Comorbidity of anxiety and depression in children and adolescents.

Anxiety and depression in children and adolescents are reviewed, including differential diagnosis, assessment of symptoms, family history data, developmental features, and clinical correlates. Findings indicate that 15.9% to 61.9% of children identified as anxious or depressed have comorbid anxiety and depressive disorders and that measures of anxiety and depression are highly correlated. Family history data are inconclusive. Differences emerged among children with anxiety, depression, or both disorders. Anxious children were distinguishable from the other 2 groups in that they showed less depressive symptomatology and tended to be younger. The concurrently depressed and anxious group tended to be older and more symptomatic. In this group, the anxiety symptoms tended to predate the depressive symptoms. Findings are discussed in the context of a proposed developmental sequence.     

Assessment of symptoms of DSM-IV anxiety and depression in children: a revised child anxiety and depression scale

The practical significance of assessing disorders of emotion in children is well documented, yet few scales exist that possess conceptual if not empirical relevance to dimensions of DSM anxiety or depressive disorders. The current study evaluated an adaptation of a recently developed anxiety measure (Spence Children's Anxiety Scale; [Spence, S. H. (1997). Structure of anxiety symptoms among children: a confirmatory factor-analytic study. Journal of Abnormal Psychology, 106, 280-297; Spence, S. H. (1998). A measure of anxiety symptoms among children. Behaviour Research and Therapy, 36, 545-566]), revised to correspond to dimensions of several DSM-IV anxiety disorders as well as major depression. This investigation involved initial evaluation of the factorial validity of the revised measure in a school sample of 1641 children and adolescents and reliability and validity in an independent sample of 246 children and adolescents. Results yielded an item set and factor definitions that demonstrated structure consistent with DSM-IV anxiety disorders and depression. The revised factor structure and definitions were further supported by the reliability and validity analyses. Some implications for assessment of childhood anxiety and depressive disorders are discussed.     

Adaptive working memory training can reduce anxiety and depression vulnerability in adolescents

Adolescents can be at heightened risk for anxiety and depression, with accumulating research reporting on associations between anxiety and depression and cognitive impairments, implicating working memory and attentional control deficits. Several studies now point to the promise of adaptive working memory training to increase attentional control in depressed and anxious participants and reduce anxiety and depression symptoms, but this has not been explored in a non‐clinical adolescent population. The current study explored the effects of adaptive dual n‐back working memory training on sub‐clinical anxiety and depression symptomology in adolescents. Participants trained on either an online adaptive working memory task or non‐adaptive control task for up to 20 days. Primary outcome measures were self‐reported anxiety and depression symptomology, before and after intervention, and at 1‐month follow‐up. Self‐reported depression (p = 0.003) and anxiety (p = 0.04) decreased after training in the adaptive n‐back group relative to the non‐adaptive control group in the intention‐to‐treat sample (n = 120). These effects were sustained at follow‐up. Our findings constitute proof of principle evidence that working memory training may help reduce anxiety and depression vulnerability in a non‐clinical adolescent population. We discuss the findings’ implications for reducing risk of internalizing disorders in youth and the need for replication.     

Anxiety sensitivity within the anxiety disorders: disorder-specific sensitivities and depression comorbidity

The tendency to perceive anxious states as aversive and harmful is hypothesized to confer vulnerability to the development of anxiety disorders. The most commonly used measure of anxiety sensitivity, the Anxiety Sensitivity Index [ASI; Reiss, S., Peterson, R.A., Gursky, D.M., & McNally R.J. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behavior Research and Therapy, 24, 1-8], is composed of multiple lower-order factors, assessing fear of physical symptoms, fear of publicly observable anxious symptoms, and fear of cognitive dyscontrol. This study examined the convergent validity of the lower-order anxiety sensitivity dimensions in DSM-IV diagnosed anxiety disorders. Participants with primary diagnoses of panic disorder with agoraphobia, social phobia, and generalized anxiety disorder (GAD) completed the ASI and measures of anxiety and depression severity. Support was found for the convergent validity of all ASI dimensions in reference to thematically related anxiety disorders and in the identification of patients presenting with and without secondary major depressive disorder (MDD). The ASI-fear of cognitive dyscontrol dimension displayed strong and nonredundant associations with GAD, dimensional depression scores, and secondary diagnoses of MDD. The conceptual implications of the shared importance of fear of cognitive dyscontrol in GAD and MDD are discussed.     

Evaluating anxiety and depression symptoms in children and adolescents with prior mild traumatic brain injury: Agreement between methods and respondents

Psychological functioning can be adversely impacted after a mild traumatic brain injury (mTBI) and may be a potential target for intervention. Despite the use of symptom ratings or structured diagnostic interview to assess long-term anxiety and depression symptoms in children and adolescents post-injury, no known studies have considered the agreement between different assessment methods and between respondents. The objectives of this study were to investigate the agreement between symptom ratings and structured diagnostic interview and between children and parents’ symptom reporting. Participants (N = 33; 9–18 years old) were recruited from the Emergency Department and assessed on average 22.8 months (SD = 5.6) after their mTBI. Anxiety and depression symptoms were evaluated via subscales of a questionnaire (Behavior Assessment System for Children) and parts of a computerized structured diagnostic interview (generalized anxiety disorder and major depressive episode; Diagnostic Interview Schedule for Children – C-DISC-IV) administered individually to children and their parents. Results showed that the inter-method agreement to identify high levels of anxiety and depression was moderate to perfect in children while it was lower in parents. Although a similar percentage of participants with elevated anxiety or depression were identified by both children and parents, the agreement between youth and parents was variable, ranging from poor to good for anxiety and poor to moderate for depression. These results highlight the importance of collecting youth and parents’ reports of anxiety and depression symptoms and considering potential discrepancies between informants’ answers.     

Rumination as a transdiagnostic factor in depression and anxiety

The high rate of comorbidity among mental disorders has driven a search for factors associated with the development of multiple types of psychopathology, referred to as transdiagnostic factors. Rumination is involved in the etiology and maintenance of major depression, and recent evidence implicates rumination in the development of anxiety. The extent to which rumination is a transdiagnostic factor that accounts for the co-occurrence of symptoms of depression and anxiety, however, has not previously been examined. We investigated whether rumination explained the concurrent and prospective associations between symptoms of depression and anxiety in two longitudinal studies: one of adolescents (N = 1065) and one of adults (N = 1317). Rumination was a full mediator of the concurrent association between symptoms of depression and anxiety in adolescents (z = 6.7, p < .001) and was a partial mediator of this association in adults (z = 5.6, p < .001). In prospective analyses in the adolescent sample, baseline depressive symptoms predicted increases in anxiety, and rumination fully mediated this association (z = 5.26, p < .001). In adults, baseline depression predicted increases in anxiety and baseline anxiety predicted increases in depression; rumination fully mediated both of these associations (z = 2.35, p = .019 and z = 5.10, p < .001, respectively). These findings highlight the importance of targeting rumination in transdiagnostic treatment approaches for emotional disorders.     

Drinking motives in alcohol use disorder patients with and without social anxiety disorder

The high comorbidity of alcohol use disorders (AUD) and social anxiety disorder (SAD) is often explained by excessive drinking in social situations to self-medicate social anxiety. Indeed, the motive to drink alcohol to lower social fears was found to be elevated in socially anxious persons. However, this social anxiety specific motive has not been directly investigated in primarily alcohol dependent individuals. We explored social anxiety, the motivation to drink alcohol in order to cope with social fears, and social anxiety as a consequence of drinking in AUD with and without comorbid SAD. Male AUD inpatients with (AUD+SAD group, N=23) and without comorbid SAD (N=37) completed a clinical interview and a questionnaire assessment. AUD+SAD patients reported higher levels of depression and an elevated motive to drink due to social anxiety but did not experience more social fears as a consequence of drinking. Previous results concerning alcohol drinking motives in order to relieve social fears could be replicated in a clinical AUD sample. Additionally, our findings suggest comorbid AUD+SAD patients to be more burdened regarding broader psychopathological symptoms. Thus, accessibility to SAD-specific screening and treatment procedures may be beneficial for primary AUD patients.     

Interpretation of ambiguous emotional information in clinically anxious children and adolescents

Cognitive theories of anxiety based on adult data predict that individuals vulnerable to anxiety should show threat - related interpretations of ambiguous material and it is proposed that this is an important maintaining factor in anxiety disorders. In the present study, interpretation of ambiguous emotional/neutral information was examined in child and adolescent anxious patients. Two groups of participants, anxious patients (n = 17) and healthy controls (n = 40), were presented with a series of homographs, each with a threatening and a neutral interpretation. For each homograph, the participants were asked to construct a sentence using the homograph. Anxious children and adolescents produced significantly more sentences consistent with threatening homograph interpretations and less consistent with neutral interpretations than did normal controls. Regression analyses revealed no relationship between age and this interpretive bias. Preliminary developmental and theoretical implications are discussed.     

Parental Anxiety Disorders, Child Anxiety Disorders, and the Perceived Parent–Child Relationship in an Australian High-Risk Sample

This study was designed to explore the role of perceived parenting behavior in the relationship between parent and offspring anxiety disorders in a high-risk sample of adolescents. We examined the relationship between parental and child anxiety disorders and tested whether perceived parenting behavior acted as a mediator between these variables. Analyses were performed on a high-risk sample of 816 fifteen-year-olds drawn from a birth cohort in Queensland, Australia. Parental depression and income were covaried. Maternal anxiety disorder significantly predicted the presence of anxiety disorders in children; the association between paternal anxiety disorder and child anxiety disorder was not significant. There was no evidence that perceived parenting played a mediating role in the association between mother and child anxiety disorders. These results replicate earlier studies' findings of elevated rates of anxiety disorders among the offspring of anxious parents, but only when the child's mother is the anxious parent.     

Interactions between mothers and children: impacts of maternal and child anxiety

This study, an expansion of an earlier study of parenting behaviors of anxious mothers, examined the relationship of both mother and child anxiety disorders to mother behavior in parent--child interactions. Participants were 68 mother--child dyads with children ranging in age from 7 to 15 years. Mothers and children completed diagnostic evaluations and engaged in conversational tasks; behaviors were rated by coders who were blind to diagnosis. Mothers of anxious children, regardless of their own anxiety, were less warm (p <.05) toward their children. They also granted less autonomy (p <.01). There was an interaction between mother and child anxiety in predicting maternal catastrophizing (p <.01), with anxious mothers and nonanxious mothers of anxious children likely to catastrophize. Theoretical and research implications are discussed.     

Substance abuse and panic-related anxiety: a critical review

The relationship between substance abuse and panic-related anxiety can be divided into two broad areas: the incidence of anxiety disorders in substance abuse patients and the incidence of substance abuse in patients with panic-related anxiety disorders. Studies indicate that approx. 10-40% of alcoholics have a panic-related anxiety disorder, and about 10-20% of anxiety disorder patients abuse alcohol or other drugs. The majority of patients with both an anxiety and alcohol disorder report that anxiety problems preceded alcohol problems. In some cases substance abuse (e.g. cocaine) triggers the onset of panic attacks. Most patients believe that self-medication is efficacious despite the fact that they appear to have a more serious clinical condition (e.g. higher rates of depression). Directions for future research are outlined, including the proposal for a study to examine the effects of an anxiety intervention procedure for anxious alcoholics to reduce relapse rates.     

An examination of the interactions between mothers and children with anxiety disorders

This study examined the association between parenting styles and mother and child anxiety. Maternal overinvolvement and negativity/criticism were evaluated during a speech preparation task (N = 135 dyads) and a Five Minute Speech Sample (FMSS) from mothers (N = 155). During the speech task interaction, mothers of anxious children (aged 4–16 years), regardless of their own anxiety, were observed to be more overinvolved than mothers of nonanxious children. Similarly, the FMSS showed that mothers of anxious children (aged 4–17 years) were more overprotective, self-sacrificing, or nonobjective than mothers of nonanxious children, irrespective of maternal anxiety status. No differences in maternal negativity were found on the speech task between any of the groups. However, the FMSS showed that mothers of anxious children were more critical than mothers of nonanxious children, regardless of maternal anxiety status. These results support the relationship between overinvolved, critical parenting and child anxiety, but suggest that maternal anxiety is not associated with increased overinvolvement or criticism. Theoretical implications are discussed.     

Prognostic value of implicit and explicit self-associations for the course of depressive and anxiety disorders

Dysfunctional self-beliefs are assumed to play an important role in maintaining depression and anxiety. Current dual-process models emphasize the relevance of differentiating between implicit and explicit self-beliefs. Therefore, this study tested the prognostic value of automatic and explicit self-associations for the naturalistic course of depressive and anxiety disorders over two years follow-up. Both self-depressed and self-anxious associations were measured in unipolar depressed patients (n = 313), anxious patients (n = 566), and patients with comorbid depressive and anxiety disorders (n = 577) as part of the Netherlands Study of Depression and Anxiety. Outcomes showed that in single predictor models specifically automatic self-anxious associations were related to a reduced chance of remission from anxiety, whereas automatic self-depressed associations were related to a reduced chance of remission from depression. Explicit self-anxious associations and fearful avoidance behaviour showed independent predictive validity for remission from anxiety, whereas explicit self-depressed associations and having both major depressive disorder and dysthymia showed independent predictive validity for remission from depression. These findings are not only consistent with the view that both implicit and explicit dysfunctional self-associations are related to the course of anxiety and unipolar depressive disorders, but also suggest that both types of self-beliefs are proper targets for therapeutic interventions.     

The effects of anxiety and depression on in vitro fertilisation outcomes of infertile Chinese women

The object was to assess anxiety and depression during in vitro fertilisation (IVF) treatment and determine IVF-related psychological factors in infertile Chinese women. The self-rating anxiety scale (SAS) and self-rating depression scale (SDS) were used to evaluate anxiety and depression among 842 patients, respectively. A univariate analysis was used to compare variables among three SAS groups and three SDS groups. Anxiety and depression were both represented in 21.3% of the cases. Patients <35 years tended to be more anxious. In women <35 years, the SDS scores were higher with lower educational backgrounds and female or couple’s infertility, while the SAS scores were higher in female or couple’s infertility. In older ones, the SDS scores were higher in those with lower educational backgrounds and longer time for infertility, while the SAS scores were higher in those with lower educational backgrounds. In SAS groups 1–3, the embryo availability was 5.0 (3.0–8.0), 5.0 (3.0–8.0), and 3.0 (2.0–4.5) (p = .013); and the fertilisation rate was 91.9, 90.4, and 81.8% (p < .001), respectively. We concluded that infertile women experience anxiety and depression during IVF treatment, especially in women <35 years. Younger women with female infertility would be more anxious and depressive while higher education can protect them from depression. In older ones, they would experience more depressive with longer time for infertility and be less anxious and depressive with higher education. Anxiety affects the fertilisation rate and embryo availability.     

Anxious Solitude and Clinical Disorder in Middle Childhood: Bridging Developmental and Clinical Approaches to Childhood Social Anxiety

It was hypothesized that children identified by their peers at school as anxious solitary would report more symptoms of social anxiety disorder on a self report questionnaire and, on the basis of child and parent clinical interviews, receive more diagnoses of social anxiety disorder and additional anxiety and mood disorders. Participants were 192 children drawn from a community sample of 688 children attending public elementary schools. Half of these children were selected because they were identified as anxious solitary by peers and the other half were demographically-matched controls. 192 children provided self reports of social anxiety disorder symptoms on a questionnaire, and 76 of these children and their parent participated in clinical interviews. Results indicate that children identified by their peers as anxious solitary in the fall of 4th grade, compared to control children, were significantly more likely to receive diagnoses of social anxiety disorder, specific phobia, and selective mutism based on parent clinical interviews. Additionally, there was a tendency for these children to be diagnosed with generalized anxiety disorder and post traumatic stress disorder based on parent clinical interviews. Furthermore, children who had been identified as anxious solitary at any time in the 3rd or 4th grades were more likely than control children to report symptoms of social anxiety disorder that fell in the clinical range and to receive diagnoses of social anxiety disorder and dysthymia (both trends) and major depression (a significant effect) according to parental clinical interview.     

The mediating role of anxiety in self-reported somatic complaints of depressed adolescents

This study examined the mediating role of anxiety in the self-reports of somatic complaints in 96 depressed adolescent inpatients. Sixty-four subjects with major depressive episodes and comorbid anxiety disorders (MDE-A) determined from the Diagnostic Interview for Children and Adolescents-Revised (DICA-R) reported significantly more somatic complaints than 32 adolescents having major depressive episodes without comorbid anxiety (MDE). An analysis of covariance demonstrated that, with anxiety symptoms controlled, MDE and MDE-A groups did not differ significantly in somatic complaints. A hierarchical multiple-regression analysis revealed that, with demographic and anxiety symptoms controlled, depressive symptoms did not contribute to the explanation or prediction of somatic complaints. The results suggest that anxious, but not depressive symptoms, are independently associated with somatic complaints. The results are discussed in light of new affective models of psychopathology.     

Temporal patterns of anxious and depressed mood in generalized anxiety disorder: a daily diary study

Research suggests that anxiety disorders tend to temporally precede depressive disorders, a finding potentially relevant to understanding comorbidity. The current study used diary methods to determine whether daily anxious mood also temporally precedes daily depressed mood. 55 participants with generalized anxiety disorder (GAD) and history of depressive symptoms completed a 21-day daily diary tracking anxious and depressed mood. Daily anxious and depressed moods were concurrently associated. Daily anxious mood predicted later depressed mood at a variety of time lags, with significance peaking at a two-day lag. Depressed mood generally did not predict later anxious mood. Results suggest that the temporal antecedence of anxiety over depression extends to daily symptoms in GAD. Implications for the refinement of comorbidity models, including causal theories, are discussed.     

The relation between anxiety disorder and experiential avoidance in inpatient adolescents

The current study aimed to examine the relation between experiential avoidance and anxiety disorders, as well as the usefulness of the Avoidance and Fusion Questionnaire for Youth (AFQ-Y; Greco, Lambert, & Baer, 2008) in detecting anxiety disorder in a sample of adolescent inpatients. First, the relation between experiential avoidance and anxiety among inpatient adolescents was investigated from categorical and dimensional points of view, making use of self-report and parent report, as well as clinical interview, while controlling for depression and externalizing problems. Second, we sought to establish the clinical utility value of the AFQ-Y by determining the sensitivity, specificity, and clinical cutoff score of this measure in predicting anxiety disorder. To this end, a sample of inpatient adolescents (N = 111) with a mean age of 16.14 (SD = 1.39) years completed the AFQ-Y, alongside interview- and questionnaire-based measures of psychopathology. Results showed a significant relation between anxiety disorder and experiential avoidance, independent of depression. Receiver operating characteristics analysis revealed that the AFQ-Y has moderate accuracy (area under the curve = .815, SE = .047, p < .001) in discriminating adolescents with a diagnosis of any anxiety disorder (cutoff score 26.5; sensitivity = .74, specificity = .76). Given the comorbidity of anxiety and depression in this sample, this cutoff is not indicative of pure anxiety disorder but may be helpful in predicting those with emotional disorders in general.     

Separation anxiety in mothers of latency-age fearful children

The hypothesis that mothers of children who have symptoms indicative of separation anxiety are themselves separation-anxious was tested by scoring mothers' TAT themes for separation concerns. The stories of 15 mothers of fearful children were compared to the stories of 26 mothers of children manifesting behavior disorders and 21 mothers of children having had no psychiatric contact. Different kinds of separation concerns were found to differentiate the groups of mothers. The stories of mothers of fearful children expressed significantly more concerns about abandonment and rejection and more often expressed a desire to stay near the loved one; the mothers of children with behavior disorders were found to tell significantly more stories with nurturance-succorance themes. The results lend support to the theory of anxious attachment in that mothers of fearful children seem to share the same concerns that have been ascribed to their children. On the other hand, it seems that separation anxiety may not be a unidimensional construct as different components seem to be more relevant to some symptom clusters than to others.     

A case series of attention modification in clinically anxious youths

Research in the last fifteen years suggests that anxious individuals selectively attend towards threatening information. Attention modification interventions for internalizing adults have been developed to target cognition at this basic level; these programs have demonstrated initial efficacy in attention bias and anxiety symptom reduction. To date, there have been no published studies of attention modification in youths with clinical levels of anxiety. The current case series examined the initial efficacy of a four-week (12 sessions) attention modification program (AMP) designed to train attention away from threat in 16 children and adolescents (ages 10 to 17) diagnosed with DSM-IV anxiety disorders. Overall, youths experienced a significant decrease in anxiety and depression symptoms, and 12 of 16 youths no longer met criteria for any anxiety diagnosis at post-treatment. AMP was feasible with youths, and all youths and parents deemed the program acceptable. These findings provide support for further research on the use of cognitive bias modification interventions with clinically anxious youths.