questionnaires assessing anxiety, sleep, depression, and obsessive symptoms. RESULTS: Both children and mothers in the clinical group exhibited more sleep difficulties compared to controls. A regression analysis revealed that pre-sleep arousal negatively predicted children's sleep. Furthermore, children's anxiety level was associated with parental levels of sleep disturbances. This link was fully mediated by the children's sleep disturbances score. CONCLUSION: Mothers of children with anxiety disorders exhibit higher levels of sleep disturbances than controls. These difficulties are linked to children's anxiety and sleep problems. When treating children with anxiety, it is therefore important to assess their overall sleep disturbances, as well as parental sleep difficulties, and when appropriate to add a specific sleep intervention component.

Quality of life of adult daughters of women with schizophrenia: Associations with psychological resource losses and gains.

OBJECTIVE: This study examined the relationship between perceived losses and gains of psychological resources and quality of life of adult daughters of women with schizophrenia. METHOD: Thirty one adult daughters of mothers with schizophrenia (age range 30 to 50years) and thirty women of similar socio-demographic characteristics whose mothers were mentally healthy (the control group) participated in this study. RESULTS: (a) Resource loss was higher and resource gains were lower among daughters of women with schizophrenia, compared to the control group; (b) despite resource gains total score of quality of life was significantly lower among daughters of mothers with schizophrenia compared to the controls; (c) daughters of mothers with schizophrenia had lower levels of family functioning, a higher level of negative emotions and a lower level of positive emotions; (d) resource gains moderated the negative relationship between resource loss and quality of life; (e) the most significant predictor of quality of life was the group (i.e. daughters of women with schizophrenia compared with controls); (f) quality of life was more strongly associated with resource loss than with resource gain. DISCUSSION: The findings of this research underscore the importance of raising awareness of caregivers and healthcare authorities to the needs of the unique population of daughters of women diagnosed with schizophrenia for support and even treatment.

The link between parent and child sleep disturbances in children with attention deficit/hyperactivity disorder.

OBJECTIVE: Although sleep problems are widely known to be a prominent feature of childhood attention deficit/hyperactivity disorder (ADHD), little is known about the link between these difficulties and parental sleep disturbances. METHODS: The design was cross-sectional assessing a clinical sample of 62 children, aged 7-17 years (mean age = 10.0 years) diagnosed with ADHD and their parents. All participants completed measures of ADHD symptoms, sleep, anxiety, and executive functioning. RESULTS: Regression analysis revealed that child's pre-sleep arousal significantly predicted parental sleep, and that medication status and children's anxiety significantly predicted children's sleep. Children with a clinical sleep score were more impaired in behavioral, emotional, and cognitive domains. CONCLUSION: Parents of children with ADHD exhibit sleep disturbances that might be affected by their child's arousal prior to bedtime. The nature of the interaction between children with ADHD and their parents' sleep abnormalities is yet to be elucidated.

Parents' and Teachers' Perceptions of Abnormal Attention Span of Elementary School-Age Children.

BACKGROUND: To determine teacher and parental perception of minimal expected sustained attention span during various daily tasks among elementary school children. METHODS: 54 parents and 47 teachers completed the attention span questionnaire (AtSQ) that was developed for this study. The AtSQ consists of 15 academic and leisure tasks that require a child's sustained attention. The study focused on third and fourth graders in Israel. RESULTS: There was a high degree of variability among teachers and parents in their responses to the AtSQ. The expected attention span of children as judged by parents was higher and more varied compared to teachers, and higher for girls than for boys. CONCLUSIONS: Our results indicate poor agreement in cutoff values for sustained attention span between teachers and parents and within each group.

The outcome of children with selective mutism following cognitive behavioral intervention: a follow-up study.

UNLABELLED: Selective mutism (SM) is a relatively rare childhood disorder and is underdiagnosed and undertreated. The purpose of the retrospective naturalistic study was to examine the long-term outcome of children with SM who were treated with specifically designed modular cognitive behavioral therapy (MCBT). Parents of 36 children who met diagnostic criteria of SM that received MCBT treatment were invited for a follow-up evaluation. Parents were interviewed using structured scales and completed questionnaires regarding the child, including the Selective Mutism Questionnaire (SMQ). Twenty-four subjects were identified and evaluated. Their mean age ± SD of onset of SM symptoms, beginning of treatment, and age at follow-up were 3.4 ± 1.4, 6.4 ± 3.1, and 9.3 ± 3.4 years, respectively. There was robust improvement from beginning of treatment to follow-up evaluation in SM, social anxiety disorder, and specific phobia symptoms. The recovery rate from SM was 84.2 %. CONCLUSION: SM-focused MCBT is feasible in children and possibly effective in inducing long-term reduction of SM and comorbid anxiety symptoms. WHAT IS KNOWN: • There are limited empirical data on selective mutism (SM) treatment outcome and specifically on cognitive-behavioral therapy, with the majority of studies being uncontrolled case reports of 1 to 2 cases each. • There is also limited data on the long-term outcome of children with SM following treatment. What is New: • Modular cognitive behavioral treatment is a feasible and possibly effective treatment for SM. Intervention at a younger age is more effective comparing to an older age. • Treatment for SM also decreases the rate of psychiatric comorbidities, including separation anxiety disorder and specific phobia.

Cultural Impact on SAD: Social Anxiety Disorder among Ethiopian and Former Soviet Union Immigrants to Israel, in Comparison to Native-born Israelis.

BACKGROUND: Social Anxiety Disorder (SAD) is linked to social norms and role expectations which are culture dependent, such as the construal of one's self as independent or interdependent in relation to others. The current study is the first to examine SAD symptoms among Ethiopian and former Soviet Union immigrants to Israel compared to a sample of native Israelis. We investigated the relationship between SAD, ethnicity and independent/ interdependent self-construals. METHODS: A total of 261 students (151 native-born Israelis, 60 Ethiopian immigrants and 50 students from the former USSR) were administrated the Liebowitz Scale (LSAS), the Self-construal Scale (SCS), Beck Depression Inventory (BDI) and a socio-demographic questionnaire. RESULTS: Ethiopians exhibited highest SAD scores while no differences were found between the FSU immigrants and native-born Israelis. Additionally, Ethiopians and native-born Israeli students exhibited similar high interdependence scores. Finally, SAD scores were predicted by gender, origin, independent and interdependent self-construals. CONCLUSION: Immigration per se is not a universal risk factor of SAD and ethnological-cultural factors do contribute specifically to SAD. A possible psychological mediator between culture and the susceptibility to SAD are the interdependence and independent self-construals. When treating immigrants, clinicians and health care providers are advised to consider the effect of cultural influence on the mental well-being and integration process of immigrants in to their host country.

Assessing fears of preschool children with nighttime fears by a parent version of the fear survey schedule for preschool children.

BACKGROUND: Although excessive fears are common in preschool children, validated assessment tools for this age are lacking. Our aim was to modify and provide preliminary evidence of the utility of a preschoolers' fear screening tool, a parent-reported Fear Survey Schedule for Preschool Children (FSS-PC). METHODS: 109 Israeli preschool children (aged 4-6 years) with chronic night time fears (NF) and 30 healthy children (controls) participated. The FSS-PC analysis included: 1) internal reliability, 2) correlations between FSS-PC scores and Child Behavior Checklist (CBCL) measures, 3) differences between NF and a comparison sample of FSS-PC scores, and 4) FSS-PC sensitivity in detecting change in NF following an intervention for NF. RESULTS: There were low-to-medium positive correlations between the FSS-PC scores and several internalizing scales of the CBCL measures. FSS-PC scores in the NF group were significantly higher than the control children's score. FSS-PC scores had adequate internal reliability and were also sensitive for detecting significant changes in fear levels following behavioral interventions. LIMITATIONS: Unique cultural and environmental circumstances and specific study group. CONCLUSIONS: This new version of the FSS-PC may provide clinicians with a novel and useful screening tool for early assessment of fear- and anxiety-related phenomena of preschool children.

Threat perception, anxiety and noncompliance with preoperative fasting instructions among mothers of children attending elective same day surgery.

PURPOSE: The current study examined possible links between threat perception, anxiety, conscientiousness and parental noncompliance with preoperative fasting instructions for their children. METHODS: 100 mothers of children about to undergo an ambulatory elective surgery were divided to two equal groups based on compliance/noncompliance with pre surgery fasting requirements. Logistic regression analysis was preformed to predict compliance/noncompliance. In addition a logistic model estimating the effect of anxiety and conscientiousness levels, and their interaction, on the probability of fasting was performed. RESULTS: Mothers who did not comply with fasting requirements perceived the procedure as more threatening, were more anxious and had lower conscientiousness levels. Additionally, mother's anxiety prior to surgery mediated the association between mothers' threat perception and compliance. Finally, conscientiousness moderated the anxiety and compliance association so that high conscientiousness levels reduced the effect of anxiety, elevating the likelihood of anxious mothers to comply with fasting guidelines. CONCLUSIONS: Based on these findings we recommend medical staff to make significant efforts to identify highly anxious parents as early as possible during the preoperative process. Innovative assessment and intervention tools should be developed in order to conduct a smooth medical operation and reduce the chance of unnecessary and costly surgery cancelation.

The link between social anxiety disorder, treatment outcome, and sleep difficulties among patients receiving cognitive behavioral group therapy.

OBJECTIVE: The aim of our study was to examine the association between sleep disturbances and social anxiety disorder (SAD). Another aim was to explore the impact of cognitive behavioral group therapy (CBGT) for SAD on co-occurring sleep difficulties. METHODS: Data were obtained retrospectively from patient files receiving CBGT for SAD. The sample included 63 patients with SAD (mean age, 30.42 years [standard deviation, 6.92 years]). There were 41 men and 22 women, of whom 41 participants completed the treatment protocol. Before treatment onset participants completed the Liebowitz Social Anxiety Scale (LSAS), the Beck Depression Inventory (BDI), the Pittsburgh Sleep Quality Index, and several sociodemographic questions. On completion of the treatment protocol, the same measures were completed, with the addition of the Sheehan Disabilities Scale (SDS). RESULTS: The results of our study suggest that: (1) subjective insomnia is associated with SAD severity even after controlling for depression severity and additional variables; (2) participants with SAD with co-occurring clinical levels of subjective insomnia present a more severe clinical picture both at treatment onset and termination; and (3) although CBGT lead to reduction in SAD and depression symptoms severity, it had no significant impact on co-occurring sleep difficulties. CONCLUSIONS: Sleep difficulties predict SAD severity regardless of depressive symptoms and may be linked to a more severe clinical picture. Clinicians should be aware of these sleep difficulties co-occurring with SAD and consider implementing specific sleep interventions. Future studies should incorporate larger samples sizes from clinical populations outside of Israel.

Nighttime fears of preschool children: a potential disposition marker for anxiety?

OBJECTIVE: To examine if children who suffer from significant Nighttime Fears (NF) experience higher degree of general fears and behavioral problems and to explore whether effortful control mediates NF association with internalizing problems. METHODS: One-hundred and nine preschool children (64 boys) between the ages 4 and 6years suffering from significant NF and 30 healthy children (16 boys) were evaluated using parental reports of behavioral problems [Child Behavior Checklist (CBCL)], parental and child report of fears [Fear Survey Revised for Parents (FSS-PC), Koala Fear Questionnaire (KFQ)], and a measure of effortful control derived from the Child Behavior Questionnaire (CBQ). RESULTS: Children with severe NF also suffer from an increased level of a wide variety of fears other than NF, and exhibit more behavioral problems than controls both on parental and children's measures of general fears, and main CBCL scale scores (Internalizing, Externalizing, Total score). Additionally, children with NF had lower abilities of effortful control (as manifested in CBQ attention and inhibitory control scales). Attention control mediated NF association to internalizing problems scale. CONCLUSIONS: NF may serve as a marker for anxiety vulnerability, and this vulnerability might be mediated by abnormal attentional control. Our finding also highlights the need for a more comprehensive assessment of behavioral problems, fears and anxiety phenomena among children referred with NF.

Correspondence between reported and actigraphic sleep measures in preschool children: the role of a clinical context.

STUDY OBJECTIVES: The aim of this study was to assess the role of clinical context in determining the correspondence between actigraphic and reported sleep measures in preschool children. METHODS: Sleep was assessed using actigraphy and parental reports in a clinical sample of 109 preschool children between the ages 4 and 6 years suffering from significant nighttime fears and in a sample of 30 healthy controls. RESULTS: In comparison to actigraphy, parents in both groups indicated that their children fell asleep earlier and overestimated their sleep period. These gaps were significantly larger in the control group than the clinical group. Parents from both groups similarly underestimated the time their child was awake during the night in comparison to actigraphy. Significant correlations were found in both groups between parental reports and actigraphy sleep schedule measures. Low correlations were found for wake after sleep onset in both groups and for the number of night wakings. CONCLUSIONS: Clinicians and researchers should be highly aware that parental reports on their children's sleep may not be accurate, and that accuracy may be affected by the context of the study. The use of complimentary sleep assessment tools in clinical and research settings should be encouraged.

Night diapers use and sleep in children with enuresis.

OBJECTIVE: We aimed to assess the association between night diapers use and sleep quality of school-aged children with enuresis. METHODS: The sleep patterns of 72 school-aged children (ages 6-9 y) with enuresis referred to a clinic specializing in bladder disorders and 63 healthy control children were assessed. Sleep measures were derived from four to five monitoring nights of actigraphy and daily logs. RESULTS: In comparison to controls, children with enuresis who did not wear night diapers had poorer sleep quality as reflected by both actigraphic measures (more activity during sleep and shorter periods of continuous sleep) and one reported measure (lower sleep quality). However, no differences were found on any of the sleep measures between children with enuresis wearing night diapers and controls. The reported sleep quality of all children with enuresis with and without night diapers was lower than controls. CONCLUSIONS: Our results suggest that sleep patterns of school-aged children with enuresis who do not wear night diapers are impaired, and the sleep quality of children using night diapers is similar to those of healthy children. Thus, clinicians and healthcare providers should consider recommending sleeping with night diapers for untreated children with enuresis, based on its positive impact on sleep.

Nighttime fears and fantasy-reality differentiation in preschool children.

Nighttime fears are very common in preschool years. During these years, children's fantasy-reality differentiation undergoes significant development. Our study was aimed at exploring the links between nighttime fears and fantasy-reality differentiation in preschool children. Eighty children (aged: 4-6 years) suffering from severe nighttime fears were compared with 32 non-fearful controls. Fears were assessed using child and parental reports. Children viewed images depicting fantastic or real entities and situations, and were asked to report whether these were imaginary or could occur in real life. The results revealed that children with nighttime fears demonstrated more fantasy-reality confusion compared to their controls. These differences in fantasy-reality differentiation were more pronounced in younger children. Additional significant associations were found between fantasy-reality differentiation and age and specific characteristics of the stimuli. These preliminary findings, suggesting a developmental delay in fantasy-reality differentiation in children with nighttime fears, have significant theoretical and clinical implications.

Assessment of brief interventions for nighttime fears in preschool children.

UNLABELLED: Nighttime fears (NF) and sleep problems continue to be major problems in clinical services. The aim was to assess the effects of two brief interventions on NF, and related sleep problems and parental fear-reducing behaviors in children. One hundred and four children aged 4-6 years with significant NF were randomly assigned into two intervention groups: the Huggy-Puppy intervention (HPI), which is based on providing children a puppy doll with a request to take care of the doll, and a revised version (HPI-r) which is based on providing the same doll with a cover story that the doll will serve as a protector. At baseline, the domains of NF, behavior problems, and sleep disruptions were assessed. Data were collected from parents and children using objective and subjective measures. The effects of the interventions were assessed by comparing four time points: baseline, first week of intervention, 1 month, and 6 months after initial intervention time. A waiting list comparison group (WL) was used as spontaneous recovery comparison group. Both interventions significantly reduced NF with similar impact. The improvement after 1 month was significantly higher than in the WL group. Furthermore, both interventions significantly reduced parental fear management behaviors and children's sleep problems. Finally, the reduction in NF and parental fear management strategies were maintained 6 months post-treatment. CONCLUSIONS: Relatively simple and cost-effective doll interventions can reduce NF and their associated sleep problems. Further research is needed to implement these interventions for other anxiety disorders in childhood.

Coping with preoperative anxiety in cesarean section: physiological, cognitive, and emotional effects of listening to favorite music.

BACKGROUND: Listening to music has a stress-reducing effect in surgical procedures. The effects of listening to music immediately before a cesarean section have not been studied. The objective of this study was to assess the effects of listening to selected music while waiting for a cesarean section on emotional reactions, on cognitive appraisal of the threat of surgery, and on stress-related physiological reactions. METHODS: A total of 60 healthy women waiting alone to undergo an elective cesarean section for medical reasons only were randomly assigned either to an experimental or a control group. An hour before surgery they reported mood, and threat perception. Vital signs were assessed by a nurse. The experimental group listened to preselected favorite music for 40 minutes, and the control group waited for the operation without music. At the end of this period, all participants responded to a questionnaire assessing mood and threat perception, and the nurse measured vital signs. RESULTS: Women who listened to music before a cesarean section had a significant increase in positive emotions and a significant decline in negative emotions and perceived threat of the situation when compared with women in the control group, who exhibited a decline in positive emotions, an increase in the perceived threat of the situation, and had no change in negative emotions. Women who listened to music also exhibited a significant reduction in systolic blood pressure compared with a significant increase in diastolic blood pressure and respiratory rate in the control group. CONCLUSION: Listening to favorite music immediately before a cesarean section may be a cost-effective, emotion-focused coping strategy. (BIRTH 39:2 June 2012).

Sleep of preschool children with night-time fears.

BACKGROUND: Night-time fears are very common in preschool and early school years. However, to date, the links between night-time fears and sleep have not been assessed systematically. The aim of this study was to evaluate natural sleep patterns in children with night-time fears, and to assess the association between parental fear-related strategies and children's sleep disruptions. METHODS: Sleep was assessed in a sample of 109 preschool children (64 boys and 45 girls) aged 4-6 years suffering from significant night-time fears, and in 30 healthy controls using actigraphy and parental reports. RESULTS: Controls slept significantly better than the children with night-time fears. The disrupted sleep patterns of the children with night-time fears were reflected in a higher number of actigraphic night wakings, shorter periods of continuous sleep, shorter true sleep time, and a lower percentage of actual sleep time. Similar findings were manifested in sleep measures reported by the parents. Parental fear-management strategies were found to be linked to impaired actigraphic sleep measurements. CONCLUSIONS: Children with night-time fears are at risk for developing poor sleep quality, which may further compromise their psychological well-being.

Sleep and sleepiness in children with nocturnal enuresis.

STUDY OBJECTIVES: To assess if sleep patterns and sleepiness are compromised in children with nocturnal enuresis (NE), in comparison with normal control subjects, and to evaluate the role of enuresis-related events during sleep. DESIGN: Assessment of natural sleep patterns at home in a sample of children referred to enuresis clinics and controls. SETTING: Children's homes. PARTICIPANTS: Thirty-two children (19 boys and 13 girls aged 5.1 to 9.1 years) who suffer from primary NE and 94 healthy control subjects (49 boys and 45 girls aged 5 to 8.58 years). INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Sleep measures were derived from 3 to 5 nights of actigraphy and daily logs. Additional information on events related to enuresis and daytime sleepiness was collected using daily reports. Children with NE slept significantly worse than did the control subjects. Their compromised sleep patterns were reflected in a higher number of actigraphic nighttime awakenings, the reduced percentages of motionless sleep, the higher number of reported nighttime awakening, and the increased sleep latency. Children with NE also reported higher levels of sleepiness in the morning and in the evening. CONCLUSIONS: Compared with the sleep of control subjects, the natural sleep of children with NE is significantly more fragmented, and the children with NE experience higher levels of daytime sleepiness. This phenomenology is associated with bedwetting episodes and attempts to keep the child dry during the night. These findings may suggest that children with NE suffer from sleep fragmentation, which may explain their higher arousal threshold. These findings have clinical implications for enuresis management.

Exploring physician perceptions of the impact of emotions on behaviour during interactions with patients.

BACKGROUND: There is relatively little research on affective influences on physician behaviour, especially on prescribing and referrals. Affects include transitory moods and lasting emotions. OBJECTIVES: We explored physician perceptions of the impact of four mood states on perceived rates of five behaviours: talking with patients, prescribing medications and referrals for laboratory tests, diagnostic tests and specialists. We also examined whether burnout modified the impact of moods on behaviour. METHODS: A total of 188 family physicians responded anonymously to a self-reporting questionnaire that assessed the perceived rate of behaviours when in a positive, negative, tired and nervous mood and burnout level. RESULTS: Five analyses of variance with repeated measures on mood states and contrast analyses computed the effects of mood and burnout on the behaviours. The mood factor was found significant for each of the behaviours, in all P < 0.001. The respondents reported that on good mood compared with negative mood days, they talked more, prescribed less and referred less. The burnout factor was also significant: high compared with low burnout physicians had higher perceived rates of all referral behaviours. Significant mood × burnout interactions indicated that the effects of mood were stronger among high compared with low burnout physicians. CONCLUSIONS: The physicians perceived that their moods had different effects on different behaviours: the negative mood decreased talking and increased prescribing and referral behaviours and vice versa for the positive mood. Burnout intensified the effects of moods. The incremental effects of negative moods and burnout may impair quality of health care and may be costly to health services.

Childhood fears, neurobehavioral functioning and behavior problems in school-age children.

The objective is to examine underlying associations between childhood fears, behavior problems and neurobehavioral functioning (NBF) in school-age children. Healthy, regular school children (N = 135), from second, fourth and sixth grade classes were assessed. Data regarding children's fears and behavioral problems were obtained with the Revised Fear Survey Schedule for Children, the Child Behavior Checklist, and NBF was assessed using a computerized neurobehavioral evaluation system. Significant correlations between childhood fears and NBF measures and somatic complaints were found. Children who reported higher levels of fears demonstrated lower working memory span (r = 0.24, p < 0.05), lower motor speed (r = -0.23, p < 0.05), and had more somatic complaints (r = 0.20, p < 0.05). Furthermore, younger children reported less fears than older ones and girls reported more fears than boys. These results highlight significant association between childhood fears, NBF and behavior problems in a non-clinical group children. Lower working memory span is an important component of executive control that may be an underlying factor in fears and anxiety in children.