Anxiety Disorders in Children and Adolescents

• The review focuses on the etiological factors and treatment strategies for anxiety disorders in children/adolescents.

Development and Demographics

• Approximately 5% of children and adolescents in Western populations meet the criteria for an anxiety disorder at any given time.
• Anxiety disorder rates are similar in Puerto Rico.
• Specific phobias are the most prevalent anxiety disorder.
• Anxiety disorders are 1.5-2 times more common in females than males, beginning as early as age 5.
• Treatment-seeking samples have a more equal gender balance.
• Anxiety disorders usually begin in middle childhood to mid-adolescence, with varying average onset ages:
• Animal phobias: early childhood (6-7 years).
• Separation anxiety: early to mid-childhood (7-8 years).
• Social anxiety: early adolescence (11-13 years).
• Generalized anxiety: mid-adolescence to adulthood.
• Panic disorder: early adulthood (20-24 years).

Aetiology

• Key etiological factors for anxiety disorders:
• Genetics: Parental anxiety/depression is associated with anxiety disorders in offspring; twin studies suggest about 40% heritability in adults.
• Temperament: Anxious/withdrawn behavior in childhood increases the risk of anxiety disorders.
• Parenting: Parental anxiety predisposes children to functional impairment and anxiety disorders.
• Individual experiences: Stressful events like frequent moves, parental conflicts, illness, school issues, or abuse may contribute.

Treatment Strategies

• Cognitive-behavioral therapy (CBT) is the primary treatment for anxiety disorders in children and adolescents.
• Family-based CBT is most effective for children under 8 years.
• Various CBT modalities are effective for older children and adolescents.
• Controlled studies demonstrate the efficacy of CBT for pediatric anxiety disorders.

Future Directions

• Recent developments in treatment, including alternative models of delivery and prevention strategies, will be discussed.

Epidemiology of Depression & Anxiety

• Childhood and adolescence area a critical time for mental health when peak onset happens for many disorders.
• Mood disorders onset from 14-37

Types of Anxiety Disorder (DSM-V)

• Generalised Anxiety Disorder
• Specific Phobia
• Panic Disorder with/out Agoraphobia
• Separation Anxiety Disorder

Major Depression in DSM

• Persistent depressed mood (or irritability in YP) AND/OR
• Marked loss of interest
• At least 5 symptoms in total
• Lasts at least 2 weeks
• Clinically significant impairment
• Symptoms include:
• Significant weight loss/weight gain or changes in appetite
• Insomnia or hypersomnia
• Unable to sit still or lethargy
• Loss of energy or fatigue
• Feelings of worthlessness or excessive, inappropriate guilt
• Impaired concentration/slowed down thinking/indecisiveness
• Recurring thoughts of death/suicide

Depressive Symptomatology

• 100 young people referred to Berkshire CAMHS for assessment of depression
• Age 12-17 years
• 60% aged 15-16
• 75% female
• 89% White British
• Most to least prevalent (%)
• Low mood/irritability (100)
• Suicidal ideation (86)
• Negative self-perception (86)
• Sleep disturbance (71)
• Cognitive disturbance (70)
• Eating disturbance (60)
• Anhedonia (50)
• Fatigue (43)
• Psychomotor changes (19)
• Loades et al. (2022) conducted secondary analysis of data from the IMPACT trial
• 465 young people with moderate to severe depression
• Conducted latent class analysis and identified 3 subtypes:
• Severe: high prevalence of all symptoms
• Moderate: less symptoms and lower rates of suicidal ideation
• Somatic: much lower rates of depressed mood, suicidal ideation and worthlessness, but very high rates of sleep disturbance, and decreased concentration
• The groups report differing levels of comorbidity, in expected direction, i.e. severe more comorbidity than moderate, who have more than somatic
• Severe and moderate group had more self-harm than the somatic group
• No difference in therapeutic working alliance or daily functioning

Measuring Depression and Anxiety

• Typically use:
• Questionnaire measures of symptomology
• E.g. Revised Child Anxiety and Depression Scale (RCADS) (used in IAPT/MHSTs), Spence Child Anxiety Scale, Child Anxiety Impact Scale, Mood and Feelings Questionnaire etc.
• Diagnostic Interviews - Gold-standard for diagnosing in research
• Anxiety: Anxiety Disorder Interview Schedule (ADIS)
• Depression: Schedule for Affective Disorders and Schizophrenia in School Age Children (Kiddie-SADS)

Parental Understanding of Youth Depression

• Higher score in mood and feelings questionnaire for Adolescent than Parent
• Just over 25 for parents (just below criteria)
• Low possibly due to being unaware of how child is feeling or what exactly they're struggling with
• Over 35 for young people
• Correlation matrix of measures of anxiety and depression taken from parent and child:
• 1st circle: .09 for correlation between parent and child score (very low/no association)
• 2nd circle: -.02 → no correlation between parent and child score
• Tells us what score you get from one, you won't get from the other
• Highlights the importance of taking multiple reports
• But this is time-consuming and almost impossible with multiple questionnaires

Risk Factors for Development of Depression & Anxiety

• Broad overview of risk and protective factors
• Many risk factors associated with anxiety / depression
• Likely to be a complex, multifactorial causal explanation
• Interaction amongst Risk Factors:
• Genes
• Temperament
• Stress / Life events
• Individual characteristics - e.g. sleep habits
• Co-morbid anxiety or depressive disorders
• Parental psychopathology
• Parental responses
• Cognitive biases
• Protective Factors:
• Connections to other non-parental adults
• School safety
• Neighbourhood safety
• Overall resilience
• Closeness to caring friends
• Parent connectedness
• Academic achievement
• Awareness of an access to local health services

Parental anxiety in interpretation bias

• Orchard, Creswell and Cooper (2017)
• 271 anxious and non-anxious mothers of 7-12 year old anxious children
• Mother completed hypothetical ambiguous scenario questionnaires, and challenge tasks, and responded about self- and child- expectations
• There was a significant association between maternal anxiety disorder status and negative expectations of child coping behaviours
• Anxious mothers expected their children to struggle to cope
• Mothers' self-referent interpretations were found to mediate this relationship
• Mothers expectations of their children were reflections of their own expectations of themselves
• A Causal Role for Sleep
• For evidence of a causal relationship, we want to see the following:
• Evidence of an association
• Evidence of a prospective relationship
• Evidence of effects of manipulation
• Evidence of pathways to change
• The Avon Longitudinal Study of Parents and Children (ALSPAC)
• At age 15 years, 5000 young people took part in a diagnostic interview and completed measures of sleep
• Sleep qualities were split into:
• Patterns
• Quality
• Diagnoses and symptoms of anxiety and depression available at multiple time points across later adolescence and early adulthood
• Predicting symptoms and diagnoses at 17, 21 and 24 years
• Sleep patterns:
• Less total sleep time on school nights at age 15 was a significant predictor of future anxiety and depression Seen at every time-point assessed
• Sleep quality:
• Three sleep quality variables measured at 15 years consistently predicted future anxiety and depression - Daytime sleepiness - Night-time waking - Perception of getting enough sleep

Access to Mental Health Support

• Rates of access are poor across world
• It is reported that approx. 2/3 of children with anxiety disorders do not access professional help.
• GPs feel ill-equipped to manage and support childhood anxiety disorders, including uncertainty identifying disorders

Barriers and Facilitators for Parents

• Research has identified some key barriers for parents accessing treatments (Reardon et al., 2017):
  • Knowledge and understanding of mental health problems
  • Knowledge and understanding of help-seeking process
  • Views and attitudes towards services and treatments
  • Family circumstances
• Key next steps for improving access include (Reardon et al., 2018):
• For readily available tools to help parents and professionals identifying clinically significant anxiety in children
• to ensure that families and professionals can easily access guidance on the help-seeking process and available support

Existing Treatment Approaches

• CBT is the most commonly used and recommended treatment for anxiety and depression in young people
• For depression, medication is sometimes advised in addition to CBT
• Effectiveness of CBT
• A number of RCTs and reviews have highlighted the effectiveness of CBT for childhood and adolescent anxiety
• Depression is less promising:
• Pivotal research by Weisz et al. (2006) - small effect sizes, and cognitive treatments no better than non-cognitive
• But methodology for trials still poor

The IMPACT Study 2017

• Published in The Lancet by Ian Goodyer and colleagues
• Large RCT; London
• 475 young people with depression randomised to one of 3 treatment conditions
• Short-Term Psychodynamic Psychotherapy
• CBT
• Specialist Clinical Care
• 30-40% of all participants still had depression diagnosis
• Self-reported depression symptoms did not differ significantly between patients given CBT and those given short-term psychoanalytical therapy at weeks 36 (end of tx) or 86 (1 year fl/u)
• These two psychological treatments had no superiority effect compared with brief psychosocial intervention at weeks 36 or 86
• Total costs did not differ significantly between groups

Updated Meta-Analysis - Eckshtain et al. (2020)

• The overall effect size (g) was 0.36 (small effect-size) at post-treatment and 0.21 at fl/u (averaging 42 weeks after post-treatment).
• Effects were significantly larger:
• For interpersonal therapy than for CBT
• For youth self-reported outcomes than parent-reports
• And for comparisons with inactive control conditions (e.g. waitlist) than active controls (e.g. usual care).

Possible Next Steps for Improving Treatments

• Anxiety
• Prevention / early intervention
• Access
• Depression
• Adapt current approaches?
• Or develop new ones?

Treating Maternal Anxiety

• Creswell et al. (2015)
• Role of parents / disorder specific treatments
• 211 children with primary anxiety disorder whose mothers also had anxiety disorder
• Randomised to individual child CBT or child CBT & maternal CBT
• CCBT + mCBT did not outperform cCBT on child anxiety disorder status or global improvement ratings

Effectiveness of Guided Parent-Delivered CBT

• Thirlwall et al. (2013)
• RCT
• 194 children with anxiety disorder allocated to Overcoming (4 sessions face-to-face and 4 over the phone) or waitlist
• Results
• At post-treatment: 25 (50%) of those in the full guided CBT group had recovered from their primary diagnosis
• Compared with 16 (25%) of those on the waitlist
• An effective and inexpensive first step

Effectiveness of Online Delivery

• Two-arm RCT to evaluate the effectiveness of therapist supported online parent-led CBT, compared to treatment as usual for child anxiety problems in routine child mental health services
• Children aged 5 to 12 years who were offered treatment for child anxiety problems were eligible
• Results
• 222 participants were randomly assigned
• At 26 weeks, the online intervention was non-inferior for parent reported anxiety interference and all secondary outcomes
• Therapist time for treatment delivery averaged 185.93 minutes for online

Effect of CBT for Insomnia on Depression and Anxiety Symptoms (Meta-Analytical Data)

• compared to 308.57 treatment as usual
• Depression
• 49 studies examining effect of psychological treatments for sleep on depression symptoms
• Small to moderate effect on depression, but large effect on amongst clinical samples
• Anxiety
• 43 trials included examining effect on anxiety symptoms
• Small to moderate effect on anxiety, moderate for clinical samples
• Limited research on adolescents, 4 studies for depression, 2 studies for anxiety

The IBLISS Study

• Pilot, feasibility RCT
• CBT-informed
• Group sleep workshops in secondary school
• Outcomes for sleep and wellbeing
• Measures of pathways to change