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Body-focused repetitive behavior disorders (BFRBs) include Trichotillomania (TTM; Hair pulling disorder) and Excoriation (Skin Picking) Disorder (SPD). These conditions are prevalent, highly heterogeneous, under-researched, and under-treated. In order for progress to be made in optimally classifying and treating these conditions, it is necessary to identify meaningful subtypes. 279 adults (100 with TTM, 81 with SPD, 40 with both TTM and SPD, and 58 controls) were recruited for an international, multi-center between-group comparison using mixture modeling, with stringent correction for multiple comparisons. The main outcome measure was to examine distinct subtypes (aka latent classes) across all study participants using item-level data from gold-standard instruments assessing detailed clinical measures. Mixture models identified 3 subtypes of TTM (entropy 0.98) and 2 subtypes of SPD (entropy 0.99) independent of the control group. Significant differences between these classes were identified on measures of disability, automatic and focused symptoms, perfectionism, trait impulsiveness, and inattention and hyperactivity. These data indicate the existence of three separate subtypes of TTM, and two separate subtypes of SPD, which are distinct from controls. The identified clinical differences between these latent classes may be useful to tailor future treatments by focusing on particular traits. Future work should examine whether these latent subtypes relate to treatment outcomes, or particular psychobiological findings using neuroimaging techniques., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: (1) To describe rates of long-term service use among subjects previously enrolled in a landmark study of youth anxiety disorder treatment and followed into early adulthood; (2) to examine predictors of long-term service use; and (3) to examine the relationship between anxiety diagnosis and service use over time., Method: The Child/Adolescent Anxiety Multimodal Extended Long-term Study prospectively assessed youths treated through the Child/Adolescent Anxiety Multimodal Study at ages 7-17 years into early adulthood. A total of 319 youths (mean age 17.7, 55.2% female) previously randomized to cognitive-behavioral therapy, sertraline, combination, or placebo for the treatment of anxiety participated; 318 had service use data. Four annual clinic assessments were conducted along with telephone check-ins every 6 months., Results: Overall, 65.1% of participants endorsed receiving some form of anxiety treatment over the course of the follow-up period, with more subjects reporting medication use than psychotherapy; 35.2% reported consistent use of services over the course of the study. Overall, service use declined over time in subjects with less severe anxiety but remained more steady in those with recurrent/chronic symptoms. Levels of life stress and depressive symptoms were associated with amount of service use over time whereas treatment-related variables (type of initial intervention, acute response, remission) were not. A subset of youths remained chronically anxious despite consistent service use., Conclusion: These findings point to the need to develop models of care that approach anxiety disorders as chronic health conditions in need of active long-term management., (Copyright © 2020 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Normal developmental activities (eg, going to school, raising a hand in class, and managing typical life uncertainties) are 'triggers' for children and adolescents with anxiety disorders. To cope, children with anxiety avoid; however, when avoidance of developmentally appropriate activities is not possible, catastrophic responses can ensue. If these catastrophic reactions result in successful avoidance, they are likely to recur leading to a generalized pattern of dysregulated behavior. Interventions include treating anxiety disorder symptoms to remission. For parents the goal is to challenge their child to engage in important developmental activities, reward positive coping and avoid reinforcing avoidance behavior., Competing Interests: Disclosure We would like to acknowledge the support of the Pritzker Foundation for their support of Pritzker Department of Psychiatry and Behavioral Health at Lurie Children's Hospital of Chicago. Dr J.T. Walkup has served on the advisory board of the Tourette Syndrome Association, Trichotillomania Learning Center, and Anxiety and Depression Association of America; and has received royalties from Oxford University Press, Guilford Press, and Wolters Kluwer. Dr. Peris receives research support from NIMH, PCORI, and the TLC Foundation for Body Focused Repetitive Behaviors. She also receives royalties from Oxford University Press. Dr. Strawn has received research support from AbbVie, Neuronetics, Lundbeck, Otsuka, PCORI, the National Institutes of Health (NIEHS, NIMH, NICHD) and the Yung Family Foundation. He has provided consultation to Intracellular Therapeutics and the Food and Drug Administration in 2020. He receives royalties from Springer Publishing for two texts and received material support from Myriad. He has also received honoraria from CMEology, Genomind and Neuroscience Educational Institute., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Avoidant behavior is a defining feature of pediatric anxiety disorders. Although prior research has examined it from the perspective of early information processing events, there has been relatively less consideration of the processes by which anxious youth make avoidant decisions and how these choices are reinforced over time. Studies of risk taking are valuable in this regard because they consider how individuals identify the pros and cons of their choices, how they weigh potential gains and losses and estimate their respective probabilities, and how they tolerate the uncertainty intrinsic to any decision. In this review, we place risk taking within existing models of information processing in pediatric anxiety disorders and highlight the particular value of this construct for informing models of developmental psychopathology and individual differences in outcome over time. We review existing behavioral and neurobiological studies of risk taking in anxious youth and conclude by identifying directions for future research., (Copyright © 2020 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Trichotillomania (TTM) is a chronic and impairing psychiatric disorder with suspected dysfunctional cortico-striato-thalamo-cortical (CSTC) circuit activity reflecting excitatory/inhibitory signaling imbalance. TTM neurochemistry is understudied, with no prior research using magnetic resonance spectroscopy (MRS). This pilot investigation examined associations between TTM diagnosis, symptom severity, and response to behavioral treatment with MRS neurometabolites glutamate (Glu) and γ-aminobutyric acid (GABA) in CSTC structures., Methods: Proton echo-planar spectroscopic imaging (PEPSI) MRS was acquired from bilateral pregenual anterior cingulate cortex (pACC), caudate, putamen, globus pallidus, thalamus, and proximal white matter in 10 unmedicated girls with TTM, ages 9-17 years, before and after treatment, and from 13 age- and sex-matched healthy controls., Results: Nine of 10 TTM patients were treatment responders. Pretreatment mean Glu and GABA did not differ significantly between participants and controls. Pretreatment TTM symptoms were correlated with Glu in (left + right) pACC (r = 0.88, p = 0.02) and thalamus (r = 0.82, p = 0.012), and were negatively correlated with pACC GABA (r = -0.84, p = 0.034). Mean GABA in putamen increased 69% (baseline to post-treatment) (p = 0.027). Higher pretreatment Glu in caudate, putamen, globus pallidus, and thalamus predicted greater symptom decreases with treatment (all r < -0.6, p < 0.05); higher caudate GABA predicted less treatment-related symptom decline (r = 0.86, p = 0.014)., Limitations: Small sample, GABA quantified with spectral fitting rather than editing., Conclusion: Consistent with other neuroimaging, MRS reveals discrete CSTC chemical changes with effective behavior therapy, and possibly with TTM etiology. TTM symptoms relate to excess excitatory versus inhibitory signaling in pACC and thalamus; symptom improvement may reflect reduced excitatory drive of the CSTC direct-pathway activity., Competing Interests: Declaration of Competing Interest Dr. Peris receives funding from the National Institutes of Mental Health (NIMH) and the TLC Foundation for Body Focused Repetitive Behavior and royalties from Oxford University Press. Dr. McCracken reports receiving consultant income from Roche, Octapharma, and GW Biosciences; research clinical trial contracts from Roche, Think Now, Inc, and NICHD; and payment for expert witness participation for Lannett Pharmaceuticals. Dr. Piacentini has received grant or research support from NIMH, the TLC Foundation for Body-focused Repetitive Behaviors, the Tourette Association of America, and Pfizer Pharmaceuticals through the Duke University Clinical Research Institute Network. He receives publication royalties from Guilford Press and Oxford University Press. He receives speaking honoraria and/or travel support from the Tourette Association of America, the International Obsessive Compulsive Disorder Foundation, and the TLC Foundation for Body-focused Repetitive Behaviors., (Copyright © 2020. Published by Elsevier B.V.)

Background: Childhood obsessive-compulsive disorder (OCD) is a heterogeneous psychiatric condition, with varied symptom presentations that have been differentially associated with clinical characteristics and treatment response. One OCD symptom cluster of particular interest is religious symptoms, including fears of offending religious figures/objects; patients affected by these symptoms have been characterized as having greater overall OCD severity and poorer treatment response. However, the extant literature primarily examines this symptom subtype within adults, leaving a gap in our understanding of this subtype in youth., Method: Consequently, this study examined whether presence of religious symptoms in OCD-affected children and adolescents (N = 215) was associated with greater clinical impairments across OCD symptoms and severity, insight, other psychiatric comorbidity, family variables, or worse treatment response., Results: Results found that youth with religious OCD symptoms presented with higher OCD symptom severity and exhibited more symptoms in the aggressive, sexual, somatic, and checking symptom cluster, as well as the symmetry, ordering, counting, and repeating cluster. Religious OCD symptoms were also significantly associated with poorer insight and higher family expressiveness. No differences in treatment response were observed in youths with versus without religious OCD symptoms., Conclusion: Ultimately, youths with religious OCD symptoms only differed from their OCD-affected counterparts without religious symptoms on a minority of clinical variables; this suggests they may be more comparable to youths without religious OCD symptoms than would be expected based on the adult OCD literature and highlights the importance of examining these symptoms within a pediatric OCD sample., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Exposure tasks are recognized widely as a key component of cognitive-behavioral therapy (CBT) for child and adolescent anxiety. However, little research has examined specific exposure characteristics that predict outcomes for youth with anxiety and that may guide its application in therapy., Method: This study draws on a sample of 279 children and adolescents (48.4% male; 79.6% white) with a principal anxiety disorder who received 14 sessions of CBT, either alone or in combination with medication, through the Child/adolescent Anxiety Multimodal treatment Study (CAMS). The present study examines therapist-reported quantity, difficulty level, compliance, and mastery of exposure tasks as they related to CBT response (i.e., Clinical Global Impressions-Improvement ratings). Secondary treatment outcomes included reduction in anxiety symptom severity on the Pediatric Anxiety Rating Scale, global impairment measured via the Children's Global Assessment Scale, and parent-report of anxiety-specific functional impairment on the Child Anxiety Impairment Scale., Results: Regression analyses indicated a dose-response relationship between therapist-reported quantity of exposure and independent evaluations of treatment outcome, with more time devoted to exposure linked to better outcomes. Similarly, greater time spent on more difficult (rather than mild or moderate) exposure tasks predicted better outcomes, as did therapist ratings of child compliance and mastery., Conclusion: The present findings highlight the importance of challenging children and adolescents with difficult exposure tasks and of collaborating to ensure compliance and mastery., (Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: To date, few studies of childhood obsessive compulsive disorder (OCD) have been adequately powered to examine patterns and predictors of comorbidity, despite the frequency with which it occurs. We address this gap, drawing on a large sample of youth with OCD who were systematically assessed through research and clinical programs in a university-based specialty program for children and adolescents with OCD. We examine patterns of comorbidity across different epochs of development and predict specific classes of OCD (comorbidity internalizing/externalizing/both) from key demographic and clinical variables that may be useful in guiding individualized treatment., Method: A total of 322 youths (mean age = 12.28, 53% male) were assessed using the Anxiety Disorders Interview Schedule (ADIS; Silverman and Albano, 1996), the Children's Yale Brown Obsessive Compulsive Scale (CYBOCS; Scahill et al., 1997) and other standardized measures., Results: Consistent with prior research, 50% of youth met criteria for a co-occurring anxiety or depressive disorder. Rates of externalizing disorders were lower (16%). Developmental differences emerged such that older youth met criteria for a higher number of co-occurring disorders. As expected, adolescents in particular were more likely to have a co-occurring internalizing disorder compared to early or pre-adolescent peers. Surprisingly, they were also more likely to have a comorbid externalizing disorder. Developmental trends were particularly striking with respect to depression, with adolescents with OCD demonstrating a six-fold greater likelihood of co-occurring depressive disorder compared to younger counterparts., Discussion: Clinical implications are discussed with eye toward tailoring interventions, particularly during the transition to adolescence when youth are at heightened risk for depression., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To evaluate changes in the trajectory of youth anxiety following the introduction of specific cognitive-behavior therapy (CBT) components: relaxation training, cognitive restructuring, and exposure tasks., Method: Four hundred eighty-eight youths ages 7-17 years (50% female; 74% ≤ 12 years) were randomly assigned to receive either CBT, sertraline (SRT), their combination (COMB), or pill placebo (PBO) as part of their participation in the Child/Adolescent Anxiety Multimodal Study (CAMS). Youths in the CBT conditions were evaluated weekly by therapists using the Clinical Global Impression Scale-Severity (CGI-S; Guy, 1976) and the Children's Global Assessment Scale (CGAS; Shaffer et al., 1983) and every 4 weeks by blind independent evaluators (IEs) using the Pediatric Anxiety Ratings Scale (PARS; RUPP Anxiety Study Group, 2002). Youths in SRT and PBO were included as controls., Results: Longitudinal discontinuity analyses indicated that the introduction of both cognitive restructuring (e.g., changing self-talk) and exposure tasks significantly accelerated the rate of progress on measures of symptom severity and global functioning moving forward in treatment; the introduction of relaxation training had limited impact. Counter to expectations, no strategy altered the rate of progress in the specific domain of anxiety that it was intended to target (i.e., somatic symptoms, anxious self-talk, avoidance behavior)., Conclusions: Findings support CBT theory and suggest that cognitive restructuring and exposure tasks each make substantial contributions to improvement in youth anxiety. Implications for future research are discussed. (PsycINFO Database Record, ((c) 2015 APA, all rights reserved).)

The aim of this investigation was to evaluate how parental anxiety predicted change in pediatric anxiety symptoms across four different interventions: cognitive-behavioral therapy, medication (sertraline; SRT), their combination (COMB), and pill placebo. Participants were 488 youths (ages 7-17) with separation anxiety disorder, generalized anxiety disorder, and/or social phobia and their primary caregivers. Latent growth curve modeling assessed how pre-treatment parental trait anxiety symptoms predicted trajectories of youth anxiety symptom change across 12 weeks of treatment at four time points. Interactions between parental anxiety and treatment condition were tested. Parental anxiety was not associated with youth's pre-treatment anxiety symptom severity. Controlling for parental trait anxiety, youth depressive symptoms, and youth age, youths who received COMB benefitted most. Counter to expectations, parental anxiety influenced youth anxiety symptom trajectory only within the SRT condition, whereas parental anxiety was not significantly associated with youth anxiety trajectories in the other treatment conditions. Specifically, within the SRT condition, higher levels of parental anxiety predicted a faster and greater reduction in youth anxiety over the acute treatment period compared to youths in the SRT condition whose parents had lower anxiety levels. While all active treatments produced favorable outcomes, results provide insight regarding the treatment-specific influence of parental anxiety on the time course of symptom change.

Objective: We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS)., Method: Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures., Results: Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I)., Discussion: Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.

Background: Although interpretation biases are well documented among youth with anxiety disorders, understanding of their neural correlates is limited. In particular, there has been little study of how anxious youth neurobiologically represent changing contextual cues that may trigger anxiety. This study examined neural responses during a task in which participants viewed neutral faces paired with experimentally manipulated contextual stimuli., Methods: Participants (16 youth with a primary anxiety disorder diagnosis and 15 age- and gender-matched controls) passively viewed neutral faces that were paired with either neutral descriptive vignettes or with vignettes that were potentially anxiety provoking (for example, those that involved performance/social evaluation)., Results: The two groups were differentiated by their medial prefrontal cortex (mPFC) responses, such that context modulated mPFC activation in anxious youth while non-anxious youth demonstrated no such differentiation. Counter to expectations, the performance/evaluation frames were not associated with amygdala reactivity for either group., Conclusions: The present investigation is among the first to identify how context modulates mPFC responding to neutral stimuli among anxious youth. It takes an important step toward understanding the neurobiological correlates underlying interpretation biases of neutral stimuli in this population.