Anxiety is distressing, impairing, and the most prevalent mental health problem in children and adolescents. Theoretical models implicate biases in cognitive processes as underlying the development and maintenance of anxiety disorders. Yet little work has been done to test theoretical models of information processing (IP) in clinically anxious youths. The present dissertation sought to examine relationships between youth anxiety and the basic cognitive processes of attention and interpretation using performance-based methodology. The aims of this investigation were to: 1) empirically test the IP model of youth anxiety, specifically whether biased interpretation statistically mediates the association between biased attention and anxiety symptoms, 2) unpack the components of interpretation (i.e., threat valence judgments, speed of responding) on a performance-based task of interpretation bias, and 3) probe the impact of comorbid depressive symptoms on these cognitive processes. Youths (N=26, ages 9 to 17) and their primary caregivers completed diagnostic interviews and a comprehensive self- report battery, and youths completed performance-based assessments of attention and interpretation. In this sample, attention bias towards threat was significantly associated with percentage of negative interpretations endorsed (r=.46, p=.019). However, attention was not significantly related to anxiety symptoms, and the indirect effect of attention on anxiety through interpretation was not statistically significant. Negative interpretations of ambiguous information strongly predicted youth anxiety symptom severity, accounting for 46% of variance in clinician-rated anxiety severity. Deconstructing interpretation into its components, youth response latencies on the interpretation task as measured by threat and benign reaction time indices were not significantly associated with attention. Percentage of negative interpretations endorsed (r=.68, p<.001) and response latencies on the interpretation threat reaction time index (r=.45, p=.022) were significantly related to anxiety severity. Conversely, response latencies on the benign interpretation reaction time index were not related to anxiety. Finally, depressive symptoms were not significantly related to attention or to any of the components of interpretation assessed in this sample of clinically anxious youths. These findings provide preliminary evidence for a relationship between attention and interpretation biases, and stronger evidence for a relationship between interpretation bias and anxiety. Clinical and theoretical implications of this study are discussed

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

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

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

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

Objective

Although evidence-based treatments for pediatric obsessive-compulsive disorder (OCD) exist, many youth fail to respond, and interventions tailored to the needs of specific subsets of patients are lacking. This study examines the efficacy of a family intervention module designed for cases of OCD complicated by poor family functioning.

Method

Participants were 62 youngsters aged 8 to 17 years (mean age = 12.71 years; 57% male; 65% white) with a primary diagnosis of OCD and at least 2 indicators of poor family functioning. They were randomized to receive 12 sessions of individual child cognitive-behavioral therapy (CBT) plus weekly parent psychoeducation and session review (standard treatment [ST]) or the same 12 child sessions plus 6 sessions of family therapy aimed at improving OCD-related emotion regulation and problem solving (positive family interaction therapy [PFIT]). Blinded raters evaluated outcomes and tracked responders to 3-month follow-up.

Results

Compared to ST, PFIT demonstrated better overall response rates on the Clinician Global Impression-Improvement scale (CGI-I; 68% versus 40%, p = .03, φ = 0.28) and rates of remission (58% PFIT versus 27% ST, p = .01, φ = 0.32). PFIT also produced significantly greater reductions in functional impairment, symptom accommodation, and family conflict, and improvements in family cohesion. As expected, these shifts in family functioning constitute an important treatment mechanism, with changes in accommodation mediating treatment response.

Conclusion

PFIT is efficacious for reducing OCD symptom severity and impairment and for improving family functioning. Findings are discussed in terms of personalized medicine and mechanisms of change in pediatric OCD treatment. Clinical trial registration information-Family Focused Treatment of Pediatric Obsessive Compulsive Disorder; http://clinicaltrials.gov/; NCT01409642.

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

Trichotillomania (TTM; hair-pulling disorder) is characterized by an irresistible urge or desire to pull out one's own hair, and a sense of pleasure when hair is pulled out. Evidence from translational neuroscience has shown that 'wanting' (motivation to seek a reward) and 'liking' (enjoyment when reward is received) are each mediated by overlapping but distinct neural circuitry, and that 'wanting' contributes to addictive/compulsive behaviors more so than 'liking'. In the present study, we developed the Hair Pulling Reward Scale (HPRS), a self-report measure that consists of two subscales designed to assess (a) cue-triggered urges and appetitive motivation to pull hair (i.e., putative correlates of 'wanting'), and (b) momentary pleasure and gratification during pulling episodes (i.e., putative correlates of 'liking'). We administered the HPRS to 259 individuals with TTM and examined its psychometric properties. Confirmatory factor analysis supported a two-factor model reflecting correlated Wanting and Liking scales. Consistent with predictions, Wanting, much more than Liking, had robust correlations with TTM severity, impulsiveness, difficulties in emotion regulation, psychiatric symptoms, and sleep dysfunction. The results suggest that the HPRS is a psychometrically sound instrument that can be used as a symptom-level measure of reward processing in TTM.

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

Objective

Although adult hoarding disorder is relatively common and often debilitating, few studies have examined the phenomenology of pediatric hoarding. We examined the clinical phenomenology and response to cognitive-behavioral therapy (CBT) treatment in youths with a diagnosis of obsessive-compulsive disorder (OCD) with and without hoarding symptoms. Age was tested as a moderator across analyses, given prior findings that the impact of hoarding symptoms may not become apparent until adolescence.

Method

Youths (N = 215; aged 7-17 years) with OCD pursuing evaluation and/or treatment at a university-based specialty clinic participated in the current study. Presence of hoarding symptoms was assessed as part of a larger battery. Data from a subset of youths (n = 134) who received CBT were included in treatment response analyses.

Results

Youths with hoarding symptoms did not differ from those without hoarding symptoms with respect to overall OCD symptom severity and impairment. Youths with hoarding met criteria for more concurrent diagnoses, including greater rates of internalizing and both internalizing/externalizing, but not externalizing-only, disorders. Youths with and without hoarding symptoms did not significantly differ in rate of response to CBT. Age did not moderate any of these relationships, suggesting that the presence of hoarding symptoms was not associated with greater impairments across the clinical presentation of OCD or its response to treatment by age.

Conclusion

We found no evidence that hoarding is associated with greater OCD severity or poorer treatment response in affected youth. Theoretical and clinical implications of these findings, including future directions for research on testing developmental models of hoarding across the lifespan, are discussed.