IntroductionSupportive Parenting for Anxious Childhood Emotions (SPACE) is an evidence-based treatment for parents of children with anxiety disorders and/or obsessive-compulsive disorder (OCD). Given the many barriers to accessing such evidence-based treatments, we evaluated for the first time the application of group-based SPACE, delivered to parents via telemedicine within a public health outpatient setting.MethodsIn this single arm retrospective analysis of routine-care data participants, recruited from a hospital-based anxiety clinic, were mothers (N=50) of fifty children, ages 6.7-18.0 years (mean 11.2 ± 3.1), diagnosed with an anxiety disorder and/or OCD. Parent and child self-report measures assessed the impact of treatment on child anxiety symptoms, parental accommodation, parental anxiety and depression. Treatment feasibility, acceptability and satisfaction were assessed.ResultsPost treatment, significant reductions were evident in child self-reported separation anxiety symptoms (p =0.008), mother-reported child anxiety symptoms (p=0.002), maternal accommodation (p=0.006), anxiety (p=0.004) and depressive symptoms (p=0.011). Treatment proved feasible, with completion rates of 77.3%, and participants reported high levels of satisfaction with the telemedicine format.DiscussionThis is the first study of group-based SPACE over telemedicine. Results support the utility of this modality for overcoming treatment barriers in public health settings with highly heterogenous populations.

BACKGROUND:Because pediatric anxiety disorders precede the onset of many other problems, successful prediction of response to the first-line treatment, cognitive-behavioral therapy (CBT), could have a major impact. This study evaluates whether structural and resting-state functional magnetic resonance imaging can predict post-CBT anxiety symptoms. METHODS:Two datasets were studied: (A) one consisted of n = 54 subjects with an anxiety diagnosis, who received 12 weeks of CBT, and (B) one consisted of n = 15 subjects treated for 8 weeks. Connectome predictive modeling (CPM) was used to predict treatment response, as assessed with the PARS. The main analysis included network edges positively correlated with treatment outcome and age, sex, and baseline anxiety severity as predictors. Results from alternative models and analyses are also presented. Model assessments utilized 1000 bootstraps, resulting in a 95% CI for R2, r, and mean absolute error (MAE). RESULTS:The main model showed a MAE of approximately 3.5 (95% CI: [3.1-3.8]) points, an R2 of 0.08 [-0.14-0.26], and an r of 0.38 [0.24-0.511]. When testing this model in the left-out sample (B), the results were similar, with an MAE of 3.4 [2.8-4.7], R2-0.65 [-2.29-0.16], and r of 0.4 [0.24-0.54]. The anatomical metrics showed a similar pattern, where models rendered overall low R2. CONCLUSIONS:The analysis showed that models based on earlier promising results failed to predict clinical outcomes. Despite the small sample size, this study does not support the extensive use of CPM to predict outcomes in pediatric anxiety.

Background Mood episodes and high suicide risk of bipolar disorder (BD) are thought to derive from amygdala–ventral prefrontal cortex emotion regulation brain circuitry dysfunction and resulting emotion dysregulation, making these potential intervention targets.Objective To assess feasibility, acceptability, and preliminary efficacy in engaging the emotion regulation targets of two Brain Emotion Circuitry-targeted Self-Monitoring and Regulation Therapy (BE-SMART) variations in adolescents and young adults with BD (BDAYA): BE-SMART-ER, which directly targets emotion regulation, and BE-SMART-DR, a social rhythm therapy (SRT)-based chronotherapeutic intervention designed to reduce daily rhythm (DR) irregularities.Methods In a single-blind, parallel, pilot-randomised trial, 60 BDAYA (aged 16–29 years) were randomised to 12 weekly sessions (9 telehealth) of BE-SMART-DR or BE-SMART-ER. Nineteen BE-SMART-DR and 16 BE-SMART-ER participants completed the intervention, with 11 and 13, respectively, having pre-intervention and post-intervention functional MRI data.Findings In addition to demonstrating feasibility, only BE-SMART-DR showed pre-treatment to post-treatment improvements in DR regularity (Cohen’s d=0.55; 95% CI [0.06, 1.03]), associated with reductions in left amygdala responses to emotional face stimuli (pFWE (family-wise error)-SVC (small volume correction)<0.05), difficulties in emotion regulation (d=0.75; 95% CI [0.23, 1.25]) and suicide risk (d=0.65; 95% CI [0.15, 1.14]). Significant correlations were observed among these changes (p<0.05). Both interventions showed high acceptability and improvements in depression and mania symptoms. No intervention-related adverse events were observed.Conclusions Regularising DRs may enhance emotion regulation brain circuitry functioning, emotion regulation, and reduce suicide risk in BDAYA.Clinical implications Chronotherapeutic interventions regularising DRs, such as SRT, should be studied further as potential treatment strategies for BDAYA.Trial registration number NCT03183388.

Questions have been raised about how social media may be experienced by adolescents with mental health concerns. Among socially anxious adolescents, social media may be experienced both negatively, because it can exacerbate core fears (e.g., negative evaluation), and positively, because it can alleviate other core fears (e.g., in-person interactions). We examined whether adolescent social anxiety is associated with social media experiences and is influenced by sex (girl/boy). Participants were 282 early adolescents (Mage = 11.79 years, 63

Background Anxiety disorders are common, debilitating psychiatric conditions that frequently onset in childhood and place youth at increased risk for mental health conditions throughout their lifetimes. Research has long demonstrated the role of genetics in the development of childhood anxiety disorders, but few specific genetic risk factors have yet to be identified. Genomic studies of parent-child trios have proven to be a powerful approach for identifying genetic risk factors in other related childhood onset neuropsychiatric conditions, and this approach has yet to be extensively leveraged in the study of childhood anxiety. In this presentation, we discuss new findings from a DNA sequencing study of parent-child trios with childhood anxiety disorders. Methods Children and their biological parents were recruited and assessed in an anxiety disorders clinic as part of an ongoing genetic study at Yale. Low-pass (2x) whole genome DNA sequencing (WGS) and high-coverage (80x) whole-exome DNA sequencing (WES) was conducted in 130 parent-child trios (390 samples total) so far. The low-pass WGS data was imputed with GLIMPSE2 and polygenic risk scores (PRS) were calculated using PRS-CS and available GWAS summary statistics with anxiety (ANX), depression (MDD), obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD). GenoPred was used for quality control, ancestry classification, and PRS scoring. Initial analyses focused on the 101 families of European Ancestry that passed quality control with plans to examine other ancestry groups as more data is generated. The polygenic transmission disequilibrium test (pTDT) was used to assess whether the affected child had an increased polygenic load for psychiatric conditions compared to their parents. Results In this sample, children with anxiety disorders show an elevated transmission of polygenic risk from their parents, with MDD and OCD achieving statistical significance (MDD mean pTDT=0.34, p=0.0009; OCD mean pTDT=0.27, p=0.01; ANX mean pTDT=0.21, p=0.05; ADHD mean pTDT=0.06, p=0.57). Analyses are also currently underway examining rare de novo and transmitted gene-damaging variants in these parent-child trios in order to assess the combinatorial effects of PRS and rare variation in childhood anxiety disorders. Discussion This research provides new insight into the transmission of polygenic risk for psychiatric conditions in children with anxiety disorders. Our findings suggest that children presenting with anxiety disorders inherit an elevated polygenic risk for MDD and OCD, consistent with possible shared genetic predispositions to these disorders and increased risk of children with anxiety developing MDD and OCD later on. The lack of statistical significance of anxiety PRS may be due to our limited sample size or may suggest distinct genetic factors in this childhood anxiety sample and the adult anxiety GWAS. We expect as our sample size increases, we will be able to make more robust conclusions about the genomic architecture of childhood anxiety. Overall, this work advances our understanding of the genetic underpinnings of childhood anxiety disorders, underscoring the value of DNA sequencing in larger cohorts.

Trichotillomania (TTM) and excoriation disorder (ED) run in families and are thought to have shared etiological underpinnings. Only a few small studies have compared the family history of individuals with TTM, ED, and both conditions. To better understand shared predispositions, we examined self-reported family history of mental health disorders using cross-sectional survey responses from a genetics study of probands ages 4-66 years with TTM only (n = 69), ED only (n = 34), and both conditions (n = 70). Individuals with TTM only reported higher rates of having a first-degree relative with TTM (25 %, 17/69) compared to individuals with ED only (6 %, 2/34) (p = 0.03). Those with ED only reported higher rates of a first-degree relative with ED (41 %, 14/34) compared to individuals with TTM only (13 %, 9/69) (p = 0.002). Individuals with both conditions reported high rates of first-degree relatives with TTM (21 %, 15/70) and ED (39 %, 27/70). All three groups reported high rates of family history of anxiety (48 %-59 %), depression (41 %-49 %), ADHD (23 %-31 %), and OCD (17 %-18 %). Comparing mental health history in parents, there were no significant differences between the parents for TTM or ED, but mothers had higher rates than fathers of anxiety (42 % maternal vs. 18 % paternal) and depression (34 % maternal vs. 14 % paternal) (p-values < 0.001). Our results provide evidence of both shared and distinct predispositions between TTM and ED, highlighting the need for further research on genetic and environmental factors contributing to these conditions.

Parental anxiety and family accommodation have been implicated in the development and maintenance of child anxiety, yet their relationships with specific child anxiety dimensions remain unclear. This study applied network analysis to examine these interconnections in a clinical sample of 433 children with primary anxiety disorders. The estimated network revealed that family accommodation was strongly associated with separation anxiety. Generalized and panic/somatic anxiety were the most interconnected child anxiety dimensions, whereas social anxiety and parental anxiety were the least. Clustering analysis identified two groups: one comprising family accommodation, parental anxiety, and separation anxiety, and another including all other child anxiety dimensions. Stability metrics supported confidence in the network's structure, and network comparisons revealed no significant structural differences across informants or age groups. These findings provide further insight into the relationships between parental factors and child anxiety dimensions, particularly the strong link between family accommodation and separation anxiety.

Background: Pediatric obsessive-compulsive disorder (OCD) is a severely impairing disorder, associated with high levels of family accommodation (FA). Approximately 40 % of youth do not benefit from first-line treatment options (cognitive behavioral therapy or pharmacotherapy). Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based treatment, teaching parents to reduce FA and increase supportive parenting, thereby aiming to improve the child's OCD. This article presents the protocol of a multiple baseline single-case experimental design (SCED) study to test the efficacy of SPACE in reducing OCD severity and FA in youth with OCD. Methods: This SCED consists of a baseline, treatment, and follow-up phase. In total 25 youth (7-18 years) with OCD, who previously received cognitive behavioral therapy (CBT) unsuccessfully, aborted treatment early, or were not able to receive CBT due to too high levels of OCD/anxiety, and their parents will be included. They will be randomly allocated to one of three baseline phase options (4, 6 or 8 weeks). The treatment phase consists of 12 weekly sessions of SPACE with parents. Throughout all phases, OCD severity and FA will be briefly assessed thrice a week. Standard clinical measurements assessing OCD severity and FA and secondary parameters will be conducted at six timepoints, till 6 months follow-up. Conclusion: Combining the innovative SPACE treatment with a SCED provides detailed insight into the relationship between OCD and FA over time. Studying this in clinical practice in complex cases that are normally understudied, helps to improve more personalized care for youth with OCD.

Objective: To examine the efficacy of the parent-led intervention Supportive Parenting for Anxious Childhood Emotions (SPACE) relative to a low-dose version of the protocol among children and adolescents with clinically significant anxiety and/or obsessive-compulsive disorder (OCD).Method: 68 youth (7-17) with anxiety/OCD and their parents were randomized to receive 12 weekly telehealth SPACE sessions (SPACE-Standard) or bibliotherapy plus 4 telehealth sessions over 12 weeks (SPACE-light). After screening, assessments were conducted via videoconferencing at baseline, post-treatment, and one-month follow-up. Independent evaluators were blind to treatment condition.Results: Treatment condition did not predict whether a participant responded to the intervention (SPACE-Standard = 70%; SPACE-Light = 68%), nor was treatment condition a predictor of anxiety severity, parent-reported anxiety, or parent-/child-reported functional impairment at post-treatment or one-month follow-up. Youth in SPACE-Light self-reported higher post-treatment anxiety than youth in SPACE-standard, though this was no longer significant at one-month follow-up. Parent-reported family accommodation total change scores were associated with anxiety severity at post-treatment across both arms.Conclusion: This is the second randomized controlled trial (RCT) evaluating SPACE and provides further support for the efficacy of this intervention both in standard and low-dose formats. This study provides support for parent-led anxiety treatment targeting family accommodation as a primary mechanism of change and extends evidence of efficacy to a more clinically diverse sample.Trial registration: ClinicalTrials.gov Registry: NCT04922502.https://classic.clinicaltrials.gov/ct2/show/NC T04922502.

Introduction: Oxytocin has been implicated as a biological mechanism within obsessive-compulsive disorder (OCD). Few studies only involving adults have investigated this hypothesis and found inconsistent results. We investigated whether salivary oxytocin concentrations differed between children and adolescents with and without OCD and qualified our comparative analysis by investigating the possible covariates age, pubertal stage, and sex. Methods Participants included 113 children and adolescents (8–17 years) with OCD and 88 children and adolescents without any previous or current psychiatric disorder and their parents (254 parents included). Salivary oxytocin concentrations were measured with enzyme-linked immunosorbent assay (ELISA). Statistical analyses were performed using frequentist and Bayesian approaches. Results We found no evidence of a difference in mean salivary oxytocin concentrations between children and adolescents with and without OCD. Bayesian analyses indicated anecdotal to moderate support for the null hypothesis. We found an association between oxytocin and age and pubertal stage, which by visual inspection of plots and post-hoc tests indicated a nonlinear relationship. We found no association between oxytocin and sex. Conclusion Our findings do not suggest elevated oxytocin concentrations in pediatric OCD. Nonlinear changes in oxytocin across development show the importance of accounting for hormonal and behavioral changes during puberty.

Attention training is an evidence-based, computerized treatment for anxiety and its disorders rooted in cognitive neuroscience. Though experimental research and clinical trials data on attention training in children span two decades, the literature has focused on attention training’s anxiety reduction effects, with little guidance on its implementation in clinical practice. Guidance on implementation is needed given recent efforts to increase accessibility of attention training in clinical practice settings. In this article, we move from research to clinical implementation, providing guidelines with pragmatic clinical steps. We include guidance on psychoeducation, setting and delivery of sessions, potential challenges, and frequently asked questions regarding implementation.

Although cognitive behavioral therapy (CBT) can be effective for treating pediatric anxiety disorders, up to 50% of clinically anxious youth do not respond sufficiently to CBT. Parents play a central role in guiding children's learning about threat and safety and in regulating their anxiety, highlighting the possibility of a parent-focused treatment to enhance clinical efficacy. However, the neural mechanisms that support anxiety reduction in parent-focused treatment remain unknown. Comparing neural correlates of symptom change in parent-focused treatment versus CBT may help to guide treatment optimization and targeted treatment recommendations.

Family accommodation, or changes in parental behavior aimed at avoiding or alleviating child anxiety-related distress, contributes to the severity of anxiety symptoms, and is most strongly associated with separation anxiety. This study examined whether child attachment security, characterized as the degree to which children perceive their parents to be reliable, available, and communicative, moderates the association between family accommodation and separation anxiety symptoms, and whether this moderation is specific to separation anxiety among other anxiety symptoms. In a sample of clinically anxious children (N = 243, 6–12 years), family accommodation was significantly positively associated with separation anxiety symptoms across levels of attachment security. Family accommodation was more strongly associated with parent-reported separation anxiety symptoms in children with lower attachment security compared with those with higher attachment security. No significant moderation effect emerged for other anxiety symptoms. Findings enhance understanding of the role of attachment within family accommodation of child anxiety.

Background: Despite broad recognition of the central role of avoidance in anxiety, a lack of specificity in its operationalization has hindered progress in understanding this clinically significant construct. The current study uses a multimodal approach to investigate how specific measures of avoidance relate to neural reactivity to threat in youth with anxiety disorders. Methods: Children with anxiety disorders (ages 6-12 years; n = 65 for primary analyses) completed laboratory task- and clinician -based measures of avoidance, as well as a functional magnetic resonance imaging task probing neural reactivity to threat. Primary analyses examined the ventral anterior insula (vAI), amygdala, and ventromedial prefrontal cortex (vmPFC). Results: Significant but distinct patterns of association with task- versus clinician -based measures of avoidance emerged. Clinician -rated avoidance was negatively associated with right and left vAI reactivity to threat, whereas laboratory -based avoidance was positively associated with right vAI reactivity to threat. Moreover, left vAI-right amygdala and bilateral vmPFC-right amygdala functional connectivity were negatively associated with clinicianrated avoidance but not laboratory -based avoidance. Limitations: These results should be considered in the context of the restricted range of our treatment -seeking sample, which limits the ability to draw conclusions about these associations across children with a broader range of symptomatology. In addition, the limited racial and ethnic diversity of our sample may limit the generalizability of findings. Conclusion: These findings mark an important step towards bridging neural findings and behavioral patterns using a multimodal approach. Advancing understanding of behavioral avoidance in pediatric anxiety may guide future treatment optimization by identifying individual -specific targets for treatment.

OBJECTIVE:Functional somatic symptoms are associated with significant distress and impairment for children and their families. Despite the central role that families play in their children's care, there is little clinical research to guide how parents can support their children with functional somatic symptoms and promote better functioning. To address this gap, we developed a parent-based intervention for functional somatic symptoms in children and obtained preliminary data on acceptability, feasibility, treatment satisfaction, and clinical outcomes. METHOD:The intervention was adapted from SPACE (Supportive Parenting for Anxious Childhood Emotions), an evidence-based treatment for anxiety and related disorders in children. The intervention, SPACE-Somatic, was delivered to parents of 16 children (Mage = 14.50 years; 75% girls) with a range of functional somatic symptoms. Parents participated in seven weekly group sessions conducted via telehealth. RESULTS:We found that SPACE-Somatic was acceptable, feasible, and satisfactory to parents. There were significant improvements in several clinical outcomes from baseline to posttreatment, including children's level of functional impairment, with some gains maintained at 3-month follow-up. Parents also reported improvements in their own stress and their accommodation of children's symptoms. CONCLUSION:This pilot study provides preliminary evidence that a parent-based intervention is viable and beneficial to children with functional somatic symptoms and their parents.