Cognitive change and enhanced coping: missing mediational links in cognitive behavior therapy with anxiety-disordered children

In this review, we examine the recent cognitive behavior therapy (CBT) outcome literature with anxiety-disordered children and, specifically, explore the status of cognitive change and increased coping ability as (1) specific treatment effects, and (2) possible mediators of the efficacy of CBT. In the past decade, the number of controlled CBT studies with clinically diagnosed anxiety-disordered children has increased substantially. CBT aims to restructure distorted or maladaptive cognitions and teach the anxious child to effectively use diverse coping strategies. Our review shows that in recent CBT research with anxiety-disordered children the use of domain-specific measures like cognitive and coping measures is, unfortunately, not common practice. Furthermore, only one study examined the issue of treatment mediation. Generally, recent CBT research has not been designed to test mediational issues and does not clarify whether cognitive change and enhanced coping—the presumed central components of CBT—are in fact responsible for its efficacy. Implications for the direction of future CBT research with anxiety-disordered children are discussed.     

Models-of-self and models-of-others as related to facial muscle reactions at different levels of cognitive control

The hypotheses of this investigation were based on attachment theory and Bowlby's conception of "internal working models", supposed to consist of one mainly emotional (model-of-self) and one more conscious cognitive structure (model-of-others), which are assumed to operate at different temporal stages of information processing. Facial muscle reactions in individuals with positive versus negative internal working models were compared at different stages of information processing. The Relationship Scale Questionnaire (RSQ) was used to categorize subjects into positive or negative model-of-self and model-of-others and the State-Trait Anxiety Inventory was used to measure trait anxiety (STAI-T). Pictures of happy and angry faces followed by backward masking stimuli were exposed to 61 subjects at three different exposure times (17 ms, 56 ms, 2,350 ms) in order to elicit reactions first at an automatic level and then consecutively at more cognitively elaborated levels. Facial muscle reactions were recorded by electromyography (EMG), a higher corrugator activity representing more negative emotions and a higher zygomaticus activity more positive emotions. In line with the hypothesis, subjects with a negative model-of-self scored significantly higher on STAI-T than subjects with a positive model-of-self. They also showed an overall stronger corrugator than zygomatic activity, giving further evidence of a negative tonic affective state. At the longest exposure time (2,350 ms), representing emotionally regulated responses, negative model-of-self subjects showed a significantly stronger corrugator response and reported more negative feelings than subjects with a positive model-of-self. These results supported the hypothesis that subjects with a negative model-of-self would show difficulties in self-regulation of negative affect. In line with expectations, model-of-others, assumed to represent mainly knowledge structures, did not interact with the physiological emotional measures employed, facial muscle reactions or tonic affective state.     

The Nature of Generalized Anxiety in Older Primary Care Patients: Preliminary Findings

Clinical features of older primary care patients with GAD (PC-GAD; n = 22) were examined relative to older patients with GAD recruited for two academic clinical trials (M. A. Stanley, J. G. Beck, et al., 2003; J. L. Wetherell, M. Gatz, & M. G, Craske, 2003) and to a sample of older primary care patients without psychiatric diagnoses (No Dx; n = 10). Comparisons revealed similar levels of worry, anxiety, depressive symptoms, quality of life, and functional status between the PC-GAD subsample and patients recruited for academic trials, although primary care patients were older, less well educated, and more ethnically diverse. The PC-GAD subgroup, however, reported greater symptom severity, reduced quality of life, and poorer perceived general health, mental health, and vitality than the No Dx subgroup (² = .23–.43). Service utilization was not different between PC-GAD and No Dx subgroups, with the exception of psychotropic medication use. The Penn State Worry Questionnaire (PSWQ) and an abbreviated version of this measure may be useful for identifying late-life GAD in primary care. Cutoff scores of 50 and 22 on the full and abbreviated versions of the PSWQ, respectively, demonstrated excellent specificity, sensitivity, and positive predictive value. Negative predictive value was less impressive, probably as a result of high base rates for GAD in this sample.     

Evaluating the Social Acceptability of Persons with Habit Disorders: The Effects of Topography, Frequency, and Gender Manipulation

In this study, 120 undergraduate students were asked to rate the social acceptability of a male and female who portrayed different habit behaviors (motor tics, vocal tics, Tourette's disorder, and trichotillomania). The portrayals of these behaviors were clinically valid as viewed by mental health professionals. Each habit behavior was portrayed in a variety of frequency/topography combinations including low frequency/mild topography, low frequency/severe topography, high frequency/mild topography, and high frequency/ severe topography. Participants were randomly assigned to one of four habit conditions (motor tic, vocal tic, Tourette's disorder, and trichotillomania) and were asked to rate the social acceptability of the frequency/topography combinations exhibited by each actor. Results showed that across the various habit conditions, the man with the habit was seen as less socially acceptable than the woman with the habit. In addition, low-frequency habit behaviors were more acceptable than high-frequency behaviors, and behaviors with mild topographies were more acceptable than those with severe topography habits. Motor tics were seen as more acceptable than vocal tics, Tourette's disorder, or trichotillomania. Implications and directions for future research are discussed.     

Histrionic Personality Disorder, Physical Attractiveness, and Social Adjustment

Histrionic personality disorder (HPD) is the only DSM-IV personality disorder (PD) explicitly linked to a person's physical appearance. This study examined the HPD–attractiveness link in a mixed-sex sample of college students. Consistent with expectations, HPD women were rated higher in attractiveness than women with other PDs or no PD. However, a parallel HPD–attractiveness link was not found in men. Subsequent analyses indicated that, relative to less attractive HPD women, more attractive HPD women (a) had a more varied and supportive social network, (b) exhibited more negative behaviors in important relationships, and (c) showed greater use of immature defenses, and less reliance on image-distorting, self-sacrificing, and mature defenses. Similar attractiveness–defense relationships were found in HPD men, but parallel results did not emerge for men in the other two domains. Implications of these findings are discussed, and suggestions for future studies are offered.     

Prevalence of Attention-Deficit/Hyperactivity Disorder Symptoms in 4- to 17-Year-Old Children in the General Population

The purposes of this study were (a) to estimate the prevalence of Attention-Deficit/Hyperactivity Disorder (AD/HD) symptoms in the general preschool and school population; and (b) to analyze the influence of gender, age, and socioeconomic status (SES) variables on AD/HD symptoms. Out of the 80,000 preschool and schoolchildren living in Manizales, Colombia, a random sample of 540 children was selected. Two gender, three age (4- to 5-year olds, 6- to 11 -year olds, and 12- to 17-year olds), and three SES (low, middle, and high) groups were used. The 18 DSM-IV symptoms corresponding to AD/HD Criterion A were assessed on a scale of 0 (never) to 3 (almost always). All three demographic variables established statistically significant differences: AD/HD symptoms were more frequent in 6-to 11-year-old, low-SES, male participants. DSM-IV Criterion A for AD/HD was fulfilled by 19.8% of the boys and 12.3% of the girls. However, this difference was marginally significant only in the AD/HD Subtype I: Combined. It was concluded that demographic variables are significant correlates of the AD/HD diagnosis. The prevalence found in this study was higher than usually reported, even though only the symptomatic DSM-IV AD/HD criterion was analyzed. We failed to confirm the assumed AD/HD gender ratio.     

Relation of Age of Onset to the Type and Severity of Child and Adolescent Conduct Problems

In a cross-sectional household sample of 9-through 17-year-old youths from 4 U.S. communities, youths with earlier ages of onset of conduct problems engaged in more conduct problems than youths with later ages of onset when current age and gender were controlled. Specifically, youths with earlier ages of onset were more likely to engage in several types of physical aggression, frequent lying, theft, and vandalism and were less likely to engage in only truancy. There also was an inverse relation between age of onset and level of functional impairment, mental health service use, and meeting diagnostic criteria for conduct disorder, attention-deficit hyperactivity disorder, and oppositional defiant disorder. Within the limits of cross-sectional data, these results support the hypothesis that key aspects of the heterogeneity of conduct problems among youths are related to the age of onset of conduct problems.     

Exploratory Eye Movements to Pictures in Childhood-Onset Schizophrenia and Attention-Deficit/Hyperactivity Disorder (ADHD)

We investigated exploratory eye movements to thematic pictures in schizophrenic, attention-deficit/hyperactivity disorder (ADHD), and normal children. For each picture, children were asked three questions varying in amount of structure. We tested if schizophrenic children would stare or scan extensively and if their scan patterns were differentially affected by the question. Time spent viewing relevant and irrelevant regions, fixation duration (an estimate of processing rate), and distance between fixations (an estimate of breadth of attention) were measured. ADHD children showed a trend toward shorter fixations than normals on the question requiring the most detailed analysis. Schizophrenic children looked at fewer relevant, but not more irrelevant, regions than normals. They showed a tendency to stare more when asked to decide what was happening but not when asked to attend to specific regions. Thus, lower levels of visual attention (e.g., basic control of eye movements) were intact in schizophrenic children. In contrast, they had difficulty with top-down control of selective attention in the service of self-guided behavior.     

Behavioral Genetics as a Tool for Developmental Psychology: Anxiety and Depression in Children and Adolescents

Over the past decade there has been a huge increase in the number of behavioral genetic studies looking into anxiety and depression in children and adolescents. There are now enough data in this area to make a review of the results useful. This paper begins with an outline of the methods used in such research and moves on to review the results in extant studies. Overall, these studies indicate modest to moderate genetic influence on both anxiety and depression. However, behavioral genetic methods are also paramount for exploring environmental influences in addition to genetic influences. Shared environment (that which makes family members resemble one another) is rarely identified in adult studies of personality or psychopathology and does not appear to be a significant influence for depression but it is for anxiety. Nonshared environment, which makes family members differ from one another, is found to be a significant influence for both anxiety and depression. Patterns within these results due to rater effects, age effects, sex effects, the precise phenotype measured, and the study design are explored.