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

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Anxiety, Mood, and Substance Use Disorders in
Parentsof Children With Anxiety Disorders

• Kristi Tschetter
• 11/6/09

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Model between genes and early enviornment
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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)

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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

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GAD

• Diagnosed when a person worries excessively about
  a variety of everyday problems for at least 6
  months
• 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
  age.
• There is evidence that genes play a modest role
  in GAD.
• Other anxiety disorders, depression, or substance
  abuse often accompany GAD, which rarely occurs
  alone.

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Obsessive-Compulsive Disorder (OCD)

• Characterized by recurrent, unwanted thoughts
  (obsessions) and/or repetitive behaviors
  (compulsions).
• 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.

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OCD

• 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
  families.

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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
  distress.
• Feelings of terror that strike suddenly and
  repeatedly with no warning.

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PD

• 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.

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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
  startled.

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PTSD

• 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.

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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.

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SP/SAD

• 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
  adults.
• Women and men are equally likely to develop the
  disorder.
• Usually begins in childhood or early adolescence.
• There is some evidence that genetic factors are
  involved.
• Often accompanied by other anxiety disorders or
  depression, and substance abuse may develop if
  people try to self-medicate their anxiety.

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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
  symptoms.
• These mental disorders form a subcategory of the
  substance-related disorders.

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Internalizing vs. Externalizing

• Trait
• Anxiety
• Depression
• Withdrawal
• Somatic complaints

• State
• Attention problems
• Aggressive behavior
• Rule-breaking actions

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CHILDREN OF LOW-INCOME DEPRESSED MOTHERS
PSYCHIATRIC DISORDERS AND SOCIAL ADJUSTMENTFeder
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

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• 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

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Hypothesis

• 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

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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
  duration
• Never depressed mothers with no lifetime history
  of MDD
• Up to 3 children per family 8-17 years old

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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

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Table 1
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Table 2
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Table 3
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Table 4
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Discussion

• 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

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Discussion

• 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

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Limitations

1. Samle size
2. Recruited a sample of convience - may not be
   representative
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

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Conclusion

• 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

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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.

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Background

• 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

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Background

• 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
  relatives
• 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
  SAD
• A relationship between child SAD and maternal
  lifetime SAD has been documented

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Background

• 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
  parents

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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

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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
  children
• 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

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Hypothesis

• 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)

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Methods

• 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
  medication
• All participants were administered the anxiety
  disorders interview schedule-parent and child
  versions for DSM-IV to asses for child diagnoses

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Methods

• 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

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Table 1Percentage of youth who met criteria for
DSM-IV anxiety and mood disorders
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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

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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

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Table 2 Maternal and Paternal Diagnoses
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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

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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

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Table 2 Maternal and Paternal Diagnoses
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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

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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
  disorders
• ADIS-C assessed symptomatology and severity of
  anxiety, mood, and externalizing disorders in
  youth

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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
  interview
• 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
  self-talk

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Measures parent diagnostic status

• Automatic Thoughts Questionanaire (ATQ-R)
• 40 item adult self-report questionnaire
• 30 negative self-statements and 10 positive
  self-statements
• 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)

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Procedures

• 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

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Diagnostic reliability

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

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Results

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

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Results

• 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

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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

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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

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Table 3
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Discussion

• Anxiety disorders aggregate in families
• Increased rates of anxiety disorders were found
  in the parents of AD youth compared to parents of
  NPD
• 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

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Discussion

• 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
  diagnoses
• 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
  stress

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Discussion

• 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
  disorder)
• Many AD youth met the criteria for multiple
  anxiety disorders or comorbid mood and
  externalizing disorders

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Discussion

• 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

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Summary

• 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

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Summary

• 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

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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
  mistreated.
• 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
  abuse.

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.