[June 14, 2013] Effects of Age and Subtype on Emotional Recognition in Children With Anxiety Disorders: Implications for Cognitive-Behavioural Therapy [Canadian Journal of Psychiatry] Tweet (Canadian Journal of Psychiatry Via Acquire Media NewsEdge) Objective: It remains unclear whether an anxiety diagnosis is associated with children's emotional recognition. We considered children's age and types of primary anxiety diagnosis, which have been neglected, to elucidate this relationship. Methods: Sixty-three referred children with anxiety disorder(s) and 59 volunteer children without anxiety disorder(s), aged between 6 and 11 years, were presented with animated characters, displaying a range of simple and complex emotions, for identification. Statistical analyses examined identification accuracy based on presence or absence of anxiety disorder, age, and types of primary diagnoses. Results: Children with anxiety disorder(s) as a group performed comparably to children without anxiety disorder(s) in identifying emotions (z = -0.72, P = 0.47). In both groups, accuracy for disgust increased significantly each year of age ([anxiety group] OR 2.6; 95% CI 1.6 to 4.3, ? < 0.001, [control group] OR 2.1 ; 95% CI 1.3 to 3.3, P = 0.002). When primary anxiety types were considered, while controlling for age, children with separation anxiety disorder (SAD) showed deficits in overall emotional recognition, compared with children with other subtypes or without anxiety (P = 0.004). Further regression analyses showed that children with generalized anxiety disorder (GAD) presented significantly lower accuracy than children without anxiety disorder(s) at a young age, but the deficit disappeared with increased age. Conclusion: Children with anxiety disorder(s) as a group may not appear to be impaired in emotional recognition. However, when age and subtypes are considered, children with SAD and young children with GAD appear to have difficulty, compared with children without anxiety disorder(s). Key Words: emotion recognition, anxiety, anxious children, cognitive-behavioural therapy, computer animation Received August 2012, revised, and accepted November 2012. Effets de l'âge et du sous-type sur la reconnaissance émotionnelle chez les enfants souffrant de troubles anxieux : implications pour la thérapie cognitivo-comportementale Objectif : il n'est pas encore déterminé si un diagnostic d'anxiété est associé à la reconnaissance émotionnelle des enfants. Nous avons pris en compte l'âge des enfants et les types des diagnostics d'anxiété primaires, qui ont été négligés pour éclaircir cette relation. Méthodes : Soixante-trois enfants référés souffrant de trouble(s) anxieux et 59 enfants volontaires sans trouble(s) anxieux, âgés entre 6 et 11 ans, se sont fait présenter des personnages animés, qui affichaient une gradation d'émotions simples et complexes, aux fins d'identification. Des analyses statistiques ont examiné l'exactitude de l'identification d'après la présence ou l'absence de trouble anxieux, l'âge, et les types des diagnostics primaires. Résultats : Comme groupe, les enfants souffrant de trouble(s) anxieux ont eu un rendement comparable à celui des enfants sans trouble(s) anxieux pour identifier les émotions (? = -0,72; ? = 0,47). Dans les deux groupes, l'exactitude de l'identification du dégoût augmentait significativement à chaque âge ([groupe anxieux] RC 2,6; IC à 95 % 1,6 à 4,3; ? < 0,001, [groupe témoin] RC 2,1; IC à 95 % 1,3 à 3,3; ? = 0,002). Lorsque les types d'anxiété primaires étaient examinés, en contrôlant l'âge, les enfants souffrant du trouble d'anxiété de séparation (TAS) présentaient des déficits de reconnaissance émotionnelle générale, comparativement aux enfants souffrant d'autres sous-types ou sans anxiété (? = 0,004). Des analyses de régression ont indiqué les enfants souffrant du trouble d'anxiété généralisée (TAG) présentaient une exactitude significativement plus faible que les enfants sans trouble(s) anxieux à un jeune âge, mais le déficit s'estompait avec l'âge. Conclusion : Comme groupe, les enfants souffrant de trouble(s) anxieux peuvent ne pas sembler être déficients en matière de reconnaissance émotionnelle. Cependant, lorsque l'âge et les sous-types sont pris en compte, les enfants souffrant de TAS et les jeunes enfants souffrant de TAG semblent éprouver des difficultés, comparativement aux enfants sans trouble(s) anxieux. Abbreviations CBT cognitive-behavioural therapy GAD generalized anxiety disorder MAAC Mood Assessment via Animated Characters SAD separation anxiety disorder SP social phobia STAIC State-Trait Anxiety Inventory for Children Childhood anxiety disorders, especially SAD, GAD, and SP, are most effectively treated with medication and CBT.' CBT or medication (for example, sertraline) alone is more effective than placebo, and CBT tends to cause fewer side effects than medication.1 For some clinicians, therefore, CBT may be preferred as a first-line treatment for anxiety disorders in children. In an evidence-based, manualized CBT for anxiety disorders in children (that is, coping cat CBT), clinicians include activities that may help clinically anxious children facilitate emotional recognition (for example, discussion of nonverbal cues for feelings or pictorial representations of feelings).2 However, there is a lack of consistent empirical evidence for these children's deficits in recognizing others' emotions.3" Rather, recent research has identified deficits in other emotional domains in children with anxiety disorder(s), such as emotion regulation skills9 and identifying their own emotional states.10 Therefore, the new emotion-focused CBT for children with anxiety disorders) adds sessions to existing CBT protocols" focusing on improving emotion regulation and identifying one's own emotional states. The emphasis is less clearly placed on training children with anxiety disorder(s) to identify others' emotions. As the ability to recognize others' emotions is crucial for social interactions,12-14 and is postulated to help children with anxiety disorder(s) adaptively regulate their emotional experiences,15 scrutinizing the developmental trajectory of this conscious ability informs both anxiety- and emotion-focused CBT for children with anxiety disorder(s). Emotional Recognition in Anxious Children It remains unclear whether children with anxiety disorders) are impaired in identifying the emotional states of others.3"8 Findings for children with SP are inconsistent7·8 and emotional recognition in children with SAD or GAD (commonly treated with CBT) has not been examined to date. Conflicting results may relate to study limitations. First, previous studies generally had small sample sizes. Only one study4 had an anxiety group size comparable with our own, but this study contained few control subjects without anxiety disorder(s) and included preschool children whose emotional vocabulary is generally limited.'6 Another study6 included a much larger total number of participants aged between 7 and 18 years, but there were only 14 children with anxiety disorder(s), and they were mixed with children with depression into a single experimental group. Second, there was a lack of well-validated, developmentally sensitive tools to measure the ability to identify both simple and complex emotions in young children with anxiety disorder(s). Past research relied on facial pictures, which have not been well-validated for use with children younger than 8 years. Also, greyscale facial pictures may be unappealing to children. Further, these stimuli cannot provide some types of emotional cues that children often use. For example, preschool children with anxiety disorder(s) can use both facial and bodily cues for identifying emotions,17 and with increased age, school-age children rely more on situational cues than facial cues.'" Third, age effects on emotion recognition ability have not been examined in children with anxiety disorder(s), although age significantly predicts the ability to recognize emotions in children without anxiety disorders).I9·20 The effect of this developmental proxy may explain the inconsistent results of past studies. Finally, past studies have lumped diverse anxiety disorders into one proband group without assessing the relative impact of distinct subtypes on emotional recognition. By contrast, our study examines a large sample of children old enough to express a range of feelings using a developmentally sensitive tool that displays facial, bodily, and situational cues. We pursued 3 main objectives: to compare the accuracy in identifying others' emotions in children with and without anxiety disorder(s), to examine age effects on the emotion recognition accuracy in children with anxiety disorders), and to determine how the anxiety disorders commonly treated with CBT in youth with anxiety disorders) (SAD, GAD, and SP) are related to children's emotional recognition. Methods Participants A total of 130 participants aged between 6 and 11 years were recruited, including referred patients from an outpatient anxiety clinic in the Hospital for Sick Children in Toronto and volunteer control participants through community advertisement in the Toronto area. The institutional review board of the hospital approved our study. Children were not considered for sampling if they were taking psychoactive medications or receiving any type of psychological treatment; suffering from any psychosis or intellectual disability; or presenting with the primary diagnosis of a mood disorder or developmental disorder. Written informed assent and consent were obtained from children and parents, respectively. All participants completed a semi-structured diagnostic interview (Anxiety Disorders Interview Schedule) as part of clinical assessment,21 administered by trained psychiatrists with at least 3 years of experience using this instrument. After this screening process, the sample was reduced to 122 participants because 6 children from the control group had marked difficulties understanding instructions in English, and 2 children from the anxiety group had only subclinical levels of anxiety. The anxiety group contained 63 children with mainly primary diagnoses of SAD, GAD, and SP, and a few children with specific phobia and posttraumatic stress disorder. The control group had 59 children without anxiety disorders) with no other diagnosis (for example, attention-deficit hyperactivity disorder and oppositional defiant disorder) (Table 1). In the anxiety group, 38.1% of children had a secondary anxiety diagnosis, and 8.0% had an additional nonanxiety diagnosis. Instruments Mood Assessment via Animated Characters. Previously, our team of researchers developed and validated a novel computer-based self-report feelings assessment instrument, MAAC, which displays a female teenage animated character expressing 16 feelings (relaxed, bored, tired, surprised, sad, guilty, ashamed, angry, irritable, jealous, scared, nervous, disgusted, happy, elated, and proud).22 This standardized measure was specifically tailored for young children with anxiety disorders) to elicit their internalizing symptoms and feelings associated with their psychopathology.22 At default mode, MAAC displays a tableau of the 16 facial expressions of an animated character's emotions. If a child presses a picture on the tablet screen with a PC stylus pen, the selected emotion picture is turned into a short (3 to 4 seconds) animated cartoon. Each of these clips shows the character's facial expression, bodily motions, and situational cues that young children can use to identify the expressed emotion. State-Trait Anxiety Inventory for Children. The STAIC contains 2 sets of 20 items that assess both long-term trait anxiety and transitory state anxiety specific to a situation, and it can be administered to children aged between 6 and 14 years.23 Our participants completed the STAIC to assess their transitory anxiety state at the time of MAAC administration. Procedures The instructor introduced MAAC to a child ("On this computer is a cartoon character named Teena who has a number of different feelings."). The child was first allowed to explore static representations of the animated character, selecting pictures to view the emotion-specific animations ("Right now, she is just sort of hanging out. If you press a button at the bottom of the screen, she will act out one of her feelings"). Then, the child was asked to pick the emotion(s) that he or she was feeling and how intensely ("Pick the button where Teena seems to feel the way you're feeling right now. How can you tell? If 5 checkmarks is a perfect match between how you feel right now and how Teena feels and 'X' means you don't feel that way at all right now, show how much you feel like Teena right now on the scale"). Then, the instructor and child visited each emotion-specific animation together in order from top to bottom, left to right, asking the child to identify the emotional state of the animated character ("Tell me how Teena is feeling"). This standardized instruction was repeated until all 16 emotion-specific animations were viewed ("Let's have a look at Teena's other feelings"), selecting all buttons not previously selected. All verbal responses were tape-recorded for subsequent scoring of identification accuracy. For scoring, each response was converted to a numerical score based on how accurately the child identified the emotion: 0 (incorrect), 1 (close but not exactly correct), and 2 (correct). The child's overall or general ability to identify the emotional states of others was defined by a total accuracy score, obtained by adding the individual scores across the 16 emotions presented on MAAC. To establish interrater reliability, 2 graduate students in our laboratory independently scored the responses endorsed by participants, and the Kappa statistic was computed. Statistical Analysis For the first main analysis, comparing the emotional recognition accuracy between children with and without anxiety disorders), a Wilcoxon rank sum test was used to compare total accuracy scores between the anxiety group and the control group. Then, ordinal regression analyses were used to compare these 2 groups' ability to identify each of the 16 emotions on MAAC. For the second main analysis, examining age effects on emotional recognition, linear regression analyses were conducted in the anxiety and control groups for modelling the relation between age (predictor) and total accuracy score (outcome). Then, ANCOVA was conducted for comparing the slopes and intercepts of these 2 regression lines to determine if the general ability to identify emotions in children with anxiety disorder(s) differentially correlates with age, in comparison with that of children without anxiety disorder(s). Additionally, we conducted ordinal logistic regression analyses to determine if the ability to identify any specific type of emotion also differentially changes with age in children with and without anxiety disorder(s). For the third main analysis, comparing the emotional recognition accuracy as a function of the primary anxiety diagnosis, the ANCOVA was used to contrast differences in mean total accuracy scores among groups while age was controlled for. Then, Bonferroni-adjusted pairwise comparisons were used, with the 2-tailed alpha level set at 0.05 for statistical significance. Additionally, linear regression methods were used to model the association between age and total accuracy score in each primary diagnosis group to examine the development of general ability to identify emotions in these subtype groups. Then, the slopes and intercepts of these regression lines were also compared with those of the control group without anxiety disorder(s) using ANCOVA. Results Mean ages of the anxiety group (mean = 8.7, SD 1.2) and the control group without anxiety disorder(s) (mean = 8.3, SD 1.4) were similar, t = 1.60, df= 120, />=0.11. A1 -way ANO VA indicated that SAD (mean = 8.5, SD 1.3), GAD (mean = 8.8, SD 1.1), SP (mean = 8.4, SD 1.3), and control groups were also comparable in mean age (F = 1.18, df = 3/113, ? = 0.32). The normality assumption in age and total accuracy score variables was satisfied within each comparison group. The interrater reliability for scoring was excellent (? = 0.92, ? < 0.001 ). The state anxiety scores did not differ among the SAD, GAD, SP, and control groups (F = 0.79, df= 3/86, ? = 0.50). There was no significant gender effect in the sample on overall accuracy (/ = 0.64, df= 120, ? = 0.52). Effect of Diagnosis on Accuracy Total accuracy score in children with anxiety disorder(s) was not significantly different from children without anxiety disorder(s), ? = -0.72, ? = 0.47. The mean of the ranks of total accuracy score in the anxiety group was 59.27, while that of the control group was 63.88. The restricted, ordinal total accuracy score range could justify our use of the nonparametric test; however, the results were unchanged when an independent t test was conducted (t = 0.73, df= 120, ? = 0.68). Ordinal logistic regression analyses failed to reveal a significant difference in identification accuracy of any specific emotions between children with and without anxiety disorder(s) (Table 2). Note that children with anxiety disorders) performed exceptionally well on correctly identifying basic emotions, such as happy (91 %), angry (95%), and scared (83%). Effect of Age on Accuracy Age was positively correlated with total accuracy score on MAAC (that is, age was correlated with the general ability to identify emotions) for both children with anxiety disorder(s) (r = 0.52, ? = 0.001) and control children (r = 0.36, ? = 0.005). Linear regression equations showed that age was a significant predictor for total accuracy score in both groups: predicted total accuracy score in anxiety group = 7.79 + 1.49 age (years); and, predicted total accuracy score in control group = 14.35 + 0.81 age (years). ANCOVA indicated that these slopes were similar (? B1(A,x.,ONT)= 0.68, 95% CI -0.13 to 1.48, ? = 0.10), and their intercepts were also comparable (? ???4(.? T = -6.56,95% CI -13.53 to 0.39, ? = 0.06). Ordinal logistic regression analyses revealed that the recognition accuracy of disgusted, jealous, and proud emotions increased significantly each year in children without anxiety disorder(s) (Table 3). Similarly, the recognition of disgusted and jealous emotions also increased significantly during this period in children with anxiety disorder(s); however, their identification accuracy of tired and nervous emotions was also found to increase significantly. Effects of Primary Anxiety Diagnosis on Accuracy The results of ANCOVA indicated that group differences by primary anxiety diagnosis (covarying forage) was significant (F = 4.47, df = 3/112, ? = 0.004, ?2 = 0.11) (Figure 1). Pairwise comparisons between SAD (mean = 18.3, SD 0.75) and all other groups were significant with Bonferroni corrections (GAD [mean = 21.05, SD 0.46, ? = 0.01]; SP [mean = 21.42, SD 0.86, ? = 0.04]; control group [mean = 21.28, SD 0.35, ?=0.003]), but those among GAD, SP, and control groups were not. Although the assumption of homogeneity of regression was met (F= 2.28, df= 3/109, ? = 0.08), interpreting this result requires caution because age was significantly correlated only with the total accuracy score in the SAD (r = 0.60, ? = 0.04) and GAD groups (r = 0.68, ? < 0.001), but not in the SP group (r = 0.20, ? = 0.59). Therefore, we repeated the ANCOVA without the SP group, while age was controlled for. The ANCOVA for group differences by primary diagnosis was still significant (F = 7.06, df= 2/103, ? = 0.001), but very close to violating the homogeneity of regression assumptionm (F = 2.90, df= 2/101, P=0.05). Bonferroni-corrected pairwise comparisons showed that SAD group was still significantly lower on total accuracy score than GAD (? = 0.001) and control groups (? = 0.006). However, the GAD and control groups were not significantly different from each other (? > 0.99). Linear regression equations of age predicting total accuracy score in both SAD and GAD groups were: predicted total accuracy score in SAD group = 6.64 + 1.36 age (years); and, predicted total accuracy score in GAD group = 3.90 + 1.99 age (years). Both of these regression lines had an intercept lower than that for the control group, but only that for the GAD group was statistically significant (SAD [? B0(SAD.CONT) = -7.71, 95% CI -19.19 to 3.77, ? = 0.18] and GAD [? B0 (OAD.CONT) = -10.45, 95% CI -19.04 to -1.87, ? = 0.02]). The slope of the SAD group line was not significantly different from that for the control group, ? ?, (SAD.CONT) = 0.55, 95% CI -0.79 to 1.89, ? = 0.42, whereas the slope of the GAD group line was significantly steeper than that for the control group, ? ?, (0?[????) =1.18, 95% CI 0.20 to 2.16, F = 0.02. To compare the identification of specific emotions between the groups of SAD and children without anxiety disorder(s), ordinal regression analyses were performed for each emotion. However, the analyses did not detect a deficit in recognition of a specific type of emotion (Table 2). Discussion To our knowledge, our study was the first to examine age effects on the emotional recognition in children with anxiety disorders) and the first to examine how some of the most documented anxiety disorders in CBT for children with anxiety disorder(s), SAD and GAD, are related to the ability to recognize others' emotions. Children in our study ranged from 6 to 11 years, when children's verbal skills are not correlated with the ability to identify emotions.24 With these considerations, we revisited the question of whether anxiety diagnosis is associated with children's ability to recognize the emotional states of others, illuminating explanations for contradictory findings in the past. Effect of Anxiety Diagnosis on Emotional Recognition Because the prevalence of specific anxiety disorders in children varies across epidemiologic studies,25 our anxiety group may not show the same diagnostic proportions as children with anxiety disorder(s) in the general population. Initially, we placed anxiety subtypes into one proband group to replicate conventional research designs that neglected to examine various types of primary diagnosis. When children with and without anxiety disorder(s) are compared on emotion recognition abilities, our results show that children with anxiety disorder(s) can identify the emotional states of others as accurately as children without anxiety disorder(s). This finding is consistent with a recent meta-analysis of emotion recognition in children with anxiety disorder(s)26 and with the findings of McClure et al,3 Manassis and Young,4 and Guyer et al.6 Moreover, we failed to detect any difficulty in children with anxiety disorder(s) in recognizing any specific type of emotion, compared with children without anxiety disorders). Rather, children with anxiety disorder(s) seem proficient in recognizing basic emotions when various types of emotion-related cues are available. Effects of Age and Anxiety Subtype on Emotional Recognition Our findings indicate that, as in children without anxiety disorder(s), the general ability to recognize others' emotions in children with anxiety disorders) increases significantly with age, and the rate of improvement is comparable with that of children without anxiety disorder(s). In both children with and without anxiety disorder(s), recognition of disgust improves significantly between 6 and 11 years of age. Further, in both groups, identification accuracy of some complex emotions increases significantly each year, especially emotions conveyed through bodily or contextual cues (for example, jealous, proud, tired, and nervous). However, the recognition of a complex fear-related emotion (nervous) appears to improve significantly each year in children with anxiety disorders), whereas the recognition of a complex positive emotions (proud) improves significantly in children without anxiety disorder(s) aged between 6 and 11 years. When age effects were controlled, children with SAD demonstrated a significantly lower overall ability to recognize the emotional states of others, compared with children without anxiety disorders) and children with the primary diagnosis of GAD or SP. On the other hand, children with GAD showed difficulty at a young age, but their ability to identify others' emotions seemed to improve with age at a faster rate to catch up with that of children without anxiety disorders) during school years. Limitations and Clinical Implications Our study has limitations. First, our results do not reveal a plateau in emotion recognition accuracy in either comparison group at the highest age included. It is therefore not clear if the emotion recognition ability of children with anxiety disorder(s) continues to increase with age after age 11. Second, our findings do not address whether children with anxiety disorder(s) have problems recognizing their own emotional states, but the scope of our research is limited to recognizing others' emotional states through nonverbal animated characters. Third, including more participants with SAD or SP would have much improved statistical confidence, especially regarding age effects on emotion recognition accuracy in these subgroups. Fourth, we did not measure general intelligence of our participants as a covariate. However, the link between general intelligence and emotional recognition is unknown in children with anxiety disorders), and a study27 assessing the relation between general intelligence and emotional understanding in such children found no correlation. Fifth, children with anxiety disorders) in our study were not more state anxious than their nonanxious counterparts at the time of testing. Therefore, our findings do not capture these children's ability to recognize emotions during anxiety-provoking situations (for example, social activities for children with SP). Lastly, MAAC does not measure processing time for emotional recognition Our findings suggest that augmenting emotion recognition skills may help children with SAD and early school-age children with GAD, as they appear to have difficulty identifying various emotions, compared with their nonanxious counterparts. However, the treatment may be more effective if clinicians discuss various types of cues for both basic and complex feelings, not limited to facial cues for basic emotions only, with these children. Finally, our findings support the flexible use of anxiety-focused CBT, allowing for increased emphasis on understanding emotions in children with anxiety disorders) with deficits in social or emotional understanding.28 However, such flexibility may be less crucial in children with GAD, whose impaired emotional recognition seems transitory at a young age. Future Directions First, future directions include a comparison of emotion recognition deficits with other clinical groups using a developmental^ sensitive tool in school-age children with SAD. Second, as the ability to identify others' emotions in children with SP was not linearly commensurate with age, this clinical subgroup needs to be re-examined with a larger sample size of varying ages. Third, emotion recognition ability of children with anxiety disorders) needs to be measured during anxious states to determine if their recognition is distorted in such situations, and in relation to gender. Lastly, longitudinal studies will be required to confirm the developmental trajectory of emotion recognition ability in children with anxiety disorders). Conclusion In the context of limitations, school-age children with SAD in our study show a deficit in recognition of others' emotions. Young school-age children with GAD also show some deficit in this regard. These underlying associations can be masked if we neglect to take into account age and specific diagnostic factors. Such factors could relate to inconsistent results of past studies. Facilitating emotional recognition may be a useful component of CBT for these children with anxiety disorders). Acknowledgements Dr Manassis receives book royalties from Barron's Educational, Routledge, and Guilford. The books are not directly related to this study. All other authors report no financial conflict of interest. The research has been funded by the Social Sciences and Humanities Research Council of Canada (487003). We thank Dr Rosemary Tannock, Dr Paul Arnold, Dr Judy Wiener, Dr Lisa Fiksenbaum, Dr Ryan H Kim, Dr Maclntyre Burnham, Mr David Avery, and Mr Nie Weststrate for their advice and assistance on this project. We also express our gratitude to the codevelopers of our main measure (MAAC) of the study. Clinical Implications * In CBT for children with anxiety disorder(s), clinicians are advised to augment children with anxiety disorders emotional recognition without clear empirical support. * We find that children with SAD and young children with GAD show deficits in emotional recognition, compared with children without anxiety disorder(s). * Emotional recognition training in CBT may be beneficial for children with anxiety disorder(s). Limitations * Findings are limited to urban Canadian school-age children, between ages 6 to 11 years. * Deficits in children with SAD may need to be compared with other clinical groups in the future. References 1. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New Engl J Med. 2008;359(26):2753-2766. 2. Kendall PC, Hedtke K. Cognitive-behavioral therapy for anxious children: therapist manual. Ardmore (PA): Workbook Publishing; 2006. 3. McClure EB, Pope K, Hoberman AJ, et al. Facial expression recognition in adolescents with mood and anxiety disorders. Am J Psychiatry. 2003; 160(6): 1172-1174. 4. Manassis K, Young A. Perception of emotions in anxious and learning disabled children. Depress Anxiety. 2000; 12<4):209-216. 5. Easter J, McClure EB, Monk CS, et al. Emotion recognition deficits in pediatric anxiety disorders: implications for amygdala research. J Child Adolesc Psychopharmacol. 2005; 15(4):563-557. 6. Guyer AE, McClure EB, Adler AD, et al. Specificity of facial expression labeling deficits in childhood psychopathology. J Child Psychol Psychiatry. 2007;48(9):863-871. 7. Simonian SJ, Beidel DC, Turner SM, et al. 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Emotion knowledge skills in low-income elementary school children: associations with social status and peer experiences. Soc Dev. 2005;14(4):637-651. 14. Ciarrochi J, Heaven PC, Supavadeeprasit S. The link between emotion identification skills and socio-economic functioning in early adolescence: a 1-year longitudinal study. J Adolesc. 2008;31 (5):565-582. 15. Suveg C, Sood E, Comer JS, et al. Changes in emotion regulation following cognitive-behavioral therapy for anxious youth. J Clin Child Adolesc Psychol. 2009;38(3):390-401. 16. Aldridge M, Wood J. Talking about feelings. Young children's ability to express emotions. Child Abuse Neglect. 1997;21(12):1221-1233. 17. Nelson NL, Russell JA. Preschoolers' use of dynamic facial, bodily, and vocal cues to emotion. J Exp Child Psychol. 2011 ; 110( 1 ):52-61. 18. Hoffner C, Badzinski DM. Children's integration of facial and situational cues to emotion. Child Dev. 1989;60(2):411-422. 19. Durand ?, Gallay M, Seigneurie A, et al. The development of facial emotion recognition: the role of configurai information. J Exp Child Psychol. 2007;97(1): 14-27. 20. Feldman RS, Philippot P. Age and social competence in preschoolers decoding of facial expression. Br J Soc Psychol. 1990;29{ 1 ):43-54. 21. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for Children for DSM-IV: child and parent versions. New York (NY): Psychological Corporation; 1996. 22. Manassis K, Mendlowitz S, Kreindler D, et al. Mood assessment via animated characters: a novel instrument to evaluate feelings in young children with anxiety disorders. J Clin Child Adolesc Psychol. 2009; 38(3):380-389. 23. Spielberger C, Gorusch R, Lushene R, et al. Manual for the State-Trait Anxiety Inventory. Palo Alto (CA): Consulting Psychologists Press; 1983. 24. Steele H, Steele M, Croft C. Early attachment predicts emotion recognition at 6 and 11 years old. Attach Hum Dev. 2008; 10(4):379-393. 25. Cartwright-Hatton S, McNicol K, Doubleday E. Anxiety in neglected population: prevalence of anxiety disorders in preadolescent children. Clin Psychol Rev. 2006;26(7):817-833. 26. Demenescu LR, Kortekaas R, den Boer JA, et al. Impaired attribution of emotion to facial expressions in anxiety and major depression. PLoS ONE. 2010;5( 12):e 15058. 27. Southan-Gerow MA, Kendall PC. A preliminary study of emotion understanding of youths referred for treatment of anxiety disorders. J Clin Child Psychol. 2000;29(3):319-327. 28. Beidas RS, Benjamin CL, Puleo CM, et al. Flexible applications of the coping cat program for anxious youth. Cogn Behav Pract. 2010; 17(2): 142-153. Trevor Changgun Lee, BSc (MSc Candidate)1; Annie Dupuis, PhD2; Emily Jones, BSc (MSc Candidate)3; Carly Guberman, MA (PhD Candidate)4; Monique Herbert, PhD5; Katharina Manassis, MD, FRCPC6 'Student, Institute of Medical Science, University of Toronto, Toronto, Ontario. Correspondence: Department of Psychiatry, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8; [email protected]. 2Biostatistician, Biostatistics, Design and Analysis Unit, Hospital for Sick Children, Toronto, Ontario; Assistant Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario. 'Student, Institute of Medical Science, University of Toronto, Toronto, Ontario. 'Student, Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, University of Toronto, Toronto, Ontario. 'Senior Research Officer, Office of the Associate Dean, Innovations and Opportunities, Ontario Institute for Studies in Education, University of Toronto. Toronto, Ontario. "Full Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario; Staff Psychiatrist and Senior Associate Scientist, Hospital for Sick Children, Toronto, Ontario; Associate Member, Institute of Medical Science, University of Toronto, Toronto, Ontario; Member, Department of Applied Psychology and Human Development, Ontario Institute for Studies in Education, University of Toronto, Toronto, Ontario. (c) 2013 Canadian Psychiatric Association [ Back To TMCnet.com's Homepage ]