The Development of Anxiety Symptoms in Adolescents - Trails

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The Development of Anxiety Symptoms in Adolescents Christina Mathyssek The study reported in this thesis was performed at the Department of Child and Adolescent Psychiatry/ Psychology, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam, The Netherlands. This research is part of the TRacking Adolescents’ Individual Lives Survey (TRAILS). Participating centers of TRAILS include the University Medical Center and University of Groningen, the Erasmus University Medical Center Rotterdam, the University of Utrecht, the Radboud Medical Center Nijmegen, and the Parnassia Bavo group, all in the Netherlands. Publication of this thesis was supported by various grants from the Netherlands Organization for Scientific Research (NOW), the Sophia Foundation for Medical Research, the Dutch Ministry of Justice (WODC), the European Science Foundation, and the participating universities. ISBN: 978-94-6182-443-1 Cover photo: C. Mathyssek Print: Off Page ©2014 by Christina Mathyssek All rights reserved. Copyright of the published articles is with the corresponding journal or otherwise with the author. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic or mechanical, without prior written permission from the holder of the copyright. The Development of Anxiety Symptoms in Adolescents De ontwikkeling van angstsymptomen in adolescenten Proefschrift ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de rector magnificus Prof.dr. H.A.P. Pols en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op woensdag 11 juni 2014 om 11.30 uur door Christina Maria Mathyssek geboren te Starnberg, Duitsland Promotiecommissie Promotor: Prof.dr. F.C. Verhulst Overige leden: Prof.dr. J. Ormel Prof.dr. I.H.A. Franken Dr. E.M.W.J. Utens Copromotor: Dr. F.V.A. van Oort Paranimfen: Sonia Selvasingam Sylvana Robbers Table of Contents Chapter 1 │ General introduction 7 Chapter 2 │ Childhood internalizing and externalizing problems predict the onset of clinical panic attacks over adolescence. 17 Chapter 3 │ Does the Revised Child Anxiety and Depression Scale (RCADS) measure anxiety symptoms consistently across adolescence? 31 Chapter 4 │ Pubertal timing and anxiety symptoms: A dynamic association across adolescence. 45 Chapter 5 │ The bidirectional association between sleep problems and anxiety symptoms in adolescents. 59 Chapter 6 │ Does heart rate variability moderate the effect of anxiety on sleep problems? 75 Chapter 7 │ General discussion 89 │ Summary 101 │ Samenvatting (Dutch summary) 105 │ Acknowledgments 111 │ Curriculum Vitae 115 │ PhD Portfolio 117 │ TRAILS Dissertations 119 Chapter 1 General introduction General introduction | 9 Anxiety disorders are the most frequent mental health problem in children and adolescents, with prevalence rates estimated to be around 10-15% [1] and extensive debilitating consequences [2, 3]. Adolescence is an important time window in the development of anxiety disorders, as 75% of all cases of anxiety disorders have their onset between ages 11 and 21 years [4]. Furthermore, many anxiety disorders in adolescents are characterized by low rates of remission if untreated [4, 5]. Consequently, it is relevant to study anxiety onset, development and consequences in adolescence. Anxiety can be studied in a categorical way (diagnosis: yes or no), or in a dimensional way (symptom or severity scores). While in the past the categorical approach dominated, in recent years, increasing attention has been given to anxiety symptoms which do not meet diagnostic criteria. Due to the large variety in definitions and assessment methods of anxiety symptoms, it is difficult to estimate their prevalence. Anxiety symptoms predict the onset of anxiety disorder and depression [4, 6], and have been associated with lower levels of well-being even before they reach disorder status [7]. Hence, it is important to assess anxiety symptoms across adolescence in order to recognize potential anxiety problems and prevent the development of anxiety disorders. By merely focusing on anxiety disorders, we would disregard warning signs and an opportunity for prevention and early intervention. In this thesis, I focus on factors that are associated with anxiety symptoms in adolescence in order to better help understand potential risk factors and outcomes of anxiety symptoms. In this chapter, I will introduce the research themes of the thesis. Proper measurement of anxiety symptoms in longitudinal studies Longitudinal studies are an invaluable tool for tracking the development of anxiety symptoms. To study the development of anxiety, anxiety needs to be measured repeatedly over time in the same individuals. In doing so, it is tempting to assume that any change we measure with our instrument reflects true and potentially meaningful changes in the anxiety symptom levels. However, for this assumption to be true, it first needs to be established that the instrument measures anxiety symptoms similarly at different ages across adolescence - a feature called longitudinal measurement invariance. An instrument can be tested for its measurement invariance properties with a hierarchical set of psychometric tests [8, 9]. If longitudinal measurement invariance has been established, we can assume that a change in measured anxiety severity reflects a true change in the anxiety level across time; whereas if longitudinal measurement invariance criteria are not being met, a change in assessed anxiety symptom levels over time may reflect differences in measurement sensitivity across time rather than a true change in anxiety levels. Most importantly, if measurement invariance has not been established in an instrument, we simply cannot tell how much our findings can be trusted. Hence, it is important to first establish the measurement invariance properties of an instrument, so that the level of longitudinal measurement invariance can be taken into account when interpreting change or stability of anxiety symptom levels across time. Puberty and anxiety A developmental process that coincides with adolescence is puberty. Puberty is a period during which extensive physical development occurs, including physical growth and the development of primary 10 | Chapter 1 and secondary sexual characteristics. Along with these physical changes, social and emotional changes occur. Most research on puberty has focused on the level of physical development, which can be assessed by determining the pubertal status through questions or examination of the occurrence of physical changes that typically happen during puberty. Findings from studies assessing the association between anxiety symptoms and pubertal status are mixed: some found either a lack of association, or state anxiety to be higher at early stages of pubertal development (e.g., [10, 11]), while studies assessing anxiety subtypes found symptoms to positively correlate with pubertal status (e.g., [12, 13]. In summary, previous studies carefully suggest that advanced pubertal status is associated with a higher likelihood of anxiety symptoms, which cannot merely be explained by increasing chronological age [14]. More recently, studies have focused on pubertal timing as a potentially significant factor when assessing anxiety symptoms. Pubertal timing refers to the timing of when pubertal development occurs in relation to peers, i.e. it relates whether an adolescent is ahead of peers in pubertal development (early pubertal timing), in line with peers (on-time) or behind peers in pubertal development (late pubertal timing). Notably, while pubertal status is of influence when determining pubertal timing, it is mostly the peer reference group that determines pubertal timing, e.g. early pubertal timing can refer to almost any pubertal developmental stage. Therefore, pubertal timing is closely related to the social component of pubertal development. Adolescents who are ahead of peers in pubertal development may experience the biological, psychological and social challenges associated with puberty before they may be psychologically prepared to cope with them effectively [15], which can be a risk factor for anxiety symptoms and disorders [15, 16]. Studies investigating the association between pubertal timing and anxiety symptoms have found mixed support for the theory that early developers have more anxiety symptoms, with several studies supporting this theory [16-18], while others finding conditional support [19], or no support [15]. These inconsistencies in findings spur new approaches to better understand this association. In most of the studies, pubertal timing was determined once. The implicit assumption is that pubertal timing does not change across puberty. However, studies have shown that adolescents go through puberty at a different tempo, so that an adolescent who is “late” in pubertal timing at one point may “catch up” and be “on-time” at a later point. Yet, so far merely one study has explicitly adopted this dynamic approach: Reynolds and Juvonen allowed for intraperson variability when they assessed pubertal timing six times across a three year period. Indeed, they found pubertal timing to be a dynamic concept, with on average 18% of their sample changing in pubertal timing between assessment waves [20]. A related issue concerns the assumption that the association between pubertal timing and anxiety symptoms is constant across all of adolescence. The study by Reynolds and Juvonen [20] was the first to explicitly consider and confirm that the association between pubertal timing and social anxiety symptoms probably depends on age across adolescence. Both the dynamic approach to pubertal timing and an age-varying approach to the association between pubertal timing and anxiety General introduction | 11 symptoms are new and important domains to explore as they may contribute to a better understanding of individuals at risk for anxiety symptoms. Anxiety symptoms and sleep problems An important health behavior that has been associated with anxiety symptoms is sleep and sleep problems. The interest in sleep research has spiked in recent years as more research revealed poor health outcomes associated with inadequate sleep, including mental health [21], physical health [22], and cognitive functioning [23, 24]. Most of the initial work on consequences of poor sleep was done in adults. However, it has been argued that these findings cannot blindly be extrapolated to children and adolescents due to their different sleep needs and characteristics [25-27]. Adolescence specifically has been recognized as a period where important changes in sleep need, sleep physiology and circadian rhythm occur. These considerations prompted sleep research in child and adolescent populations. The importance of this research is stressed by the fact that during childhood, and also adolescence, exposure to extreme stress can lead to deviant neural connections, impacting future cognitive, emotional and behavioral functioning [28]. Inadequate sleep has been hypothesized to qualify as such a stressor [29]. In most studies, it was implicitly or explicitly assumed that anxiety symptoms cause sleep problems. Longitudinal studies on the effect of anxiety problems on sleep problems in adolescents are rare and findings are mixed, as not all adolescents with anxiety symptoms experience sleep problems to the same extent: some may experience many sleep problems, while others experience fewer or none [30, 31]. Identifying factors that predict a higher risk for experiencing sleep problems in light of anxiety symptoms is important for a better understanding of who is at increased risk for developing sleep problems, and why. The mechanism underlying the association between anxiety symptoms and sleep problems is not well understood, but it has been suggested it goes through the arousal system. Specifically, one mechanism that might explain individual differences in risk for sleep problems is activity and reactivity of the parasympathetic nervous system (PNS), since PNS activity and reactivity is associated with both sleep [32, 33] and anxiety symptoms [34, 35]. Furthermore, in recent years researchers started to question the unilateral association between anxiety symptoms and sleep problems. The notion developed that the direction of this association is not unidirectional as assumed, but rather reciprocal. Indeed, one experimental study and several longitudinal studies in children and adolescents found that sleep problems preceded anxiety symptoms [30, 36-38], while another longitudinal study found that anxiety disorders preceded sleep problems [31]. However, some studies have failed to find any longitudinal association in one or the other direction [30]. Identifying temporal precedence is an important first step in understanding the etiology of anxiety symptoms and sleep problems, and longitudinal research may be the most valuable tool in adolescents, where experimental studies can be difficult to implement [39]. While the literature so far suggests a bidirectional association, much remains to be learned about the nature of this association, including the strength of this association across adolescence. Such studies are an important first step toward a better understanding of causality between these domains and can have important implications for prevention and intervention efforts. 12 | Chapter 1 Aim and research questions of this thesis The main aim of this study is to further our knowledge of what factors are associated with anxiety symptoms in late childhood and adolescence. This includes predictors and outcomes of anxiety symptoms, as well as factors that may influence these associations. In this thesis, the following research questions are addressed: 1. Do internalizing and externalizing problems in childhood predict the onset of panic attacks in adolescence (chapter 2)? 2. Does the Revised Child Anxiety and Depression Scale (RCADS) measure anxiety symptoms similarly across age groups over adolescence (chapter 3)? 3. Does the association between pubertal timing and anxiety symptoms vary by age across adolescence (chapter 4)? 4. Is the longitudinal association between sleep problems and anxiety symptoms bidirectional across adolescence (chapter 5)? 5. Does (re)activity of the parasympathetic nervous system moderate the effect of anxiety on sleep problems (chapter 6)? We investigated these research questions with data from the TRacking Adolescents’ Individual Lives Survey (TRAILS). TRAILS is a longitudinal cohort study of children and adolescents from the general population in the Netherlands. Starting at age 10-12 years, 2,230 children have been followed across adolescence and into early adulthood, with assessments at 2-3 year intervals. TRAILS assessment waves were completed in 2002 (T1), 2004 (T2), 2007 (T3), and 2010 (T4). 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