Anger in youth with anxiety:Relationship with reinforcement sensitivity, parental rejection and treatment outcome

Anxiety disorders are among the most prevalent disorders in children and young people (CYP). Around 20-30% of CYP with anxiety disorders also expresses oppositional behaviors. This subgroup presents with more severe mental health problems, worse psychosocial functioning, profits less from current treatments and has an increased risk of continued mental health problems later in life. In this dissertation, I investigated two pathways that may explain how CYP with anxiety disorders can develop behavioral problems. First, these comorbid behavioral problems may arise as a defensive response in for the CYP threatening situations, where they cannot avoid; especially for CYP with relatively high punishment sensitivity this may lead to behavioral problems. As a second possibility, behavioral problems could arise from frustration in situations where expected and desired rewards are not attained; especially for CYP with relative high reward sensitivity this may lead to behavioral problems. Additionally I investigated whether comorbid behavioral problems – via experiencing rejection from the environment – play a role in the maintenance of anxiety complaints. Lastly, it was investigated whether the treatment for anxiety would also reduce behavioral problems when they arise from experienced threat. For those where the behavioral problems arise out of frustration due to expected rewards that are not attained, it was expected that regular treatment for anxiety would not decrease the behavioral problems. This dissertation project provided consistent evidence for the role of frustration of not attaining expected rewards in comorbid behavioral problems. For the role of defensive responses herein, results were not univocal. In addition, the findings indicated that behavioral problems in adolescence indeed increased the risk of anxiety symptoms in young adulthood, although this appeared unrelated to experiencing more rejection from their parents. Importantly, behavioral problems generally decreased after anxiety-focused treatment, however not all CYP with behavioral problems had a reduction of their behavioral problems following treatment for anxiety. This seemed especially the case when the behavioral problems were not so much related to sensitivity for threat, but to the sensitivity for not attaining expected rewards. For CYP with this comorbid profile it seems important to add additional treatment modules focusing on the comorbid behavioral problems

Behavioral problems in anxious youth:Cross-sectional and prospective associations with reinforcement sensitivity and parental rejection

A subsample of children and young people (CYP) with anxiety disorders presents with comorbid behavioral problems. These CYP have greater impairment in daily life, profit less from current treatments, and have an increased risk for continued mental problems. We investigated two potential explanations for these comorbid behavioral problems. First, high punishment sensitivity (PS) may lead to a strong inclination to experience threat, which may not only elicit anxiety but also defensive behavioral problems. Second, behavioral problems may arise from high reward sensitivity (RS), when rewards are not obtained. Behavioral problems may subsequently elicit parental rejection, thereby fueling anxiety. We used a cross-sectional (age = 16.1, N = 61) and prospective (age = 22.2, N = 91) approach to test the relationship between PS/RS and comorbid behavioral problems. Participants were a subsample of highly anxious CYP from a large prospective cohort study. PS/RS were indexed by a spatial orientation task. We also investigated the prospective association between behavioral problems and anxiety at 6-year follow-up, and the proposed mediation by parental rejection. PS and RS showed no cross-sectional or prospective relationships with comorbid behavioral problems in highly anxious CYP. Yet, behavioral problems in adolescence showed a small prospective relationship with anxiety in young adulthood, but this was not mediated nor moderated by parental rejection. No evidence was found for PS/RS being involved in comorbid behavioral problems in anxious CYP. Findings point to comorbid behavioral problems as potential factor contributing to the further increase of anxiety

Research Review: Recommendations for reporting on treatment trials for child and adolescent anxiety disorders - an international consensus statement

Background: Anxiety disorders in children and young people are common and bring significant personal and societal costs. Over the last two decades, there has been a substantial increase in research evaluating psychological and pharmacological treatments for anxiety disorders in children and young people and exciting and novel research has continued as the field strives to improve efficacy and effectiveness, and accessibility of interventions. This increase in research brings potential to draw together data across studies to compare treatment approaches and advance understanding of what works, how, and for whom. There are challenges to these efforts due largely to variation in studies' outcome measures and variation in the way study characteristics are reported, making it difficult to compare and/or combine studies, and this is likely to lead to faulty conclusions. Studies particularly vary in their reliance on child, parent, and/or assessor-based ratings across a range of outcomes, including remission of anxiety diagnosis, symptom reduction, and other domains of functioning (e.g., family relationships, peer relationships). Methods: To address these challenges, we convened a series of international activities that brought together the views of key stakeholders (i.e., researchers, mental health professionals, young people, parents/caregivers) to develop recommendations for outcome measurement to be used in treatment trials for anxiety disorders in children and young people. Results and conclusions: This article reports the results of these activities and offers recommendations for selection and reporting of outcome measures to (a) guide future research and (b) improve communication of what has been measured and reported. We offer these recommendations to promote international consistency in trial reporting and to enable the field to take full advantage of the great opportunities that come from data sharing going forward

Replication Data for: Cognitive-behavior therapy for children and adolescents with anxiety disorders: a meta-analysis of secondary outcomes

Anxiety-focused cognitive-behavioral therapy (CBT) effectively reduces anxiety in children and adolescents. An important remaining question is to what extent anxiety-focused CBT also affects broader outcome domains. Additionally, it remains unclear whether parental involvement in treatment may have impact on domains other than anxiety. A meta-analysis (nstudies=42, nparticipants=3239) of the effects of CBT and the moderating role of parental involvement was conducted on the following major secondary outcomes: depressive symptoms, externalizing behaviors, general functioning, and social competence. Randomized controlled trials were included when having a waitlist or active control condition, a youth sample (aged19) with a primary anxiety disorder diagnosis receiving anxiety-focused CBT and reported secondary outcomes. Controlled effect sizes (Cohen’s d) were calculated employing random effect models. CBT had a large effect on general functioning (-1.25[-1.59;0.90], nstudies=17), a small to moderate effect on depressive symptoms (-0.31[-0.41;-0.22], nstudies=31) and a small effect on externalizing behaviors (-0.23[-0.38;-0.09], nstudies=12) from pre-to post-treatment. Effects remained or even further improved at follow-up. Social competence only improved at follow-up (nstudies = 6). Concluding, anxiety-focused CBT has a positive effect on broader outcome domains than just anxiety. Higher parental involvement seemed to have beneficial effects at follow-up, with improvements in general functioning and comorbid symptoms