Threat interpretation in anxious children and their mothers: comparison with nonclinical children and the effects of treatment

Interpretation biases towards threat play a prominent role in cognitive theories of anxiety, and have been identified amongst highly anxious adults and children. Little is known, however, about the development of these cognitive biases although family processes have been implicated. The current study investigated the nature of threat interpretation of anxious children and their mothers through (i) comparison of a clinic and non-clinic population, (ii) analysis of individual differences; and (ill) pre- and post-treatment comparisons. Participants were 27 children with a primary anxiety disorder and 33 children from a non-clinic population and their mothers. Children and mothers completed self-report measures of anxiety and indicated their most likely interpretation of ambiguous scenarios. Clinic and non-clinical groups differed significantly on measures of threat interpretation. Furthermore, mothers' and children's threat interpretation correlated significantly. Following treatment for child anxiety, both children and their mothers reported a reduction in threat interpretation. (c) 2005 Elsevier Ltd. All rights reserved.

A randomised controlled trial of cognitive behavioural treatment for obsessive compulsive disorder in children and adolescents

Cognitive behaviour therapy (CBT) for young people with obsessive compulsive disorder (OCD) has become the treatment of first choice. However, the literature is largely based on studies emphasising exposure and response prevention. In this study, we report on a randomised controlled trial of CBT for young people carried out in typical outpatient clinic conditions which focused on cognitions. A randomised controlled trial compares 10 sessions of manualised cognitive behavioural treatment with a 12-week waiting list for adolescents and children with OCD. Assessors were blind to treatment allocation. 21 consecutive patients with OCD aged between 9 and 18 years were recruited. The group who received treatment improved more than a comparison group who waited for 3 months. The second group was treated subsequently using the same protocol and made similar gains. In conclusion, CBT can be delivered effectively to young people with OCD in typical outpatient settings.

Early identification of stimulant treatment responders, partial responders and non-responders using objective measures in children and adolescents with hyperkinetic disorder

Background: The aim of this study was to evaluate stimulant medication response following a single dose of methylphenidate (MPH) in children and young people with hyperkinetic disorder using infrared motion analysis combined with a continuous performance task (QbTest system) as objective measures. The hypothesis was put forward that a moderate testdose of stimulant medication could determine a robust treatment response, partial response and non-response in relation to activity, attention and impulse control measures. Methods: The study included 44 children and young people between the ages of 7-18 years with a diagnosis of hyperkinetic disorder (F90 & F90.1). A single dose-protocol incorporated the time course effects of both immediate release MPH and extended release MPH (Concerta XL, Equasym XL) to determine comparable peak efficacy periods post intake. Results: A robust treatment response with objective measures reverting to the population mean was found in 37 participants (84%). Three participants (7%) demonstrated a partial response to MPH and four participants (9%) were determined as non-responders due to deteriorating activity measures together with no improvements in attention and impulse control measures. Conclusion: Objective measures provide early into prescribing the opportunity to measure treatment response and monitor adverse reactions to stimulant medication. Most treatment responders demonstrated an effective response to MPH on a moderate testdose facilitating a swift and more optimal titration process.

Children and adolescents referred for treatment of anxiety disorders: differences in clinical characteristics

Background: Reports of the clinical characteristics of children and adolescents with anxiety disorders are typically based on community populations or from clinical samples with exclusion criterion applied. Little is known about the clinical characteristics of children and adolescents routinely referred for treatment for anxiety disorders. Furthermore, children and adolescents are typically treated as one homogeneous group although they may differ in ways that are clinically meaningful. Methods: A consecutive series of children (n = 100, aged 6-12 years) and adolescents (n = 100, aged 13-18 years), referred to a routine clinical service, were assessed for anxiety and comorbid disorders, school refusal and parental symptoms of psychopathology. Results: Children were significantly more likely to be diagnosed with separation anxiety disorder than adolescents. Adolescents with a primary anxiety disorder had significantly higher self and clinician rated anxiety symptoms and had more frequent primary diagnoses of social anxiety disorder, diagnoses and symptoms of mood disorders, and irregular school attendance. Limitations: Childhood and adolescence were considered categorically as distinct, developmental periods; in reality changes would be unlikely to occur in such a discrete manner. Conclusions: The finding that children and adolescents with anxiety disorders have distinct clinical characteristics has clear implications for treatment. Simply adapting treatments designed for children to make the materials more ‘adolescent-friendly’ is unlikely to sufficiently meet the needs of adolescents.

Children’s physic: medical perceptions and treatment of sick children in early modern England, c. 1580-1720

Historians of medicine, childhood, and paediatrics, have often assumed that early modern doctors neither treated children, nor adapted their medicines to suit the peculiar temperaments of the young. Through an examination of medical textbooks and doctors’ casebooks, this article refutes these assumptions. It argues that medical authors and practising doctors regularly treated children, and were careful to tailor their remedies to complement the distinctive constitutions of children. Thus, this article proposes that a concept of ‘children’s physic’ existed in early modern England: this term refers to the notion that children were physiologically distinct, requiring special medical care. Children’s physic was rooted in the ancient traditions of Hippocratic and Galenic medicine: it was the child’s humoral makeup that underpinned all medical ideas about children’s bodies, minds, diseases, and treatments. Children abounded in the humour blood, which made them humid and weak, and in need of medicines of a particularly gentle nature.

Multi-sensory treatment for children with developmental motor speech disorders

What this paper adds? What is already known on the subject? Multi-sensory treatment approaches have been shown to impact outcome measures positively, such as accuracy of speech movement patterns and speech intelligibility in adults with motor speech disorders, as well as in children with apraxia of speech, autism and cerebral palsy. However, there has been no empirical study using multi-sensory treatment for children with speech sound disorders (SSDs) who demonstrate motor control issues in the jaw and orofacial structures (e.g. jaw sliding, jaw over extension, inadequate lip rounding/retraction and decreased integration of speech movements). What this paper adds? Findings from this study indicate that, for speech production disorders where both the planning and production of spatiotemporal parameters of movement sequences for speech are disrupted, multi-sensory treatment programmes that integrate auditory, visual and tactile–kinesthetic information improve auditory and visual accuracy of speech production. The training (practised in treatment) and test words (not practised in treatment) both demonstrated positive change in most participants, indicating generalization of target features to untrained words. It is inferred that treatment that focuses on integrating multi-sensory information and normalizing parameters of speech movements is an effective method for treating children with SSDs who demonstrate speech motor control issues.

Hypo-accommodation responses in hypermetropic infants and children

Aims: Accommodation to overcome hypermetropia is implicated in emmetropisation. This study recorded accommodation responses in a wide range of emmetropising infants and older children with clinically significant hypermetropia to assess common characteristics and differences. Methods: A PlusoptiXSO4 photorefractor in a laboratory setting was used to collect binocular accommodation data from participants viewing a detailed picture target moving between 33cm and 2m. 38 typically developing infants were studied between 6-26 weeks of age and were compared with cross-sectional data from children 5-9 years of age with clinically significant hypermetropia (n=15), corrected fully accommodative strabismus (n=14) and 27 age-matched controls. Results: Hypermetropes of all ages under-accommodated compared to controls at all distances, whether corrected or not (p<0.00001) and lag related to manifest refraction. Emmetropising infants under-accommodated most in the distance, while the hypermetropic patient groups underaccommodated most for near. Conclusions: Better accommodation for near than distance is demonstrated in those hypermetropic children who go on to emmetropise. This supports the approach of avoiding refractive correction in such children. In contrast, hypermetropic children referred for treatment for reduced distance visual acuity are not likely to habitually accommodate to overcome residual hypermetropia left by an under-correction.

Self-, parent-report and interview measures of obsessive-compulsive disorder in children and adolescents

Self-report measures of obsessive-compulsive disorder (OCD) in children and adolescents are needed for practical evaluation of severity and treatment response. We compared the self- and parent-report Obsessional Compulsive Inventory Revised (CHOCI-R) to the interview-based Child Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in a clinical sample of 285 children and adolescents with OCD. Classical test theory and item-response theory were applied to compare the instruments. The self- and parent-report CHOCI-R had good internal consistency and were strongly related to each other. The self- and parent-report CHOCI-R severity scores correlated with the CY-BOCS (Pearson's r 0.55 and 0.45 respectively). The CY-BOCS discriminated better at the severe end of the spectrum. The CHOCI-R provided better discrimination in the mild to moderate range. The time-efficient self- and parent-report alternatives will enable routine measurement of OCD severity in clinical practice. Estimates of equivalent summed scores are provided to facilitate comparison. (c) 2007 Elsevier Ltd. All rights reserved.

Theory of mind in children with traumatic brain injury

Objective: This study was designed to examine the existence of deficits in mentalizing or theory of mind (ToM) in children with traumatic brain injury (TBI). Research design: ToM functioning was assessed in 12 children aged 6-12 years with TBI and documented frontal lobe damage and compared to 12 controls matched for age, sex and verbal ability. Brief measures of attention and memory were also included. Main outcome and results: The TBI group was significantly impaired relative to controls on the advanced ToM measure and a measure of basic emotion recognition. No difference was found in a basic measure of ToM. Conclusion: Traumatic brain damage in childhood may disrupt the developmental acquisition of emotion recognition and advanced ToM skills. The clinical and theoretical importance of these findings is discussed and the implications for the assessment and treatment of children who have experienced TBI are outlined.

Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression 2. Impact on the mother-child relationship and child outcome

Background: Postnatal depression is associated with adverse child cognitive and socio-emotional outcome. It is not known whether psychological treatment affects the quality of the mother-child relationship and child outcome. Aims: To evaluate the effect of three psychological treatments on the mother-child relationship and child outcome. Method: Women with post-partum depression (n=193) were assigned randomly to routine primary care, non-directive counselling, cognitive-behavioural therapy or psychodynamic therapy The women and their children, were assessed at 43, [8 and 60 months post-partum. Results: Indications of a positive benefit were limited. All three treatments had a significant benefit on maternal reports of early difficulties in relationships with the infants, counselling gave better infant emotional and behaviour ratings at 18 months and more sensitive early mother-infant interactions. The treatments had no significant impact on maternal management of early infant behaviour problems, security of infant-mother attachment. Infant cognitive development or any child outcome at 5 years. Conclusions: Early intervention was of short-term benefit to the mother-child relationship and infant behaviour problems. More-prolonged intervention may be needed. Health visitors could deliver this.

Future directions for child anxiety theory and treatment

The aim of this introductory paper, and of this special issue of Cognition and Emotion, is to stimulate debate about theoretical issues that will inform child anxiety research in the coming years. Papers included in this special issue have arisen from an Economic and Social Research Council (ESRC, UK) funded seminar series, which we called Child Anxiety Theory and Treatment (CATTS). We begin with an overview of the CATTS project before discussing (1) the application of adult models of anxiety to children, and (2) the role of parents in child anxiety. We explore the utility of adult models of anxiety for child populations before discussing the problems that are associated with employing them uncritically in this context. The study of anxiety in children provides the opportunity to observe the trajectory of anxiety and to identify variables that causally influence its development. Parental influences are of particular interest and new and imaginative strategies are required to isolate the complex network of causal relationships therein. We conclude by suggesting that research into the causes and developmental course of anxiety in children should be developed further. We also propose that, although much is known about the role of parents in the development of anxiety, it would be useful for research in this area to move towards an examination of the specific processes involved. We hope that these views represent a constructive agenda for people in the field to consider when planning future research.

A systematic review of the routine monitoring of growth in children of primary school age to identify growth-related conditions

Objectives: To clarify the role of growth monitoring in primary school children, including obesity, and to examine issues that might impact on the effectiveness and cost-effectiveness of such programmes. Data sources: Electronic databases were searched up to July 2005. Experts in the field were also consulted. Review methods: Data extraction and quality assessment were performed on studies meeting the review's inclusion criteria. The performance of growth monitoring to detect disorders of stature and obesity was evaluated against National Screening Committee (NSC) criteria. Results: In the 31 studies that were included in the review, there were no controlled trials of the impact of growth monitoring and no studies of the diagnostic accuracy of different methods for growth monitoring. Analysis of the studies that presented a 'diagnostic yield' of growth monitoring suggested that one-off screening might identify between 1: 545 and 1: 1793 new cases of potentially treatable conditions. Economic modelling suggested that growth monitoring is associated with health improvements [ incremental cost per quality-adjusted life-year (QALY) of pound 9500] and indicated that monitoring was cost-effective 100% of the time over the given probability distributions for a willingness to pay threshold of pound 30,000 per QALY. Studies of obesity focused on the performance of body mass index against measures of body fat. A number of issues relating to human resources required for growth monitoring were identified, but data on attitudes to growth monitoring were extremely sparse. Preliminary findings from economic modelling suggested that primary prevention may be the most cost-effective approach to obesity management, but the model incorporated a great deal of uncertainty. Conclusions: This review has indicated the potential utility and cost-effectiveness of growth monitoring in terms of increased detection of stature-related disorders. It has also pointed strongly to the need for further research. Growth monitoring does not currently meet all NSC criteria. However, it is questionable whether some of these criteria can be meaningfully applied to growth monitoring given that short stature is not a disease in itself, but is used as a marker for a range of pathologies and as an indicator of general health status. Identification of effective interventions for the treatment of obesity is likely to be considered a prerequisite to any move from monitoring to a screening programme designed to identify individual overweight and obese children. Similarly, further long-term studies of the predictors of obesity-related co-morbidities in adulthood are warranted. A cluster randomised trial comparing growth monitoring strategies with no growth monitoring in the general population would most reliably determine the clinical effectiveness of growth monitoring. Studies of diagnostic accuracy, alongside evidence of effective treatment strategies, could provide an alternative approach. In this context, careful consideration would need to be given to target conditions and intervention thresholds. Diagnostic accuracy studies would require long-term follow-up of both short and normal children to determine sensitivity and specificity of growth monitoring.

Treatment of child anxiety. an exploratory study of the role of maternal anxiety and behaviours in treatment outcome

Anxiety disorders are common among parents of anxious children and have been found to impede child treatment outcomes, yet it is unclear whether it is parental anxiety that needs to be targeted in therapy or associated parental behaviours. Twenty-two children (6-12 years) with a current anxiety disorder and their mothers received cognitive-behavioural treatment (CBT) for child anxiety. In addition, of the 12 mothers who met criteria for a current anxiety disorder, 6 received CBT for their own disorder. Assessments were made of the mother-child interaction. The main findings were: (1) children did less well from treatment where their mothers had a current anxiety disorder; (2) treatment of maternal anxiety disorder did not improve child treatment outcome; and (3) maternal overinvolvement and expression of fear was associated with child treatment outcome. The results suggest that in the context of maternal anxiety disorder, child treatment outcome may be improved by specifically targeting parenting behaviours. Copyright (C) 2008 John Wiley & Sons, Ltd.

Family treatment of child anxiety: outcomes, limitations and future directions

Anxiety of childhood is a common and serious condition. The past decade has seen an increase in treatment-focussed research, with recent trials tending to give greater attention to parents in the treatment process. This review examines the efficacy of family-based cognitive behaviour therapy and attempts to delineate some of the factors that might have an impact on its efficacy. The choice and timing of outcome measure, age and gender of the child, level of parental anxiety, severity and type of child anxiety and treatment format and content are scrutinised. The main conclusions are necessarily tentative, but it seems likely that Family Cognitive Behaviour Therapy (FCBT) is superior to no treatment, and, for some outcome measures, also superior to Child Cognitive Behaviour Therapy (CCBT). Where FCBT is successful, the results are consistently maintained at follow-up. It appears that where a parent is anxious, and this is not addressed, outcomes are less good. However, for children of anxious parents, FCBT is probably more effective than CCBT. What is most clear is that large, well-designed studies, examining these factors alone and in combination, are now needed.

Treatment response in child anxiety is differentially related to the form of maternal anxiety disorder

An examination was made of the extent to which maternal anxiety predicted response to treatment of children presenting with an anxiety disorder. In a sample of 55 children referred to a local NHS CAMH service for treatment of an anxiety disorder, systematic mental state interview assessment was made of both mothers and children, and both completed self-report questionnaires to assess aspects of anxiety, both immediately before the children received treatment and following treatment. Children of mothers with anxiety disorder overall responded less well to treatment than children of mothers with no anxiety disorder. There was some diagnostic specificity in this in that children of mothers with GAD did as well in treatment as children whose mothers had no anxiety, whereas children of mothers with social phobia did poorly. The outcome for children with anxiety appears to be related to the presence and nature of maternal anxiety. It would seem prudent that treatment of children with anxiety involves assessment of maternal anxiety. It is important to establish in systematic investigation whether treatment of maternal anxiety improves the outcome for child anxiety.