Background Poor persistence and adherence to attention-deficit/hyperactivity disorder (ADHD) medication is a significant barrier to effective long-term care, particularly during adolescence, yet age-specific and sex-specific trajectories remain poorly characterised.Objective To characterise medication initiation, discontinuation and long-term adherence patterns for children and adolescents diagnosed with ADHD in a real-world setting.Methods A nationwide retrospective cohort study, including 8961 children and adolescents (aged <18 years) with a new ADHD diagnosis in child and adolescent mental health services between 1 January 2010 and 31 December 2012, with follow-up until 31 December 2021. Main outcomes were medication initiation rates; time to first medication discontinuation, analysed using Kaplan-Meier estimates and restricted mean survival time at 1 year and longitudinal adherence, measured by the proportion of days covered over 9 years.Findings Of the 8961 individuals in the cohort (mean age at diagnosis, 12 years; 69% male), 6661 (74.3%) initiated medication, with a median time from diagnosis to initiation of 106 days (IQR 17–231); 55% initiated within 90 days. Discontinuation increased significantly with age; adolescents aged 15–17 years remained on treatment for 31.9 fewer days (95% CI −40.8 to −23.1; p<0.001) in the first year compared with children aged 5–11 years. Females also discontinued significantly earlier than males (difference −13.2 days; 95% CI −19.8 to −6.5; p<0.001). Longitudinal analysis confirmed that older age at initiation and female sex were associated with a significantly steeper decline in medication coverage over time.Conclusions Discontinuation and low adherence to ADHD medication were common and increased substantially through adolescence, with females at higher risk of early cessation.Clinical implications Late adolescence warrants closer clinical monitoring and shared decision-making to support appropriate treatment continuation or well-informed discontinuation, particularly for older adolescents and females. Integrating structured transition planning and attention to sex-specific barriers may help reduce avoidable non-adherence during this high-risk period.

BACKGROUND:Children and adolescents with attention-deficit hyperactivity disorder (ADHD) have a higher likelihood of contact with child welfare services (CWS). Evidence on whether pharmacological treatment of ADHD reduces such contact is limited. AIMS:To estimate the causal effect of pharmacological treatment of ADHD on CWS contact. METHOD:In this quasi-experimental study, we used nationwide registry data covering all individuals aged 5-14 years and diagnosed with ADHD during 2009-2011 in Norway. We used linear probability models and instrument variable analyses to estimate the associations and causal effects of pharmacological treatment on CWS contact up to 4 years after diagnosis. As instrument variable analysis uses natural variation in treatment decisions between clinics as pseudo-randomisation, estimates inform effects for children and adolescents at the margin of treatment, i.e. patients whose treatment is more influenced by variation in treatment practice, e.g. due to less severe or atypical symptom presentation. RESULTS:A total of 5930 children and adolescents aged 5-14 years were diagnosed with ADHD between 2009 and 2011 (mean (s.d.) age 10.1 (2.4) years; 4380 males (73.9%)). Instrument variable analyses showed a reducing effect of pharmacological treatment on the use of supportive interventions by 11.9 percentage points (95% CI: -20.12, -3.80) and out-of-home-placement by 3.30 percentage points (95% CI: -6.44, -0.15) at 2-year follow-up. This corresponds to the numbers needed to treat estimates of 8 and 30, respectively. CONCLUSIONS:Pharmacological treatment of ADHD reduces CWS contact among children and adolescents at the margin of treatment, lowering the probability of receiving supportive interventions and out-of-home placements. Findings suggest that medication reduces behavioural symptoms, which may improve the family coping mechanism and reduces the need for CWS involvement. TRIAL REGISTRATION:ISRCTN11891971.

BACKGROUND:Geographical variation in Attention-Deficit/Hyperactivity Disorder (ADHD) diagnoses remains poorly understood. Previous research has found that the variation in ADHD rates between Child and Adolescent Mental Health Services (CAMHS) is not attributable to ADHD symptom load in the catchment areas of the CAMHS. This study aimed to investigate if geographical variation in rates of ADHD-diagnosis per population and per patient, as well as referral rates to CAMHS, were associated with catchment area characteristics. METHODS:We used data from the Norwegian Patient Registry, covering everyone aged 5-18 in contact with CAMHS 2009-2011, and catchment area level data from Statistics Norway, including population size, centrality, socioeconomic position, welfare reliance, and general population health. Spearman's Rho was calculated to assess the strength and direction of monotonic correlation. RESULTS:Referral rates to CAMHS per population were lower in catchment areas with higher proportion of non-European population; more urban areas; fewer adults receiving disability benefits; and more economic inequality. Higher rates of ADHD per population were seen in areas characterised by lower socio-economic position. The rate of ADHD diagnosis per patient in CAMHS ranged from 5 to 27% and was not associated with catchment area characteristics. CONCLUSION:This study found that the proportion of ADHD diagnoses per population was moderately related to catchment area characteristics, following a social gradient in health. However, the proportion of ADHD diagnoses among patients in CAMHS was unrelated to area characteristics. This suggests that other factors, such as variation in clinician attitudes or local practice styles, may contribute to the strong variation in ADHD diagnoses.

Children and adolescents with attention-deficit/hyperactivity disorder (ADHD) and their parents often face challenges that may lead to contact with child welfare services (CWS). However, there is a lack of studies addressing this issue. This study assessed the rate and association between ADHD and different types of CWS contact compared to the general population. We also examined whether individual and parental characteristics were associated with CWS contact among children and adolescents with ADHD. We employed a longitudinal research design and examined an 18-year age trajectory for a cohort of 8,051 children and adolescents aged 5 to 18 years diagnosed with ADHD between 2009 and 2011, linking several Norwegian nationwide registries. Descriptive statistics and logistic regression analysis assessed rate and association between ADHD and CWS contact. Chi-square tests and t-tests examined associations between individual and parental characteristics and CWS contact among those with ADHD. Children and adolescents with ADHD had considerably higher rate of any CWS contacts (32.7%) compared to the general population (6.1%). ADHD was significantly associated with both out-of-home placement (aOR = 7.3, 95% CI: 5.2–10.2) and supportive interventions (aOR = 6.3, 95% CI: 5.1–7.7). Among those with ADHD, comorbid conduct disorder and a criminal record were significantly associated with CWS contact compared to those without CWS contact. Additionally, they were more likely to have unmarried parents and parents with lower income and educational level. These findings provide novel insight into the relationship between ADHD and contact with CWS. Future research should examine the impact of clinical and behavioral treatment of ADHD on contact with CWS.

Mental health difficulties in preschool children often go unnoticed and may result in delayed access to potentially beneficial services. In Norwegian kindergartens, teachers get to know the children well over time and have parent-teacher conferences once or twice a year. Kindergarten is thus a well-suited arena for early identification and intervention of mental health difficulties. To address the need for a kindergarten-specific method for secondary prevention, we have developed Dialogue-Based Early Detection (DBED) in close collaboration with educators and parents in eight different kindergartens. Results from a feasibility study indicate that DBED works well as a parent-teacher collaborative screening method and is well accepted by the users. In the PRO-DIALOG project, we will examine the potential of DBED and explore its possible long-term effects in a randomized controlled trial. Ten kindergartens will be randomly selected to implement DBED, while ten will act as controls, offering ordinary parent-teacher conferences. Parents of at least 100 + 100 children will be recruited. The primary outcome will be children’s mental health in the intervention group as assessed by the Strengths and Difficulties Questionnaire (SDQ), during the 5-year follow-up, compared to the control group. Secondary outcomes will be (i) the effect of DBED on parental stress as measured by the Parental Stress Scale (PSS) and (ii) time to activation of support, as measured by the duration from the first parent-teacher conference to activation of any support, comparing the two groups. We will also assess (iii) socio-demographic predictors for mental health development, parent and teacher concern for the child, parental stress, and parent satisfaction with DBED, (iv) screening properties of DBED compared to SDQ, and (v) social validity of DBED as measured by user-satisfaction questionnaires and interviews with both parents and teachers. This complex intervention study includes a wide range of outcomes beyond the mental health scores of kindergarten children. If the intervention is well accepted and has a positive influence on the children’s mental health, the DBED method has a potential for a wide dissemination. This study will produce new knowledge on kindergarten as an arena for the promotion of mental health among young children. ClinicalTrials.gov NCT06471816. Registered on 2024–06-22 16:06. Retrospectively registered.

Background Psychiatric comorbidity is frequent among persons with attention-deficit/hyperactivity disorder (ADHD). Whether pharmacological treatment of ADHD influences the incidence of psychiatric comorbidity is uncertain. Objective To investigate associations and causal relations between pharmacological treatment of ADHD and incidence of subsequent comorbid psychiatric diagnoses. Methods We employed registry data covering all individuals aged 5-18 years in Norway who were diagnosed with ADHD during 2009-2011 (n=8051), followed until 2020. We used linear probability models (LPM) and instrumental variable (IV) analyses to examine associations and causal effects, respectively, between pharmacological treatment and subsequent comorbidity. Findings From time of ADHD diagnosis to 9 years of follow-up, 63% of patients were registered with comorbid psychiatric disorders. For males, LPM showed associations between ADHD medication and several incident comorbidities, but strength and direction of associations and consistency over time varied. For females, no associations were statistically significant. IV analyses for selected categories isolating effects among patients 'on the margin of treatment' showed a protective effect for a category of stress-related disorders in females and for tic disorders in males for the first 2 and 3 years of pharmacological treatment, respectively. Conclusions Overall, LPM and IV analyses did not provide consistent or credible support for long-term effects of pharmacological treatment on later psychiatric comorbidity. However, IV results suggest that for patients on the margin of treatment, pharmacological treatment may initially reduce the incidence of certain categories of comorbid disorders. Clinical implications Clinicians working with persons with ADHD should monitor the effects of ADHD medication on later psychiatric comorbidity. Trial registration number ISRCTN11891971.

Objective: Criminality rates are higher among persons with attention-de fi cit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers ' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4 -year criminal outcomes. Method: We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider ' s preference. Results: Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients ' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and publicorder - related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traff i c-, sexual-, or propertyrelated charges. Conclusion: This is the fi rst study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a populationbased natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning. Study preregistration information: The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971.

Prevalence and medication rates of ADHD vary geographically, both between and within countries. No absolute cutoff exists between ADHD and normal behavior, making clinician attitudes (leading to local practice cultures) a potential explanation for the observed variation in diagnosis and medication rates. The objective of this study was to describe variation in attitudes toward diagnosis and medication of ADHD among clinicians working in child and adolescent mental health services (CAMHS). We hypothesized that attitudes would vary along a spectrum from “restrictive” to “liberal”. We also explored whether differences in attitudes between clinicians were related to professional background and workplace (clinic). A survey in the form of a web-based questionnaire was developed. All CAMHS outpatient clinics in Norway were invited. Potential respondents were all clinicians involved in diagnosing and treating children and adolescents with ADHD. To investigate the existence of attitudes toward diagnosis and medication as latent constructs, we applied confirmatory factor analysis (CFA). We further examined how much of variance in attitudes could be ascribed to profession and clinics by estimating intraclass correlation coefficients. In total, 674 respondents representing 77 (88%) of the clinics participated. We confirmed variation in attitudes with average responses leaning toward the “restrictive” end of the spectrum. CFA supported “attitude toward diagnosis” and “attitude toward medication” as separate, and moderately correlated ( r = 0.4) latent variables, representing a scale from restrictive to liberal. Professional background and workplace explained only a small part of variance in these attitudes.

OBJECTIVE:Criminality rates are higher among persons with attention-deficit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4-year criminal outcomes. METHOD:We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider's preference. RESULTS:Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and public-order-related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traffic-, sexual-, or property-related charges. CONCLUSION:This is the first study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a population-based natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning. STUDY PREREGISTRATION INFORMATION:The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971.

ADHD is associated with an increased risk of injury. Causal evidence for effects of pharmacological treatment on injuries is scarce. We estimated effects of ADHD medication on injuries using variation in provider preference as an instrumental variable (IV). Using Norwegian registry data, we followed 8051 patients who were diagnosed with ADHD aged 5 to 18 between 2009 and 2011 and recorded their ADHD medication and injuries treated in emergency rooms and emergency wards up to 4 years after diagnosis. Persons with ADHD had an increased risk of injuries compared to the general population (RR 1.35; 95% CI: 1.30-1.39), with higher risk in females (RR 1.47; 95% CI: 1.38-1.56) than males (RR 1.23; 95% CI: 1.18-1.28). The between-clinics variation in provider preference for ADHD medication was large and had a considerable impact on patients' treatment status. There was no causal evidence for protective effects of pharmacological treatment on injuries overall for young individuals with ADHD characterized by milder or atypical symptoms. However, there was an apparent effect of pharmacological treatment over time on the risk of injuries treated at emergency wards in this patient group.

BackgroundThere are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.MethodsWe searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.ResultsThe prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.ConclusionsDespite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.

Rates of ADHD diagnosis vary across regions in many countries. However, no prior study has investigated how much within-country geographic variation in ADHD diagnoses is explained by variation in ADHD symptom levels. We examine whether ADHD symptom levels explain variation in ADHD diagnoses among children and adolescents using nationwide survey and register data in Norway. Geographical variation in incidence of ADHD diagnosis was measured using Norwegian registry data from the child and adolescent mental health services for 2011–2016. Geographical variation in ADHD symptom levels in clinics’ catchment areas was measured using data from the Norwegian mother, father and child cohort study for 2011–2016 (n = 39,850). Cross-sectional associations between ADHD symptom levels and the incidence of ADHD diagnoses were assessed with fractional response models. Geographical variation in ADHD diagnosis rates is much larger than what can be explained by geographical variation in ADHD symptoms levels. Treatment in the Norwegian child and adolescent mental health services is free, universally available upon referral, and practically without competition from the private sector. Factors beyond health care access and unequal symptom levels seem responsible for the geographical variation in ADHD diagnosis.

Background Among 1–7 years old children the worldwide prevalence of mental disorders is ~20%. Without treatment, the prognosis of such disorders in children is poor. Early intervention is estimated to result in a positive return. However, traditional screening to detect children at need is particularly challenging due to the concerns by false positives. The aim of the current study was to develop a more acceptable though effective method using the existing annual evaluation meetings between parents and teachers in a more systematic and goal directed way. The method should build on the teacher's and parents' complementary knowledge and perception of the child, and fit into the everyday routines in daycare centers. Method During a period of 6 years, a developmental process aiming for a novel screening method was carried out in cooperation with eight Norwegian daycare centers. After conception of the idea, the framework of the Dialogue Based Early Detection including the first version of the Early Worry Questionnaire (EWQ) was constructed. An iterative process involving parents and teachers completing workshops and subsequent testing facilitated a re-modeling of the method. Results In the resulting Dialogue Based Early Detection a 36-item version of EWQ was completed by both parents and teachers ahead of the annual parent-teacher meeting. During that meeting the participants should try to reach a consensus whether there was a concern, some uncertainty, or no worry for the child, and which appropriate actions should be taken for a possible follow up. Both parents and teachers reported that the EWQ supported them in verbalizing already existing worries for the child. Teachers reported that parents were better prepared and participated more actively in the evaluation meetings. However, some parents complained that there was too much focus on possible worries. During the testing, challenges of language development, conduct, emotional reactions, toileting, attention, and eating were detected among the children. Conclusion The Dialogue Based Early Detection method was endorsed by both teachers and parents and holds promise as a tool for improving early awareness and identification of developmental and mental health problems of preschool children in daycare centers.

Introduction Attention-deficit/hyperactivity disorder (ADHD) is among the most common mental disorders in children and adolescents, and it is a strong risk factor for several adverse psychosocial outcomes over the lifespan. There are large between-country and within-country variations in diagnosis and medication rates. Due to ethical and practical considerations, a few studies have examined the effects of receiving a diagnosis, and there is a lack of research on effects of medication on long-term outcomes.Our project has four aims organised in four work packages: (WP1) To examine the prognosis of ADHD (with and without medication) compared with patients with other psychiatric diagnoses, patients in contact with public sector child and adolescent psychiatric outpatient clinics (without diagnosis) and the general population; (WP2) Examine within-country variation in ADHD diagnoses and medication rates by clinics’ catchment area; and(WP3) Identify causal effects of being diagnosed with ADHD and (WP4) ADHD medication on long-term outcomes.Method and analysis Our project links several nationwide Norwegian registries. The patient sample is all persons aged 5–18 years that were in contact with public sector child and adolescent psychiatric outpatient clinics in 2009–2011. Our comparative analysis of prognosis will be based on survival analysis and mixed-effects models. Our analysis of variation will apply mixed-effects models and generalised linear models. We have two identification strategies for the effect of being diagnosed with ADHD and of receiving medication on long-term outcomes. Both strategies rely on using preference-based instrumental variables, which in our project are based on provider preferences for ADHD diagnosis and medication.Ethics and dissemination The project is approved by the Regional Ethics Committee, Norway (REC number 2017/2150/REC south-east D). All papers will be published in open-access journals and results will be presented in national and international conferences.Trial registration numbers ISRCTN11573246 and ISRCTN11891971.

Background: Mothers' and fathers' internalizing symptoms may influence children's anxiety symptoms differently. Objective: To explore the relationship between parental internalizing symptoms and children's anxiety symptoms in a clinical sample of children with anxiety disorders. Method: The sample was recruited through community mental health clinics for a randomized controlled anxiety treatment trial. At pre-intervention, children (n = 182), mothers (n = 165), and fathers (n = 72) reported children's anxiety symptoms. Mothers and fathers also reported their own internalizing symptoms. The children were aged 8 to 15 years (M-age = 11.5 years, SD = 2.1, 52.2% girls) and all had a diagnosis of separation anxiety, social phobia, and/or generalized anxiety disorder. We examined parental internalizing symptoms as predictors of child anxiety symptoms in multiple regression models. Results: Both mother and father rated internalizing symptoms predicted children's self-rated anxiety levels (adj. R-2 = 22.0%). Mother-rated internalizing symptoms predicted mother-rated anxiety symptoms in children (adj. R-2 = 7.0%). Father-rated internalizing symptoms did not predict father-rated anxiety in children. Conclusions: Clinicians should incorporate parental level of internalizing symptoms in their case conceptualizations.

Cognitive behavioral therapy (CBT) has proven long-term effects in youth with anxiety disorders. However, only a few studies have examined predictors of long-term outcomes of CBT treatment. The present study investigated possible predictors of long-term treatment outcomes in youth with mixed anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11-21 years) with a principal diagnosis of separation anxiety disorder, social anxiety disorder, and/or generalized anxiety disorder were evaluated a mean of 3.9 years post-treatment (range 2.2-5.9 years). Outcomes were loss of all inclusion anxiety diagnoses, loss of the principal inclusion anxiety diagnosis, and changes in youth- and parent-rated youth anxiety symptoms. Predictors encompassed youth, parent and demographic factors, and post-treatment recovery. The most consistent finding was that low family social class predicted poorer outcomes. Higher treatment motivation was associated with better outcome whereas a diagnosis of social anxiety was associated with poorer outcome. Identified predictors extend on previous findings from efficacy trials, and the results indicate a need for more specific treatment protocols.

Beskrivelse: Children’s Global Assessment Scale (CGAS) ble laget av David Shaffer og medarbeidere i 1983. Den skåres av kliniker og er et mål på barns psykososiale funksjonsnivå i den siste måneden før vurderingstidspunktet på en skala fra 1 (lavest fungering) til 100 (utmerket fungering). Den anbefalte aldersgruppen er 4-16/17 år. Det tar mindre enn 10 minutter å skåre CGAS. Det er ikke kjent om det er krav til kompetanse for å skåre CGAS. Ny informasjon om oversettelse og opphavsrett i 2022. Det foreligger nå en offisiell godkjent norsk oversettelse av CGAS. Denne er godkjent av rettighetshaverne ved Colombia University i USA for fri non-profit bruk både digitalt og i papirformat. Den ble oversatt i august 2022 av Lars Ravn Øhlckers, Børge Idar Mathiassen og Ketil Hanssen-Bauer, på vegne av Universitetssykehuset Nord-Norge. Litteratursøk: 34 norske artikler ble inkludert. Av disse hadde 19 flere enn 100 deltagere. De fleste studiedeltakerne var barn i 6-18 års alder, men også noen oppfølgingsstudier av voksne ble inkludert. De inkluderte studiene varierte betydelig med hensyn til type klinisk utvalg og det var både tverrsnitts- og longitudinelle studier. Psykometri: Vi fant tilfredsstillende dokumentasjon på konvergens-, diskriminerende og prediktiv validitet og interraterreliabilitet, men noe mindre på endringssensitivitet. Det manglet studier av test-retest reliabilitet. Konklusjon: Vi anbefaler bruken av den norske versjonen i både forskning og klinikk under forutsetningen av at man systematisk trener klinikere i skåringen.

Few empirical studies have examined subtypes of social anxiety disorder (SAD) in youth, and limited consensus resides on the nature of potential subtypes. Identifying subtypes, based on both fear and avoidance patterns, can help improve assessment and treatment of SAD. Subtypes of fear and avoidance were examined in a sample comprising 131 youth (age 8-15 years) diagnosed with SAD using the Anxiety Disorders Interview Schedule for children and parents (ADIS-C/P). Exploratory factor analysis of fear responses revealed three factors, defining fear subtypes linked to: (1) performance, (2) observation, and (3) interaction situations, respectively. Exploratory factor analysis of avoidance responses showed these were best represented by one avoidance factor. Few youth qualified exclusively for either of the fear subtypes, thus calling into question the clinical utility of these subtypes. Nevertheless, the findings indicate distinct contributions of fear and avoidance in SAD presentation. This finding might help clinicians target and improve treatment of the disorder.

Cognitive behavioral therapy (CBT) has demonstrated favorable long-term outcomes in youth with anxiety disorders in efficacy trials. However, long-term outcomes of CBT delivered in a community setting are uncertain. This study examined the long-term outcomes of individual (ICBT) and group CBT (GCBT) in youth with anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11-21 years) with a principal diagnosis of separation anxiety disorder (SAD), social anxiety disorder (SOP), and/or generalized anxiety disorder (GAD) were evaluated, on average, 3.9 years post-treatment (range 2.2-5.9 years). Outcomes included loss of all inclusion anxiety diagnoses, loss of the principal anxiety diagnosis and changes in youth- and parent-rated youth anxiety symptoms. At long-term follow-up, there was loss of all inclusion anxiety diagnoses in 53%, loss of the principal anxiety diagnosis in 63% of participants as well as significant reductions in all anxiety symptom measures. No statistical significant differences in outcome were obtained between ICBT and GCBT. Participants with a principal diagnosis of SOP had lower odds for recovery, compared to those with a principal diagnosis of SAD or GAD. In conclusion, outcomes of CBT for youth anxiety disorders delivered in community mental health clinics were improved at nearly 4 years post-treatment, and recovery rates at long-term follow-up were similar to efficacy trials.