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Anxiety, Mood, and Substance Use Disorders in Parents of Children With Anxiety Disorders


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Title: Anxiety, Mood, and Substance Use Disorders in Parents of Children With Anxiety Disorders

Anxiety, Mood, and Substance Use Disorders in
Parentsof Children With Anxiety Disorders
  • Kristi Tschetter
  • 11/6/09

Model between genes and early enviornment
Five Major Types
  1. Generalized Anxiety Disorder (GAD)
  2. Obsessive-Compulsive Disorder (OCD)
  3. Panic Disorder
  4. Post-Traumatic Stress Disorder (PTSD)
  5. Social Phobia (or Social Anxiety Disorder)

Generalized Anxiety Disorder
  • Characterized by chronic anxiety, exaggerated
    worry and tension, even when there is little or
    nothing to provoke it
  • Can't seem to shake their concerns
  • Worries are accompanied by physical symptoms,
    especially fatigue, headaches, muscle tension,
    muscle aches, difficulty swallowing, trembling,
    twitching, irritability, sweating, and hot flashes

  • Diagnosed when a person worries excessively about
    a variety of everyday problems for at least 6
  • GAD affects about 6.8 million American adults,
    including twice as many women as men.
  • The disorder develops gradually and can begin at
    any point in the life cycle, although the years
    of highest risk are between childhood and middle
  • There is evidence that genes play a modest role
    in GAD.
  • Other anxiety disorders, depression, or substance
    abuse often accompany GAD, which rarely occurs

Obsessive-Compulsive Disorder (OCD)
  • Characterized by recurrent, unwanted thoughts
    (obsessions) and/or repetitive behaviors
  • Repetitive behaviors such as handwashing,
    counting, checking, or cleaning are often
    performed with the hope of preventing obsessive
    thoughts or making them go away.
  • Performing these "rituals" only temporary relief,
    and not performing them increases anxiety.

  • OCD affects about 2.2 million American adults and
    can be accompanied by eating disorders, other
    anxiety disorders, or depression.
  • It strikes men and women in roughly equal numbers
    and usually appears in childhood, adolescence, or
    early adulthood. One-third of adults with OCD
    develop symptoms as children, and may run in

Panic Disorder
  • Panic disorder is an anxiety disorder and is
    characterized by unexpected and repeated episodes
    of intense fear accompanied by physical symptoms
    that may include chest pain, heart palpitations,
    shortness of breath, dizziness, or abdominal
  • Feelings of terror that strike suddenly and
    repeatedly with no warning.

  • During a panic attack, most likely your heart
    will pound and you may feel sweaty, weak, faint,
    or dizzy. Your hands may tingle or feel numb, and
    you might feel flushed or chilled. You may have
    nausea, chest pain or smothering sensations, a
    sense of unreality, or fear of impending doom or
    loss of control.
  • Often accompanied by other serious problems, such
    as depression, drug abuse, or alcoholism.

Post-Traumatic Stress Disorder (PTSD)
  • Can develop after exposure to a terrifying event
    or ordeal in which grave physical harm occurred
    or was threatened. Traumatic events that may
    trigger PTSD include violent personal assaults,
    natural or human-caused disasters, accidents, or
    military combat.
  • People with PTSD have persistent frightening
    thoughts and memories of their ordeal and feel
    emotionally numb, especially with people they
    were once close to. They may experience sleep
    problems, feel detached or numb, or be easily

  • Anyone can get PTSD at any age. This includes war
    veterans and survivors of physical and sexual
    assault, abuse, accidents, disasters, and many
    other serious events.
  • Some people get PTSD after a friend or family
    member experiences danger or is harmed. The
    sudden, unexpected death of a loved one can also
    cause PTSD.

Social Phobia (or Social Anxiety Disorder)
  • Characterized by overwhelming anxiety and
    excessive self-consciousness in everyday social
    situations. Social phobia can be limited to only
    one type of situation, such as a fear of speaking
    in formal or informal situations, or eating or
    drinking in front of others or, in its most
    severe form, may be so broad that a person
    experiences symptoms almost anytime they are
    around other people.
  • People with social phobia have a persistent,
    intense, and chronic fear of being watched and
    judged by others and being embarrassed or
    humiliated by their own actions. Their fear may
    be so severe that it interferes with work or
    school, and other ordinary activities.

  • Physical symptoms often accompany the intense
    anxiety of social phobia and include blushing,
    profuse sweating, trembling, nausea, and
    difficulty talking.
  • Social phobia affects about 15 million American
  • Women and men are equally likely to develop the
  • Usually begins in childhood or early adolescence.
  • There is some evidence that genetic factors are
  • Often accompanied by other anxiety disorders or
    depression, and substance abuse may develop if
    people try to self-medicate their anxiety.

Substance Use Disorder (SUD)
  • This term encompasses both dependence on and
    abuse of drugs usually taken voluntarily for the
    purpose of their effect on the central nervous
    system (usually referred to as intoxication or
    "high") or to prevent or reduce withdrawal
  • These mental disorders form a subcategory of the
    substance-related disorders.

Internalizing vs. Externalizing
  • Trait
  • Anxiety
  • Depression
  • Withdrawal
  • Somatic complaints
  • State
  • Attention problems
  • Aggressive behavior
  • Rule-breaking actions

et. al.
  • Children of depressed mothers had significantly
    higher rates of lifetime depressive, separation
    anxiety, oppositional defiant, and any
    psychiatric disorders
  • Children of depressed mothers also reported
    significantly lower psychosocial functioning and
    had higher rates of psychiatric treatment

  • Association between lower socioeconomic status
    and higher rates of psychiatric disorders
    (including MDD)
  • Higher prevalence of lifetime MDD in families
    with yearly incomes below 10,000 and in poor
    mothers with low income
  • Results indicate a significant relationship
    between maternal depression and behavioral and
    emotional problems in the children

  • Higher prevalence of depressive, anxiety, and
    disruptive behavior disorders as well as lower
    psychosocial functioning in children of mothers
    with lifetime depression compared to children of
    never depressed mothers

Materials and methods
  • Predominately Hispanic immigrants from the
    Caribbean Islands and Central America and speak
    primarily Spanish
  • 2 bilingual trained clinical interviewers
    administered the Structured Clinical Interview
    for the DSM-IV
  • Depressed mothers who had at least one lifetime
    episode of DSM-IV MDD of at least 4 weeks in
  • Never depressed mothers with no lifetime history
    of MDD
  • Up to 3 children per family 8-17 years old

Materials and methods
  • 58 children
  • 26 children of 16 depressed mothers
  • 32 children of 19 never-depressed mothers
  • Mothers were administered the clinical interviews
    in Spanish and children in English

Table 1
Table 2
Table 3
Table 4
  • Significantly higher lifetime prevalence of
    depressive disorders, separation anxiety
    disorder, oppositional defiant disorder, any
    psychiatric disorder, and suicidal ideation
    compared to children of never depressed mothers
  • Lower psychosocial functioning across several
    areas, including lower general competence,
    overall home functioning, more problems with
    peers and parents, and lower quality
    relationships with their mother and siblings
  • These findings in low-income minority population
    parallel the findings in studies of children from
    more affluent Caucasian populations
  • Children of depressed parents social and school
    problems are not due to lower scores on
    intelligence measures, however other studies have
    reported lower scores on intelligence measures
    and academic performance

  • Results indicate that the overall lifetime
    prevalence of psychiatric disorders in children
    of low-income depressed mothers
  • Combination of socioeconomic factors and maternal
    depression might place children at particularly
    high risk for emotional and behavioral problems
  • Poor people are less likely to seek mental health
    treatment, less likely to receive treatment from
    mental health specialists, and more likely to
    rely on primary-care physicians for their mental
    health needs
  • Studies have reported that treatment of maternal
    depression can improve outcomes in children
    including symptoms and function

  1. Samle size
  2. Recruited a sample of convience - may not be
  3. Information on 6 children was obtained solely
    from the mothers
  4. Only on low-income families so doesnt allow for
    direct comparison across socioeconomic groups

  • Risk for psychiatric disorders may be
    particularly high in children of low-income
    depressed mothers
  • Multiple risk factors often coalesce in poor
    children and early detection and intervention
    become especially important

Anxiety, Mood, and Substance Use Disorders in
Parents of Children With Anxiety DisordersHughes
et. al.
  • Examined prevalence of anxiety, mood, and SUD in
    parents of children with anxiety disorders and
    with no psychological disorders.
  • Investigated the relationship between parent and
    child anxiety disorders.

  • Anxiety disorders aggregate in families
  • Concordance between child and parent anxiety is
    thought to result from a combination of genetics,
    environment, and parenting (including
    discouragement of social interaction, modeling of
    cautious or fearful responses, increased levels
    of parental control and emotional involvement,
    and less granting of autonomy)
  • Parents with anxiety disorders may model or
    communicate through anxious self-talk their
    specific anxieties to their children and place
    them at greater risk for anxiety disorders

  • Family members have a greatest influence on one
    another when offspring are in childhood or
    adolescence it seems likely that children and
    their parents would exhibit levels of diagnostic
    specificity similar to adult first-degree
  • Parent-child association for OCD and a
    significant mother-child but not father-child
    association for SP
  • Theory that PD is a the adult manifestation of
  • A relationship between child SAD and maternal
    lifetime SAD has been documented

  • Twin pair study support relationship between
    maternal depression in the first 5 years of the
    twins lives and behavioral problems displayed at
    7 years of age in a dose-response relationship
  • Relationship between anxiety and depressive
    disorders in children and parent substance use
    problems may be accounted for by a positive
    history of anxiety or depressive disorders in

Limitations in Determining Concordance Between
Child and Parent
  1. Small samples
  2. Lack of blind evaluators and/or structured
    interviewers which may influence diagnoses
  3. No or low father participation
  4. Findings that predate changes to childhood
    anxiety disorders in the DSM-IV

Study Examined
  • Lifetime rates of anxiety, mood, and SUD in
    mothers and fathers of AD (anxiety disordered)
    children compared to mothers and fathers of NPD
    (no psychological disorder)
  • Relationship between specific anxiety disorders
    in children and their mothers and fathers in AD
  • Predicted that mothers and fathers of AD children
    would exhibit greater lifetime rates of anxiety,
    mood, and SUD as well as anxious and depressive
    self-talk and self-reported symptoms than mothers
    and fathers of NPD children

  • Parents of AD children would demonstrate similar
    diagnostic pattern of anxiety diagnoses as their
    AD children (ex children with social phobia would
    have parents with social phobia, mothers of panic
    disorder would have children with SAD)

  • 230 children total presenting to the Child and
    Adolescent Anxiety Disorders Clinic (CAADC) and
    their parents
  • 178 AD 52 NPD
  • Children had an IQ gt 80
  • English speaking
  • Not taking any anti-anxiety or anti-depressant
  • All participants were administered the anxiety
    disorders interview schedule-parent and child
    versions for DSM-IV to asses for child diagnoses

  • NPD (No Psychological Disorder) Children
  • AD (Anxiety Disordered) Children
  • 178 children total
  • 7-14 years old
  • 53.4 males
  • 85.8 Caucasian
  • 14.2 Ethnic minority
  • 57 diagnosed with more than 1 anxiety disorder
  • 12 mood disorder
  • 23 ADHD
  • 7 ODD
  • 6 selective mutism
  • 4 functional enuresis
  • Percentage of children meeting criteria for
    specific child anxiety disorder and mood disorder
    diagnoses (Table 1)
  • 52 children total
  • 8-14 years old
  • From same communities as AD youth, responded to
    notices for families to participate in research
  • Did not met criteria for any disorder
  • 48.1 males
  • 76.9 Caucasian
  • 17.3 African-American
  • 5.7 ethnic minority

Table 1Percentage of youth who met criteria for
DSM-IV anxiety and mood disorders
Parents of AD (Anxiety Disordered) Children
  • 165 mothers
  • 23-67 years old
  • 87.1 Caucasian
  • 12.9 ethnic minority
  • 15 some graduate school training
  • 31.2 college graduates
  • 25.3 some college training
  • 25.3 high school graduates or (GED)
  • 2.4 less than a high school education
  • 73.5 employed
  • 157 fathers
  • 26-63 years old
  • 87.1 Caucasian
  • 12.9 ethnic minority
  • 23 some graduate school training
  • 23.8 college graduates
  • 20.0 some college training
  • 29.4 high school graduates or (GED)
  • 4.3 less than a high school education
  • 93.8 employed

Family Income of AD (Anxiety Disordered)
  • 4.2 below 20,000
  • 11.5 between 20,000-40,000
  • 23.0 between 40,000-60,000
  • 25.5 between 60,000-80,000
  • 35.8 above 80,000

Table 2 Maternal and Paternal Diagnoses
Parents of NPD (No Psychological Disorder)
  • 52 mothers
  • 28-52 years old
  • 80.4 Caucasian
  • 17.6 African-American
  • 5.7 ethnic minority
  • 20.0 some graduate school training
  • 40.0 college graduates
  • 30.0 some college training
  • 10.0 high school graduates or (GED)
  • 82.0 employed
  • 50 fathers
  • 33-56 years old
  • 75.5 Caucasian
  • 22.4 African-American
  • 2.0 Hispanic
  • 14.0 some graduate school training
  • 30.6 college graduates
  • 30.6 some college training
  • 20.4 high school graduates or (GED)
  • 4.0 less than a high school education
  • 95.9 employed

Family Income of NPD (No Psychological Disorder)
  • 4.2 below 20,000
  • 14.6 between 20,000-40,000
  • 25.0 between 40,000-60,000
  • 35.4 between 60,000-80,000
  • 20.8 above 80,000

Table 2 Maternal and Paternal Diagnoses
Marital Status of AD and NPD Children
  • AD (Anxiety Disordered)
  • 78.7 married
  • 7.7 divorced
  • 5.3 separated
  • 7.1 never married
  • 1.2 widowed
  • NPD (No Psychological Disorder)
  • 78.0 married
  • 6.0 divorced
  • 4.0 separated
  • 12.0 never married

Measures child diagnostic status
  • Anxiety disorders interview schedule-parent and
    child versions for the DSM-IV (parent (ADIS-P)
    and child version (ADIS-C))
  • Semi-structured diagnostic interviews
    administered to parents and children
    independently to assess for DSM-IV anxiety
  • ADIS-C assessed symptomatology and severity of
    anxiety, mood, and externalizing disorders in

Measures parent diagnostic status
  • Anxiety Disorders Interview Schedule-IV Lifetime
    Version (ADIS-IV-L)
  • assesses for the lifetime presence of DSM-IV
    disorders in adults
  • Administered by interviewer blind to reason for
  • Diagnoses coded as absent or present, included
    PD with or without agoraphobia, SP, GAD, OCD,
    specific phobias, mood disorders (MDD, dysthymia,
    and bipolar disorder), and SUD
  • Anxious self-statements questionnaire (ASSQ)
  • 32 item self-report measure that assesses the
    frequency of self-talk associated with anxiety
  • 1-5 pt scale
  • Distinguishes between depressive and anxious

Measures parent diagnostic status
  • Automatic Thoughts Questionanaire (ATQ-R)
  • 40 item adult self-report questionnaire
  • 30 negative self-statements and 10 positive
  • Rated on 1-5 pt scale to indicate the frequency
    of thought in the last 2 months
  • Beck Depression Inventory, Second Ed (BDI-II)
  • 21 self-report measure of depressive symptoms
  • Rated on a 0-4 pt scale
  • State-Trait Anxiety Inventory (STAI)
  • 20-item measure used to assess state (STAI-S) and
    trait (STAI-T)

  • If child met initial criteria and parents agreed
    then the children and parents were scheduled for
    a diagnostic evaluation
  • If child met criteria for an anxiety disorder
    then parents were scheduled for a second
    assessment to complete diagnostic interviews
  • Separate diagnosticians blind to child diagnoses
    and reason for evaluation administered the
    ADIS-IV-L to each parent

Diagnostic reliability
  • Diagnosticians completed and passed a 2-phase
    training process before conducting interviews
  • Required to met 85 agreement with experienced

  • MANOVA conducted to examine variance between AD
    and NPD youth on parental self-reports of
    anxiety, depression, and anxious and depressive
  • Significant difference with mothers of AD youth
    reporting higher levels of trait and state
    anxiety compared to mothers of NPD

  • Fathers of AD youth compared to fathers of NPD
    youth showed significant group differences in
    state anxiety but not trait anxiety
  • Both mothers and fathers of AD youth reported
    more depressive symptoms than mothers and fathers
    of NPD youth
  • Mothers, not fathers, of AD youth reported more
    anxious and depressive self-talk than mothers of
    NPD youth

Father anxiety, mood, and SUD
  • Odds of any paternal lifetime anxiety disorder
    were 2.33x higher in AD compared to NPD youth
  • No significant associations between lifetime
    paternal SP with or without agoraphobia, GAD,
    OCD, or specific phobias
  • Significant association between AD youth and
    lifetime SUD, odds of paternal SUD were 2.52x
    higher in AD relative to NPD youth

Mother anxiety, mood, and SUD
  • Combined SAD and PD as one group, significant
    association between child SAD/PD and maternal
    lifetime PD
  • Maternal lifetime PD was 2.53x higher in youth
    with SAD/PD
  • Maternal lifetime SP was 2.09x higher in youth
    with SP relative to youth without
  • Odds of having OCD was 7.61x higher in mothers
    of youth with OCD compared to those without
  • Odds of a lifetime diagnosis of a specific phobia
    was 2.55x higher in mothers of youth with the
    diagnosis compared to those without

Table 3
  • Anxiety disorders aggregate in families
  • Increased rates of anxiety disorders were found
    in the parents of AD youth compared to parents of
  • Mothers of AD youth were over 3x as likely to
    meet criteria for SP in particular compared to
    mothers of NPD youth
  • Fathers of AD youth were over 2x as likely to
    meet criteria for any anxiety disorder
  • Associations between mother and child
    psychopathology may be stronger than those
    between father and child

  • Parental modeling of catastrophic thinking and
    anxious avoidance are related to the etiology and
    maintenance of anxiety disorders in youth
  • In this study maternal modeling may contribute to
    the similarity between mother and child anxiety
  • Presence of an AD child may be a stressor for
    parents and may affect parents mental health
  • Women may be more likely than men to experience
    psychological distress in response to familial

  • Fathers of AD youth had increased risk for
    lifetime SUD
  • Parents of AD youth were not found to be at
    increased risk for a lifetime mood disorder,
    however both reported higher levels of depressive
    symptomatology and mothers of AD youth reported
    more frequent depressive self-talk compared to
    NPD parents
  • Rates of parental mood disorders were high in
    both AD and NPD especially mothers (32 AD and
    27 NPD met the criteria for lifetime mood
  • Many AD youth met the criteria for multiple
    anxiety disorders or comorbid mood and
    externalizing disorders

  • Sample was predominantly Caucasian families with
    children between the ages of 7-14 and it is
    unclear whether these findings will generalize to
    other ethnicities or older children
  • High levels of parental anxiety may be associated
    with poorer treatment response

  • Anxiety disorders aggregate in families and place
    individuals at greater risk for developing mood
    and SUD
  • Similarity in the diagnoses of AD children and
    their mothers but not fathers suggest the
    psychopathology between mother and child may be
    stronger than father and child

  • Increased rates of anxiety disorders in parents
    of youth with anxiety disorders compared to
    parents of non-disordered youth
  • Child-mother relationship between SAD, PD, SP,
    OCD, and specific phobias
  • Child-father- fathers of AD children had an
    increased risk for lifetime SUD and when the
    presence of a paternal lifetime anxiety disorder
    was controlled the association disappeared
    suggesting the SUD was secondary to increased
    rates of paternal anxiety

Child Maltreatment
  • 905,000 children were abused or neglected in 2006
    in the US.
  • 64.2 were neglected.
  • 16 were physically abused.
  • 8.8 were sexually abused.
  • 6.6 were emotionally or psychologically
  • High rates of major depression, PTSD, and other
    behavioral disorders have been reported in
    maltreated children and these disorders are
    frequent in adults with a history of childhood

According to the National Center of Child Abuse
and Neglect C. Heim and C. B. Nemeroff. The role
of childhood trauma in the neurobiology of mood
and anxiety disorders preclinical and clinical
studies. Biol.Psychiatry 49 (12)1023-1039, 2001.
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