DIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS: ASSESSMENT AND TREATMENT
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ПРИЛОЗИ. Одд. за мед. науки, XL 1, 2019 МАНУ
CONTRIBUTIONS. Sec. of Med. Sci., XL 1, 2019 MASA
10.2478/prilozi-2019-0001 ISSN 1857-9345
UDC: 616.89-008.441-053.5/.6
DIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS
IN CHILDREN AND ADOLESCENTS: ASSESSMENT AND TREATMENT
Nada Pop-Jordanova
Macedonian Academy of Sciences and Arts, Skopje, Republic of Macedonia
Corresponding author: Nada Pop-Jordanova, Bul Krste Misirkov br.2, P.O.Box 428, 1000 Skopje,
Republic of Macedonia, e-mail: popjordanova.nadica@gmail.com
ABSTRACT
Background: Fearful and anxious behaviour is especially common in children, when they come across new
situations and experiences. The difference between normal worry and an anxiety disorder is in the severity
and in the interference with everyday life and normal developmental steps. Many longitudinal studies in
children suggest that anxiety disorders are relatively stable over time and predict anxiety and depressive
disorders in adolescence and adulthood. For this reason, the early diagnostic and treatment are needed.
Researchers supposed that anxiety is a result of repeated stress. Additionally, some genetic, neurobiological,
developmental factors are also involved in the aetiology.
Methods and subjects: The aim of this article is to summarize and to present our own results obtained
with the assessment and treatment of different forms of anxiety disorders in children and adolescents
such as: Posttraumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD), Dental anxiety,
General Anxiety Disorder (GAD), and Anxious-phobic syndrome. Some results are published separately
in different journals.
a) Post Traumatic Stress Disorder (PTSD) in 10 young children aged 9 ± 2, 05 y. is evaluated and discussed
concerning the attachment quality.
b) The group with OCD comprises 20 patients, mean age 14,5 ± 2,2 years, evaluated with Eysenck Person-
ality Questionnaire (EPQ), Child behaviour Checklist (CBCL), K-SADS (Schedule for Affective Disorders
and Schizophrenia for School age children), Beck Depression Inventory (BDI), SCWT (Stroop Colour
Word task), WCST (Wisconsin Card Scoring test).
c) Dental stress is evaluated in a group of 50 patients; mean age for girls 11,4 ± 2,4 years; for boys 10,7 ±
2,6 years, evaluated with (General Anxiety Scale (GASC), and Eysenck Personality Questionnaire (EPQ).
d) Minnesota Multiphasic Personality Inventory ( MMPI) profiles obtained for General Anxiety Disorder
in 20 young females and 15 males aged 25,7± 5,35 years, and a group with Panic attack syndrome N=15
aged 19,3±4,9 years are presented and discussed by comparison of the results for healthy people.
e) Heart Rate Variability (HRV) was applied for assessment and treatment in 15 anxious-phobic patients,
mean age 12, 5±2,25 years and results are compared with other groups of mental disorder.
Results: Children with PTSD showed a high level of anxiety and stress, somatization and behavioural
problems (aggression, impulsivity, non-obedience and nightmares), complemented by hypersensitive and
depressed mothers and misattachment in the early period of infancy. Consequently, the explanation of the
early predisposition to PTSD was related to be the non-developed Right Orbital Cortex. The later resulted
from insecure attachment confirmed in all examined children.
The obtained neuropsychological profile of children with OCD confirmed a clear presence of obsessions
and compulsions, average intellectual capacities, but the absence of depressive symptoms. Executive
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6 Nada Pop-Jordanova
functions were investigated through Event Related Potentials on Go/NoGo tasks. Results showed that no
significant clinical manifestations of cognitive dysfunction among children with OCD in the early stage
of the disorder are present, but it could be expected to be appearing in the later stage of the disorder if it
is no treated.
In a study of 50 children randomly selected, two psychometric instruments were applied for measuring
general anxiety and personal characteristics. It was confirmed that there was presence of significant anxiety
level (evaluated with GASC) among children undergoing dental intervention. The difference in anxiety
scores between girls and boys was also confirmed (girls having higher scores for anxiety). Results obtained
with EPQ showed low psychopathological traits, moderate extraversion and neuroticism, but accentuated
insincerity (L scale). L scales are lower by increasing of age, but P scores rise with age, which can be re-
lated to puberty. No correlation was found between personality traits and anxiety except for neuroticism,
which is positively correlated with the level of anxiety.
The obtained profiles for MMPI-201 in a group of patients with general anxiety are presented as a figure.
Females showed only Hy peak, but in the normal range. However, statistics confirmed significant differ-
ence between scores in anxiety group and control (t= 2, 25164; p= 0, 038749). Males showed Hs-Hy-Pt
peaks with higher (pathological) scores, related to hypersensitivity of the autonomic nervous system, as
well as with manifested anxiety. Calculation confirmed significant difference between control and anxiety
in men (t= 15.13, p=0.000).
Additionally, MMPI profiles for patients with attack panic syndrome are also presented as a figure.
Control scales for females showed typical V form (scales 1 and 3) related to conversing tendencies. In
addition, females showed peaks on Pt-Sc scales, but in normal ranges. Pathological profile is obtained in
males, with Hy-Sc peaks; this profile corresponds to persons with regressive characteristics, emotionally
instable and with accentuated social withdraw.
Heart rate variability (HRV) is a measure of the beat to beat variability in heart rate, related to the work
of autonomic nervous system. It may serve as a psychophysiological indicator for arousal, emotional state
and stress level. We used HRV in both, the assessment and biofeedback training, in a group of anxious-pho-
bic and obsessive-compulsive school children. Results obtained with Eysenck Personality Questionnaire
showed significantly higher psychopathological traits, higher neuroticism and lower lie scores. After 15
session HRV training very satisfying results for diminishing stress and anxiety were obtained.
Keywords: anxiety, clinical signs, children, adolescents, assessment, treatment
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DIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS... 7
INTRODUCTION one symptom is necessary for a diagnosis of
GAD.
Researchers supposed that anxiety is a re-
Anxiety comprises an unpleasant state sult of repeated stress. Additionally, some genet-
ranging from mild uneasiness to intense fear. ic, neurobiological, developmental and environ-
It is presented with physical and psychological mental factors are also involved in the aetiology.
symptoms, which could inhibit normal thought The theories explaining the causes of
and disrupt normal everyday activities. Anxi- anxiety can be divided in three main groups: a)
ety disorders are widespread in today’s society. Physiological theories, based on measurements,
Based on statistical data, it is supposed that one showed hyperarousal of the central nervous sys-
person in four people has had an experience with tem which make more excited reaction and slow
some form of anxiety in their lifetime. The se- adaptation to normal events. b) Psychoanalytical
verity of anxiety disorder can range from moder- approach explain the anxiety as a repressed, un-
ate and manageable to debilitating. resolved childhood experiences, related to the
Fearful and anxious behaviour is especial- quality of attachment. c) Behavioural theories
ly common in children, when they come across describe the anxiety as a learned response to pain
new situations and experiences during their de- or mental discomfort.
velopmental process. The difference between Genetic epidemiology has assembled con-
normal worry and an anxiety disorder is in the vincing evidence that anxiety and related disorders
severity and in the interference with everyday are influenced by genetic factors, where the genet-
life and normal developmental steps. ic component is highly complex. Some data con-
Anxiety comprises many phenotypes and firmed that children manifest anxiety in situation
clinical descriptions. It is routinely partitioned where their parents are anxious, as well. Recent
into disorders of general anxiety (GAD), pan- study from the University of Wisconsin-Madison
ic, phobia, and obsessive-compulsive disorder shows how an over-active brain circuit, involving
(OCD). Two main classifications are used for di- three brain areas inherited from generation to gen-
agnosis of anxiety disorders: International Clas- eration, may set the stage for developing anxiety
sification of Diseases, 10th Revision (ICD10), and depressive disorders [1]. It was shown that el-
and Diagnostic and Statistical Manual of Mental evated activity in the prefrontal - limbic - midbrain
Disorders (DMS-5). circuit is involved in mediating the in-born risk
for extreme anxiety and anxious temperament that
In the fifth edition of the Diagnostic and can be observed in early childhood. Additionally,
Statistical Manual of Mental Disorders (DSM-5) researchers confirmed that about half of children
edited in 2013, the following anxiety disorders who show extreme anxiety develop stress-related
are notified: Separation Anxiety Disorder, Se- psychiatric disorders later in life. The duplication
lective Mutism, Specific Phobia, Social Anxiety of a part of chromosome 15 is supposed to be a
Disorder (Social Phobia), Panic Disorder, Pan- major genetic factor of susceptibility for panic
ic Attack Specifier, Agoraphobia, Generalized and phobic disorders, and its identification may
Anxiety Disorder, Substance/Medication-In- have important implications for psychiatry and
duced Anxiety Disorder, Anxiety Disorder Due health [2].
to Another Medical Condition, Other Specified
Anxiety Disorder and Unspecified Anxiety Dis- In Evolution Letters (2018) recently Japa-
order. nese authors published that they have discovered
SLC18A1 (VMAT1), which encodes vesicular
According DMS-5, at least three of the monoamine transporter 1, as one of the genes
following physical or cognitive symptoms are evolved through natural selection in the human
needed for diagnosis: Edginess or restlessness; lineage. VMAT1 is mainly involved in the trans-
Tiring easily (more fatigued than usual); Im- port of neurochemicals, such as serotonin and
paired concentration (feeling as though the mind dopamine in the body, and its malfunction leads
goes blank); Irritability (which may or may not to various psychiatric disorders. VMAT1 has
be observable to others); Increased muscle aches variants consisting of two different amino acids,
or sorenes; Difficulty sleeping (due to trouble threonine (136Thr) and isoleucine (136Ile), at
falling asleep or staying asleep, restlessness at site 136. Several other studies have shown that
night, or unsatisfying sleep). In children, only these variants are associated with psychiatric
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8 Nada Pop-Jordanova
disorders, including schizophrenia, bipolar dis- self-comforting behaviours, headaches and
order, anxiety, and neuroticism (as a personality stomach aches, nervous fine motor behaviours
trait). It has been known that individuals with (e.g., hair twirling or pulling, chewing and suck-
136Thr tend to be more anxious and more de- ing, biting of skin and fingernails), toileting acci-
pressed and have higher neuroticism scores. dents, and sleep disturbances [4].
With the achievement of the sequencing of the Later, information load, opportunities and
human genome, and the active development of high competitiveness are some of the important
techniques for large-scale molecular genetic sources of stress which create tension, fear, an-
analysis of the genome, there is now hope for ger and anxiety together with high expectations
the identification of the contribution of particular of parents and teachers, academic pressures, un-
genes to the development of these disorders. realistic ambitions, and limited employment in
Some neuroanatomical specifics are relat- youngsters. Some studies indicate that psycho-
ed to anxiety disorders such as: changes in the somatic symptoms are common in children with
size of the amygdala and regions of the temporal stress, the most frequent being: tiredness, stom-
lobe in close proximity to the amygdala, smaller ach ache, headache, and psychological problems
regional grey matter volume in the right hippo- that can be triggered by different situations in the
campus, as well as smaller regional brain volume child’s life, such as school demands and admin-
in the left anterior prefrontal cortex, especially istration of time for homework. In Fig 1 diagram
in females. Using brain imaging techniques, it of genetic factors interacting with developmental
was found that functional connectivity between stress to impact vulnerability to develop anxiety
two regions of the central extended amygdala is and other psychopathology, adopted from Lancet
associated with anxious temperament in pre-ad- is presented [5].
olescent animals. Having in mind the similarity
with human brain, the same pathway for anxi-
ety in children was postulated. In this context,
research relates anxiety with some new mutation
of different genes. Modest, but measurable link
between anxiety-related behaviour and the gene
that controls the brain’s ability to use an essen-
tial neurochemical called serotonin is found. Ad-
ditionally, lower densities of peripheral GABA
receptors are found in children with separation
anxiety [3].
The growing evidence for the genetic bas- Fig 1. Diagram of genetic factors interacting with devel-
es of anxiety disorders has suggested that a single opmental stress to impact vulnerability to develop anxiety
gene may contribute additively and interchange- and other psychopathology.
ably to vulnerability to anxiety disorders, but its (Adopted from Lancet, 2002)
contribution is neither necessary, nor sufficient for
manifesting the expression of the phenotype of an Concerning the onset, the earliest age of the
anxiety disorder. Bearing this in mind, many stud- manifestation has been consistently found for sep-
ies have examined potential gene by environment aration anxiety disorder and some types of specif-
(GxE) interactions that underlie anxiety disorder ic phobias (particularly the animal, blood injec-
vulnerability and symptomatology. tion injury, and environmental type), with most
In this context, additionally to genetics, cases emerging in childhood before the age of 12
several variables have been identified as poten- years, followed by the onset of social phobia with
tial risk factors for anxiety disorders, such as pa- incidences in late childhood and throughout ado-
rental style and psychopathology, behaviourally lescence, with very few cases emerging after the
inhibited temperament, or early life traumatic age of 25. Panic disorder, agoraphobia, and GAD,
events (e.g., loss of parents, parental divorce, in contrast, have their core periods for first onset
physical and sexual abuse). Stress in small chil- in later adolescence with further first incidences in
dren is most often seen as an overt physical re- early adulthood, despite the fact that some cases,
action: crying, sweating palms, running away, especially with panic attacks, might occur as early
aggressive or defensive outbursts, rocking and as at the age of 12 years or before. In the Fig.2
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DIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS... 9
Fig. 2. Mean age of onset estimates for anxiety disorders
(Used from the Meta analysis of Jasmijn M. de Lijster, et al, 2017)
mean age of onset estimated for anxiety disorders 4. Scott Elizabeth. “Stress Management. Be mind-
is presented based on Meta analysis of de Lijster ful of stress relief” Oct (2007): Available from
(2017) [6]. http://stress.about.com/.
Many longitudinal studies in children sug- 5. Richie Poulton, Avshalom Caspi, Barry J. Milne,
gest that anxiety disorders are relatively stable Murray Thomson, Alan Taylor, Malcolm R.
Sears, and Terrie E. Moffitt. “Association be-
over time and predict anxiety and depressive dis-
tween children’s experience of socioeconom-
orders in adolescence and adulthood. For this rea- ic disadvantage and adult health: a life-course
son, the early diagnostic and treatment are needed. study”. Lancet. 2002;360: 1640–5.
The comorbidity of anxiety disorders with other
6. Jasmijn M. de Lijster, Bram Dierckx, Elisabeth
psychiatric disorders, particularly mood, has been M.W.J. Utens, Frank C. Verhulst, Carola Ziel-
observed and accepted for many decades. dorff, Gwen C. Dieleman, and Jeroen S. Legerst-
The aim of the review is to present our ee. “The Age of onset of anxiety disorder. A
own results obtained with the assessment and Meta-analysis”. Can J Psychiatry.; 62, 4 (2017)
treatment of different forms of anxiety disorders : 237–246.
in children and adolescents such as: Posttraumat-
ic stress disorder (PTSD), obsessive compulsive METHODS AND PARTICIPANTS
disorder (OCD), Dental anxiety, General anxiety
disorder (GAD), and Anxious-phobic syndrome.
Additionally, results of heart rate variability
(HRV) used as a tool for assessment and treat- Several groups of children and adolescents
ment will be presented. Additionally, our own are elaborated:
formula for spectral mean frequency (brain rate) A) Post Traumatic Stress Disorder (PTSD)
was applied to calculate arousal in general anxi- in 10 young children aged 9 ± 2, 05 y. is eval-
ety group. uated and discussed concerning the attachment
quality.
REFERENCES (B) The group with Obsessive-Compulsive
1. Intergenerational Neural Mediators of Early-Life Disorder (OCD) comprises 20 patients, mean age
Anxious Temperament, Proceedings of the Na- 14, 5 ± 2, 2 years, evaluated with Eysenck Per-
tional Academy of Sciences, 2015. www.pnas. sonality Questionnaire (EPQ), Child Behaviour
org/cgi/doi/10.1073/pnas.1508593112 ). Checklist (CBCL), K-SADS (Schedule for Af-
2. Gratacôs Monica., Nadal Marga, Martin-Santos fective Disorders and Schizophrenia for School
Rocio., et al. “A polymorphic genomic duplica- age children), Beck Depression Inventory (BDI),
tion on human chromsome 15 is a susceptibility Stroop Colour Word Task (SCWT), and Wiscon-
factor for panic and phobic disorders”. Cell. 106, sin Card Scoring Test (WCST).
(2001):367–379.
(C) Dental stress is evaluated in a group of
3. Nuss Philippe. “Anxiety disorders and GABA 50 patients; mean age for girls 11, 4 ± 2, 4 years;
neurotransmission: a disturbance of modulation”.
for boys 10, 7 ± 2, 6 years, evaluated with Gen-
Neuropsychiatr Dis Treat. 11, (2015): 165–175.
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10 Nada Pop-Jordanova
eral Anxiety Scale (GASC), Eysenck Personality existence, keep their feelings well controlled,
Questionnaire (EPQ). and are more passive than aggressive. Generally
(D) Minnesota Multiphasic Personality In- reliable, although somewhat pessimistic, typical
ventory (MMPI) was used for the assessment of introverts seldom lose their temper and tend to
a group with General Anxiety Disorder, compris- place great value on ethical standards. Introverts
ing 20 young females and 15 males, mean age 25, have over arousal as a basic brain activity.
7± 5, 35 years, and a group of 15 patients with High N scores indicate strong emotional
Panic attack syndrome, aged 19, 3±4,9 years. lability and over activity. Persons with high N
(E) Heart Rate Variability (HRV) was ap- scores tend to be emotionally over responsive,
plied in 15 anxious-phobic patients, mean age and encounter difficulties in calming down. Such
12, 5±2,25 years and 10 children with obses- persons complain of vague somatic upsets, and re-
sive-compulsive manifestations (OCD), mean port many worries, anxieties, and irritating emo-
age 14.5 ± 2.20; results are compared with the tional feelings. They may develop neurotic disor-
control. ders when under stress, which fall short of actual
(H) Calculation of Brain rate parameter neurotic collapses. However, high N scores do not
in 40 anxious patients with mean age 12 ± 3, preclude such persons functioning adequately in
5 years shows specific finding in laterality and the family, school and work situations.
brain location. Persons with high P scores are inclined
In this research several psychometric in- toward being cruel, inhumane, socially indiffer-
struments are used. Short description is below. ent, hostile, aggressive, and not considerate of
danger, and intolerant. They show a propensity
Child Behaviour Check List (CBCL) - is towards making trouble for others, belittling,
a questionnaire for behaviour assessment filled acting disruptively, and lacking in empathy. The
out by the parents of the children. It is combined physiological basis suggested by Eysenck for
with 113 questions related to the assessment of psychoticism is testosterone, with higher levels
depression, social communication or withdraw- of psychoticism associated with higher levels of
al, somatic complaints, schizoid behaviour, hy- testosterone.
peractivity, problems in the psychosexual de-
velopment, delinquent and aggressive conduct, EPQ has an additional fourth scale, the lie
problems in the conduct, problems with the judg- (L) scale which is a measure of non-sincerity,
ment and level of anxiety. This questionnaire is when a person gives social available answers to
adjusted based on the child’s age and gender [1]. show him/her as adaptable and without conflicts.
EPQ has proven useful for numerous applica-
Eysenck Personality Questionnaire (EPQ) tions in human resources, career counselling,
- is a self-report personality inventory which as- clinical settings and research. Our own experi-
sumes three basic factors (extraversion/ intro- ence with EPQ is very positive.
version, neuroticism and psychopathology). The
EPQ was developed by Hans J. Eysenck and his The General Anxiety Scale for Children
colleagues [2, 3]. (GASC) – is a 45 item yes/no scale for use with
children in grades 1-9. It measures chronic, gen-
Obtained high E scores indicate extraver- eralized anxiety. Obtained score of 12 or below
sion, and individuals tend to be outgoing, impul- ranks in the low anxiety range. A score of 12-20
sive, uninhibited, having many social contacts, ranks in the medium range. Any score above 20
and often taking part in group activities. Typi- signifies high anxiety. Scoring 15 or greater is a
cally, the extravert is highly social, likes gath- good indication that the child experiences con-
erings, has many friends, needs to have people siderable discomfort about the situation in which
to talk to and dislikes solitary pursuits such as he/she is [4].
reading, studying, and contemplation. From the
neurological point of view, extraverts have under Stress-test – is simple (and very fast) yes/
arousal as a basic characteristic of brain activ- no 20 items questionnaire, where the higher
ity. By contrast, the introvert tends to be quiet, scores are related to higher stress level [5].
retiring and studious. The typical introvert is The Schedule for Affective Disorders
reserved and distant, except to intimate friends, and Schizophrenia for School-Age Children
tends to plan ahead and usually distrusts acting (K-SADS) – is a semi structural questionnaire for
on impulse. Such persons prefer a well-arranged children between 6 and 18 years of age with the
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DIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS... 11
aim to generate DSM-IV diagnosis, such as the and adolescents by semi-structured interview.
affective, psychotic and behaviour disorders [6]. Test-retest reliability of the schedule for affective
disorders and schizophrenia for school-age chil-
The Stroop Colour Word Test, measures the
dren, present episode version”. Arch Gen Psychi-
mental vitality and flexibility, cognitive abilities atry; 42 (1985): 696–702.
to direct the attention, inhibition of automatic re-
8. Berg Esta. “A simple objective technique for
sponses and initiation of correct ones [7].
measuring flexibility in thinking”, J. Gen. Psy-
The Wisconsin Card Sorting Test (WCST) chol.; 39 (1948): 15-22.
– is a neuropsychological test for evaluation of 9. Arbisi Paule, Butcher James. “Relationship be-
the mental flexibility (“set-shifting” when the tween personality and health symptoms: Use of
stimulus is changed), the attention, the working the MMPI-2 in medical assessments”. Interna-
memory and visual processing [8]. tional Journal of Clinical and Health Psychology,
Minnesota Multiphasic Personality Inven- Vol. 4, Nº 3, (2004): 571- 595.
tory (MMPI-201) – was used as a psychometric 10. Heart Math Freeze-Framer System. A Scientifi-
test for evaluating the personality profiles of cally Proven Technique for Clear Decision Mak-
people over 12 years. In this context, we used ing and Improved Health, DOC Children, Plane-
MMPI for evaluation of the personalities in peo- tary Publications, Boulder Creek, CA. Edited by
ple with general anxiety, as well as with attack Bruce Cryer (1998).
panic syndrome [9].
Heart rate variability (HRV) is a measure (1) Posttraumatic Stress Disorder (PTSD)
of the beat-to-beat variations in heart rate relat- in young children
ed to the work of autonomic nervous system. It
may serve as a psychophysiological indicator for Posttraumatic Stress Disorder (PTSD), is
arousal, emotional state and stress level. We used classified under anxiety disorders in both ICD-
this parameter in both, the assessment and bio- 10 and DMS-IV. In the DSM-5 (2013), PTSD is
feedback training, for dealing with some groups included in a new category named as ‘Trauma
of common mental health problem in school and Stressor-Related Disorders’. Posttraumat-
children [10]. ic Stress Disorder, additionally, includes a new
subtype for children younger than 6 years. This
REFERENCES change is based on recent research detailing what
1. Achenbach, Thomas. Manual for the Child Be- PTSD looks like in young children. Adding the
haviour Checklist/4-18 and 1991 Profile. Burl- developmental subtype should help clinicians
ington, VT: University of Vermont, Department tailor treatment in a more age-appropriate and
of Psychiatry (1991). age-effective way.
2. Eysenck Hanse, Eysenck Sybile. Manual of the All of the conditions included in this clas-
Eysenck Personality Questionnaire, London, sification require exposure to a traumatic or
Hodder & Stoughton (1975). stressful event as a main diagnostic criterion.
3. Eysenck Hanse and Eysenck Sybile. Eysenck In young children, the disorder is characterized
Personality Questionnaire - Revised (EPQ-R); by three main types of symptoms: re-experi-
Hodder & Stoughton (1991). encing the trauma through intrusive distressing
4. Sarason, Seymour. Anxiety in Elementary recollections of the event, flashbacks, and night-
Schoolchildren (co-authored with Kenneth S. mares. Children’s responses to severe trauma
Davidson, Frederick F. Lighthall, and Richard R. may be more disorganized than in an adult and
Waite) (1960). can involve agitated behaviour. In this context,
5. Susan Spence, Paula Barrett, Cynthia Turner. their response may include intensive fear, help-
“Psychometric Properties of the Spence Chil- lessness or horror. The event must be persistently
dren’s Anxiety Scale with Young Adolescents”. J remembered and ‘relived’ with concomitant dis-
Anxiety Disorder 17, 6 (2003): 605-625.
tress, particularly when current circumstances
6. Ridley Stroop. “Studies of interference in serial are associated with the original event.
verbal reactions”. Journal of Experimental Psy-
chology;18 (1935): 643-662. Main clinical characteristics of PTSD are
intrusive and distressing recollections of the
7. Chambers J, Puig-Antich Joakim, Hirsch M,
Paez P, Ambrosini J, Tabrizi A, Davies M. “The event seen by them in play, nightmares, re-enact-
assessment of affective disorders in children ing the event behaviourally, avoidance of stimuli
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12 Nada Pop-Jordanova
associated with the trauma, increased arousal, vi- perience (nature of caregiver). It is obvious that
sual imagery (flashbacks), and especially in ad- the brain growth spurts continue from the end of
olescents increasing risk of irritable moods and the last trimester of pregnancy through the first
sleep deprivation. It was noticed that girls are two years of life. Both DNA and RNA levels in
more susceptible to PTSD than boys. the cortex increase over the first year, and the
There are no precise epidemiological data maturation of the brain is experience-dependent.
about PTSD in children. Some studies in the Thus, an integrative, interdisciplinary approach
USA show that about 15% to 43% of girls and to the development of the child is needed [3,4].
14% to 43% of boys go through at least one trau- Interaction between mothers and babies
ma during their life. Of those children and teens plays an important role in the formation of at-
who have had a trauma, 3% to 15% of girls and tachment and in determining maternal response
1% to 6% of boys develop PTSD. Rates of PTSD to the infant’s signals. In this context, there is
are higher for certain types of trauma survivors. research evidence that breast-feeding mothers
In war conditions the incidence is about 11. 5%, differ from bottle-feeders in satisfaction with the
while after some accidents the incidence is high- experience, in acceptance of the maternal model
er, approaching 30% [1]. and emotional investment in the infant [5, 6].
The right orbitofrontal cortex (ROFC) has Attachment is a term firstly used by John
been pointed out as crucial in the regulation of Bowlby [7] to describe the affective bond that
emotions and the autonomous nervous system develops between an infant and a primary care-
(ANS). Consequently, infants with attachment giver. Bowlby described the infant as biologi-
problems have a problematic ROFC and are cally predisposed to use the caregiver as a se-
more predisposed to PTSD. ROFC is not on line cure base, while exploring the environment. The
in birth. It develops only through interaction caregiver’s response to such bids helps shape the
with another self, another brain. The engagement attachment relationship into a pattern of interac-
and attunement of the mother stimulate positive tion that develops over the first year of life. The
emotions and develop the ventral tegmental history of this developing relationship between
dopaminergic pathways of excitatory arousal. the infant and the caregiver allows the infant to
Thousands of positive interactions are needed to begin to anticipate the caregiver’s response to
develop this system regulation of the sympathet- bids for comfort [8, 9, 10].
ic system. In the second year parasympathetic in- Secure attachment arises out of responsive
hibiting circuits become internalised. Infants ex- and sensitive parenting and is contrasted to adult
perience a shame-based inhibition of unbounded neurosis. By studying a sample of unweaned
excitation. These negative experiences develop babies and their mothers, Ainsworth et al. [6]
the lateral tegmental parasympathetic noradren- discovered three different levels of attachment:
ergic system. For this reason, the caregiver must securely attached, insecurely attached (avoidant,
avoid toxic shame in the first year of the child’s ambivalent and disorganised) and non-attached
life. A poorly attuned mother does not allow in- children.
fant self-promotion, and severe humiliation or In ICD-10 and DMS-IV two varieties of
aggressive interaction produce excessive anxiety attachment disorders are recognised: a) non-at-
and infantile rage responses. Flexible switching tachment with emotional withdrawal, typically
between these two systems (Sy and PaSy) allows associated with abuse and b) non-attachment
successful methods for rudimentary coping with with indiscriminate sociability, most usually ob-
stress [2]. served when children have been exposed to re-
Within the attachment relationship the peated changes of caregivers.
mother is shaping the infant ‘s coping systems Generally, the findings do not support a
(brain-body reaction to the stress). The model of strong genetic basis for PTSD. The strongest evi-
Bowlby, enriched by the neurobiological find- dence for a genetic contribution to the disorder is
ings of Shore, shows how early social emotional the observation that only a subset of individuals
interactions within the attachment relationship will develop PTSD following trauma exposure.
impact the experience-dependent maturation of In addition, the most compelling evidence for
the baby’s brain. This is partly determined by ge- genetic influences on PTSD comes from signifi-
netic factors (encoded in the temperament) and cant interactions between specific gene variants
partly determined by early socio-affective ex- and environmental factors (e.g., homozygous S
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genotype for 5HTTLPR and low degree of social members (parent or grandparent), in three other
support in hurricane victims). The effect of ge- cases - a car accident, and in four last cases - the
netics alone on PTSD has been shown to be quite war conditions (i.e. explosion of a bomb near the
minimal and, as such, the focus going forward school).
should be on large-scale GxE examinations and The interview with mothers in all cases
potential epigenetic mechanisms. showed different types of insecure attachment.
We selected a group of 10 children man- In two cases, the mother was still a psychiatric
ifesting PTSD diagnosed by ICD-10 criteria, patient (severe depression), and in others some
mean age 12 ± 3.05 years, (girls 3, boys 7). In specific situations in the family were assumed to
our study boys were predominant, as opposed be the reason for insecure attachment.
to other authors who noticed that girls are more All children manifested PTSD after a rel-
susceptible to PTSD. Through anamnesis, symp- atively small stress because of insecure attach-
tomatology and psychometric evaluation we ment.
tried to reveal and explore the relationship be- Results for CBCL - boys, illustrating be-
tween the earl y child experience (attachment haviour problems, are presented in Figure 1.
bonding) and the degree of stress reaction. Generally, high internalising scores are obtained
Mothers are checked by Minnesota Multi- for all children, while externalising scores ap-
phasic Personality Inventory (MMPI) and Child peared to be high only in boys, with particularly
Behaviour Checklist (CBCL) , while older chil- accentuated aggression.
dren were examined by Eysenck Personality
Questionnaire (EPQ) and State Anxiety Invento-
ry (STAI).
As stressful events provoking PTSD were
identified: in three cases - the death of family
Fig. 1. Results obtained for CBCL-boys
(1. Anxious; 2. Depressed; 3. Uncommu- Results obtained for EPQ confirmed neu-
nicative; 4. Obsessive-compulsive; 5. Somati- rotic tendencies, introversion, psychopathologic
zation ; 6. Social withdrawal; 7. Hyperactive; 8. traits and tendencies to social liability (Table
Aggressive; 9. Delinquent; series 1=norm; series I). The control group for EPQ consisted of 35
2=PTSD) healthy school children, both sexes, matched by
age.
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Table 1. Group’s results for EPQ
Neuroticism (N) Extraversion (E) Social Liability (L) Psychopathology (P)
PTSD 17,4 ± 3,5 9 ± 2,3 8,5 ± 5,3 12,5 ± 4,3
Control 13 ±3,7 16 ± 2,7 14 ± 4,03 6 ± 3,003
t-test 3,55 p< 0,01 t-test 7,07 pDIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS... 15
biological signals. BF has several modalities de- EDR BF are presented. The increase of the EDR
pending on the type of bio signals: electrodermal resistance shows the relaxation after 20 sessions
response (EDR), electromyography (EMG), elec- training. On the right, the change in SMR-NFB
troencephalography (EEG), BVP (blood volume (in µV) followed by lower arousal is presented.
pulse), RWF (respiratory waveform), etc. Figure 3 In addition to EDR biofeedback, we used
shows the biofeedback process schematically. neurofeedback (EEG biofeedback) for stress re-
Figure 3 . Schematic presentation of the biofeedback method
The EDR-biofeedback was used for as- ducing in PTSD children. PTSD is followed by
sessment of the stress level, which is related to high beta waves (16-20Hz) and decreased alpha
skin electric resistance. By the reduction of the (8-12 Hz) and theta (4-8 Hz) waves. Consequent-
stress-level by relaxation, the skin resistance in- ly, standard neurofeedback (NFB) training for
creases. On the other hand, the recalling of a post-traumatic stress disorder in adults compris-
stressful event provokes the abatement of the es alpha-theta training. Dealing with children,
curve, i.e. increasing stress-level, resistance we introduced SMR (12-16 Hz) training which
decreases (Fig.4). we consider as more adequate for children. The
increase of SMR intensity by NFB was from
Figure 4 . Short-term abatement of electrode mal resistance (in kQ/10)
provoked by recalling a stressful event
In the Figure 5 the summarized results of mean 6.344 to 7.176 (in µV ). So, by EEG-op-
the change of biofeedback indicators for PTSD erant conditioning we obtained higher SMR fol-
are displayed. On the left, results obtained for the lowed by relaxation, motor control, and lower
whole group from the first and the last session of beta (lower arousal).
Unauthentifiziert | Heruntergeladen 10.02.20 09:54 UTC16 Nada Pop-Jordanova
Figure 5 . The changes of biofeedback indicators for PTSD
(1- first session; 2- last session)
In essence, neurofeedback is based on 2. Begić Drazen, Jokić-Begić Natasa. “Heterogene-
monitoring neuronal synchrony (local and glob- ity of Posttraumatic Stress Disorder Symptoms
al) and shifting the frequency bandwidth by op- in Croatian War Veterans: Retrospective Study”.
erant conditioning training. An important find- Croat Med J. ; 48, 2 (2007): 133–139.
ing of neurofeedback research and clinics is that 3. Schneider C. “Early Infant development and
global (i.e. long-distance) synchrony represents Predisposition to Psychophysiologic Disorders”.
a physiological mechanism of attention [18]. Biofeedback, 4 (1998): 15-17.
Our studies of attention deficit disorder in chil- 4. Manzano Jesus Gil. Les relations precoces par-
dren have also shown a positive correlation be- ents- enfants et leurs troubles, Med& Hyg., Su-
tween attention and increased synchrony in the isse (1996).
high (beta) frequency range [19]. 5. Mazet Philippe. & Lebovici Serge. Emotions et
affects chez le bebe et ses parents. Editions Esh-
In summary, it was shown that all children el, Paris (1992)
manifested PTSD in the early period of life and
the clinical presentation was disproportional- 6. Birch L. L, Marl in D. W, Kramer L., Reyer C.:
Mother-child interaction pa t terns and the degree
ly greater according to the real level of trauma. of fatness in chi ldren. J Nutr Educ, 1 3 (1981):
This could be correlated to the fact that all of 17-21.
them had an insecure attachment. The social
7. Mary D. Salter Ainsworth, Mary C. Blehar, Ev-
conditions (war, economic poverty) have been erett Waters, and Sally Wall. Patterns of attach-
the additional background for PTSD. However, ment, A Psychological Study of the Em-
PTSD is only a form of anxiety disorder. mge Situation, Hillsdale, NI, Erlbaurn. (1978)
In our treatment we used supportive and be- 8. Bowlby John. La perte, P.U.F., l.vol , Paris
haviour-cognitive therapy, combined with EDR (1984).
and EEG-SMR biofeedback training. The results 9. Nada Pop-Jordanova “Rano emocionalno vrzu-
obtained are very encouraging. The symptoms of vanje(Attachment)” Pedijatrija, (1984): 56-66.
PTSD in all children had been eliminated after 10. John Andreassi Human behaviour and Psycho-
20 sessions EDR - EEG biofeedback (one ses- logical respon se, Lawrence Erl baum Associ-
sion of 50 minute duration per week). ates, New Jersey, London (2000).
In brief, two general conclusions can be de- 11. Schore Allan. Affect Regulation and the origin
duced: (1) The lack of secure attachment, confirmed ofthe Self: The Neurobiology of Emotional De-
in all children, contributed to early predisposition velopment, Lawrence Erlbaurn Assoc. (1999)
to PTSD, related to non-developed ROFC; and (2) 12. Vinsent Van Hasselt , Hersen Michel. Handbook
Multimodal biofeedback technique appeared to be of Behaviour Therapy and Pharmacotherapy for
a good complementary tool for both, assessment Children. Allyn & Bacon (1993).
and therapy of PTSD in children. 13. Matsakis Aphrodite. Post-traumatic stress disor-
der: a complete treat1nent guide. New Harbinger
Publications, Oakland (1992).
REFERENCES
14. Pynoos R., Nader K. Issues in the Treatment of
1. [1] Mackaud M., Dyregrov Altle., Raundalen M.
Post-traumatic Stress in Children and Adoles-
Traumatic War Experiences and Their Effects on
cents (Eds.) Jensen S. WHO, Zagreb. (1994)
Children, (Eds.) Jensen S. WHO, Zagreb (1994).
Unauthentifiziert | Heruntergeladen 10.02.20 09:54 UTCDIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS... 17
15. Peterson J. M. and Claire E. (2000): Notes on 14.6% etc. Median age of onset is much earlier
the role of Neurotherapy in the Treatment of for anxiety (11 years) and for impulse-control
Post-Traumatic-Stress Disorder, Biofeedback , disorders (11 years) compared with the onset of
28,3: 10-12. substance abuse (20 years) and mood (30 years)
16. [Scott Fitzgerald. “EEG Biofeedback for Chil- disorders [1].
dren and Adolescents: A Pediatrician’s Perspec-
The cause of OCD is still unknown. Howev-
tive”. Biofeedback, 26, 3 (1998): 18-20.
er, it appears to be some genetic components with
17. Evans James & Abarbanel Andrew. Introduction identical twins more often affected than non-iden-
to quantitative EEG and neurofeedback. San Di-
tical twins. Risk factors include a history of child
ego: Academic Press (1999).
abuse or other stress inducing events. Some cases
18. Fehmi Les. “Synchrony Training”, Journal of have been documented to occur following severe
Neurotherapy, 5, 3 (2001): 69-72.
infections. Males and females are affected equally.
19. Pop-Jordanova Nada. Biofeedback application Recent volumetric magnetic resonance imaging
for somatoform disorders and attention deficit (MRI) and genotyping of seven polymorphisms
hyperactivity disorder (ADHD) in children, In-
ternational Journal of Medicine and Medical Sci-
in two genes conducted in paediatric OCD pa-
ences, 1, 2 (2009): 17–22. tients showed that GRIN2B and SLC1A1 may be
associated with regional volumetric alterations in
orbit frontal cortex, anterior cingulate cortex and
(2) Obsessive-compulsive disorder (exec- thalamus in children with OCD [2].
utive functions) One third of adults with OCD developed
their symptoms when they were children. Unlike
Following ICD-10 criteria the OCD be- adults, children may not always recognize that
longs to the group of anxiety disorders, but in their symptoms are senseless or that their com-
DSM-5 it was separated from these entities. pulsions are excessive. They can also involve
However, with their characteristic symptoms their family members in their rituals. The recent
OCD really belongs to the anxiety syndromes interest of researchers is to find some measur-
and I will discuss about it in this chapter. able neurobiological characteristics in OCD. In
Obsessive–compulsive disorder (OCD) is this context, the executive functions (EF) are fre-
a mental disorder where people feel the need to quently evaluated.
check things repeatedly, have certain thoughts The aim of our research was to inspect EF
repeatedly, or feel they need to perform cer- among children with OCD by using both, psy-
tain routines repeatedly. People with this disor- chometric testing and QEEG recording from
der are unable to control either their thoughts, which we extracted Event Related Potentials
or their activities. Common activities include (ERPs) on the Go/No Go tasks.
hand-washing, counting of things, and check- The evaluated sample comprised 20 chil-
ing to see if a door is locked. Often they take up dren (both genders), mean age 14,5 ± 2,2 years,
more than an hour per day. The condition could all diagnosed using DSM-IV criteria. Psycholog-
be associated with other mental problems such ical evaluation, as mentioned before, was per-
as tics, depression, high general anxiety, and formed with Child Behaviour Check List, Kohs
there is an increased risk of suicide. In general, cubes for assessment of the intellectual capaci-
such behaviour can disturb the normal function- ties, Beck Depression Inventory, The Schedule
ing of the child. Anxiety is the basic emotional for Affective Disorders and Schizophrenia for
state which pushes the individual to perform ob- School-Age Children, Stroop Colour Word Test
sessive activity in order to relieve the tension, and Wisconsin Card Sorting Test.
due to the high anxiety level. In this context, in Neuropsychological evaluation was per-
my opinion OCD cannot be separated from other formed with the Visual Continuous Performance
anxiety disorders. Test (VCPT) from which the Event Related Po-
It is estimated that OCD affects 1–3% of tentials (ERP) components were extracted. In
the general population. Following National Co- the study we included 20 healthy subjects as a
morbidity Survey Replication, lifetime preva- control group, which at the time of conducting
lence estimates are as follows: anxiety disorders- the study did not have any psychological prob-
28.8%; mood disorders- 20.8%; impulse-control lems. The control group was corresponding to
disorders - 24.8%; substance abuse disorders- the gender and age of the experimental group.
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Preliminary, each subject went through detailed OCD there are no signs of clinical depression
interview regarding the course, length and clini- (BDI=7). The K-SADS shows clear presence of
cal manifestation of the symptoms. Then, a psy- compulsions and obsessions in all subjects (Table
chometric battery of tests was performed, com- 1). In the table we are showing only significant
bined with general scales and scales specific for results. The WCST and Stroop Test are showing
the EF evaluation. presence of perseverative errors and mild diffi-
The results obtained from the psychomet- culties in the mental flexibility (Tables 2 and 3).
ric measuring are presented in a form of scores EEG was recorded with Quantitative EEG
and compared to adequate test norms, adopted by equipment (Mitsar, Ltd.) amplifier from 19 elec-
the age and gender of the examinees. Apart from trodes, referenced to linked ears (according to
that, we have conducted Student t-test analysis the International 10-20 system) with 250 Hz
for independent variables to establish if there is a sampling rate in 0.3 – 70 Hz frequency range in
statistical significance between the experimental the following conditions: eyes opened (EO) –5
and the control group. minutes, and eyes closed (EC) –5 minutes. The
Results obtained for the CBCL scale for ground electrode was placed between Fpz and
girls and boys have confirmed that there is a sig- Fz. The impedance levels for all electrodes were
nificant presence of obsessions (Figure 1 and 2). set at 5 KΩ. Two stimuli GO/NOGO tasks devel-
The results obtained with Kohs cubes for eval- oped specifically for HBI (Human Brain Insti-
uation of the intellectual capacity have shown tute) database were used. Subjects were instruct-
that this group of children is having superior in- ed to press a button with index finger of their
telligence (IQ =112±11,5). The BDI results are right hand for GO condition and not to press a
showing that among this group of children with button for NOGO condition.
Legend
1. anxiety
2. depression
3. uncommunicating
4. obsessions
5. psychosomatic reactions
6. social withdraw
7. hyperactivity
8. aggressivity
9. delinquency
OCD
______ control
Fig. 1. CBCL profile for OCD boys and control
Legend
1. anxiety
2. depression
3. uncommunicating
4. obsessions
5. psychosomatic reactions
6. social withdraw
7. hyperactivity
8. aggressivity
9. delinquency
OCD
______ control
Fig. 2. CBCL for girls with OCD compared with control
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Fig. 3 shows QEEG spectra for a boy with Generally, psychometric scales are show-
OCD. The low/negative alpha band and signifi- ing a clear presence of obsessions and compul-
cant high beta band especially in the frontal re- sions, superior intelligence, no depressive symp-
gions due to high anxiety can be seen. toms and presence of perseverative errors and
The obtained results showed that at the mild difficulties in the mental flexibility. QEEG
P3Go (activation) ERP component there are not showed deficit of alpha brain waves and high
significant deviations according to the latency beta in frontal regions related to anxiety.
and amplitude, while the P3NoGo component
(inhibition) is showing diversity for the latency Executive functions and self-regulation
values compared to the norm (Table 5). skills are defined as mental processes that enable
Table 1. K-SADS results for compulsions and obsessions among OCD subjects
parent parent patient patient conclusion conclusion
(PE) (FE) (PE) (FE) (PE) (FE)
compulsions
М М М М М М
touching 3 1 3 1 3 1
washing 2 1 3 1 2,5 1
checking 2 1 3 1 2,5 1
repeating 2,9 1 3 1 3 1
obsessions
fear of germs 3 1 3 1 3 1
nihilistic thoughts 3 1 3 1 3 1
PE-present episode; FE-former episode; M-mean; 0=no data; 1=not present; 2=no clinical value;
3= compulsions/obsessions
Table 2. T-value and statistical significance for WCST among children with OCD and the control group
Т-values Test Т-values Test
WCST categories p
OCD significance control significance
N categories 45 55 0,32
low average average
N perseverations 2 31 51 0,000001
bellow average average
N errors 42 50 0,55
low average average
cards total 43 low average 52 0,16
average
M categories 40 low average 51 0,6
average
*bold means statistical significance
Table 3. T-value and statistical significance of the Stroop Test in OCD and control group
Т-values Test Т-values Test p
Stroop Test categories
OCD significance control significance
errors (St) II
52 average 55 average 0,1
errors III
25 very low 50 average 0,00001
errors III/II
44 low average 53 average 0,33
St III-St II
25 very low 53 average 0,00000
*bold means statistical significance
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Table 4. VCPT performance for OCD children
OCD norm t-test p
omission errors (Go) 15,4 4 15, 38 0,00001
commission errors (NoGo) 2,66 1 3,22 0,0016
RT (ms) Go 450,26 486 - 2, 56 0,00001
var RT 18,48 11,7 4,4 0,00002
Fig. 3. QEEG spectra for boy with OCD
Table 6. P3Go and P3NoGo component values for the children with OCD compared with the norm
OCD norm t-test p
P3Go (ms) 300,26 328,53 -1,94 0,061
P3Go (mv) 9,67 8,4 1,09 0,28
P3NoGo (ms) 374,66 412 -4,56 0,00009
P3NoGo (mv) 5,4 6,22 -1,08 0,28
*bold indicates statistical significance
us to plan, focus attention, remember instruc- functioning of school children in their everyday
tions, and juggle multiple tasks successfully. The activities [3, 4, 5, 6].
brain needs this skill set to filter distractions, It is supposed that these functions are
prioritize tasks, set and achieve goals, and con- not innate; children are born with the poten-
trol impulses. Executive functions (EF) depend tial to develop them. The development of these
mainly on three types of brain function: work- functions is related mainly to the environmen-
ing memory, mental flexibility, and self-control. tal conditions. If children do not get what they
These functions are highly interrelated. Each need from their relationships with adults and the
type of skill draws on elements of the others, and conditions in their environments, their skill de-
the successful application of executive function velopment can be seriously delayed or impaired.
skills requires them to operate in coordination Adverse environments resulting from neglect,
with each other. Working memory governs the abuse, or violence may expose children to toxic
ability to retain and manipulate distinct pieces of stress, which disrupts brain architecture and im-
information over short periods of time. Mental pairs the development of executive functions. In
flexibility helps to sustain or shift attention in re- this context, anxiety may contribute to enable the
sponse to different demands or to apply different development of executive functions in children.
rules in different settings. Self-control enables The localization of the executive functions is in
to set priorities and resist impulsive actions or the prefrontal cortex, a part of the human brain
responses. This system is very important for the which reaches its maturity in the adulthood.
Unauthentifiziert | Heruntergeladen 10.02.20 09:54 UTCDIFFERENT CLINICAL EXPRESSION OF ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS... 21
Different investigations have revealed 3. Olley A , Malhi G, Sachdev P. “Memory and
mixed findings for various executive tasks. executive functioning in obsessive–compulsive
Whereas Alarco´n, Libb, and Boll (1994) infer disorder: A selective review”, Journal of Affec-
from previous research that OCD is associated tive Disorders; 104, 1–3 (2007): 15–23.
with frontal impairments, in a review from Cox 4. Harvey Norman. “Impaired cognitive set shifting
(1997) [9,10] it is speculated that comorbid psy- in obsessive compulsive neurosis”. IRCS Medi-
chotic and depressive symptoms may have in- cal Science 1986; 936-937.
duced neuropsychological deficits, which were 5. Head D, Bolton D, Hymas N. “Deficit in cog-
misattributed to OCD psychopathology. This nitive shifting ability in patients with obses-
hypothesis has been confirmed in a study of sive-compulsive disorder”. Biological Psychia-
Moritz et al.[11]. It was found that OCD patients try; 25 (1989): 929-937.
exhibiting elevated depressive scores revealed 6. Veale M, Sahakian J, Owen M, Marks M. “Spe-
cognitive deficits, whereas OCD patients with cific cognitive deficits in tests sensitive to frontal
low depressive scores could not be distinguished lobe dysfunction in obsessive-compulsive disor-
der”. Psychological Medicine ; 26 (1996): 1261-
from controls regarding executive functioning. 1269.
Our clinical experience confirms that OCD is
becoming a common disorder in the childhood; 7. Purcell R, Maruff P, Kyrios M, Pantelis C. “Cog-
nitive deficits in obsessive-compulsive disorder”.
Evaluation of frontal lobe functioning showed Arch Gen Psychiatry; 55, 5 (1998):415-23.
that all subjects in this group had high cognitive
8. Renato Alarcon, J W Libb, T J Boll. “Neuropsy-
abilities; Obsessions and compulsions are veri-
chological testing in obsessive-compulsive dis-
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and the K- SADS psychometric instruments; The chiatry 6, 3 (1994):217-28
Stroop Test and WCST are showing difficulties
9. Rutter Michael, Cox A. “Psychiatric interview-
in some aspects of the EF which is within the ing techniques: I. Methods and measures”. Br J
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study cannot be understood in the context of ex-
10. Cox A. Rutter Michel. Diagnostic appraisal and
ecutive dysfunction, but in the sense of disturbed interviewing. In: Child and AdolescentPsychia-
normal functioning caused by the high anxiety try: Modern Approaches, 2nd ed, Rutter Michel,
level. However, our research corresponds with Hersov Lionel. eds, Oxford. England: Blackwell-
methodology and results of other similar studies Scientific Publications. (1985):233-248
for OCD [12, 13, 14]. Generally, there is no sig- 11. Moritz Steffen, Jacob Fink, Franciska Miegel
nificant clinical manifestation of cognitive dys- et al (2018). “Obsessive-compulsive disorder is
function among children with OCD in the early characterized by a lack of adaptive coping rath-
stage of the disorder, but it could be expected the er than an excess of maladaptive coping”, Cog-
same one to be appearing in the later stages of nitive Therapy and Research DOI: 10.1007/
the disorder. s10608-018-9902-0
12. Jessica Beer, William G. Kronenberger, Irina
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