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Interpretation bias, or the threatening appraisal of ambiguous information, has been linked to anxiety disorder. Interpretation bias has been demonstrated for linguistic (e.g., evaluation of ambiguous sentences) and visual judgments (e.g., categorizing emotionally ambiguous facial expressions). It is unclear how these separate components of bias might be associated. We examined linguistic and visual interpretation biases in youth and emerging adults with (n = 44) and without (n = 40) anxiety disorder, and in youth-parent dyads (n = 40). Linguistic and visual biases were correlated with each other, and with anxiety. Compared to non-anxious participants, those with anxiety demonstrated stronger biases, and linguistic bias was especially predictive of anxiety symptoms and diagnosis. Age did not moderate these relationships. Parent linguistic bias was correlated with youth anxiety but not linguistic bias; parent and youth visual biases were correlated. Linguistic and visual interpretation biases are linked in clinically-anxious youth and emerging adults., Competing Interests: Declaration of Competing Interest Dr. Rozenman has received funding from the National Institute of Mental Health and the American Psychological Foundation in the last three years to conduct work unrelated to this research. Dr. Rozenman also receives royalties from Oxford University Press for two treatment books unrelated to the current research. Dr. Sweeny has received funding from the National Science Foundation and National Institute of Child Health & Human Development for research unrelated to the current work. Other authors have no declaration of interest., (Copyright © 2024. Published by Elsevier Ltd.)

The burden of OCD in children and adolescents extends to their caregivers. Prior work in other disorders and unaffected youth has found synchrony in psychophysiological arousal for youth-caregiver dyads. This preliminary study explored whether psychophysiological trend synchrony in youth-caregiver dyads (N = 48) occurred and was moderated by youth OCD diagnosis. We also explored whether psychophysiological indices (i.e., electrodermal activity, heart rate, respiratory sinus arrhythmia) were correlated with reported family functioning in the OCD subsample (n = 25). Youth with OCD had higher resting heart rate than unaffected peers; this was not replicated in caregivers. Trend synchrony was found across the full sample of dyads for electrodermal activity and heart rate, with no moderation by diagnostic group. In the OCD group, youth heart rate was correlated with family conflict and caregiver heart rate with expressiveness. Findings provide preliminary support for further examination of heart rate and family factors in OCD-affected youth and their caregivers., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective : This preliminary study examined the interactive influences of interpretation bias and emotion dysregulation in predicting autonomic stress response. Methods : Participants ( N  = 72 college students; ages 18-25, 70% female, 47% Hispanic/Latinx), completed a performance-based assessment of threat interpretation bias and self-report measures of emotion regulation difficulties. Electrodermal activity (EDA; skin conductance level) was collected while participants completed a standardized psychosocial stressor task. Results : Interpretation bias and emotion regulation difficulties interacted to predict EDA trajectories ( β  = 0.054, SE = .001, CI:.007, .002, p  < .001) during acute stress: presence of either interpretation bias toward threat ( β  = 6.950, SE = 2.826, CI: 1.407, 12.488, p  = .013) or emotion regulation difficulties ( β  = 9.387, SE = 3.685, CI: 2.141, 16.636, p  = .011) was associated with greater reactivity and poorer recovery; presence of both was associated with the lowest resting state EDA and blunted reactivity ( β  = 1.340, SE = 3.085, CI: -4.721, 7.407, p  = .66). Conclusions : Preliminary findings support interpretation bias and emotion regulation difficulties, and their distinct interactive patterns, as predictors of autonomic reactivity trajectories during stress. Interpretation bias modification and emotion regulation skills may be important intervention targets for common psychological conditions that are influenced by aberrant psychophysiological processes.

By adolescence, two-thirds of youth report exposure to at least one traumatic event, yet the impact of trauma history is not routinely considered when evaluating the effect of psychotherapeutic interventions. Trauma may be a particularly important moderator of the effects of transdiagnostic therapies for emotional disorders, as trauma exposure is associated with risk for the development of comorbid depression and anxiety. The current study examined the history of trauma exposure and the presence of clinically significant depression as moderators of treatment outcomes in the Brief Behavioral Therapy (BBT) trial, the largest study of transdiagnostic psychotherapy for youth. Youths (age 8-16 years) were randomized to BBT (n = 89) based in pediatric primary care or assisted referral to outpatient community care (ARC; n = 86). Clinical response, functioning, anxiety symptoms, and depression symptoms were assessed at post-treatment (Week 16) and at follow-up (Week 32). A significant three-way interaction emerged between the treatment group, comorbid depression, and trauma exposure. BBT was broadly effective for 3/4 of the sample, but, for anxious-depressed youth with trauma exposure, BBT never significantly separated from ARC. Differences in outcome were not accounted for by other participant characteristics or by therapist-rated measures of alliance, youth engagement, or homework completion. Implications for models of learning and for intervention theory and development are discussed., (© 2024. The Author(s).)

Social anxiety symptoms are one of the most common mental health concerns across the lifespan (Bandelow and Michaelis in Dialogues Clin Neurosci 17(3):327-335, 2015. https://doi.org/10.31887/DCNS.2015.17.3/bbandelow ) and are especially relevant during emerging adulthood, when social feedback occurs daily (Auxier and Anderson in Social media use in 2021, 2021. https://www.pewresearch.org/internet/2021/04/07/social-media-use-in-2021/ ) as emerging adults navigate new social environments. Two cognitive processes have been identified as relevant to social anxiety: high threat interpretation bias (i.e., the tendency to appraise threat from ambiguity; Rozenman et al. in Behav Ther 45(5):594-605, 2014. https://doi.org/10.1016/j.beth.2014.03.009 ; J Anxiety Disord 45:34-42, 2017. https://doi.org/10.1016/j.janxdis.2016.11.004 ) is associated with high social anxiety, whereas high perceived social support is associated with low social anxiety. In this study, emerging adults (N = 303) completed an online adaptation of the Chatroom task (Guyer et al. in Arch Gener Psychiatry 65(11):1303-1312, 2008. https://doi.org/10.1001/archpsyc.65.11.1303 ), an experimental paradigm designed to simulate social acceptance and rejection, as well as a performance-based measure of interpretation bias (Word Sentence Association Paradigm; Beard and Amir in Behav Res Ther 46(10):1135-1141, 2008. https://doi.org/10.1016/j.brat.2008.05.012 ), and a self-report measure of perceived social support (Multidimensional Scale of Perceived Social Support; Zimet et al. in J Pers Assess 52(1), 30-41, 1988. https://doi.org/10.1207/s15327752jpa5201&#95;2 ). Social anxiety symptoms did not increase as a function of acceptance or rejection during the Chatroom task. However, there were significant interactions between each cognitive predictor and social anxiety change: emerging adults with low interpretation bias towards threat and emerging adults with high perceived social support both experienced decreases in social anxiety from pre- to post-Chatroom task, regardless of whether they were accepted or rejected during the Chatroom task. If replicated, low interpretation bias and high perceived social support may serve as promotive factors in social interactions for emerging adults., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Pediatric anxiety and depression are prevalent, impairing, and highly comorbid. Available evidence-based treatments have an average response rate of 60%. One path to increasing response may be to identify likely non-responders midway through treatment to adjust course prior to completing an episode of care. The aims of this study, thus, were to identify predictors of post-intervention response assessing (a) mid-treatment symptom severity, (b) session-by-session treatment process factors, and (c) a model optimizing the combination of these., Method: Data were drawn from the treatment arm (N = 95, ages 8-16) of a randomized transdiagnostic intervention trial (M sessions  = 11.2). Mid-point measures of youth- and parent-reported anxiety and depression were collected, and therapists rated homework completion, youth and parent engagement, and youth therapeutic alliance at each session. Logistic regression was used to predict response on the Clinical Global Impression Improvement Scale (CGI-I ≤2) rated by independent evaluators masked to treatment condition., Results: Mid-point symptom measures were significant predictors of treatment response, as were therapist-ratings of youth and parent engagement, therapeutic alliance, and homework completion. Therapist ratings were significant when tested as mean ratings summing across the first eight sessions of treatment (all ps < .004) and at individual session points (all ps <0.05). A combined prediction model included youth-reported anxiety, parent-reported depression, youth engagement at Session 2, and parent engagement at Session 8. This model correctly classified 76.5% of youth as non-responders and 91.3% as responders at post-treatment (Nagelkerke R 2  = .59, χ 2 (4, 80) = 46.54, p < .001)., Conclusion: This study provides initial evidence that response to transdiagnostic intervention for pediatric anxiety and depression may be reliably predicted by mid-point. These data may serve as foundational evidence to develop adaptive treatment strategies to personalize intervention, correct treatment course, and optimize outcomes for youth with anxiety and depression., (© 2023 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Attention bias confers risk for anxiety development, however, the influence of sociodemographic variables on the relationship between attention bias and anxiety remains unclear. We examined the association between attention bias and anxiety among rural Latinx youth and investigated potential moderators of this relationship. Clinical symptoms, demographic characteristics, and a performance-based measure of attention bias were collected from 66 rural Latinx youth with clinical levels of anxiety (33.3% female; M age  = 11.74; 92.4% Latinx, 7.6% Mixed Latinx). No moderating effects for age or gender were found. Youth below the poverty line displayed an attention bias away from threat in comparison to youth above the poverty line, who displayed an attention bias towards threat. Among youth below the poverty line, this bias away from threat was associated with increased anxiety. Findings highlight the importance of economic adversity in understanding the relationship between attention bias and anxiety., (© 2023. The Author(s).)

This study examined whether domain-general cognitive weaknesses in processing speed (PS) or executive functioning (EF) moderate the relation between word reading scores and anxiety such that lower word reading scores in combination with lower cognitive scores are associated with higher anxiety symptoms. The sample consisted of 755 youth ages 8-16 who were recruited as part of the Colorado Learning Disabilities Research Center twins study. Lower scores on PS ( R 2 = .007, p = .014), EF ( R 2 = .009, p = .006), and word reading ( R 2 = .006-.008, p = .010-.032) were associated with higher anxiety scores. In addition, the word reading × cognitive interactions were significant such that lower scores on PS ( R 2 = .010, p = .005) or EF ( R 2 = .013, p = .010) combined with lower word reading were associated with higher-than-expected anxiety symptoms. Results suggest that weaknesses in PS, EF, and word reading are modestly associated with higher anxiety symptoms, and these anxiety symptoms may be compounded in youth with both PS or EF weaknesses and word reading difficulties. These findings can guide assessment approaches for identifying youth with word reading challenges who may be at increased risk for anxiety.

Brief behavioral therapy (BBT) is an efficacious transdiagnostic intervention for pediatric anxiety and depression that targets behavioral avoidance as a key mechanism. It is unknown if change in avoidance mediates treatment effects, as theorized. Data on avoidance at baseline and Week 16 were available on 52 youth (ages 8-16 years) from a randomized controlled trial (Weersing, Jeffreys, et al., 2017) comparing BBT and assisted referral to community care (ARC). BBT had significant effects on youth-reported behavioral avoidance, and significant indirect effects on functioning and anxiety, statistically mediated through changes in youth-reported behavioral avoidance. Change in youth-reported avoidance was not a significant mediator of depression. Parent-report of avoidance was not impacted by treatment and was not a significant mediator. Overall, BBT appears to be an effective treatment for targeting behavioral avoidance, which in turn, may improve functioning and lessen anxiety. CLINICAL TRIAL REGISTRATION INFORMATION: https://clinicaltrials.gov; NCT01147614., Competing Interests: Declaration of competing interest Drs. Weersing, Rozenman, and Gonzalez may receive royalties from Oxford University Press related to the Brief Behavioral Therapy treatment manual. No additional competing interests are reported by the authors., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Sleep problems are common in children with Tourette Syndrome (TS). However, research regarding their demographic and clinical profile is limited., Methods: We examined characteristics of 114 children aged five to 17 years with a lifetime diagnosis of TS and compared children with sleep disorder (n = 32) and without sleep disorder (n = 82). Parent report from the 2014 National Survey of the Diagnosis and Treatment of ADHD and Tourette Syndrome provided demographics and clinical information, other diagnosed disorders, medication use, TS severity, and impairment., Results: More children with TS with sleep disorder were from households with lower parental education (P < 0.01) and poverty (P = 0.04); had other diagnoses (P = 0.03), including obsessive-compulsive disorder (P < 0.01), oppositional defiant disorder or conduct disorder (P < 0.01), attention-deficit/hyperactivity disorder (ADHD) (P = 0.02), and autism (P = 0.03); and had ever used TS medication (P = 0.01) than children with TS without sleep disorder. More children with TS with sleep disorder had severe TS symptoms (P <0.01), tic-related impairment (P<0.01), and severe ADHD symptoms (P < 0.01) compared with children with TS without sleep disorder., Conclusions: Findings suggest greater parent-reported impact and tic-related interference in children with TS with sleep disorder compared with TS without sleep disorder. Results underscore the importance of monitoring and intervention for TS exacerbations, other diagnosed disorders, and medication use, and consideration of socioeconomic context in sleep disorder management and prevention in children with TS., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To report on broad-based outcomes of the Brief Behavioral Therapy (BBT) trial for pediatric anxiety and depression. Secondary data analyses expand on previous reports by assessing diagnostic remission and independent functioning, impact on targeted psychopathology, and spillover effects on non-targeted outcomes., Method: Youth (N = 185; 8-16.9 years; 58% female; 78% White; 21% Hispanic) with anxiety and/or depression were eligible for this multi-site trial. Enrolled youth were randomly assigned to receive 8 to 12 sessions of BBT in primary care or assisted referral to outpatient care (ARC). Assessments were conducted 16 and 32 weeks post randomization., Results: BBT was superior to ARC on remission of all targeted diagnoses (week 16: 56.8% vs 28.2%, p < .001; week 32: 62.5% vs 38.9%, p = .004), clinician-rated independent functioning (week 16: 75.0% vs 45.7%, p < .001; week 32: 81.2% vs 55.7%, p < .001), and on measures of anxiety, depression, suicide items, total comorbid behavioral and emotional problems, and hyperactivity (d = 0.21-0.49). Moderation analyses revealed superior outcomes for Hispanic youth in BBT vs ARC for diagnostic remission, anxiety, emotional problems, and parent-child conflict. Youth depression at baseline moderated effects on peer problems and parent-child conflict, with effects favoring BBT. Significant main and moderated effects of BBT on change in non-targeted outcomes were largely mediated by change in anxiety (24.2%-49.3% of total effects mediated)., Conclusion: BBT has positive effects on youth, mediated by the strong impact of the intervention on anxiety. Analyses continue to support positive outcomes for Hispanic youth, suggesting that BBT is a broadly effective transdiagnostic treatment option for diverse populations., Clinical Trial Registration Information: Brief Cognitive Behavioral Therapy (CBT) for Pediatric Anxiety and Depression in Primary Care; https://clinicaltrials.gov; NCT01147614., (Copyright © 2022 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Anxiety is the most common mental health problem in youth. Numerous studies have identified that youth anxiety is associated with interpretation bias or the attribution of threatening meaning to ambiguity. Interpretation bias has been proposed as a mechanism underlying the development and maintenance of pediatric anxiety. Theoretically, interpretation bias should be content-specific to individual youth anxiety symptom domains. However, extant studies have reported conflicting findings of whether interpretation bias is indeed content specific to youth anxiety symptoms or diagnoses. The present meta-analysis aimed to synthesize the literature and answer the question: is the relationship between interpretation bias and anxiety content specific? Search of PubMed and PsycINFO databases from January 1, 1960 through May 28, 2019 yielded 9967 citations, of which 19 studies with 20 comparisons and 2976 participants met eligibility criteria. Meta-analysis with random effects models was conducted to examine an overall effect (Pearson r) between anxiety domain and content-specific interpretation bias in single sample studies, and an overall effect size difference (Cohen's d) in studies comparing anxious to non-anxious youth. Results support a content specific correlation between interpretation bias and anxiety symptom domain in single sample studies (r = 0.18, p = 0.03). However, it is currently undetermined whether this relationship holds in studies that compare the relationship between content-specific interpretation bias and anxiety in anxious versus non-anxious youth. A variety of methodologic considerations across studies are discussed, with implications for further investigation of interpretation bias and youth anxiety., (© 2021. Springer-Verlag GmbH, DE part of Springer Nature.)

Objective: A lack of universal definitions for response and remission in pediatric obsessive-compulsive disorder (OCD) has hampered the comparability of results across trials. To address this problem, we conducted an individual participant data diagnostic test accuracy meta-analysis to evaluate the discriminative ability of the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) in determining response and remission. We also aimed to generate empirically derived cutoffs on the CY-BOCS for these outcomes., Method: A systematic review of PubMed, PsycINFO, Embase and CENTRAL identified 5,401 references; 42 randomized controlled clinical trials were considered eligible, and 21 provided data for inclusion (N = 1,234). Scores of ≤2 in the Clinical Global Impressions Improvement and Severity scales were chosen to define response and remission, respectively. A 2-stage, random-effects meta-analysis model was established. The area under the curve (AUC) and the Youden Index were computed to indicate the discriminative ability of the CY-BOCS and to guide for the optimal cutoff, respectively., Results: The CY-BOCS had sufficient discriminative ability to determine response (AUC = 0.89) and remission (AUC = 0.92). The optimal cutoff for response was a ≥35% reduction from baseline to posttreatment (sensitivity = 83.9, 95% CI = 83.7-84.1; specificity = 81.7, 95% CI = 81.5-81.9). The optimal cutoff for remission was a posttreatment raw score of ≤12 (sensitivity = 82.0, 95% CI = 81.8-82.2; specificity = 84.6, 95% CI = 84.4-84.8)., Conclusion: Meta-analysis identified empirically optimal cutoffs on the CY-BOCS to determine response and remission in pediatric OCD randomized controlled clinical trials. Systematic adoption of standardized operational definitions for response and remission will improve comparability across trials for pediatric OCD., (Copyright © 2021 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

This study describes impairment in academic, interpersonal, recreational, and family financial or occupational domains across children in three mutually exclusive diagnostic groups: ever diagnosed with Tourette syndrome (TS), attention-deficit/hyperactivity disorder (ADHD), and both disorders. In 2014, parents reported on impairment and diagnostic status of children aged 4-17 years (n = 3014). Weighted analysis and pairwise t-tests showed more children with ADHD (with or without TS) experienced impairment in overall school performance, writing, and mathematics, relative to children with TS but not ADHD. More children with TS and ADHD had problematic handwriting relative to children with ADHD but not TS. More children with TS and ADHD had problematic interpersonal relationships relative to those with ADHD but not TS. Children with TS and ADHD had higher mean impairment across domains than children with either TS or ADHD. Findings suggest assessing disorder-specific contributions to impairment could inform targeted interventions for TS and ADHD., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

In the last decade, an abundance of research has utilized the NIMH Research Domain Criteria (RDoC) framework to examine mechanisms underlying anxiety and depression in youth. However, relatively little work has examined how these mechanistic intrapersonal processes intersect with context during childhood and adolescence. The current paper covers reviews and meta-analyses that have linked RDoC-relevant constructs to ecological systems in internalizing problems in youth. Specifically, cognitive, biological, and affective factors within the RDoC framework were examined. Based on these reviews and some of the original empirical research they cover, we highlight the integral role of ecological factors to the RDoC framework in predicting onset and maintenance of internalizing problems in youth. Specific recommendations are provided for researchers using the RDoC framework to inform future research integrating ecological systems and development. We advocate for future research and research funding to focus on better integration of the environment and development into the RDoC framework., Competing Interests: Conflicts of interest: None.

Evidence of associations between obsessive compulsive disorder (OCD) and alterations in neural indices of performance monitoring, i.e., elevated neural activity following errors, have accelerated interest in the error-related negativity (ERN) as a biomarker for pediatric OCD. The study investigates the degree to which attention bias training is linked to changes in neural measures of performance monitoring (ERN, correct response negativity or CRN) and whether pre-to-post training changes in these neural indices are associated with symptom changes in youth with OCD. The sample included 36 youth (8-17 years) diagnosed with OCD who completed a 12-session attention training program and pre- and post-training EEG assessment of performance monitoring using cognitive and emotional flanker tasks. The emotional flanker task was individualized to each participant's negative ratings of stimuli at pre-treatment to enhance salience of threat-related stimuli across youth. Results indicated that unlike participants who received attentional control protocol (CON), those who received attentional bias modification protocol (ABM) showed significant attenuations in neural activity following erroneous and correct responses in the emotional flanker task. The ERN amplitude during the cognitive flanker task was unchanged in both ABM and CON groups. Attenuations in the ERN were also linked to decreases in social anxiety and depressive symptoms. Findings highlight the relevance of including emotionally-salient tasks when investigating potential neural mechanisms of treatments and suggest that alterations in neural processes underlying performance monitoring can be targeted via attention training programs in pediatric OCD., (Copyright © 2021. Published by Elsevier B.V.)

Background: Anxiety disorders are the most prevalent psychiatric problem across the lifespan, with typical onset during the pediatric period. Prior literature has examined cognitive mechanisms associated with youth anxiety and identified interpretation bias, the threatening appraisal of ambiguity, as a ubiquitous correlate and likely mechanism. A small set of studies have examined interpretation bias and anxiety in parent-child dyads, although results about this potential relationship are conflicted. This systematic review and meta-analysis investigates the association between parent interpretation bias with child interpretation bias and child anxiety., Methods: Eight studies met the rigorous inclusion criteria, which required direct assessment of interpretation bias in both youth and parent., Results: Meta-analysis with a random effects model indicated a small and significant correlation between parent and child interpretation biases (r = 0.14, p < .01), as well as a small and significant correlation between parent interpretation bias and child anxiety (r =  = 0.20, p = .01)., Limitations: As only eight studies were included in this meta-analysis, reflecting the state of the extant literature, it is possible that, as data accumulate and this work continues in the future, results may or may not be replicated., Conclusions: Despite variability in findings across the included empirical studies, the current meta-analysis suggests that a correlational relationship between parent interpretation bias and child bias/anxiety exists. This work has implications for conceptualizing parent interpretation bias as a possible explanatory mechanism underlying youth interpretation bias and anxiety., (Copyright © 2021. Published by Elsevier B.V.)

Although exposure-based cognitive behavior therapy (CBT) and pharmacotherapy have demonstrated efficacy for obsessive-compulsive disorder (OCD), the lack of clinicians effectively trained in these treatments significantly limit effective intervention options for affected youth. This is very unfortunate since child onset is reported by 50% of adults with OCD. To ameliorate this serious global issue the 14 nation International Obsessive-Compulsive Disorders Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) has developed knowledge and competency standards recommended for specialized treatments for OCD through the lifespan. Currently available guidelines are considered by experts to be essential but insufficient because there are not enough clinicians with requisite knowledge and competencies to effectively treat OCD. This manuscript presents knowledge and competency standards recommended for specialized cognitive behavior therapy (CBT) for pediatric OCD, derived from comprehensive literature review and expert synthesis. In addition to standards covering the elements of individual CBT-based assessment and treatment, family and school interventions are addressed given the critical role these domains play in the psychosocial development of youths. The ATF standards presented in these phase two papers will be foundational to the upcoming development of certification (individuals) and accreditation (sites) for specialized treatments in OCD through the lifespan., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: To assess pediatric primary care providers' (PCPs) knowledge, perceived barriers, and needs related to child and adolescent anxiety in their practice., Methods: Primary care providers licensed and practicing in the state of Colorado were invited to complete an online knowledge and needs assessment. The survey queried their knowledge of pediatric anxiety, experience in assessing and treating anxiety, perceived barriers in their practice setting to adequately addressing youth anxiety, and interest in additional training on this topic., Results: Survey completers included 115 PCPs (51 medical doctors and 64 nurses/nurse practitioners). PCPs had been practicing with their current medical license with pediatric patients for an average of 14 years (SD = 10.45), and 70% reported that they regularly discuss anxiety with patients and parents. Although PCPs had a basic knowledge of youth anxiety, there appeared to be significant gaps in PCP knowledge. Specifically, knowledge gaps included evidence-based assessment and treatment, how to differentiate between developmentally appropriate, transient episodes of anxiety versus anxiety disorders, and where and how to refer youth for specialty services. Nearly all (80%) PCPs indicated that they would be "extremely interested" in additional training in pediatric anxiety, particularly if it occurred in their organizational setting, at a nearby community setting, or online., Conclusion: Primary care providers reported that a substantial proportion of the patients they see struggle with anxiety. PCPs also reported a growing need for training in how to assess, treat, and refer anxious youth. This needs assessment supports a need for the development of easily accessible training and resources for PCPs to better support their pediatric patients.

Background and Objectives: High levels of psychological control (PC), the (intentional or unintentional) attempt by parents to control their child's emotional experience, have been associated with increased risk for anxiety in youth. However, little is known regarding the association between PC and anxiety in emerging adulthood, a developmental period marked by various life transitions and high risk for the onset of internalizing symptoms, or about the relation between current parental PC and emotional regulatory processes during this stage. The current study examined whether perceived maternal PC was significantly associated with anxiety symptoms and both objective (psychophysiological; respiratory sinus arrhythmia) and subjective (self-reported) emotion regulatory processes., Methods: Participants (N = 125; ages 18 to 25) completed self-reports on their anxiety symptoms, emotion regulation abilities, and perceptions of their mother' behavior, and participated in a laboratory stressor, the Trier-Social Stress Test, while psychophysiological data were acquired., Results: Emerging adults who reported higher maternal PC also reported higher anxiety symptoms and evidenced greater emotion regulation difficulties on both objective and subjective indices than those who reported lower maternal PC. Moreover, the association between PC and anxiety levels was statistically mediated by self-reported emotion regulation difficulties., Limitations: Results of this study should be interpreted in light of its limitations, which include it being cross-sectional in nature with a primarily female sample. Further, perceptions of maternal, but not paternal, parenting were examined., Conclusions: Findings might have implications for targeting both psychological control and emotion regulation difficulties in personalized anxiety interventions during this high-risk developmental period., Competing Interests: Declaration of competing interest We have no conflicts of interest to disclose – although this study was supported with grants (details on title page), the design; collection, analysis, and interpretation of data; and write-up were entirely our own., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Cognitive bias modification for interpretations (CBM-I) is a computerized intervention that has received increasing attention in the last decade as a potential experimental intervention for anxiety. Initial CBM-I trials with clinical populations suggest the potential utility of this approach. However, most CBM-I experiments have been conducted with unaffected samples, few (one or two) training sessions, and have not examined transfer effects to anxiety-related constructs such as stress reactivity., Method: This study compared a 12-session CBM-I intervention (n = 12) to an interpretation control condition (ICC; n = 12) in individuals (N = 24) with elevated trait anxiety on interpretation bias, anxiety symptom, and stress reactivity outcomes (electrodermal activity, heart rate, and respiratory sinus arrhythmia)., Results: Compared to the ICC group, participants assigned to CBM-I experienced significantly greater improvements in interpretation bias and anxiety symptoms by post-intervention 4 weeks later, with impact on anxiety maintained at 1-month follow-up. While CBM-I and ICC groups did not differ in stress reactivity during an acute stressor at pre-intervention, the CBM-I group evidenced improved stress reactivity at post-intervention compared to ICC on two psychophysiological indices, electrodermal activity and heart rate., Conclusions: The results of this pilot study suggest that CBM-I may hold promise for reducing anxiety symptoms, as well as impact psychophysiological arousal during an acute stressor., (© 2020 Wiley Periodicals, Inc.)

Pediatric trichotillomania (TTM) is an understudied condition that can be highly impairing; little is known about family environmental features that shape its development and course. We examined family functioning among age and gender-matched groups of youth with primary TTM (n = 30; mean age = 12.87), obsessive compulsive disorder (OCD; n = 30; mean age = 12.70), and no psychiatric history (healthy controls; HC; n = 30; mean age = 12.46). An additional group of n = 25 TTM cases was employed to examine relationships between TTM severity and family functioning. All youth completed standardized diagnostic assessment, including the Family Environment Scale (FES) and Children's Report of Parenting Behavior Inventory (CRPBI). Family functioning was more impaired among both TTM and OCD cases relative to controls, as evidenced by higher levels of child-reported FES conflict and lower cohesion, expressiveness, and organization. Less consistent findings emerged on parent report, with cohesion, but not conflict, distinguishing the HC and clinical groups. In keeping with prior research, parents of TTM-affected youth also reported lower expressiveness and cohesion than parents in the OCD group. There was limited evidence for links between hair-pulling severity and family impairment and no links to parenting behavior. Findings are discussed in terms of implications for family focused treatment., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objective: Although adult hoarding disorder is relatively common and often debilitating, few studies have examined the phenomenology of pediatric hoarding. We examined the clinical phenomenology and response to cognitive-behavioral therapy (CBT) treatment in youths with a diagnosis of obsessive-compulsive disorder (OCD) with and without hoarding symptoms. Age was tested as a moderator across analyses, given prior findings that the impact of hoarding symptoms may not become apparent until adolescence., Method: Youths (N = 215; aged 7-17 years) with OCD pursuing evaluation and/or treatment at a university-based specialty clinic participated in the current study. Presence of hoarding symptoms was assessed as part of a larger battery. Data from a subset of youths (n = 134) who received CBT were included in treatment response analyses., Results: Youths with hoarding symptoms did not differ from those without hoarding symptoms with respect to overall OCD symptom severity and impairment. Youths with hoarding met criteria for more concurrent diagnoses, including greater rates of internalizing and both internalizing/externalizing, but not externalizing-only, disorders. Youths with and without hoarding symptoms did not significantly differ in rate of response to CBT. Age did not moderate any of these relationships, suggesting that the presence of hoarding symptoms was not associated with greater impairments across the clinical presentation of OCD or its response to treatment by age., Conclusion: We found no evidence that hoarding is associated with greater OCD severity or poorer treatment response in affected youth. Theoretical and clinical implications of these findings, including future directions for research on testing developmental models of hoarding across the lifespan, are discussed., (Copyright © 2019 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Trichotillomania (TTM; hair-pulling disorder) is characterized by an irresistible urge or desire to pull out one's own hair, and a sense of pleasure when hair is pulled out. Evidence from translational neuroscience has shown that 'wanting' (motivation to seek a reward) and 'liking' (enjoyment when reward is received) are each mediated by overlapping but distinct neural circuitry, and that 'wanting' contributes to addictive/compulsive behaviors more so than 'liking'. In the present study, we developed the Hair Pulling Reward Scale (HPRS), a self-report measure that consists of two subscales designed to assess (a) cue-triggered urges and appetitive motivation to pull hair (i.e., putative correlates of 'wanting'), and (b) momentary pleasure and gratification during pulling episodes (i.e., putative correlates of 'liking'). We administered the HPRS to 259 individuals with TTM and examined its psychometric properties. Confirmatory factor analysis supported a two-factor model reflecting correlated Wanting and Liking scales. Consistent with predictions, Wanting, much more than Liking, had robust correlations with TTM severity, impulsiveness, difficulties in emotion regulation, psychiatric symptoms, and sleep dysfunction. The results suggest that the HPRS is a psychometrically sound instrument that can be used as a symptom-level measure of reward processing in TTM., Competing Interests: Conflict of Interest Ivar Snorrason, Emily J. Ricketts, Ragnar P. Olafsson, Michelle Rozenman, Christopher S. Colwell, and John Piacentini declare no potential conflict of interest.

Pediatric obsessive-compulsive disorder (OCD) co-occurs frequently with other mental health conditions, adding to the burden of disease and complexity of treatment. Cognitive behavioral therapy (CBT) is efficacious for both OCD and two of its most common comorbid conditions, anxiety and depression. Therefore, treating OCD may yield secondary benefits for anxiety and depressive symptomatology. This study examined whether anxiety and/or depression symptoms declined over the course of OCD treatment and, if so, whether improvements were secondary to reductions in OCD severity, impairment, and/or global treatment response. The sample consisted of 137 youths who received 12 sessions of manualized CBT and were assessed by independent evaluators. Mixed models analysis indicated that youth-reported anxiety and depression symptoms decreased in a linear fashion over the course of CBT, however these changes were not linked to specific improvements in OCD severity or impairment but to global ratings of treatment response. Results indicate that for youth with OCD, CBT may offer benefit for secondary anxiety and depression symptoms distinct from changes in primary symptoms. Understanding the mechanisms underlying carryover in CBT techniques is important for furthering transdiagnostic and/or treatment-sequencing strategies to address co-occurring anxiety and depression symptoms in pediatric OCD., (Copyright © 2019. Published by Elsevier B.V.)

The study objective was to perform a confirmatory factor analysis of the SLEEP-50 Questionnaire (SLEEP-50) in Trichotillomania (Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder and compare sleep complaints in adults with Trichotillomania, Excoriation Disorder and non-affected controls. Participants were 234 adults with Trichotillomania, 170 with Excoriation Disorder, and 146 non-affected controls. Participants rated sleep using the SLEEP-50 and Pittsburgh Sleep Quality Index (PSQI). Confirmatory factor analysis was used to assess fit of the originally-proposed SLEEP-50 factors within Trichotillomania and Excoriation Disorder. Findings revealed acceptable to good fit of the original factors. Internal consistency was excellent in Trichotillomania and good in Excoriation Disorder for the total score and poor to good for subscales. Convergent validity was strong for the total and weak to strong for subscales in both groups. Findings suggest greater sleep complaints in Trichotillomania and Excoriation Disorder than in the general population. Trichotillomania and Excoriation Disorder groups reported greater rates of sleep apnea, narcolepsy, restless leg syndrome/periodic limb movement disorder, circadian rhythms sleep disorder, and sleep-related affective disorder relative to controls. There were no significant differences for insomnia, sleep state misperception, sleepwalking, nightmares, or hypersomnia. Results underscore the importance of clinical assessment of sleep disorders in Trichotillomania and Excoriation Disorder., (Copyright © 2019. Published by Elsevier B.V.)

Rationale: Attentional bias toward drug-related stimuli is a feature of drug addiction that is linked to craving and drug-seeking behavior., Objectives/method: An attentional bias modification (ABM) program was tested in 42 methamphetamine-dependent clients (DSM-IV criteria) receiving residential treatment for their drug use. Participants were randomly assigned to one of two groups (N = 21 each), receiving 12 sessions of either computerized ABM training (designed to train attention away from methamphetamine stimuli 100% of the time) or an attentional control condition (designed to train attention away from methamphetamine stimuli 50% of the time). Outcome measures included attentional bias to methamphetamine-related stimuli on a probe detection task, self-reported craving, and preferences to view methamphetamine-related images on a Simulated Drug Choice Task. A subset of participants (N = 17) also underwent fMRI in a cue-induced craving paradigm., Results: Poor split-half reliability was observed for the probe detection task. Using this task, attentional bias toward methamphetamine-related stimuli was greater after training than at baseline, irrespective of group (p = 0.037). Spontaneous and cue-induced methamphetamine craving diminished with time (ps < 0.01), but ABM training did not influence these effects (group by time interactions, ps > 0.05). ABM training did not influence selection of methamphetamine-related pictures in the Simulated Drug Choice task (p > 0.05). In the fMRI assessment, cue-induced activation in the ventromedial prefrontal cortex was reduced over time, without an effect of ABM training., Conclusions: ABM training did not improve several clinically relevant variables in treatment-seeking methamphetamine users. Additional research is needed to improve the measurement of attentional bias.

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.)

Predictors of math achievement in attention-deficit/hyperactivity disorder (ADHD) are not well-known. To address this gap in the literature, we examined individual differences in neurocognitive functioning domains on math computation in a cross-sectional sample of youth with ADHD. Gender and anxiety symptoms were explored as potential moderators. The sample consisted of 281 youth (aged 8-15 years) diagnosed with ADHD. Neurocognitive tasks assessed auditory-verbal working memory, visuospatial working memory, and processing speed. Auditory-verbal working memory speed significantly predicted math computation. A three-way interaction revealed that at low levels of anxious perfectionism, slower processing speed predicted poorer math computation for boys compared to girls. These findings indicate the uniquely predictive values of auditory-verbal working memory and processing speed on math computation, and their differential moderation. These findings provide preliminary support that gender and anxious perfectionism may influence the relationship between neurocognitive functioning and academic achievement.

Deficits in social communication are a core feature of autism spectrum disorder (ASD), yet significant social problems have been observed in youth with many neurodevelopmental disorders. In this preliminary investigation, we aimed to explore whether domains of social reciprocity (i.e., social communication, social cognition, social awareness, social motivation, and restricted and repetitive behaviors) represent transdiagnostic traits. These domains were compared across youth ages 7-17 with obsessive-compulsive disorder (OCD; N = 32), tic disorders (TD; N = 20), severe mood dysregulation (N = 33) and autism spectrum disorder (N = 35). While the ASD group was rated by parents as exhibiting the greatest social reciprocity deficits across domains, a high proportion of youth with severe mood dysregulation also exhibited pronounced deficits in social communication, cognition, and awareness. The ASD and severe mood dysregulation groups demonstrated comparable scores on the social awareness domain. In contrast, social motivation and restricted and repetitive behaviors did not appear to be transdiagnostic domains in severe mood dysregulation, OCD, or TD groups. The present work provides preliminary support that social awareness, and to a lesser extent social communication and cognition, may represent features of social reciprocity that are transdiagnostic across ASD and severe mood dysregulation., (Copyright © 2018 Elsevier B.V. All rights reserved.)

In the past decade, cognitive biases and physiological arousal have each been proposed as mechanisms through which paediatric anxiety develops and is maintained over time. Preliminary studies have found associations between anxious interpretations of ambiguity, physiological arousal, and avoidance, supporting theories that link cognition, psychophysiology, and behaviour. However, little is known about the relationship between youths' resolutions of ambiguity and physiological arousal during acute stress. Such information may have important clinical implications for use of verbal self-regulation strategies and cognitive restructuring during treatments for paediatric anxiety. In this brief report, we present findings suggesting that anxious, but not typically developing, youth select avoidant goals via non-threatening resolution of ambiguity during a stressor, and that this resolution of ambiguity is accompanied by physiological reactivity (heart rate, heart rate variability, and respiratory sinus arrhythmia). We propose future empirical research on the interplay between interpretation bias, psychophysiology, and child anxiety, as well as clinical implications.

Objective: The present study compared sleep sufficiency in youth with current Tourette's disorder (TD), history of TD and matched case controls, and examined predictors of sufficient sleep using a large US population-based survey., Method: Participants were 673 caregivers of youth aged 6 to 17 years (298 with current TD, 122 with a history of TD with no endorsement of current diagnosis, and 254 matched case controls) from the 2007 and 2011-2012 versions of the National Survey of Children's Health. History and current TD status, current comorbidity (attention deficit/hyperactivity disorder, anxiety, and depression) and psychiatric medication status were assessed by yes/no items. Current TD severity was dichotomized into mild or moderate/severe symptoms. Sleep was assessed by parent-reported number of sufficient nights their child slept in the past week., Results: Univariate analysis of variance yielded significant group differences in nights of sufficient sleep (F[2,369.70] = 71.53, p < .001), with controls having 1.5 more nights per week relative to both TD groups (p < .001). With respect to predictors of sufficient sleep, the analysis of covariance yielded a significant age × sex × TD severity interaction (F[1,15.84] = 4.28, p = .04) such that older adolescent males with mild TD had significantly fewer nights of sufficient sleep than children (p = .004) and early adolescents (p = .002; F[2,54.93] = 7.45, p = .001). Early adolescent females with moderate/severe TD had fewer nights of sufficient sleep relative to males (p = .008). Comorbidity type and psychiatric medication status did not significantly predict sleep., Conclusion: Findings suggest that insufficient sleep in youth with TD persists independently of comorbidity or psychiatric medication status. Findings highlight the importance of clinical sleep monitoring in this population.

Anxiety has been proposed to influence psychophysiological reactivity in children and adolescents. However, the extant empirical literature has not always found physiological reactivity to be associated with anxiety in youth. Further, most investigations have not examined psychophysiological reactivity in real time over the course of acute stress. To test the impact of anxiety disorder status on autonomic arousal in youth, we compared youth with primary anxiety disorders (N = 24) to typically developing (TD) youth (N = 22) on heart rate (HR), heart rate variability (HRV), and respiratory sinus arrhythmia (RSA) during an acute stressor in which youth received error-related feedback. We also conducted exploratory analyses on youth performance during the task. Youth ages 9-17 participated in the arithmetic portion of the Trier Social Stress Test for Children (Buske-Kirschbaum et al., Psychosom 59:419-426, 1997), during which time they received consecutive, standardized feedback that they made calculation errors. Results indicated that, compared to their TD counterparts, the anxious group demonstrated elevated HR and suppressed HRV during initial provision of error feedback and during the recovery period. No group differences were found for RSA. Additionally, overall TD youth made a greater proportion of errors than anxious youth. Clinically, these findings may provide preliminary support for anxious youth exhibiting physiological reactivity in response to receipt of error-related feedback, and may have implications for understanding biological processes during stress. This work underscores the need for further study of when and how anxiety may influence autonomic reactivity over the course of stress.

Cognitive-behavioral therapy (CBT) is effective for pediatric obsessive-compulsive disorder (OCD), but non-response is common. Brain glutamate (Glu) signaling may contribute to OCD pathophysiology and moderate CBT outcomes. We assessed whether Glu measured with magnetic resonance spectroscopy (MRS) was associated with OCD and/or CBT response. Youths aged 7-17 years with DSM-IV OCD and typically developing controls underwent 3 T proton echo-planar spectroscopic imaging (PEPSI) MRS scans of pregenual anterior cingulate cortex (pACC) and ventral posterior cingulate cortex (vPCC)-regions possibly affected by OCD-at baseline. Controls returned for re-scan after 8 weeks. OCD youth-in a randomized rater-blinded trial-were re-scanned after 12-14 weeks of CBT or after 8 weeks of minimal-contact waitlist; waitlist participants underwent a third scan after crossover to 12-14 weeks of CBT. Forty-nine children with OCD (mean age 12.2±2.9 years) and 29 controls (13.2±2.2 years) provided at least one MRS scan. At baseline, Glu did not differ significantly between OCD and controls in pACC or vPCC. Within controls, Glu was stable from scan-to-scan. Within OCD subjects, a treatment-by-scan interaction (p=0.034) was observed, driven by pACC Glu dropping 19.5% from scan-to-scan for patients randomized to CBT, with minor increases (3.8%) for waitlist participants. The combined OCD participants (CBT-only plus waitlist-CBT) also showed a 16.2% (p=0.004) post-CBT decrease in pACC Glu. In the combined OCD group, within vPCC, lower pre-CBT Glu predicted greater post-CBT improvement in symptoms (CY-BOCS; r=0.81, p=0.00025). Glu may be involved in the pathophysiology of OCD and may moderate response to CBT.

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.)

Background: Anxiety disorders are among the most common mental health problems in youth, and faulty interpretation bias has been positively linked to anxiety severity, even within anxiety-disordered youth. Quick, reliable assessment of interpretation bias may be useful in identifying youth with certain types of anxiety or assessing changes on cognitive bias during intervention., Objective: This study examined the factor structure, reliability, and validity of the Self-report of Ambiguous Social Situations for Youth (SASSY) scale, a self-report measure developed to assess interpretation bias in youth., Methods: Participants (N=488, age 7 to 17) met diagnostic criteria for Social Phobia, Generalized Anxiety Disorder, and/or Separation Anxiety Disorder. An exploratory factor analysis was performed on baseline data from youth participating in a large randomized clinical trial., Results: Exploratory factor analysis yielded two factors (Accusation/Blame, Social Rejection). The SASSY full scale and Social Rejection factor demonstrated adequate internal consistency, convergent validity with social anxiety, and discriminant validity as evidenced by non-significant correlations with measures of non-social anxiety. Further, the SASSY Social Rejection factor accurately distinguished children and adolescents with Social Phobia from those with other anxiety disorders, supporting its criterion validity, and revealed sensitivity to changes with treatment. Given the relevance to youth with social phobia, pre- and post-intervention data were examined for youth social phobia to test sensitivity to treatment effects; results suggested that SASSY scores reduced for treatment responders., Conclusions: Findings suggest the potential utility of the SASSY Social Rejection factor as a quick, reliable, and efficient way of assessing interpretation bias in anxious youth, particularly as related to social concerns, in research and clinical settings., Competing Interests: Disclosure of potential conflicts of interest: Araceli Gonzalez declares that she has no conflict of interest. Michelle Rozenman declares that she has no conflict of interest. Audra Langley declares that she has no conflict of interest. Philip Kendall declares that he has no conflict of interest. Golda Ginsburg declares that she has no conflict of interest. Scott Compton declares that he has no conflict of interest. John Walkup declares that he has no conflict of interest. Anne Marie Albano declares that she has no conflict of interest. John Piacentini declares that he has no conflict of interest.

The present study assessed sleep functioning in Trichotillomania (TTM; Hair-Pulling Disorder) and Excoriation (Skin-Picking) Disorder (ExD), and a non-affected comparison group, and examined the prevalence and correlates of bedtime and sleep-related hair pulling and skin picking. Participants were adult internet survey respondents, who met diagnostic criteria for TTM ( N =259), ExD ( N =182), or did not meet criteria for these disorders ( N =148). Individuals with TTM and ExD endorsed significantly greater sleep disturbance relative to the comparison group, even after controlling for internalizing (anxiety and depression) symptoms. Hair pulling and skin picking severity were not significantly correlated with sleep disturbance after controlling for internalizing symptoms. Pulling and picking during sleep occurred at rates of 13% and 27%, respectively. Picking severity, anxiety and depressive symptoms, and sleep disturbance were significantly increased in those who engaged in picking during sleep relative to those who did not endorse this behavior. No significant differences were found between those endorsing pulling during sleep and those not endorsing this on demographic, clinical, or sleep variables. The present study highlights the potential role of sleep disturbance in TTM and ExD, and the need for further research in this area.

Prior research has identified OCD subtypes or "clusters" of symptoms that differentially relate to clinical features of the disorder. Given the high comorbidity between OCD and anxiety, OCD symptom clusters may more broadly associate with fear and/or distress internalizing constructs. This study examines fear and distress dimensions, including physical concerns (fear), separation anxiety (fear), perfectionism (distress), and anxious coping (distress), as predictors of previously empirically-derived OCD symptom clusters in a sample of 215 youth diagnosed with primary OCD (ages 7-17, mean age = 12.25). Self-reported separation fears predicted membership in Cluster 1 (aggressive, sexual, religious, somatic obsessions, and checking compulsions) while somatic/autonomic fears predicted membership in Cluster 2 (symmetry obsessions and ordering, counting, repeating compulsions). Results highlight the diversity of pediatric OCD symptoms and their differential association with fear, suggesting the need to carefully assess both OCD and global fear constructs that might be directly targeted in treatment.

Cognitive bias and physiological arousal are two putative markers that may underlie youth anxiety. However, data on relationships between cognitive bias and arousal are limited, and typically do not include behavioral measurement of these constructs in order to tap real-time processes. We aimed to examine the relationship between performance-based cognitive bias and sympathetic arousal during stress in clinically anxious and typically-developing youth. The sample included children and adolescents ages 9 to 17 (Mean age=13.18, SD=2.60) who either met diagnostic criteria for primary generalized anxiety, social phobia, or separation anxiety (N=24) or healthy controls who had no history of psychopathology (N=22). Youth completed performance-based measures of attention and interpretation bias. Electrodermal activity was assessed while youth participated in the Trier Social Stress Test for Children (TSST-C; Buske-Kirschbaum, Jobst, & Wustmans, 1997). A mixed models analysis indicated significant linear and non-linear changes in skin conductance, with similar slopes for both groups. Interpretation bias, but not attention bias, moderated the relationship between group status and sympathetic arousal during the TSST-C. Arousal trajectories did not differ for anxious and healthy control youth who exhibited high levels of threat interpretation bias. However, for youth who exhibited moderate and low levels of interpretation bias, the anxious group demonstrated greater arousal slopes than healthy control youth. Results provide initial evidence that the relationship between anxiety status and physiological arousal during stress may be moderated by level of interpretation bias for threat. These findings may implicate interpretation bias as a marker of sympathetic reactivity in youth. Implications for future research and limitations are discussed., (Published by Elsevier Ltd.)

The current investigation examined the internal structure and discriminant validity of the parent-report Mood and Feelings Questionnaire (MFQ-P), a commonly used measure of depressive symptoms in youth. A total of 1493 families with youth ages 5 to 18 (61.02 % male) presenting for treatment at an outpatient mental health clinic were randomly allocated to an Exploratory Sample 1 or to a Replication Sample 2. Internal structure of the MFQ-P was examined using exploratory factor analysis in Sample 1 (N = 769) and then replicated using confirmatory factor analysis in Sample 2 (N = 724). Results of the exploratory factor analysis yielded a 5-factor structure comprised of core mood, vegetative, suicidality, cognitive, and agitated distress symptom subscales. The 5-factor solution was replicated in Sample 2 with adequate fit, (CFI = 0.908, TLI = 0.974, RMSEA =0.067). Results lend statistical support for 5 candidate subscales of the MFQ-P. These potential subscales may aid in efficient identification of critical symptoms of depression.

This study compared youth ages 5-17 years with a primary diagnosis of trichotillomania (TTM, n = 30) to those with primary OCD (n = 30) and tic disorder (n = 29) on demographic characteristics, internalizing, and externalizing symptoms. Findings suggest that youth with primary TTM score more comparably to youth with tics than those with OCD on internalizing and externalizing symptom measures. Compared to the OCD group, youth in the TTM group reported lower levels of anxiety and depression. Parents of youth in the TTM group also reported fewer internalizing, externalizing, attention, and thought problems than those in the OCD group. Youth with TTM did not significantly differ from those with primary Tic disorders on any measure. Findings suggest that pediatric TTM may be more similar to pediatric tic disorders than pediatric OCD on anxiety, depression, and global internalizing and externalizing problems.

Importance: Recent health care legislation and shifting health care financing strategies are transforming health and behavioral health care in the United States and incentivizing integrated medical-behavioral health care as a strategy for improving access to high-quality care for behavioral health conditions, enhancing patient outcomes, and containing costs., Objective: To conduct a systematic meta-analysis of randomized clinical trials to evaluate whether integrated medical-behavioral health care for children and adolescents leads to improved behavioral health outcomes compared with usual primary care., Data Sources: Search of the PubMed, MEDLINE, PsycINFO, and Cochrane Library databases from January 1, 1960, through December 31, 2014, yielded 6792 studies, of which 31 studies with 35 intervention-control comparisons and 13,129 participants met the study eligibility criteria., Study Selection: We included randomized clinical trials that evaluated integrated behavioral health and primary medical care in children and adolescents compared with usual care in primary care settings that met prespecified methodologic quality criteria., Data Extraction and Synthesis: Two independent reviewers screened citations and extracted data, with raw data used when possible. Magnitude and direction of effect sizes were calculated., Main Outcomes and Measures: Meta-analysis with a random effects model were conducted to examine an overall effect across all trials, and within intervention and prevention trials. Subsequent moderator analyses for intervention trials explored the relative effects of integrated care type on behavioral health outcomes., Results: Meta-analysis with a random-effects model indicated a significant advantage for integrated care interventions relative to usual care on behavioral health outcomes (d = 0.32; 95% CI, 0.21-0.44; P < .001). Moderator analyses indicated larger effects for treatment trials that targeted diagnoses and/or elevated symptoms (d = 0.42; 95% CI, 0.29-0.55; P < .001) relative to prevention trials (d = 0.07; 95% CI, -0.13 to 0.28; P = .49). The probability was 66% that a randomly selected youth would have a better outcome after receiving integrated medical-behavioral treatment than a randomly selected youth after receiving usual care. The strongest effects were seen for treatment interventions that targeted mental health problems and those that used collaborative care models., Conclusions and Relevance: Our results, demonstrating the benefits of integrated medical-behavioral primary care for improving youth behavioral health outcomes, enhance confidence that the increased incentives for integrated health and behavioral health care in the US health care system will yield improvements in the health of children and adolescents.

Tourette's Disorder and other chronic tic disorders are common neurodevelopmental conditions. One characteristic of tic disorders is the premonitory urge, an aversive or unpleasant sensory phenomenon that may precede tics. Initial examination of premonitory urge in pediatric tic disorders suggests that awareness and experience of sensations preceding tics may be related to anxiety and OCD. However, it may be possible that specific anxiety-related symptoms, such as anxious physiologic arousal, are particularly relevant to the experience of premonitory urge. The current study examines relationships between tic-related premonitory urge and anxiety-related symptom clusters in treatment-seeking youths with a primary diagnoses of Tourette's or other chronic tic disorder. The sample consisted of 124 youth, ages 9 to 17, who participated in the multi-site Comprehensive Behavioral Intervention for Tics randomized controlled trial (CBIT; Piacentini et al., 2010). Specific anxiety-related subtypes, including generalized worry, separation, social, and panic/somatic symptoms, as well as severity of obsessions and compulsions, were assessed as potential correlates of premonitory urge. Findings indicated that age, global tic-related impairment, and specific panic/somatic symptoms accounted for a substantial proportion of variance in youth report of premonitory urge. These findings provide information about the characteristics of premonitory urge in pediatric tic disorders, and have implications for the treatment of pediatric tic syndromes.

This preliminary investigation sought to examine basic interpretive biases, as assessed via performance-based means, in the context of anxious symptomatology, attention, and negative cognition in children and adolescents. At a single assessment, 26 youths diagnosed with primary separation anxiety, social phobia, or generalized anxiety disorder completed performance-based assessments of interpretation and attention. Youths and parents also completed diagnostic interviews and youths completed a measure of negative self-statements. Components of interpretation (threat-valence judgments and speed of responding) were examined, and interpretation was explored as a correlate of youth anxiety, attention bias, and negative self-statements. Results found percentage of negative interpretations endorsed as the strongest predictor of anxiety symptoms; this index was also correlated with attention bias. Slower rejection of benign interpretations was also associated with youth-reported negative self-statements.This initial investigation provides support for a relationship between interpretation bias and anxiety and preliminary evidence for a relationship between attention and interpretation biases. Continued research dismantling the stages of basic cognition within the chain of information processing may provide a better understanding of the mechanisms underlying anxiety disorders in youths and lead to continued development and refinement of cognitive interventions., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Recent research suggests the efficacy of attention modification programs (AMP) in treating adult anxiety.([1]) Though some research supports the success of AMP treatment in anxious youths,([2, 3]) to date no study has examined the efficacy of AMP as an adjunctive treatment to other psychosocial and pharmacological interventions for anxious youths within the community., Methods: In the current study, we examined the efficacy of AMP as an adjunctive treatment to standard care at a residential anxiety treatment facility. Adolescents (N = 42) completed either an active (attention modification program, AMP; n = 21) or a control (attention control condition, ACC; n = 21) condition, in addition to the facility's standard treatment protocol, which included cognitive behavioral therapy with or without medication., Results: While anxiety symptoms decreased for participants across both groups, participants in the AMP group experienced a significantly greater decrease in anxiety symptoms from point of intake to point of discharge, in comparison to participants in the ACC group., Conclusions: These results suggest that AMP is an effective adjunctive treatment to the standard treatments of choice for anxiety disorders, and may hold promise for improving treatment response in highly anxious youths., (© 2013 Wiley Periodicals, Inc.)

Background: The brain mechanisms of cognitive-behavioral therapy (CBT), a highly effective treatment for pediatric obsessive-compulsive disorder (OCD), are unknown. Neuroimaging in adult OCD indicates that CBT is associated with metabolic changes in striatum, thalamus, and anterior cingulate cortex. We therefore probed putative metabolic effects of CBT on these brain structures in pediatric OCD using proton magnetic resonance spectroscopic imaging (1H MRSI)., Method: Five unmedicated OCD patients (4 ♀, 13.5±2.8) and 9 healthy controls (7 ♀, 13.0±2.5) underwent MRSI (1.5 T, repetition-time/echo-time=1500/30 ms) of bilateral putamen, thalamus and pregenual anterior cingulate cortex (pACC). Patients were rescanned after 12 weeks of exposure-based CBT. The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) of OCD symptoms was administered before and after CBT., Results: Four of 5 patients responded to CBT (mean 32.8% CY-BOCS reduction). Multiple metabolite effects emerged. Pre-CBT, N-acetyl-aspartate+N-acetyl-aspartyl-glutamate (tNAA) in left pregenual anterior cingulate cortex (pACC) was 55.5% higher in patients than controls. Post-CBT, tNAA (15.0%) and Cr (23.9%) in left pACC decreased and choline compounds (Cho) in right thalamus increased (10.6%) in all 5 patients. In left thalamus, lower pre-CBT tNAA, glutamate+glutamine (Glx), and myo-inositol (mI) predicted greater post-CBT drop in CY-BOCS (r=0.98) and CY-BOCS decrease correlated with increased Cho., Conclusions: Interpretations are offered in terms of the Glutamatergic Hypothesis of Pediatric OCD. Similar to 18FDG-PET in adults, objectively measurable regional MRSI metabolites may indicate pediatric OCD and predict its response to CBT., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Children (n = 126) ages 9 to 17 years with chronic tic or Tourette disorder were randomly assigned to receive either behavior therapy or a control treatment over 10 weeks. This study examined acute effects of behavior therapy on secondary psychiatric symptoms and psychosocial functioning and long-term effects on these measures for behavior therapy responders only. Baseline and end point assessments conducted by a masked independent evaluator assessed several secondary psychiatric symptoms and measures of psychosocial functioning. Responders to behavior therapy at the end of the acute phase were reassessed at 3-month and 6-month follow-up. Children in the behavior therapy and control conditions did not differentially improve on secondary psychiatric or psychosocial outcome measures at the end of the acute phase. At 6-month posttreatment, positive response to behavior therapy was associated with decreased anxiety, disruptive behavior, and family strain and improved social functioning. Behavior therapy is a tic-specific treatment for children with tic disorders.