NORMAL AND ABNORMAL FEAR AND ANXIETY IN CHILDREN AND ADOLESCENTS
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NORMAL AND ABNORMAL FEAR AND ANXIETY IN CHILDREN AND ADOLESCENTS
PETER MURIS
AMSTERDAM • BOSTON • HEIDELBERG • LONDON NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO
Elsevier 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA 525 B Street, Suite 1900, San Diego, California 92101-4495, USA 84 Theobald’s Road, London WC1X 8RR, UK This book is printed on acid-free paper. Copyright © 2007, Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone: (+44) 1865 843830, fax: (+44) 1865 853333, E-mail:
[email protected]. You may also complete your request on-line via the Elsevier homepage (http://elsevier.com), by selecting “Support & Contact” then “Copyright and Permission” and then “Obtaining Permissions.” Library of Congress Cataloging-in-Publication Data Muris, Peter. Normal and abnormal fear and anxiety in children and adolescents/ Peter Muris. p. ; cm.—(BRAT series in clinical psychology) Includes index. ISBN-13: 978-0-08-045073-5 (alk. paper) ISBN-10: 0-08-045073-3 (alk. paper) 1. Anxiety in children. 2. Anxiety in adolescence. 3. Fear in children. I. Title. II. Series. [DNLM: 1. Anxiety Disorders—etiology. 2. Adolescent. 3. Anxiety—psychology. 4. Anxiety Disorders. 5. Child. 6. Fear—psychology. WM 172 M977n 2007] RJ506.A58M87 2007 618.92'8522—dc22 2007006299 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN 978-0-08-045073-5 For information on all Elsevier publications visit our Web site at www.books.elsevier.com Printed in the United States of America 07 08 09 10 9 8 7 6 5 4 3
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To my beautiful daughters, Jip and Kiki, who so far have developed without serious anxiety problems
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Table of Contents
Preface
ix
Introduction
xi
1.
Normal and Abnormal Fear and Anxiety in Children and Adolescents
1
2.
Genetically Based Vulnerability
31
3.
Environmental Influences
61
4.
Protective Factors
99
5.
Maintaining Factors
129
6.
The Aetiology of Childhood Phobias and Anxiety Disorders: A Dynamic Multifactorial Model
163
7.
Assessment of Fear and Anxiety in Children and Adolescents
193
8.
Treatment and Prevention of Childhood Anxiety
225
Appendix
Questionnaires
267
References
299
Index
373
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Preface
In the Behaviour Research and Therapy (BRAT) Series in Clinical Psychology, Craske (2003) wrote her monograph “Origins of phobias and anxiety disorders: Why more women than men?” in which she provided an excellent overview of current theories on the aetiology of phobias and anxiety disorders. Although the emphasis of Craske’s book is mainly on adults, it is also clear that she assumes that the foundation of these problems is already laid during childhood. In the past decades, the research domain of childhood phobias and anxiety disorders has made an enormous progress, as evidenced by a massive amount of empirical articles in scientific journals. This book provides an overview of the accumulating knowledge on the pathogenesis of fear and anxiety in youths. The main target will be to give the reader an idea of the factors that are thought to be involved in the development of abnormal fear and anxiety in children and adolescents, and to integrate this knowledge in a comprehensive model. An additional purpose will be to provide an update of current assessment methods as well as empirically supported intervention strategies for fear and anxiety problems in young people. In the Appendix, the reader will find a number of instruments that can be employed for research (and eventually clinical) purposes. Admittedly, many good books have been published that deal with the domain of childhood fear and anxiety (see Weems, 2005). Most books are more predominantly concerned with the phenomenology and treatment of various phobias and anxiety disorders in children and adolescents (e.g., Essau & Petermann, 2001; Morris & March, 2004; Ollendick & March, 2004) and only partially cover the aetiology of this type of child psychopathology. Exceptions are the volumes edited by Vasey and Dadds (2001; “The developmental psychopathology of anxiety”) and Silverman and Treffers (2001; “Anxiety disorders in children and adolescents”), which both give an in-depth coverage of the multiple factors involved in the origins of phobias and anxiety disorders in youths. However, having appeared more than five years ago, the field seems ready for a new update of this rapidly expanding and intriguing research area. Peter Muris
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Introduction
“My dear professor, I am sending you a little more about Hans—but this time, I am sorry to say, material for a case history. As you will see, during the last few days he has developed a nervous disorder, which has made my wife and me most uneasy, because we have not been able to find a means of dissipating it. I shall venture to call upon you tomorrow, . . . but in the meantime . . . I enclose a written record of the material available. “No doubt the ground was prepared by sexual overexcitation due to his mother’s tenderness, but I am not able to specify the actual exciting cause. He is afraid a horse will bite him in the street, and this fear seems somehow to be connected with his having been frightened by a large penis. As you know from a former report, he had noticed at a very early age what large penises horses have, and at that time he inferred that as his mother was so large she must have a widdler like a horse. “I cannot see what to make of it. Has he seen an exhibitionist somewhere? Or is the whole thing simply connected with his mother? It is not very pleasant for us that he should begin setting us problems so early. Apart from his being afraid of going into the street and from his being in low spirits in the evening, he is in other respects the same Hans, as bright and cheerful as ever.” (Freud, 1909/1955; p.22) The preceding quotation was taken from a letter written to Sigmund Freud by the father of a five-year-old boy at the beginning of the 20th century. It is clear that the boy, also known as Little Hans, was troubled by fear and anxiety, and apparently these negative emotions were so intense that his parents decided to seek help from a psychiatrist. Freud was of course interested in the case, carefully documented it as the “Analysis of a phobia in a five-year-old boy,” and he used this case history to further illustrate his theoretical notions on the genesis of neurotic behavior. Due to Freud, Little Hans became the subject of one of the most famous case studies in psychological history. However, the symptoms displayed by the boy are certainly not exceptional, as it is a well-known fact that many children and adolescents suffer from fear and anxiety complaints at some point of time during their development to adulthood. In such a way, fear and anxiety have long been considered as normal developmental phenomena, and as a result little research effort was made to properly understand these emotions in youths. Since the early 1980s, this situation has gradually changed. Clinicians, and in their wake researchers, gradually came to the conclusion that although fear and anxiety are transitory in most children, in some of the youths these symptoms may become so severe that they do significantly interfere with daily functioning and clearly warrant the diagnosis of an anxiety disorder. This insight has resulted in a host of empirical studies examining the phenomenology, prevalence, aetiology, persistence, assessment, and treatment of anxiety symptoms and disorders in youths.
xii
Introduction
This book is titled Normal and Abnormal Fear and Anxiety in Children and Adolescents, and as such it covers many aspects of these internalizing symptoms in youths. However, another focus of the book is What Was Really Wrong with Little Hans? That is, many of the sections in this book discuss why some children develop serious fear and anxiety problems. In Freud’s (1909/1955) opinion, Little Hans was afraid of horses because he suffered from a so-called Oedipus complex. That is, Hans wanted to have sex with his mother and therefore expected to be punished by his father. As a result, Hans became afraid of his father. However, this was considered as unacceptable by his Ego, and therefore the fear was displaced to another object, resulting in a phobia of horses. From a scientific point of view, Freud’s analysis of the case is of course unacceptable, as the main concepts of his account (i.e., Oedipus complex, Ego) cannot be validated empirically (Eysenck, 1985). Moreover, after a reanalysis of the case, Wolpe and Rachman (1960) rightly indicated that there was no convincing connection between Little Hans’s sexual behavior and his phobia of horses. Further, these authors pointed at a number of negative learning experiences (e.g., Hans witnessed a horse crashing on the street), which likely played a more plausible role in the aetiology of Hans’s phobic symptoms. This book makes no attempt to reconstruct the aetiology of the phobia of Little Hans’s in detail. Instead, a general theoretical framework will be described that may help clinicians and researchers to understand the pathogenesis of excessive anxiety in youths. It has become clear that an “understanding of the pathways by which childhood anxiety disorders develop, persist, and remit is likely to require consideration of a wide range of influences and, most importantly, their potential for complex, dynamic, transformational interactions (i.e., transactions) across development” (Vasey & Dadds, 2001; p.3). Clearly, this notion fits nicely with the major tenets of the developmental psychopathology perspective (Cicchetti & Cohen, 1995), which imply that (1) most forms of psychopathology are the result of multiple causal influences, (2) both successful and unsuccessful adaptation are important for understanding the origins of psychopathology, and (3) psychopathology occurs in a developing organism, which is of course particularly relevant in childhood and adolescence, when developmental changes are most pronounced. As such, the framework that is explicated in this book emphasizes multicausality, includes vulnerability as well as protective factors, and stresses the importance of developmental transitions. The main perspective of the book is psychological, although in some chapters biological processes (genetics, brain processes) are also discussed. After an introductory chapter, in which the basic phenomena of normal and abnormal fear and anxiety in children and adolescents are described, following chapters of the book will extensively discuss various vulnerability (Chapters 2 and 3), protective (Chapter 4), and maintaining (Chapter 5) variables that are involved in the pathogenesis of phobias and other anxiety disorders. In Chapter 6, this information will be integrated and a dynamic, multifactorial model for the aetiology of pathological fear and anxiety will be presented. In this chapter, an attempt will be made to analyze the case of Little Hans in terms of this model and to provide an answer to the question that was posed in the case of Little Hans. Chapter 7 will give an overview of empirically validated assessment instruments that can be used for measuring normal and abnormal fear and anxiety in youths. Finally, Chapter 8 describes psychological and pharmacological interventions that are employed for children and adolescents with anxiety problems, and summarizes the research that has demonstrated their effectiveness.
Chapter 1
Normal and Abnormal Fear and Anxiety in Children and Adolescents
Introduction Fear and anxiety are common in childhood, but in most cases short-lived and dissipating within a brief period of time (see Craske, 1997). Initially, this has led many child psychologists to the faulty conclusion that childhood fear and anxiety should not be taken too seriously, and as a result these phenomena received little research attention (Cartwright-Hatton, McNicol, & Doubleday, 2006). During the past decade, this opinion has changed as researchers have increasingly demonstrated that a substantial minority of children do suffer from such high fear and anxiety levels that a diagnosis of an anxiety disorder is clearly warranted. In fact, epidemiological studies have shown that anxiety disorders are among the most prevalent forms of psychopathology among youths (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Ford, Goodman, & Meltzer, 2003; Verhulst, Van der Ende, Ferdinand, & Kasius, 1997). Moreover, there is evidence indicating that a significant proportion of the childhood anxiety disorders have a chronic course and, although they may change form, even last into adulthood (Biederman, Petty, Faraone et al., 2005; Goodwin, Fergusson, & Horwood, 2004; Keller, Lavori, Wunder, Beardslee, Schwartz, & Roth, 1992; Last, Perrin, Hersen, & Kazdin, 1996; Roza, Hofstra, Van der Ende, & Verhulst, 2003). The main purpose of the present chapter is to provide a description of the basic phenomena under study. To begin with, definitions of fear and anxiety will be given, and evidence will be catalogued showing that fear and anxiety are common experiences to most children and adolescents. It is argued that these normal manifestations of fear and anxiety follow a predictable developmental course that is strongly guided by children’s level of development. This does not mean, however, that fear and anxiety sometimes interfere significantly with youths’ daily functioning, and ultimately may take the form of a phobia or an anxiety disorder. The remainder of the chapter will focus on abnormal fear and anxiety in children and adolescents, and will discuss their phenomenology, epidemiology, severity, persistence, and comorbidity with other forms of psychopathology.
Definitions of Fear and Anxiety Although the terms fear and anxiety are frequently employed interchangeably, a close examination of the literature indicates that both concepts are quite different in terms of their
2
Normal and Abnormal Fear and Anxiety in Children and Adolescents
manifestation, function, and biological underpinnings (e.g., Barlow, 2002; Craske, 2003). To begin with, factor analytic studies of the symptomatology in anxious youths have clearly identified two separate factors (Chorpita, Albano, & Barlow, 1998). The first factor is characterized by autonomic arousal, and at a behavioral level fight-flight reactions, and can be labelled as fear. The second factor is typified by tension, apprehension, and worry, and can best be defined as anxiety. Fear typically occurs when threat is proximate and imminent. Its function is clear: The organism must be alert, and the body is quickly prepared for immediate action, either fight or flight. This is achieved by an activation of the sympathetic nervous system, which shows itself in a pupil dilatation and increases in heart rate, respiration, and muscle tension. Because fear pertains to a fast response that is universal and innate and clearly serves survival purposes, theorists have since long assumed that the more primitive subcortical brain systems are involved in this type of emotion (LeDoux, 1996). Research has indeed provided evidence for this notion and has shown that in particular the amygdala seems to play a key role in the formation of fear. Briefly, this relatively small subcortical brain structure detects and organizes responses to natural dangers (like predators) and learns about novel threats and stimuli that predict their occurrence (LeDoux, 1998). Incoming information about (potentially threatening) stimuli is quickly scanned in the amygdala, and once threat is detected, various types of defensive responses (e.g., activation of the sympathetic nervous system) are immediately activated. Whereas fear arises when threat is certain and/or detected, anxiety may become manifest without the presence of actual danger. Worry is the prototypical example of anxiety—that is, when worrying, a person engages in thinking about negative things that might happen. In a way, worry also has adaptive features as it prepares for unexpected aversive events. However, there is increasing evidence demonstrating that worry functions as a cognitive avoidance strategy, which inhibits emotional processing (Borkovec, Ray, & Stöber, 1998). Worry predominantly is a cognitive-verbal activity and as such primarily involves left cortical activation and ongoing inhibition of autonomic activation in order to facilitate cognitive processing and planning to deal with impending danger. Craske (2003) described the threat imminence model, which assumes that anxiety/worry and fear are related but functionally different defensive systems that are determined by varying levels of proximity to threat. Confrontation with distal threat (i.e., threat related to the possible occurrence of negative, future events) will elicit anxiety/worry. Once threat is actually detected, anxious worry will shift to fear. The fear response itself may vary from anticipatory arousal when confronted with stimuli closely associated with the threat, to intense fear or even panic when fully exposed to the threatening stimulus or situation. Although the threat imminence model nicely illustrates the functionality and biological basis of fear and anxiety, this account is not used as the guiding principle for describing these negative emotions in the present book. The main reason for this is that it is largely unknown how the defensive systems of fear and anxiety/worry vary with the anxiety disorders as defined in contemporary classification systems such as the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association [APA], 2000). Therefore, fear and anxiety will be defined in terms of the nosologic descriptions employed by most current researchers and clinicians. Thus, fear explicitly refers to phobic disorders that are all characterized by a negative emotional response in relation to a certain stimulus
Normal and Abnormal Fear and Anxiety in Children and Adolescents
3
or situation that is out of proportion to its actual danger, whereas anxiety refers to the anxiety disorders that are typified by tension, apprehension, worry, and general distress that arise without any objective source of danger (see Pavuluri, Henry, & Allen, 2002). A factor analytic study by Muris, Schmidt, Merckelbach, and Schouten (2001b) demonstrated that this division of fear and anxiety is empirically justifiable. In their study, a large sample of nonclinical youths (N = 968) completed self-report questionnaires for measuring symptoms of anxiety disorders, phobias, and depression. Structural equations modeling was employed to test the following models for the structure of these negative emotions: (1) a one-factor model with all symptoms loading on a single factor; (2) a two-factor model with symptoms of anxiety disorders and phobias loading on one factor and depression symptoms loading on the other factor; (3) a two-factor model with symptoms of anxiety disorders and depression loading on one factor and symptoms of phobias loading on the other factor; (4) a three-factor model in which symptoms of anxiety disorders, phobias, and depression load on three separate factors; and (5) a correlated three-factor model with symptoms of anxiety disorder, phobias, and depression loading on three correlated factors. Results indicated that the fifth model provided the best fit for the data, (see Figure 1.1) which implies that anxiety disorders, phobias, and depression are reasonably distinct but correlated components of negative emotions. Most pertinent for the present discussion is that fear (phobias) and anxiety (anxiety disorders) were distinguishable types of negative emotion. The fact that fear and anxiety are discernible and related to, respectively, phobias and anxiety disorders, does not imply that it is easy to separate these phenomena. This point was nicely illustrated in a study by Muris, Merckelbach, Mayer, and Meesters (1998), who examined the relationship between common fears and anxiety disorders symptoms in nonclinical children. The results of this investigation clearly showed that childhood fears are not merely connected to symptoms of phobias, but also frequently reflect other anxiety disorders. For example, fear of getting a serious illness may represent a blood-injectioninjury phobia, but may also point in the direction of an obsessive-compulsive disorder or a generalized anxiety disorder.
.72 .55
.38
Anxiety
.83
A1
A2
.82
.73
A3
Fear
.71
.71
A4
A5
.72
F1
.71
F2
Depression
.62
F3
.87
D1
D2
.62
.61
D3
.59
D4
.56
.49
D5
D6
Figure 1.1: Correlated three-factor model of negative emotions in youths. Based on: Muris, Schmidt, Merckelbach, & Schouten (2001b).
4
Normal and Abnormal Fear and Anxiety in Children and Adolescents
Normal Fear and Anxiety Studies of normal childhood fears have predominantly relied on surveys that list a broad range of potentially fear-provoking stimuli and situations. A widely used instrument for this purpose is the Revised version of the Fear Survey Schedule for Children (FSSC-R; Ollendick, 1983). The FSSC-R asks children to indicate on three-point scales (“none,” “some,” “a lot”) how much they fear specific stimuli and situations. FSSC-R surveys indicate that nonclinical children and adolescents report a surprisingly large number of fears. For example, Ollendick, King, and Frary (1989) found an average of 14 fears reported by American and Australian youths aged 7 to 17 years. A cross-cultural study by Ollendick, Yang, King, Dong, and Akande (1996) has demonstrated that this high prevalence of fears is quite similar across Western and non-Western countries. Typically, most of the common fears as obtained with the FSSC-R pertain to dangerous situations and physical harm. Thus, according to various FSSC-R studies, the 10 most common fears among nonclinical youths are (1) not being able to breathe, (2) being hit by a car or truck, (3) bombing attacks/being invaded, (4) getting burned by fire, (5) falling from a high place, (6) burglar breaking into the house, (7) earthquake, (8) death/dead people, (9) illness, and (10) snakes (e.g., Gullone & King, 1992; King, Ollier, Iacuone et al., 1989; Mellon, Koliadis, & Paraskevopoulos, 2004; Ollendick & King, 1994; Ollendick et al., 1989, 1996; Ollendick, Yule, & Ollier, 1991). Since the development of the FSSC-R in the early 1980s, society has changed, and youths are increasingly confronted with “new” threatening stimuli and situations: School violence, sexual assaults, domestic violence, parental divorce, abuse, and neglect are real-life threats for a growing number of children and adolescents (e.g., Fishkin, Rohrbach, & AndersonJohnson, 1997). In addition, television makes youths increasingly aware of diseases (e.g., AIDS), disasters (e.g., floods), and other threatening events (e.g., drugs, terrorist attacks) that may occur (e.g., Cole & Cole, 1996; Hicks & Holden, 1994). Research with updated versions of the FSSC-R, which include more of these contemporary fear stimuli and situations, has indicated that although most prevalent fears are still concerned with the theme of danger and harm, a number of the new fear items list high in the top 10 of most common fears (e.g., Burnham & Gullone, 1997; Shore & Rapport, 1998; Muris & Ollendick, 2002). While a questionnaire like the FSSC-R certainly yields important information on childhood fears, it is also clear that this type of assessment is determined by the items that are included in this scale. This point was nicely illustrated by Muris and colleagues (Muris, Merckelbach, & Collaris, 1997; Muris, Merckelbach, Meesters, & Van Lier, 1997), who examined the prevalence of common childhood fears by employing two different methods. That is, in these studies, fear rank orders were not only obtained by means of the FSSC-R, but also by asking children what they feared most without specifying items a priori (i.e., “free option” method). Results indicated that the fear rank order based on the free option method substantially deviated from that produced by the FSSC-R survey. More precisely, whereas the FSSC-R ranking again suggested that top intense fears have to do with danger and death, the free option method consistently showed that top intense fears pertain to animals (in particular, spiders). Further, as can be seen in Table 1.1, a number of prevalent
Normal and Abnormal Fear and Anxiety in Children and Adolescents
5
Table 1.1 Fear rank order in 9- to 13-year-old children (N = 129) based on the question “What do you fear most?”
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Number of subjects
Percentage of sample
Number in FSSC-Rbased rank order
24 10 8 8 7 6 5 5 5 4
18.6 7.8 6.2 6.2 5.4 4.7 3.9 3.9 3.9 3.1
10 — 21 15 23 11 4 28 — 6
Spiders Being kidnapped Predators The dark Frightening movies Snakes Being hit by a car Being teased Parents dying Burglar breaking into the house
From: Muris, Merckelbach, & Collaris (1997).
free option fears ranked relatively low in the FSSC-R-based ranking (i.e., predators, scary movies, and being teased). The preceding studies merely focused on childhood fears, but there are also studies that investigated the prevalence of anxiety symptoms among youths. One example is a study by Bell-Dolan, Last, and Strauss (1990), who examined the prevalence of symptoms of DSMIII-R anxiety disorders in a sample of 62 nonclinical children and adolescents aged between 5 and 18 years. Youths and parents were administered a semistructured interview in order to check present and past psychiatric problems, including a variety of anxiety disorders. Although it was found that these children and adolescents had never displayed any serious psychiatric problems, the results also indicated that subclinical anxiety disorders symptoms were relatively common among these youths. More precisely, not only phobic symptoms were highly prevalent, but also symptoms of generalized anxiety disorder, separation anxiety disorder, and social phobia (see Table 1.2). Similar results were obtained in a more recent study by Spence (1997), who examined the frequency of self-reported anxiety disorders symptoms in large community sample of 8- to 12-year-old children. Results showed that especially symptoms of social phobia and generalized anxiety were most prevalent. Symptoms of obsessive-compulsive disorder, separation anxiety disorder, and specific phobias were less common, whereas symptoms of panic disorder and agoraphobia appeared the least frequent. These results were largely replicated in a follow-up study by Spence, Rapee, McDonald, and Ingram (2001), who examined the prevalence of DSM-defined anxiety symptoms in preschoolers aged 2 to 6 years by means of parent ratings. Thus, even in very young children, anxiety disorders symptoms are highly prevalent. Separate studies have investigated the prevalence of more specific anxiety phenomena in youths. These studies have shown that worry (Muris, Meesters, Merckelbach, Sermon, &
6
Normal and Abnormal Fear and Anxiety in Children and Adolescents
Table 1.2 Most common anxiety disorders symptoms in a sample of never psychiatrically ill youths aged 5 to 18 years (N = 62) Symptom
Anxiety disorder
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
GAD GAD SP SOP SP SAD GAD GAD SOP GAD SOP
Overconcern about competence Excessive need for reassurance Fear of heights Fear of public speaking Fear of the dark Fear of harm of attachment figure Excessive worry about past behavior Self-consciousness Fear of dressing in front of others Somatic complaints Shrinks from contact with others
Percentage of sample with subclinical symptoms 30.6 22.6 22.6 21.7 19.4 16.1 16.1 16.1 14.5 14.5 14.5
Note. GAD = Generalized Anxiety Disorder, SP = Specific Phobia, SOP = Social Phobia, SAD = Separation Anxiety Disorder (current diagnostic terms are used). Based on: Bell-Dolan, Last, & Strauss (1990).
Zwakhalen, 1998; Orton, 1982; Silverman, LaGreca, & Wasserstein, 1995), nighttime fears (Mooney, 1985; Mooney, Graziano, & Katz, 1985; Muris, Merckelbach, Ollendick, King, & Bogie, 2001), scary dreams and nightmares (Mindell & Barrett, 2002), anxietyrelated physiological symptoms (Weems, Zakem, Costa, Cannon, & Watts, 2005), panic attacks (Hayward, Killen, & Taylor, 1989; King, Gullone, Tonge, & Ollendick, 1993; King, Ollendick, Mattis, Yang, & Tonge, 1997), and OCD-related rituals (Leonard, Goldberger, Rapoport, Cheslow, & Swedo, 1990) are commonly observed in youths. All these findings further justify the conclusion that fear and anxiety seem to be part and parcel of children’s normal development (Craske, 1997; Gullone, 2000).
Developmental Patterns in Fear and Anxiety If it is true that fear and anxiety in youths are intimately linked to development, one would expect to find a clear developmental pattern in the manifestation of these negative emotions. This topic was first addressed in an older study by Bauer (1976) who asked 4- to 12-yearold children to specify what they feared most. Results showed that 74% of the 4- to 6-yearolds but 53% of the 6- to 8-year-olds but only 5% of the 10- to 12-year-olds reported fear of ghosts and monsters. In contrast, only 11% of the 4- to 6-year-olds but 53% of the 6- to 8-year-olds and 55% of the 10- to 12-year-olds reported fears of bodily injury and physical danger. A more recent study by Muris, Merckelbach, Gadet, and Moulaert (2000) investigated the prevalence of fears, worries, and scary dreams among 4- to 12-year-old children by means of a semistructured interview, which included pictures to explain these anxiety
Normal and Abnormal Fear and Anxiety in Children and Adolescents 100 90 80 70 60 50 40 30 20 10 0
7
Fears Worries Scary dreams
4 to 6
7 to 9
10 to 12
Figure 1.2: Prevalence rates (percentages) of various anxiety phenomena in three age groups of children. Based on: Muris, Merckelbach, Gadet, & Moulaert (2000).
phenomena to the (younger) children. Inspection of the general developmental pattern of these phenomena revealed that fears and scary dreams were common among 4- to 6-yearolds, became even more prominent in 7- to 9-year-olds, and then decreased in frequency in 10- to 12-year-olds. The developmental pattern of worry deviated from this pattern. This phenomenon was clearly more prevalent in older children (i.e., 7- to 12-year-olds) than in younger children (see Figure 1.2). As to the frequency of specific types of fears, some developmental patterns emerged that were comparable to those obtained by Bauer (1976). For example, the prevalence of fears and scary dreams pertaining to imaginary creatures decreased with age, whereas worry about performance at school increased as children became older. Weems and Costa (2005) recently carried out a study to examine developmental differences in the expression of childhood anxiety symptoms. Symptoms of separation anxiety disorder, generalized anxiety disorder, and social phobia were assessed using child- and parent-report questionnaires. Three age groups of youths were compared: children aged 6 to 9 years, preteens aged 10 to 13 years, and adolescents aged 14 to 17 years. The results indicated that there were systematic age differences in the expression of childhood anxiety symptoms. More precisely, separation anxiety was predominant in 6- to 9-year-olds, but steadily decreased as children were older. The opposite pattern was observed for symptoms of generalized anxiety and social phobia, which were relatively infrequent among the youngest group but prevalent during adolescence (see Figure 1.3). This pattern was most clearly visible in the child report data. Although the parent data were largely comparable, the increase of generalized anxiety symptoms across the three age groups was not found, which makes sense because these types of symptoms are not readily observable. An investigation by Westenberg, Drewes, Goedhart, Siebelink, and Treffers (2004) also performed a developmental analysis of fears in 8- to 18-year-old youths. Based on Campbell and Rapee’s (1994) observation that childhood fears can be divided in two broad categories of physical harm and social problems, these researchers focused their analysis on the developmental pattern of fears concerning physical danger and fears concerning social evaluation. For this purpose, children in three age groups (i.e., 8- to 11-year-olds, 12- to 14-year-olds,
8
Normal and Abnormal Fear and Anxiety in Children and Adolescents 0,5 0,4 0,3 0,2 0,1 0 –0,1 –0,2 –0,3 –0,4 –0,5
Separation anxiety Generalized anxiety Social anxiety
6 to 9
10 to 13
14 to 17
Figure 1.3: Standardized scores of self-reported anxiety symptoms in youths across three age groups. Based on: Weems & Costa (2005).
and 15- to 18-year-olds) completed the FSSC-R. Results indicated that scores on FSSC-R subscales pertaining to physical fears clearly decreased across the three age groups. A differential pattern was observed within the category of social fears. That is, whereas fears of social evaluation (e.g., “Being criticized by others”) and achievement evaluation (e.g., “Failing a test”) clearly increased when children were older, fear of punishment (e.g., “Getting punished by mother”) significantly decreased with age. Research on the development of rituals (which can be seen as the normal expression of compulsions as seen in obsessive-compulsive disorder [OCD]) has also yielded a meaningful pattern. That is, Evans, Leckman, Carter et al. (1997) examined the prevalence of rituals in a large sample of 1488 children aged between 1 and 6 years by means of a parent-report questionnaire. The results indicated that rituals were not very frequent among 1-year-old children, became more prevalent among 2-, 3-, and 4-year-olds, and then decreased after the age of 4. Further research by Zohar and Bruno (1997) has demonstrated that ritualistic behaviors continue to decline during the remainder of childhood. Interestingly, it has also been observed that rituals, which tend to persist as children grow older, are more clearly related to anxiety and gradually acquire OCD-like properties (see also Evans, Gray, & Leckman, 1999; Leonard, Goldberg, Rapoport, Cheslow, & Swedo, 1999). Altogether, research has shown that normal fear and anxiety follow a predictable course, a phenomenon that has been termed “the ontogenetic parade” (Marks, 1987; p.109). It is generally assumed that children’s cognitive capacities are an important determinant of this ontogenetic parade of fear and anxiety. This is not surprising given the fact that fear and anxiety originate from threat, and threat must be conceptualized. Conceptualization, in turn, critically depends on cognitive abilities (e.g., Vasey, 1993). Thus, at very young ages, fear and anxiety are primarily directed at immediate, concrete threats (e.g., loud noises, loss of physical support). As cognitive abilities reach a certain maturational stage, fear and anxiety become more sophisticated. For example, at 9 months, children learn to differentiate between familiar and unfamiliar faces, and, consequently, separation anxiety and fear of strangers become manifest. Following this, fears of imaginary creatures occur, and it is believed that these are closely linked to the magical thinking of toddlers (e.g., Bauer, 1976). Fears of
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Table 1.3 Important developmental issues and related normal fear and anxiety in children and adolescents Age
Developmental issues
Fear and anxiety
0–6 months
Biological regulation
6–18 months
Object permanence Formation of attachment relationship Exploration of external world Magical thinking Autonomy Self-control
Fear of loud noises Fear of loss of support Fear of strangers Separation anxiety Fear of animals Fear of imaginary creatures Fear of the dark Fear of storms Fear of loss of caregivers Fear of school Worry Concerns about bodily injury and physical danger Social concerns
2–3 years 3–6 years
6–10 years
10–12 years 13–18 years
School adjustment Concrete operations: inference of cause-effect relations and anticipation of dangerous events Social understanding Friendship Identity Formal operations: catastrophizing about physical symptoms Sexual relationships Physical changes
Social anxiety Panic
Partly based on: Warren & Sroufe (2004). In Ollendick & March (2004), pp.92–115.
animals also develop during this phase. These fears are believed to be functionally related to the increased mobility of the child and its exploration of the external world. Some authors assume that fears of animals have survival value, as they would protect the mobile child from predators and other dangerous animal species (e.g., spiders, snakes; Öhman, Dimberg, & Öst, 1985). From age 7 onwards, children are increasingly able to infer physical causeeffect relationships and to anticipate potential negative consequences. These cognitive changes broaden the range of fear-provoking stimuli and enhance the more cognitive features of anxiety (e.g., worry). Taken together, in the course of their life, children are confronted with various developmental issues that have to be resolved and that largely determine the content of their fears and anxiety (see Table 1.3).
Fear, Anxiety, and Cognitive Development Indirect support for the notion that cognitive abilities and, in its wake, conceptualization have an influence on manifestations of fear and anxiety in youths comes from studies of children with autism or related disorders for which it is well known that they exhibit various
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
cognitive aberrations (e.g., Frith, 1989). For example, Evans, Canavera, Kleinpeter, Maccubin, and Taga (2005) compared the fears of children with an autism spectrum disorder (ASD), children with Down syndrome, and chronologically age-matched children (with average ages ranging between 9 and 12 years), using parent ratings of a standardized fear questionnaire. Results indicated that children with ASD more frequently reported situational, social, and medical fears but less often fears of harm and injury as compared to the other two groups. In another study, Weisbrot, Gadow, DeVincent, and Pomeroy (2005) obtained parent and teacher ratings of anxiety symptoms in a large sample of 3- to 12-yearold clinically referred children with and without a pervasive developmental disorder (PDD). These researchers noted that both informants rated children with PDD as significantly more anxious than non-PDD children, which led them to the conclusion that “anxiety appears to be a clinically important concern in many children with PDD” (p.477). Finally, Muris, Steerneman, Merckelbach, Holdrinet, and Meesters (1998) found that children with PDD (i.e., autistic disorder and pervasive developmental disorder—not otherwise specified; N = 44) frequently displayed clinically relevant fear and anxiety symptoms. In particular, severe symptoms of specific phobia (63.6%) and agoraphobia (45.5%) were highly prevalent within this group, whereas symptoms of panic disorder, social phobia, and generalized anxiety disorder were relatively less common. With respect to these results, Muris et al. (1998; p.392) note that “it is conceivable that a serious cognitive dysfunction rules out those types of anxiety phenomena that presuppose sophisticated cognitive processes (e.g., worrying, fearful anticipation) . . . fear and anxiety symptoms of these children originate from their weak integration capacity. That is, PDD children have extreme difficulties in relating diverse sources of information. As a result, PDD children would experience many everyday situations as chaotic, obscure, and thus frightening,” which of course clearly link the manifestation of fear and anxiety to the cognitive abilities of children with this type of developmental disorder. While it is a widely accepted notion that the developmental pattern of fear and anxiety reflects everyday experiences and to an important extent is mediated by children’s cognitive capacities (Marks, 1987), it should also be acknowledged that direct empirical evidence for this idea is extremely sparse. One exception is a study by Muris, Merckelbach, Meesters, and Van den Brand (2002), who examined the connection between cognitive development and worry. Children were interviewed about the presence and content of a personal worry. Furthermore, a worry elaboration score was obtained by encouraging children to think up potential negative outcomes associated with a series of worry topics. Finally, a number of Piaget’s (1970) conservation tasks were administered in order to assess children’s level of cognitive maturation. Results revealed a mediation model in which increased age and, in its wake, cognitive development lead to enhanced worry elaboration, which in turn increases the possibility of a personal worry to emerge (see Figure 1.4). Thus, it can be concluded that worry becomes increasingly manifest in middle childhood when children reach a certain level of cognitive maturation (see also Vasey, Crnic, & Carter, 1994). Another example involves the aforementioned investigation by Westenberg et al. (2004). These researchers examined developmental patterns in fears concerning both physical danger and social evaluation in a large sample of children and adolescents. Interestingly, participants’ level of sociocognitive maturation was also assessed. Results demonstrated that fears of physical danger decreased with age, whereas fears concerning social evaluation increased as children got older. Most important, however, it was found that the age effect
Normal and Abnormal Fear and Anxiety in Children and Adolescents
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.08
Age .23*
Cognitive development
.30*
Worry elaboration
.18*
Personal worry
–.04
Figure 1.4: Model showing the mediational effects of worry elaboration on the relationship between cognitive development and age, on the one hand, and the emergence of a personal worry, on the other hand. *Significant path at p < .05. From: Muris, Merckelbach, Meesters, & Van den Brand (2002).
in social-evaluative fears was entirely explained on the basis of developmental differences in sociocognitive maturity. This led the authors to the conclusion that the social fear and anxiety, which frequently arise during adolescence, are a corollary of sociocognitive development. A final example that illustrates the developmental course of fear and anxiety among youths pertains to the phenomenon of panic. Several researchers have argued that real panic symptoms usually do not occur before adolescence because younger children are less capable of experiencing the cognitive symptoms that accompany panic, such as “fear of going crazy” and “fear of dying” (e.g., Nelles & Barlow, 1988). A recent investigation by Muris, Vermeer, and Horselenberg (in press) indeed provided some evidence to suggest that cognitive development is associated with children’s ability to consider physical symptoms as a sign of anxiety. In that study, children aged between 4 and 13 years were presented with a number of vignettes in which the presence and absence of physical symptoms (e.g., “difficulties with breathing,” “heart beating fast,” “feeling dizzy”) was systematically varied. Results revealed a clear developmental pattern for anxiety-related interpretations of physical symptoms. More precisely, from age 7, children were increasingly capable of linking physical symptoms to the emotion of anxiety. Moreover, cognitive development as measured by Piagetian conservation tasks also appeared to influence children’s anxiety-related interpretations of physical symptoms. That is, children who had reached a more advanced stage of cognitive development (e.g., concrete operations) were better in linking physical symptoms to the emotion of anxiety. Unfortunately, this study did not examine to what extent these children were capable of making catastrophic, panic-like interpretations of the physical symptoms. This issue was addressed in a study by Mattis and Ollendick (1997), who reported that even children as young as 9 years were able to attribute physical symptoms to internal, threat-related cognitions, although less to catastrophic ones. Further, these researchers assume that such cognitions more frequently occur in adolescence when children’s cognitive abilities have further matured. All these studies seem to indicate that cognitive development in particular plays a prominent role in the occurrence of various “normal” anxiety phenomena and may herald periods in which vulnerable children are prone to develop high levels of fear and anxiety or even anxiety disorders.
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
Gender Differences in Fear and Anxiety It is well established that girls display higher levels of fear and anxiety than boys (Bernstein, Borchardt, & Perwien, 1996; Ollendick, King, & Muris, 2002). For example, it is a consistent finding that girls exhibit significantly higher scores on standard self-report questionnaires for measuring fear and anxiety as compared to boys. To illustrate this point, Figure 1.5 shows mean standardized fear and anxiety scores for nonclinical boys and girls, using data of studies that either employed the FSSC-R or the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher, Khetarpal, Brent et al., 1997) for measuring these types of symptoms in youths. As can be seen, girls clearly reported higher fear (FSSC-R) and anxiety (SCARED) levels than boys (see also Craske, 2003). Although there is abundant evidence for gender differences in self-reported fear and anxiety, it should be noted that these differences are less clear-cut when using parents as raters of children’s symptoms. For example, a recent study by Muris, Meesters, and Knoops (2005) demonstrated that when employing children’s self-report data, substantial gender differences in fear and anxiety were observed. However, when using parent report data, the effects of gender were only present for fear and not for anxiety. This probably has to do with the fact that anxiety is not as easy to observe as fear (e.g., Stallings & March, 1995). More precisely, whereas children’s fear is, at least to some extent, visible to parents (and other caregivers), anxiety symptoms such as worry and somatic sensations may remain largely hidden when the child does not communicate them (see Layne, Bernstein, & March, 2006). Support for this idea was obtained in a recent study by Comer and Kendall (2004), who demonstrated better parent-child agreement for observable, school-based fear and anxiety symptoms (e.g., “There are places the child won’t go because he/she is afraid to be away from his/her parents,” “Child gets more nervous or scared than other children of his/ her age when answering questions in class”) than for unobservable, non-school-based
0,8 0,6 0,4 0,2
Boys
0
Girls
–0,2 –0,4 –0,6 –0,8 FSSC-R
SCARED
Figure 1.5: Mean standardized fear (FSSC-R) and anxiety (SCARED) scores for nonclinical boys and girls using self-report data of 20 studies published between 1983 and 2005. FSSC-R = Revised Fear Survey Schedule for Children, SCARED = Screen for Child Anxiety Related Emotional Disorders. Both gender differences are significant at p < .01.
Normal and Abnormal Fear and Anxiety in Children and Adolescents
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symptoms (e.g., “Child worries a lot about that something bad might happen to him/her,” “Child has bad dreams about being away from his/her parents”).
Severity of Childhood Fear and Anxiety As mentioned before, fear and anxiety are normal phenomena that occur in many children and adolescents. Still, it is largely unknown how serious fear and anxiety actually are. In other words, to what extent do children and adolescents engage in worry about feared stimuli and situations at a frequent or regular basis? Do they engage in avoidance behavior to prevent their occurrence? Do these fear and anxiety symptoms interfere with youths’ daily functioning? (see Ollendick & King, 1994). Few studies have addressed these questions in a systematic fashion. In a survey by McCathie and Spence (1991), 7- to 13-year-old children (N = 376) were asked to complete the FSSC-R and the Fear Frequency and Avoidance Survey Schedule for Children (FFASSC). The FFASSC measures the frequency with which children respond with fearful thoughts and avoidance behavior to fear items as listed by the FSSC-R. McCathie and Spence noted that there were robust connections between the most commonly reported fears on the FSSC-R and the frequency of fearful thoughts and avoidance behaviors. Thus, not only did children report having FSSC-R defined fears, they also said that these fears were accompanied by aversive thoughts and avoidance behavior. Similarly, Ollendick and King (1994) found that a large majority of children (i.e., more than 60%) reported that their fears interfered substantially with daily activities. These findings emphasize the point that symptoms of childhood fear and anxiety are often seriously disturbing and distressing. This point can also be illustrated by a study of Strauss, Frame, and Forehand (1987), who compared the general functioning of anxious children with that of nonanxious controls. Peer, teacher, and self-reports clearly indicated that the anxious youths showed impairments in social, emotional, and school functioning as compared to their nonanxious counterparts. Similar results were obtained by Muris and Meesters (2002a), who examined the relation between children’s self-reported anxiety symptoms and teacher ratings of school functioning in a sample of 317 primary school children. Results indicated that higher levels of anxiety symptoms were accompanied by less optimal school functioning. More specifically, anxiety symptoms were associated with lower levels of selfesteem and school performance. Finally, it should be mentioned that fear and anxiety symptoms in nonclinical youths are accompanied by heightened levels of depression, difficulties in establishing social and romantic relationships, and in some cases alcohol abuse (Cole, Peeke, Martin, Truglio, & Seroczynski, 1998; Glickman & La Greca, 2004; Kaplow, Curran, Angold, & Costello, 2001; Strauss, Lease, Kazdin, Dulcan, & Last, 1989). Research has also indicated that children and adolescents who display high levels of fear and anxiety symptoms at one point in time are at increased risk for exhibiting high levels of such symptoms on a later occasion. For example, prospective studies employing the FSSC-R, in which children and adolescents were followed for longer time periods (i.e., 2 to 3 years), have demonstrated that youths’ fear levels generally decreased from the initial to the follow-up assessment (Gullone & King, 1997; Spence & McCathie, 1993). However, the data also showed that initial fear scores were good predictors of follow-up fear scores, suggesting that such symptoms were relatively stable over time. Similar results have been
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
obtained by Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam (1995), who longitudinally followed a group of 356 school children over a four-year period. In grade 1, selfreported anxiety symptoms appeared inversely related to adaptive functioning (see also Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1994). Most importantly, firstgrade anxious symptoms were found to have significant prognostic value in terms of children’s levels of anxious symptoms and adaptive functioning in grade 5. Taken together, high levels of fear and anxiety symptoms tend to be stable over longer time periods (see also Gullone, King, & Ollendick, 2001), thereby causing youths to experience long-lasting difficulties. In order to get a better picture of the clinical significance of “normal” fear and anxiety symptoms among youths, their connection to DSM-defined phobias and anxiety disorders should be considered. A study by Muris, Merckelbach, Mayer, and Prins (2000) explored this issue. In that study, fears of 290 children aged 8 to 13 years were assessed, and then their severity was evaluated by means of a structured diagnostic interview measuring anxiety disorders in terms of DSM criteria. Results showed that in a sizable minority of the children (22.8%), fears reflected significant anxiety disorders, notably specific phobias. Similar findings were reported in a follow-up study that investigated the connection between childhood fears and specific phobias by interviewing children’s parents (Muris & Merckelbach, 2000). Other studies that examined the severity of normal children’s nighttime fears and worries through their links with DSM classifications (Muris et al., 1998, 2001) also revealed that such fear and anxiety phenomena reflect serious problems in a fair proportion of the youths (see Table 1.4). Thus, while there has been a strong tendency in the literature to portray childhood fear and anxiety as mild and nonpathological (e.g., Rutter, Tizard, & Whitmore, 1968), the studies summarized in this section make clear that at least a subgroup of children evidence significant phobias and anxiety disorders that not only hinder current functioning but also may have a negative impact on future life (see, e.g., Vignoli, Croity-Belz, Chapeland, De Fillipis, & Garcia, 2005).
Abnormal Fear and Anxiety in Children and Adolescents Abnormal fear and anxiety in children and adolescents are typically expressed in terms of the phobias and anxiety disorders as defined in the DSM. The latest edition of the DSM (i.e., the DSM-IV-TR; APA, 2000) for the most part employs the same diagnostic criteria and entities for classifying “anxiety disorders” in youths as in adults. The only exception is separation anxiety disorder, which is subsumed under the section “disorders usually first diagnosed in infancy, childhood, or adolescence.” Table 1.5 lists the various phobias and anxiety disorders that, according to the DSM, can be classified in children and adolescents, as well as a brief description of the essential features of each disorder. It is good to keep in mind that during the past decades, the classification of anxiety disorders in youths has been somewhat changed. For example, previous editions of the DSM (e.g., DSM-III-R; APA, 1987) included anxiety disorders that were specifically diagnosed in youths. That is, avoidant disorder and overanxious disorder were the child and adolescent counterparts of the adult classifications of respectively social phobia and generalized anxiety disorder. In later editions, this distinction was no longer made (APA, 1994, 2000), and now similar criteria are used for defining these disorders in youths and adults (although some differences
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Table 1.4 The severity of common childhood fear and anxiety phenomena as expressed by their relations to DSM anxiety disorder diagnoses Fear and anxiety phenomenon (study) Worry (Muris et al., 1998)
Childhood fears (Muris et al., 2000)
Childhood fears (Muris & Merckelbach, 2000) Nighttime fears (Muris et al., 2001)
Informant/sample Child report 193 children aged 8 to 13 years Child report 290 children aged 8 to 13 years
Parent report 160 children aged 4 to 12 years Parent report 176 children aged 4 to 12 years
DSM anxiety disorder GAD
Percentage of total sample 6.2
SP Situational-environmental SP Blood-injection-injury SP Animals GAD SAD PD At least 1 anxiety disorder SP Situational-environmental SP Blood-injection-injury SP Animals
4.5 7.9 7.2 5.5 4.8 1.7 22.8 6.3 1.3 10.0
SP Situational-environmental SP Animals GAD
1.3 1.9 4.4
Note. SP = Specific Phobia, GAD = Generalized Anxiety Disorder, SAD = Separation Anxiety Disorder, PD = Panic Disorder (current diagnostic terms are used).
in the precise symptomatology of various anxiety disorders may still be observed; see Geller, Biederman, Faraone et al., 2001; Kendall & Pimentel, 2003). For reasons of clarity, the current nosologic terms are consistently employed throughout this book, even when describing older studies that used diagnoses based on somewhat different diagnostic criteria (Kendall & Warman, 1996). Nevertheless, this procedure seems defendable because the core features of the anxiety disorders in youths (see Table 1.5) have remained unchanged throughout the years. It should be noted that the current edition of the DSM also includes two other types of anxiety disorders: “substance-induced anxiety disorder” and “anxiety disorder—not otherwise specified.” The first type refers to a variety of serious anxiety symptoms that occur after substance intoxication or withdrawal, whereas the second type pertains to disorders with prominent anxiety and phobic avoidance that do not meet the criteria for any specific anxiety disorder (APA, 2000). However, these two types of anxiety disorders are not listed in Table 1.5 because they are not characterized by a specific set of symptoms but rather “borrow” symptoms from various other anxiety disorders. Further, there are a number of
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
Table 1.5 DSM-IV-TR defined phobias and anxiety disorders in children and adolescents Anxiety disorder
Essential features
Specific phobia
Marked and persistent fear of clearly discernible, circumscribed objects or situations. Five types: animal, situational, blood-injection-injury, natural environment, and other. The presence of recurrent, unexpected panic attacks, i.e. discrete periods of intense fear that are accompanied by somatic and cognitive symptoms. There is also persistent concern about having another panic attack, worry about the implications or consequences of the panic attacks, or a significant behavioral change related to the attacks. Anxiety about being in places or situations from which escape might be difficult or in which help may not be available in the event of having a panic attack or panic-like symptoms. Marked and persistent fear of social or performance situations in which embarrassment may occur. Recurrent obsessions and/or compulsions. Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts, the goal of which is to prevent or reduce anxiety or distress. Following exposure to an extreme traumatic stressor, which elicited intense fear, helplessness, or horror, the person develops a characteristic pattern of symptoms including reexperiencing the traumatic event, persistent avoidance of stimuli associated with the trauma, and increased arousal. Enduring and excessive anxiety and worry (apprehensive expectation) about a number of events and activities. Excessive anxiety concerning separation from the home or from those to whom the person is attached.
Panic disorder
Agoraphobia
Social phobia (previously known as avoidant disorder) Obsessive-compulsive disorder
Posttraumatic or acute stress disorder
Generalized anxiety disorder (previously known as overanxious disorder) Separation anxiety disorder
Based on: American Psychiatric Association (2000).
Normal and Abnormal Fear and Anxiety in Children and Adolescents
17
other mental disorders that occur in youths in which fear and/or anxiety seem to play an important role. For instance, selective mutism, which can be defined as the refusal or withholding of speech in some situations while displaying normal speech in other settings, may reflect high levels of social anxiety (e.g., Vecchio & Kearney, 2005; Yeganeh, Beidel, Turner, Pina, & Silverman, 2003). As another example, some adolescents come to suffer from the somatoform disorder of hypochondriasis, which refers to the preoccupation with having a serious disease, which is accompanied by high levels of fear and worry (Fritz, Fritsch, & Hagino, 1997). Epidemiological surveys have yielded prevalence rates of childhood phobias and anxiety disorders that vary between 2% and 27% (see, for a recent review, Costello, Egger, & Angold, 2004). This range is rather broad, but it should be kept in mind that rates are largely dependent on the type of prevalence that is studied. More precisely, three-month estimates ranged from 2.2% to 8.6%, six-month estimates from 5.5% to 17.7%, 12-month estimates from 8.6% to 20.9%, whereas lifetime prevalence estimates varied between 8.3% and 27.0%. A comparison with the prevalence rates of other psychiatric disorders in youths reveals that anxiety disorders are among the most common psychological problems in children and adolescents. For example, in a sample of 10,438 5- to 15-year-old children and adolescents, Ford et al. (2003) found a three-month prevalence rate of 3.7% for anxiety disorders, which means that this type of problem ranks high among the psychiatric disorders that occur in youths. Only disruptive behavior disorders (including oppositional-defiant disorder, conduct disorder, and attention-deficit and hyperactivity disorder) were more prevalent (Figure 1.6). On the basis of a large cohort study carried out in the Great Smoky Mountains in the United States, Costello et al. (2003) report a cumulative prevalence rate of 9.9% for anxiety disorders by the age of 16 years. This implies that 1 out of 10 children in this study had suffered from an anxiety disorder at some point during their youth. Figure 1.7 displays the prevalence rates for various types of anxiety disorders in youths using the data of 14 epidemiological studies that included children and adolescents of
6 5 4 3 2 1 0 Disruptive behavior disorders
Anxiety disorders
Depressive disorders
PDDs
Eating disorders
Tic disorders
Figure 1.6: Percentage of youths with DSM-IV defined anxiety disorders as compared to other psychiatric disorders. PDDs = Pervasive Developmental Disorders. Based on: Ford, Goodman, & Meltzer (2003).
18
Normal and Abnormal Fear and Anxiety in Children and Adolescents 4 3 2 1 0 SP
SOP
GAD
SAD
AGO
PTSD
PD
OCD
Figure 1.7: Mean prevalence rates of various anxiety disorders in youths, using the data of 14 epidemiological studies. SP = Specific Phobia, SOP = Social Phobia, GAD = Generalized Anxiety Disorder, SAD = Separation Anxiety Disorder, AGO = Agoraphobia, PTSD = Posttraumatic Stress Disorder, PD = Panic Disorder, OCD = Obsessive-Compulsive Disorder. Based on: Costello, Egger, & Angold (2004). In Ollendick & March (2004), pp.61–91.
various ages. As can be seen, specific phobia, social phobia, generalized anxiety disorder, and separation anxiety disorder are most common, with mean prevalence rates between 2.2% and 3.6%. Agoraphobia (1.5%) and posttraumatic stress disorder (1.5%) are less prevalent, whereas panic disorder and obsessive-compulsive disorder are relatively rare (i.e., <1%). Altogether, in spite of considerable variation in the prevalence of specific anxiety disorders, it can be concluded that abnormal manifestations of fear and anxiety are fairly common among youths and clearly belong to the most prevalent psychiatric problems in children and adolescents.
Gender Differences in Childhood Anxiety Disorders As with normal fear and anxiety symptoms, girls more frequently suffer from phobias and other anxiety disorders as compared to boys (Craske, 2003). For example, the aforementioned study of Costello et al. (2003), who assessed the prevalence and development of psychiatric disorders in a large community sample of 9- to 16-year-old youths, showed that by the age of 16, 12.1% of the girls had suffered from an anxiety disorder versus only 7.7% of the boys. On the basis of these and other findings, Costello et al. (2004; p.85) concluded: “Recent research confirms the 2 to 1 (girls to boys) sex ratio for anxiety disorders, although this varies from diagnosis to diagnoses.” More precisely, girls are generally found to predominate over males with respect to specific phobias, separation anxiety disorder, and generalized anxiety disorder, whereas few, if any, gender differences are noted for obsessive-compulsive disorder and social phobia (Craske, 1997). The conclusion that girls are about twice as likely to develop an anxiety disorder as compared to boys can be nicely illustrated by means of retrospective data obtained by Lewinsohn, Gotlib, Lewinsohn, Seeley, and Allen (1998). These researchers used a life
Normal and Abnormal Fear and Anxiety in Children and Adolescents
19
0,14 0,12 0,10 0,08
Girls
0,06
Boys
0,04 0,02 0,00 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Figure 1.8: Cumulative hazard for developing an anxiety disorder in boys and girls at various ages. From: Lewinsohn, Gotlib, Lewinsohn, Seeley, & Allen (1998).
table survival analysis to compare the time of the first occurrence of any anxiety disorder for female and male youths. This analysis clearly demonstrated the higher prevalence of anxiety disorders in girls as compared to boys. Most interestingly, however, the data showed that the cumulative hazard rates for girls and boys begin to diverge at a very early age. For example, at age 6, girls were already twice as likely to have developed an anxiety disorder than were boys (see Figure 1.8).
Course of Abnormal Anxiety in Youths Few studies have examined the natural course of anxiety disorders in youths. One exception is a study by Cantwell and Baker (1989), who examined the stability and natural history of anxiety disorder diagnoses in a sample of 151 children and adolescents who visited a community speech and language clinic. The researchers noted that many youths with initial diagnoses of social phobia (71%), separation anxiety disorder (89%), and generalized anxiety disorder (75%) no longer met the criteria of these classifications at a four-year follow-up. Similar results were reported by Last et al. (1996), who examined the recovery from anxiety disorders in clinically referred children and adolescents. The results of this study showed that, at a follow-up assessment 3 to 4 years after the intake at the clinic, the majority of anxiety disordered youths (81.7%) no longer suffered from their problems. Particularly high recovery rates were found for separation anxiety disorder (95.7%), whereas relatively low recovery was found for panic disorder and specific phobias (respectively 70.0% and 69.2%). Thus, the overall prognosis appeared good for children with anxiety disorders (see also Last, Hansen, & Franco, 1997), although one must consider that the majority of the youths included in this study had received some kind of treatment following the intake assessment. In addition, results showed that 29.8% of this sample had developed a new psychiatric disorder during the follow-up period, and in half of the cases (15.5%) this concerned a new anxiety disorder. A less favorable course was observed in a
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
longitudinal study by Keller et al. (1992), who followed 38 clinically referred youths with anxiety disorders over an eight-year period. Results indicated that 46% of the children and adolescents failed to recover before the end of the study. Moreover, of those who did show recovery from their anxiety disorder, a substantial proportion (31%) experienced a new episode of an anxiety disorder. A further study by Essau, Conradt, and Petermann (2002) investigated the course of anxiety disorders in a sample of German adolescents. The results of this study indicated that 22.6% of the adolescents who fulfilled the DSM-IV criteria of an anxiety disorder at the initial interview continued to have an anxiety disorder at the follow-up assessment, more than one year later. Many of these young people (41.9%) no longer suffered from a psychiatric problem, whereas the remainder had developed another disorder (e.g., somatoform disorder, depression). Notably, of those adolescents who suffered from chronic anxiety disorders, more than half (57.9%) still showed serious symptoms of their initial diagnosis; however, the others had developed new anxiety complaints. Recently, Foley, Pickles, Maes, Silberg, and Eaves (2004) assessed the course and short-term outcome of separation anxiety disorder in a community-based sample of twins aged 8 to 17 years. Of the 161 youths who were diagnosed with separation anxiety disorder at time 1, 80% had remitted and 59% were free of any disorder at a follow-up of 18 months. Results also indicated that a substantial minority of the children and adolescents (26%) who had been diagnosed with separation anxiety disorder at time 1 but no longer fulfilled the criteria for this diagnosis at time 2 had developed a new psychiatric disorder—in most cases a generalized anxiety disorder. Furthermore, this risk for developing new disorders was even higher in youths with persistent separation anxiety disorder: 56% of them had developed another disorder at follow-up, with other anxiety disorders (i.e., generalized anxiety disorder and phobias) and depression being the most prevalent comorbid diagnoses. Thus, available evidence suggests that phobias and anxiety disorders are transitory phenomena in most children and adolescents. Yet, in a subgroup of youths, these pathological manifestations of fear and anxiety become chronic, causing significant problems and interference with daily functioning for many years. The latter point is further illustrated by studies that examined the persistence of anxiety disorders from youth into adulthood. Kessler, Berglund, Demler et al. (2005) examined the lifetime prevalence and age of onset of DSM-IV disorders, including anxiety disorders, in a large community sample of adults (N = 9282). The lifetime prevalence estimates indicated that anxiety disorders were the most common DSM-IV disorder (with a prevalence rate of 28.8%). Most importantly for the present discussion, it was found that anxiety disorders had an early age of onset: The median age of onset for these problems was 11 years, and some types of anxiety disorders were even characterized by an earlier onset (i.e., specific phobias: seven years; separation anxiety disorder: seven years). Kessler et al. conclude: “About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life, with first onset usually in childhood or adolescence. Interventions aimed at prevention or early treatment need to focus on youth” (p.593), and in view of their results, this conclusion certainly applies to anxiety disorders. A somewhat different research approach was followed by Newman, Moffitt, Caspi et al. (1996), who gathered mental health data at ages 11, 13, 15, 18, and 21 in an epidemiological sample using a standardized interview schedule. At age 21, anxiety disorders were among the most frequent psychiatric problems, with some of them approaching a prevalence rate of 10% (i.e., specific phobias, social phobia). Follow-
Normal and Abnormal Fear and Anxiety in Children and Adolescents Adolescence No history of a previous disorder History of a previous anxiety disorder History of another psychiatric disorder
21
Young adulthood
19.5% 61.5%
Anxiety disorder at age 21
19.0%
Figure 1.9: Developmental history of anxiety disorders identified in young adults at age 21. From: Newman, Moffitt, Caspi, Magdol, Silva, & Stanton (1996). back longitudinal analysis carried out to determine the developmental history of the disorders indicated that anxiety disorders showed substantial homotypic continuity. As can be seen in Figure 1.9, the majority of the subjects who suffered from an anxiety disorder at age 21 already had anxiety problems at an earlier age. Epidemiological research by Pine, Cohen, Gurley, and Brook (1998) in which 776 adolescents were followed for nine years demonstrated that an anxiety disorder in adolescence predicted an approximate two- to three-fold increased risk for an anxiety disorder in adulthood. The results further showed that there was evidence of specificity in the course of specific phobias and social phobias. Other anxiety disorders like generalized anxiety disorder exhibited a more variable course and frequently changed in some other anxiety or psychiatric disorder. Another study of Aschenbrand, Kendall, Webb, Safford, and Flannery-Schroeder (2003) investigated the link between anxiety disorders in youths (i.e., separation anxiety disorder, generalized anxiety disorder, and social phobia) and adult anxiety disorders, in order to test the hypothesis whether separation anxiety disorder in childhood is a risk factor for panic disorder and agoraphobia in adulthood (see Silove, Manicavasagar, Curtis, & Blaszczynski, 1996). The results did not confirm this hypothesis (see also Brückl, Wittchen, Hofler et al., 2006) but demonstrated that childhood anxiety disorders in general show significant continuity into adulthood, in spite of the fact that youths had received treatment for their problem. A final study by Woodward and Fergusson (2001) prospectively examined the link between anxiety disorders in middle adolescence (14 to 16 years) and young people’s subsequent adjustment in various domains (i.e., mental health, educational, and social) at ages 16 to 21 years. Results clearly indicated that adolescents with an anxiety disorder showed poorer adjustment when they became older than adolescents without an anxiety disorder. More precisely, adolescents with an anxiety disorder at ages 14 to 16 were more at risk for later anxiety disorders, depression, substance use problems, and suicide, and were less successful in academic and social settings. Interestingly, a linear association was observed between the number of anxiety disorders at ages 14 to 16 and later adjustment; that is, with each additional anxiety disorder, the frequency of adverse outcomes also substantially increased. Taken together, whereas anxiety disorders show considerable instability during childhood, they seem to become progressively more stable toward the end of adolescence and regularly persist into adulthood.
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
As mentioned earlier, especially in younger children, anxiety disorders are rather changeable. It is not uncommon that an anxiety disorder at a certain age is substituted by another anxiety disorder some years later (Öst & Treffers, 2001). It is conceivable that developmental factors play a role in the metamorphosis of anxiety disorders in youths. However, research examining the role of development on the manifestation of anxiety disorders in youths is extremely sparse. An exception is a study by Westenberg, Siebelink, Warmenhoven, and Treffers (1999), which investigated the developmental underpinnings of age trends in the prevalence of separation anxiety disorder and generalized anxiety disorder in children and adolescents. Their sample consisted of 118 children and adolescents aged 8 to 18 years who fulfilled the criteria of either separation anxiety disorder or generalized anxiety disorder, or both disorders. The researchers used a revised version of the Sentence Completion Test (Loevinger, 1985) to assess youths’ ego development in three successive levels: (1) The impulsive level is the first most primitive level. Children at this level live by the moment of their immediate thoughts, feelings, and wishes; they generally feel vulnerable and still need others to protect them; (2) the self-protective level is mainly concerned with control; self-protective children want to be in charge of themselves, other people, and situations; (they become apprehensive when self-control and control over others and situations is anticipated) and (3) the conformist level that is no longer geared toward the protection of one’s self-interest but more toward social tuning. At this level, children try to meet the demands of others, in terms of correct opinions, behavior, and appearance. Dangers are not as much located outside oneself, but more within oneself (see Westenberg, Siebelink, & Treffers, 2001). In their study, Siebelink et al. (1999) found a clear relation between age and type of anxiety disorder. That is, children with a separation anxiety disorder were considerably younger than children with generalized anxiety disorder (mean ages were 10.3 years versus 14.5 years, respectively), whereas children with comorbid separation and generalized anxiety disorder were in between (with a mean age of 12.4 years). Most importantly, level of ego development also appeared a strong predictor of anxiety disorder status (i.e., separation anxiety disorder, generalized anxiety disorder, or both disorders). That is, separation anxiety disorder was primarily related to the impulsive ego level, generalized anxiety disorder was predominantly linked to the conformist ego level, whereas the comorbid condition was associated with the impulsive as well as the intermediate self-protective ego level (see Figure 1.10). Interestingly, when controlling for age, level of ego development remained a significant predictor of type of anxiety disorder. In contrast, when controlling for ego development, age no longer contributed to anxiety disorder status. On the basis of these results, it can be concluded that the presence of separation anxiety disorder and generalized anxiety disorder appears to be related to specific levels of psychosocial maturity. Thus, there seems to be some evidence demonstrating that, just like normal fear and anxiety phenomena, the manifestation of anxiety disorders in youths is determined by developmental factors. Clearly, more research on this issue is urgently needed.
Severity and Comorbidity Among Childhood Anxiety Disorders Although it is clear that anxiety disorders per definition are associated with significant interference of daily functioning (APA, 2000), there is a tendency among clinicians to define
Normal and Abnormal Fear and Anxiety in Children and Adolescents
23
90 80 70 60
Impulsive
50
Self-protective
40
Conformist
30 20 10 0 SAD
SAD+GAD
GAD
Figure 1.10: The relationship between separation and generalized anxiety disorders and level of ego development. SAD = Separation Anxiety Disorder, GAD = Generalized Anxiety Disorder (current diagnostic labels are used). Based on: Westenberg, Siebelink, Warmenhoven, & Treffers (1999). these problems as relatively mild. However, studies that actually examined the severity of anxiety disorders in youths have indicated that this type of psychiatric problem is associated with clinically significant impairment. For example, in their community sample, Newman et al. (1996) reported that a substantial proportion of the youths with anxiety disorders had sought treatment for their problems (29.5%), had used psychotropic medication (9.9%), had been hospitalized for their symptoms in the past year (4.2%), and had attempted suicide (7.2%), which indicates that these disorders do reflect serious problems in youths. A study by Van Ameringen, Mancini, and Farvolden (2003) demonstrated the impact of anxiety disorders on educational achievement. Adult anxiety disordered patients were asked to report their educational functioning when they were adolescents. Almost half of the patients (49%) reported that they had left school prematurely, and a substantial proportion of them (24%) indicated that anxiety was the primary reason for this decision (see also Last & Strauss, 1990). An examination of data collected in a sample of patients who had been referred to an outpatient treatment center (Muris, Dreessen, Bögels, Weckx, & Van Melick, 2004) reveals that children and adolescents with anxiety disorders on average had a global assessment of functioning (GAF) score of 57.6 (range 40 to 80), which according to DSM-IV reflects “moderate symptoms or moderate difficulty in social and school functioning” (APA, 2000). As can be seen in Figure 1.11, this figure compared rather well with those found for youths with other common psychiatric problems such as depression and disruptive behavior disorders. Note in passing that panic disorder, posttraumatic stress disorder, and generalized anxiety disorder were the anxiety disorders with the most severe impairment in functioning. In a similar vein, Bastiaansen, Koot, Ferdinand, and Verhulst (2004) found that parents of children with anxiety disorders reported significant deficits in the quality of life of their offspring, in particular in the domain relating to emotional functioning. Comorbidity among childhood phobias and anxiety disorders is high, and this appears true for community as well as clinical samples of youths. Figure 1.12 shows the strengths
24
Normal and Abnormal Fear and Anxiety in Children and Adolescents
Depression PD ODD/CD PTSD GAD SOP OCD SP Anxiety disorders SAD ADHD 50
55
60
Figure 1.11: Mean global assessment of functioning (GAF) ratings of clinically referred children and adolescents with anxiety disorders and other psychiatric problems (N = 231). PD = Panic Disorder, ODD/CD = Oppositional-Defiant Disorder and Conduct Disorder, PTSD = Posttraumatic Stress Disorder, GAD = Generalized Anxiety Disorder, SOP = Social Phobia, OCD = Obsessive-Compulsive Disorder, SP = Specific Phobias, SAD = Separation Anxiety Disorder, ADHD = Attention-Deficit and Hyperactivity Disorder.
AGO
SAD
SOP
GAD
SP
PD
OCD
Figure 1.12: Comorbidity among anxiety disorders. Arrows show the strength of the relations between various anxiety disorders. AGO = Agoraphobia, SAD = Separation Anxiety Disorder, SOP = Social Phobia, GAD = Generalized Anxiety Disorder, SP = Specific Phobia, PD = Panic Disorder, OCD = Obsessive-Compulsive Disorder. Based on the literature review by Curry, March, & Hervey (2004). In Ollendick & March (2004), pp.116–140.
Normal and Abnormal Fear and Anxiety in Children and Adolescents
25
of the relations between various anxiety disorders in children and adolescents.1 As can be seen, particularly strong comorbidity was found among the anxiety disorders that are most prevalent in children and adolescents. More precisely, research has indicated that generalized anxiety disorder, separation anxiety disorder, specific phobia, and to a somewhat lesser extent, social phobia frequently co-occur. Other anxiety disorders (agoraphobia, panic disorder, and obsessive-compulsive disorder) seem to show less clear-cut comorbidity, although it should be mentioned that this is probably due to their relatively low prevalence rate and, as a result, lack of research examining this issue (see Costello et al., 2004). For example, in adults the connection between panic disorder and agoraphobia is well established: Approximately one-third to one-half of the individuals diagnosed with panic disorder in community samples also have agoraphobia, whereas a much higher rate of agoraphobia is encountered in clinical samples (White & Barlow, 2002). However, in youth populations the link between panic disorder and agoraphobia is less clear (Hayward, Killen, & Taylor, 2003; (see Figure 1.12)), although a recent prospective study of adolescents has indicated that over a four-year period, adolescents who have experienced a panic attack are at higher risk for also developing agoraphobia (Wilson & Hayward, 2005). As a final note, posttraumatic stress disorder is not included in Figure 1.12 because Curry et al. (2004) do not report actual comorbidity rates for this anxiety disorder in their review. This does not mean, however, that posttraumatic stress disorder displays no comorbidity with other anxiety disorders in youths. For example, in a study of hospitalized adolescents, Lipschitz, Winegar, Hartnick, Foote, and Southwick (1999) reported comorbid anxiety disorders (i.e., separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and specific phobias) in 83.3% of the youths diagnosed with posttraumatic stress disorder. This percentage was significantly higher than that found for the nonposttraumatic stress disorder adolescents in their sample (56.2%). Actual comorbidity rates among anxiety disorders in youths may vary considerably, depending on the population under study. For example, in a large German community sample of adolescents, Essau, Conradt, and Petermann (2000) found that 20.9% of the youths diagnosed with an anxiety disorder also suffered from at least one other anxiety disorder. Another study that examined lifetime prevalence in nonclinical high school students aged between 14 and 19 years showed that 18.7% of the adolescents with a history of an anxiety disorder had suffered from more than 1 anxiety disorder (Lewinsohn, Zinbarg, Seeley, Lewinsohn, & Sack, 1997). In contrast, studies carried out in anxiety specialty clinics have documented comorbidity rates of about 50% (Kendall, Brady, & Verduin, 2001: 52.1%; Rapee, 2003: 52.7%).
1
The following procedure was used to construct this figure. Based on the review by Curry, March, and Hervey (2004), for each anxiety disorder, the mean prevalence rate of various comorbid anxiety disorders was computed. The three most frequently occurring comorbid anxiety disorders were given a rating: 1 for the third most common anxiety disorder, 2 for the second most prevalent disorder, and 3 for the anxiety disorder that had the highest comorbidity with that anxiety disorder. In this way, the mutual relation between two anxiety disorders could vary between 0 (no convincing comorbidity between the two disorders) and 6 (very strong comorbidity between the two disorders). For reasons of clarity, only relations with a total rating of 3 or higher are shown.
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
The high comorbidity among childhood anxiety disorders has led some researchers to question the validity of the DSM classification system of anxiety problems in children (e.g., Ferdinand, Van Lang, Ormel, & Verhulst, 2006; Weems & Stickle, 2005). However, there is evidence coming from confirmatory factor analytic studies, which provide support for the anxiety disorder symptom clusters as described in the DSM. For example, Spence (1997) investigated the factor structure of anxiety disorders symptoms in two samples of nonclinical children aged 8 to 12 years. Anxiety symptoms were scored with a self-report questionnaire that was largely based on the most essential diagnostic criteria for anxiety disorders as listed in the DSM (see Table 1.5). Results revealed the most satisfactory fit for a model with six discrete but correlated anxiety disorders factors (i.e., panic disorder and agoraphobia, social phobia, separation anxiety disorder, obsessive-compulsive disorder, generalized anxiety disorder, and specific phobias) that loaded onto one higher-order factor (see Figure 1.13). The loadings on the higher-order factor indicate that there are clear commonalities among these anxiety clusters (Weems & Stickle, 2005), whereas the intercorrelations among the factors seem to be in keeping with the high comorbidity among anxiety disorders in youths (see supra). Highly similar findings were obtained by Spence et al. (2001), who performed exploratory and confirmatory factor analysis on parent ratings of anxiety symptoms in preschoolers aged 2 to 6 years. Again, a five-correlated-factor model was found, with anxiety
Childhood anxiety
.97
Generalized anxiety disorder
.90
Separation anxiety disorder
.87
.81
Social phobia
Specific phobia
.90
.86
Panic and agoraphobia
Obsessivecompulsive disorder
.67–.87
Figure 1.13: Best fitting model of anxiety disorders symptoms in children: six DSM-defined anxiety clusters loading on one higher-order factor. Based on: Spence (1997).
Normal and Abnormal Fear and Anxiety in Children and Adolescents
27
clusters of social phobia, separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and specific phobias. Panic disorder was not included in the model as symptoms of this anxiety disorder are rare in children of this age (Nelles & Barlow, 1988). Thus, even in nonclinical youths the specific categories of anxiety as defined by the DSM can be successfully identified. The conclusion seems to be justified that in spite of considerable comorbidity among childhood anxiety disorders, there are good reasons to consider them as separate diagnostic entities (but see Ferdinand, Bongers, Van der Ende et al., 2006).
Comorbidity with Other Psychiatric Disorders Anxiety disorders in youths also show considerable comorbidity with other psychiatric problems. Based on an extensive review of the literature, Costello et al. (2004) conclude that anxiety disorders have the highest comorbidity with depression. More precisely, even when controlling for other comorbid conditions, a median odds ratio of 8.2 was observed, which means that depression is 8.2 times as likely in youths with anxiety disorders than in youths without anxiety disorders. Data suggest that the comorbidity with depression is relevant for most types of anxiety disorders. For example, Lewinsohn et al. (1997) found significant comorbidity between depression and all of the anxiety disorders, with the exception of obsessive-compulsive disorder. Nevertheless, some anxiety disorders seem to occur more frequently with depression than others. In particular, social phobia and generalized anxiety disorder seem to covary quite often with depression. For example, in a sample of clinically referred youths with generalized anxiety disorder, Masi, Millepiedi, Mucci et al. (2004) found that the prevalence of depression (56%) was higher than that of any other psychiatric disorder, including other anxiety disorders. In a similar vein, social phobia is likely to be accompanied by social isolation and loneliness (Beidel, Turner, & Morris, 1999), and as such it is hardly surprising that a substantial proportion of the youths with this anxiety disorder also develop a depression (Essau, Conradt, & Petermann, 1999). On the basis of the observation that anxiety disorders such as generalized anxiety disorder and social phobia show strong comorbidity with depression, some researchers have even suggested to consider a new diagnostic category for a mixed anxiety-depression syndrome (Lahey, Applegate, Waldman et al., 2004). The latter idea is not totally new as many clinicians and researchers have noted the considerable overlap between anxiety and depression, and since long questioned whether there is a valid and useful distinction between these two disorders (Brady & Kendall, 1992; Seligman & Ollendick, 1998). However, recent years have seen great advancement in research studying the phenomenology of anxiety disorders and depression in youths. These investigations have shown that both disorders are related but nevertheless clearly have distinct features. A useful theory for discussing the similarities and differences of anxiety and depression is the tripartite model of negative emotions (Clark & Watson, 1991). Briefly, this model posits three factors that may be particularly relevant for understanding the precise nature of anxiety and depression. The first factor of negative affect is characterized by tendencies to feel distressed, worried, sad, and tired, and seems to be clearly present in both anxiety disorders and depression. The second factor of physiological hyperarousal refers to
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
feelings of tension, nervousness, shakiness, and panic, and seems to be specific for anxiety disorders. The third factor of positive affect pertains to experiences of joy, enthusiasm, excitement, and activeness, and seems to be particularly relevant for depression as this disorder is characterized by low levels of positive emotions. There is increasing evidence showing that the tripartite model is largely applicable to anxiety and depression in children and adolescents (Chorpita, 2002; Chorpita & Daleiden, 2002; Joiner, Catanzaro, & Laurent, 1996; Joiner & Lonigan, 2000; Ollendick, Seligman, Goza, Byrd, & Singh, 2003; Turner & Barrett, 2003), and as such there is at least some empirical ground for treating anxiety disorders and depression as separate diagnostic constructs. Further, the high comorbidity between anxiety disorders and depression raises the issue of whether these disorders share common aetiological pathways (which is an issue that will be dealt with in the next chapters) or whether there is a temporal association between these two disorders, with one disorder predating the other (see Seligman & Ollendick, 1998). With respect to the latter issue, there is some evidence indicating that anxiety is more frequently an antecedent of depression than vice versa. For example, Cole et al. (1998) carried out a three-year longitudinal study to examine the temporal relation between symptoms of anxiety and depression in children. Every six months, children and their parents completed anxiety and depression questionnaires for a total of six waves. Structural equations modeling indicated that symptoms of anxiety and depression were fairly stable over time. Furthermore, results showed that anxiety symptoms at one point in time predicted depression symptoms at subsequent points in time, even when controlling for prior levels of depression symptoms. Thus, these findings support the notion that anxiety leads to depression in children and adolescents rather than vice versa. Comparable results were obtained by Essau et al. (2000), who assessed DSM-classifications of anxiety disorders and other psychiatric disorders in a sample of 12- to 17-year-old adolescents. These researchers noted that about one-third of the youths with an anxiety disorder also suffered from a depression. Most important, an analyses of the age of onset data for various disorders revealed that in 62.9% of the cases, the anxiety disorder occurred before the depression. In the remaining cases, the anxiety disorder occurred simultaneously or after the depression. Interestingly, social phobia, specific phobia, agoraphobia, and anxiety disorder not otherwise specified typically emerged before the depression, whereas other anxiety disorders (e.g., generalized anxiety disorder, panic disorder) developed at the same time or after the depression. The comorbidity with other common psychiatric disorders in youths also appears significant: The median odds ratio for oppositional-defiant disorder and conduct disorder was 3.1, whereas that for attention-deficit and hyperactivity disorder was 3.0 (Costello et al., 2004; see also Marmorstein, 2007). A considerable number of studies have investigated the comorbidity between anxiety disorders and substance abuse disorder. In general, this research has demonstrated that there seems to be an association between these two disorders. However, when controlling for other comorbid disorders, the concurrent comorbidity between anxiety and substance abuse often disappears (e.g., Armstrong & Costello, 2002). Nevertheless, there is evidence showing that anxiety disorders may predict later substance abuse (Weisman, Wolk, Wickramaratne et al., 1999), and that this is particularly true for certain types of anxiety disorders (e.g., generalized anxiety disorder; Kaplow et al., 2001).
Normal and Abnormal Fear and Anxiety in Children and Adolescents
29
Taken together, pathological manifestations of fear and anxiety in children and adolescents should be taken seriously. Anxiety disorders represent a class of debilitating and serious psychiatric disorders that are also characterized by high levels of comorbidity. Nevertheless, it has been noted that researchers and clinicians frequently have difficulties for assessing these disorders in youths and that a substantial proportion of the youths remain undiagnosed (Angold, Costello, Farmer, Burns, & Erkanli, 1999).
The Bridge Between Normal and Abnormal Fear and Anxiety in Youths In conclusion, then, fear and anxiety are common in childhood. In most children and adolescents, fear and anxiety represent relatively mild and transitory phenomena. However, in a subgroup of youths, fear and anxiety become severe and chronic, and ultimately develop into a phobia or anxiety disorder. The main question then is: What factors are involved in the radicalization and persistence of abnormal fear and anxiety in children and adolescents? During the past years, our knowledge of the factors that are involved in the aetiology of childhood anxiety disorders has increased considerably (Muris, 2006a). Not only have a large number of vulnerability factors been identified, but we also have a good notion of the protective influences that may shield youths against the development of anxiety problems. In the next chapters, the evidence for the involvement of various vulnerability and protective factors in the development and maintenance of anxiety disorders in children and adolescents will be summarized. As noted by several authors (Craske, 1997; Manassis & Bradley, 1994; Vasey & Dadds, 2001), it is important to keep in mind that these factors do not operate in isolation. Rather, we should consider multifactorial models in which vulnerability and protective factors interact with each other to produce an adaptive or a maladaptive outcome (see Chapter 6). The developmental psychopathology perspective (Cicchetti & Cohen, 1995) provides a good starting point for such a model, as it is based on the assumption that there is a continuum with normal fear and anxiety on the one end, and pathological manifestations of the emotions on the other end (see Figure 1.14). When confronted with a potentially threatening stimulus or situation, children and adolescents’ level of anxiety is determined by the current constellation of vulnerability and protective factors. Obviously, vulnerability factors increase or maintain anxiety, whereas protective factors reduce or shield against this negative emotion. When vulnerability is high and protection is low, the child or adolescent displays anxiety levels in the pathological range, and when this occurs repeatedly within a certain frame of time, he or she may qualify for an anxiety disorder. It should be stressed that the model as depicted in Figure 1.14 is dynamic in nature and allows factors to influence or to interact with each other at various levels. For example, vulnerability factors may be interrelated or even reinforce each other, and the same may be true for protective factors. Further, it is also possible that vulnerability factors have an impact on protective factors and vice versa. Altogether, the pathogenesis of childhood anxiety disorders is best represented as a multifactorial model in which various vulnerability and protective factors operate in dynamic interaction (see also Vasey & Dadds, 2001).
30
Normal and Abnormal Fear and Anxiety in Children and Adolescents
Developmental level
Pathological anxiety
Protection
Vulnerability
Normal anxiety
Figure 1.14: Hypothesized model for the pathogenesis of childhood anxiety disorders in which vulnerability and protective factors operate in dynamic interaction.
Developmental phenomena play an important role in the model (Figure 1.14). First, there is increasing evidence showing that cognitive maturation is linked to the content and manifestation of fear and anxiety in youths. More precisely, it is possible that shifts in cognitive development herald periods in which vulnerable children are prone to develop high levels of fear and anxiety or even anxiety disorders. Further, it may well be the case that the developmental changes are responsible for the lack of stability that is observed for specific anxiety disorders during childhood. In Warren and Sroufe’s (2004) words: “The disorders appear to be associated with certain developmental levels because the specific developmental levels provide opportunities for manifesting specific behaviors that can be diagnosed as particular anxiety disorders” (pp.98–99). However, as mentioned earlier, more research is required to define the developmental pathways of anxiety disorders in children and adolescents. There seems to be a clear bridge between normal and abnormal fear and anxiety in youths. The basic issue is to get more understanding of the factors that push children and adolescents toward the wrong (“abnormal”) side of the bridge and the variables that pull youths back to the good (“normal”) side. In the ensuing chapters, I will discuss the pathogenesis of childhood anxiety disorders in terms of the following categories of factors: (a) child-related vulnerability factors, which include biological vulnerability and genetically based individual difference variables (Chapter 2); (b) environmental risk factors, which pertain to negative life events, other learning experiences, and family-based vulnerability (Chapter 3); (c) protective factors that incorporate executive functioning-based regulatory processes, positive cognition, and coping mechanisms (Chapter 4); and (d) maintaining factors, which are concerned with avoidance and cognitive distortions (Chapter 5).
Chapter 2
Genetically Based Vulnerability
Introduction From birth onward, one can observe clear individual differences in the fear and anxiety levels of children. Not surprisingly, then, behavioral-genetic research has demonstrated that a substantial proportion of the variance in childhood fear and anxiety symptoms can be attributed to genetic influences (e.g., Rutter, Silberg, O’Conner, & Siminoff, 1999). This has led some researchers to speculate about innate temperament dispositions that would make children prone to developing fear and anxiety problems. The most typical example is Kagan’s (1994) construct of behavioral inhibition, which refers to inborn tendencies to be timid, fearful, and shy with unfamiliar people, and to respond with restraint, caution, and withdrawal to novel situations and objects. However, there are more examples of genetically based vulnerability factors that play a role in the pathogenesis of phobias and anxiety disorders in youths. This chapter summarizes the results of behavioral-genetic research on fear, anxiety, and their disorders in children and adolescents. Further, a number of vulnerability factors will be addressed, some of which are relevant to a broad range of anxiety problems (i.e., behavioral inhibition, neuroticism, trait anxiety) and others that are only related to a specific type of fear and anxiety (i.e., anxiety sensitivity, disgust sensitivity). The biological underpinnings of genetically based vulnerability to childhood anxiety will also be discussed in brief.
Genetic Influences Phobias and anxiety disorders run in families. This point is illustrated by (1) top-down studies, in which the children of adults with anxiety disorders are studied; (2) bottom-up research, in which the parents of children with anxiety disorders are examined; and (3) sibling investigations, in which the aggregation of anxiety disorders among siblings is explored. An example of a top-down approach is a study by Biederman, Rosenbaum, Bolduc, Faraone, and Hirshfeld (1991), who examined patterns of psychopathology in children of parents with panic disorder and depression. Four groups were compared: (1) offspring of parents with panic disorder (2) offspring of parents with panic disorder and comorbid depression, (3) offspring of parents with depression, and (4) offspring of parents without psychiatric problems. Results demonstrated that separation anxiety disorder and multiple anxiety disorders were more frequent among children of parents with panic disorder and/or depression. Further, panic disorder (including agoraphobia) appeared to be the only disorder that was more
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
prevalent among youths of parents who suffered from panic disorder, which suggests a specific familial link for this anxiety disorder. The bottom-up design was employed by Last, Hersen, Kazdin, Orvaschel, and Perrin (1991). In their study, the first-degree relatives of children with anxiety disorders were compared with relatives of children with attentiondeficit and hyperactivity disorder (ADHD) and children who had never been psychiatrically ill. Results from blind, diagnostic interviews indicated an increased prevalence of anxiety disorders in the first-degree relatives of children with anxiety disorders as compared with relatives of both ADHD and never psychiatrically ill children. More precisely, 34.6% of the relatives of anxiety disordered children suffered from an anxiety disorder themselves versus 23.5% and 16.3% of the relatives of, respectively, ADHD and never psychiatrically ill children. A longitudinal sibling study was carried out by Rende, Warner, Wickramaratne, and Weissman (1999), who examined the prevalence of various types of psychiatric disorders, including anxiety disorders, in siblings who were raised in high-risk (i.e., lifetime major depression present in one of the parents) or low-risk (i.e., no history of depression in the parents) families over a 10-year-period. Results showed that the sibling aggregation of psychiatric disorders was predominantly present in the high-risk group. Most importantly, sibling aggregation was particularly notable for anxiety disorders (see also Rende, Wickramaratne, Warner, & Weissman, 1995). In the high-risk group, an odds ratio of 4.86 was found, which indicated that if one sibling had a history of an anxiety disorder, then the second sibling was nearly five times more likely to also have had an anxiety disorder. Further, although the sample size was too small to generate meaningful odds ratios for specific anxiety disorders, the researchers noted that the sibling aggregation for anxiety disorders was primarily due to aggregation of separation anxiety disorder, social phobia, and specific phobias. In their conclusion regarding family studies of anxiety disorders, Eley and Gregory (2004; p.72) rightly noted: “Although such studies have been valuable in highlighting the aggregation of anxiety symptoms and disorders in families, they are unable to provide information as to whether environmental influences shared by family members or shared genes account for family resemblance.” In contrast, twin studies can be employed to disentangle genetic and environmental influences on normal and abnormal fear and anxiety. Briefly, such studies are grounded on the fact that monozygotic twins are fully identical as to their genetic makeup, whereas dizygotic twins share only half of their genes. Twin researchers assume that the variance in a certain phenotype is the result of three types of influences—namely, heritability or additive genetic effects (A), common or shared environmental effects (C, which make family members resemble one another), and nonshared environmental effects (E, which make family members differ from one another). Correspondence among monozygotic twins is due to their fully identical genes and the shared environment (i.e., rMZ = A + C), whereas correspondence among dizygotic twins is the result of sharing half of their genes and the shared environment (i.e., rDZ = ½A + C). On the basis of these equations, it is possible to estimate the genetic effects as twice the difference between the correlation of monozygotic twins and the correlation of dizygotic twins [i.e., A = 2(rMZ − rDZ)], the shared environmental effects as the difference between the correlation of monozygotic twins and the heritability coefficient (i.e., C = rMZ − A), whereas the remainder of the variance is due to nonshared environmental effects and measurement errors [i.e., E = 1 − (A + C)].
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A number of twin studies can be found that examined the genetic and environmental influences on childhood fears. In one of the first studies on this issue, Rose and Ditto (1983) compared the frequency of self-reported fears in monozygotic and dizygotic same-sex twin pairs with ages ranging between 10 and 34 years. These researchers found that a twin’s level of fearfulness could be predicted from the co-twin’s score. Most importantly, the frequency of fears was clearly more similar in monozygotic than in dizygotic twin pairs, which indicated that there was a significant influence of heritability. On average, heritability accounted for between 28% (fear of a loved one’s fortune) and 72% (fear of personal death) of the variance. Highly similar results were obtained in a study by Stevenson, Batten, and Cherner (1992). These authors collected scores on the Revised Fear Survey Schedule for Children (Ollendick, 1983) for monozygotic and dizygotic twins in the 8 to 16 years age range. Analyses of these data led to three important conclusions. First of all, whereas heritability was significant for the total fear score, the specific fear components revealed a diverse picture, with some components having a nonsignificant heritability (i.e., fear of failure and criticism, medical fears) and others having a highly significant heritability (i.e., fear of minor injury and small animals, fear of the unknown: A = .46). Second, both shared and nonshared environmental influences accounted for a substantial proportion in the variance of various types of fears. Third and finally, when studying youths at the extreme end of the fear continuum, results remained highly comparable. That is, no evidence was obtained to suggest that heritability played a more prominent role in the high-fear group. A final investigation by Lichtenstein and Annas (2000) used parent reports of animal, situational, and mutilation fears for 1106 pairs of 8- to 9-year-old twins. Results indicated that genetic, shared environmental, and nonshared environmental effects contributed to individual differences in fears and fearfulness, although the magnitude of the effects varied considerable for each type of fear and between genders. Several studies have examined the genetic and environmental influences on anxiety symptoms in children and adolescents. For example, Topolsky, Hewitt, Eaves et al. (1997) investigated individual variation in general anxiety symptoms as measured by the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978) in a large sample of twins in three age groups (8- to 10-year-olds, 11- to 13-year-olds, and 14- to 16year-olds). Results revealed a clear genetic contribution to anxiety symptoms, but this effect was mainly observed in girls. In boys, the environmental contributions were more dominant. Further, genetic and environmental influences were found to be highly comparable across various age groups. Thapar and McCuffin (1995) administered the RCMAS to 376 same-sex twin pairs and their parents and found that children’s self-reported anxiety scores were best explained by shared (C = .55) and nonshared (E = .45) environmental factors, whereas parental ratings of children’s anxiety levels were accounted for by heritability (A = .59) and nonshared environmental influences (E = .41). Another study by Warren, Schmitz, and Emde (1999) also obtained RCMAS data in a sample of 226 7-year-old same-sex twin pairs. Results revealed that total RCMAS scores were explained by genetic (A = .25) and nonshared environmental (E = .64) influences. Interestingly, the genetic influence was only significant for physiological and social anxiety symptoms and not for worry symptoms. Eley and Stevenson (1999) administered the trait anxiety scale of the State-Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973) to 395 pairs of same-sex twins aged 8 to 16 years. The results of this study indicated that genetics had no significant effect on youths’
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
trait anxiety scores (A = .10), whereas shared and nonshared environmental factors did have substantial impact (C = .36 and E = .54; see also Lau, Eley, & Stevenson, 2006). However, the authors were reserved in concluding that there was no genetic influence on trait anxiety as they pointed at the small sample size of their study. Indeed, somewhat different results were reported by Legrand, McGue, and Iacono (1999), who administered the STAIC to 547 twin pairs in two age cohorts: i.e., 10- to 12-year-olds and 16- to 18-year-olds. Results showed that trait anxiety was predominantly explained by genetic (A = .40) and nonshared environmental (E = .56) effects, a finding that is somewhat at odds with that obtained by Eley and Stevenson (1999). Twin studies have also been carried out to examine the genetic and environmental effects on pathological manifestations of childhood fear and anxiety. In the aforementioned study by Topolski et al. (1997), youths were also questioned about the presence of separation anxiety disorder and generalized anxiety disorder symptoms. It was found that 4% (boys) to 6.7% (girls) met the criteria for separation anxiety disorder, whereas 6% (boys) to 11% (girls) fulfilled the DSM-III-R criteria for generalized anxiety disorder. It was found that heritability played a significant role in generalized anxiety disorder (A = .37) but had no significant effect of separation anxiety disorder (A = .04). Shared environmental effects only made a significant contribution to separation anxiety disorder (C = .40), whereas nonshared environmental factors were of equal importance to both types of anxiety disorders (E = .56 for separation anxiety disorder and E = .52 for generalized anxiety disorder). Eaves, Silberg, Meyer, and colleagues (1997) conducted semistructured interviews with twins and both of their parents to examine the presence of psychiatric disorders, including separation anxiety disorder and generalized anxiety disorder. The results indicated that both anxiety disorders were best explained by genetic and nonshared environmental factors, although it should be mentioned that the contributions of these factors showed great variability dependent on the gender of the twins and the informant. For example, in the case of separation anxiety disorder, a substantial contribution of heritability was found when mothers rated these anxiety symptoms in girls (A = .74), whereas no effect of a genetic factor emerged (A = .00) when fathers rated the very same symptoms in boys. In an investigation by Feigon, Waldman, Levy, and Hay (2001), the mothers of 2043 3- to 18-year-old twin pairs were asked to rate DSM-defined symptoms of separation anxiety disorder. Results revealed significant effects of genetics (A = .47), shared environment (C = .21), and nonshared environment (E = .32). Interestingly, these effects were significantly moderated by gender and age. More precisely, genetic influences were larger for girls, whereas shared environmental effects were greater for boys. Further, genetic influences increased with age, whereas shared environmental influences decreased as children became older. Lichtenstein and Annas (2000) also documented the occurrence of specific phobias in their sample of monozygotic and dizygotic twins. The prevalence rate of this anxiety disorder was 7.3% in boys and 10.0% in girls. A substantial and significant contribution of heritability was found (A = .65), while the effects of shared and nonshared environmental influences were considerably smaller (C = .14 and E = .20). Results also showed that the genetic effect was larger for animal phobia and situational phobia (A = .58 and A = .50, respectively) than for mutilation phobia (A = .28). Another investigation by Silberg, Rutter, and Eaves (2001) indicated that the genetic and shared environmental effects on symptoms of separation anxiety disorder, generalized anxiety disorder, and specific phobias were all rather modest, and that most of
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the variation in these symptoms was explained by nonshared environmental influences. A final investigation that should be mentioned was carried out by Nelson, Grant, Bucholz et al. (2000), who explored genetic and environmental influences to social phobia in 1344 16- to 19-year-old female adolescents. These researchers found support for a model in which genetic (A = .28) and nonshared environmental (E = .72) effects accounted for the variation in symptoms of this type of anxiety disorder. It should be mentioned that there are a few studies that have examined the possibility that pathological anxiety may be qualitatively different from anxiety that falls within the normal range. For example, Stevenson et al. (1992) not only performed behavioral-genetic analyses on the fear scores of their total sample, but also carried out separate analyses for youths who displayed extremely high fear scores. No evidence was obtained that the influence of heritability increased at the extreme end of the fear continuum. This result is in keeping with findings from other studies, which have failed to show etiological differences between normal and abnormal fear and anxiety, and thus suggests that anxiety disorders simply reflect the extremes of normal fear and anxiety phenomena (see Chapter 1). Taken together, available evidence indicates that fear, anxiety, and related disorders aggregate in families, and there is support for the notion that childhood fear and anxiety phenomena are explained by heritable as well as environmental factors (see also Bolton, Eley, O’Connor et al., 2006; Ehringer, Rhee, Young, Corley, & Hewitt, 2006; Eley, Bolton, O’Connor et al., 2003; Ogliari, Citterio, Zanoni et al., 2006). In Eley and Gregory’s (2004; p.74) words: “Typically, genetic influences account for roughly 30%, shared environment 20%, and nonshared environment the remaining 50% of the variance in childhood anxiety.” As can be seen in Figure 2.1, the percentages still show considerable variation across various types of childhood anxiety phenomena. Furthermore, it should be kept in mind that even within a specific domain of anxiety, studies have yielded quite diverging results regarding the relative contributions of heritability, shared and nonshared environment. This is probably due to a number of factors. First of all, several studies have demonstrated that gender differences play an important role (Eaves et al., 1997; Feigon et al., 2001; Topolski et al., 1997). These studies have generally shown that the influence of heritability is considerably larger in girls compared to boys. Second, age has been proposed as another variable that accounts for the variation in genetic and environmental effects across studies (Eley & Gregory, 2004). For example, the study by Feigon et al. (2001) clearly indicated that the magnitude of genetic influences increased during development, while the impact of shared environmental influences decreased in significance as youths became older. Several explanations for these age effects are possible. The theory of active genotype-environment correlation (Scarr & McCartney, 1983) suggests that maturation is associated with increasing opportunities to select environmental experiences that are consistent with one’s genetic characteristics, which results in a gradually increasing influence of the genetic factor. Otherwise, it may well be the case that family influences become less dominant as children grow older, which would be reflected in a steady decline of shared environmental effects. Third and finally, the outcome of behavioral-genetic studies may also depend on the informant that is used to assess fear and anxiety in children (e.g., Thapar & McGuffin, 1995). As will become clear in Chapter 7, many aspects of fear and anxiety are not easily observable, which means that symptom ratings of children may differ considerably from ratings of parents or other informants.
Fears
General anxiety symptoms
SAD
Additive genes (A) Shared environment (C) Non-shared environment (E)
GAD
Figure 2.1: Results of studies examining the influence of heritability or additive genetics (A), common or shared environment (C), and nonshared environment (E) on various types of childhood anxiety phenomena. SAD = Separation Anxiety Disorder, GAD = Generalized Anxiety Disorder. Based on: Eley & Gregory (2004). In Morris & March (2004), pp.71–97.
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What becomes clear from the behavioral-genetic research on childhood anxiety is that a significant proportion of abnormal fear and anxiety phenomena in youths can be attributed to a genetic component, which means that some children from birth onward already display greater vulnerability for developing these type of psychiatric problems. However, as Rapee (2001; p.495) rightly remarked: “The more interesting question for the psychology of anxiety is not whether there is a genetic component but in what way this component is manifested.” A nice framework for discussing genetically based vulnerability factors of phobias and anxiety disorders was launched by Taylor (1998), who distinguished two types of genetic factors that are involved in the pathogenesis of phobias and anxiety disorders: a general genetic factor that acts as a vulnerability factor to a broad range of phobias and anxiety disorders, and specific genetic factors that only predispose to certain types of anxiety problems. The general genetic component is thought to constitute the biological substrate of what is typically referred to as “neuroticism” (or “negative affectivity” or “emotionality”). In the context of childhood anxiety, many studies have focused on the observable behavioral manifestation of this higher-order trait, which has been labelled as “behavioral inhibition.”
Behavioral Inhibition Behavioral inhibition is the tendency of some children to interrupt ongoing behavior and react with vocal restraint and withdrawal when confronted with unfamiliar people or settings (Kagan, 1994). Behavioral inhibition is typically measured by observing children’s responses in a laboratory setting in which they are confronted with novel and unfamiliar objects and persons. During this procedure, latency to approach these objects and persons, withdrawal from the object or situation, and absence of spontaneous interaction with the examiner are measured as they are regarded as the typical signs of an inhibited temperament (Garcia-Coll, Kagan, & Reznick, 1984). Approximately 10% to 15% of the children clearly exhibit the signs of this temperamental characteristic (e.g., Kagan, Reznick, Clarke, Snidman, & GarciaColl, 1984). A study by Robinson, Kagan, Reznick, and Corley (1992) has demonstrated that behavioral inhibition has a genetic basis. In a sample of 178 monozygotic and dizygotic same-sex twin pairs who were assessed at ages 14, 20, and 24 months, these researchers found heritability estimates for behavioral inhibition to range between .51 and .64. Not surprisingly, various studies have noted that behavioral inhibition shows considerable stability over time, and this seems particularly true for children who display extremely high levels of this temperamental characteristic (see also Pfeifer, Goldsmith, Davidson, & Rickman, 2002; Rubin, Hastings, Stewart, Henderson, & Chen, 1997). For example, Kagan, Reznick, and Snidman (1988) demonstrated that 75% of the children who had been classified as either “inhibited” or “uninhibited” retained their status at a six-year follow-up. In another study, Scarpa, Raine, Venables, and Mednick (1995) observed fair stability of behavioral inhibition in a large sample of children tested as ages 3, 8, and 11 years. These researchers noted that when children retained their inhibited status between 3 and 8 years, there was a good chance that they were still inhibited when they reached the age of 11, as compared to the children who displayed variable levels of behavioral inhibition between 3 and 8 years. Van Brakel and Muris (2006) obtained parent-reports of behavioral inhibition in 7- to 12-year-old
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Normal and Abnormal Fear and Anxiety in Children and Adolescents 28 24 20
Uninhibited Inhibited
16 12 8
Occasion 1
Occasion 2
Figure 2.2: Behavioral inhibition scores of inhibited and noninhibited children on occasion 1 and occasion 2 (two years later). From: Van Brakel & Muris (2006).
children and observed that behavioral inhibition scores of inhibited children significantly increased over a two-year period, whereas those of noninhibited control children significantly decreased (see Figure 2.2). Overall, behavioral inhibition scores were fairly stable over the two-year period, with a test-retest correlation of .77. Finally, a longitudinal study by Gest (1997) demonstrated that observational ratings of behavioral inhibition characteristics in childhood (at ages 8 to 12) were predictive of the very same characteristics in early adulthood (at ages 17 to 24; r = .57). On the basis of these studies, it can be concluded that behavioral inhibition can be regarded as an inherited and stable response disposition that is present in a substantial minority of the youths. Most important, there is evidence that strongly indicates that behavioral inhibition acts as a general vulnerability factor for the development of anxiety disorders in children and adolescents. One of the first studies that found support for this notion was carried out by Biederman, Rosenbaum, Hirshfeld et al. (1990), who conducted structured clinical interviews to assess psychiatric disorders in two samples of children: a sample of children of patients with panic disorder and agoraphobia (Rosenbaum, Biederman, Gersten et al., 1988) and a longitudinal cohort of inhibited and uninhibited children that had been followed from a very young age (Garcia-Coll et al., 1984). In both samples, it was found that inhibited children showed significantly more multiple (i.e., two or more) anxiety disorders than uninhibited children. Differences between inhibited and uninhibited children were observed for all anxiety disorders, but were particularly clear-cut for generalized anxiety disorder (in the sample of children whose parents suffered from panic disorder and agoraphobia) and phobias (in the longitudinal cohort; (see Figure 2.3)). Interestingly, when the combined samples were reassessed at a follow-up of three years, it was noted that inhibited children had displayed a significant increase of anxiety problems from baseline to follow-up, whereas such a marked increase was not observed in the uninhibited group. In particular, the rates of multiple anxiety disorders (see Figure 2.4), separation anxiety disorder, and social phobia had substantially increased (Biederman, Rosenbaum, Bolduc-Murphy et al., 1993). Additional analysis of these data revealed that in particular children with stable levels of behavioral inhibition are prone to develop anxiety disorders. More precisely, stably inhibited
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Children of patients with panic disorder and agoraphobia (Rosenbaum et al., 1988) 30 25 20 15 10 5 0 Multiple anxiety disorders
GAD
SAD
SOP
SP
Longitudinal cohort (Garcia-Coll et al., 1984) 35 30 25 20
Inhibited
15
Uninhibited
10 5 0 Multiple anxiety disorders
GAD
SAD
SOP
SP
Figure 2.3: Percentages of inhibited and uninhibited children with anxiety disorders. GAD = Generalized Anxiety Disorder, SAD = Separation Anxiety Disorder, SOP = Social Phobia, SP = Specific Phobia. Based on: Rosenbaum, Biederman, Bolduc-Murphy et al. (1993).
children displayed significantly higher prevalence rates of any anxiety disorder, multiple anxiety disorders, and specific phobias, as compared to their nonstably inhibited counterparts (Hirshfeld, Rosenbaum, Biederman et al., 1992). In a further study by Kagan, Snidman, Zentner, and Peterson (1999), a group of 164 children were followed from infancy (4 months) to middle childhood (7 years). Temperament was extensively assessed on both occasions, and on the second occasion, mothers completed a rating scale for measuring children’s fear and anxiety symptoms. Results showed that children who were identified as reactive (i.e., inhibited) at 4 months of age had developed higher levels of fear and anxiety symptoms at age 7 years, again indicating that this type of temperament is associated with the development of anxiety.
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Normal and Abnormal Fear and Anxiety in Children and Adolescents Multiple anxiety disorders 45 40 35 30 25 20 15 10 5 0
Inhibited Uninhibited
Baseline assessment
3-year follow-up assessment
Figure 2.4: Percentages of inhibited and uninhibited children with multiple (i.e., two or more) anxiety disorders at baseline and at three-year follow-up. Based on: Rosenbaum et al. (1993).
45 40 35 30 25 20 15 10 5 0
Low Middle High
SAD
GAD
SP Animal
SP Bloodinjection-injury
SP Situationalenvironmental
Any anxiety disorder
Figure 2.5: Percentages of children classified as low, middle, and high behaviorally inhibited who exhibit anxiety scores in the (sub)clinical range. SAD = Separation Anxiety Disorder, GAD = Generalized Anxiety Disorder, SP = Specific Phobia. Based on: Muris et al. (1999).
Further support for a link between behavioral inhibition and anxiety in older youths comes from a series of studies conducted by Muris and colleagues (1999, 2001, 2003; Van Brakel, Muris, & Bögels, 2004). In these studies, children, adolescents, and their parents completed the Behavioral Inhibition Instrument (BII; see Appendix), a self/parent-report instrument for assessing behavioral inhibition in older children and adolescents (for an alternative scale, see Bishop, Spence, & McDonald, 2003). The results of these studies consistently demonstrated that self- and parent-rated behavioral inhibition in children and adolescents is associated with higher levels of symptoms of a wide range of anxiety disorders (see Figure 2.5). One of the studies (Muris et al., 2001) also demonstrated that self-reported behavioral inhibition was not only related to anxiety symptoms but also to depressive symptomatology. However, further analyses of the data indicated that the link between behavioral inhibition and depres-
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sion was mediated by anxiety symptoms, which seems to suggest that behavioral inhibition is a specific vulnerability factor for anxiety problems, which in turn may lead to the development of a comorbid depression (see also Cole, Peeke, Martin, Truglio, & Seroczynski, 1998). Whereas the preceding studies indicate that behavioral inhibition is associated with a broad range of anxiety problems in youths, more recent research seems to suggest that this temperamental characteristic is primarily related to social phobia. For example, Biederman, Hirshfeld-Becker, Rosenbaum et al. (2001) assessed psychopathology in a large sample of 2-, 4-, and 6-year-old children with and without behavioral inhibition. Although multiple anxiety disorders again tended to be more common among inhibited children, the only significant difference was observed for social phobia—that is, 17% of the children in the inhibited group met the diagnostic criteria of this disorder versus only 5% in the uninhibited group. A similar result was obtained in the long-term prospective study by Schwartz, Snidman, and Kagan (1999), who conducted a diagnostic interview in 79 13-year-old children who had been classified as either inhibited or uninhibited in their second year of life. These researchers observed a significant association between behavioral inhibition and social phobia but not with any of the other types of anxiety problems. The link between behavioral inhibition and social phobia was robust: 61% of the adolescents who had been identified as inhibited as toddlers had current symptoms of social anxiety as compared to 27% of the youths who had been identified as uninhibited. When looking at clinical diagnosis, 34% of the adolescents in the inhibited group met the criteria for a severely impairing social phobia versus only 9% of the youths in the uninhibited group, and this difference was even more pronounced in girls (44% versus 6%). Another investigation by Hayward, Killen, Kraemer, and Taylor (1998) specifically addressed the link between behavioral inhibition and social phobia. A large sample of adolescent high school students (N = 2242) was followed for a four-year period, receiving yearly diagnostic interviews to check for social phobia. At the end of the study, students retrospectively assessed their level of behavioral inhibition, using the Retrospective Self-Report of Inhibition (RSRI; Reznick, Hegeman, Kaufman, Woods, & Jacobs, 1992). Results indicated that behavioral inhibition was significantly associated with the onset of adolescent social phobia. In particular, the RSRI components of social avoidance and fearfulness increased the risk for developing social phobia. Among adolescents who were both socially avoidant and fearful, 22.3% developed social phobia, which reflected a risk of more than four times greater than that of adolescents who displayed no features of behavioral inhibition. Finally, a number of studies have examined the link between retrospectively rated behavioral inhibition and mental health in adult clinical samples (Gladstone, Parker, Mitchell, Wilhelm, & Mahli, 2005; Reznick et al., 1992; Van Ameringen, Mancini, & Oakman, 1998). These studies have consistently shown that there is a link between early manifestations of this temperament factor and social phobia in adulthood. Although behavioral inhibition refers to children’s reactions to novel social and nonsocial stimuli, some researchers have focused on the social aspects of this response pattern. In the late 1980s and early 1990s, Asendorpf and Rubin (Asendorpf, 1990; Rubin & Mills, 1988; see Rubin & Asendorpf, 1993) already pointed out that shyness may have serious, negative consequences for the psychological well-being of children and adolescents. Stevenson-Hinde and Glover (1996) employed mothers’ ratings and behavioral observations of shyness to
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assign 4- to 4½-year-old children to low, medium, and high shyness groups. The results indicated that the high shyness group displayed significantly higher levels of negative mood, fears, worries, and problem behaviors as compared to the low and medium shyness groups. A follow-up assessment of these children, some five years later, revealed that high shyness remained highly consistent over time and was significantly associated with the development of low self-esteem (see also Crozier, 1995) and high levels of trait anxiety (Fordham & Stevenson-Hinde, 1999). Similar results were obtained in the Australian Temperament Project (Prior, Smart, Sanson, & Oberklaid, 2000; Sanson, Pedlow, Cann, Prior, & Oberklaid, 1996) in which it was documented that shy children exhibited elevated levels of internalizing problems when they were 5 to 6 years old, and a higher frequency of anxiety symptoms at the age of 13 to 14 years. Furthermore, it was observed that the risk for anxiety problems increased as a function of shyness stability. More precisely, 57.1% of those who had been classified as always shy developed such problems as compared to 10.6% of those who had never been identified as shy. Finally, in a study by Cox, MacPherson, and Enns (2005), retrospective reports of excessive shyness during childhood were correlated to current and past anxiety and mood disorders in a large sample of 5877 adults. The results indicated that childhood shyness was significantly associated with a lifetime history of social phobia but not with other anxiety and mood disorders. Altogether, available evidence suggests that the temperament-based factor of behavioral inhibition (or related constructs such as shyness) represents a significant vulnerability factor for the development of anxiety problems in youths. A trend can be observed in the literature that behavioral inhibition is particularly relevant for the aetiology of social phobia (Turner, Beidel, & Wolff, 1996). However, it should be borne in mind that many of the instruments and procedures that have been employed to measure behavioral inhibition are biased to the assessment of the social aspects of this temperamental characteristic, hence it is not that surprising that researchers have obtained more robust connections with social phobia than with the other anxiety disorders (see Van Brakel, Muris, & Bögels, 2001).
Neuroticism Several authors have argued that behavioral inhibition is the perceptible manifestation of one or more underlying temperament/personality dimensions (Craske, 1997; Turner et al., 1996). The most important candidate in this respect is neuroticism, which is also known as negative affectivity or emotionality. Neuroticism can be defined as psychological instability and proneness to experience negative emotions and thus bears strong similarity to behavioral inhibition. There is indeed evidence showing that children high on behavioral inhibition are characterized by higher levels of neuroticism, although it is clear that other personality factors are also involved (i.e., low extraversion and low regulative traits; see Ivarson & Winge-Westholm, 2004; Muris & Dietvorst, 2006; Van Brakel & Muris, 2006). Most research has not specifically focused on the relation between neuroticism and anxiety but rather investigated the link between this temperament/personality factor and child psychopathology in general (Calkins & Fox, 2002; Lonigan & Phillips, 2001; Muris & Ollendick, 2005; Nigg, 2006). For example, John, Caspi, Robins, Moffitt, and StouthamerLoeber (1994) demonstrated that neuroticism was associated with high levels of psycho-
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pathological symptoms, and this appeared especially true for internalizing problems such as anxiety. Similar findings were obtained by Huey and Weisz (1997), who assessed personality factors in 116 clinic-referred youths by means of the Q-sort technique administered to a teacher who was familiar with the child. Results demonstrated that neuroticism was again positively related to internalizing but not to externalizing symptoms. A further study by Ehrler, Evans, and McGhee (1999), which employed a teacher-rated questionnaire for assessing personality variables including neuroticism in a small sample of 86 schoolchildren, yielded a highly similar finding. That is, neuroticism was accompanied by higher levels of anxiety and depression but not with conduct problems. Prior, Sanson, Smart, and Oberklaid (1999) studied temperament factors in 11- to 12-year-old “at risk” children (N = 186), of whom almost half met the diagnostic criteria for DSM-defined disorders including various anxiety disorders. Results demonstrated that “at risk” children displayed higher levels of negative reactivity and withdrawal (which are both indicators of neuroticism) as compared to children in the control group. While the preceding, cross-sectional studies demonstrate that there are clear links between neuroticism (or related temperament/personality traits) and psychopathology in youths, there is also prospective research showing this relationship. For example, Caspi, Henry, McGee, Moffitt, and Silva (1995) assessed various temperament dimensions when children were 3 to 5 years of age. Results demonstrated that the temperament dimension of withdrawal, which can be regarded as a derivate of neuroticism, predicted parent- and teacherrated internalizing symptoms when children reached middle childhood and early adolescence. A longitudinal twin study of Gjone and Stevenson (1997) examined the significance of genetic and common environmental influences on temperament and behavioral and emotional problems in a sample of 758 twin pairs aged 7 through 17 years who were followed for a two-year period. Results supported the idea that the temperament factor of neuroticism is (at least in part) genetically determined. Further, the data indicated that neuroticism was the strongest predictor of emotional and behavioral problems. In an investigation by Asendorpf and Van Aken (2003), the personality development of 151 children was followed from the first or second year in preschool until age 12, using Q-sorts and rating scale data of teachers, parents, and friends. In addition to personality characteristics, judgments and behavioral observations of anxiety/inhibition, aggressiveness, and self-esteem were also obtained. Results demonstrated that the personality factor of neuroticism was fairly stable and even showed continuity over longer time periods. Further, neuroticism was significantly linked to higher levels of anxiety/inhibition (but not to aggression) and lower levels of selfesteem. In a prospective study by Ruschena, Prior, Sanson, and Smart (2005), the impact of a negative family transition—that is, parental separation, divorce, or death—on the lives of children and adolescents was examined. Results again indicated that the temperamental characteristic of withdrawal was a significant predictor of internalizing symptoms, and this appeared not only the case in youths who had been confronted with a negative family transition but also in youths where the families remained intact. Mun, Fitzgerald, Von Eye, Puttler, and Zucker (2001) investigated temperamental characteristics as predictors of externalizing and internalizing behavior problems in boys who were 3 to 5 years old and again when they were 6 to 8 years old. Results clearly indicated that reactivity and withdrawal, which both represent aspects of neuroticism, were significant predictors of behavior problems. Interestingly, reactivity was clearly linked to externalizing behavior problems, whereas
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withdrawal was convincingly associated with internalizing behavior problems. A final longitudinal study by Craske, Poulton, Tsao, and Plotkin (2001) examined the role of neurotic traits (emotionality) at age 3 as a predictor of panic disorder and agoraphobia at ages 18 or 21 in an unselected sample (N = 992). Results indicated that emotionality at age 3 predicted later panic disorder and agoraphobia, but this appeared only the case in males. Recently, a number of studies have included self-report questionnaires when investigating temperament and personality correlates of child psychopathology. This seems to be an important development as it is generally assumed that self-description is an important source of information in the field of personality research (Carver & Scheier, 1996). Muris, Winands, and Horselenberg (2003) showed that neuroticism as measured by the Junior version of the Eysenck Personality Questionnaire (Eysenck & Eysenck, 1975) was significantly associated with various types of psychopathological symptoms in adolescents but most strongly with symptoms of anxiety disorders (see Figure 2.6). In an investigation by Masi, Mucci, Favilla et al. (2003), adolescents with anxiety disorders, adolescents with comorbid anxiety and depression, adolescents with learning difficulties, and normal youths completed a scale for measuring basic temperament factors. Results demonstrated that youths with anxiety disorders and comorbid anxiety-depression displayed higher levels of emotionality and shyness as compared to youths with learning difficulties and normal youths. Two studies that employed the recently developed Big Five Questionnaire for Children (Barbaranelli, Caprara, Rabasca, & Pastorelli, 2003; Muris, Meesters, & Diederen, 2005; see Appendix) found that neuroticism as indexed by this self-report inventory was not only associated with internalizing but also with externalizing symptoms, and this appeared true for various age groups of nonclinical children and adolescents. Finally, a longitudinal study by Lonigan, Phillips, and Hooe (2003) examined the tripartite theory in relation to children’s symptoms of anxiety and depression. Results showed that self-reported negative affectivity (which, as mentioned earlier can be viewed as an equivalent of neuroticism) was relatively stable over a seven-month period. Most importantly, negative affectivity appeared to be a significant correlate of anxiety and
0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 –0,1 Anxiety disorders
Depressive disorders
Oppositional- Conduct disorder defiant disorder
Figure 2.6: Correlations (corrected for other personality traits) between neuroticism and symptoms of various psychopathological disorders in adolescents. All positive correlations were significant at p < .001. Based on: Muris, Winands, & Horselenberg (2003).
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depression symptoms (see also Anthony, Lonigan, Hooe, & Phillips, 2002; Austin & Chorpita, 2004) on both occasions and was found to predict changes in anxiety and depression symptoms over time. This review of the link between neuroticism and child psychopathology suggests that this temperament/personality factor is associated with a broad range of symptoms, although the relation with emotional symptoms such as anxiety and depression seems somewhat more prominent. In this regard, it is important to keep in mind that neuroticism consists of various lower-order traits, of which fear, anger/frustration, and sadness are most important (Rothbart & Bates, 1998). Most instruments that have been used to assess neuroticism are mainly tapping the lower-order traits of fear and sadness, and as such it is not overly surprising that these measures are more convincingly related to internalizing symptoms than to externalizing symptoms. In fact, a recent study by Muris, Meesters, and Blijlevens (in press) demonstrated that when neuroticism is measured by an instrument that covers the full range of lower-order traits (i.e., the Early Adolescent Temperament Questionnaire; Ellis & Rothbart, 2001), this reactive personality trait is predictive of both internalizing and externalizing symptoms in youths. Also noteworthy in this regard is a longitudinal study by Rydell, Berlin, and Bohlin (2003), who collected data on neurotic characteristics (emotionality) when children were 5 years old and internalizing and externalizing behavior problems some 1.5 years later. Results indicated that emotionality was positively linked to mental health problems. Interestingly, evidence was obtained for the notion that lower-order traits of the neuroticism determine the type of psychological symptoms. That is, the lower-order trait of fear predicted internalizing problems, whereas the lower-order trait of anger/frustration was predictive of externalizing problems. Similar findings were obtained by Blair (2002), who followed low-birth-weight, premature infants for a two-year period. Negative temperament assessed when infants were 12 months old appeared to be predictive for the occurrence of behavior problems in children at age 3. Again, temperamental fear specifically predicted internalizing symptoms, whereas anger/frustration augured externalizing symptoms. Thus, it seems plausible that neuroticism predisposes children to internalizing as well as externalizing disorders. Further, it can be assumed that the lower-order traits of this reactive personality factor play an important role in the type of psychopathology from which children eventually come to suffer. A child with a fearful temperament is more prone to develop an anxiety disorder, a child with a temperament characterized by high anger/frustration runs greater risk to develop a disruptive behavior disorder, whereas a child with sad temperament is more susceptible to develop a depression. However, empirical evidence for this idea is still meagre, so the issue certainly needs further validation. It should be mentioned that the position that temperament plays a role in the aetiology of child psychopathology has been repeatedly criticized by pointing to the presumed tautological nature of the link between neurotic temperament factors and psychopathology (Frick, 2004; Lahey, 2004). For example, it can be argued that children who are frequently fearful suffer from an anxiety disorder, children who become easily angry and frustrated display the symptoms of a disruptive behavior disorder, and those who are regularly sad show the signs of depression. Nevertheless, research has demonstrated that neuroticism-related temperamental characteristics are different from the symptoms of psychological disorders. For example, Lemery, Essex, and Smider (2002) asked a group of experts (consisting of child psychologists with a clinical and/or a research background) to sort out items taken from
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
behavioral rating scales for assessing temperament/personality and psychopathology. Results showed that items for most part were correctly assigned to either the temperament/personality or the psychopathology construct. This finding was confirmed in an empirical study in which temperament and psychopathology data of a large sample of children were subjected to a factor analysis. This analysis produced the expected two-factor solution with most temperament items loading on one factor and most psychopathology items loading on the other factor. Most important, the elimination of confounded items did not affect the relation between temperament and psychopathological symptoms: Neuroticism remained a significant predictor of psychological problems, suggesting that this link was not due to measurement confounding (see also Lengua, West, & Sandler, 1998).
Trait Anxiety The lower-order temperamental factor of fear bears strong similarity to the construct of trait anxiety, which has been defined as “relatively stable individual differences in anxiety proneness—that is, differences between children in the tendency to experience anxiety states” (Spielberger, 1973). In their hierarchical model of anxiety, Zinbarg and Barlow (1996) describe neuroticism as the higher-order factor that is related to the general tendency to react with negative affect in response to stressful stimuli, whereas trait anxiety is considered as a lower-order factor referring to the more specific tendency to react anxiously to potentially threatening stimuli and situations. Although its definition clearly suggests that trait anxiety should be considered as a factor that is relevant for the aetiology of anxiety problems, Reiss, Silverman, and Weems (2001) have rightly noted that the most frequently employed instrument for measuring this construct in youths, the trait scale of the State-Trait Anxiety Inventory for Children (STAIC-T; Spielberger, 1973), is not exclusively focused on anxiety but also includes items referring to feelings of depression, guilt, and insecurity. In fact, the STAIC-T is constructed in such a way that it can best be considered as a scale measuring general distress with the accent on anxiety (see Chapter 7). Not surprisingly, then, trait anxiety is generally viewed as an anxiety symptom construct rather than as an anxiety vulnerability factor.
Biological Intermezzo It is generally assumed that behavioral inhibition and its associated personality factor of neuroticism both have a clear genetic basis (Eysenck, 1990; Robinson et al., 1992), and hence it is not surprising that various biological theories have been formulated to account for these temperament/personality-based vulnerability factors. Essentially, these biological accounts are based on the assumption that personality characteristics such as neuroticism and behavioral inhibition are grounded in genetically determined individual differences in the arousability of various brain systems, which in turn influence behavior and adjustment. The basic idea is that in the case of phobias and anxiety disorders, certain brain areas are too easily aroused, which has not only direct (e.g., arousal effects on attention) and indirect (e.g., avoidance of stimuli or situations) behavioral consequences, but also influences learn-
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ing processes (e.g., faster conditioning; see Gray, 1981; Matthews, Deary, & Whiteman, 2003). According to the arousal theory of Eysenck (1967, 1981, 1997), neuroticism is associated with a neural circuit that interconnects the cerebral cortex with the limbic system, which consists of various interrelated structures in the forebrain, such as the amygdala, the hippocampus, and the hypothalamus. The function of this viscero-cortical circuit is to control subjective and autonomic emotional responses, particularly in stressful environments. Eysenck assumes that this system is more excitable in high-neurotic individuals than in emotionally stable individuals. Thus, high-neurotic individuals are more likely to become autonomically aroused and to experience more discomfort and tension under stressful circumstances. If one assumes that behavioral inhibition is not merely a manifestation of neuroticism but is also grounded in the temperament/personality factor of extraversion (Van Brakel & Muris, 2006), a second brain circuit in Eysenck’s theory becomes relevant. This cortico-reticular loop includes the cerebral cortex, the thalamus, and the ascending reticular activating system (ARAS). The circuit is activated by sensory stimulation, and projects via ascending pathways to the cerebral cortex, where the incoming information is further processed. According to Eysenck, this circuit should be viewed as the neural substrate of extraversion. In low-extravert (introvert) individuals, which clearly show the signs of behavioral inhibition, this system would be more easily activated, resulting in higher levels of cortical arousal, and as a consequence greater susceptibility to conditioning processes. Gray (1987, 1991) proposes a somewhat different biological theory in which he describes three basic brain systems that are relevant for understanding behavior in response to salient environmental stimuli, and as such are associated with temperament and personality. The first system is the behavioral inhibition system (BIS), which consists of subcortical structures such as the hippocampus, the septum, and parts of the limbic system, and has projections to the frontal lobes of the cerebral cortex. The BIS serves to alert the person to the possibility of danger or punishment, thereby enhancing avoidance behavior. Activity in the BIS is responsible for feelings of anxiety and incites the individual to stop whatever action is going on and to scan the environment for further cues. The second system is the behavioral approach system (BAS), which is sensitive to signals of reward and involved in approach behavior. Activity in the BAS produces impulsive behavior: The person will vigorously pursue any action that might result in reward, with little attention for the possibility of negative consequences. This system is primarily located in various forebrain structures that are guided by the neurotransmitter of dopamine. Finally, the fight-flight system is sensitive to unconditioned, aversive stimuli (such as pain, loud noises) and is thought to be involved in strong emotions such as panic. This system is associated with brain structures that are involved with the control of negative emotions, such as the amygdala and the hypothalamus. Gray (1987, 1991; see also Gray & McNaughton, 2000) has hypothesized that differences in the reactivity of these three brain systems determine differences in temperament and personality. Although the empirical evidence is not totally consistent, most research has demonstrated that a stronger reactivity of the BIS and the fight-flight system are associated with higher levels of neuroticism, whereas stronger responsivity of the BAS is related to extraversion (e.g., Caseras, Avila, & Torrubia, 2003; Franken, Muris, & Rassin, 2005). Not surprisingly, then, the BIS is thought to be involved in anxiety, whereas the BAS is thought to be involved in externalizing behavior problems. A recent study by Muris, Meesters, De
48
Normal and Abnormal Fear and Anxiety in Children and Adolescents 1 0,8 0,6
*
0,4 0,2
*
*
*
* *
BIS BAS
0 –0,2 –0,4 –0,6
*
Neuroticism Extraversion Internalizing
Anxiety
Externalizing
Figure 2.7: Correlations between BIS/BAS scales (child report), on the one hand, and scales measuring personality traits (child report), anxiety and other psychopathological symptoms (parent report), on the other hand, in a sample of nonclinical children aged 8 to 12 years. * p < .01. BIS = Behavioral Inhibition System, BAS = Behavioral Activation System. Based on: Muris et al. (2005).
Kanter, and Eek Timmerman (2005) examined Gray’s theory in a child population. Normal school children (N = 284) aged 8 to 12 years (and their parents) completed an age-downward version of Carver and White’s (1994) BIS/BAS scales (see Appendix), as well as scales that measured neuroticism, extraversion, and psychopathological symptoms. Results were largely as anticipated—that is, neuroticism was strongly associated with BIS, whereas extraversion was negatively related to BIS but positively to BAS. Further, BIS was convincingly connected to higher levels of internalizing problems and anxiety symptoms, whereas BAS was related to externalizing symptoms (see Figure 2.7). Further support for a link between BIS and fear was obtained by Leen-Feldner, Zvolensky, and Feldner (2004). Adolescents (aged 12 to 17 years) completed the BIS/BAS scales and were then subjected to a fear-relevant slide-viewing paradigm. Results indicated that BIS scores significantly predicted the subjective aversiveness and dyscontrol facets of the emotional responses to the slides. Altogether, these findings provided tentative evidence for the applicability of Gray’s biological temperament factors in youths. According to Pine (1999; see Pine & Grun, 1999), the biological basis for anxiety-related vulnerability is predominantly grounded in three interrelated limbic brain circuits: (A) the amygdala-based circuit, (B) the septum-hippocampus-based circuit, and (C) the brain stemhypothalamus-based circuit (see Figure 2.8). Various researchers have suggested that these brain circuits are part of a larger system devoted to the organization of the body’s responses to different forms of threat (Gray & McNaughton, 1996; LeDoux, 1996; Panksepp, 1998). The first neural circuit centers on the amygdala, an almond-sized limbic structure located in the medial temporal lobe of the brain. There is evidence indicating that the amygdalabased circuit mediates fear conditioning. As such, the amygdala has been described as a simple Pavlovian learning machine that associates aversive events with neutral events, helping animals and humans react to the environment (see Ressler & Davis, 2003). Evidence for this notion comes from experimental studies which have demonstrated that the amygdala
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Figure 2.8: The three limbic brain circuits that according to Pine (1999) play an important role in the pathogenesis of anxiety disorders in youths: the amygdala-based circuit (white), the septum-hippocampus-based circuit (black), and the brain stem-hypothalamus-based circuit (cross-hatched). 1 = Septum, 2 = Amygdala, 3 = Hypothalamus, 4 = Hippocampus, 5 = Brain stem periaqueductal gray. Based on: Pine & Grun (1999).
changes during conditioning, the degree of conditioning correlates linearly with the degree of activity in the amygdala, and lesions in the amygdala in humans impair fear conditioning. This circuit seems to be particularly relevant for those anxiety disorders in which fear conditioning plays a critical role, such as phobias and posttraumatic stress disorder. Pine and Grun (1999) propose several models for the role of the amygdala in these childhood anxiety disorders (see also Milham, Nugent, Drevets et al., 2005). First, the amygdala seems to play a critical role in the preattentive processing of threatening information. In this brain structure, incoming information is subjected to a first quick-and-dirty analysis, and as soon as a threat is detected, the fear response is activated to prepare the organism for action. Several authors have noted that the amygdala is especially responsive to biologically “prepared” stimuli such as spiders, snakes, and angry faces (see LeDoux, 1998; Marks, 1987; Öhman, 2005; see also Chapter 3) and stimuli associated with extremely traumatic experiences, which have left clear physiological traces in the amygdala (e.g., Bremner, Vermetten, Schmal et al., 2005; Rauch, Whalen, Shin et al., 2000). Second, there may be marked individual differences in the sensitivity of the amygdala-based circuit. Kagan (1994) has suggested that in particular children with a behaviorally inhibited temperament are characterized by highly sensitive amygdala-based brain circuits and as a result are more prone to fear conditioning processes (see Schwartz, Wright, Shin, Kagan, & Rauch, 2003). Tentative evidence for this notion comes from a study by Grillon, Dierker, and Merinkangas (1997),
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
who elicited startle responses in offspring of parents with anxiety disorders (who often show the signs of behavioral inhibition; see Rosenbaum, Biederman, Bolduc-Murphy et al., 1993). Briefly, the startle reflex is thought to be an amygdala-mediated, inborn protective response to a sudden and unexpected stimulus that is marked by the cessation of ongoing behaviors and by a particular series of protective behaviors. The complete response in humans consists of a brief closing of the eyes (i.e., an eyeblink) and a facial grimace, followed by neck flexion and then, shoulder and back contraction and flexion of the legs as the body assumes a defensive shrunken posture (Landis & Hunt, 1939; Lang, 1995). Interestingly, Grillon et al. (1997) found greater startle reponsivity in children of parents with anxiety disorders as compared to control children. The greater responsivity of the at risk children was not only observed for the first startle but also for the full series of startles, suggesting that these children displayed greater reactivity of this response system as well as less habituation over time (see Figure 2.9). The second limbic brain circuit involves the septum and the hippocampus. This system helps the organism to determine the appropriate response in response to ambiguous, potentially threatening situations. Briefly, when confronted with such situations, the septumhippocampus-based system produces an emotional/cognitive state of anxiety and a bias toward cues of the impending threat (McNaughton, 1997). Vulnerable children would exhibit a relatively strong bias for threat in this system and as a result display increased levels of arousal and various types of cognitive distortions (see Chapter 5). Pine and Grun (1999) assume that this circuit plays a prominent role in generalized anxiety disorder. The third neural circuit is concerned with the periaqueductal gray areas of the brain stem and the hypothalamus, which are thought to underlie responses to specific unconditioned stimuli. In younger children, this system would be involved in distress reactions following separation from attachment figures, whereas in older youths, this system would underlie panic-like symptoms in response to marked bodily sensations (due to respiratory stimulation or other agents that challenge the noradrenergic system in the brain; Perna, Ieva, Caldirola, Bertani, & Bellodi, 2002; Pine, Klein, Coplan et al., 2000). As such, it has been hypothesized that hypersensitivity of the brain stem-hypothalamus-based circuit would enhance 6
5
Children of parents with anxiety disorder Children of parents without anxiety disorder
4
3 First startle
Series of startles
Figure 2.9: Mean startle response magnitudes in children of parents with and without an anxiety disorder. Based on: Grillon, Dierker, & Merikangas (1997).
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youths’ susceptibility to separation anxiety disorder and panic disorder (Pine, 1999; Pine & Grun, 1999). Taken together, it has been proposed that anxiety-prone (i.e., behaviorally inhibited, neurotic, temperamentally fearful) children have hyperexcitable subcortical brain circuits that promote fear and anxiety (see for an extensive review, Rosen & Schulkin, 1998). It is important to note that the three brain circuits do not operate in isolation but frequently interact with each other. These interactions among the circuits would be in keeping with the clinical observation that various types of anxiety disorders frequently covary in children and adolescents (Pine & Grun, 1999; Chapter 1). Further, it should be borne in mind that the hyperarousability of subcortical brain circuits is only part of the full picture: That is, various cortical brain areas (in particular in the frontal lobes) are thought to moderate subcortical arousal, and so it is also possible that dysregulation of this cortical regulation system is also involved in childhood anxiety disorders (Pine, 1999). A recent functional magnetic resonance imaging (fMRI) study by McClure, Monk, Nelson et al. (2007) indeed seems to indicate that cortical and subcortical circuits are involved in the processing of threat cues. In this study, 15 youths with generalized anxiety disorder (GAD) and 20 diagnosis-free controls underwent an fMRI scan while they completed a face-emotion-rating task that systematically manipulated attention. Results indicated that, when attending to their own fear, GAD youths showed greater activation to fearful than to happy faces in a circuit involving the amygdala, the ventral prefrontal cortex, and the anterior cingulate cortex as compared to control youths. This finding also points out that Pine’s (1999; Pine & Grun, 1999) idea about the three brain circuits being specifically related to the separate childhood anxiety disorders may be too simple, and may critically depend on the fear or anxiety process under study. To complicate the picture even further, research has also focused on the connection between frontal brain asymmetries and anxiety-related vulnerability. Based on the observation that the left frontal areas in the brain sustain approach behavior, whereas the right frontal areas are involved in avoidance behavior (Davidson, 1992, 1998; Fox, 1991, 1994), the possibility can be raised that a stable right frontal hyperactivation represents a biological substrate of the tendency to react with withdrawal to potentially threatening stimuli (see Fox, Henderson, Marshall, Nichols, & Ghera, 2005). Davidson and Fox (1989) indeed demonstrated that young infants with a strongly activated right frontal hemisphere tend to react with crying in response to subsequent maternal separation. More recent research suggests that relative right frontal hyperactivation in children is linked to a much broader response style that comes close to behavioral inhibition (Calkins, Fox, & Marshall, 1996; Fox, Henderson, Rubin, Calkins, & Schmidt, 2001; Henderson, Fox, & Rubin, 2001). In other words, relative right frontal hyperactivation might be a good marker of an anxietyprone temperament/personality and, possibly, predictive of the severity of childhood anxiety disorders, but clearly more research is required to delineate the precise connections. The finding that “fear of suffocation” and subsequent panic attacks seem to be involved in the onset of situational and environmental phobias (e.g., phobias of elevators, claustrophobia; see Verburg, Griez, & Meijer, 1994), has led Klein (1993) to the proposition that some individuals may have “hypersensitive suffocation detectors.” These brain detectors would trigger panic attacks in response to a broad range of stimuli that may signal a lack of useful air (i.e., suffocation). Support for this hypothesis comes from various sources.
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
First, Pine and colleagues (1998, 2000, 2005) noted that children with anxiety disorders more frequently display respiratory abnormalities in response to a CO2 challenge than nonanxious control children. Second, other studies have demonstrated that anxiety symptoms and even anxiety disorders are more prevalent among children with asthma (Bussing, Burket, & Kelleher, 1996; Goodwin, Pine, & Hoven, 2003; Rietveld, Van Beest, & Prins, 2005; Slattery, Klein, Mannuzza et al., 2002; see for a review Katon, Richardson, Lozano, & McCauley, 2004). Third and finally, in a medical condition known as congenital hypoventilation syndrome (or Ondine’s curse), children have deficient suffocation detectors, and it has been shown that these children typically display lower levels of anxiety symptoms (Pine, Weese-Mayer, Silvestri et al., 1994). All these findings are in keeping with the notion that some children suffer from a genetically determined physical defect, which makes them more prone to develop panic, situational and environmental phobias, and other pathological anxiety conditions (Muris & Merckelbach, 2001). A final model of biology-based susceptibility to anxiety involves the hypothalamic-pituitary-adrenal (HPA) axis, which is involved in the behavioral and physiological response to stress (see Coplan, Moreau, Chaput et al., 2002). Briefly, the HPA works as follows: As soon as the system evaluates a situation as stressful, the hypothalamus releases a chemical substance, the corticotropine releasing hormone (CRH), which activates the pituitary gland to produce the adrenocorticotropic hormone (ACTH). The ACTH is transported via the blood to the adrenal cortex, where it stimulates the production of cortisol, which is a hormone that helps, within the short term, to prepare the body to adapt to or eliminate the stressful circumstances. Schmidt, Fox, Rubin et al. (1997) found evidence indicating that 4-year-old behaviorally inhibited children exhibit relatively high morning levels of the cortisol (Figure 2.10; see also Feder, Coplan, Goetz et al., 2004; Kagan et al., 1988), suggesting that youths with this temperamental vulnerability experience more stress even in relatively benign circumstances. Interestingly, Smoller, Yamaki, Fagerness et al. (2005) obtained evidence to demonstrate that behavioral inhibition is associated with the CRH gene, which underlines the involvement of the HPA-axis in this anxiety-related temperamental characteristic.
1 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 Low BI
Middle BI
High BI
Figure 2.10: Average morning salivary cortisol (in ug/dl) in 4-year-old children with low, middle, or high levels of behavioral inhibition. Based on: Schmidt et al. (1997).
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Anxiety Sensitivity Whereas neuroticism, behavioral inhibition, and trait anxiety can be qualified as general genetic factors as they predispose children and adolescents to a broad range of anxiety disorders, there are also more specific genetically based factors, which make youths prone to develop certain types of anxiety disorders. A first example of such a specific genetic factor is anxiety sensitivity. Anxiety sensitivity refers to the fear of anxiety-related sensations that are interpreted as having potentially harmful somatic, psychological, or social consequences and so give rise to significant anxiety (e.g., Reiss, 1991). Anxiety sensitivity is generally regarded as a subtrait of the more general factor of trait anxiety (e.g., Zinbarg & Barlow, 1996) and has been shown to run in families (Tsao, Myers, Craske et al., 2005; Van Beek & Griez, 2003) and to possess a clear-cut genetic basis. For example, Stein, Jang, and Livesley (1999) examined the heritability of anxiety sensitivity in 179 monozygotic and 158 dizygotic adult twin pairs. These authors found that anxiety sensitivity has a strong heritable component, accounting for nearly half of the variance in anxiety sensitivity levels (A = 0.45). Research in adult populations has provided evidence for the notion that anxiety sensitivity should be considered as a specific vulnerability factor for panic disorder (e.g., Rachman, 1998; Taylor, 1995, 1999). During the past decade, an increased amount of research attention has been devoted to the study of anxiety sensitivity in children and adolescents. This increase is associated with the development of scales like the Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991; see Appendix) and the Anxiety Sensitivity Index for Children (ASIC; Laurent, Schmidt, Catanzaro, Joiner, & Kelley, 1998), which are both self-report questionnaires for measuring this anxiety-related individual difference variable in children and adolescents. Both scales contain items such as “It scares me when my heart beats fast”; “When my stomach hurts, I worry that I might be really sick”; and “Unusual feelings in my body scare me,” and as such primarily assess youths’ affective reactions to anxiety symptoms. There is good evidence for the reliability of the CASI and ASIC (e.g., Silverman et al., 1991; Lambert, Cooley, Campbell, Benoit, & Stansbury, 2004), and research has also shown that scores on anxiety sensitivity indexes are predictive for youths’ responses to physiological arousal, which supports the validity of these scales. For example, Rabian, Embry, and MacIntyre (1999) asked 8- to 11-year-old children to engage in a stair-stepping task designed to increase physiological arousal. The results of this experiment indicated that anxiety sensitivity scores (as measured by the CASI) were a significant predictor of state anxiety and subjective fear in response to the symptoms elicited by the challenging task. Comparable results were obtained by Unnewehr, Schneider, Margraf, Jenkins, and Florin (1996), who exposed children of anxiety disorder and control children to a hyperventilation provocation task. The researchers found that subjective anxiety in response to the hyperventilation task was significantly predicted by children’s anxiety sensitivity levels—that is, those with higher levels of anxiety sensitivity also displayed higher levels of subjective anxiety to the task (see also Leen-Feldner, Feldner, Bernstein, McCormick, & Zvolensky, 2005). Several cross-sectional studies have demonstrated that anxiety sensitivity is associated with symptoms of panic in children and adolescents. For example, Lau, Calamari, and Waraczynski (1996) examined the relationship between anxiety sensitivity and panic attack symptoms in a sample of nonclinical adolescents aged 14 to 18 years. For this purpose,
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participants completed the CASI as well as a modified version of the Panic Attack Questionnaire (Norton, Dorward, & Cox, 1986), which measures the prevalence and severity of panic symptoms. Results indicated that anxiety sensitivity scores were positively associated with the frequency and severity of panic symptomatology (see also Calamari, Hale, Heffelfinger et al., 2001). Moreover, adolescents who had experienced a full-blown panic attack displayed significantly higher anxiety sensitivity scores as compared to adolescents who had not experienced such an attack. Survey studies have also shown that there are clear positive correlations between scales measuring anxiety sensitivity (i.e., CASI and ASIC) and questionnaires for assessing panic-related symptoms in youths (e.g., Deacon, Valentiner, Gutierrez, & Blacker, 2002; Eley, Stirling, Ehlers, Gregory, & Clark, 2004; Ginsburg & Drake, 2002). A somewhat different research method was applied by Hayward, Killen, Kraemer et al. (1997), who employed a structured interview to index the prevalence of panic attacks in a large sample of 11- to 16-year-old adolescent girls (N = 1013). Results showed that the 5.4% of the girls who reported to have ever experienced a panic attack scored higher on a measure of anxiety sensitivity compared to the girls who had never experienced a panic attack. In a similar vein, Schneider and Hensdiek (2003) assessed panic attacks in a sample of 1268 adolescents aged 12 to 16 years. More than half of the adolescents (i.e., 55%) had already experienced a panic attack. However, most of the attacks were not indicative of “real” panic as they occurred in response to a threatening situation. Interestingly, the researchers found that adolescents who had experienced “real” panic attacks displayed significantly higher anxiety sensitivity scores than adolescents who had experienced a situation-related panic attack. In a clinical study by Kearney, Albano, Eisen, Allan, and Barlow (1997), 8- to 17-year-old youths with panic disorder were compared to age-matched youths with other anxiety disorders. Results demonstrated that youths with panic disorder clearly exhibited higher levels of anxiety sensitivity than their nonpanic counterparts. There is also prospective research underlining the link between anxiety sensitivity and panic in youths. A first study by Hayward, Killen, Kraemer, and Taylor (2000) assessed panic attacks, depression, and various risk factors (i.e., anxiety sensitivity and neuroticism) in 2365 high school students over a four year period. Results showed that anxiety sensitivity and neuroticism both predicted the onset of panic attacks, whereas only neuroticism predicted the onset of depression. On the basis of these findings, Hayward et al. (2000) conclude that neuroticism appears to be a rather nonspecific risk factors for psychopathology in general, whereas anxiety sensitivity appears to be a specific factor that increases the risk for panic attacks. In a re-analysis of these data, Weems, Hayward, Killen, and Taylor (2002) identified different developmental pathways in levels of anxiety sensitivity. Briefly, the researchers employed cluster analysis to assign the adolescents to a stable low-anxiety sensitivity group, a stable high-anxiety sensitivity group, and an escalating anxiety sensitivity group. Adolescents with stable high or escalating levels of anxiety sensitivity were found to be more likely to experience a panic attack as compared to the adolescents with stable low levels of anxiety sensitivity (see Figure 2.11). It should be mentioned that this conclusion was only true for the Caucasian youths in this study. It is true that Asian and Hispanic adolescents generally displayed higher levels of anxiety sensitivity, but in these cultural groups anxiety sensitivity was less strongly associated with panic, which suggests that there may be cultural differences in the experience of anxiety phenomena (see also Chapter 3).
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18 16 14 12 10 8 6 4 2 0 Stable low-anxiety sensitivity
Escalating anxiety sensitivity
Stable high-anxiety sensitivity
Figure 2.11: Percentage of adolescents in the stable low, escalating, and stable high-anxiety sensitivity groups that report to have experienced a panic attack. Based on: Weems et al. (2002).
Although anxiety sensitivity is convincingly associated with (the development of) panic disorder symptoms in youths, and as such is generally regarded as a specific genetic factor (Taylor, 1998), there are two research findings that seem to qualify this conclusion. First of all, several studies have demonstrated that anxiety sensitivity is not specifically associated with panic disorder symptoms but with anxiety disorders symptoms in general (e.g., Joiner, Schmidt, Schmidt et al., 2002; Pollock, Carter, Avenevoli et al., 2002; Rabian, Peterson, Richters, & Jensen, 1993; Weems, Hammond-Laurence, Silverman, & Ginsburg, 1998). Second, some studies have shown that anxiety sensitivity is also positively associated with depression (e.g., Weems, Hammond-Laurence, Silverman, & Ferguson, 1997; Wilson & Hayward, 2005) and even externalizing disorders (e.g., Rabian et al., 1993). These findings can be explained in various ways. To begin with, as noted in Chapter 1, it should be borne in mind that there is high comorbidity among the anxiety disorders (which implies that panic symptoms also frequently occur in other anxiety disorders; Mattis & Ollendick, 2002) and between anxiety disorders and other psychological disorders. Indeed, research has demonstrated that, when controlling for comorbid symptoms, the correlation between anxiety sensitivity and anxiety, and panic in particular, becomes more clear cut (e.g., Joiner et al., 2002; Muris, Schmidt, Merckelbach, & Schouten, 2001a). Further, several authors have noted that anxiety sensitivity is a multidimensional construct that consists of various lowerorder factors (see Reiss, et al., 2001). For example, exploratory and confirmatory factor analytic studies have demonstrated that anxiety sensitivity as indexed by instruments such as the CASI and the ASIC do not reflect a unitary construct but rather consist of multiple components. For example, Silverman, Ginsburg, and Goedhart (1999) who tested the factor structure of the CASI in clinical (ages 7 to 16 years) and nonclinical (ages 7 to 12 years) youths found evidence for separate lower-order components of anxiety sensitivity referring to “fear of physiological symptoms,” “fear of publicly observable anxiety symptoms,” and “fear of mental incapacitation.” Admittedly, other researchers have obtained somewhat different factor structures of anxiety sensitivity (Dehon, Weems, Stickle, Costa, & Berman, 2005; Laurent et al., 1998; Muris et al., 2001; Walsh, Stewart, McLaughlin, &
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
Comeau, 2004), but this can best be explained by the fact that questionnaires like the CASI and the ASIC only consist of a limited set of items. When using an expanded scale for measuring anxiety sensitivity in youths (the Revised version of the CASI, or CASI-R; see Appendix), Muris (2002a) found clear support for the factors as reported by Silverman et al. (1999), although the “fear of physiological symptoms” factor was split in two factors: “fear of cardiovascular symptoms” and “fear of respiratory symptoms” (see Figure 2.12). The identification of anxiety sensitivity components may be relevant for the discussion of the specificity of this vulnerability factor, as it may well be the case that some components (i.e., “fear of cardiovascular symptoms” and “fear of respiratory symptoms”) are most relevant for panic disorder, whereas other components (i.e., “fear of publicly observable anxiety symptoms” and “fear of cognitive dyscontrol”) seem to be more important for other types of psychopathology (respectively, social phobia and depression/generalized anxiety disorder). Empirical tests of this idea are sparse (but see Lambert, McCreary, Preston, Schmidt, Joiner, & Ialongo, 2004), hence more research is needed, preferably employing the expanded CASI to further establish the specificity of anxiety sensitivity as a risk factor for panic disorder.
Anxiety sensitivity
.86
.76
.75
Fear of cardio-vascular symptoms
Fear of publicly observable anxiety
Fear of cognitive dyscontrol
It scares me when my heart beats fast
It is important for me not to appear nervous
When I feel strange, I worry that I might go crazy
.88
Fear of respiratory symptoms
It scares me when I am short of breath
Figure 2.12: The factor structure of anxiety sensitivity. For each component, an example of an item taken from the Revised CASI is given. Based on: Muris (2002a).
Genetically Based Vulnerability
57
Disgust Sensitivity Another more specific genetic factor involves disgust. Disgust has been identified as a foodrelated basic emotion that has clear biologically prewired antecedents. For example, young babies react with a spitting reflex when they are exposed to bitter substances (Ekman, 1992). The basic emotion of disgust is thought to have adaptational value, as it would have the important function of avoiding contamination and diseases (Matchett & Davey, 1991). There are marked individual differences in disgust sensitivity that can be reliably measured with self-report questionnaires that contain items like “It bothers me to see someone in a restaurant eating messy food with his fingers” (Haidt, McCauley, & Rozin, 1994). Psychometric research has revealed that scores on such disgust scales are positively correlated with neuroticism and negatively linked to sensation seeking, although the correlations with these fundamental personality traits are rather modest (Druschel & Sherman, 1999; Haidt et al., 1994; Hennig, Pössel, & Netter, 1996). Haidt and colleagues (1994; p.711) concluded that “disgust appears to make people cautious not only about what they put into their mouths, but about what they do with their bodies,” and as such it can be argued that disgust sensitivity plays a role in a broad range of anxiety problems. Yet, recent research findings indicate that the contribution to disgust sensitivity to anxiety is rather specific. There is now good evidence that disgust sensitivity is involved in the genesis of certain types of specific phobias, in particular animal phobias and blood-injection-injury phobias. For example, Matchett and Davey (1991; see also Merckelbach, De Jong, Arntz, & Schouten, 1993) found a positive association between measures of disgust sensitivity and scores on the animal phobia scale of a fear survey. A subsequent study (Davey, Forster, & Mayhew, 1993) not only noted a significant correlation between parents’ and children’s disgust scores but also indicated that parental disgust sensitivity was the main predictor of offspring animal fear. Only a few studies can be found that have directly investigated the role of disgust sensitivity in childhood animal phobia. De Jong, Andrea, and Muris (1997) assessed fear of spiders, disgust sensitivity, and spiders’ disgust-evoking status in spider-phobic girls who applied for treatment, in nonphobic girls, and in the parents of both groups of children. Phobic girls were tested twice, before and after behavioral treatment. The notion that disgust is an important aspect of spider phobia was supported by the following findings. To begin with, compared to control girls, spider-phobic girls exhibited higher levels of disgust sensitivity and considered spiders per se as more disgusting. Second, after treatment, the reduction in spider fear was closely paralleled by a decline in spiders’ disgust-evoking status. Third, mothers of spider-phobic girls also attributed a high disgust-evoking status to spiders. De Jong et al. (1997; p.559) interpret the latter finding in terms of modeling experiences: “The acquisition of spider fear is facilitated by specific parental disgust reactions when confronted with spiders.” Alternatively, it may well be the case that a genetic factor is involved in the familial transmission of disgust sensitivity and, in its wake, animal phobia. In a followup study by De Jong and Muris (2002), spider-phobic and nonphobic girls were confronted with vignettes that described potential encounters with spiders. Both groups of girls then rated the subjective probability of spiders entering their private living space, their tendency to approach and make physical contact, and the probability of spiders doing physical harm. In addition, all girls indicated their eagerness to eat a favorite food item after a spider had
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
contacted it. Results showed that phobic girls reported relatively high ratings concerning spiders’ tendency to enter their private living space and to approach and make physical contact, and low ratings of eagerness to eat a spider-contaminated food item. This finding seems to indicate that spider phobia results from the convergence of disgust and the probability of physical contact. All these results indicate that disgust plays a role in this type of phobia. Muris, Merckelbach, Schmidt, and Tierney (1999) examined to what extent disgust sensitivity is also related to other anxiety symptoms in youths. For this purpose, nonclinical children (N = 189) completed a measure of disgust sensitivity, the trait anxiety scale for children, and the revised version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-R; Birmaher, Khetarpal, Brent et al., 1997; Muris, Merckelbach, Schmidt, & Mayer, 1999), which is a questionnaire for measuring DSM-defined anxiety disorders symptoms. Results indicated that disgust sensitivity was positively correlated with a broad range of anxiety disorders symptoms. However, findings also indicated that these correlations were predominantly carried by trait anxiety. When controlling for levels of trait anxiety, disgust sensitivity only remained significantly related to symptoms of specific phobias (animal phobia, blood-injection-injury phobia, and situational-environmental phobia) and separation anxiety disorder. In a similar study, Muris, Van der Heiden, and Rassin (in press) assessed disgust sensitivity by means of two self-report questionnaires (i.e., the Disgust Sensitivity Questionnaire; Rozin, Fallon, & Mandell, 1984; see Appendix, and the Disgust Scale; Haidt et al., 1994) and a behavioral test involving the choice of defiled candy in a large sample of nonclinical school children (Ns between 231 and 348). Correlations were computed between the disgust sensitivity indexes and children’s scores on various scales for measuring symptoms of phobias, anxiety disorders, and other types of psychopathology (i.e., eating disorders). Results showed that disgust sensitivity was associated with a broad range of psychopathological symptoms, although again the most clear-cut and consistent links were observed with symptoms of animal phobia and bloodinjection-injury phobia. Thus, although it has been argued that the basic emotion of disgust may be relevant for a broad range of psychiatric symptoms (Phillips, Senior, Fahy, & David, 1998), available evidence indicates that disgust sensitivity is mainly important for certain types of specific phobias (see also Muris, Merckelbach, Nederkoorn et al., 2000), and therefore can best be conceptualized as a rather specific vulnerability factor. However, this overview also makes clear that more research is needed to examine the role of disgust sensitivity in childhood phobias.
Conclusion Some children and adolescents display a heightened vulnerability to develop phobias and anxiety disorders. Research has demonstrated that part of this vulnerability can be attributed to heritability (see Eley & Gregory, 2004). This chapter summarized evidence on the role of genetics in childhood fear and anxiety, and the way in which this genetic vulnerability is manifested. It can be concluded that roughly one-third of the variance in normal and abnormal manifestations of fear and anxiety in youths can be attributed to the genetic component. Various genetically based vulnerability factors were described, of which some play
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59
a role in a broad range of anxiety problems (i.e., general vulnerability factors such as behavioral inhibition), whereas some seem to be only involved in certain types of anxiety disorders (i.e., specific vulnerability factors such as disgust sensitivity). Further, biological processes were discussed that are thought to be relevant in the context of childhood anxiety disorders. These processes predominantly involve the hyperarousability of subcortical, in particular limbic, brain structures, which enhance children’s susceptibility to fear and anxiety. In conclusion, then, two remarks are in order: First, in this chapter, only main effects of various vulnerability factors were discussed. However, it is likely that, in reality, vulnerability factors frequently interact with each other (see Chapter 1; Figure 1.14), thereby strengthening their involvement in the pathogenesis of phobias and anxiety disorders. Such interactive effects of vulnerability (and protective) factors will be an important topic in Chapter 6. Second, the behavioral-genetic research clearly indicates that, besides heritability, environmental factors also play an important role in the aetiology of pathological anxiety in youths, which is the topic that will be addressed in the next chapter.
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Chapter 3
Environmental Influences
Introduction Behavioral-genetic research has demonstrated that a significant proportion of the variance in childhood fear, anxiety, and their disorders can be explained by heritable factors (see Chapter 2), which means that the environment also plays a significant role in the pathogenesis of phobias and anxiety disorders in youths. This point can be nicely illustrated by means of a meta-analytic study of Twenge (2000), who observed substantial shifts toward higher anxiety levels in American children and adolescents during the past decades. Briefly, this researcher systematically investigated self-reported anxiety scores of nonclinical youths aged 9 to 17 years who had completed the Children’s Manifest Anxiety Scale (CMAS; Castenada, McCandless, & Palermo, 1956) in studies that were published between 1954 and 1981. Correlation analyses revealed a clear positive and linear association between the year of data collection and youths’ anxiety scores. As an illustration of this result, children and adolescents that had been tested in 1954 displayed a mean CMAS score of 15.08, whereas those who had been tested in 1981 exhibited a mean CMAS score of 22.42. Remarkably, a comparison of the mean anxiety score of the most recent sample with that of clinically referred youths in the 1950s demonstrated that normal children and adolescents in the 1980s displayed even higher anxiety scores than their clinically referred counterparts in the 1950s (who had a mean score of 20.82; (see Figure 3.1)). Most important to the present discussion, the increase in anxiety levels across time was intimately related to a number of societal changes. More precisely, the rise of anxiety was largely explained by a decline in social connectedness (as indexed by the number of divorces) and an increase of threat (as indexed by crime rates) in society. This result nicely shows that the environment, even when indexed at a rather general societal level, plays a prominent role in the development of high fear and anxiety levels in children and adolescents. This chapter provides an overview of environmental factors that are thought to be involved in the aetiology of childhood anxiety disorders. First, evidence will be summarized indicating that traumatic incidents and other negative life events elicit high anxiety levels or even anxiety disorders in youths. Next, the role of the specific learning processes of conditioning, modeling, and negative information transmission in the acquisition of childhood fear and anxiety will be discussed. Then, family factors that are associated with the development of anxiety phenomena will be addressed, and the chapter will close with a discussion of societal and cultural factors that are thought to be relevant for the emergence of fear and anxiety.
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Normal and Abnormal Fear and Anxiety in Children and Adolescents 25 20 15 10 5 0 Nonclinical youths 1954
Nonclinical youths 1981
Clinically referred youths 1954
Figure 3.1: Mean scores on a standardized self-report anxiety questionnaire for nonclinical children and adolescents in 1954 and 1981 and clinically referred youths in 1954. Based on: Twenge (2000).
Traumatic Events and PTSD According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), a traumatic event involves the “direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate” (p.463). It is obvious that such experiences elicit intense fear and anxiety in youths, and a substantial proportion of them will even develop the signs of a posttraumatic stress disorder (PTSD). The key features of this anxiety disorder involve reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, and increased arousal (Foa, Riggs, & Gershuny, 1995), and there is clear evidence that such symptoms are also present in children and adolescents (e.g., McKnight, Compton, & March, 2004). Although the precise prevalence rates of PTSD in youths remain unknown, a number of studies have indicated that children and adolescents are at increased risk for developing PTSD after they have been exposed to life-threatening events. For example, Pynoos et al. (1987; see also Nader, Pynoos, Fairbanks, & Frederick, 1990) assessed PTSD symptoms in a sample of children aged 5 to 13 years following a sniper attack on their school playground in which 1 child was killed and 14 others were wounded. These researchers noted that symptoms of posttraumatic stress were common among the children and that these symptoms were more prominent and persistent when children were more fully exposed to this traumatic incident. In another study, Terr (1981, 1983) studied the posttraumatic emotional sequelae in a small group of children who had been kidnapped in a schoolbus. Results demonstrated that most children clearly displayed PTSD-like symptoms such as trauma-related fears, psychophysiological disturbances, and repeated nightmares and dreams of personal death and that a number of such symptoms were still present some four years after the traumatic event. Further, PTSD symptoms have also been documented in children and adolescents confronted with military violence. For instance, Qouta, Punamaki, and Sarraj (2003) studied
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the responses of 121 Palestinian youths aged 6 to 16 years who had been exposed to Israeli warfare in the Gaza Strip. The vast majority of these children and adolescents had been the target of military violence (e.g., shelling of the home) and/or witnessing such violence. The results of the study showed that more than half of these youths (54%) suffered from severe levels of PTSD symptomatology. Similar findings were obtained by Clarke, Sack, and Goff (1993), who observed PTSD symptoms in Cambodian adolescents who had left their country after being exposed to the terror of the Khmer Rouge regime. Catastrophes and disasters are another potential source for PTSD-related symptoms in youths. In a study by Shannon, Lonigan, Finch, and Taylor (1994), a large sample of children and adolescents were surveyed about their experiences and reactions in relation to a hurricane. It was found that more than 5% of the sample reported sufficient symptoms to be classified as exhibiting PTSD. Furthermore, results indicated a linear association between the degree of exposure to the trauma and the severity of the PTSD symptoms (Lonigan, Shannon, Finch, Daugherty, & Taylor, 1991). March, Amaya-Jackson, Terry, and Costanzo (1997) evaluated the prevalence of PTSD symptomatology in 10- to 16-year-old children and adolescents, nine months after their community had been exposed to an industrial fire disaster. Results showed that 11.9% of the youths met the DSM-criteria for PTSD, and again the degree of exposure to the incident appeared the most powerful predictor of this anxiety disorder diagnosis. An investigation by Yule (1992) among adolescent survivors of the cruise ship Jupiter demonstrated that nearly half of the subjects had developed PTSD when assessing them 1 year after the disaster. A follow-up study, five to eight years later, demonstrated that about one-third still continued to display clear signs of PTSD (Yule, Bolton, Udwin et al., 2000). Green, Korol, Grace et al. (1991) examined 179 children (aged 2 to 15 years) who were exposed to the flood disaster at Buffalo Creek (West Virginia) in 1972, and noted that two years after this event, 32% of the youths displayed the full picture of PTSD. Fifteen years later, 7% of the child survivors continued to display clear symptoms of PTSD (Green, Grace, Vary et al., 1994). A final study by Morgan, Scourfield, Williams, Jasper, and Lewis (2003) followed the children who survived the disaster in Aberfan, where in 1966 a coal slag heap collapsed onto a primary school. A 33-year follow-up assessment of the survivors demonstrated that almost half of them (46%) had developed PTSD at some point after the disaster, while 29% of them currently met the criteria for this anxiety disorder. On the basis of their findings, Morgan et al. (2003) conclude that “trauma in childhood can lead to PTSD, and PTSD symptoms can persist for as long as 33 years into adult life” (p.532). Confrontation with a life-threatening disease such as cancer may not only elicit symptoms of fear and anxiety (see Varni & Katz, 1987), but also PTSD in youths. For example, Stuber, Nader, Houskamp, and Pynoos (1996) reported that 27% of the children who underwent a bone marrow transplantation to treat leukemia displayed clear signs of PTSD, and there is some evidence that these symptoms persist up to 12 months after the medical intervention (Stuber, Nader, Yasuda, Pynoos, & Cohen, 1991). Even the siblings of childhood cancer patients are prone to develop PTSD symptoms. This point is nicely illustrated in a study of Alderfer, Labay, and Kazak (2003), who investigated PTSD symptomatology in adolescent siblings of childhood cancer survivors. The results showed that nearly half of siblings (49%) displayed mild symptoms of PTSD, whereas almost a third (32%) even exhibited moderate to severe reactions to this traumatic experience.
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Normal and Abnormal Fear and Anxiety in Children and Adolescents
Sexual and physical abuse represents a further category of traumas that have clear detrimental effects on youths affected by these events. In this case, the traumatic events are more chronic and caused by a predictable repeated stressor. While it is obvious that physical and sexual abuse may result in PTSD (e.g., Famularo, Fenton, Augustyn, & Zuckerman, 1996; Famularo, Kinscherff, & Fenton, 1990), it has been noted that these traumatic experiences generally yield a mixed, nonspecific clinical picture including emotional symptoms, behavior problems, sexualized behaviors, and poor self-esteem (Kendall-Tackett, Meyer Williams, & Finkelhor, 1993; Kinzl & Biebl, 1992). Children and adolescents may also develop PTSD after they have been injured in road traffic accidents. For example, Max, Castillo, Robin et al. (1998) quantified PTSD symptomatology in 50 children aged between 6 and 14 years, directly after the accident and at 3-, 6-, 12-, and 24-month follow-ups. Although the results demonstrated that only 4% of these youths developed the full picture of PTSD, the researchers also noted that subsyndromal symptoms of this anxiety disorder were common: In the first three months 68% of the children reported at least one PTSD symptom, and this percentage declined to 12% at the two-year follow-up (see also DiGallo, Barton, & Parry-Jones, 1997). Taken together, there is convincing evidence showing that children and adolescents, just like adults, develop PTSD after they have been exposed to traumatic events (see also Rossman, Bingham, & Emde, 1997). Several studies have indicated that there seems to be a linear dose-response relationship between exposure and symptoms: A more direct and intense exposure to the trauma will yield more severe PTSD symptoms (March et al., 1997; Pynoos et al., 1987). This point was further illustrated by Korol, Green, and Gleser (1999), who studied children’s responses to a nuclear waste disaster. Although this disaster certainly posed a serious threat to people’s health, the direct consequences remained largely hidden (i.e., there were no direct victims and no physical destruction), and thus the researchers hardly observed posttraumatic stress symptoms, even in children who resided very close to the nuclear plant. Apparently, appraisal of actual death, injury, or threat of physical integrity seems necessary to elicit the typical PTSD reaction (Pynoos, Steinberg, & Piacentini, 1999).
Trauma and Other Anxiety Disorders Several studies have shown that trauma not only results in PTSD but also increases the risk for developing other anxiety disorders. For example, Famularo, Fenton, Kinscherff, and Augustyn (1996) examined psychiatric comorbidity in youths who had developed PTSD after severe maltreatment and psychological trauma. Results showed that other anxiety disorders were the most frequent concurrent psychiatric diagnosis, affecting about 39% of the youths with PTSD. In a prospective investigation by Goodwin, Fergusson, and Horwood (2005), the links between exposure to traumatic events during childhood and the subsequent development of panic attacks and panic disorder were examined. Results demonstrated that youths who had been traumatized before the age of 16, were at higher risk for developing panic attacks and panic disorder in young adulthood (aged 16 to 21 years). Even after controlling for various social and family factors, childhood sexual and physical abuse remained significantly associated with the development of panic symptoms. A study by Libby, Orton,
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4 3 Pre-accident
2
Post-accident
1 0 Total anxiety
GAD
OCD
SAD
Phobia
Figure 3.2: Mean number of DSM-defined anxiety disorders symptoms in youths before and after an accident involving severe head injury. GAD = Generalized Anxiety Disorder, OCD = Obsessive-Compulsive Disorder, SAD = Separation Anxiety Disorder. All pre-post differences were significant at p < .05. Based on: Vasa, Gerring, Grados et al. (2002). Novins et al. (2005) examined whether childhood abuse was related to a lifetime prevalence of anxiety disorders in a large sample of American Indians. The results showed that a substantial minority of the abused Indians not only developed PTSD but also comorbid anxiety disorders such as panic disorder and generalized anxiety disorder. Vasa, Gerring, Grados et al. (2002) obtained parent ratings of DSM-defined anxiety symptoms in a sample of 4- to 19-year-old youths who were involved in a serious accident, which resulted in closed head injury. Importantly, parents scored youths’ anxiety symptoms before the accident and at a one-year follow-up. Results indicated that there were significant increases in the frequency of anxiety symptoms after the accident as compared with before the accident (see Figure 3.2). While the preceding studies have indicated that anxiety symptoms/disorders other than PTSD increase after children and adolescents have been exposed to a traumatic incident, there is also evidence showing that the increase in other anxiety problems is intimately related to the increase in PTSD symptomatology. A recent study by Cortes, Saltzman, Weems et al. (2005) examined the development of anxiety disorders in 34 children with a history of interpersonal trauma. The researchers observed that besides the diagnosis of PTSD (26%), other anxiety disorders were also prevalent in this sample (29%). Interestingly, anxiety disorders were more frequent among youths who developed PTSD (88%) than among youths who did not develop PTSD (22%). Similar results were obtained by Bolton, O’Ryan, Udwin, Boyle, and Yule (2000), who studied the long-term psychological effects in a sample of adolescents who had survived the sinking of a cruise ship and a group of matched controls. Anxiety disorders such as specific phobia, separation anxiety disorder, and panic disorder were found to be more clearly prevalent among adolescent survivors than among controls. However, additional analyses demonstrated that this conclusion was only true for the survivors who had developed PTSD in the aftermath of the traumatic event. Those survivors who had not developed PTSD displayed similar prevalence rates for anxiety disorders as compared to the controls (see Figure 3.3). A final investigation by
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Normal and Abnormal Fear and Anxiety in Children and Adolescents 70 60 50 40 30 20 10 0 Survivors with PTSD Survivors without PTSD
Controls
Figure 3.3: Prevalence rates of anxiety disorders during a follow-up period of five to eight years after a disaster (i.e., the sinking of the cruise ship Jupiter) for adolescent survivors with PTSD, survivors without PTSD, and controls. Based on: Bolton, O’Ryan, Udwin et al. (2000).
Saigh, Yasik, Oberfield, Halamandaris, and McHugh (2002) analyzed internalizing (including anxious and withdrawn behaviors) and externalizing symptoms in a traumatized urban youth sample. Results demonstrated that traumatized children and adolescents with PTSD displayed significantly higher levels of internalizing (but not externalizing) symptoms as compared to traumatized youths without PTSD, who exhibited similar levels of symptoms as youths in a nontraumatized control group. What is the reason for this related development of PTSD and comorbid anxiety symptoms/disorders after exposure to a trauma? First of all, it may well be the case that both PTSD and concurrent anxiety disorders are the result of a premorbid general anxiety vulnerability factor that is activated by the traumatic event. For example, while it is clear that neuroticism is linked to the development of anxiety problems in general (Chapter 2), there is also evidence for the idea that neuroticism is associated with an increased risk for developing PTSD, probably because highly neurotic subjects display a tendency to negative appraisal of trauma-related symptoms (Van den Hout & Engelhard, 2004; see also Ehlers & Clark, 2000). Another possibility is that the PTSD symptoms can best be viewed as a psychological, cognitive, and physiological attempt to manage the distress elicited by the traumatic experience. As a result of this effort, the ability to effectively deal with other stressors is compromised, which may result in a rise of other anxiety problems. A final explanation pertains to the fact that the trauma has changed the way in which children and adolescents process threat-related information. For instance, it may well be the case that the traumatic event has sensitized certain brain areas, resulting in an increased responsivity to potentially threatening stimuli, which not only elicits PTSD symptomatology but other fear and anxiety symptoms as well (see Cortes et al., 2005).
Negative Life Events Besides traumatic incidents, children and adolescents are regularly confronted with less severe but nevertheless negative life events to which they have to adjust. It is obvious that
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events such as parental divorce, changes in school, and health problems may cause considerable stress (e.g., Cohen, Burt, & Bjorck, 1987; Swearingen & Cohen, 1985), and so it is well conceivable that such adversities are associated with heightened levels of fear and anxiety symptoms in youths. Supporting evidence for this notion has been provided by Faravelli, Webb, Ambonetti, Fonnesu, and Sessarego (1985), who examined the history of major life events up to age 15 in a sample of adult patients with panic disorder and agoraphobia and normal controls. Results showed that the rate of life events in the patients was significantly higher than in controls. In particular, maternal separation and parental divorce were more prevalent among the patients with panic disorder and agoraphobia. Rapee and Szollos (2002) asked mothers of anxiety disordered youths and nonclinical controls to complete questionnaires on several aspects of children’s early life. These researchers found that the mothers of anxious youths more frequently reported birth complications, difficulties in the first year, and general settling difficulties. Some differences were also observed among the specific anxiety disorders—that is, children with social phobia were more likely to be the first child and tended to spend less time in day care, whereas children with separation anxiety disorder had experienced more stressful life events in general. Boer, Markus, and Maingay et al. (2002) compared anxiety disordered children with nonclinical controls and with their nearest in age nonreferred sibling on the number of parent-reported stressful life events. Results indicated that anxiety disordered children differed significantly from healthy controls in the number of negative life events reported by their parents over their lifetime and during the year preceding referral (see Figure 3.4). Anxiety disordered children also differed significantly from their nonreferred sibling in the number of negative life events. Surprisingly, this appeared also the case for events that co-occurred for the two children in the same family (i.e., shared events). Additional analyses revealed that the difference in shared events was due to the fact that parents appraised the impact of these events as more negative for their anxious child than for their nonanxious child. In a study by Gothelf, Aharonovsky, Horesh, Carty, and Apter (2004), children and adolescents with obsessivecompulsive disorder, other anxiety disorders, and nonanxious controls completed a life events checklist that not only catalogued negative events that occurred during the lifetime and the past year but also assessed the degree of impact of each event. The results showed that youths with OCD and other anxiety disorders indeed reported higher levels of negative events during lifetime and the year prior to the onset of the disorder as compared to the nonanxious controls. Further, children and adolescents with OCD and other anxiety disorders also perceived the life events as having more impact. Recent longitudinal research by Grover, Ginsburg, and Ialongo (2005) examined the link between a number of adverse life events and child and parent ratings of anxiety symptoms at a six-year follow-up in a highrisk community sample of African-American children. Evidence was found indicating that a negative family environment, academic difficulties, and the total number of negative life events at time 1 were predictive of anxiety symptoms at time 2, even when controlling for initial anxiety symptom levels. A number of studies have specifically examined anxiety reactions in children and adolescents who are confronted with chronic illness and disease. For example, Von Weiss, Rapoff, Varni et al. (2002) studied emotional adjustment in 8- to 17-year-old youths with pediatric rheumatic diseases and noted that the number of daily hassles, which is generally conceived as an index of perceived life stress, were a significant predictor of children
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Normal and Abnormal Fear and Anxiety in Children and Adolescents 5 4 AD children
3
Siblings
2
Controls
1 0 Lifetime
Past year
Figure 3.4: Mean number of negative life events in anxiety disordered (AD) children, siblings, and control children. All differences between AD children and the other groups were significant at p < .05. Based on: Boer, Markus, Maingay et al. (2002). and adolescents’ trait anxiety scores. Another study by LeBovidge, Lavigne, and Miller (2005) further examined the link between stress and psychological adjustment in 75 youths with chronic arthritis. Results showed that chronic stress (i.e., negative events experienced during the lifetime), episodic stress (i.e., negative events experienced in the past year), and disease-related stress (i.e., negative experiences due to the arthritis) each accounted for significant and unique proportions of the variance in anxiety symptoms. Adewuya and Ola (2005) investigated the prevalence of anxiety disorders in Nigerian adolescents with epilepsy. The researchers observed that 31% of the youths suffered from an anxiety disorder and also noted that the frequency of epileptic seizures as well as adverse family events increased the risk for anxiety disorders. Finally, children who are confronted with the chronic illness of their brother and sister may also experience serious stress. A meta-analytic study by Sharpe and Rossiter (2002) demonstrated that siblings of children with a chronic illness more frequently display internalizing symptoms (including anxiety) and, although to a lesser extent, externalizing problems, as compared to comparison children. Interestingly, the effect sizes of these adjustment problems in the siblings were similar for diseases such as diabetes, bowel disease, and hearing impairments as for a life-threatening, trauma-like illness such as cancer. While it is certainly true that negative life events are linked to anxiety problems, it is clear that such stressful experiences are also associated with other psychological problems. An example is provided by a study of Tiet, Bird, Hoven et al. (2001), who investigated the relationship between specific negative life events and psychiatric disorders by interviewing a large sample of 9- to 17-year-old youths. As is shown in Table 3.1, various life events were associated with an increased risk for anxiety disorders. Note also that in particular generalized anxiety disorder and separation anxiety disorder were linked to a large number of negative life events. However, it should be mentioned that many of the life events were not specific for anxiety disorders but also increased the risk for other types of psychopathology (i.e., mood disorders and disruptive behavior disorders). Another study by Eley and Stevenson (2000) made a more systematic attempt to investigate the specific relationships
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Table 3.1 Relationship (odds ratios) between negative life events in the past year and anxiety disorders in the past six months in a community sample of youths
Negative life event Saw crime/accident Victim of crime/violence/ assault Death of a close friend Breakup with boyfriend/ girlfriend Loss of a close friend Started going to a new school Family member had drug/ alcohol problem Family member had mental/ emotional problem Family member was seriously ill/injured Someone in the family was arrested Parents argued more than previously Parental separation Got new stepmother/ stepfather One parent was away from home more often Parent got a new job Parent went to jail Number of events related to the diagnosis
Generalized anxiety disorder
Separation anxiety disorder
Agoraphobia
Social phobia
1.9
1.7
1.7 2.5 2.1 2.4
2.8 2.5
2.6
4.9
2.8 2.2 1.6
1.7
2.4 1.8 2.5
2.0
4.4 2.9
2.2 4.0
6.3 11
8
3
1
Based on: Tiet, Bird, Hoven et al. (2001).
between various types of life events and symptoms of anxiety and depression. For this purpose, 61 twin pairs of which at least one child displayed very high levels of anxiety or depression, and 29 nonanxious and nondepressed controls were interviewed about life events and chronic stressors in the past 12 months. Results indicated that threatening life events (e.g., being witness of a trauma) were significantly more frequent in anxious children than in depressed youths. Yet, loss events and chronic stressors relating to school, family relationship, and friendship problems were significantly more prevalent in depressed
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children. Williamson, Birmaher, Dahl, and Ryan (2005) compared 6- to 12-year-old children with an anxiety disorder, a depressive disorder, and control children, and also noted that antecedent loss events were more prevalent among depressed youths than among anxious children who did not deviate in this respect from control children (see also Pine, Cohen, Johnson, & Brook, 2002). A prospective study by Phillips, Hammen, Brennan, Najman, and Bor (2005) also explored the specificity of early-childhood adversities as predictors of anxiety and depressive disorders in adolescents. Information on early childhood adversities had been obtained from the mothers around the birth of the child, at age 6 months, and at age 5 years, whereas psychiatric classifications were made when children were adolescents. Results showed that adolescents with anxiety disorders were more likely than depressed youths to have been exposed to early stressors such as maternal stress and parental relation problems, whereas very few early childhood experiences predicted depressive disorders. Even when controlling for current stress experiences, early childhood adversities still predicted anxiety disorders. On the basis of these findings, Phillips et al. (2005) suppose that “anxiety disorders may be more strongly related to early stress exposure, while depressive disorders may be related to more proximal stressors.” Altogether, these and other findings (e.g., Benjamin, Costello, & Warren, 1990; Goodyer, Wright, & Altham, 1990; Kashani, Vaidya, Soltys et al., 1990) seem to point out that negative life events may promote to the development of high levels of anxiety symptoms in youths. Some evidence has been obtained that certain types of life events (i.e., threat-related events and early childhood adversities) are more predictive of anxiety symptoms/disorders relative to other types of psychopathology. Further, it is important to keep in mind that although negative life events may give rise to acute feelings of fear and anxiety, more chronic adjustment (in casu anxiety) problems occur by the mediating and moderating effects of other variables (Grant & Compas, 1995; Grant, Compas, Thurm et al., 2006).
Peer Victimization Peer victimization during childhood is a common experience that negatively affects psychosocial adjustment of youths (Eisenberg & Aalsma, 2005; Olweus, 1993). While it was originally thought that relatively few children and adolescents are victimized, research findings indicate that approximately one in five youths are chronically exposed to ongoing physical (e.g., hitting, pushing), verbal (e.g., calling names, threatening), and/or relational (e.g., ignoring, spreading rumors) aggression (Crick & Bigbee, 1998; Crick & Grotpeter, 1996). Several studies have demonstrated that peer victimization is associated with higher levels of concurrent and prospective levels of internalizing symptoms. For example, Hanish and Guerra (2002) followed a large sample of primary school children for a longer time period and noted that peer victimization was not only related to internalizing symptoms on the first assessment point but also predictive of such symptoms at a two-year follow-up. A meta-analytic review by Hawker and Boulton (2000) investigated the effects of peer victimization on various types of maladjustment. Although their analysis demonstrated that victimization was most strongly linked to depression, loneliness, and low self-esteem, associations with various indexes of anxiety were also clearly positive and significant (see Figure 3.5).
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0,5 0,4 0,3 0,2 0,1 0 Depression Low selfesteem
Loneliness
Social anxiety
Generalized anxiety
Overall anxiety
Figure 3.5: Mean effect sizes (r) of the association between peer victimization and psychosocial maladjustment (derived from cross-sectional studies published between 1978 and 1997). All rs were significant at p < .001. Based on: Hawker & Boulton (2000). Recently, a number of studies have appeared studying the impact of childhood teasing experiences on psychosocial distress in adults (Roth, Coles, & Heimberg, 2002; Storch, Roth, Coles et al., 2004; Strawser, Storch, & Roberti, 2005). In these studies, undergraduate students completed the Teasing Questionnaire (TQ), which measures the degree to which people recall having been teased during childhood, and various scales measuring psychopathological symptoms, including various types of anxiety problems. Results consistently demonstrated that TQ scores were positively linked to social anxiety, fear of negative evaluation, trait anxiety, worry, and anxiety sensitivity, although the correlations with some anxiety phenomena (e.g., fear of negative evaluation) were stronger than with others (e.g., worry; Roth et al., 2002). An investigation by Muris and Little (2005) explored the links between domains of childhood teasing (as indexed by the TQ) and psychopathological symptoms in 14- to 18-year-old adolescents and also documented positive and significant correlations between self-reported recollections of teasing and various symptoms (including social anxiety). Most interestingly, some evidence was found indicating that specific domains of teasing were associated with specific types of symptoms. For example, symptoms of social anxiety were most strongly related to teasing experiences in the performance domain. In a similar vein, Storch and colleagues (Storch & Masia-Warner, 2004; Storch, MasiaWarner, Crisp, & Klein, 2005) noted that negative social experiences were significantly associated with social anxiety symptoms and even predictive of social phobia at a one-year follow-up. Thus, it can be concluded that peer victimization is a negative environmental factor that seems to be linked to the development of anxiety symptoms in youths. To explain the detrimental effects of teasing and bullying, several mechanisms have been implicated (Storch, Brassard, & Masia-Warner, 2003). First, overt aggression may directly elicit fear and anxiety in the child victim. Second, it can be assumed that the negative feedback from aggressive peers is internalized in the form of negative self-evaluations, which in turn enhance fearful responding and even avoidance in subsequent social situations. Third, it may well be that peer victimization interacts with adverse personality characteristics to produce high anxiety levels. For example, Grills and Ollendick (2002) demonstrated that
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self-esteem moderates the link between victimization and anxiety. More precisely, victimized boys with low self-esteem were found to report higher levels of anxiety symptoms than victimized boys with high self-esteem.
Trauma, Stress, and the Neurobiology of Fear and Anxiety It has been suggested that trauma and stress have important neurobiological consequences, which in turn may result in heightened susceptibility for developing pathological manifestations of fear and anxiety. For instance, based on the observation that at least in animal research, anxiety and stress experienced during pregnancy by the mother have disruptive effects on offspring’s adaptation to stress-inducing situations, various researchers have begun to examine the relationship between antenatal maternal anxiety and stress and later emotional problems in children (see for a review Van den Bergh, Mulder, Mennes, & Glover, 2005). A longitudinal study by O’Connor, Heron, Golding et al. (2003) tested this idea by measuring the anxiety levels in pregnant mothers at 32 weeks’ gestation and children’s emotional and behavioral problems when they were almost 7 years old. Results indicated that maternal antenatal anxiety scores were associated with the development of higher levels of emotional and behavioral problems in the offspring, even when controlling for various confounding variables such as obstetric difficulties, postnatal anxiety in the mother, and psychosocial disadvantages. This led these researchers to the conclusion that antenatal stress and anxiety have a programming effect on the unborn child, which lasts at least until middle childhood (see also O’Connor, Heron, Glover et al., 2002; O’Connor, Heron, Golding, Beveridge, & Glover, 2002; Van den Bergh & Marcoen, 2004). Although the precise mechanisms by which maternal stress and anxiety affect children’s subsequent development of psychopathological problems are far from clear, it has been suggested that high levels of stress hormone in the mother may have various detrimental effects on the fetal brain. More precisely, the hypothalamic-pituitary-adrenal (HPA) axis could be negatively affected (O’Connor, Ben-Shlomo, Heron et al., 2005), resulting in heightened sensitivity to stress. Alternatively, the optimal maturation of the prefrontal cortex might be hindered, which would lead to a decreased ability to regulate negative emotional states (see also Chapter 4; Van den Bergh et al., 2005). Postnatal experiences with stress and trauma are also thought to have neurobiological consequences for children and adolescents. Levine (2005) has argued that early stressful experiences, usually involving a serious disruption of the mother-infant relationship, seem to have long-term influences on children’s (neuro)endocrine responses to stress. More precisely, Bremner (2002) has noted that early life stressors and trauma may lead to long-term alterations of the HPA axis, which would be primarily exhibited by an increase in HPA axis reactivity following reexposure to stress. This notion was nicely supported in an experimental study by Bremner, Vythilingam, Vermetten et al. (2005), who examined the cortisol response to a stressful cognitive challenge in adult patients with PTSD related to childhood abuse. The results revealed that PTSD patients, as compared to healthy controls, displayed elevated cortisol levels in the time period in anticipation of the stressful challenge and during the cognitive challenge itself. No differences were found at baseline or during the recovery period after the challenge. Altogether, these findings suggest that the HPA axis of trauma-
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tized individuals is more easily activated when exposed to stress, which of course may play a role in the intensification of fear and anxiety responses. In a similar vein, early stress and trauma have also been associated with increases in sensitivity of the noradrenergic system in the brain (Bremner, Krystal, Southwick, & Charney, 1996). For example, Francis, Caldji, Champagne, Plotsky, and Meaney (1999) demonstrated that maternal separation results in a decrease of the alpha-2 autoreceptor in the locus coeruleus. Since the alpha-2 receptor is inhibitory, this would be expected to result in an increase of locus coeruleus activity, which is generally regarded as a common feature of pathological anxiety (Vermetten & Bremner, 2002). Thus, it can be concluded that excessive and/or repeated stress can lead to longlasting changes in brain circuits and systems involved in stress responsiveness (Heim & Nemeroff, 2001). Other authors have also pointed out that traumatic and stressful life events may result in neurobiological changes, which make youths more prone to develop pathological fear and anxiety. For example, Jacobs and Nadel (1985) have described a well-articulated theory about the contribution of negative life events on the aetiology of specific phobias. Briefly, Jacobs and Nadel assume that phobias are extreme manifestations of normal developmental fears (Muris & Merckelbach, 2001). According to their theory, the slowly maturing hippocampus is responsible for contextual control and inhibition of developmental fears. However, stressful conditions would disrupt hippocampal functioning and this would result in the re-emergence of context-free and stereotyped fear responses that are typical for early maturational stages. Jacobs and Nadel’s theory offers an interesting perspective on the role of negative life events in the radicalization of fears, certainly since there is recent evidence indicating that stress is indeed associated with deficits in the functioning of the hippocampus (Sapolsky, 1996). Another theoretical framework was described by Rosen and Schulkin (1998), who propose that pathological anxiety can best be conceptualized as exaggerated fear states in which hyperexcitability of brain circuits is expressed as hypervigilance and increased behavioral responsivity to fear-relevant stimuli. These authors describe an intriguing experiment in which fear-potentiated startle responses were assessed in rats that were conditioned to be fearful of a light (by means of light-footshock pairing). Prior to the assessment of the startle responses, half of the rats received an amygdala kindling stimulation, whereas the other half received a sham stimulation (as a control procedure). As can be observed in Figure 3.6, the rats showed exaggerated fear-potentiated startle responses as a result of the amygdala kindling procedure. Two additional remarks should be made with regard to this study. First, startle responses were not enhanced during baseline, which indicates that the kindling procedure did not yield a general hyperresponsiveness to the experimental stimuli. Second, a similar procedure involving kindling of the hippocampus did not yield enhanced startle responding to the conditioned stimuli (see Figure 3.6). On the basis of these and other findings, Rosen and Schulkin (1998) hypothesize that stressful life experiences may sensitize brain circuits, in particular the amygdala, which results in greater susceptibility to develop pathological fear and anxiety. Taken together, there seems to be clear support for the notion that trauma and stress have enduring neurobiological consequences, which may increase the risk for children and adolescents for developing phobias and anxiety disorders. However, more research is needed to explore the effects of timing, kind, intensity, and duration of the stressful and traumatic
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Normal and Abnormal Fear and Anxiety in Children and Adolescents 450 400
*
350 300 250
Baseline
200
Light
150 100 50 0 Sham amygdala
Kindled amygdala
Sham Kindled hippocampus hippocampus
Figure 3.6: Mean fear-potentiated startle responses in rats that were conditioned to be fearful of a light in four experimental conditions: sham amygdala, kindling amygdala, sham hippocampus, and kindled hippocampus. * p < .05 (difference in startle response as compared to sham-kindled rats). Based on: Rosen et al. (1996). events on neurobiological processes, so that it becomes more clear under what detrimental environmental conditions youths run the greatest risk for pathological fear and anxiety.
Conditioning Experiences Discrete learning experiences are also thought to be involved in the aetiology of anxiety disorders in children and adolescents. Most of the empirical research for this idea focused on childhood fears and phobias (see Muris & Merckelbach, 2001) and was originally concerned with the study of conditioning processes. In their famous experiment, but questionable from an ethical point of view, Watson and Rayner (1920) demonstrated that classical conditioning is indeed involved in the development of certain childhood anxiety disorders. They introduced a white rat to an 11-month-old boy, Little Albert, who initially showed no fear of the animal and appeared to want to play with it. However, whenever Albert approached the rat, the experimenters produced a loud noise (the UCS) by striking a steel bar behind his head, causing him great fright (the UCR). After five such experiences, Albert became very upset (the CR) by the sight of the white rat, even without the presentation of the loud noise. Obviously, the fear originally associated with the loud noise had come to be elicited by the previously neutral stimulus, the white rat (now the CS). Although some phobias can be explained in terms of “traditional” classical conditioning, it has also been noted that this learning model is not satisfactory as there are many phobic cases for which no clear-cut conditioning event can be identified to explain the onset of the disorder (see for a more extended discussion of the shortcomings of the traditional conditioning theory of phobias: Davey, 1992; Field, 2006a; Rachman, 1977). In a response to the unsatisfactory classical conditioning account, new views on fear conditioning have been formulated, which are somewhat more complicated as they emphasize the importance of cognitive, evaluative processes (Dadds, Davey, & Field, 2001). Briefly, these views imply
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Fear
– CS
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UCS
CR
+ UCS inflation
Figure 3.7: A contemporary model of fear conditioning: some influences of cognitive, evaluative processes. CS = Conditioned Stimulus, UCS = Unconditioned Stimulus, CR = Conditioned Response. Based on: Dadds, Davey, & Field (2001).
that fear conditioning is no longer conceptualized as reflex-like stimulus-response learning but rather should be viewed as a process during which individuals learn that a certain stimulus (the CS) is likely to predict the occurrence of another, aversive stimulus (UCS), which in turn under some conditions will elicit a conditioned response (CR). As can be seen in Figure 3.7, evaluative processes have an important impact on the CS-UCS-CR relationship as they may influence (1) the strength of the association between the CS and the UCS and (2) the representation of the UCS. An example of the first process is latent inhibition, which refers to the phenomenon that a large number of neutral experiences with the CS will hinder the subsequent formation of a strong link between the CS and the UCS (Lubow, 1973). Latent inhibition has been demonstrated in the dental practice where children are less likely to develop a dental phobia after a painful treatment, when they have previously experienced a larger number of neutral visits to the dentist (Ten Berge, Veerkamp, & Hoogstraten, 2002). The second process can be illustrated by means of a phenomenon named UCS inflation (see Davey, De Jong, & Tallis, 1993). During UCS inflation, the perceived aversiveness of the UCS may be enhanced by an experience with a similar UCS of greater intensity or by subsequent negative information about the UCS. In both cases, the aversiveness of the UCS will increase, resulting in a stronger conditioned fear response. There are no studies on UCS inflation in youth populations, but the phenomenon can be illustrated by means of the following clinical case: Michael is a 10-year-old who applied for behavior therapy because of a severe dog phobia. Currently, he is so afraid of dogs that he does not dare to go out on the street alone. Only because one of his parents accompanies him every day, he is still able to attend school. His phobia started about a year ago after he was attacked by a stray dog. Michael was not seriously injured, and initially he was not particularly frightened. However, this changed some two weeks after the incident, when Michael learned from his grandfather that many stray dogs suffer from rabies, a disease that can be transmitted to humans by bite, and which, if left untreated, can cause a painful death. From that moment on, Michael was extremely fearful of dogs and started to exhibit persistent avoidance behavior.
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This case exemplifies how verbally transmitted information rather than the incident per se, increased the aversiveness of the UCS (that was first experienced as rather mild) and how this information eventually led to phobic fear for the CS (i.e., dogs) supposedly by activating a representation of an inflated UCS. Altogether, it is clear that by incorporating cognitive, evaluative processes, contemporary conditioning theories provide a more flexible and optimal account for the acquisition of fears and phobias (Field, 2006a).
Three Pathways to Fear and Phobia A valuable framework for discussing the role of learning experiences in the acquisition of fears and phobias was provided by Rachman (1977, 1991), when he launched his wellknown three-pathways theory. In short, this theory implies that besides the direct route of (1) aversive classical conditioning, there are two other indirect ways along which fears and phobias can be learned—namely, (2) modeling (i.e., vicarious learning) and (3) negative information transmission (i.e., exposure to negative information about the feared object or situation). Rachman (1977) further speculated that the severity of the fears is a function of the acquisition mode. More precisely, fears acquired through vicarious learning or exposure to negative information would be less intense, whereas clinical phobias would be more likely to have a direct conditioning aetiology. Several studies have made an attempt to test Rachman’s three-pathways theory in adult phobias (see for a review, Menzies & Clarke, 1994). In most of these studies, adult patients were simply asked to what extent the three pathways contributed to the onset of their phobic complaints. Overall, these studies have yielded some (although by no means univocal) support for Rachman’s idea that direct conditioning is the dominant pathway to clinical phobias, while indirect pathways (i.e., modeling and negative information transmission) more frequently figure in the aetiology of mild fears (e.g., Öst, 1991). One problematic feature of these findings was that they are based on patients who were asked to assign their pertinent learning experiences to the three pathways, some 10 to 20 years after the onset of their specific phobias (Menzies, Kirkby, & Harris, 1998). Thus, support for the threepathways theory would be stronger if it came from children and adolescents who were closer to the onset of their fears and phobias. A series of studies examined the relevance of this theory by asking fearful or phobic children to what extent the three pathways contributed to the onset of their complaints (see for a review, King, Gullone, & Ollendick, 1998). A number of these studies interviewed parents about the aetiological pathways of their child’s fears and phobias, whereas others explored the aetiological routes by asking children and adolescents directly about their learning experiences. An example of the first category of studies is an investigation by Graham and Gaffan (1997), who examined a small group of water-fearful children aged 5 to 8 years by asking their mothers to complete an “origins of fear” questionnaire. Most mothers (78%) said that their child’s fear had always been present, but they also reported exposure to negative information (78%), and to a lesser extent conditioning (22%) and modeling (11%). Comparable results were obtained by Menzies and Clarke (1993) in their study on childhood water phobia. Again, the majority of parents (56%) believed that the phobia of the child was present at their first contact with water. Even so, modeling (26%),
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exposure to negative information (14%), and conditioning (2%) were reported as influential factors in the aetiology of their child’s phobia. Apparently, Rachman’s pathways are not so much responsible for this type of fear but rather play a role in their persistence. Somewhat different results have been documented for other types of fear and phobia. For instance, in their large-scale study on the origins of dental fear in 5- to 11-year-old children, Milgrom, Mancl, King, and Weinstein (1995) did not specify exact frequencies of conditioning, modeling, and negative information experiences for the subsample of fearful children. However, information about potential learning experiences reported by the mothers was subjected to a regression analysis, and this led the researchers to conclude that “both direct conditioning and parental modeling factors were significant independent predictors of [children’s] fear level even when controlling for gender, age, and other sociodemographic and attitudinal factors” (p.318). Other studies have also demonstrated that conditioning and, to a lesser extent, modeling are involved in the aetiology of dental fear (Ten Berge et al., 2002; Townend, Dimigen, & Fung, 2000). Another study was performed by King, Clowes-Hollins, and Ollendick (1997), who evaluated Rachman’s theory of fear acquisition in a sample of 30 children with dog phobia. Parents were asked to indicate the most influential factor in the onset of their child’s dog phobia. Nearly all parents (87%) were able to attribute their child’s phobia to one of the fear pathways. Modeling was the most frequently endorsed pathway (53%), followed by direct conditioning (27%), whereas exposure to negative information was relatively rare (7%). The studies described so far were based on parental attributions, but as King et al. (1997) rightly pointed out, reliance on parental perceptions of fear acquisition “may be invalid in terms of what actually occurred” (p.77). In what seems to be the largest study on the origins of childhood fears, Ollendick and King (1991) evaluated Rachman’s theory of fear acquisition in relation to the top 10 most intense fears as listed by the FSSC-R. More precisely, children who reported “a lot” of fear to FSSC-R items such as “not being able to breathe,” “being hit by a car or truck,” and so forth, were given a brief questionnaire that asked them whether they had experienced conditioning, modeling, and/or informational events in relation to these stimuli or situations. The authors found that a majority of the children (89%) attributed their fear to negative information. Conditioning and modeling were less often mentioned by the children (36% and 56%, respectively). In an attempt to replicate these findings, Muris, Merckelbach, and Collaris (1997) asked children to specify their top intense fear and then asked them whether conditioning, modeling, and negative information played a role in that fear. Like Ollendick and King (1991), these authors found that exposure to negative information was the most common pathway to fear mentioned by the children (88%), followed by conditioning (61%) and modeling (50%). In the Muris et al. study, children were also explicitly asked to what extent these learning experiences had intensified their fear. Thus, whereas Ollendick and King (1991) employed a rather broad definition of the three types of learning experiences (“Did it play a role?”), children in the Muris et al. study answered the additional question about whether these experiences served as antecedents of a radicalization of their fear. With this more strict definition, 46% of the children endorsed a conditioning pathway, while modeling and negative information were less often mentioned (4% and 35%, respectively). An investigation by Doogan and Thomas (1992), who examined the three pathways in dog-fearful children, demonstrated that the vast majority reported aversive conditioning
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encounters with dogs (91%), whereas the modeling and negative information pathways were somewhat less frequent (73% and 82%, respectively). In a study by Merckelbach, Muris, and Schouten (1996), children with a severe spider phobia were interviewed about conditioning events, modeling experiences, and negative information transmission. To evaluate the reliability of the information provided by the children, parents were interviewed independently about the origins of their child’s phobia. Conditioning events were reported by a substantial proportion of spider-phobic children (41%) and a majority of these events were confirmed by their parents. Interestingly, nearly half of the children (46%) said that they had always been afraid of spiders, but even in this subsample, reports of conditioning and modeling were found. These results were largely replicated by Merckelbach and Muris (1997), who also found a relatively high frequency of conditioning reports that were substantiated by parents. Three important conclusions can be drawn from the studies reviewed in this section. First of all, Rachman’s three-pathway model is a valuable framework for conceptualizing the role of learning experiences in the development of childhood fears and phobias. Interestingly, researchers have also begun to examine learning experiences such as conditioning, modeling, and negative information in the context of other childhood anxiety phenomena. For example, Muris, Merckelbach, Gadet, and Moulaert (2000) not only evaluated the three pathways in relation to children’s main fear, but also examined the role of these learning experiences in worry and scary dreams. As shown in Figure 3.8, conditioning, modeling, and negative information were involved in fear, worry, and scary dreams, although the contribution of the pathways to each anxiety phenomenon was quite different. More precisely, conditioning was most dominant in worry, modeling was most frequent in fear, whereas negative information was most often endorsed in the context of scary dreams. In another investigation, Muris, Merckelbach, and Meesters (2001) examined the relationships between learning experiences with respect to somatic symptoms and levels of anxiety sensitivity in youths. Nonclinical adolescents were interviewed about their learning experiences
70 60 50 40
Conditioning
30
Negative information
Modeling
20 10 0 Fears
Worries
Scary dreams
Figure 3.8: Percentages of children reporting conditioning, modeling, and negative information experiences in relation to their main fears, worries, and scary dreams. Based on: Muris et al. (2000).
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with anxiety-related and nonanxiety-related somatic symptoms and then completed the Childhood Anxiety Sensitivity Index (Silverman, Fleisig, Rabian, & Peterson, 1991), a self-report scale for measuring anxiety sensitivity. Results showed that informational learning to some extent contributed to adolescents’ anxiety sensitivity levels. That is, parents’ transmission of the idea that somatic symptoms might be dangerous was significantly associated with levels of anxiety sensitivity. Other learning experiences such as parental reinforcement or observational learning were not found to be related to anxiety sensitivity. It was concluded that learning experiences play a small but significant role in the development of high levels of anxiety sensitivity (see also Stewart, Taylor, Jang et al., 2001; Watt & Stewart, 2000, Watt, Stewart, & Cox, 1998). Second, the results of the studies also suggest that conditioning and modeling are more important factors in the aetiology of severe childhood fears than negative information transmission. Third and finally, given the high percentages of fearful children and adolescents who claim to have always been afraid and the observation in some studies (e.g., Doogan & Thomas, 1992; Graham & Gaffan, 1997), a considerable proportion of the nonfearful youths also reported negative learning experiences, it is highly unlikely that Rachman’s pathways represent simple aetiological antecedents of specific childhood fears, phobias, or other anxiety disorders. Rather, it is more likely that in some children such experiences have a stronger impact and thus contribute to the transition of normal fear and anxiety into persistent phobias and anxiety disorders. More precisely, as already noted in Chapter 2, youths with traits related to neuroticism and behavioral inhibition acquire fear and anxiety more easily as compared with children and adolescents without such traits (see also Chapter 6).
Modeling and the Transmission of Negative Information Admittedly, the preceding studies on the role of learning experiences in the onset of anxiety phenomena are all retrospective in nature. That is, children and adolescents who displayed these phenomena (or their parents) were interviewed about the presence of learning experiences during their history. Fortunately, there is also recent experimental work, which underlines the role of learning experiences in the origins of childhood fear and anxiety. A study that should be mentioned in this regard is that by Gerull and Rapee (2002), who investigated the influence of modeling on the acquisition of fear and avoidance toward novel, fear-relevant stimuli in a sample of 15- to 20-month-old toddlers. The toddlers were shown a rubber snake and spider, which were alternately paired with either negative or positive facial expressions by their mothers. Both stimuli were presented after a brief delay, and fear and avoidance reactions were assessed. Results clearly indicated that children showed more fear and avoidance following negative reactions from their mothers (see Figure 3.9). A comparable investigation by De Rosnay, Cooper, Tsigaras, and Murray (2006) examined the responses of 1-year-old infants to an unfamiliar person after they had observed their mother interacting either normally or socially anxious with the stranger. The results showed that infants who had seen their mother interacting socially anxious with the stranger were significantly more avoidant with this unfamiliar person as compared to infants who had observed their mothers interacting normally with the stranger. Altogether, both studies seem to provide support for the modeling pathway, and in particular the role of social referencing
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1
Mother's positive expression Mother's negative expression
0
–1 Directly after modeling
After 1 minute After 10 minutes
Figure 3.9: Mean behavioral responses of toddlers to unfamiliar toy animals (i.e., rubber spider/snake) that were paired with a positive or negative facial expression of their mother. Positive values indicate approach behavior toward the toy animal, negative values indicate avoidance behavior toward the toy animal. Based on: Gerull & Rapee (2002).
(Feinman, Roberts, Hsieh, Sawyer, & Swanson, 1992), whereby young children use their mother’s responses to inform their own emotional responses and behavior. Field, Argyrus, and Knowles (2001) carried out an experimental study on the role of negative information in the exacerbation of childhood fear. Seven- to 9-year-old children received either negative or positive information about an unknown monster doll. Results showed that negative information significantly increased children’s fear ratings, whereas after positive information fear ratings slightly decreased. These results were replicated by Muris, Bodden, Merckelbach, Ollendick, and King (2003), who provided children with either negative or positive information about an unknown, doglike animal, called “the beast.” This study demonstrated that information-induced fear effects endured over a oneweek follow-up period and generalized to other stimuli—that is, children who became more fearful of the beast after receiving negative information also became more apprehensive of other dogs and predators (see Figure 3.10). Further research by Field and Lawson (2003) demonstrated that these effects of negative information do not simply reflect demand characteristics of children conforming to experimental instructions. In this study, 6- to 9-year-old children either received negative, positive, or no information about three unknown animals (Australian marsupials). The effects of these types of information were studied by three measures: (1) a questionnaire measuring explicit fear beliefs for each of the animals; (2) an implicit association task (IAT), which assessed implicit fear attitudes toward the animals (i.e., the extent to which each of the animals was automatically linked to the basic categories of “pleasant” and “unpleasant”); and (3) a behavioral approach test during which children were asked to touch each of the animals in a covered box that actually contained a furry, cuddly toy. The results were in keeping with those of previous studies, as they clearly demonstrated fear-enhancing effects of negative information on the explicit measure of fear beliefs. Most important, however, similar results were obtained on the implicit fear measure and the behavioral approach test. That is, children showed a greater tendency to automatically link an animal to the “unpleasant” category during the IAT and were more reluctant
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Fear of the beast 36 30 Negative information
24
Positive information
18 12 Pre
Post
Follow-up
Fear of dogs and predators 22 21 20 19 18 17 Pre
Post
Follow-up
Figure 3.10: Mean “fear of the beast” and “fear of dogs and predators” scores in children who have been exposed to either negative or positive information about an unknown animal (the beast) at pre-, post-, and follow-up assessment. Based on: Muris et al. (2003). to touch the animal after hearing negative information about that animal (see Figure 3.11). Another study by Field (2006b) demonstrated that negative information was also sufficient to install an attention bias for an unknown animal. More precisely, children aged 7 to 9 years were given negative information, positive information, or no information about an unknown animal and were then subjected to a dot probe task (see Chapter 5). It was found that children in the negative information condition were faster to react to a probe if it was preceded by a picture of the pertinent animal rather than a picture of a control animal (for which they had received no information). Apparently, the negative information caused the children to display hyperattention toward the presumably threatening animal. Thus, experimental studies indicate that negative information indeed promotes fear in children and adolescents. With respect to this conclusion, a number of remarks are in order. First of all, the negative information pathway seems to play a role in the development of PTSD and other anxiety disorders (such as agoraphobia and separation anxiety disorder) after children have been exposed by television to invasive traumatic events such as the terrorist attack on the World Trade Center (Duggal, Berezkin, & John, 2002) or the explosion of the space shuttle Challenger (Terr, Bloch, Michel et al., 1999). Although it is clear that direct exposure to such events is clearly related to the onset of anxiety problems
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Latency to approach (Z-score)
0,4
0,2
0
–0,2
–0,4 Negative information
Positive information
No information
Figure 3.11: Mean latency time (Z-scores) to approach a box in which an animal was hidden about which children had received either negative, positive, or no information. Based on: Field & Lawson (2003). (Hoven, Duarte, Lucas et al., 2005), there is evidence demonstrating that exposure to television coverage of the attack also yielded higher levels of anxiety symptoms (Hoven, Duarte, Wu et al., 2004; Lengua, Long, Smith, & Meltzoff, 2005). Second, negative information seems to have the most impact on youths’ fear responses when children or adolescents have no prior information about the stimulus or situation. For example, two studies that examined the effects on youths’ fear beliefs about social situations have indicated that negative information has less impact on this type of fear (Lawson, Banjeree, & Field, 2007; Field, Hamilton, Knowles, & Plews, 2003). As indicated by substantial correlations between social anxiety and fear beliefs about social situations prior to the experimental manipulation (Lawson et al., 2007), it is clear that children as young as 7 years have already formed relatively stable personal expectations about what they have to fear (or not to fear) in these events. Third, in most cases, it is highly unlikely that negative information about a stimulus or situation will install pathological fear or anxiety. It seems most plausible to assume that negative information promotes fear in conjunction with other learning processes. For example, as described earlier, negative information may enhance conditioning processes either by strengthening the connection between the CS and the UCS or by inflating the aversiveness of the UCS (Field, 2006a). Interestingly, some evidence for this notion was provided by Lawson (2006), who demonstrated that negative information facilitated subsequent learning that the CS will be followed by a negative outcome (UCS). Altogether, besides the frequently criticized, retrospective research on Rachman’s threepathways model, there is now convincing support from experimental studies for at least the modeling and the negative information routes to fear and phobia in children and adolescents. In the near future, further investigations should try to explore to what extent indirect learning experiences (modeling and negative information transmission) influence subsequent direct learning (conditioning; Field, 2000a). Such research could really make us understand when and under what environmental conditions children and adolescents acquire extreme fears and phobias.
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Preparedness and Nonassociative Fear Acquisition When discussing the role of learning experiences in the acquisition of childhood fears and phobias, some attention should be devoted to the fact that some fears (e.g., fear of snakes) are more prevalent than others (e.g., fear of cars; Merckelbach, De Jong, Muris, & Van den Hout, 1996). Likewise, factor analytic studies of nonclinical children and adolescents’ responses to fear questionnaires have indicated that the most prevalent fears can be grouped together in a relatively small number of distinct categories, such as animals, blood-illnessinjury, and situational-environmental (see Muris, Schmidt, & Merckelbach, 1999). In other words, childhood fears and phobias typically pertain to a relatively narrow and restricted class of stimuli and situations, such as snakes, spiders, predators, enclosed spaces, thunderstorms, and heights. This selectivity has been explained in Seligman’s (1971) preparedness theory. According to this theory, the stimuli and situations feared by phobics reflect the dangers that prehistoric ancestors faced in their environment. As a result of natural selection, fear of these evolutionary dangers became genetically coded in the form of a primitive learning mechanism. Seligman assumes that this mechanism very easily associates fear with formerly survival-threatening stimuli and situations. The preparedness account is nicely illustrated by Marks (1977; p.192), who described the aetiology of a snake phobia of an adult woman: A 4-year-old girl was playing in the park. Thinking that she saw a snake, she ran to her parents’ car and jumped inside, slamming the door behind her. Unfortunately the girl’s hand was caught by the closing car door, the results of which were severe pain and several visits to the doctor. Before this she may have been afraid of snakes, but not phobic. After this experience a phobia developed, not of cars or car doors, but of snakes. The snake phobia persisted into adulthood. Interestingly, Mineka and Öhman (2002) assume that evolutionary pressures have resulted in the formation of a brain module, which plays a central role in fear elicitation and fear acquisition. In short, this brain system is located in the amygdala and has three primary characteristics. First, the module is preferentially activated by stimuli that once posed a threat to the survival of human beings. Second, the module is automatically activated by fear-relevant stimuli or situations, which of course should be regarded as a consequence of the survival premium for rapid activation and subsequent behavioral responding. Third, the fear module is activated before conscious analysis of the stimulus or situation occurs and is also relatively insusceptible for conscious cognitive control. Note that this account shares various features with the biological models of fear, anxiety, and their disorders that were described in Chapter 2. There is some empirical support for the preparedness account of fear and phobias. For example, Öhman and colleagues (see for a review, Öhman & Mineka, 2001) carried out a series of experimental studies in which they conditioned autonomic reactions of normal subjects to evolutionary relevant (e.g., slides of spiders) or evolutionary neutral (e.g., slides of flowers) stimuli by pairing these stimuli with an aversive UCS (i.e., electric shock). These studies demonstrated that once acquired, conditioned responses to evolutionary relevant stimuli are slower to extinguish than conditioned responses to evolutionary neutral cues,
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which is of course in support of the central feature of the preparedness theory—namely, that subjects easily learn associations between evolutionary relevant stimuli and aversive outcomes. Prepared learning seems also relevant to learning fear by modeling. Illustrative are the experiments carried out by Mineka and coworkers (Cook & Mineka, 1989; Mineka & Cook, 1993; Mineka, Davidson, Cook, & Keir, 1984), who exposed laboratory-raised monkeys with no prior experience with snakes to technically manipulated videos in which a model monkey reacted fearfully in the presence of a snake or a flower. With this paradigm, the researchers showed that monkeys acquire an extremely persistent fear of snakes after they have watched a model reacting fearfully to snakes. In contrast, monkeys failed to acquire a fear of flowers after they had seen a model exhibiting an identical fear reaction to flowers. In spite of this supportive evidence, the preparedness hypothesis is still in dispute (e.g., McNally, 1987; Merckelbach & De Jong, 1997). For example, it has been argued that it is difficult to determine the evolutionary relevance of various stimuli and Darwinian arguments run the risk of being “adaptive stories” that heavily rely on plausibility (McNally, 1995). Other critics have pointed out that the results of Öhman, Mineka, and associates are open to alternative explanations. For example, specific stimulus characteristics (e.g., unpredictability; Merckelbach, Van den Hout, Jansen, & Van der Molen, 1988) or culturally determined expectancies about certain stimuli (e.g., the idea that snakes or spiders represent evil; Davey, 1995) may also explain why these stimuli are easily associated with aversive outcomes. While the preparedness theory points at the role of evolution but still accepts the idea that learning processes such as conditioning and modeling are crucial for the acquisition of fears and phobias, the so-called nonassociative account (Menzies & Clarke, 1995) proposes that discrete learning experiences only play a marginal role in the aetiology of these anxiety phenomena. The basic assumption of this account is that common developmental fears reflect innate and spontaneous responses to evolutionary prepotent cues. Specific phobias would echo these spontaneous fear reactions. But, if this is the case, (one might ask why not all children suffer from specific phobias.) Menzies and Clarke (1995) assume that “poor habituators” may remain fearful of innate fear cues. In these individuals, developmental fears would become chronic and take the form of a specific phobia. Alternatively, nonspecific stressors (e.g., life events) could produce dishabituation and the reinstatement of developmental fears. In either case, specific phobias would originate directly from developmental fears, which in turn would derive from innate responses to evolutionary dangers (see also Poulton & Menzies, 2002). A weak point of the nonassociative account is that this theory fails to explain why some individuals habituate so poorly to prepotent fear stimuli (see Mineka & Öhman, 2002; Muris, Merckelbach, De Jong, & Ollendick, 2002). Furthermore, from a scientific point of view, it is not satisfactory to think of phenomena as “spontaneous” or “nonassociative.” After all, science is about finding causal associations, so one would like to know where “spontaneous” phobias originate from (Davey, 2002; Muris & Merckelbach, 2001). The preparedness theory and the nonassociative account both provide an evolutionary explanation for why some fears and phobias are more prevalent than others. The main problem with both theoretical frameworks is that the evolutionary premise cannot be empirically tested. In the meantime, contemporary learning theory still provides sufficient
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avenues to be tested in future research, before accepting the idea that fears and phobias simply reflect inborn tendencies as a result of natural selection.
Family Influences Various studies have investigated the role of family issues in the development of childhood anxiety problems (Bögels & Brechman-Toussaint, 2006). Basically, these studies have followed one of two research lines. The first line is inspired by attachment theory and focuses on the formation of early parent-child interactions. The second line is based on a somewhat broader perspective and examines the connection between parental rearing behaviors and childhood anxiety phenomena.
Insecure Attachment Attachment refers to the affectional bonding between children and their parents and is regarded as an important determinant of development (e.g., Bowlby, 1969). Early in life, through interactions with primary caregivers, children develop expectations about their caregivers’ availability, which serve as the basis for internal working models of the self and the other. When experiences lead to the expectation that caregivers will be loving and responsive, children develop a model of the self as loved and valued, and a model of the other as warm and loving (Bretherton, 1985). This confidence allows children to develop secure strategies for seeking out their caregivers when distressed or in need, with the expectation that their needs will be met. In contrast, when children have experiences that lead them to expect caregivers to be rejecting or unreliable, they develop a model of the self as unloved and rejected, and a model of the other as unloving and rejecting. These children do not expect that caregivers will be available when needed, and they develop alternative, insecure strategies for coping with their distress. It is assumed that these early developed expectations about parents serve as a mold for the formation of future relationships with other individuals (e.g., Irons & Gilbert, 2005; see also Bretherton & Munholland, 1999). Since the work of Ainsworth, Blehar, Waters, and Wall (1978), there is general consensus on the notion that there are three basic patterns of attachment. The first pattern of “secure attachment” concerns children who use their caregivers as a secure base to regulate anxiety and distress when confronted with stressful stimuli or situations. The second pattern of “avoidant attachment” refers to children who do not use the caregiver as a source of comfort to regulate negative affect: They tend to avoid or ignore the caregiver. The third pattern of “ambivalent attachment” involves children who make inconsistent and ambivalent attempts to use the caregiver when in distress: Although these children sometimes cling excessively to the caregiver, they also display angry, rejecting behaviors. More recently, a fourth pattern of disorganized attachment has been described (Main & Solomon, 1990). Briefly, this pattern refers to children who certainly want intimate relationships but have difficulties with trusting others and do not have a consistent and coherent strategy of using caregivers when in distress (see also Green & Goldwyn, 2002).
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Attachment theory proposes that children’s level of anxiety is affected by the way in which they are attached to their caregivers (Bowlby, 1973). While it is generally assumed that, at least in the preschool years, insecure attachment is intimately linked to separation anxiety (e.g., Warren, Emde, & Sroufe, 2000; see for a review, Thompson, 2001), research has demonstrated that early attachment problems are predictive of a broad range of anxiety disorders in later childhood. An exemplary study in this regard is that by Warren, Huston, Egeland, and Sroufe (1997), who examined whether insecurely attached infants develop more anxiety disorders during childhood and adolescence than infants who were securely attached. At 12 months of age, infants were subjected to Ainsworth et al.’s (1978) strange situation procedure and classified as either securely, avoidantly, or ambivalently attached. When children reached 17.5 years of age, current and past anxiety disorders were assessed by means of a structured interview schedule. Results showed that 15% of the youths had developed at least one past or present anxiety disorder, including social phobia, separation anxiety disorder, generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder. Most importantly, it was found that insecurely attached children, and in particular those who were ambivalently attached, more frequently displayed anxiety disorders than children who were securely attached (see Figure 3.12). As it is generally assumed that early formed attachment relationships remain relatively stable over time (e.g., Hamilton, 2000; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000; see for a review, Fraley, 2002), various researchers have developed instruments for assessing attachment styles in older children and adolescents. One example is the Inventory of Parent and Peer Attachment (IPPA; Armsden & Greenberg, 1987), which measures the quality of children and adolescents’ attachment to peers and parents in three domains: trust, communication, and alienation. Several studies have examined the relationships between the quality of attachment to parents and peers as indexed by the IPPA and anxiety symptoms in children and adolescents (Armsden, McCauley, Greenberg, Burke, & Mitchell, 1990; Buist, Dekovic, Meeus, & Van Aken, 2004; Hale, Engels, & Meeus, 2006; Nada-Raja, McGee, & Stanton, 30
*
25 20 15 10 5 0
Avoidant attachment
Secure attachment
Ambivalent attachment
Figure 3.12: Percentage of youths with various types of early attachment classifications who developed an anxiety disorder by the age of 17. * p < .05 (as compared to the other groups). Based on: Warren et al. (1997).
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1992; Vivona, 2000). In general, this research has demonstrated that low levels of trust and communication but high levels of alienation are associated with higher levels of anxiety symptoms in youths. Other studies have employed age-downward versions of Hazan and Shaver’s (1987) single-item measure of attachment style. The original version of this instrument (the Attachment Questionnaire for Children, or AQ-C; see Appendix) consists of descriptions concerning a child’s feelings about and perceptions of his/her relationship with current significant others. There are three descriptions, each referring to one of three basic attachment patterns just described. Children and adolescents are simply asked to choose one of the descriptions and thus classify themselves as being either securely, avoidantly, or ambivalently attached. Research employing this instrument has consistently demonstrated that children and adolescents who identify themselves as insecurely (i.e., ambivalently and avoidantly) attached display higher levels of anxiety disorders symptoms as compared to youths who define themselves as securely attached (Muris, Mayer, & Meesters, 2000; Muris, Meesters, Merckelbach, & Hülsenbeck, 2000; Muris, Meesters, Van Melick, & Zwambag, 2001). Subsequent investigations that employed dimensional modifications of Hazan and Shaver’s (1987) instrument, which also included items referring to the disorganized attachment pattern (Bartholomew & Horowitz, 1991), have generally showed that anxiety, internalizing symptoms, and anxiety vulnerability are negatively correlated with secure attachment but positively linked to insecure and in particular ambivalent and disorganized attachment (Doyle & Markiewicz, 2005; Nakash-Eisikovits, Dutra, & Westen, 2002; Weems, Berman, Silverman, & Rodriguez, 2002). Altogether, insecure attachment certainly represents a vulnerability factor for the development of anxiety problems in youths. In particular, the ambivalent attachment pattern is associated with higher levels of anxiety and anxiety disorders (e.g., Warren et al., 1997). Further, there is some evidence that a similar conclusion can be drawn for disorganized attachment (Nakash-Eisikovits et al., 2002). This is not totally surprising as this attachment pattern is frequently observed in children and adolescents who have been the victim of physical and sexual abuse, serious maltreatment, and neglect (Van Ijzendoorn, Schuengel, & Bakermans-Kranenburg, 1999), which as mentioned earlier are experiences that also increase the risk for developing PTSD and other anxiety problems. While it is clear that some attachment patterns are predictive of anxiety problems, it is also good to keep in mind that insecure attachment is not a specific vulnerability factor to anxiety but also seems to be involved in other types of psychopathology such as depression (Graham & Easterbrooks, 2000) and disruptive behavior disorders (Greenberg, Speltz, DeKlyen, & Endriga, 1991; Laible, Carlo, & Raffaelli, 2000; see for a review Greenberg, 1999). As a final note, attachment relationships are determined by a variety of factors. Besides the opportunity to establish a close relationship (e.g., Feldman, Weller, Leckman, Kuint, & Eidelman, 1999) and the quality of caregiving (i.e., high levels of parental sensitivity and responsiveness; De Wolff & Van Ijzendoorn, 1997), parents’ own internal working models might play a particularly important role in the development of childhood anxiety. Research has not only shown that insecure attachment patterns are transmitted from one generation (father/mother) to the next generation (child; Van Ijzendoorn, 1992; Peleg, Halaby, & Whaby, 2006), but also demonstrated that insecurely (in particular ambivalently) attached parents frequently model anxiety to their children (Costa & Weems, 2005; Crowell & Feldman, 1991; Scher & Mayseless, 2000).
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Parental Rearing Behaviors While attachment researchers emphasize that disturbances in early parent-child interactions promote the development of high anxiety levels in children and adolescents, others have stressed the importance of particular parental rearing behaviors (see for a review, Wood, McLeod, Sigman, Hwang, & Chu, 2003). In the context of childhood anxiety problems, three types of parental rearing behaviors can be discerned. The first type of anxious rearing is closely linked to the fact that parents of anxious children are often anxious themselves (e.g., Last, Hersen, Kazdin, Orvaschel, & Perrin, 1991), so they employ a rearing style that is characterized by modeling of fear and anxiety, warning children against all possible dangers, and encouraging their offspring to engage in avoidance behavior. The other parental rearing behaviors that are thought to be involved in the pathogenesis of anxiety problems in children and adolescents refer to two basic dimensions of upbringing that have been identified in the literature (Rapee, 1997). One dimension has to do with parental control and actually opposes an autonomy-promoting and an overprotective rearing style to each other, while the other is concerned with parental care and has two opposite poles: an accepting and warm rearing style on one side and a rejecting and cold rearing attitude on the other side. Anxious Rearing. In a study by Barrett, Rapee, Dadds, and Ryan (1996), anxious, oppositional-defiant, and nonclinical children (aged 7 to 14 years) and their parents were presented with ambiguous scenarios and asked to provide plans of action for these hypothetical situations. Solutions were categorized in two broad classes of avoidant and aggressive solutions. As predicted, children with anxiety disorders and their parents most frequently chose avoidant solutions, whereas children with oppositional-defiant disorder and their parents clearly preferred aggressive solutions. Interestingly, after a family discussion during which children and parents first deliberated about the possible solutions for the scenarios, it was observed that anxious children’s avoidant action plans significantly increased (see Figure 3.13), which was defined by the researchers as the family enhancement of avoidant responses or FEAR effect. A subsequent observational investigation by this research group in which the specific sequences of communications exchanged between parents and children were examined
80 70 60 50 40 30 20 10 0
Anxious children Oppositional-defiant children Nonclinical controls
Prediscussion Prediscussion Postdiscussion parents children children
Figure 3.13: Mean percentages of children and parents choosing avoidant solutions before and after the family discussions. Based on: Barrett et al. (1996).
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(Dadds, Barrett, Rapee, & Ryan, 1996), revealed that parents of anxious children indeed show the tendency to encourage the fearful avoidant behavior of their offspring. Furthermore, a more recent study has demonstrated that maternal distress further promoted the FEAR effect in anxious children (Shortt, Barrett, Dadds, & Fox, 2001). Another noteworthy study by Muris, Steerneman, Merckelbach, and Meesters (1996) investigated the relation between fearfulness of children and fearfulness of parents and the role of parents’ expressing their own fears in the presence of the child. Forty clinically referred children aged 9 to 12 years and their parents completed a fear survey. In addition, parents rated to what extent they generally expressed fears to their children. Results showed that fearfulness of children was significantly related to fearfulness of the mothers. Most important, the data showed that mothers’ expression of fears played a role in this relationship. As can be seen in Figure 3.14, a linear association between children’s fear scores and mothers’ rating of expressing fears to their children was found. That is to say, children of mothers who never expressed their fears had the lowest fear scores, children of mothers who often expressed their fears had the highest fear scores, whereas children of mothers who sometimes expressed their fears scored in between. Another study by Hock, Hart, Kang, and Lutz (2004) also found indications that mothers’ expression of fear promotes fearful feelings in children. Forty-eight mothers and their 11-year-old children who participated in a longitudinal research project were interviewed after the terrorist attacks of September 11, 2001. Results demonstrated that children’s fearful reactions to the terrorist attacks were not only predicted by preexisting child anxiety but also by mothers’ worrisome reactions about the child in the aftermath of this negative event. Further support for the idea that anxious rearing contributes to the development of anxiety in young people comes from studies that have used questionnaires to measure this type of rearing behavior. For example, the modified version of the EMBU [Egna Minnen Betraffende Uppfostran (My memories of upbringing); Castro, Toro, Van der Ende, & Arrindell, 1993; Muris, Meesters, & Van Brakel, 2003; see Appendix] includes items that specifically tap anxious attitudes and rearing behaviors of parents (e.g., “Your parents are afraid that something might happen to you” and “Your parents warn you of all possible dangers”). So far, a number of studies have employed the modified EMBU-C to assess relationships between
150 140 130 120 110 100 90 80 Never
Sometimes Expression of fear
Often
Figure 3.14: Mean fear scores of children of mothers who never, sometimes, or often expressed their fears. Based on: Muris et al. (1996).
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children and adolescents’ perceptions of parental rearing, and in particular anxious rearing, and symptoms of anxiety (Grüner, Muris, & Merckelbach, 1999; Muris, 2002c; Muris et al., 2000; Muris et al., 2003; Muris & Merckelbach, 1998). These studies have indeed shown that anxious rearing is positively related to anxiety symptomatology in youths. Parental Control. From an empirical point of view, parental control certainly is the parenting variable that has been most consistently linked to childhood anxiety (Bögels & Brechman-Toussaint, 2006; Rapee, 1997; Wood et al., 2003). In short, some parents are excessively intrusive and controlling, thereby strongly regulating their child’s daily activities and routines and hindering the development of independent problemsolving skills. Theoretically, such a controlling rearing style is hypothesized to limit the development of the child’s autonomy and results in perceptions of the environment as uncontrollable and a limited sense of personal competence or mastery (Siqueland, Kendall, & Steinberg, 1996). In turn, these negative self-perceptions are thought to contribute to the development of anxiety in children and adolescents (Chorpita, Brown, & Barlow, 1998). Various observational studies have yielded support for the idea that parental control plays a role in childhood anxiety. For example, in a study by Hudson and Rapee (2001), children with anxiety disorders, oppositional-defiant disorder, or no psychiatric disorder were asked to complete two difficult cognitive tasks (i.e., a tangram puzzle and a scrabble task). The mothers were present while children solved the tasks and explicitly told that they were allowed to help their children if needed. Parent-child interactions were recorded and the mothers’ behavior was coded in two broad categories: involvement that can be regarded as an equivalent of control and negativity that reflected mothers’ negative affect, critical attitude, and tension during the task. The results of this study are displayed in Figure 3.15. As can be seen, mothers of anxious children and children with oppositional-defiant disorder both displayed higher levels of involvement as compared to the nonclinical control group. 7 6
*
*
5 4
*
Involvement Negativity
3 2 1 0 Children with Children with ODD anxiety disorders
Nonclinical children
Figure 3.15: Mean observed involvement and negativity scores of children with anxiety disorders, children with oppositional-defiant disorder (ODD), and nonclinical control children. * Significant difference with the nonclinical control group. Based on: Hudson & Rapee (2001).
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Further, the mothers of anxious children also displayed higher levels of negativity during the interaction than mothers of nonclinical children. Although these findings are in keeping with the notion that (over)involvement is positively linked to childhood anxiety, the results also indicate that such parental rearing behaviors are not specific for anxiety disorders. Moreover, anxious mothers’ behaviors were characterized by relatively high levels of negativity, which suggests that other types of negative rearing behaviors are also involved in childhood anxiety. In a comparable investigation of Hudson and Rapee (2002), the interactions of anxiety disordered children and nonclinical controls as well as their siblings with both of their parents were observed while completing a complex puzzle task. In agreement with the previous study, the mothers of anxiety disordered children were more involved and intrusive during the task as compared to the mothers of nonclinical control children. No significant differences in involvement and intrusiveness were found between fathers of anxiety disordered children and fathers of control children. Interestingly, mothers and fathers were equally involved with the anxious child and the sibling of the anxious child, which suggests that overinvolvement and control are not typical for parents’ relationship to the anxiety disordered child but seem to reflect a general parental rearing style. However, it should be borne in mind that the preceding results were based on observational data. When asking parents to rate their levels of involvement toward their anxious child and siblings, in particular the mothers frequently reported that they were more overprotective of the anxious child than of the nonanxious sibling (Hudson & Rapee, 2005). Observational studies by other research groups have generally confirmed the hypothesis that anxious children’s parents are more controlling and less granting of autonomy than parents of children with no psychiatric problems (Barrett, Fox, & Farrell, 2005; Greco & Morris, 2002; Mills & Rubin, 1998; Moore, Whaley, & Sigman, 2004; Whaley, Pinto, & Sigman, 1999). Further, in several questionnaire-based investigations, positive correlations between parental control scores and anxiety symptoms of children and adolescents have been reported. A good example is a study by Bögels and Van Melick (2004), who examined the relationship between parental rearing behaviors and DSM-defined anxiety disorder symptoms in a sample of 9- to 12-year-old nonclinical children. Interestingly, this study employed a multiple informant approach, which implies that parental rearing behaviors were determined using input from children, parents, and partners. The main finding of this study was that the combined informant score of autonomy-granting overprotection was substantially associated with children’s level of anxiety. Again, low levels of autonomy granting and high levels of control were related to higher levels of anxiety symptoms (see also Lindhout, Markus, Hoogendijk et al., 2006). It should be acknowledged that not all studies have found the presumed positive correlation between parental control and childhood anxiety (e.g., Bögels, Van Oosten, Muris, & Smulders, 2001). In this respect, it seems important to note that there are various types of control, which may be differentially connected to childhood anxiety. For example, Dumas, LaFreniere, and Serketich (1995) distinguished between positive and negative control behaviors, and noted that mothers of socially anxious children displayed lower levels of positive control but higher levels of negative control as compared to mothers of aggressive and socially competent children. Apparently, parental control not only has negative features that seem to promote anxiety, but may also have positive characteristics that decrease childhood anxiety. Further, when discussing the role of parental control, it seems important to
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adopt a developmental perspective. For example, when raising a young child, it may be perfectly adequate for parents to rely on a controlling rearing style (e.g., Rubin, Cheah, & Fox, 2001). However, this style may be totally inappropriate for an adolescent who generally fares better with an autonomy-granting attitude of his parents (Muris, 2006c). Parental Care. As mentioned earlier, the dimension of parental care consists of an accepting and warm rearing style on one side and a rejecting and cold rearing attitude on the other side. It has been hypothesized that a parenting style characterized by a lack of warmth and high rejection would enhance the development of anxiety in children and adolescents (Rapee, 1997), probably because such a style may contribute to perceptions of the environment as hostile and threatening, the self as being less competent, and negative outcome expectancies (Bögels & Brechman-Toussaint, 2006; Krohne & Hock, 1991). Although several studies have demonstrated that low parental care or high parental negativity are associated with higher anxiety levels in youths (e.g., Grüner et al., 1999; Hale et al., 2006; Hudson & Rapee, 2001; Moore et al., 2004; Scher & Stein, 2003), the evidence in the literature is less convincing than that found for parental control (Rapee, 1997; Wood et al., 2003). Another parental characteristic that is associated with low levels of care is expressed emotion, which has been defined as the tendency of parents to be overly critical and emotionally overinvolved toward their children. While expressed emotion was initially investigated as a family factor contributing to relapse in severe psychopathological conditions such as schizophrenia (see Birchwood & Jackson, 2001), a number of studies have appeared in the literature investigating expressed emotion in the context of child psychopathology. A few of these have addressed the link between expressed emotion and childhood anxiety. For example, Stubbe, Zahner, Goldstein, and Leckman (1993) assessed psychiatric disorders in a sample of 6- to 11-year-old children and then conducted interviews to assess levels of expressed emotion in children’s parents. Results indicated that disruptive behavior disorders were more frequent in children of parents who expressed high levels of criticism, whereas anxiety disorders were more often found in children of parents who expressed high levels of emotional overinvolvement. In two studies by Hirshfeld and colleagues (1997a, 1997b), further indications for a link between expressed emotion and childhood anxiety were found. That is, anxiety-proneness (i.e., behavioral inhibition) of children was associated with higher levels of criticism, whereas the presence of separation anxiety disorder was related to higher levels of emotional overinvolvement. In conclusion, while research on the connection between expressed emotion and anxiety symptoms in youths is sparse, available evidence suggests that this family factor might be involved in childhood anxiety (see also Kwon, Delaney-Black, Covington et al., 2006). In conclusion, there is sufficient evidence to conclude that parental rearing behaviors are involved in the pathogenesis of anxiety disorders in children and adolescents (Bögels & Brechman-Toussaint, 2006; Rapee, 1997; Wood et al., 2003). However, it should be mentioned that it is difficult to find out what is cause and what is effect in the relation between parental rearing behavior and childhood anxiety. It may well be that negative rearing behaviors (such as anxious rearing, excessive parental control, lack of care, and high expressed emotion) contribute to the development of anxiety problems. Otherwise, it is also possible that children who display high levels of anxiety elicit negative rearing behaviors
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in their parents. Currently, researchers assume that both scenarios are applicable, which means that parental rearing behaviors are thought to play a role in the aetiology and maintenance of psychopathology in youths (Dadds & Roth, 2001). Another point that needs to be addressed is that whereas most studies have focused on the main effects of various rearing behaviors, it may be preferable to examine combinations of parental styles. For example, it has been suggested that a pattern of negative, affectionless parental control may be especially characteristic for parents of anxiety disordered youths (Berg-Nielsen, Vikan, & Dahl, 2002). Further, while the effects of negative parental rearing are obvious, it may well be that such rearing behaviors reflect other problems in the family such as parental psychopathology, marital difficulties, and general family dysfunctioning (e.g., Maccoby, 2000a). As a general note on family influences on childhood anxiety, it is well conceivable that the two factors that were discussed in this section—namely, insecure attachment and negative parental rearing behaviors—are related to each other. While it is generally assumed that high levels of parental rejection (in attachment terms: lack of sensitivity and responsivity) are associated with the formation of insecure attachment relationships, direct support for a link between parental rearing behaviors and attachment insecurity is sparse. In a recent study, Roelofs, Meesters, and Muris (submitted) asked parents to rate themselves in terms of Baumrind’s (1971) three typologies of parenting: authoritarian (low care, high control), permissive (moderate to high care, low control), and authoritative (high care, moderate control), while children reported their attachment style to both parents using a modified version of the AQ-C. Results indicated that in particular authoritarian and authoritative parenting were associated with insecure attachment patterns. As hypothesized, the parents of insecurely attached children reported themselves as more authoritarian and less authoritative. Similar results were obtained by Muris, Meesters, and Van den Berg (2003), who found that insecurely attached adolescents perceived their parents as less emotionally warm and more rejecting as compared to their securely attached counterparts. Finally, as mentioned earlier, many family factors lack specificity, which means that they are likely to be involved in a broad range of childhood disorders. Only anxious rearing and parental control seem to play a more exclusive role in the aetiology and maintenance of anxiety disorders in youths. This does not mean, however, that other factors are irrelevant for the study of childhood anxiety. Insecure attachment, rejection, and expressed emotion are certainly important as they all seem to increase a child’s vulnerability to develop anxiety problems.
Gender Role Orientation Gender stereotypes are widely held beliefs about characteristics that are considered as appropriate for specifically boys/males or girls/females. Gender roles are the reflection of these stereotypes in everyday behavior. Although it is generally assumed that gender roles have a biological basis (Maccoby, 2000b), it is also true that environmental influences are involved in the further development of these gender-specific roles. For example, from an early age on, adults view boys and girls differently and treat them in a different way. In addition, children have many opportunities to observe and imitate males and females in gender-stereotypical ways. And finally, when children become older, their contemporaries vigorously promote gender-typed behavior. Both biological and environmental factors make
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boys and girls quite different, which is reflected in differences in personality traits, activities, and achievements (Berk, 2006). However, it is also true that variations exist in gender role orientation within each gender: Some boys display relatively strong feminine traits, whereas some girls clearly exhibit masculine characteristics. According to some authors, these individual differences in gender role orientation to a certain extent account for variations in fear and anxiety levels in youths. For example, Ollendick, Yang, Dong, Xia, and Lin (1995) have proposed that individual differences in gender role orientation may explain the common finding that girls generally are more fearful and anxious than boys. According to theories on gender roles (e.g., Bem, 1981), the expression of fear and anxiety is in agreement with the feminine gender role, which is generally acquired by girls and which tolerates the expression of negative emotions and related behaviors (e.g., avoidance behavior). Conversely, fearfulness and anxiety are inconsistent with the masculine gender role. Such emotions are less accepted in boys who are expected to behave bravely and to display active and purposeful coping behavior. Few studies have examined the connection between gender role orientation and fear and anxiety in childhood samples. One exception is a study by Brody, Hay, and Vandewater (1990), who investigated the relations between gender and gender role orientation and children’s feelings toward peers as indexed by an Emotional Story Task in 120 nonclinic referred children aged 6 to 12 years. Results showed that girls reported higher levels of fear toward peers than boys. Most importantly, gender role orientation accounted for more of the variance in predicting fear than did the child’s sex. That is, biological gender was no longer associated with fear toward peers, after the influence of gender role orientation was partialled out. In general, boys and girls who scored higher on feminine gender role traits were more prone to report higher levels of fears toward peers. Another investigation by Ginsburg and Silverman (2000) addressed the relation between gender role orientation and the intensity of fears in a sample of clinically referred children with anxiety disorders ranging in age between 6 and 11 years. Children completed a questionnaire measuring masculinity and femininity and the Revised Fear Survey Schedule for Children (FSSC-R; Ollendick, 1983) as an index of childhood fear. Results indicated that masculinity was negatively related to fearfulness. Unexpectedly, however, no relation was found between femininity and children’s fearfulness. To account for these mixed findings, Ginsburg and Silverman (2000) pointed out that the children in their study were on average relatively young (i.e., 8.9 years) and that it may well have been the case that gender roles were insufficiently crystallized in their sample. With this in mind, Muris, Meesters, and Knoops (2005) examined the relation between gender role orientation and fear and anxiety in a somewhat older sample of nonclinic referred children (aged 10 to 13 years). Children and their parents completed questionnaires assessing children’s gender role orientation, toy and activity preferences, and fear and anxiety. Results generally indicated that femininity and a preference for girls’ toys and activities were positively associated with fear and anxiety, whereas masculinity and a preference for boys’ toys and activities were negatively related to these emotions (see Figure 3.16). Furthermore, gender role orientation accounted for more of the variance in fear and anxiety scores than the child’s sex. Similar findings emerged in a study by Palapattu, Newman Kingery, and Ginsburg, (2006) of 14- to 19-year-old African-American youths. That is, femininity was positively associated with anxiety symptoms, whereas masculinity was negatively related to such symptoms, and these links remained significant even
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0,8 Child report
0,6
Parent report *
0,4 *
0,2
*
* *
*
Fear Anxiety
0 –0,2 *
–0,4 Masculinity
Femininity
*
*
Preference for Preference for Preference for Preference for boys’ toys girls’ toys boys’ toys girls’ toys
Figure 3.16: Correlations between gender role orientation and toy and activity preferences, on the one hand, and fear and anxiety scores, on the other hand, in a sample of nonclinical children aged 10 to 13 years. * Significant correlation at p < .05. Based on: Muris et al. (2005).
when controlling for biological sex. Altogether, there is some support for the notion that gender role orientation is in a theoretically meaningful way related to fear and anxiety in youths, but more research is needed to explicitly demonstrate that this concerns a causal relationship.
Cultural Differences A final group of environmental factors that might be involved in the pathogenesis of childhood anxiety operates at a societal level and is concerned with ethnic or cultural differences. Even within modernized Western countries, researchers have observed that anxiety levels in children and adolescents vary as a function of cultural group membership. Most studies have been carried out in the United States and have generally found that children and adolescents from ethnic minorities (e.g., African American, Hispanic American) display higher levels of fear and anxiety than Caucasian autochthons (e.g., Glover, Pumariega, Holzer, Wise, & Rodriguez, 1999; Last & Perrin, 1993; Pina & Silverman, 2004; Varela, Vernberg, Sanchez-Soza et al., 2004). Similar results have been obtained in a country like the Netherlands. In a recent study, Hale, Raaijmakers, Muris, and Meeus (2005) collected anxiety disorders symptoms scores of authentic Dutch children and adolescents and youths from various ethnic minorities (e.g., Moroccan, Turkish, Surinam). Results demonstrated that ethnic minority youths consistently exhibit higher anxiety symptom scores as compared to authentic Dutch youths. Several investigations have made an attempt to compare the fear and anxiety levels of youths across Western and non-Western countries. For example, in a study by Ollendick, Yang, King, Dong, and Akande (1996), fears were measured in a sample of 1200 American, Australian, Chinese, and Nigerian children and adolescents. It was found that Nigerian children and adolescents reported higher levels of fears than American and Australian
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youths, whereas the fear levels of Chinese children and adolescents were in between. Furthermore, cultural differences emerged with respect to the content of fears. While some fears were highly prevalent in all countries, there were also fears that appeared to be highly specific and idiosyncratic to each of the nations (e.g., looking foolish in America, snakes in Africa, ghosts in China). Ollendick et al. (1996; see also Ingman, Ollendick, & Akande, 1999) assume that cultural differences as well as exposure to specific fear-provoking stimuli and situations explain these differences in the content of fears across countries. Another study that should be mentioned is that by Elbedour and colleagues (1997), who compared self-reported fears of Jewish and Bedouin children. Results revealed quantitative and qualitative differences between the two groups, with the Bedouin children reporting higher levels of fear and a greater variety of fear-provoking stimuli and situations than the Jewish children. Altogether, the results of these and other studies (e.g., Essau, Sakano, Ishikawa, & Sasagawa, 2004; Maduewesi, 1982; Opolot, 1976) suggest that manifestations of fear and anxiety are at least to some extent culturally determined. This point is further illustrated by a series of studies that have been carried out in South Africa (Burkhardt, Loxton, & Muris, 2003; Muris, Loxton, Neumann, DuPlessis, King, & Ollendick, 2006; Muris, Schmidt, Engelbrecht, & Perold, 2002). Children and adolescents from various cultural backgrounds completed fear and anxiety questionnaires. Results consistently demonstrated that youths from black communities displayed higher fear and anxiety scores as compared to South African youths from the white community. Interestingly, the latter group showed similar fear and anxiety levels as those observed for children and adolescents in Western countries (Muris et al., 2002; (see Figure 3.17)). Taken together, at least on a group level, variations in fear and anxiety scores can be observed among children and adolescents with different cultural backgrounds. As noted by Weisz and colleagues (1987, 1989, 1993), differences in socialization practices across the various cultures may account for these findings. More specifically, compared to Western cultures, Asian and African societies more strongly emphasize self-control, social inhibition, and compliance with social norms, which in turn may foster the development of anxiety
40
*
30 20 10 0 White South African Black/colored South White Dutch youths youths African youths
Figure 3.17: Mean SCARED total anxiety scores of white South African, black/colored South African, and white Dutch youths. SCARED = Screen for Child Anxiety Related Emotional Disorders. * Significant difference with the other groups. Based on: Muris et al. (2002).
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problems. There is some evidence to support this hypothesis: Muris et al. (2006) found that differences in parental rearing behaviors (i.e., higher levels of anxious rearing, overprotection, and rejection) accounted for a significant proportion of the differences in anxiety symptoms among various groups of South African youths. However, an important part of the cultural variations in childhood fear and anxiety might simply be explained by detrimental socioeconomic living conditions. That is, some youths live in a neighborhood that is characterized by deprivation, violence, and poverty, and it is obvious that such an environment is more stressful and threatening, which may enhance feelings of fear and anxiety (e.g., Spence, Najman, Bor, O’Callaghan, & Williams, 2002).
Conclusion It is clear that environmental factors contribute to the development of fear and anxiety problems in youths. As described in this chapter, such environmental influences not only include antenatal maternal stress, traumatic incidents, negative life events, and aversive conditioning experiences, but also involve more subtle learning processes based on negative information that children and adolescents receive about various stimuli and situations (e.g., Field, 2006c). While negative information in itself usually will be insufficient to produce pathological fear and anxiety levels, it is conceivable that such information facilitates and enhances subsequent fear acquisition processes. Further, various family factors were described that seem to play a role in the pathogenesis of childhood anxiety, including parental modeling, insecure attachment, and negative parental rearing behaviors. Finally, there is some evidence indicating that cultural factors are also involved as they are to a certain extent associated with differences in socialization practices and variations in general living conditions. When turning back to the study of Twenge (2000) that was described at the beginning of this chapter, it has been observed by various scientists that youths’ environment has changed dramatically during the past decades (e.g., Grinde, 2005). Children and adolescents are growing up in a much more complicated, stressful, and threatening world. Meanwhile, the role of the family has changed in such way that it provides less protection and security. Thus, from an environmental point of view, the increase of anxiety among youths as observed by Twenge certainly makes sense. However, even when exposed to severe threat and stress, some children and adolescents show remarkable resilience and do not develop anxiety problems, which will be the topic of the next chapter on protective factors.
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Chapter 4
Protective Factors
Introduction Genetically based variables such as neuroticism, behavioral inhibition, and disgust sensitivity and other vulnerability and risk factors such as negative learning experiences, stressful life events, and adverse family factors will make children prone to develop anxiety disorders. Fortunately, there are also protective influences, which may serve to shield children and adolescents against the development of an anxiety disorder. According to researchers in the field of developmental psychopathology, it is not only important to study the characteristics and conditions that cause youths to display maladaptive behavior but also to investigate those factors and circumstances that seem to immunize children and adolescents against the development of problem behavior and mental disorders (e.g., Cicchetti & Cohen, 1995). The past two chapters may have given the reader the impression that phobias and anxiety disorders in youths simply arise when a vulnerable child is exposed to negative environmental influences. However, there are children and adolescents who, in spite of the clear presence of vulnerability and risk factors, do not develop anxiety problems. Although several authors have carefully described the factors that determine such resilience (Masten, 2001), relatively few studies have investigated protective factors in relation to the development of anxiety problems in youths. This chapter nevertheless attempts to describe the phenomenon of resilience in youths and discusses various protective factors that have been examined in the context of childhood fear and anxiety. It should be noted that the chapter devotes little attention to factors and processes that have already been discussed in the context of temperamental vulnerability and environmental risk factors. For example, while it is clear that emotional stability, secure attachment, positive parenting qualities, and high socioeconomic status can be regarded as protective variables that contribute to youths’ resilience, the focus of this chapter is more on variables that have not been described so far and that are not just the “inverse” of vulnerability and risk factors.
Resilience According to Luthar, Cicchetti, and Becker (2000), resilience pertains to “a dynamic process encompassing positive adaptation within the context of significant adversity” (p.543). In the context of childhood fear and anxiety, resilience seems to incorporate two critical conditions: (1) the child or adolescent is exposed to a threatening stimulus, a negative or traumatic life event, or an adverse learning experience, and (2) the young person shows successful
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adaptation and does not develop a severe and/or persisting anxiety problem despite these adverse circumstances (see also Masten, 2001). In other words, the phenomenon of resilience seems to refer to an inferential and contextual construct that requires two major kinds of judgments. The first judgment addresses the threat condition and simply refers to the fact that a child or adolescent cannot be considered as resilient if he or she has never been exposed to a significant threatening or stressful event that has the potential to disrupt normal development. The second judgment is concerned with the adaptation condition and refers to the appreciation of whether the developmental outcome is “good” in spite of the difficult circumstances (Masten, 2001). In terms of anxiety problems, this would imply that the child or adolescent displays low levels of anxiety symptoms and does not show impairment in daily functioning. The fact that resilience is an inferential construct that is based on the judgments of threat and adaptation has caused problems in the assessment and study of this concept (Luthar, 1999). This has led some researchers to focus on variables that are thought to promote adaptation to difficult circumstances. For example, in a longitudinal study by Fergusson, Horwood, and Ridder (2005), the supposedly protective influence of children’s intelligence on adjustment in late adolescence and early adulthood was examined. When children were 8 to 9 years old, their IQ was tested by means of the Wechsler Intelligence Scale for Children-Revised (Wechsler, 1974). Symptoms of anxiety disorders (and other mental health problems) were assessed with a structured interview to classify the participants in terms of DSM-diagnoses when they were between 15 and 25 years of age. As can be seen in Figure 4.1, a linear relationship between IQ and anxiety disorders was observed: Children with the lowest IQ scores displayed almost twice as much anxiety disorders when they reached late adolescence and early adulthood as compared to children with the highest IQ scores. While interesting, this result should be interpreted with caution as additional analysis revealed that the link between childhood IQ and later anxiety disorders largely disappeared when controlling for possible confounding variables such as social and family disadvantages and individual characteristics (Fergusson et al., 2005). Another study by Saltzman, Weems,
30 25 20 15 10 5 0 <85
85–94 95–104 105–114 Child IQ at 8–9 years
115+
Figure 4.1: Mean percentage of anxiety disorders in 15- to 25-year-old participants of whom IQ had been assessed when they were 8–9 years of age. Based on: Fergusson, Horwood, & Ridder (2005).
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and Carrion (2005) examined the relationship between IQ and symptoms of posttraumatic stress disorder in youths that had been exposed to interpersonal violence. It was found that total IQ and verbal IQ scores were negatively related to symptoms of reexperiencing and impairment. This means that lower IQ scores were accompanied by higher levels of posttraumatic stress symptoms. While these results are promising, more research on this issue is required. Meanwhile, it should be kept in mind that IQ is not only linked to psychopathology but also to other protective/vulnerability variables, which means that it may be too simple to assume a main effect of IQ on youths’ adjustment (Masten, 2001). In their longitudinal investigation, Masten and colleagues (1999, 2004) have employed a somewhat different approach to study resilience in youths. Briefly, these researchers employed a person-based approach, which implies that they identified resilient adolescents (who adapt well in spite of risk and adversity) and then compared them to maladaptive adolescents (who fail to adapt under adverse circumstances) with respect to a number of protective childhood variables. By definition, resilient adolescents displayed higher levels of global self-worth and psychological well-being than their maladaptive counterparts. Most important, results showed that intellectual functioning (IQ) and parenting resources were associated with good adaptation, even in the context of severe, chronic adversity. That is, resilient adolescents displayed higher IQ scores when they were young and had parents with better rearing qualities as compared to maladaptive youths. On the basis of their research, Masten and her colleagues have come to the interesting conclusion that “resilience is a common phenomenon that usually arises from the normative functions of human adaptational systems, with the greatest threats to human development being those that compromise these protective systems” (see Masten, 2001; p.227). While this research does not specifically focus on resilience in the context of childhood anxiety disorders, this would imply that youths would be particularly susceptible to anxiety problems when a number of normal adaptive processes are undermined. Note that this notion is not in keeping with the general tendency in the literature to focus on risk and vulnerability when studying the origins of psychopathology, such as childhood phobias and anxiety disorders (Masten, 2006). As a final note on resilience, it should be mentioned that some researchers have operationalized this construct in terms of a personality prototype. For example, Robins, John, Caspi, Moffitt, and Stouthamer-Loeber (1996) used Block and Block’s (1980) Q-sorting technique to measure (a) ego-resilience, which refers to the tendency to respond flexibly rather than rigidly to changing situational demands and in particular stressful situations, and (b) ego-control, which pertains to the inclination to suppress versus express emotional and motivational impulses (respectively, overcontrol and undercontrol). The combination of these two dimensions basically yields three personality prototypes: a well-adjusted, resilient type, which represents youths who display high levels of ego-resilience and adequate levels of ego-control, and two maladjusted types, which involve youths who either adjust and approach the world in an overcontrolled (low ego-resilience and high ego-control) or an undercontrolled (low ego-resilience and low ego-control) manner. In terms of Big Five personality traits, resilient youths are characterized by emotional stability and fairly normative levels of other personality traits. In contrast, overcontrolled youths typically display low levels of extraversion and emotional stability, whereas undercontrolled youths exhibit low levels of agreeableness, conscientiousness, and emotional stability. Interestingly, several studies have linked these personality prototypes to the occurrence of psychopathological
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Normal and Abnormal Fear and Anxiety in Children and Adolescents 50 40
Internalizing
30
Externalizing
20
Mixed internalizing/ externalizing
10 0 Resilient
Overcontrolled Undercontrolled
Figure 4.2: Percentages of resilient, overcontrolled, and undercontrolled youths displaying internalizing, externalizing, and mixed internalizing/externalizing problems (parent and teacher report combined). Based on: Robins, John, Caspi et al. (1996).
symptoms in children and adolescents (Asendorpf & Van Aken, 1999; Flores, Cicchetti, & Rogosch, 2005; Robins et al., 1996; Wolfson, Fields, & Rose, 1987). As can be seen in Figure 4.2, the vast majority of the resilient youths does not develop psychopathological symptoms. However, overcontrolled youths generally exhibit internalizing symptoms, while undercontrolled youths seem to be more prone to developing externalizing or mixed internalizing/externalizing symptoms. In other words, children and adolescents with phobias and anxiety disorders can be qualified as “overcontrolled,” and some even view this characteristic as prototypical for this type of psychopathology (Wenar & Kerig, 2000). This notion is further supported by the finding that overcontrolled youths consistently display high levels of behavioral inhibition (Asendorpf & Van Aken, 1999), which as described in Chapter 2, can be viewed as an important temperament-based vulnerability factor for developing childhood anxiety problems. While childhood anxiety problems have been associated with an overcontrolled personality type, which is concerned with excessively high levels of control over emotional and behavioral responses, there are several theoretical accounts, which assume that phobias and anxiety disorders in youths are linked to relatively low levels of certain control processes. On first sight, these contradictory views on the role of control in relation to childhood anxiety seem difficult to reconcile. However, a careful consideration makes clear that various control processes are concerned with different aspects of mental processes and behavior. More precisely, whereas an overcontrolled personality type has to do with control that occurs when children actually respond to their environment, other control processes are more linked to the formation of emotional and cognitive reactions to certain stimuli and situations. An example of a control-related variable that seems to be involved in both types of control processes is effortful control, which will be the topic of the next section.
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Effortful Control While earlier theories of temperament mainly focused on the relevance of neuroticism in the pathogenesis of child psychopathology, current accounts stress the importance of regulative temperament factors (Rothbart & Bates, 1998; see Muris & Ollendick, 2005). A regulative temperament factor that has attracted considerable research attention in the past years is effortful control. Briefly, effortful control refers to self-regulative processes and can best be defined as “the ability to inhibit a dominant response to perform a subdominant response” (Rothbart, Ellis, & Posner, 2004). This definition suggests that effortful control pertains to controlling or regulating one’s behavior under certain circumstances. Yet, it should be kept in mind that effortful control not only pertains to behavioral control but also attention control processes. More specifically, effortful control is generally thought to consist of two main components: inhibitory control, which pertains to the ability to inhibit one’s behavior if necessary, and attention control, which can be defined as the ability to focus and shift attention as needed. Effortful control shows strong similarities to what neuropsychologists refer to as “executive functions,” and as such this temperament factor is usually assessed by means of cognitive performance tests, which tap children’s capacity of governing their attention and controlling their behavior (Murray & Konchanska, 2002). Various tests have been employed that map on to diverse aspects of effortful control. For example, various researchers have adapted go/no-go tasks for use with children (e.g., Schachar & Logan, 1990). These tasks tap children’s level of impulsivity or lack of inhibitory control. In addition, the Test of Everyday Attention for Children (TEA-Ch; Manly, Anderson, NimmoSmith et al., 2001; Manly, Robertson, Anderson, & Nimmo-Smith, 2004) includes various tasks that call on focusing, sustaining, and switching attention, thereby indexing important aspects of attention control. There are also behavior rating scales on which youths, parents, and teachers indicate to what extent children and adolescents possess effortful controlrelated abilities (e.g., Ellis & Rothbart, 2001; Rothbart, Ahadi, Hershey, & Fisher, 2001). It is generally assumed that the capacity for effortful control processes is innate (Poggi Davis, Bruce, & Gunnar, 2002). Relatively few data exist on the temporal stability of this regulative temperament factor, but available evidence has revealed fairly robust stability from infancy through preschool and into early school years (Kochanska & Knaack, 2002; Kochanska, Murray, & Coy, 1997), and so it can be concluded that effortful control has trait-like qualities (see also Rothbart & Bates, 1998). Meanwhile, it is also clear that this regulative temperament factor further develops as a result of brain maturation, especially in the frontal lobes, in interaction with the environment (Kochanska, Murray, & Harlan, 2000; Posner & Rothbart, 2000). The gradual improvement of effortful control increasingly enables children to regulate emotions and to control their behavior, which may have positive effects on the social interactions with other children (Eisenberg, Liew, & Pidada, 2004; Fabes, Eisenberg, Jones et al., 1999). In children who have little effortful control by nature or who fail to adequately develop this regulative trait, such normal processes can be disturbed. Most research on the link between effortful control and child psychopathology has focused on externalizing problem behaviors (Eisenberg, Fabes, Guthrie et al., 1996; Eisenberg, Guthrie, Fabes et al., 2000; Olson, Sameroff, Kerr, Lopez, & Wellman, 2005; Rubin, Burgess, Dwyer, & Hastings, 2003; Valiente, Eisenberg, Smith et al., 2003). However,
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a number of studies have also examined the relation between effortful control and internalizing symptoms. For example, in an investigation by Eisenberg and colleagues (2001), parents and teachers completed rating scales for measuring reactive (emotionality, which as described in Chapter 2 can be regarded as an equivalent of neuroticism) and regulative (effortful control) temperament factors in a sample of 4- to 8-year-old children displaying either internalizing problems, externalizing problems, or no psychological problems. Results showed that children with internalizing problems and children with externalizing problems scored relatively high on emotionality but low on effortful control, as compared to children without psychological problems. Comparable results were obtained in subsequent research by Eisenberg, Sadovsky, Spinrad et al. (2005). In this study, not only concurrent but also prospective relations between reactive and regulative temperament and behavior problems were investigated. Again, high emotionality and low effortful control were predictive of behavioral problems, although the role of effortful control appeared more prominent in the case of externalizing symptoms. Recently, Oldehinkel, Hartman, De Winter, Veenstra, and Ormel (2004) studied a large sample of nonclinical youths aged between 10 and 12 years. Children’s internalizing and externalizing problems were assessed by means of the Child Behavior Checklist (CBCL; Achenbach, 1991), whereas temperament was evaluated with the parent version of the Early Adolescent Temperament Questionnaire (EATQ; Ellis & Rothbart, 2001). Temperament patterns were studied in control children who neither displayed internalizing nor externalizing problems, children with only internalizing problems, children with only externalizing problems, and children with comorbid problems. The expected patterns of temperament factors were found for the various groups. That is, compared to control children, children with internalizing problems and children with externalizing problems scored high on emotionality and low on effortful control. On the basis of these findings, Oldehinkel et al. (2004) conclude that both reactive and regulative temperament factors are involved in internalizing as well as externalizing psychopathology in children. A follow-up study by Ormel, Oldehinkel, Ferdinand et al. (2005), in which youths were assessed more than two years later, largely confirmed this conclusion, although it should be noted that when controlling for concurrent externalizing problems, the relation between effortful control and internalizing problems largely disappeared. On the basis of these results, one might conclude that the link of effortful control with internalizing problems is less robust than that with externalizing problems. However, it should be borne in mind that the regulative temperament factor of effortful control consists of various components that might not be equally relevant for each type of psychopathology. Briefly, disruptive behavior disorders are frequently marked by impulsive and disinhibited behavior. Thus, problems with inhibitory control seem more typical of externalizing disorders and this regulative factor may even be enhanced in anxiety-prone children (Aksan & Kochanska, 2004). In contrast, as anxiety and depression are characterized by uncontrollable negative thought processes, it may well be that lack of attention control is closely associated with the internalizing disorders. Thus, it is possible that the link between effortful control and internalizing problems has not clearly emerged in previous studies because the assessment of these regulative temperament factors has been confined to instruments that do not differentiate between attention control and inhibitory control. Meanwhile, a number of studies have appeared in the literature that either examined (1) the relation between specifi-
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cally attention control and (internalizing) behavior problems in youths or (2) the differential links between attention and inhibitory control, on the one hand, and internalizing and externalizing problems, on the other hand. As an example of the first class of studies, Muris, De Jong, and Engelen (2004) examined the relationship between attention control and anxiety disorders symptoms in nonclinical children aged 8 to 13 years (N = 303). For this purpose, participants completed a set of questionnaires that contained the child version of the Attention Control Scale for Children (ACS-C; see Derryberry & Reed, 2002; see Appendix), which measures attention focusing (i.e., the ability to concentrate and to focus attention on one task) and attention shifting (i.e., the ability to engage in dual tasks and to shift attention from one task to another), and the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher, Brent, Chiappetta et al., 1999), which is a scale for assessing symptoms of childhood anxiety disorders. Results revealed a clear-cut negative correlation between attention control and anxiety disorders symptoms. In other words, low levels of attention control were associated with higher levels of anxiety symptoms. Another study by Muris, Meesters, and Rompelberg (2007) investigated the links between child- and parent-rated attention control and a broad range of psychopathological complaints, including symptoms of anxiety, depression, aggression, and ADHD, in a sample of nonclinical youths. As predicted, lower levels of attention control were accompanied by higher levels of these symptoms. Importantly, when controlling for neuroticism, attention control only remained significantly associated with symptoms of anxiety disorders and ADHD (see also Meesters, Muris, & Van Rooijen, in press). A recent examination by Muris, Meesters, and Blijlevens (in press) can be regarded as an example of the second class of studies. In this study, the relation between self-reported reactive and regulative temperament traits and psychopathological symptoms was examined in a group of nonclinical youths aged 9 to 13 years. Children completed the EATQ to measure various aspects of effortful control including attention control and inhibitory control, and the self-report version of the CBCL (i.e., the Youth Self-Report; Achenbach, 1991) as an index of internalizing and externalizing symptoms. Results indeed yielded support for differential relations between lower-order temperament traits and internalizing and externalizing symptoms. As shown in Figure 4.3, fear and (low) attention control appeared more clearly associated with internalizing symptoms, whereas anger/frustration and (low) activation and inhibitory control were more convincingly linked to externalizing symptoms. To recap, effortful control is a regulative temperament factor that is thought to enhance children and adolescents’ adjustment to stressful situations, and as such seems to be involved in the aetiology of psychopathological symptoms in youths (Muris & Ollendick, 2005). Three important remarks can be made with regard to the latter conclusion. First, although research has yielded more support for the notion that effortful control processes are more relevant to externalizing problems in youths, there is increasing evidence that in particular the attention control component of this regulative temperament factor plays a role in internalizing symptoms (e.g., Muris et al., in press). Second, previous research has relied on rating scales to examine the link between effortful control and child psychopathology. Given the fact that effortful control bears strong similarity to executive functioning, it might certainly be worthwhile to employ neuropsychological tasks to investigate effortful control processes in relation to psychopathological symptoms in youths. Interestingly, the first
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Normal and Abnormal Fear and Anxiety in Children and Adolescents A. Temperament
Effortful control Attention control
Neuroticism
Inhibitory control
Fear
Anger/ frustration
B.
Attention control Fear
–.14
.34
Anger/ frustration
.26
Inhibitory control
–.24
Anger/ frustration
.28
Internalizing
Externalizing
Figure 4.3: A. Schematic representation of Rothbart’s temperament model, B. The associations between reactive and regulative temperament traits and psychopathological symptoms. All βs were significant at p < .05. Based on: Rothbart & Bates (1998); and Muris, Meesters, & Blijlevens (in press).
studies using such a method are just beginning to emerge. For example, Emerson, Mollet, and Harrison (2005) compared a group of boys with high levels of anxiety and depression symptoms and a control group with low levels of such symptoms with respect to their performance on the Trail Making Test (Lezak, 1983) and the Woodcock and Johnson (1989) Concept Formation subtest, which are both well-validated measures of frontal functioning. The results showed that anxious/depressed boys demonstrated deficits in sequencing, alternation, and problem-solving tasks as evidenced by longer completion times and higher error rates than control participants. Emerson et al. (2005; p.540) conclude that the “results provide supportive evidence for deficits in frontal lobe functioning” (see also Jazbec, McClure, Hardin, Pine, & Ernst, 2005). Third, as a related point, a recent functional magnetic resonance imaging (fMRI) investigation by Monk, Nelson, McClure et al. (2006) demonstrated that greater activation of frontal brain areas were associated with less severe anxiety symptoms in a sample of clinically anxious youths (of whom some had a comorbid
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depression), which indeed seems to provide some support for the regulative function of this brain area. Fourth and finally, most studies have focused on the association between effortful control and internalizing symptoms in general. While it may well be the case that similar effortful control deficits underlie depression and anxiety problems in youths, research examining these regulative processes in separate childhood internalizing disorders is clearly warranted.
Perceived Control Another control-related variable that has been considered as important for the pathogenesis of childhood anxiety disorders is perceived control. For example, Alloy, Kelly, Mineka, and Clements (1990) assume that negative emotions such as anxiety and depression are strongly allied states that are both part of one dimension reflecting the individual’s level of perceived control. More precisely, when an individual experiences uncertainty about the ability to control internal and external events (i.e., uncertain helplessness), the resulting affective state will be anxiety. When perceived control further decreases (i.e., certain helplessness), the individual will experience a state of mixed anxiety-depression. Finally, when an individual’s perception of control is completely diminished (i.e., hopelessness) and there is certainty about a negative outcome, one experiences a depressive state. In the child literature, various studies can be found that have investigated Locus of Control in relation to anxiety symptoms in youths. Locus of Control refers to children’s belief about the source of their control over reinforcement and positive outcomes (Rotter, 1975). Children with an internal Locus of Control believe that their own actions determine the rewards that they obtain, while those with an external Locus of Control believe that their own behavior doesn’t matter much and that rewards in life are generally outside of their control (i.e., fate, chance, luck, or powerful others). Research has generally indicated that anxiety symptoms in youths are associated with an external Locus of Control. For example, Nunn (1988) found a significant and positive correlation between an external-oriented Locus of Control as indexed by the Nowicki and Strickland (1973) Locus of Control scale and trait anxiety as measured with the Spielberger (1973) State-Trait Anxiety Inventory for Children. Other studies have yielded highly similar results (Capps, Sigman, Sena, Henker, & Whalen, 1996; Gomez, 1998; Ollendick, 1979; Rawson, 1992; Shriberg, 1974; St-Yves, Dompierre, Freeston, Jacques, & Malo, 1989; see for a review, Bell-Dolan & Wessler, 1994). Barlow (2002) employed a somewhat different definition of perceived control. In his anxiety model, perceptions of control over external threats (i.e., stimuli and situations that are fear-provoking) and negative internal feelings and bodily sensations play a crucial role. Briefly, individuals who hold the belief that anxiety-related external and internal events and sensations are uncontrollable would be particularly prone to develop pathological manifestations of anxiety. Support for this model in adult populations has been obtained by Rapee, Craske, Brown, and Barlow (1996) who found that low levels of perceived control over external threats and internal sensations were accompanied by higher levels of self-reported anxiety. Further, patients with anxiety disorders clearly displayed lower levels of perceived control over internal and external events and sensations as compared to nonreferred adults. In a recent study, Weems, Silverman, Rapee, and Pina (2003) investigated the role of control
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beliefs in relation to childhood anxiety problems. Participants were 117 youths aged between 9 and 17 years: 86 children and adolescents had been referred to an anxiety clinic and met the diagnostic criteria for an anxiety disorder, whereas the remaining 31 were nonanxious control participants. All participants completed self-report scales for measuring anxiety symptoms and their perceptions of control over external (e.g., “I can usually stay away from things that might hurt me pretty easily”) and internal (e.g., “If I begin to shake and tremble, I can stop myself”) anxiety-related events. In keeping with Rapee et al. (1996), the findings showed that perceived control over anxiety-related events was negatively related to selfreported anxiety scores. Further, children and adolescents with anxiety disorders clearly displayed lower levels of perceived control over internal and external anxiety-related events than the nonanxious controls (see Figure 4.4). On the basis of these results, Weems et al. (2003; p.557) concluded that “anxiety disorders in youths are associated with beliefs that anxiety is uncontrollable.” Further support for the notion that a diminished perception of control over anxiety-related events is involved in the development of childhood anxiety comes from a study by Ginsburg, Lambert, and Drake (2004). These researchers examined the concurrent and prospective relations between perceived control, anxiety sensitivity, and panic disorder symptoms in a community sample of African-American adolescents. Participants completed self-report questionnaires of anxiety sensitivity and panic symptoms on two occasions, some six months apart. In addition, two scales for assessing perceived control, one for general situations and another for anxiety-specific events, were completed on occasion 1. On occasion 2, adolescents also completed the Panic Attack Questionnaire (Norton, Dorward, & Cox, 1986) on the basis of which they were classified as panickers or nonpanickers. Overall, the results indicated that lower perceived control was associated with higher levels of anxiety sensitivity and panic symptomatology. Further, only decreased control perceptions for anxiety-specific events, and not general situations, possessed predictive value for panic
90 80 70 60 50 40
AD youths Controls
30 20 10 0 Control over Control over Total control external internal events sensations
Figure 4.4: Levels of perceived control over external threatening events and internal sensations in youths with anxiety disorders and nonanxious controls. All differences were significant at p < .001. Based on: Weems, Silverman, Rapee, & Pina (2003).
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symptoms and panic status over time, even after controlling for levels of anxiety sensitivity. Note that these results fit nicely with Barlow’s (2002) idea that beliefs about the uncontrollability of anxiety-related events seem to promote anxiety. Chorpita and Barlow (1998) have formulated an interesting theory about the role of control in the pathogenesis of childhood anxiety, which may also be relevant for understanding the aetiology of depression (see Chorpita, 2001). Briefly, this theory suggests that early experiences with uncontrollable events may be thought of as a primary pathway to the development of negative emotions in that such experiences may foster a cognitive style that is characterized by the tendency to perceive and process events as not within one’s control. Children who have this information-processing style will experience uncertainty about controlling events or even may have the idea that nothing can be done to prevent negative outcomes. At a biological level, diminished levels of perceived control will result in increased activity of the Behavioral Inhibition System (BIS), which manifests itself in terms of increased caution, vigilance, and processing of threat-relevant information and so will promote children’s proneness to develop high levels of anxiety and depression (see Figure 4.5). According to Chorpita and Barlow (1998), during development, children gradually gain a sense of control in a number of subsequent domains: the caregiver (early childhood), the world (middle childhood), and the self (adolescence). Parenting behaviors are thought to play a crucial role in the development of perceived control. For example, parents who are characterized by low levels of sensitivity and responsivity will install an insecure attachment style in their offspring, which means that these children do not learn to use their caregivers as a secure basis to explore the environment, hence giving them a diminished sense of control. In a similar vein, parents who are anxious and overprotective toward their offspring, may hinder the development of autonomy, thereby attenuating youths’ sense of control over the external world (Schneewind, 1995). There is indeed some support for the notion that a controlling parenting style plays a role in the formation of control-related cognitions. For example, Chorpita, Brown, and Barlow (1998) hypothesized a model in which the anxiogenic and depressogenic influences of parental rearing behaviors are mediated by youths’ perceptions of control. This model was tested in a mixed sample of clinically referred and nonclinical children and adolescents aged 6 to 15 years. Youths and parents completed questionnaires that measured parental rearing behaviors (in particular controlling rearing practices), children’s perception of control, and symptoms of anxiety and depression. Results
Uncontrollable events
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Figure 4.5: Model depicting the role of perceived control in the development of anxiety problems in children and adolescents. Based on: Chorpita (2001).
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were in keeping with the hypothesized mediational model. That is, controlling rearing behaviors were associated with low levels of perceived control in youths, which in turn resulted in high levels of negative affect and, in its wake, more severe clinical symptoms of anxiety and depression (see Figure 4.6). A further study by Muris, Meesters, Schouten, and Hoge (2004) examined the role of perceived control on the relationship between perceived parental rearing behaviors (i.e., anxious rearing, overprotection, and rejection) and symptoms of anxiety and depression in a sample of nonclinical youths aged 11 to 14 years. In contrast with the study of Chorpita et al., no support was found for a mediation effect of perceived control on the link between perceived parental rearing behaviors and symptoms. In fact, results generally indicated that negative parental rearing behaviors and low levels of perceived control both made a significant and independent contribution to symptoms of anxiety and depression, suggesting that they had additive effects on the formation of these negative emotions. Further, some evidence was found for a moderation effect of perceived control on the relation between anxious rearing and anxiety symptoms. As can be seen in Figure 4.7, the presence of low
Perceived control –.62
Parental control
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Negative affect
.75
Clinical symptoms
Anxiety symptoms (standardized)
Figure 4.6: Structural model of the relationships between parental control, children’s perceptions of control, negative affect, and clinical symptoms of anxiety and depression. All paths were significant at p < .05. Based on: Chorpita, Brown, & Barlow (1998). 0,6 0,4 0,2 0
High anxious rearing
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Figure 4.7: Moderational effect of perceived control on the relation between anxious rearing and anxiety symptoms in 11- to 14-year-old youths. Based on: Muris, Meesters, Schouten, & Hoge (2004).
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perceived control and high anxious rearing yielded relatively high levels of anxiety symptoms, but it was especially the combination of high perceived control and low-anxious rearing that clearly yielded the lowest anxiety levels. Note that this finding underlines the notion that (high) perceived control acts as a protective factor against the development of anxiety problems. A final remark should be made regarding the somewhat diverging results of both studies. That is, while Chorpita et al. (1998) found support for a model in which perceived control mediated the anxiogenic influences of parental rearing behaviors, the results of Muris et al. (2004) seem to indicate that perceived control at best had a moderating effect on the link between parental rearing and anxiety. Interestingly, Chorpita and Barlow (1998) have hypothesized that the role of perceived control in the aetiology of negative emotions might change as a function of development. In younger children, a mediational role of perceived control seems more appropriate, as this cognitive characteristic is still in the process of formation, and parental influences have a significant impact on this development. In older children, a moderational effect is more applicable, because perceived control has then become a crystallized personality characteristic that is thought to amplify the effects of other variables (see also Chorpita, 2001). This developmental account makes sense as the Muris et al. (2004) study relied on a sample of young adolescents of whom most had an age of 12 or 13 years, whereas Chorpita et al. (1998) examined a sample with a rather broad age range, even including children of 6 years. Nevertheless, more research on the changing role of perceived control in the pathogenesis of childhood anxiety (and depression) is needed to further clarify this issue. Based on a review of the literature, Weisz and Stipek (1982) concluded that perceived control essentially is the result of two underlying dimensions—namely, perceived contingency of outcomes and perceived personal competence. On the basis of this observation, Weisz (1986) has formulated the contingency-competence-control (CCC) model, which hypothesizes that perceived control is logically predicted by two additional factors: outcome contingency, which refers to the degree to which an outcome depends on the behavior of the child, and personal competence, which can be defined as the ability to produce the desired outcome. For example, children and adolescents’ judgment of how well they can control academic performance is probably influenced by their perceptions of how contingent teachers are in their evaluations and how competent they are in performing the behaviors that lead to good performance. Most studies that investigated the relevance of the CCC model for child psychopathology have focused on depression (Weisz, Stevens, Curry et al., 1989; Weisz, Southam-Gerow, & McCarty, 2001; Weisz, Sweeney, Profitt, & Carr, 1993; Weisz, Weiss, Wasserman, & Rintoul, 1987). These studies have yielded mixed support for the model: Although perceived control was indeed negatively associated with youths’ symptoms of depression, tests of the full model generally indicated that perceived competence played a more important role. A similar conclusion was reached by Muris, Schouten, Meesters, and Gijsbers (2003), who examined the relevance of the CCC model for anxiety symptoms in young adolescents aged 10 to 14 years: “Beliefs about competence were the most consistent predictor of symptoms. Beliefs about control and contingency seemed to be less important” (p.337). Altogether, these findings suggest that perceived competence is more important than perceived control, which is of course difficult to reconcile with Chorpita and Barlow’s (1998) notion that the construct of control plays a central role in the aetiology of childhood anxiety. Yet, it should be noted that perceived control and perceived
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competence are closely allied constructs. So it may well be the case that the questionnaires developed for measuring control-related beliefs in youths simply cannot discriminate among these strongly resembling concepts.
Self-Related Concepts A number of self-related concepts can be found in the literature that bear strong resemblance to perceived control and competence (see Weems & Silverman, 2006). The first concept is self-esteem, which refers to children’s feelings of worthiness and value as a person. The second concept is self-efficacy, which is concerned with the perceived ability to produce a desired action. Self-esteem and self-efficacy are both thought to play a role in the regulation of emotional states, and although it is generally assumed that these concepts are relevant for various types of negative emotions, the content of this section is primarily focused on their relevance to anxiety.
Self-Esteem Harter (1999) views self-esteem as an evaluative aspect of the self-system, which is related to the image of an ideal self that we all have: When there is little discrepancy between the ideal and the perceived real self, the individual will experience high self-esteem. However, when the discrepancy is large, low self-esteem is the result. Self-esteem can be considered as an individual difference variable of which the foundation is laid in middle childhood when children develop the ability to compare themselves with peers (Ruble, Boggiano, Feldman, & Loebl, 1980). As a result of this comparison, children increasingly realize how they stand relative to their peers in various domains of functioning (school, sports, social relationships), and accordingly adjust their level of self-esteem. According to Harter (1999), two factors play an important role in the development and maintenance of self-esteem in youths. The first factor pertains to perceived competence in areas of importance, such as school, athletics, social relationships, physical appearance, and behavioral conduct: The higher children and adolescents judge their ability in these domains, the higher their level of self-esteem. The second factor refers to the experience of social support and implies that self-esteem is bolstered by support and approval of parents, teachers, and peers. A behavioral genetic study by McGuire, Manke, Saudino et al. (1999) has demonstrated that self-esteem in youths is primarily explained by genetic and nonshared environmental factors. The contribution of shared environment was negligible, which means that parents apparently play a less important role in the formation of self-esteem as previously thought. As to the development of self-esteem, various researchers have observed that selfesteem is fairly high during childhood, and then shows a significant decline when children enter adolescence (Robins, Trzesniewski, Tracy, Gosling, & Potter, 2002), probably as a result of the marked biological, cognitive, social, and academic changes that occur during this developmental transition (e.g., Finkenauer, Engels, Meeus, & Oosterwegel, 2002). Self-esteem is generally regarded as an important index of children’s well-being and mental health (see for a comprehensive review Bos, Muris, Mulkens, & Schaalma, 2006).
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High self-esteem has been linked to satisfaction and happiness in later life, while low selfesteem is associated with maladjustment both in school and social relationships (Harter, 1993). While most of the research in the field of child psychopathology has specifically focused on the link between low self-esteem and depression (e.g., Orvaschel, Beeferman, & Kabacoff, 1997), a number of studies have also examined the relationship between selfesteem and anxiety in youths. For example, in a longitudinal study by Cole, Peeke, Dolezal, Murray, and Canzoniero (1999), a large sample of young adolescents was followed during a two-year period. On four occasions, adolescents completed Harter’s (1985) Self-Perception Profile for Children as an index of self-esteem and scales measuring negative emotions, among which are anxiety symptoms. In general, a correlational analysis yielded support for the notion that low levels of self-esteem are associated with higher levels of negative emotions. Interestingly, a structural equation modeling approach to study prospective relationships indicated that the primacy of self-esteem vis-à-vis negative emotions appeared to depend on the type of self-esteem under investigation. More precisely, when self-esteem pertained to the domains of social acceptance, athletic competence, and physical appearance, low self-esteem was predictive of negative emotions. However, when self-esteem was concerned with scholastic competence and behavioral conduct, the reverse was true: Negative emotions predicted low self-esteem (see also Cole, Martin, Peeke, Seroczynski, & Fier, 1999). Various other studies have documented negative correlations between self-esteem and measures of trait anxiety and anxiety disorders symptoms in youths, which means that lower levels in various domains of self-esteem are accompanied by higher levels of anxiety (Epkins, 1996a; McCauley Ohannessian, Lerner, Lerner, & Von Eye, 1999; Muris, Meesters, & Fijen, 2003; Robinson & Kelley, 1999; Strauss, Lease, Kazdin, Dulcan, & Last, 1989; Wyman, Cowen, Hightower, & Pedro-Carroll, 1985). Terror management theory (TMT; Greenberg, Pyszczynski, & Solomon, 1986) is a theoretical account on the function of self-esteem, which assumes that there is an intimate relationship between self-esteem and anxiety. Briefly, TMT posits that people strive for positive self-evaluations, because self-esteem provides a buffer against a deeply rooted fear of death inherent to the human condition. When self-esteem is strong, this core anxiety is reduced, and the person is able to go about his or her daily affairs and act effectively in the world. When self-esteem is weak or challenged, this threatens a “breakthrough” of this basic anxiety, which instigates various forms of defensive behavior. Research so far has shown that high levels of self-esteem reduce anxiety and anxiety-related defensive behaviors (Pyszczynski, Greenberg, Solomon, Arndt, & Schimel, 2004), but no study can be found that has investigated the TMT in the context of anxiety disorders. Nevertheless, TMT researchers have hypothesized that anxiety disorders might be maladaptive attempts to focalize this core human anxiety, whereas the vulnerability factor of neuroticism has been conceptualized as a reflection of how well (or poorly) people are able to buffer death anxiety via the mechanism of self-esteem (Strachan, Pyszczynski, Greenberg, & Solomon, 2001). Clearly, these notions warrant further research, in particular in youth populations. As a final note on self-esteem, a birth cohort comparison by Twenge and Campbell (2001) indicated that the self-esteem scores of youths have shown a significant rise since the 1980s. This observation runs counter to the finding that the anxiety scores of children and adolescents did not show a decline but rather substantially increased during the last decades (Twenge, 2000). Of course, this finding seriously questions the protective qualities of
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self-esteem. Twenge and Campbell (2001) have argued that while youths’ self-esteem increased, other negative environmental influences (e.g., violence among youths) on children and adolescents accrued even more, and so the net effect of this protective buffer is nil. Another possibility raised by these authors is that whereas general self-esteem has grown, specific competence-based self-esteem has stagnated, suggesting that youths’ “elevated self-views are built on a foundation of sand” (p.341).
Self-Efficacy A second concept that is closely related to perceived control (and self-esteem) is selfefficacy. Self-efficacy has been defined as “the perceived ability to produce a desired action” (Bandura, 1997) and refers to a strong conviction of competence that is based on our evaluation of various sources of information about our abilities (Bandura, 1986). It is important to note that self-efficacy is partially independent of one’s actual abilities. For example, people who are highly competent at a particular task but have little faith in their ability are unlikely to attempt the task. In other words, when ability is high but self-efficacy is low, there is little chance that the task will be successfully accomplished. Furthermore, selfefficacy should be distinguished from outcome expectancy. While self-efficacy pertains to beliefs about one’s own competence, outcome expectancy refers to one’s estimate that a given action will lead to a certain outcome (see Bandura, 1986). According to Bandura (1997), self-efficacy plays a pivotal role in the self-regulation of affective states. In his words, “The [perceived] inability to influence events and social conditions that significantly affect one’s life can give rise to feelings of futility and despondency as well as anxiety” (p.153). Briefly, when people perceive themselves as inefficacious to gain highly valued outcomes, they will be depressed. Otherwise, when people see themselves as ill equipped to cope with potentially threatening events, they will become anxious. There seem to be three important pathways along which a low sense of self-efficacy may give rise to feelings of depression and anxiety. First of all, when people face a situation in which they have to meet highly valued standards, a low sense of self-efficacy may produce despondent mood and anticipatory apprehension. This is particularly true when people’s personal standards of merit are set well above their perceived efficacy to attain them. Second, a low sense of social self-efficacy may hinder the formation of positive social relationships that bring satisfaction to people’s life and enable them to manage stressful experiences, and thereby may promote depressed feelings. Furthermore, the lack of social self-efficacy makes people believe that they cannot meet others’ evaluative standards, and this is likely to enhance anxiety in social situations. Third and finally, low self-efficacy about the exercise of control over negative thoughts may also boost anxiety and depression. All people will experience anxious, worrisome, and depressed thoughts from time to time, but they vary in how well they are able to deal with these thoughts. While some people successfully cope with negative thinking, others may use ineffective strategies that even trigger further strings of negative thoughts (Bandura, 1997). Self-efficacy refers to various domains of functioning, but there may be three domains that are particularly relevant to children and adolescents—namely, social self-efficacy (i.e., the perceived capability of engaging in peer relationships and to display assertive behavior),
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academic self-efficacy (i.e., the perceived capability to manage one’s own learning behavior, to master academic subjects, and to fulfill academic expectations), and emotional selfefficacy (i.e., the perceived capability of coping with negative emotions; Muris, 2001). A study by Muris (2002d) examined the relationships between self-efficacy and symptoms of affective disorders in a large sample of nonclinical adolescents (N = 596). Participants completed the Self-Efficacy Questionnaire for Children (SEQ-C; see Appendix) and scales that measure symptoms of anxiety disorders and depression. Results demonstrated that a general lack of self-efficacy was accompanied by high symptom levels of anxiety disorders and depression (see also Bandura, Pastorelli, Barbaranelli, & Caprara, 1999). Further analysis revealed that low levels of social self-efficacy were uniquely related to anxiety disorders symptoms, low academic self-efficacy was exclusively associated with depression, whereas lack of emotional self-efficacy was linked to symptoms of both types of affective disorders (see Figure 4.8). Finally, some support was found for the notion that deficits in specific domains of self-efficacy were associated with particular types of anxiety problems. That is, low social self-efficacy was most strongly connected to social phobia, low academic selfefficacy to school phobia, and low emotional self-efficacy to generalized anxiety and panic symptoms. Altogether, although more prospective research is needed in this area, it is clear that self-efficacy is an important individual difference variable that may protect children and adolescents against the development of anxiety problems. In conclusion, then, self-esteem and self-efficacy are individual difference variables that have been put forward as protective factors against the development of anxiety and other negative emotions. In their thorough review, Dubois and Tevendale (1999) have noted that this positive notion on the role of such self-related concepts on youths’ well-being may be oversimplified and inaccurate. Briefly these authors argue that while “self-esteem is portrayed as a powerful positive influence on youth adjustment . . . the adaptive implications of self-esteem [and self-efficacy] during childhood and adolescence appear to be complex and differentiated, ranging from highly beneficial to possibly even negative” (p.103). For
0 –0,1 –0,2
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*
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Academic self-efficacy
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Figure 4.8: Unique associations (standardized β-coefficients) between symptoms of anxiety disorders and depression and various domains of self-efficacy in a large sample of nonclinical adolescents. * p < .001. Based on: Muris (2002).
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example, several authors have argued that externalizing problems are associated with high levels of self-esteem and may result from threatened egotism (e.g., Baumeister, Smart, & Boden, 1996). In addition, as described earlier, there are probably bidirectional relations between self-concepts and adjustment, and the difference between self-esteem and selfefficacy as the cause or the consequence of psychological problems may depend on the domain of functioning under investigation (Cole et al., 1999). Finally, it should be kept in mind that the link between self-concepts and youths’ (mal)adjustment is just one piece of the puzzle, which means that in reality other factors are likely to be also involved. This is nicely illustrated by a recent study of Troop-Gordon and Ladd (2005), who investigated the role of social self-esteem and positive beliefs about peers as mediators in the relationship between peer victimization and internalizing problems in children who were followed longitudinally between the ages of 9 and 11 years. Results indeed provided support for a model in which peer victimization reduced children’s social self-esteem and positive beliefs about peers, which in turn were both associated with increases in internalizing problems over time. Clearly, there is a need for more prospective research in which the presumed positive effects of self-concepts on adjustment in children and adolescents are further investigated.
Coping, Defense, and Emotion Regulation Coping and defense refer to psychological processes that help the individual to deal with stressful and threatening internal and external events. Briefly, these processes include ways in which a person regulates emotions, controls physiological responses, and responds to the environment to change or decrease sources of stress and adversity. This description makes clear that coping and defense essentially are adaptive mechanisms. However, not all defense mechanisms and coping styles are associated with favorable psychological adjustment. Whether a certain defense mechanism or coping style is effective may depend on situational aspects such as specific characteristics of the stressor (e.g., chronicity, controllability) or personal variables such as lack of flexibility in employing various types of coping strategies. While coping and defense serve the same purpose (American Psychiatric Association, 2000), both have their own theoretical background and research tradition, and therefore this section will discuss the two constructs in separate paragraphs.
Coping The most widely employed definition of coping is that of Lazarus and Folkman (1984), who describe coping as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (p.141). This view on coping fits within Lazarus’s (1993) motivational model of emotion, which emphasizes the importance of cognitive appraisal in determining what stimuli and situations are threatening and stressful to the individual, and which considers coping as a goal-directed process during which the individual directs thoughts and behaviors toward the purpose of resolving the source of stress and dealing with the emotional responses
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to stress. As such, two basic ways of coping are described in this model: problem-focused coping, which purports to change the stressful situation itself, and emotion-focused coping, which is directed at palliating the negative emotions that arise as a consequence of the stressful event. Clearly, Lazarus and Folkman’s (1984) have emphasized that coping is a situation-determined and dynamic process that constantly changes in response to the altering demands of the stressful encounter (Folkman & Lazarus, 1985). Many psychologists, however, hold the view that individuals during their life gradually develop a relatively stable set of response patterns that they employ as soon as they are confronted with threatening situations. These so-called coping styles would to a large extent determine how people respond to such stressful events (e.g., Carver, Scheier, & Weintraub, 1989). Since the seminal work by Lazarus and Folkman (1984), a number of perspectives on coping processes in children and adolescents have been outlined. The most influential model has probably been formulated by Compas and colleagues (Compas, 1987, 1998; Compas, Connor, Osowiecki, & Welch, 1997; Compas, Connor, Saltzman, Thomsen, & Wadsworth, 1999) who view coping as “volitional efforts to regulate emotion, cognition, behavior, physiology, and the environment in response to stressful events and circumstances” (Compas, Connor-Smith, Saltzman, Thomsen, & Wadsworth, 2001; p.89). This definition bears strong similarity to that of Lazarus and Folkman (1984). Yet, it is important to note that Compas and colleagues (2001) adapt a more developmental perspective as they noted that the coping attempts in youths “are constrained by the biological, cognitive, social and emotional development” (p.89), which means that children and adolescents’ developmental level contributes to the resources that are available for coping and limits the types of coping responses that youths can deploy. While this developmental approach certainly makes sense, it also implies that it is difficult to study the process of coping in youths as it is quite complicated to define and categorize the wide variety in coping strategies that are used by children and adolescents of various ages (Compas, 1987, 1998). Nevertheless, a number of broad dimensions in coping can be discerned that are helpful when examining this phenomenon (see Compas et al., 2001). The first dimension refers to Lazarus and Folkman’s (1984) distinction between problem- and emotion-focused coping, with the former including strategies that purport to change the stressful situation itself (e.g., information seeking, thinking up possible solutions, and active problem solving), and the second referring to strategies that try to soothe the negative emotions elicited by the situation (e.g., expressing emotions, distraction, avoidance). The second dimension is somewhat different and pertains to the distinction between engagement and disengagement coping and is concerned with, respectively, strategies that are oriented either toward the source of stress or toward one’s emotions or thoughts (e.g., problem solving, catastrophizing), and strategies that are oriented away from the stressor or one’s emotions and thoughts (e.g., avoidance, denial). Various instruments have been developed to assess aspects of these dimensions in children and adolescents such as the Kidcope (Spirito, Stark, & Williams, 1988), the Self-Report Coping Scale (Causey & Dubow, 1992), and the Responses to Stress Questionnaire (Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000). As to the links between coping and psychopathological symptoms in youths, the thorough review by Compas et al. (2001) has yielded the conclusion that problem-focused and engagement coping are generally found to be associated with better psychological adjustment, whereas emotion-focused and disengagement coping are usually reported to be linked
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to poorer psychological health. This conclusion seems also true for anxiety symptoms in children and adolescents, although it should be acknowledged that most studies in this area have focused on depression symptoms or mixed anxiety-depression (e.g., Langrock, Compas, Keller, Merchant, & Copeland, 2002; Weisz, McCabe, & Dennig, 1994). The majority of studies that have included a specific measure of childhood anxiety symptoms is concerned with the effects of engagement versus disengagement coping. For example, Herman and McHale (1993) investigated coping responses and anxiety (as indexed by the Revised Children’s Manifest Anxiety Scale; Reynolds & Richmond, 1978) in a sample of 152 9- to 12-year-old children who were confronted with parental negativity. Results showed that children’s employment of an engaging strategy (i.e., problem solving) was related to lower levels of anxiety symptoms, whereas the use of a disengaging strategy was associated with higher levels of such symptoms. Comparable findings were obtained in other studies that examined the effects of engagement coping and disengagement coping on youths’ anxiety reactions in response to a variety of stressors, including sickle cell disease (Lewis & Kliewer, 1996), cancer (Frank, Blount, & Brown, 1997), death of a biological parent (Smith & Brodzinsky, 2002), and moving to a foreign country (Lopez & Little, 1996). Research on the effects of problem- and emotion-focused coping on anxiety symptoms in youths is sparse. One exception is a study by Compas, Worsham, Ey, and Howell (1996), who examined appraisal, coping, and adjustment in 134 children, adolescents, and young adults who had a parent with cancer. Results indicated that appraisal of stress and emotion-focused coping were significant predictors of avoidance and anxiety symptoms. Although the positive effects of problem-focused/engagement coping and the negative effects of emotion-focused/disengagement coping on childhood anxiety make sense, a number of issues should be borne in mind that somewhat qualify this general conclusion. First, it should be borne in mind that the effects of a certain coping strategy may depend significantly on the type of circumstances that children have to deal with. As an example, Kochenderfer-Ladd and Skinner (2002) examined the effects of coping strategies in 9- to 10-year-old children who had been victimized by peers and nonvictimized control children. Results indicated that whereas problem solving was a beneficial strategy for nonvictimized children, this very same strategy appeared to exacerbate the problems for victimized children. Second, not only the coping strategies themselves but also the way in which they are employed seem to be important. For example, Lengua and Sandler (1996) investigated adjustment in children of whom the parents had divorced. These researchers noted that the effects of active and avoidant coping strategies were moderated by flexibility in the use of coping. More precisely, active coping was associated with lower levels of anxiety but only when children displayed high levels of flexibility. In contrast, avoidant coping was related to higher levels of anxiety, and this appeared particularly true when children exhibited low levels of flexibility (see Figure 4.9). Third, the dimensions of emotion-focused/problemfocused coping and engagement/disengagement coping are rather broad and general, and it should be borne in mind that they consist of a variety of specific strategies that do not all have similar consequences for children and adolescents’ adjustment. A case in point is the monitoring coping style (Miller, 1987), which refers to the extent to which an individual scans for or attends to threatening information. According to this definition, monitoring can be categorized as a problem-focused/engaging coping strategy and so could be considered as an adaptive way of dealing with stress. However, Hoffner (1993) carefully analyzed the
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Figure 4.9: Interaction effects of active and avoidant coping and flexibility of employing coping responses on anxiety symptoms in children of divorced parents. Based on: Lengua & Sandler (1996).
construct of monitoring in children and noted that this coping style refers to a variety of responses of which some may indeed be very useful for effectively dealing with a stressor (e.g., seeking information, taking precautions), whereas others may clearly promote distress (e.g., focusing on threat cues, anticipating negative events). Not surprisingly, a number of studies have found that monitoring is associated with higher levels of distress, fear, and anxiety symptoms in youths (Miller, Roussi, Caputo, & Kruus, 1995; Muris, Meesters, & Merckelbach, 1996; Muris, Merckelbach, Gadet, & Meesters, 2000) and thus can best be considered as a maladaptive rather than an adaptive coping style. Fourth, Compas et al. (2001; p.121) have rightly noted that “although there is evidence of an association between coping and concurrent symptoms of distress and psychopathology, the causal role of coping in [youths’] adjustment is much unclear.” Obviously, more prospective research is needed to clarify whether certain coping strategies result in psychopathological symptoms or
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whether certain symptoms enhance the employment of particular coping strategies. Fifth and finally, as mentioned earlier, few studies have addressed the specific relationship between coping and anxiety. Future investigation should examine this link, and also make an attempt to explore the links between coping and pathological manifestations of anxiety in children and adolescents.
Defense Mechanisms Since the 1990s, there has been a revival of the psychodynamic concept of defense. Even the latest editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 1994, 2000) include a defensive functioning scale as a proposed axis for further study. The DSM defines defense mechanisms as “automatic psychological processes that protect the individual against anxiety and from awareness of internal or external dangers or stressors” (p.807). Although this definition resembles that of coping, there are two specific elements that clearly refer to Freud’s (1914) theoretical ideas. The first element is anxiety, which does not refer to fear and anxiety symptoms per se but rather should be viewed as “neurotic anxiety,” which is concerned with an unconscious concern about the consequences of expressing one’s deeply rooted instincts. The second element is awareness and refers to Freud’s distinction between the consciousness and the unconsciousness: Defense mechanisms would enable a person to repress instinctual urges by keeping them from awareness, thereby reducing the unwanted arousal associated with them (A. Freud, 1936; see Kendall & Hammen, 1995). Longitudinal research by Vaillant (1977) has shown that defense style can be regarded as an enduring facet of personality, with its mature components facilitating good adjustment and mental health, and its neurotic and immature aspects promoting maladaptation and psychopathology. Further empirical studies with adult populations have indeed demonstrated that defense styles differ between patients and nonpatients (Andrews, Singh, & Bond, 1993) and among various axis I disorders (Andrews et al., 1993; Bond & Sagala Vaillant, 1986; Pollock & Andrews, 1989) and axis II personality disorders (Bond, Paris, & ZweigFrank, 1994; Vaillant, 1994). Furthermore, maturity of defense style appears to be related to general level of functioning (Vaillant, 1994). Few studies have examined the connection between defense style and psychopathology in youths, notwithstanding the fact that adolescence is a developmental transition stage that poses a lot of psychological challenges (Wenar & Kerig, 2000). In general, results have demonstrated that greater maturity of defense style in adolescents is associated with better adjustment, while greater immaturity of defense style is linked to a lower level of functioning (Erickson, Feldman, & Steiner, 1996, 1997; Steiner & Feldman, 1995). There is one study in the literature that has specifically examined the relationship between defense mechanisms and anxiety symptoms in youths. In that study, Muris, Winands, and Horselenberg (2003) asked a large sample of adolescents (N = 437) to complete an age-downward version of the Defense Style Questionnaire (Andrews et al., 1993), which is a self-report inventory for measuring defense mechanisms in three defense style categories, namely mature (e.g., sublimation, anticipation), neurotic (e.g., undoing, idealization), and immature (e.g., projection, passive aggression), a measure of neuroticism (as an index of general vul-
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Figure 4.10: Unique associations (standardized β-coefficients) between defense styles and neuroticism, on the one hand, and symptoms of anxiety disorders, on the other hand, in a sample of 437 nonclinical adolescents. AD = Anxiety Disorders, SOP = Social Phobia, SAD = Separation Anxiety Disorder, GAD = Generalized Anxiety Disorder, PD = Panic Disorder, OCD = Obsessive-Compulsive Disorder. * p < .05/4 (i.e., Bonferroni correction). Based on: Muris, Winands, & Horselenberg (2003).
nerability to psychopathology), and a scale measuring symptoms of DSM-defined disorders, including various anxiety disorders. As can be seen in Figure 4.10, defense style made a significant contribution to anxiety disorder symptoms, even when controlling for levels of neuroticism. Note that in particular neurotic defense emerged as a consistent predictor of all anxiety symptoms: all Betas were positive, which indicates that high levels of neurotic defense were linked to higher levels of anxiety symptoms. Only in the case of panic disorder symptoms, mature and immature defense styles accounted for an additional proportion of the variance: as expected mature defense was negatively associated with panic, whereas immature defense was positively related to this type of anxiety. The relationship between defense and anxiety disorders (symptoms) in youths certainly needs further research attention. Such investigations should preferably employ a longitudinal approach in order to resolve the cause-effect issue in the association between defense and anxiety. In a prelude on such research, a recent prospective study by Cramer and Tracy (2005) explored the link between childhood defense styles and subsequent adjustment in early adulthood. These researchers found that especially shifts in personality that were guided by changes in the employment of certain defense mechanisms, were the strongest predictor of adult adjustment. Clearly, this finding indicates that the link between defense and psychopathology is quite complicated and probably does not reflect a simple causeeffect relationship. As a final note, it seems important to mention that defense mechanisms, just like coping strategies, in essence serve adaptive purposes. However, the quantity and quality in the use of certain defense mechanisms may determine the pathways to either normal adjustment or psychopathology. Dissociation, for instance, which is generally
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considered as a pathogenic defense mechanism that is thought to be involved in the origins of posttraumatic stress disorder (PTSD; Merckelbach & Muris, 2001), may have negative but also positive consequences. Armstrong, Putnam, Carlson, Libero, and Smith (1997), who examined this defense mechanism in an adolescent population, have described this point as follows: “Dissociative-like experiences of identity confusion and dividedness as well as periods of depersonalisation and absorption in one’s imagination appear to be intrinsic to health in adolescence. . . . On the other hand, chronic dissociative compartmentalisation of affect, behavior, and memory is likely to interfere with the adolescent’s ability to construct a cohesive sense of the self and to integrate intensified sexual, aggressive, and relational needs” (pp.491– 492). There is indeed some empirical support for the idea that benign forms of dissociation are quite common in youths and that the more pathological forms of this defense mechanism are positively associated with psychopathology, including symptoms of PTSD and other anxiety disorders (Brunner, Parzer, Schuld, & Resch, 2000; Kassam-Adams & Winston, 2004; Kenardy, Smith, Spence et al., 2007; Kisiel & Lyons, 2001; Muris, Merckelbach, & Peeters, 2003). As another example, suppression, which in the DSM is considered to be a mature and adaptive defense mechanism, may have important negative consequences if employed too frequently. Various researchers have shown that even suppression of a neutral thought may be counterproductive in that the to-be-suppressed thought will backfire and intrude the consciousness over and over again (Wegner, Schneider, Carter, & White, 1987; see for a review, Rassin, 2005). Research on the effects of thought suppression in youth populations is sparse, but there is evidence from a prospective study by Ehlers, Mayou, and Bryant (2003) that suppression of trauma-related images and thoughts are predictive of more severe PTSD symptoms in children who had experienced a road traffic accident.
Emotion Regulation Emotion regulation is a concept that bears strong similarity with coping and defense, but nevertheless has generally been treated as a separate construct in the literature. A frequently employed definition was launched by Thompson (1994; pp.27–28), who described emotion regulation as “extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals.” Southam-Gerow and Kendall (2002; p.192) noted that emotion regulation essentially refers to “a dialectical construct involving both emotion as a behavior regulator and emotion as a regulated phenomenon” (see also Campos, Frankel, and Camras, 2004; Cole, Martin, & Dennis, 2004) and rightly pointed out that most research has focused on the latter aspect—namely, on how youths attempt to regulate their emotions, by studying behaviors that are employed by children and adolescents to adjust emotional reactions. Various emotion-regulation strategies have been described in the literature, including the use of distraction, problem-solving, attention shifting, self-soothing, cognitive restructuring, comfort-seeking, and mobilizing positive emotions (see Silk, Shaw, Skuban, Oland, & Kovacs, 2006). During childhood, children gradually develop the capacity to self-regulate their emotions. Young children deploy rather rudimentary behaviors to regulate emotional experiences (e.g., seeking physical comfort from a caregiver), but as children grow older,
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these behaviors become increasingly complex and sophisticated (e.g., cognitive restructuring; Kopp, 1989). It is widely assumed that adequate emotion regulation is a prerequisite for preserving mental health, and that dysfunctional emotion regulation is associated with the emergence of psychopathology in children and adolescents (Southam-Gerow & Kendall, 2002). Not surprisingly, problems in emotion regulation have been implicated in a wide range of childhood disorders, including depression and disruptive behavior disorders. Research on emotion regulation in youths with anxiety disorders is scant. An exception is a recent study by Suveg and Zeman (2004), who examined various aspects of emotion regulation in a sample of 26 8- to 12-year-old children with anxiety disorders and a non-psychiatrically-ill control group. For this purpose, children and their parents were investigated by means of self-report questionnaires and an interview to measure the frequency and intensity of three types of emotions (worry, anger, and sadness) and the employment of and confidence in coping skills to manage these negative emotions. The results showed that anxiety disordered youths displayed more intense and dysregulated expressions across all emotions than control children. Furthermore, children with anxiety disorders reported less adaptive coping strategies and perceived themselves as less efficacious in controlling the emotions than children without anxiety disorders (see Figure 4.11). On the basis of these findings, Suveg and Zeman (2004) conclude that children with anxiety disorders have “difficulty managing worried, sad, and anger experiences, potentially due to their report of experiencing emotions with high intensity and having little confidence in their ability to regulate this arousal” (p.750). A study by Southam-Gerow and Kendall (2000) further qualified this conclusion. These researchers found that, compared to control children, youths with anxiety disorders exhibited a poor understanding of emotions (see also Simonian, Beidel, Turner, Berkes, & Long, 2001), and in particular of the way to hide and to change emotions. Altogether, difficulties with emotion regulation seem to be clearly associated with anxiety problems in youths, and this has led some
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Figure 4.11: Scores on various aspects of emotion regulation in anxiety disordered (AD) children and control children. All between-group differences were significant at p < .01. * For this variable, scores were adjusted to make them somewhat comparable to scores on the other variables. Based on: Suveg & Zeman (2004).
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researchers to propose that “emotion regulation needs to be considered centrally in research with anxious populations” (Suveg & Zeman, 2004; p.750). Taken together, coping, defense, and emotion regulation are phenomena that come into play as soon as children and adolescents are confronted with (potentially) stressful and aversive circumstances, which give rise to negative emotions. Research has indicated that maladaptive coping and defense and dysfunctional emotion regulation are associated with anxiety problems in youths. There is accumulating evidence showing that coping, defense, and emotion regulation are not just protective factors that play a unique role in the aetiology of pathological anxiety in children and adolescents, but rather should be viewed as variables that (a) moderate the negative impact of stressful life events (e.g., Silk, Shaw, Forbes, Lane, & Kovacs, 2006), and (b) are the mediating link between family-based vulnerability factors (such as attachment, negative parental rearing behaviors, and family stress) and childhood anxiety problems. As an example, in a recent study, Langrock et al. (2002) examined coping and internalizing problems in 7- to 17-year-old children who were living with a depressed parent. Results yielded support for a mediation model in which negative parental characteristics were associated with less adaptive coping strategies, which in turn were related to higher levels of anxiety and depression. Interestingly, these findings fit nicely with the idea that family socialization practices play an important role in the formation of coping, defense, and emotion regulation skills (e.g., Eisenberg, Cumberland, & Spinrad, 1998; Purdie, Carroll, & Roche, 2004; Suveg, Zeman, Flannery-Schroeder, & Cassano, 2005; Wenzlaff & Eisenberg, 1998; Wolfradt, Hempel, & Miles, 2003).
Social Support Social support is generally viewed as a protective factor that plays an important role in the maintenance of children and adolescents’ adjustment and well-being. Obviously, this notion fits nicely with theories that ascribe primacy to interpersonal relationships in children’s development toward adulthood (e.g., attachment theory; Bowlby, 1969), but many psychologists from other theoretical backgrounds will agree on the fact that “belonging to a network of communication and mutual obligation, being esteemed and valued by others, and being loved and cared for by others” (Cobb, 1976) is a basic need for all human beings. In the context of child psychopathology, social support has been primarily investigated as a moderator variable that buffers the negative impact of stress. Indeed, various studies have shown that support from parents and peers indeed protects youths against the development of high levels of internalizing and externalizing symptoms after being confronted with adverse circumstances and negative life events (e.g., divorce, victimization, abuse, poverty; see Grant, Compas, Thurm et al., 2006). As for the link between social support and anxiety in children and adolescents, research is generally in keeping with the general conclusion that support has a protective function. For example, Quamma and Greenberg (1994) examined the moderating effects of family social support on the relation between stressful life events and children’s adjustment. For this purpose, 322 children completed self-report scales for measuring perceived family support and experiences of stressful events during the past years, while teachers provided reports on children’s internalizing problems. Results revealed a main effect of family
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support on internalizing symptoms: Children who perceived their family as less supportive displayed higher levels of teacher-reported internalizing symptoms. Most importantly, evidence was also found for the hypothesized moderating effect of family support: That is, the negative impact of stressful life events on children’s internalizing symptoms was significantly reduced by high levels of perceived family support. Comparable findings have been obtained in studies examining the anxiety-buffering effects of social support in children and adolescents who had been exposed to rheumatic disease (Von Weiss, Rapoff, Varni et al., 2002), community violence (Hill, Levermore, Twaite, & Jones, 1996; White, Bruce, Farrell, & Kliewer, 1998), dating violence victimization (Holt & Espelage, 2005), or a sibling with cancer (Barrera, Fleming, & Khan, 2004). In Chapter 3, evidence was summarized indicating that negative life events appear to increase the risk for anxiety problems. Interestingly, Shahar and Priel (2002) recently demonstrated that positive life events may be protective against the development of anxiety and depression symptoms. In their study, 603 adolescents aged 14 to 16 years completed measures of anxiety and depression during their first week at school. Sixteen weeks later, youths’ symptoms were measured again as well as a number positive and negative life events they had been experiencing since the beginning of school. Results showed that positive life events, and in particular positive interpersonal events (e.g., participating in enjoyable social activities), had a direct protective effect on the development of internalizing symptoms but also appeared to function as a buffer against the impact of negative life events. These findings suggest that socially supportive experiences may protect youths against the emergence of anxiety symptoms. While it can be concluded that social support indeed has a positive impact on youths’ adjustment to stress in that it results in lower levels of anxiety symptoms, a number of findings have emerged from the literature that seem to qualify this general conclusion. First, various studies have indicated that there may be significant gender differences in the need and employment of social support as a strategy to deal with stressful circumstances (SeiffgeKrenke, 1995). For instance, a study by Landman-Peeters, Hartman, Van der Pompe et al. (2005) on gender differences in the use and effects of social support in high-risk adolescents (who had a parent with depression and/or an anxiety disorder) has indicated that girls benefit more from social support than boys, in particular when the living conditions within the family are more problematic. Second, age may also have an impact on the protective influence of social support. There is clear evidence that parental support shows a clear decrease from childhood to adolescence. Nevertheless, even in older adolescents, parental support remains negatively linked to the emergence of emotional symptoms such as anxiety, although the effects of this protective factor appear to decline as youths grow older (Helsen, Vollebergh, & Meeus, 2000). Third, the buffering effect of social support may also depend on the severity of the stressor. A recent study by Hammack, Richards, Luo, Edlynn, and Roy (2004) seems to indicate that social support may be protective with a relatively mild stressor (i.e., witnessing violent behavior). However, when a stressor becomes more severe (i.e., being a victim of violence), social support may fail to shield youths against the development of negative emotions. Fourth, social support may also have detrimental effects. That is, when social support is too strong, children and adolescents may become dependent on the person that provides the emotional or instrumental aid, and this may hinder successful adaptation in the long term. Otherwise, if social support is interspersed with blame and
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criticism, the supporting person can be typified as high on “expressed emotion,” which as described earlier (Chapter 3) has a negative impact on the psychological well-being of youths (e.g., Fokias & Tyler, 1995).
Conclusion This Chapter summarized a variety of protective factors, including effortful control, perceived control, self-related concepts such as self-esteem and self-efficacy, coping strategies, defense mechanisms, emotion regulation, social support, and the experience of positive life events. It can be concluded that these protective variables are certainly involved in (pathological) fear and anxiety phenomena in youths. Yet, it should also be mentioned that they do not seem to be very specific to childhood anxiety, but rather play a role in a broad range of psychological disorders in youths. This might suggest that most of these factors should not be regarded as key constructs in the pathogenesis of anxiety disorders in children and adolescents. However, it should be kept in mind that such protective factors often play a mediating or moderating role in the process between threat and stress, on the one hand, and the emergence of high fear and anxiety, on the other hand, which means that these variables may eventually make the difference between normal and abnormal fear and anxiety reactions in youths. Another important point that should be mentioned here is concerned with the fact that there seem to be not only relationships between vulnerability factors and protective factors, but also among protective factors. This point can be nicely illustrated by means of a study by Lengua and Long (2002), who assessed emotionality (as an equivalent of neuroticism) and effortful control as predictors of children’s appraisal and coping styles and adjustment problems in a community sample of 8- to 12-year-old children. Mothers rated children’s temperament factors and adjustment problems, whereas children reported on threat appraisal and active and avoidant coping styles. Results demonstrated that emotionality was positively associated with threat appraisal, avoidant coping, and subsequent adjustment problems. In contrast, effortful control predicted more active coping and lower adjustment problems. Thus, evidence was obtained that vulnerability (i.e., emotionality) had an impact on a protective factor (i.e., coping), whereas one protective factor (i.e., effortful control) was related to another protective variable (i.e., coping). Obviously, this finding corresponds nicely with the conceptualization that pathological fear and anxiety in youths result from a dynamic interplay of vulnerability and protective factors (see Chapter 6). As to the relations among various protective factors, one might argue that some of these essentially refer to similar processes. For example, it is clear that coping, defense, emotion regulation, and social support are strongly allied constructs, whereas the same may be true for perceived control and self-related concepts such as self-esteem and self-efficacy. Otherwise, it seems also true that a regulative mechanism like effortful control may form the basis for other protective factors. In short, a person with high levels of effortful control may be more able to deploy adaptive and flexible coping strategies than a person with low levels of this regulative trait (see Muris & Ollendick, 2005). In a similar vein, various authors have argued that dysfunction in the frontal brain areas, which seems to be a key feature of effortful control problems, may be related to difficulties in the regulation of negative emotions such as anxiety (Lewis & Stieben, 2004).
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Admittedly, even though this chapter made an attempt to give an overview of various protective mechanisms that are associated with childhood anxiety, these positive factors were sometimes approached in a rather negative way. That is to say, in the context of child psychopathology, the emphasis is frequently on the deficiency of phenomena like control, self-esteem, and effortful control (Masten, 2006). Several authors have called for a new approach in psychology, one that focuses less on what is defect or lacking but builds more on strengths (Duckworth, Steen, & Seligman, 2005; Snyder & Lopez, 2002). Such a “positive psychology” approach (Seligman, 2002) might guide clinicians and researchers to really start looking at the protective features that may buffer children and adolescents against the development of pathological anxiety.
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Chapter 5
Maintaining Factors
Introduction Once children and adolescents have developed an anxiety disorder, this condition is likely to be maintained and intensified by a variety of influences. The two-stage model of Mowrer (1960) suggests that avoidance behavior is responsible for the continuation of anxiety problems. Briefly, the first stage of this model is concerned with the acquisition of fear and anxiety through classical conditioning (see Chapter 3). The second stage of the model addresses the maintenance of fear and anxiety and focuses on avoidance behavior that according to Mowrer (1939; p.564), “brings about a state of relief and security,” and in this way negatively reinforces the avoidant behavior. It can be assumed that avoidance prolongs fear and anxiety: As direct contact with the fear-provoking stimulus or situation is minimized, the anxious person will not have the opportunity to learn that the stimulus or situation is in fact harmless or safe. The role of avoidance behavior in the maintenance of childhood phobias and anxiety disorders seems self-evident (Ollendick, Vasey, & King, 2001): Many clinicians, and in particular behavior therapists, will quickly accept the idea that the child’s anxiety problem persists as a result of the evasion of fear-provoking stimuli and situations (e.g., Albano, Krain, Podniesinski, & Ditkowsky, 2004). Besides avoidance behavior, there are also a number of cognitive distortions that promote continuation of these psychopathological problems. Cognitive distortions refer to cognitive processes that are biased and erroneous and therefore yield dysfunctional and maladaptive thoughts and behaviors. Typically, in anxiety disorders, such distortions reflect the chronic overactivity of schemas organized around themes of danger and threat (Kendall, 1985). Recent research has demonstrated that these cognitive distortions also occur in high anxious and anxiety disordered children and adolescents (e.g., Vasey & MacLeod, 2001). This chapter is concerned with aberrant cognitive processes that are thought to play a role in the maintenance of childhood anxiety disorders. First, an information-processing approach will be adopted, and various anxiety-related biases and distortions that occur during various stages of cognitive processing will be discussed. Then, the focus will be shifted toward the faulty and negative ways of thinking of children and adolescents with anxiety problems. When studying such negative and faulty thinking, it seems important to note that some of these thinking patterns are relevant for a broad range of anxiety disorders (e.g., catastrophizing, worry), whereas other patterns are rather specific for one particular type of anxiety problem.
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Information-Processing Abnormalities In an intriguing review article, Daleiden and Vasey (1997) have formulated an informationprocessing perspective on childhood anxiety in which they described various types of cognitive distortions that occur throughout the information-processing sequence. Briefly, they employed the model proposed by Dodge (1991; see Crick & Dodge, 1994), who discerns a number of stages that describe the flow of information through the processing system. For example, during the encoding stage, children and adolescents select the most relevant information of the stimulus or situation for further processing, whereas other less important information is neglected. During the subsequent interpretation stage, meaning is attached to the information that is encoded, and during the following stages this interpretation is employed as the main guideline for the selection and enactment of a behavioral response. In particular during the early stages of information-processing (i.e., encoding and interpretation), a number of cognitive distortions have been identified that likely play a role in the maintenance of anxiety problems in youths.
Attentional Bias Some cognitive distortions occur during the early stages of information-processing and reflect unintentional, effortless, relatively fast processes that take place without awareness. A good example of such an automatic cognitive distortion is attentional bias, which refers to anxious subjects’ tendency to display hyperattention toward potentially threatening material (MacLeod, Mathews, & Tata, 1986; Mathews & MacLeod, 1985; see Beck & Clark, 1997; Mogg & Bradley, 1998). A frequently employed experimental technique for demonstrating this attentional bias is the emotional Stroop task. In this task, subjects are required to name the color in which words are printed while ignoring the meaning of these words. A consistent finding in Stroop studies with, for example, spider phobics is that their colornaming of fear-relevant words (e.g., “creepy,” “hairy”) is slower than that of neutral words (e.g., “table,” “cars”). This is due to the fact that phobics automatically direct their attention to the content of the threatening words, and this interferes with their main task of colornaming (e.g., Watts, McKenna, Sharrock, & Trezise, 1986). There are reasons to believe that learning experiences like, for example, aversive conditioning events, promote an attentional bias (Merckelbach, Van Hout, De Jong, & Van den Hout, 1990). In addition, attentional bias for threat cues disappears in anxiety patients who have been successfully treated (e.g., Lavy, Van den Hout, & Arntz, 1993; Watts et al., 1986). Together these findings indicate that attentional bias is a consequence rather than a cause of anxiety (McNally, 1998). However, this is not to say that attentional bias is just an epiphenomenon without clinical ramifications. It is highly plausible that attentional bias leads to an increased encoding of threatening material, thereby elevating fear and anxiety levels, which in turn further intensify attentional bias, and so forth (e.g., Williams, Watts, MacLeod, & Mathews, 1997). In Mineka and Sutton’s (1992) words: “One can easily see how the attentional bias toward threatening information associated with anxiety would tend to perpetuate or even enhance the emotion because of the increased focus on danger and threat cues” (p.68). Most research on anxiety-related attentional bias has been concerned with adult participants. Yet, there is
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increasing evidence that this type of cognitive distortion also occurs in fearful and anxious children and adolescents. Besides the previously described modified Stroop task, various other experimental methods (e.g., the dot probe paradigm) have been employed to examine attentional bias in youths. In the following paragraphs, a comprehensive overview of the research on attentional bias in children and adolescents will be provided. Modified Stroop Task. Martin, Horder, and Jones (1992) were the first to use this method in the context of childhood fear and anxiety. These researchers employed the modified Stroop task to test spider-fearful and nonfearful children in three age groups: 6- and 7-yearolds, 9- and 10-year-olds, and 12- and 13-year-olds. The results of their study showed that spider-fearful children exhibited retarded color-naming times when confronted with spiderrelated words but not when confronted with neutral words. Furthermore, it was observed that this fear-related interference effect was already present in the children of the youngest age group (i.e., the 6- and 7-year-olds). Similar results were obtained in a follow-up by Martin and Jones (1995), who this time used pictorial stimuli to examine Stroop interference effects in children aged between 4 and 9 years. Thus, spider-fearful children displayed slower color-naming to spider stimuli relative to neutral stimuli than nonfearful children. In further research by Richards, Richards, and McGeeney (2000), high- and low-anxious adolescents aged 16 to 18 years were presented with threat-related and neutral Stroop stimuli on separate cards. As predicted, the high-anxious group was significantly slower to identify the color of threat-related words than neutral words, whereas such a difference was not observed in the low-anxious group. Interestingly, there was a linear relationship between adolescents’ anxiety scores and the interference effect on the Stroop task: The higher the anxiety levels, the slower adolescents were in color-naming threat-words as compared to neutral words. A number of other studies have documented the attentional bias phenomenon by means of the modified Stroop color-naming task in youths that might be vulnerable for developing anxiety problems. For example, Schwartz, Snidman, and Kagan (1996) administered the Stroop task to adolescents who had been identified as behaviorally inhibited or uninhibited when they were about 2 years of age. The Stroop task contained words from three different categories: threatening, positive, or neutral. In contrast with the expectations, behaviorally inhibited youths did not show disproportionate slowing to threat words. However, an additional analysis of the extremely long response latencies revealed that behaviorally inhibited adolescents exhibited significantly more of these long latencies to threat words as compared to their uninhibited counterparts, which is of course in keeping with the idea that even anxiety-prone children to some extent display attentional bias. A comparable conclusion was reached by Moradi, Neshat-Doost, Taghavi, Yule, and Dalgleish (1999), who examined Stroop color-naming performance in 9- to 17-year-old children of whom parents suffered from posttraumatic stress disorder (PTSD; N = 21) and a group of control children. The results indicated that children of parents with PTSD were delayed in color-naming threatrelated words as compared to neutral words, whereas no such a delay was observed for the control children, a finding that also suggested that the at risk youths displayed increased attention toward threatening material. Two studies have demonstrated the presence of an attentional bias using the modified Stroop task in children and adolescents who were actually diagnosed with an anxiety
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Figure 5.1: Mean Stroop color-naming times (in milliseconds) in response to words with a threatening, depressive, and positive content as compared to the baseline response to neutral stimuli in youths with generalized anxiety disorder (GAD) and control youths. Based on: Taghavi et al. (2003). disorder. In a first study, Taghavi, Dalgleish, Moradi, Neshat-Doost, and Yule (2003) had 19 youths with generalized anxiety disorder (GAD) and 19 control youths to complete a Stroop task containing threat, depression-related, positive, and neutral words. As can be seen in Figure 5.1, children and adolescents with GAD showed significantly slower colornaming latencies in response to negative-laden emotional information as compared to control youths. The fact that this interference effect not only occurred in response to threatening but also to depressive words may have to do with methodological issues (e.g., threatening and depressive words could not be satisfactorily discriminated) or the fact that GAD and depression are highly comorbid (Masi, Millepiedi, Mucci et al., 2004) or even strongly allied disorders (Lahey, Applegate, Waldman et al., 2004). Anyway, the results seemed to justify Taghavi et al.’s (2003; p.221) conclusion that “modified Stroop processing in younger generally anxious populations broadly mirrors the profile of results in adults.” In the second study, the same research group (Moradi, Taghavi, Neshat-Doost, Yule, & Dalgleish, 1999) obtained evidence for a Stroop interference effect in a sample of children and adolescents with PTSD. Relative to neutral words, the youths with PTSD showed significantly slower response times to trauma-related words as compared to a nonanxious control group. The aforementioned studies suggest that attentional bias in anxiety-prone or anxious youths can be reliably documented by means of the modified Stroop task, as they have produced findings that closely parallel those reported in the adult literature. However, it should be pointed out that a number of studies have failed to obtain consistent attentional bias effects with the modified Stroop task in youths. Noteworthy in this regard is a series of studies performed by Kindt and colleagues (Kindt, Bierman, & Brosschot, 1997; Kindt, Van den Hout, De Jong, & Hoekzema, 2000), who examined the Stroop color-naming performance of spider-fearful and control children aged 8 to 12 years. These researchers consistently found that an attentional bias for spider-related material was not restricted to the highly fearful group but also emerged in the control group (see also Kindt, Bögels,
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& Morren, 2003; Kindt & Brosschot, 1999; Kindt, Brosschot, & Everaerd, 1997). Furthermore, some evidence emerged indicating that, in nonfearful control children, age correlated negatively with attentional bias, suggesting a decline of attentional bias for spider-related words with age (e.g., Kindt et al., 2000). On the basis of these findings, Kindt et al. argued that at early developmental stages, attentional bias for threatening material may be a pervasive and normal phenomenon. Yet, as children grow older, they would learn to inhibit selective processing of threat cues. By this view, the development of abnormal fear and anxiety would be accompanied by a failed inhibition of selective attention (see also Kindt & Van den Hout, 2001). Although such an interpretation fits nicely with the well-documented fact that, in most young children, normal developmental fears and anxieties dissipate (see Chapter 1), the evidence for this cognitive inhibition hypothesis is meagre and a direct test of the phenomenon has yielded disappointing results (Morren, Kindt, Van den Hout, & Van Kasteren, 2003). In conclusion, then, research of attentional bias in youths by means of the modified Stroop task has yielded mixed results, and this has led several researchers to the conclusion that “it is difficult to avoid the conclusion that, despite occasionally supportive findings, the modified Stroop task has proven to be a fairly unreliable method of demonstrating attentional bias to feared stimuli in children [and adolescents]” (Vasey & MacLeod, 2001; see Muris, 2003). Fortunately, there are other experimental paradigms that can be used to measure this type of information-processing bias in youths, which will be discussed in the next paragraphs. Dot Probe Paradigm. Another experimental paradigm that can be employed to measure attentional bias toward threat is the dot probe task. During this task, two words are briefly presented on a computer screen: One word is threat-relevant, whereas the other is emotionally neutral. Following the disappearance of the words, a small dot appears on the location previously occupied by one of the words. The latency to detect this probe provides an index of the extent to which a child’s attention was directed towards the word that had just disappeared. Thus, faster latencies to detect a probe following threatening words relative to neutral words would indicate an attentional bias toward threat, whereas the opposite pattern would reflect a tendency to direct attention away from the threat (see Vasey & MacLeod, 2001). A number of studies have used the dot probe paradigm for assessing attentional bias in relation to fear and anxiety in youths. For example, Vasey, Daleiden, Williams, and Brown (1995) administered the dot probe detection task to a group of 9- to 14-year-old children with anxiety disorders and a group of age-matched nonanxious control children. The results of this study demonstrated that anxiety disordered children, relative to controls, were faster to react to a probe if it was preceded by a threatening rather than a neutral word. This finding is in keeping with the hypothesis that anxious youths allocate significantly more processing resources towards threat-related material. Similar results were obtained by Vasey, El-Hag, and Daleiden (1996), who studied attentional bias with the dot probe task in nonclinical youths who were either high or low in test anxiety. A further study by Taghavi, Neshat-Doost, Moradi, Yule, and Dalgleish (1999) investigated biases in visual attention in clinically referred youths, aged 9 to 18 years, who were diagnosed with generalized anxiety disorder or mixed anxiety-depression, as well as a control group of children and adolescents without psychiatric problems. The dot probe
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Figure 5.2: Mean threat and depression bias scores (in milliseconds) as obtained with a dot probe task for youths in the anxiety disorder, mixed anxiety-depression, and control groups. Based on: Taghavi, et al. (1999).
paradigm was used to assess two types of attentional biases: a bias for threat-related words (e.g., explosion, rejected) and a bias for depression-related words (e.g., sad). As exhibited in Figure 5.2, the results of this study indicated that clinically referred youths with an anxiety disorder displayed an attentional bias for threat-related words. Youths with mixed anxietydepression did not show an attentional bias for threat words, in spite of the fact that they had the same level of anxiety as the anxiety-disordered youths. None of the groups displayed a bias for depression-related words, although the youths with mixed anxiety-depression displayed fairly high levels of depression symptoms. On the basis of these findings, it can be concluded that attentional bias for emotional information is specific to threat-related information in anxious children and adolescents. Dalgleish, Moradi, Taghavi, Neshat-Doost, and Yule (2001) employed the dot probe paradigm to examine attentional bias for emotional material in children and adolescents with PTSD and healthy controls. As in the study of Taghavi et al. (1999), the probedetection task included threat-related and depression-related words. In agreement with previous studies, it was found that children and adolescents with PTSD, relative to control youths, selectively allocated processing resources toward threatening stimuli. An interesting study was carried out by Hunt, Keogh, and French (2007), who examined whether the physical component of anxiety sensitivity is associated with a selective attentional bias toward affective stimuli. Nonclinical children aged between 8 and 10 years, who had been identified as either low or high on physical anxiety sensitivity, participated in a dot probe experiment during which anxiety symptom words (e.g., panic), social threat words (e.g., foolish), positive words (e.g., enjoy), and neutral words (e.g., floor) were presented under both masked and unmasked conditions. Irrespective of masking, children high on physical anxiety sensitivity displayed attentional vigilance for emotional words relative to neutral words, whereas those low on physical anxiety sensitivity displayed a relative avoidance of such material. These findings demonstrated that anxiety sensitivity predicted
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the occurrence of an automatic attentional bias in childhood, but also suggested that this bias pertains to emotional stimuli in general and is not specifically linked to anxiety-related stimuli. In a recent investigation by Stirling, Eley, and Clark (2006), the dot probe task was employed to study the processing of emotional facial expressions in a sample of 8- to 11year-old nonclinical children. During the experimental task, pairs of negative-neutral, negative-positive, and positive-neutral faces were presented to the children. The results showed that children overall avoided negative faces when paired with neutral, but attended toward negative faces when paired with positive, which means that the occurrence of attentional bias critically depended on the comparison stimulus that is employed. Further, only social anxiety was to some extent related to bias scores: Children with higher social anxiety levels displayed greater avoidance of angry and fearful expressions (relative to neutral expressions). Although this finding does not provide support for an anxiety-related attentional bias, the result is in keeping with the observation made in adult studies that with a longer stimulus duration vigilance may shift to avoidance (see Mogg, Philippot, & Bradley, 2004). Altogether, it can be concluded that research using the dot probe paradigm in youth populations has been more successful in demonstrating the presence of an anxiety-related attentional bias effect than studies employing the modified Stroop task (Vasey & MacLeod, 2001). Nevertheless, the results of a recent investigation by Waters, Lipp, and Spence (2004) show that even with a dot probe detection task some unexpected findings have emerged. In this study, a pictorial dot probe task was used to investigate attentional bias in nonclinical children aged 9 to 12 years, nonclinical adults, and clinically referred children aged 9 to 12 years with anxiety disorders. Results demonstrated that both adults and children showed a stronger attentional bias towards fear-related pictures than toward pleasant pictures. However, the extent of attentional bias toward fear-related pictures did not differ significantly among anxious and nonclinical children, which is of course a finding that is not in keeping with those obtained in other studies employing the dot probe task in anxious youths. As pointed out by Vasey and MacLeod (2001) and Muris (2003), it seems most likely that methodological issues (e.g., the employment of this type of experimental task in young children) explain these somewhat inconsistent results. Other Experimental Tasks. While the emotional Stroop and the dot probe paradigms are most frequently employed to index an anxiety-related attentional bias in youths, a number of studies can be found that investigated this type of information-processing bias by means of a different methodology. For example, Hadwin, Donnely, French et al. (2003) carried out two experiments in which nonclinical 7- to 10-year-old children first completed selfreport questionnaires for measuring trait anxiety and depression and then were instructed to perform a visual search for emotional faces. Briefly, during this visual search task, children were asked to detect as quickly as possible the presence or absence of angry, happy, or neutral faces, which were presented along with a number of distractor items. The results of both experiments indicated that on target absent (but not present) trials, higher levels of trait anxiety were significantly associated with faster search times in the angry face condition. No effects of depression on search times in any condition were found. It can be concluded that “these findings support previous work highlighting a specific link between anxiety and threat in childhood” (Hadwin et al., 2003; p.432).
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Figure 5.3: Mean times for providing fear ratings of photographs with faces depicting various emotions in children of parents with/without a panic disorder and in children with/ without social phobia. Based on: Pine, et al. (2005). Another intriguing experiment was conducted by Pine, Klein, Mannuzza, and colleagues (2005) who asked offspring (aged between 9 and 19 years) of parents with panic disorder, depression, or no disorder to view computer-presented photographs depicting angry, fearful, and happy faces, and to report subjective fear during the viewing of these pictures. Attention allocation was indexed by latency to perform these fear ratings, and of course it was expected that youths at risk for anxiety disorders (i.e., the offspring of panic disorder parents) would display significantly slower reaction times in response to emotionally evocative facial photographs. As can be seen in Figure 5.3, these expectations were borne out by the data. That is, offspring of panic disorder patients displayed significantly slower reaction times in providing fear ratings of various facial photographs as compared to offspring of parents who did not suffer from panic disorder. Note also that reaction times were remarkably slower in response to photographs depicting angry and fearful faces as compared to photographs showing neutral faces. Further, the results indicated that those youths who had developed an anxiety disorder (i.e., social phobia) themselves also evidenced slower reaction times. An additional analysis even revealed that a parental panic disorder and youths’ social phobia both made an independent contribution to the prediction of slower reaction times. These results seem to be in line with the conclusion that anxious and anxiety-prone youths allocate more attention resources to threat-relevant stimuli. When reviewing the empirical evidence that has emerged on anxiety-related attentional bias in children and adolescents, the overall conclusion seems justified that this informationprocessing abnormality is present in high-anxious and anxiety disordered youths, just like in anxious adults (see for reviews, Ehrenreich & Gross, 2002; Vasey & MacLeod, 2001). A strong aspect of the research on cognitive phenomena like attentional bias is its reliance on experimental paradigms, as it is clear that performance-based measures like the Stroop and the dot probe task are less sensitive to reporter bias effects (Bijttebier, Vasey, & Braet, 2003). At the same time, experimental indices of attentional bias may suffer from methodological problems, and this may be particularly true when they are employed in young people (Vasey, Dalgleish, & Silverman, 2003). There is surprisingly little evidence for the
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psychometric properties of these measures. As an example of this point, a recent study by Dalgleish, Taghavi, Neshat-Doost, and colleagues (2003) employed both the modified Stroop task and the dot probe paradigm to examine attentional bias in clinically anxious children and adolescents. These researchers noted that the dot probe method was somewhat more sensitive in tapping attentional bias in anxious youths than the Stroop task. Most importantly, however, no correlation emerged between the attentional bias scores as indexed by both tasks, which indicates that they “seem unlikely to be tapping identical underlying cognitive processes” (Dalgleish et al., 2003; p.19). Alternatively, this finding may seriously question the validity of at least one of the attentional bias measures, and it is clear that more research on this issue is urgently needed.
Interpretation Bias Attentional bias for threat can best be viewed as a fundamental process that operates at the early stages of information-processing. Yet, a number of other biases have been identified that operate at the more conceptual stages of information-processing. A good example is provided by the interpretation bias, which refers to anxious children’s tendency to disproportionately impose negative interpretations upon ambiguous situations. For instance, in a study by Bell-Dolan (1995), 9- to 11-year-old children high and low on trait anxiety watched a series of videotaped peer-interaction vignettes, each displaying peer behavior that was either hostile, nonhostile (i.e., accidental), or ambiguous. Results showed that the highanxious children were equally accurate in identifying hostile intent in peer interaction as their low-anxious counterparts. However, high-anxious children more frequently interpreted the nonhostile and ambiguous vignettes as threatening, and they more often proposed maladaptive strategies to deal with the situations. In a study of Barrett, Rapee, Dadds, and Ryan (1996), anxiety disordered children, children with oppositional-defiant disorder, and normal controls (all aged between 7 and 14 years) were presented with brief stories of ambiguous situations and asked about what was happening in each situation. Then, children were given two possible neutral outcomes and two possible threatening outcomes and asked which outcome was most likely to occur. Results showed that both anxious and oppositional children more frequently interpreted ambiguous situations as threatening than normal controls (see also Chorpita, Albano, & Barlow, 1996b). Interestingly, anxious children more often chose avoidant outcomes, whereas oppositional children more frequently chose aggressive outcomes (see Figure 5.4). Further support for the existence of interpretation bias in anxious children comes from various other studies. In a study by Hadwin, Frost, French, and Richards (1997), 7- to 9year-old children completed the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1985) to measure their level of general anxiety, and were then confronted with ambiguous homophones that either had a neutral or a threatening interpretation (e.g., dye versus die). The results showed that anxiety levels were positively associated with threatening interpretations of homophones. Thus, higher anxiety levels were accompanied by a higher frequency of threatening interpretations. A comparable experimental approach was followed by Taghavi, Moradi, Neshat-Doost, Yule, and Dalgleish (2000), who presented 9- to 16-year-old children and adolescents with homographs (i.e., words with
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Figure 5.4: Mean number of threatening interpretations, and avoidant and aggressive solutions for anxiety disordered (AD) children, children with oppositional-defiant disorder (ODD), and control children. Based on: Barrett, Rapee, Dadds, & Ryan (1996).
more than one meaning) that were printed on cards. For each homograph, the participants were asked to construct a sentence using the homograph. The results of this study indicated that anxious children and adolescents produced significantly more sentences that were consistent with a threatening homograph interpretation than did the control children. Bögels and Zigterman (2000) tested a sample of clinically referred youths (aged 9 to 18 years) who met the diagnostic criteria for either an anxiety disorder or a disruptive behavior disorder. Children and adolescents were exposed to a series of stories that depicted social anxiety, separation anxiety, and generalized anxiety situations. Following each story, participants had to answer an open-ended question, “What would you think if you were in this situation?,” and to rate a number of closed-ended questions assessing their feelings, thoughts, and competence to cope with the situation. Results indicated that anxiety disordered youths more often interpreted the ambiguous situations in a threatening way as compared to the youths with disruptive behavior disorder. Furthermore, anxious children and adolescents reported higher levels of negative emotions, danger-related thoughts, and lower levels of competence to deal with threat. In a follow-up study of this research group (Bögels, Snieder, & Kindt, 2003), some evidence was obtained that demonstrated the content specificity of anxious children’s threat interpretations. That is, children high on social phobia and separation anxiety disorder predominantly displayed interpretation bias and negative cognitions in response to situations that were consistent with their type of fear (i.e., respectively, social and separation situations). In conclusion, there is sufficient evidence to conclude that interpretation bias is present in anxious youths (see also Dineen & Hadwin, 2004), and although actually little is known about its precise role in the maintenance of anxiety problems, this type of distortion helps us understand how anxious children and adolescents perceive the external world and how easily they become entangled in anxious thought processes.
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Reduced Evidence for Danger (RED) Bias In their review article, Daleiden and Vasey (1997) speculated about another informationprocessing abnormality that may occur in anxious children. Briefly, these authors hypothesize that in anxious children “even very minor threat cues may readily trigger subsequent processing and consequently anxious responding. In essence, they may be acutely vigilant for signals of potential threat but, once they have encoded such a signal, they may quickly move through the interpretation stage and conclude that the situation is dangerous even though a search for further information would show it is not. For example, upon seeing a dog, dog-phobic children may quickly jump to the conclusion that they are in danger and, because they have ceased encoding further information, they may fail to notice that the dog is on a leash or that the dog is behaving in a friendly manner” (p.411–412). A number of studies have indeed confirmed the idea that in anxious children even very minor threat cues may readily trigger a negative interpretation (Muris, Kindt, Bögels et al., 2000; Muris, Luermans, Merckelbach, & Mayer, 2000; Muris, Meesters, Smulders, & Mayer, 2005; Muris, Merckelbach, Schepers, & Meesters, 2003; Muris, Merckelbach, & Damsma, 2000; Muris, Rapee, Meesters, Schouten, & Geers, 2003). This phenomenon, which has been labelled as Reduced Evidence for Danger (RED) bias, is typically demonstrated in interview studies in which children are exposed to ambiguous stories. Briefly, children are told that some of these stories are scary—that is, that these stories will have a bad ending—whereas other stories are not scary—that is, that these stories will have a happy ending. Children are instructed to find out as quickly as possible whether the pertinent story will be scary or not scary. Stories are presented sentence by sentence, and after each sentence children are asked whether they think that the story will be scary or not scary. Results consistently indicated that high-anxious children needed to hear fewer sentences before deciding a story to be threatening as compared to low-anxious children. For example, in a study by Muris, Merckelbach, and Damsma (2000), a large sample of 8- to 13-year-old nonclinical children (N = 252), high and low on social anxiety, were exposed to stories of social situations (for an example, see Table 5.1) and instructed to find out as quickly as possible whether a story was scary. In addition, children were invited to tell how each story would end (in order to measure interpretation bias) and to judge how they would feel and think when actually confronted with that situation. The results demonstrated that children with high levels of social anxiety displayed lower thresholds for threat perception (i.e., needed to hear fewer sentences before deciding that a story was going to be threatening) as compared to children with low levels of social anxiety, which is of course a finding that indicates the presence of a RED bias. Furthermore, socially anxious children more often interpreted the stories as threatening and displayed higher levels of negative feelings and cognitions in relation to these stories than the low-anxious control children (see Figure 5.5). In a follow-up study (Muris, Kindt, Bögels et al., 2000), which relied on a highly similar design, 105 normal school children were confronted with three types of stories: social anxiety stories, separation anxiety stories, and generalized anxiety stories (Table 5.1). Again, high levels of anxiety (as measured by questionnaires measuring anxiety symptoms and trait anxiety) were found to be accompanied by an early detection of threat (i.e., the RED bias), high frequencies of threat interpretation, and high levels of negative feelings and cognitions. Furthermore, findings seemed to suggest that these threat perception
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Table 5.1 Examples of stories that were used in studies examining RED bias in children Social anxiety story 1. Next week is your birthday and you want to organize a birthday party. 2. Mother has told you that you may invite all of your classmates. 3. The teacher allows you to speak to your class so that you can invite everyone. 4. Standing in front of the class, you hear some of your classmates laughing. 5. When you sit down again, everyone suddenly begins to laugh about you. Separation anxiety story 1. Your parents have tickets for the movies. The film they want to see is playing this evening. 2. They decide to go and try to arrange a babysitter. 3. However, nobody is available, and you hear your parents conferring about what to do. 4. Your parents say to you, “You are old enough to stay home alone tonight.” 5. Your parents put you to bed and say, “Sleep well! We will see you tomorrow!” Generalized anxiety story 1. You ride on the bike slowly because you are carrying a large bag with purchases. 2. You ride on a street without a bike path. 3. It is a very busy street. 4. The cars that pass you drive very fast. 5. Behind you, you hear a big truck approaching. Nonthreatening story 1. Next week is your birthday, and you want to organize a birthday party. 2. You have made a list of children you want to invite. 3. The children who are invited have told you that they will certainly come. 4. During the break at school, you see some of the invited children. 5. They come to you and say that they are looking forward to your party
distortions were not specific for the various types of anxiety symptoms. That is to say, no support was found for the idea that children with high levels of a specific type of anxiety symptoms (e.g., social phobia symptoms) particularly show threat perception abnormalities in relation to a specific type of stories (i.e., social anxiety stories; see Bögels et al., 2003). In fact, results indicated that threat perception distortions were predominantly mediated by children’s level of general anxiety (i.e., general level of anxiety symptoms and trait anxiety). This latter finding was confirmed in subsequent research by Muris, Rapee, Meesters, Schouten, and Geers (2003), who found that although state anxiety made a significant contribution to threat perception distortions, general anxiety appeared the most powerful predictor of this type of information-processing abnormality. In a further investigation (Muris, Luermans, Merckelbach, & Mayer, 2000), 76 normal primary school children were again exposed to stories that described social situations. Half of the stories were ambiguous and thus contained information that could be interpreted as
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Figure 5.5: Mean scores on various threat perception indices for the socially anxious and control children. All between-group differences were significant at p < .001. The “threat threshold” variable is indicative of a “Reduced Evidence for Danger” (RED) bias. Based on: Muris, Merckelbach, & Damsma (2000).
threatening, whereas the other half of the stories were nonthreatening—that is, these stories clearly had a positive content and contained no obvious trace of threat. As in the earlier studies, several threat indices were derived from children’s reactions to the stories. Levels of social anxiety were assessed by means of a self-report questionnaire. Results again indicated that high levels of anxiety were accompanied by an early detection of threat, a high frequency of threatening interpretations, and high levels of negative feelings and cognitions. Most important, significant associations were not only observed in response to ambiguous stories but also in relation to nonthreatening scenarios. On the basis of these and previous findings, Muris et al. (2000; p.134) concluded that “anxious children seem to have a motto that can be summarised as ‘Danger is lurking everywhere,’ which manifests itself in threat perception abnormalities that even occur in relatively nonthreatening situations” (see also Muris, Merckelbach, Schepers, & Meesters, 2003). RED bias seems to imply that anxious youths are very sensitive to threat cues and only need very little information before perceiving a situation as threatening. Although such a cognitive distortion is in keeping with theoretical notions on anxiety-related informationprocessing and may explain why negative affect is so easily elicited in anxious children and adolescents (Daleiden & Vasey, 1997; Kendall, 1985), the possibility cannot be ruled out that the RED bias merely is a result of its assessment with the ambiguous story paradigm. More precisely, although such stories describe ambiguous situations that do not explicitly reflect danger, they may contain certain elements that are threatening to high-anxious youths. For example, even a benign scenario such as the following contains information that may be threatening to high-anxious children and adolescents:
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You are going on holiday. Your parents have told you that you are going to a campsite where there will be a lot of children. You have just arrived and you walk around the campsite to see where everything is. You see a group of children. One of these children is a friendly classmate from school. Your classmate says: “Hey, how nice that you are also on this campsite!” The friendly children ask you to join the group and to play along. For example, “going on holiday” may represent threat for youths with high levels of generalized anxiety, “a lot of children” may reflect danger for youths with high levels of social anxiety, and “walk around the campsite” may be threatening for youths with high levels of separation anxiety. In an attempt to avoid this unintentional verbal cuing of threat as elicited by the ambiguous story paradigm, Muris and Van Doorn (2003) conducted an experiment in which they exposed 8- to 13-year-old children to nonverbal ambiguous material (i.e., a series of pictures that were taken from projective tests like the Thematic Apperception Test; Morgan & Murray, 1935). To assess RED bias, pictures were divided as a jigsaw puzzle of which the parts were presented one by one to the children, again with the instruction to find out as quickly as possible whether the pertinent picture depicted a scary or a nonscary scene. Children were also shown the complete picture and asked to tell a brief story that fitted with the picture (to index threatening interpretations) and to judge how they would feel and think when actually confronted with such a situation. Results indicated once more that anxiety in the children was significantly accompanied by RED bias, interpretation bias, and negative feelings and cognitions, which implies that these types of information-processing abnormalities are not merely artificial by-products of an experimental procedure. Altogether, there is a growing body of evidence indicating that anxious children demonstrate RED bias, which should also be regarded as a distortion that operates during the more conceptual stages of information-processing.
Memory Bias Selective memory bias is a cognitive distortion that refers to the phenomenon that information congruent with one’s current mood is remembered best. In the case of anxiety disorders, this implies that youths display enhanced memory for information about danger and threat. Relatively few studies have examined this type of cognitive bias in anxious youths. One exception is a study by Moradi, Taghavi, Neshat-Doost, Yule, and Dalgleish (2000), who presented a group of 9- to 17-year-old children and adolescents with PTSD and a group of nonclinical control children with sets of negative (e.g., horror), positive (e.g., pleasant), and neutral (animal) words (e.g., lizard). Each of the words was shown on a computer screen, and participants were asked to carefully memorize them. After all words had been presented, children engaged in a 1.5-minute distraction task (i.e., counting forward by twos: 2, 4, 6, etc), in order to control for effects of recency. Two types of memory tests were then employed: The first test concerned a free recall task during which children and adolescents were asked to write down as many words as they could remember, whereas the second test was a recognition task, which asked the participants to detect the memorized words from an extended
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list of 120 words. The results indicated that youths with PTSD in general recalled fewer words than youths in the control group. Further, PTSD and control youths did not differ with regard to the recall of negative words, but the control participants recalled significantly more neutral and positive words. One might conclude from these findings that youths with PTSD showed an inclination for recalling more negative words relative to positive and neutral words as compared with control youths. Finally, the recognition task did not reveal significant differences in memory performance of PTSD and control youths. Thus, the results of this study were rather mixed and not particularly convincing in terms of the hypothesized memory bias effect. The same group of researchers carried out another study that examined memory bias in anxious youths (Dalgleish et al., 2003). A similar experimental procedure was followed as in the previous investigation. That is, clinically referred children and adolescents (aged between 7 and 18 years) with PTSD or generalized anxiety disorder, and control youths were asked to memorize four types of words: threat-related words, positive words, neutral words, and trauma-related words (e.g., accident). A free recall test demonstrated that there were no between-group differences in the memory performance of various word types, a finding that is of course not supporting the presence of an anxietyrelated memory bias. Although the number of studies on memory bias in anxious youths is limited, and so firm conclusions cannot be drawn, available studies have provided little evidence for this type of information-processing abnormality. This is partly in keeping with the more extensive research in the adult literature, which indicated that the empirical proof for memory bias in anxiety disorders is mixed and certainly not as convincing as for other types of psychopathology, in particular depression (Harvey, Watkins, Mansell, & Shafran, 2004). Further, Daleiden (1998) has pointed out that memory is a complex psychological construct that consists of two types of processing (i.e., perceptual and conceptual), which can be associated with two types of memory systems. In order to investigate the relations between anxiety and biases in these two memory systems, Daleiden tested a large sample of 11- to 14-yearold youths either high or low on trait anxiety with a battery of memory tests. Some tests such as the word fragment completion task (in which children had to remember a previously seen word after removal of 30% to 50% of the letters, such as OV D as cue for the word LOVED) measured perceptual memory processing, whereas other tests like the semantic cue task (in which children had to recall a word in relation to a synonym, such as ADORED as cue for the word LOVED) assessed conceptual memory processing. All tests included negative, positive, and neutral words. Based on children’s performance on the memory tests, a bias score was derived that indicated a tendency to recall more negative than neutral information. As shown in Figure 5.6, the relation between anxiety and this memory bias score was highly dependent on the type of memory that was assessed. That is, no difference between high and low-anxious youths was observed for the performance on perceptual memory tasks. However, on the conceptual memory task, high-anxious youths clearly displayed a greater bias toward recalling negative relative to neutral words than their low-anxious counterparts. These findings seem to suggest that memory bias only occurred in tasks that require processing of the meaning of stimuli. Clearly, more research is necessary to evaluate this idea and to further examine anxiety-related memory bias in child and adolescent populations.
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Conceptual memory Perceptual memory
0 –1 –2 High anxious
Low anxious
Figure 5.6: Memory bias scores as measured by conceptual and perceptual tasks for youths scoring high and low on trait anxiety. Based on: Daleiden (1998). Emotional Reasoning As described in Chapter 1, the experience of physical symptoms such as palpitations, sweating, and trembling is not only the key feature of panic disorder (APA, 2000) but is an important concomitant of anxiety psychopathology in general (Marks, 1987), and this seems also true for children and adolescents (e.g., Fonseca & Perrin, 2001). Several authors have proposed that adult patients with anxiety disorders tend to infer dangerousness from their emotional responses (Arntz, Rauner, & Van den Hout, 1995), a phenomenon that has been termed “ex-consequentia reasoning” or “emotional reasoning.” This type of informationprocessing bias was first described by Beck, and Emery, & Greenberg (1985), who observed that “many anxious patients use their feelings to validate their thoughts and thus start a vicious circle: ‘I’ll be anxious when I ask for the date so there must be something to fear’ ” (p.198). In other words, anxious subjects strongly believe in the proposition “If I feel anxious, there must be danger.” Obviously, when danger is inferred from subjective anxiety responses rather than from objective threat, false alarms will not be recognized and irrational fears will tend to persist. In adult anxiety disorder patients, the phenomenon of emotional reasoning was first examined by Arntz et al. (1995). In their study, patients with anxiety disorders (e.g., specific phobia, social phobia, panic disorder) and normal controls gave ratings of the danger they perceived in scripts in which objective danger versus objective safety, and the presence versus absence of anxiety response information, was systematically varied. As hypothesized, the results indicated that the danger ratings of the patients with anxiety disorders were not only fueled by objective danger information but also by anxiety response information. In contrast, the danger ratings of normal controls were merely a function of objective danger information. A number of studies have investigated emotional reasoning in child populations. Muris, Merckelbach, and Van Spauwen (2003) asked a sample of 8- to 12-year-old primary school children first to complete a set of anxiety questionnaires (including scales for measuring trait anxiety and anxiety sensitivity) and then to rate the danger levels of
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Table 5.2 Examples of scripts that were used to assess emotional reasoning in children Objective danger/ anxiety response
Objective danger/no anxiety response
Objective safety/ anxiety response
Objective safety/no anxiety response
You are invited to a birthday party by one of the children in your class. Because you thought the party was a costume party, you dressed up as a clown. When you enter the party, you see that nobody else is wearing a costume. You start to sweat. You are invited to a birthday party by one of the children in your class. Because you thought the party was a costume party, you dressed up as a clown. When you enter the party, you see that nobody else is wearing a costume. You are invited to a birthday party by one of the children in your class. Because you thought the party was a costume party, you dressed up as a clown. When you enter the party, you see that everybody else is wearing a costume just as nice as yours. You start to sweat. You are invited to a birthday party by one of the children in your class. Because you thought the party was a costume party, you dressed up as a clown. When you enter the party, you see that everybodyelse is wearing a costume just as nice as yours.
scripts in which objective danger versus objective safety and the presence versus absence of anxiety response information was systematically manipulated (see Table 5.2). Evidence was found for a general emotional reasoning effect. That is, children’s danger ratings were not only a function of objective danger information, but also, in the case of objective safety scripts, by anxiety response information. Most importantly, high levels of trait anxiety and anxiety sensitivity were accompanied by a greater tendency to use anxiety response information as a heuristic for evaluating the dangerousness of objective safety scripts (see Figure 5.7). It is important to note that the general emotional reasoning effect as found by Muris et al. (2003) is at variance with the results of Arntz et al. (1995), who showed that normal adults merely base their danger ratings on objective danger information and not on anxiety response information. Developmental issues may be relevant here. That is to say, there may be important differences between children and adults in the prevalence and phenomenology of this type of information-processing bias. For example, it is possible that anxiety response information sensitizes all children to potential danger but that this phenomenon gradually dissipates as children grow older. Only in some children, emotional reasoning may persist as part of a general vulnerability to develop anxiety problems. Clearly, this point warrants further research. Another issue for future studies concerns the study of emotional reasoning in clinically referred youths. Although the phenomenon has been replicated in various samples of nonclinical children (Morren, Muris, & Kindt, 2004; Muris et al., 2003; Muris, Vermeer, & Horselenberg, in press), further research should clarify how this informationprocessing operates in children and adolescents with anxiety disorders.
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Danger
0,2
Safety
0 –0,2 –0,4 Low trait anxiety
High trait anxiety
Low anxiety sensitivity
High anxiety sensitivity
Figure 5.7: Mean emotional reasoning scores in response to danger and safety scripts for the high and low-anxious groups. Based on: Muris, Merckelbach, & Van Spauwen (2003).
Covariation and Probability Bias Most of the cognitive biases just discussed are concerned with the processing of past (i.e., memory bias) or current information (i.e., interpretation bias, RED bias, emotional reasoning), but there are also a number of such information-processing information abnormalities that may be particularly relevant for future confrontations with certain stimuli and situations. One example is covariation bias, which is thought to play a role in the maintenance of specific phobias. The experimental demonstration of covariation bias in phobias is straightforward. Phobic and normal subjects are shown a series of slides consisting of fear-relevant (e.g., spiders) and neutral (e.g., flowers) pictures. Slide offset is followed by one of three outcomes—namely, an aversive shock, a tone, or nothing. Fear-relevant and neutral pictures are equally often followed by each of the outcomes. After the series of slides, subjects are asked to estimate the contingencies between slides and outcomes (e.g., “Given that you saw a spider picture, on what percentage of those trials was the spider followed by a shock?”). Under these experimental conditions, phobic subjects systematically overestimate the contingency between phobic stimuli and aversive outcomes (De Jong, Merckelbach, & Arntz, 1995; Tomarken, Sutton, & Mineka, 1995). So far, only one study has made an attempt to examine covariation bias in a child population (Muris, De Jong, Meesters, Waterreus, & Van Lubeck, 2005). In that study, nonclinical children aged 8 to 13 years completed a selfreport questionnaire for measuring spider fear and then participated in a card game in which fear-relevant (i.e., spider) and fear-irrelevant (i.e., weapon and Pokémon) pictures were equally paired with negative and positive outcomes (respectively losing and winning candy). Unfortunately, no evidence was found for a relationship between children’s level of spider fear and the tendency to link negative consequences to fear-relevant pictures, which means that empirical evidence for this bias in youths is currently lacking. However, the authors offered various methodological (e.g., negative outcomes not being sufficiently aversive) and
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theoretical explanations (e.g., children being too young to apply such abstract mental operations) for this null finding, which might be the starting point for further research. Meanwhile it is easy to see how covariation bias (at least in adult phobics) determines negative expectancies toward feared stimuli and so plays a role in the continuation of the phobia. Another future-related cognitive bias that might be involved in the maintenance of anxiety problems is probability bias. Briefly, this bias implies that anxious individuals estimates that future negative events are far more likely to occur, and in particular to themselves (Butler & Mathews, 1983, 1987). The evidence for probability bias in children and adolescents is mixed. Research in clinically referred anxious and depressed children and adolescents has generally yielded negative results. For example, in a study by Dalgleish, Taghavi, Neshat-Doost et al. (1997), youths with anxiety disorders, depression, or no psychiatric disorder completed the Subjective Probability Questionnaire, a self-report scale on which participants have to indicate how likely a series of negative events are going to happen in the future. Some of the items describe events that pertain to children themselves (e.g., “How likely is it that you will have a big argument with your best friend in the next couple of weeks?”), while other items refer to events that happen to other children (e.g., “How likely is it that Andy will be very ill and miss a lot of school this year?”). Results demonstrated that neither anxious nor depressed youths estimated negative events to occur more frequently than did nonclinical youths. Furthermore, whereas depressed youths judged negative events as equally likely to occur to themselves and others, anxious youths judged such events as more likely to occur in others. This so-called other-referent bias in anxiety disordered youths has been replicated in studies that investigated separate samples of clinically referred children and adolescents with posttraumatic stress disorder and generalized anxiety disorder (Dalgleish, Moradi, Taghavi et al., 2000; Dalgleish et al., 2003). More positive results with regard to probability bias in anxious youths were obtained by Rheingold, Herbert, and Franklin (2003). These researchers asked a group of adolescents with a social anxiety disorder (aged 12 to 17 years) and a control group to complete the Probability/Cost Questionnaire for Children, which measures the likelihood and costs of negative social and nonsocial events. The results indicated that socially anxious adolescents clearly overestimated the probability and costs of negative social events as compared to nonanxious adolescents. Taken together, research in clinically referred youths has not provided univocal support for an anxiety-related probability bias. That is, some studies have shown that anxietydisordered youths do not give higher probability estimations for negative events, and do not indicate that such events are more likely to occur to themselves as compared to youths without anxiety problems. On the other hand, the results of the study by Rheingold et al. (2003) are nicely in keeping with the idea that anxious children display a probability bias for personally relevant negative events. Two studies can be found that examined probability bias in nonclinical children and adolescents, and which have provided at least some support for the presence of this type of cognitive bias in youths. In the first study by Canterbury, Golden, Taghavi et al. (2004), 66 children and adolescents aged between 9 and 18 years, who were recruited from regular schools, completed the RCMAS as an index of general anxiety, and the Subjective Probability Questionnaire. Results showed that high-anxious youths (i.e., those who scored in the top quartile of the RCMAS) estimated negative events as more likely to occur than low-anxious youths (i.e., those who scored in the bottom quartile of the RCMAS). This
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* *
4
High anxious Low anxious
3 2 1 0 Physical-self
Social-self
Physical-other Social-other
Figure 5.8: Probability estimates for various types of future events in high and low-anxious children. * Indicates significant difference (p < .05) as compared to the low-anxious group. Based on: Muris & Van der Heiden (2006).
probability bias effect was present for events referring to themselves as well as for events referring to other children. A second study by Muris and Van der Heiden (2006) investigated probability bias in a sample of nonclinical children aged between 10 and 13 years. Participants completed a self-report scale measuring symptoms of DSM-defined anxiety disorders and again the Subjective Probability Questionnaire was employed to measure the estimated likelihood of future negative physical (e.g., traffic accident) and social (e.g., big argument with best friend) events. As shown in Figure 5.8, high-anxious children displayed significantly higher probability estimates of self-referent negative events as compared to lowanxious children. No differences between high- and low-anxious children were found with regard to other-referent negative events. In other words, in keeping with the results on probability bias in the adult literature, Muris and Van der Heiden (2006) demonstrated that high-anxious, nonclinical youths judge negative events to occur more often to themselves than low-anxious youths. Taken together, one has to conclude that the evidence for probability bias in anxious children and adolescents is not very convincing. Dalgleish et al. (1997, 2000) have suggested that this type of bias may occasionally be overshadowed by inhibitory processes, and this may be particularly true in clinically anxious youths. Briefly, such processes may reflect children and adolescents’ immature but purposeful strategy to minimize the chance that negative events will actually happen to themselves (i.e., “strategic inhibition” hypothesis). Otherwise, it is also possible that the relatively low probability estimates for selfreferent negative future events in clinically anxious youths are simply a result of the fact that they actually avoid a large number of the physically or socially threatening events that are described in the Subjective Probability Questionnaire (i.e., “avoidance” hypothesis). Future research should test these two possibilities, and reveal whether an anxiety-related probability bias in childhood indeed exists, thereby uncovering the interfering processes that hinder the assessment of this type of cognitive distortion in clinically anxious youths.
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In conclusion, then, the past 10 years have seen a marked rise in research on anxietyrelated information-processing abnormalities in children and adolescents (Alfano, Beidel, & Turner, 2002; Vasey & MacLeod, 2001). These studies have generally yielded promising results, which are in keeping with the idea that anxious youths display biases and distortions in various stages of the processing of anxiety-related information (Daleiden & Vasey, 1997). However, quite a number of studies have appeared in the literature that did not show the expected results, and this seems to point at methodological and developmental issues that play a role in, respectively, the assessment and phenomenology of cognitive biases in youths. More precisely, it may well be the case that certain experimental paradigms (e.g., the emotional Stroop task) are less suitable for younger participants. Otherwise, it is also possible that certain distortions require a minimum level of cognitive maturation before they consistently emerge in (anxious) youths (see for a discussion, Alfano et al., 2002). There are a number of issues concerning information-processing abnormalities in youths that require some further comment. First, according to Daleiden and Vasey’s (1997) perspective on information-processing in childhood anxiety, it seems plausible that distortions in an early stage of processing (e.g., encoding) increase the likelihood of biases in subsequent stages of processing (e.g., interpretation). Although there is no direct test of this proposition, Dalgleish et al. (2003) found quite differential patterns on tests measuring attentional, memory, and probability bias in clinically anxious youths, suggesting that distortion in one stage is not necessarily related to bias in another stage. On the one hand, this may be due to the psychometric qualities (i.e., reliability, validity) of the tests that are employed to measure various types of information-processing abnormalities. On the other hand, it is also possible that regulative mechanisms neutralize early cognitive distortions, so that processing in a subsequent stage is again quite normal. Research on the influence of regulative factors on information-processing is just beginning to emerge (Lonigan, Vasey, Phillips, & Hazen, 2004; Muris, Meesters, & Rompelberg, 2007; see also Derryberry & Reed, 2002), and indeed the results have provided some support for the idea that a protective factor like effortful control indeed buffers children’s susceptibility to cognitive distortions. Second, it is unclear where anxiety-related information-processing abnormalities in youths originate from. It has been proposed that family factors (e.g., insecure parent-child attachment relationship) and parenting behaviors play an important role in the development of these cognitive distortions (e.g., Barrett & Holmes, 2001; Varela, Vernberg, SanchezSosa et al., 2004; see for a review, Hadwin, Garner, & Perez-Olivas, 2006). As described earlier, a number of studies have indicated that, in anxious youths, family discussions about ambiguous scenarios result in an enhancement of threatening interpretations (Barrett et al., 1996; Chorpita et al., 1996). Specific modeling experiences may also play a role in the formation of such biases. This is nicely illustrated by a study of Schneider, Unnewehr, Florin, and Margraf (2002), who studied interpretation bias in children of individuals with panic disorder, specific phobia, or no psychiatric problems. To examine whether children’s responses were affected by priming of a model, panic-related interpretation bias (see also Austin, Jamieson, Richards, & Winkelman, 2006; Schneider, In-Albon, Rose, & Ehrenreich, 2006) was measured before and after children had been exposed to scenarios in which the main character displayed either panic-relevant physical sensations, animal-relevant fear, or panic-irrelevant physical sensations (i.e., cold symptoms). Results showed that only children of parents with panic disorder displayed a significant increase in anxious interpretations
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Normal and Abnormal Fear and Anxiety in Children and Adolescents Occasion 1 Threat perception
Occasion 2 .50*
Threat perception
–.06 .30*
.47* –.08 Anxiety symptoms
.79*
Anxiety symptoms
Figure 5.9: Concurrent and prospective relationships between threat perception distortions and anxiety disorders symptoms over a four-week period. * p < .001. Based on: Muris, Jacques, & Mayer (2004). after priming. Further, this significant increase only emerged after priming through presentation of a panic-relevant model and not after priming through presentation of a phobia-relevant or irrelevant model. Third, although it is generally assumed that informationprocessing abnormalities play a role in the development of anxiety problems in youths, there are actually few investigations that have tested this supposition. One exception is a recent study by Muris, Jacques, and Mayer (2004), who examined the temporal stability and development of threat perception abnormalities and anxiety symptoms in nonclinical children aged 9 to 13 years. Children completed a self-report measure of DSM-defined anxiety disorder symptoms and were then interviewed individually using an ambiguous story paradigm from which a number of threat perception indices were derived. The assessment was repeated some four weeks later, so that it became possible to study prospective relationships for threat perception abnormalities and anxiety symptoms. As can be seen in Figure 5.9, the results indicated that, on both occasions, anxiety disorder symptoms were significantly associated with threat perception abnormalities. Furthermore, threat perception abnormalities were moderately stable over the four-week period. Finally and most importantly, no evidence was obtained for a direct prospective link between threat perception and anxiety disorder symptoms. These findings indicated that such cognitive distortions should be not be regarded as aetiological factors for childhood anxiety problems but rather should be viewed as epiphenomena of high anxiety levels, which nevertheless may play a role in the continuation of such symptoms. Fourth and finally, future studies could investigate whether the more conceptually based cognitive distortions such as interpretation bias and RED bias can be removed by effective treatment. For example, cognitive-behavioral treatment teaches children to recognize threat perception abnormalities and consciously try to combat them by using more adaptive self-talk (Barrett, 2001; Ollendick & King, 1998). As such, this type of treatment may be pre-eminently suitable for correcting such cognitive distortions.
Dysfunctional and Negative Thinking Cognitive distortions refer to biased and erroneous processing of fear- and anxiety-related information. It is clear that such distortions result in dysfunctional and maladaptive thinking,
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which according to cognitive theorists is the core of mental disorders (Beck, 1976). Several authors have pointed at the role of dysfunctional and negative thinking in child psychopathology, including the anxiety disorders (Kendall & MacDonald, 1993). This section will focus on a number of thought processes that play a role in the aetiology and maintenance of fear and anxiety in youths. First, the contribution of worry and negative self-speech to anxiety problems will be discussed. Then, general patterns of faulty or negative patterns thinking (also known as “cognitive errors”) that are characteristic for anxious youths will be discussed. Finally, a number of disorder-specific dysfunctional thought processes will pass in review.
Worry Worry can be defined as “a chain of thoughts and images, negatively affect-laden and relatively uncontrollable” (Borkovec, Robinson, Pruzinsky, & DePree, 1983) and has generally been considered as the cognitive component of anxiety (e.g., Barlow, 2002; Borkovec, 1985). In their theoretical review paper, Borkovec, Ray, and Stöber (1998) noted that although worry may certainly have adaptive features in that it prepares the individual for upcoming negative events, it is clear that excessive worry functions as a cognitive avoidance response that either suppresses somatic anxiety or serves as a distractor from emotionally laden topics. As such, high levels of worry eventually interfere with the adequate handling of threatening stimuli and situations, thereby maintaining fear and anxiety in the long run. As such, it is not surprising that worry is involved in many anxiety disorders. Not only is worry the key element of generalized anxiety disorder (American Psychiatric Association, 2000; see Chapter 1), this cognitive variable also occurs in other anxiety problems such as obsessive-compulsive disorder (OCD), social phobia, and panic disorder (e.g., Dugas, Freeston, Ladouceur et al., 1998). Relatively few studies have examined the phenomenon of worry in children and adolescents. This research has revealed that worry is a fairly common experience to most children. Community studies have found that up to 80% of the primary school children aged 8 to 12 years report to worry every now and then, mostly about school, health, dying and illness, and social issues (Henker, Whalen, & O’Neil, 1995; Muris, Merckelbach, Gadet, & Moulaert, 2000; Orton, 1982; Silverman, La Greca, & Wasserstein, 1995). In a study evaluating the severity of normal children’s worries, Muris, Meesters, Merckelbach, Sermon, and Zwakhalen (1998) inventoried the worries of 193 children aged 8 to 12 years and then evaluated the seriousness of their main worry by means of diagnostic interview. The results indicated that a substantial minority of the children exhibited symptoms of worry in the pathological range. That is, 6.2% of the children met the diagnostic criteria of generalized anxiety disorder. Further research with clinically anxious youths has demonstrated that worry is not only present in generalized anxiety disorder but also features in other anxiety disorders, such as separation anxiety disorder and social phobia (e.g., Perrin & Last, 1997; Weems, Silverman, & La Greca, 2000). Szabó and Lovibond (2004) compared the cognitive content of worry in 8- to 13-year-old clinically referred anxious and nonreferred children. Employing a thought list procedure, the content of children’s worries was carefully analyzed. Results showed that the worries
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Normal and Abnormal Fear and Anxiety in Children and Adolescents 70 60 50 40
*
30 20 10
*
0 Negative outcome expectation
Problem solving
Clinically referred anxious children
Rumination
Nonreferred children
Figure 5.10: A comparison of the cognitive content of worry in clinically referred anxious children and nonreferred children. * p < .01. Based on: Szabó & Lovibond (2004).
of clinically anxious and control children were both predominantly concerned with negative outcome anticipation (i.e., thoughts about aversive events that may occur in the future). Further, the findings indicated that the worrisome thoughts of clinically anxious children contained less problem solving (i.e., thoughts about how to deal with possible negative events) and more rumination (i.e., thoughts about the negative aspects of the present or post situation; (see Figure 5.10)). In other words, some evidence was obtained to suggest that low problem solving and high rumination were associated with the excessive and uncontrollable worry as reported by clinically anxious youths. Thus, pathological worry seems to be less directed at problem solving and obviously has a more negative focus. Although it takes little imagination to conceive that worry perpetuates feelings of anxiety, there is actually little evidence for the notion that worry is associated with the maintenance or even exacerbation of anxiety problems in youths. Results of various studies have indicated that the intensity of worrisome thoughts in children and adolescents with generalized anxiety disorder is positively associated with self-reported anxiety levels in these youths (e.g., Weems et al., 2000). However, as this research has been predominantly correlational in nature, little can be said about the direction of this link (i.e., whether high levels of worry result in more anxiety or whether high levels of anxiety lead to more worry). Interestingly, there is empirical evidence showing that rumination, which can be viewed as the cognitive counterpart of worry in depression (Nolen-Hoeksema, 1998), is predictive of symptom levels over longer time periods (e.g., Just & Alloy, 1997; Nolen-Hoeksema, 2000; NolenHoeksema, Morrow, & Fredrickson, 1993), and this appears also true for child populations (Abela, Brozina, & Haigh, 2002; Schwartz & Koenig, 1996). Given that rumination and worry in youths share similar features (e.g., Muris, Roelofs, Meesters, & Boomsma, 2004), it can be assumed that worry is also associated with the development of anxiety disorder symptoms over time. As a final note on this issue, two studies have demonstrated that worry is significantly associated with various information-processing abnormalities, which as
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mentioned earlier can be regarded as another factor involved in the continuation of anxiety problems in youths (Suarez & Bell-Dolan, 2001; Suarez-Morales & Bell, 2006). Nevertheless, it is clear that more research is required to examine whether worry indeed can be considered as a maintaining factor in pathological anxiety in children and adolescents.
Negative Self-Speech Whereas worry is concerned with negative thought activity about threatening events that might happen, there is also evidence showing that anxious youths engage in negative thinking during the actual confrontation with a (potentially) dangerous stimulus or situation. These thought processes during exposure with a threatening event are also known as selfspeech and refer to “the child’s internal dialogue, including what he says to himself about the environment, his behaviour or the relations between them” (Prins, 1985; p.641). It is clear that this self-speech helps the child to deal with potentially threatening situations, and to regulate negative emotion (e.g., Meichenbaum, 1977). A number of studies have examined the link between self-speech and anxiety in young people. In a first study, Prins (1985) conducted interviews to assess self-speech in a sample of 40 8- to 12-year-old children who visited a dental clinic to undergo treatment. There were 20 children with high, phobic-like dental fear and 20 children with low dental fear. The results showed that two-thirds of the children, equally distributed across high- and low-fearful children, reported self-speech. However, the content of the self-speech was significantly different between both groups: High-fearful children almost exclusively engaged in negative self-talk (e.g., “I think that something very bad is going to happen,” “I keep thinking about the pain and drilling”), whereas low-fearful children showed a more varied pattern of self-talk that even included positive thoughts (e.g., “The dentist is going to help me,” “I have to be brave”; (see Figure 5.11)). Highly similar results were obtained in
70 60 50 40
High-fearful children
30
Low-fearful children
20 10 0 Positive Neutral self- Negative self-speech speech self-speech
Figure 5.11: The content of self-speech (in percentages) during a dental treatment in highand low-fearful children. Based on: Prins (1985).
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a follow-up study (Prins, 1986), which examined self-speech in high-, moderate-, and lowanxious children who performed a series of fear-provoking tasks in an indoor swimming pool (e.g., jumping off the high board). That is, high-anxious children clearly exhibited more negative self-speech relative to neutral and positive self-speech as compared to their low- and moderate-anxious counterparts. It is conceivable that the negative self-speech of anxious youths promotes avoidant coping and emotion regulation strategies (see Prins, 1986), which in the longer run maintain fear and anxiety. Direct empirical evidence for this idea, however, is still lacking and could be a topic of future research.
Cognitive Errors The basic assumption of cognitive models of psychopathology is that emotional problems such as anxiety disorders are fueled by faulty or negative ways of thinking, which are also referred to as “cognitive errors.” Beck, Rush, Shaw, and Emery (1979) have described various types of such cognitive errors of which the following four appear most important: (1) overgeneralizing (i.e., thinking that one single negative event is representative for all other events), (2) selective abstraction (i.e., exaggeratedly focusing on the negative aspects of an event), (3) catastrophizing (i.e., anticipating the worst possible outcome for an event), and (4) personalizing (i.e., considering oneself as excessively responsible for all negative events). A number of studies have examined whether such cognitive errors are involved in internalizing disorders in youths. In a first study, Leitenberg, Yost, and Carroll-Wilson (1986) constructed the Children’s Negative Cognitive Error Questionnaire (CNCEQ) as an index for measuring the four aforementioned cognitive errors in children and adolescents (see Table 5.3) and then administered the scale to school children displaying low or high levels of evaluation anxiety. The results of this study indicated that children with high levels of evaluation anxiety displayed higher levels of each type of cognitive error as compared to children with low levels of evaluation anxiety. Similar results were obtained by Epkins (1996b), who compared CNCEQ scores of 8- to 12-year-old socially anxious, depressed, and control children. This researcher demonstrated that socially anxious and depressed children both reported more cognitive errors than control children. Further research by Epkins (2000) and Leung and Wong (1998) has shown that cognitive errors such as overgeneralizing, selective abstraction, catastrophizing, and personalizing are specifically related to internalizing symptoms, as they seem to be less clearly associated with externalizing problems. Finally, Weems, Berman, Silverman, and Saavedra (2001) used the CNCEQ and several self-report measures of anxiety to examine the specific relations between cognitive errors and different aspects of anxiety phenomenology in a large sample of 6- to 17-year-old children and adolescents who were referred to a university anxiety clinic. The results of this study can be summarized as follows. First, all anxiety scores were significantly related to cognitive errors, and these links were still present when controlling for youths’ level of depression. Second, different types of anxiety phenomena were uniquely predicted by a specific set of cognitive errors. That is, overgeneralizing was the strongest predictor of trait anxiety, catastrophizing and personalization were the
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Table 5.3 Item examples of the Children’s Negative Cognitive Error Questionnaire (CNCEQ) Cognitive error Overgeneralization
Selective abstraction
Catastrophizing
Personalizing
CNCEQ item Last week you had a history test, and you forgot some of the things you had read. Today you are having a math test. You think, “I will probably forget what I studied, just like last week.” You have played basketball and scored five baskets but also missed two really easy shots. After the game, you think, “I played poorly.” Your cousin calls you to ask if you would like to go on a long bike ride. You think, “I probably won’t be able to keep up, and people will make fun of me.” You call one of the kids in your class to talk about your math homework. She says, “I can’t talk to you now. My father needs to use the phone.” You think, “She doesn’t want to talk to me.”
Items were taken from: Leitenberg, Yost, & Carroll-Wilson (1986).
Catastrophizing
Personalizing
Overgeneralizing
Selective abstraction
.43 .45 .21 .20 .42 .46 .26
Manifest anxiety
Anxiety sensitivity
Trait anxiety
Depression
Figure 5.12: Unique relationships (standardized beta coefficients) between cognitive errors and various types of anxiety phenomena and depression in a sample of youths with anxiety disorders. All Betas were significant at p < .05. Based on: Weems, Berman, Silverman, & Saavedra (2001).
best predictors of anxiety sensitivity and manifest anxiety, whereas symptoms of depression were most clearly predicted by overgeneralizing and selective abstraction (see Figure 5.12). According to Beck’s (1976) theory, cognitive errors are the observable manifestations of maladaptive schemas, which can be defined as deeply rooted patterns of negative thinking
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about the world, oneself, and one’s relationships’ with others. The idea is that as soon as the person is confronted with a potentially challenging situation, these schemas are activated, resulting in erroneous and dysfunctional perception, thought, and behavior (i.e., cognitive errors and information-processing abnormalities), which may ultimately result in various types of psychopathology, including anxiety disorders. So far, few studies have been conducted on the link between cognitive schemas and anxiety symptoms in youths. One exception is the aforementioned investigation by Epkins (1996b), who measured the “cognitive triad” (i.e., a basic set of negative views of the self, the world, and the future) in socially anxious, depressed, and control youths. Results showed that socially anxious and depressed children displayed higher cognitive triad scores than control children, which indicated that both symptom groups exhibited higher levels of negative schemas. Another more recent study by Muris (2006d) investigated the relations between maladaptive schemas, as measured by an age-downward version of the Young Schema Questionnaire (Young & Brown, 1994; see Young, 1994) and various types of psychopathological symptoms in a sample of nonclinical adolescents aged 12 to 15 years. Results showed that anxiety symptoms were predominantly explained by emotional inhibition (i.e., the belief that one must inhibit one’s emotions), abandonment (i.e., expectations that one’s close emotional attachments will terminate), and social isolation/alienation (i.e., the belief that one is isolated from the world and different from other people, and the feeling of not belonging). Taken together, research on the relationships between cognitive errors and maladaptive schemas on the one hand, and anxiety symptoms in children and adolescents on the other hand, is sparse. While available studies have generally yielded the expected results, it is important to note that these investigations were all cross-sectional in nature. Much more research is needed to investigate the origins of cognitive errors and maladaptive schemas, to study whether they differ across various types of (anxiety) disorders, and to uncover the developmental course of such faulty or negative thought processes.
Disorder-Specific Thought Processes Besides worry, negative self-speech, and cognitive errors, which operate in a broad range of anxiety problems in youths, a number of more specific thought processes have been identified that seem to play a unique role in certain types of childhood anxiety disorders. Social Skill Deficits and Negative Self-Evaluation in Social Phobia. Several authors have suggested that social anxiety in childhood is associated with poor performance in social situations (e.g., Beidel & Turner, 1998). For example, Spence, Donovan, and BrechmanToussaint (1999) compared the performance of social phobic children aged 7 to 14 years and a nonclinical control group who were asked to participate in a series of role plays. The results of this study indicated that the social skills performance of social phobic children was clearly less competent than that of the nonanxious children (for a similar finding, see Alfano, Beidel, & Turner, 2006). Further, social phobic children appeared less likely to obtain favorable outcomes from their interactions with others. Based on these data, Spence et al. (1999) conclude that social skill deficits play an important role in the persistence of social phobia: “The findings are consistent with a model in which a vicious cycle maintains
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social anxiety and avoidance. Social skill deficits are proposed to lead to anxiety and avoidance. Social skill deficits are proposed to lead to lack of success from social situations, which in turn results in expectancies of poor outcomes and negative thoughts relating to situations in which evaluation by others is likely. Such negative thoughts and expectancies are suggested to generate affective and physiological responses of anxiety and subsequent avoidance behaviour. The avoidance of social situations, in turn, reduces the opportunity for learning of social skills and is proposed to perpetuate the cycle” (p.219). Others have put forward that social phobia is not necessarily accompanied by social skill deficits, and emphasized the role of negative self-evaluation in this anxiety disorder. For example, Cartwright-Hatton, Tschernitz, and Gomersall (2005) asked high and low socially anxious children of 10 and 11 years to participate in a conversation with an unfamiliar adult. Afterwards, children rated their own performance, and such ratings were also provided by independent observers. As can be seen in Figure 5.13, the results showed that independent observers did not notice differences in the performance of high and low socially anxious children. However, high socially anxious children rated themselves as significantly less skilled as compared to their low socially anxious counterparts. These and other findings (see Cartwright-Hatton, Hodges, & Porter, 2003; Chansky & Kendall, 1997; Morgan & Banerjee, 2006) seem to point out that socially anxious children and adolescents “are anxious not because they lack social skills, but because they believe that they lack them” (Cartwright-Hatton et al., 2003; p.737). Note that this conclusion nicely fits with current conceptualizations of social phobia in adults, which propose that negative self-evaluation is a prominent feature of this type of anxiety disorder. Taken together, while it may be true that some of the youths with social phobia display social skill deficits (which may also be the result of early childhood language impairment; see Voci, Beitchman, Brownlie, & Wilson, 2006), negative evaluative thought processes seem to play a crucial role in the maintenance of this anxiety problem (Morris, 2001). In
Poorness of performance
30 28 26 24
Low socially anxious
22
High socially anxious
20 18 16 Self-evaluation
Evaluation by observers
Figure 5.13: Ratings (of poorness) of performance for high and low socially anxious children, as provided by children themselves and independent observers. Based on: CartwrightHatton, Tschernitz, & Gomersall (2005).
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the meantime, one should be cautious to label all the negative thoughts of socially anxious youths as biased or distorted. The results of a recent study by Blöte and Westenberg (2007) demonstrated that high socially anxious adolescents not only felt negatively treated by others but were actually approached in a more negative way by their peers. Perfectionism, Intolerance of Uncertainty, and False Beliefs in GAD. In the context of GAD, a number of specific thought processes have been identified in adult populations, which may also be relevant for the maintenance of this specific anxiety disorder in youths. For example, McCreary, Joiner, Schmidt, and Ialongo (2004) examined the relation between self-reported perfectionism and GAD-based symptoms in a sample of nonclinical children of whom most had an African-American background. Results showed that socially prescribed perfectionism (e.g., “Other people expect me to be perfect”) and critical self-oriented perfectionism (e.g., “I get upset if there is even one mistake in my work”) were significantly associated with GAD symptoms (see also Hewitt, Caelian, Flett et al., 2002), and were even predictive of such symptoms at a one-year follow-up. Altogether, these findings indicated that perfectionism-related cognition seems to be involved in childhood GAD. Dugas, Gagnon, Ladouceur, and Freeston (1998) have formulated an interesting cognitive model of excessive worry and GAD in adults. In this model, intolerance of uncertainty plays a dominant role. Briefly, intolerance of uncertainty can be defined as the tendency to perceive uncertain situations as stressful and threatening, to believe that unexpected results are negative and should be avoided, and to think that being uncertain about the future is unfair. Individuals with high levels of uncertainty are reluctant to act when faced with an uncertain situation, and engage in excessive worry. Recently, Laugesen, Dugas, and Bukowski (2003) tested this cognitive account of GAD in a large sample of 14- to 18-year-old adolescents. Youths completed questionnaires for measuring intolerance of uncertainty, other cognitive variables such as thought suppression, positive beliefs about worry and a negative problem orientation, as well as worry symptoms. In keeping with the results obtained in adult populations (Dugas et al., 1998), it was found that intolerance of uncertainty displayed the strongest association with youths’ worry scores, and appeared to be the most important cognitive variable for discriminating between low and high adolescent worriers. A recent study by Gosselin, Langlois, Freeston et al. (in press) evaluated a number of other cognitive variables that may be associated with worry in youths. A large sample of adolescents aged between 12 and 19 years completed self-report scales for measuring worry symptoms and cognitive avoidance strategies, and the Why Worry Questionnaire (Freeston, Rheaume, Letarte, Dugas, & Ladouceur, 1994), which assesses erroneous beliefs associated with excessive worry (i.e., the belief that worry helps to prevent negative events or to avoid the worst, the belief that worries enable one to find a better way of doing things and may help to find solutions). Results indicated that high levels of worry are associated with higher levels of avoidance strategies, which supports the idea that worry basically can be conceived as a cognitive coping strategy. Interestingly, high levels of worry were also accompanied by stronger beliefs that worry has positive features, which possibly may result in a continuation of this anxiety phenomenon. In conclusion, some indications can be found in the literature that perfectionism, intolerance of uncertainty, and false beliefs about worry characterize the thought processes of children and adolescents with GAD (Kendall, Pimentel, Rynn, Angelosante, & Webb,
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2004). Two critical remarks can be made with regard to this claim, which may be a starting point for further research. First of all, it may well be the case that both perfectionism and intolerance of uncertainty are just the cognitive by-products of a neurotic temperament (see De Bruin, Rassin, & Muris, in press), and thus it remains to be seen whether these variables have any additional value beyond this general vulnerability factor to GAD (e.g., Eysenck, 1992). Second, so far it is unclear to what extent perfectionism and intolerance of uncertainty are really specific to GAD. In the adult literature, some evidence has recently emerged indicating that these cognitive variables are also relevant to other anxiety disorders (in particular OCD; see Shafran & Mansell, 2001; Sica, Coradeschi, Sanavio et al., 2004). Thought-Action Fusion and Metacognition in OCD. Common obsessions in youths with OCD pertain to fear of contamination, fear of harm to oneself and to other people, and urges related to a need for symmetry and exactness. Corresponding compulsions in children and adolescents are excessive washing and cleaning, checking, counting, repeating, touching, and ordering (Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989). Research in adults has shown that obsessions (which are generally viewed as the vehicle behind OCD as they are thought to provoke compulsive behavior; see Rachman, 1997) are relatively normal phenomena (Rachman & De Silva, 1978). However, an important difference between normal and abnormal obsessions has to do with the way by which obsessions are appraised: Individuals with OCD perceive their intrusive thoughts as more aversive, so they show a stronger tendency to resist such thoughts. According to the cognitive theory of obsessivecompulsive disorder (OCD; Salkovskis, 1985), obsessional problems arise when individuals experience an inflated sense of responsibility for their own thoughts. More specifically, a person who feels extremely responsible for his or her thoughts will experience more discomfort when an “immoral” (e.g., sexual, violent, or blasphemous) thought intrudes consciousness than a person without such a strong sense of responsibility. In other words, individuals with an exaggerated feeling of responsibility are inclined to misinterpret their intrusions in a catastrophic way. Through these catastrophic misinterpretations, an intrusion may acquire obsessional qualities (e.g., tension, anxiety, and resistance). Several cognitive factors are thought to be involved in the increase of people’s sense of responsibility for their intrusions and the resistance that these thoughts elicit. A first factor is thought-action fusion (TAF), which can be defined as a cognitive process whereby a person experiences thoughts and actions concerning harm as equivalent and views himself as equally responsible for thinking as for action. Briefly, TAF consists of two components: (1) “TAFMorality,” which pertains to the belief that unacceptable thoughts are morally equivalent to overt actions, and (2) “TAF-Likelihood,” which refers to the belief that thinking of an unacceptable or disturbing situation will increase the probability that that situation actually occurs (see Shafran, Thordarson, & Rachman, 1996). It has been proposed that individuals who display high levels of TAF are more bothered by their intrusive thoughts, and ultimately run greater risk for developing OCD. Support for a link between TAF and OCD symptomatology in youths is still limited (Shafran, 2001), but the few studies that were conducted have yielded promising results. Muris, Meesters, Rassin, Merckelbach and Campbell (2001) asked a large sample of nonclinical youths aged 13 to 16 years to complete the Thought-Action Fusion Questionnaire for Adolescents (TAFQ-A; see Appendix) and scales measuring trait anxiety, symptoms of obsessive-compulsive disorder, and other anxiety disorders. The
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results indicated that TAF was not only associated with symptoms of OCD but also with symptoms of other anxiety disorders and depression. However, when controlling for levels of trait anxiety, most connections between TAF and anxiety disorders symptoms disappeared, while symptoms of OCD and GAD remained significantly related to TAF. In a further study by Barrett and Healy (2003), TAF and other cognitive variables (e.g., responsibility, cognitive control) were measured in 7- to 13-year-old children with OCD, children with other anxiety disorders, and nonclinical control children. It was found that children with OCD displayed higher levels of TAF as compared to the nonclinical control children. However, no differences in TAF emerged between children with OCD and children with other anxiety disorders. Yet, in a sample of older youths aged between 11 and 18 years, Libby, Reynolds, Derisley, and Clark (2004) demonstrated that TAF levels of adolescents with OCD were not only significantly higher than nonclinical adolescents but also compared to adolescents with other anxiety disorders (see Figure 5.14). Thus, although the findings of these studies are not univocal (see also Barrett & Healy-Farrell, 2003), the data seem to justify the conclusion that TAF is involved in a broad range of anxiety disorders and in particular OCD. Another factor that seems to play a role in the appraisal of intrusive thoughts is metacognition. Metacognition does not refer to the content of the negative thoughts, but rather concerns an evaluation of the fact that one has such thoughts. Such an evaluation might be positive (e.g., “This thought warns me, so I can stop bad things from happening”) or negative (e.g., “This thought could make me go crazy,” “I will be punished for not controlling these thoughts”). Wells (2000) has proposed that metacognition may enhance an individual’s sensitivity to intrusive thoughts and may also promote maladaptive responses to cope with the negatively appraised thoughts (i.e., compulsions). Evidence for the idea that metacognition is associated with OCD in youths comes from a study by Mather and CartwrightHatton (2004) in which young nonclinical adolescents (aged 13 to 17 years) completed an age-downward version of the Meta-Cognitions Questionnaire (Wells & Cartwright-Hatton, 2
1
0 Adolescents with OCD
Adolescents with other anxiety disorders
Nonclinical adolescents
Figure 5.14: Mean thought-action fusion (TAF) scores of adolescents with OCD, adolescents with other anxiety disorders, and nonclinical adolescents. All between-group differences were significant at p < .05. Based on: Libby, Reynolds, Derisley, & Clark (2004).
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2004), a scale for measuring general responsibility beliefs, and questionnaires for assessing symptoms of OCD, anxiety, and depression. Results indicated that metacognition and general responsibility were both positively related to OCD symptoms. However, when controlling for age, gender, and comorbid symptoms, only metacognition was significantly associated with OCD symptoms, which of course suggests that this cognitive factor is particularly relevant for this type of anxiety disorder. In sum, then, thought-action fusion and metacognition might play a role in the preservation of OCD. Yet, it should be noted that no study so far has documented whether high levels of these cognitive factors are actually predictive of OCD symptoms over longer time periods. Furthermore, it is not fully clear to what extent these factors are specific to OCD. For example, there is some research indicating that metacognition also plays a role in worry and GAD (Wells & Carter, 2001) and in youths may even be linked to anxiety in general and depression (Cartwright-Hatton, Mather, Illingworth et al., 2004). Catastrophizing and Fear of Pain. The bio psycho social model of chronic pain proposes that pain is a complex phenomenon that is not only affected by biological mechanisms (e.g., tissue damage, diseases) but also by psychological (e.g., thoughts, beliefs, feelings) and social (e.g., family, work environment) processes. This model maintains a dynamic point of view, in which pain is influenced by biological, psychological, and social processes, but also results in changes in these three domains that, in turn, affect future responses to pain (e.g., Asmundson & Wright, 2004). This bio-psycho-social perspective on pain is echoed in current cognitive-behavioral models of chronic pain (Asmundson, Norton, & Norton, 1999; Vlaeyen & Linton, 2000), which have implicated fear of pain as an important vehicle behind the development and maintenance of chronic pain. Briefly, these models conceptualize the aetiology of chronic pain as a vicious circle in which pain experiences induce fear of pain. This fear of pain leads to avoidance behavior, which, in turn, contributes to physical deconditioning (for example, muscle atrophy, decreased mobility, weight gain) and disability. This will enhance new pain experiences, which will initiate further fear of pain and avoidance behavior. One important cognitive factor that is thought to fuel fear of pain is pain catastrophizing (Vlaeyen & Linton, 2000), which can be defined as the tendency to focus on pain and negatively evaluate one’s ability to deal with pain. There is abundant evidence that catastrophizing is significantly associated with pain, explaining between 7% and 31% of the variance in pain scores in adults (see for a review, Sullivan, Thorn, Haythornthwaite et al., 2001). Few studies have examined pain catastrophizing in children. One exception is a study by Eccleston, Crombez, Scotford, Clinch, and Connell (2004), who showed that catastrophizing was one of the most powerful predictors of symptoms of emotional distress (i.e., anxiety and depression) in a sample of clinically referred adolescents aged 11 to 17 years who suffered from chronic pain. Although not directly related to the anxiety disorders, it seems plausible that fear of pain is involved in other types of psychopathology that may have their roots during childhood (e.g., somatization disorder, hypochondriasis). Clearly, this observation justifies more research on the role of this psychological factor in the aetiology of such mental disorders in children and adolescents (see Muris, Vlaeyen, & Meesters, 2001), and special attention should be given to catastrophizing as a cognitive factor promoting fear of pain.
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Conclusion The extensiveness of this chapter indicates that researchers have a pretty good idea of what factors are involved in the maintenance of phobias and anxiety disorders in children and adolescents. That is, information-processing abnormalities and various types of dysfunctional, negative thought processes have been identified that are likely to play a role in the persistence of anxiety problems in youths. The word “likely” in the previous sentence makes clear that much of the empirical work still needs to be done. So far, research has predominantly demonstrated that childhood anxiety is indeed associated with informationprocessing biases and dysfunctional negative thoughts, but obviously more studies are needed that show that these factors are indeed involved in the continuation of anxiety over time. Several types of research methods can be employed to achieve this goal. First, prospective studies could be carried out in which the hypothesis is tested that children and adolescents who exhibit high levels of these supposedly maintaining factors are indeed more prone to maintain or even develop high levels of fear and anxiety. Second, experimental studies can be performed in which the pathogenic processes are mimicked in order to demonstrate their presumed role in the origins and continuation of anxiety. A nice example of this approach is provided in a study by Rassin, Merckelbach, Muris, and Spaan (1999), who made (adult) participants believe that thoughts of an apple resulted in the application of an electrical shock to a peer participant. This TAF-like manipulation resulted in a heightened frequency of intrusive thoughts, more discomfort and distress, and greater effort to suppress such thoughts. In other words, experimentally induced TAF transformed a normal thought (i.e., apple) into an obsession-like intrusion. Third and finally, if information-processing abnormalities and negative thought processes are indeed vehicles behind the persistence of abnormal fear and anxiety in youths, then effective treatment should eliminate these maintaining processes. Such an approach could also uncover possible mechanisms of effective treatment, which is an issue that will be further addressed in Chapter 8. Finally, it should be noted that most studies have examined the maintaining factors of childhood anxiety disorders in isolation. For example, it would be interesting to explore (1) the relationships among various types of information-processing abnormalities, (2) the links between information-processing abnormalities and dysfunctional negative thinking, and (3) relations between these cognitive processes and another important factor that is involved in the persistence of anxiety problems, namely avoidance behavior. In addition, it seems important to study the antecedents of these maintaining factors and their links to various vulnerability and protective variables that were described in previous chapters.
Chapter 6
The Aetiology of Childhood Phobias and Anxiety Disorders: A Dynamic Multifactorial Model
Introduction During the past years, our knowledge of the factors that are involved in the aetiology of childhood anxiety disorders has increased considerably (Muris, 2006a). Not only have a large number of vulnerability factors been identified but we also have a good notion of the protective influences that might play a role in the pathogenesis of anxiety problems in youths. In the preceding chapters, genetic-based vulnerability, environmental influences, and maintaining factors have been predominantly described in isolation, but it is clear that an “understanding of the pathways by which childhood anxiety disorders develop, persist and remit is likely to require consideration of a wide range of influences and, most importantly, their potential for complex, dynamic, transformational interactions (i.e., transactions) across development” (Vasey & Dadds, 2001; p.3). In this chapter we describe a comprehensive model for the aetiology of phobias and anxiety disorders in youths, which includes multiple factors that operate in dynamic interaction. First, previous models will be specified that have made an attempt to conceptualize the aetiology of childhood phobias and anxiety disorders. Then, the developmental psychopathology perspective will be discussed, as this perspective provides an optimal grounding for a development-sensitive and more dynamic multifactorial model of childhood anxiety disorders. Next, the model will be described in detail, and examples of studies will be provided that have yielded support for the interactive features of the model. Further, the model will be illustrated by means of a case history of a child with anxiety problems that was followed during various stages of her development. Finally, the case of Little Hans will be revisited and an attempt is made to analyze the aetiology of this “phobia of horses” in terms of the hypothesized model.
Aetiological Models of Pathological Fear and Anxiety in Youths In her frequently cited review article on fear and anxiety in children and adolescents, Craske (1997) noted three aetiological accounts for the development of pathological fear and anxiety in youths. The first account is biological in nature and is concerned with genetically transmitted temperament that predisposes children and adolescents to develop high fear and
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Early life experiences
Genetics
Neuroticism
Stress, learning experiences, and parental rearing behaviors
Phobias and anxiety disorders
Figure 6.1: Craske’s aetiological model for childhood phobias and anxiety disorders. Based on: Craske (1997).
anxiety. The second account is environmental and pertains to parental behaviors and learning experiences that promote the acquisition of fear and anxiety. The third and final account pertains to the interaction of biological and environmental factors. Although Craske did not make a clear statement on what account is most plausible, her graphic representation of the aetiological factors for childhood and adolescent phobias and anxiety disorders makes clear that she favors the interactional account (see also Craske, 2003). For example, as shown in Figure 6.1, Craske proposes that neuroticism, which she considers as the general vulnerability factor to this type of psychopathology, is the product of biological (i.e., genetics) and environmental (i.e., early life experiences with uncontrollability) influences. Further, it is clear that this model assumes that during the course of development, the general vulnerability factor of neuroticism may interact with various environmental variables, including stressors, negative learning experiences, and parental rearing behaviors, to eventually culminate in a phobia or an anxiety disorder. Muris and Merckelbach (2001) have described a comparable aetiological model that, although it specifically applies to childhood-specific phobias, may also be applicable to other anxiety disorders in youths (see Muris, 2006a). This multifactorial model assumes that there exists a continuum with normal fear on the one end and abnormal fear and anxiety on the other end. The basis idea is that the majority of youths has normal developmental fears that wax and wane with the passage of time. However, there is a small subgroup of children in whom these fears tend to radicalize due to a genetic vulnerability. This genetic vulnerability (i.e., neuroticism) may manifest itself in certain behavioral patterns (e.g., behavioral inhibition). Stressful life events, negative parental rearing behaviors, and specific learning experiences (e.g., conditioning, modeling, and negative information) interact with normal
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Normal childhood fears
Genetically based vulnerability (neuroticism) Stressful life events, negative parental rearing behaviors, specific learning experiences
Specific phobias
Avoidance and cognitive biases
Figure 6.2: A multifactorial model for the aetiology of childhood phobias. Based on: Muris & Merckelbach (2001).
developmental fears and genetically based vulnerability to produce excessive and extremely persistent fear that ultimately takes the form of a specific phobia (or another anxiety disorder). Once a specific phobia exists, it is maintained by avoidance and various types of cognitive mechanisms such as attentional bias and interpretation bias (see Figure 6.2). Similar multifactorial models for specific types of childhood anxiety disorders have been described by Rapee (2001; i.e., generalized anxiety disorder) and Morris (2001; social phobia). A somewhat older model by Manassis and Bradley (1994) essentially integrates two variables that represent both genetic- and environment-based vulnerability—namely, the temperamental characteristic of behavioral inhibition and the family-related factor of insecure attachment. Briefly, these authors assume that a child’s vulnerability to sympathetic arousal, which manifests itself in a behaviorally inhibited temperament, and a nonautonomously functioning caregiver, which increases the risk for the formation of an insecure caregiver-child attachment relationship, interact with each other to yield an internal working model that enhances the appraisal of threat, which in turn promotes avoidant behavior and hinders the development of adequate coping and social skills. Clearly, this state of inner insecurity has a detrimental effect on the child when dealing with social situations, developmental challenges, and traumatic incidents, and ultimately makes the child prone to develop anxiety problems (see Figure 6.3). The preceding models for the aetiology of pathological fear and anxiety in youths all seem to indicate that this type of childhood problem results from multiple factors. The
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Child’s vulnerability to sympathetic arousal
Nonautonomously functioning caregiver
Behavioral inhibition
Insecure attachment relationship
Internal working model: Appraisal of threat
Avoidance and inadequate coping and social skills
Social situations, developmental challenges, traumatic events
Phobias and anxiety disorders
Figure 6.3: Manassis and Bradley’s model for the aetiology of anxiety disorders in youths. Based on: Manassis & Bradley (1994).
factors are either child or environment related and are hypothesized to have additive or interactive effects to produce their unfavorable outcome. Noteworthy is that all models are biased toward vulnerability—that is, they predominantly focus on variables that put children and adolescents at increased risk for developing phobias and/or anxiety disorders. This disregards the fact that some youths seem to display remarkable resilience, as they do not develop a phobia or an anxiety disorder in spite of high vulnerability and clearly aversive circumstances. Obviously, this implies that, besides vulnerability factors, protective variables seem to be also at work (see Chapter 4). Interestingly, Manassis and Bradley (1994) acknowledge that children’s cognitive development may also play an important modifying role in the emergence of childhood anxiety problems: “With cognitive maturation, development of cognitive strategies may improve a vulnerable child’s ability to cope with situations, thus reducing avoidant behaviour and enhancing social interactions. . . . Conversely, new cognitive abilities may increase some children’s propensity to worry, as they become able to imagine more frightening possible outcomes for themselves” (p.359). The notion that childhood phobias and anxiety disorders originate from multiple, interacting vulnerability
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and protective factors, and the fact that cognitive development has a significant influence on this process are important tenets of the developmental psychopathology perspective, which will be discussed in the next section.
The Developmental Psychopathology Perspective The developmental psychopathology perspective has become increasingly popular as a framework that can be employed to comprehend and study the aetiology of abnormal behavior. In essence, developmental psychopathology is based on the following core assumptions (e.g., Cicchetti & Cohen, 1995; Rutter & Sroufe, 2000; Sameroff, Lewis, & Miller, 2000). First, abnormal behavior frequently is a pervasive and extreme manifestation of normal behavior, so it seems important to study normal and abnormal behavior and to try to understand what factors cause the radicalization of normal human behavior. Second, it is unlikely that abnormal human behavior is caused by one single factor. Most forms of psychopathology originate from multiple factors. Third, as mentioned earlier, not only risk and vulnerability factors are important, but protective mechanisms are also essential for understanding the aetiology of psychopathology. Fourth, psychopathology is a probabilistic rather than a predetermined phenomenon. That is, in each person, at any point in time, the current constellation of risk, vulnerability, and protective factors will determine whether the behavior is still normal or falling in the abnormal range. That is, risk/ vulnerability and protective factors will interact with each other to produce the eventual outcome. If risk and vulnerability outweigh protective factors, it is more likely that psychopathology will occur. In other words, the balance between risk/vulnerability and protection will determine successful or unsuccessful adaptation. Fifth, the diversity of aetiological factors and the fact that the constellation of risk/vulnerability factors and environmental influences vary from one person to another, indicate that there are many pathways to develop a certain disorder, a phenomenon that is known as equifinality. Sixth and finally, psychopathology occurs in a developing organism. This means that the developmental level may not only determine the specific expression of a certain disorder but also has an impact on the vulnerability and protective factors that are involved in the origins of the psychopathology. In the introductory chapter of their book The Developmental Psychopathology of Anxiety, Vasey and Dadds (2001) made a praiseworthy attempt to explain the development of childhood anxiety disorders within the developmental psychopathology perspective. As shown in Figure 6.4, these authors propose two major pathways for the onset of phobias and other anxiety disorders in youths. The first pathway involves environmentally determined variables that provoke the onset of an anxiety disorder. Such provoking factors may include (1) direct (i.e., conditioning) or indirect (i.e., modeling and negative information transmission) learning experiences. As described in Chapter 3, such experiences may contribute to the emergence of severe and persistent fear or anxiety; (2) operant conditioning experiences— for example, fear or anxiety can have an onset due to punishing experiences that follow approach behavior. In this way, a child may learn that some stimuli or situations signal punishment, which may lead to avoidance behavior, and (3) exposure to general stress: Several authors have argued that exposure to unrelated stressful incidents may produce
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Vulnerability factors
Protective factors
Cumulative risk
2 Provoking factors
1
Anxiety disorder
Figure 6.4: Vasey and Dadds’s developmental psychopathology model for the onset of childhood anxiety disorders. Pathway 1 pertains to environmentally determined variables that provoke the onset of the disorder (i.e., direct and indirect learning experiences, operant conditioning experiences, stress), whereas pathway 2 has to do with a cumulative risk that gradually develops from the interaction between various vulnerability and protective factors. Based on: Vasey & Dadds (2001).
severe anxiety through dishabituation or return of previously mastered fears (e.g., Jacobs & Nadel, 1985; see Chapter 3). The second pathway is concerned with a gradually increasing risk that results from continuous interactions between predisposing and protective factors, which eventually produce anxiety symptoms that become so intense and persistent that they reach clinical levels. Of course, it is also possible that these two pathways operate together and that an anxiety disorder develops when a child at high risk is exposed to provoking events (see Figure 6.4). Note in passing that Vasey and Dadds’s (2001) model acknowledges the major tenets of the developmental psychopathology framework. That is, the model incorporates various vulnerability and protective factors that interact with each other to produce either an adaptive or maladaptive outcome in an organism that is still strongly in development.
A Dynamic Multifactorial Model of Childhood Anxiety Disorders In previous chapters, a review has been provided on all the factors that have been put forward in the literature as playing a role in the aetiology of phobias and anxiety disorders in children and adolescents. Tables 6.1 and 6.2, respectively, provide an overview of all
Table 6.1 disorders
Variables that promote in children’s and adolescents’ vulnerability to develop and maintain phobias and anxiety Influence on childhood anxiety
Genetics
The genetic transmission of physical and psychological characteristics from parents to their offspring.
Behavioral inhibition
The behavioral tendency to react with withdrawal when confronted with unfamiliar people or situations.
Neuroticism (also known as negative affectivity or emotionality)
The temperament/personality factor referring to psychological instability and proneness to experience negative emotions. The tendency to react anxiously to potentially threatening stimuli and situations. A basic brain system that serves to alert to the possibility of danger and punishment, thereby enhancing avoidance behavior. Brain circuits situated in and around the limbic system, which are concerned with the early processing of incoming sensory information and play an important role in the organization of the body’s responses to threat.
Studies in child and adolescent twins have demonstrated that up to 50% of the variance in anxiety symptoms can be explained by a genetic factor. Children and adolescents who strongly and consistently show this behavioral tendency display higher levels of fear and anxiety symptoms. Youths high on neuroticism would be more susceptible to develop internalizing psychopathological symptoms including fear and anxiety. Children and adolescents high on trait anxiety would be more vulnerable to develop anxiety pathology. Stronger reactivity of the BIS system would be associated with greater proneness to (pathological) anxiety.
Trait anxiety
Behavioral Inhibition System (BIS)
Subcortical brain circuits
Hypersensitive subcortical brain circuits would make youths prone to experience high levels of fear and anxiety.
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Description
The Aetiology of Childhood Phobias and Anxiety Disorders
Variable
(Continued) Description
Influence on childhood anxiety
Anxiety sensitivity
Fear of anxiety-related physical sensations that are interpreted as having potentially harmful somatic, psychological, or social consequences. The tendency to react with repulsion to stimuli related with dirt and possible contamination.
Children and adolescents who are high on anxiety sensitivity are more susceptible to develop panic disorder and other anxiety problems.
Disgust sensitivity
Traumatic incidents
Negative life events and stress
Peer victimization
Conditioning
Indirect learning experiences
The experience of events involving actual or threatened death or serious injury, or threat to one’s physical integrity, or witnessing such events or hearing about unexpected or violent death, serious harm, or threat of death experienced by a close person. The experience of fairly common but nonetheless adverse incidents, and enduring negative life circumstances. The experience of being psychologically or physically bullied by other youths. The learning process through which a previously neutral stimulus is perceived as a harbinger of something aversive. Learning by observing the behavior of others (i.e., modeling) or by transmission of negative information about a stimulus or situation.
Youths who display high levels of disgust sensitivity would be more prone to develop certain types of specific phobia (in particular animal phobia and blood-injection-injury phobia). Children and adolescents who are confronted with traumatic incidents run the risk of developing PTSD and/or other anxiety disorders.
High levels of negative life events and stress would enhance youths’ proneness for developing anxiety problems. Children and adolescents who have been victimized by their peers are at increased risk for developing anxiety problems. Through conditioning children and adolescents may directly acquire a fear or phobia. Through modeling of fearful and anxious behavior and the transmission of negative information, fear and anxiety may be enhanced.
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Table 6.1
Table 6.1 (Continued) Description
Influence on childhood anxiety
Insecure attachment
An unsafe basic bonding between caregiver and child.
Parental rearing
The way parents raise their children.
Gender role orientation
The degree to which boys and girls display masculine and feminine traits and behaviors. Distortions in the perception and further processing of threat- and anxietyrelated material.
Insecurely (in particular ambivalently) attached youths may be at increased risk for developing anxiety problems. Several parental rearing behaviors may promote the development of anxiety, such as anxious rearing, overprotection, and rejection. A more feminine and less masculine gender role orientation is associated with higher levels of fear and anxiety. High levels of fear and anxiety are associated with a stronger inclination to attend to threat-related material, to disproportionately interpret ambiguous cues as threatening, and to more easily retrieve information about danger. This biased information-processing maintains high fear and anxiety. High levels of such dysfunctional and maladaptive thought processes hinder effective coping behavior and eventually maintain fear and anxiety.
Information-processing biases
Dysfunctional and negative thinking
Worry, negative self-speech, and general and disorder-specific cognitive errors.
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Variables that protect youths against the development of phobias and anxiety disorders
Variable
Description
Influence on childhood anxiety
Effortful control
A regulative temperament factor that can be defined as “the ability to inhibit a dominant response to perform a subdominant response,” which basically consists of inhibitory control and attention control. The belief that one is able to control internal and external events. An evaluation of oneself based on a comparison between the ideal and the perceived real self. The perceived ability to produce a desired action. In youths, self-efficacy pertains to social, academic, and emotional affairs. Cognitive and behavioral efforts to manage external or internal demands that are appraised as taxing or exceeding the resources of a person.
High levels of effortful control, and in particular attention control, shield children and adolescents against the development of high fear and anxiety levels.
Perceived control Self-esteem Self-efficacy
Coping and defense
Emotion regulation
Extrinsic and intrinsic processes responsible for monitoring, evaluating, or modifying emotional reactions in order to accomplish one’s goals.
Social support
Belonging to a network of other persons, being esteemed and valued by others, and being loved and cared for by others.
High levels of perceived control shelter youths from fear- and anxiety-related affective states. High levels of self-esteem are associated with lower levels of fear and anxiety symptoms. High levels of self-efficacy are thought to be protective against the development of high levels of negative emotions, including anxiety. Problem-focused (i.e., strategies that purport to change the stressful situation itself) and engagement (i.e., strategies that are oriented toward the source of stress or toward emotions) are associated with better psychological adjustment. Adequate emotion regulation is regarded as a prerequisite for preserving one’s mental health, and may help to prevent the development of pathological fear and anxiety. Social support may buffer against the development of anxiety when exposed to negative life events and stress.
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Table 6.2
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vulnerability (including maintaining)1 and protective factors that have been discussed in this book. Given the large variety of variables involved and the fact that the constellation of vulnerability and protective factors may vary from one person to another and from one point-in-time to another, it is rather difficult to give a comprehensive schematic representation of a model for the aetiology of phobias and anxiety disorders in youths. The model as proposed by Vasey and Dadds (2001; (see Figure 6.4)) is certainly a good attempt. Particular strong points of this model are the fact that both vulnerability and protective factors are included, and that these factors interact with each other as well as with provoking factors to eventually produce an anxiety disorder. However, other aspects of the developmental psychopathology account such as the dimensional nature of fear and anxiety (with normal and abnormal manifestations being part of one and the same continuum) and the impact of development on the pathogenesis of childhood phobias and anxiety disorders are less prominent in the model, although Vasey and Dadds (2001) clearly acknowledge their existence. Figure 6.5 presents a new model for the aetiology of childhood phobias and anxiety disorders that incorporates all the tenets of the developmental psychopathology perspective. The starting point of the model is that there appears to be a continuum with normal fear and anxiety, on the one end, and pathological anxiety, on the other end. At each point in time, children and adolescents’ level of anxiety is determined by the current constellation
Developmental level
Pathological anxiety
Protection
Vulnerability
Normal anxiety
Figure 6.5: A dynamic multifactorial model for the aetiology of childhood phobias and anxiety disorders. Note: Possible vulnerability and protective factors are listed in Tables 6.1 and 6.2.
1
In the context of the current model, it is less relevant to make a distinction between vulnerability and maintaining variables. That is, when a child/adolescent, at a certain point in time, suffers from high levels of fear and anxiety symptoms, maintaining variables such as information-processing abnormalities will increase vulnerability to display such symptoms.
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of vulnerability and protective factors. Obviously, vulnerability factors such as behavioral inhibition, negative parental rearing behaviors, and information-processing abnormalities increase or maintain fear and anxiety, whereas protective factors like effortful control, selfesteem, and effective coping strategies reduce or shield against these negative emotions. When vulnerability is high and protection is low, the probability increases that a child or adolescent displays anxiety levels in the pathological range, and when this occurs repeatedly within a certain frame of time, he or she may qualify for an anxiety disorder. It should be stressed that the model as depicted in Figure 6.5 is dynamic in nature and allows factors to influence or to interact with each other at various levels. To begin with, vulnerability factors may be interrelated or even reinforce each other. For instance, it is conceivable that behavioral inhibition in a child enhances the risk for parents to respond as overprotective and rejective, which in turn may seriously hinder the formation of a secure attachment relationship (Manassis, Bradley, Goldberg, Hood, & Swinson, 1995). As another example, the anxious responding of a parent to the fearful behavior of his/her behaviorally inhibited child may further reinforce the shy and timid responding of the child (HirschfeldBecker, Biederman, & Rosenbaum, 2004). Similar links can be observed among various protective factors. For example, there is tentative evidence suggesting that effortful control processes form the basis for adaptive coping responses (Salmon & Pereira, 2002). In a similar vein, it is also likely that self-efficacy, self-esteem, and perceived control are positively intercorrelated (Judge, Erez, Bono, & Thoresen, 2002), and that each of these constructs can be considered as important determinants of effective coping behavior (e.g., Cervone, Mor, Orom, Shadel, & Scott, 2004). Finally, it is also possible that vulnerability factors have an impact on protective factors and vice versa. For instance, effortful control may reduce the negative impact of neuroticism (Lonigan & Phillips, 2001) and an overprotective family environment may hinder the development of perceived control (Chorpita & Barlow, 1998). Altogether, the pathogenesis of childhood anxiety disorders is best represented as a multifactorial model in which various vulnerability and protective factors operate in dynamic interaction (see also Vasey & Dadds, 2001). Another important tenet of the model is that developmental changes play a prominent role in the origins, manifestation, and continuation of anxiety problems in children and adolescents. For example, normal fear and anxiety follow a predictable course, a phenomenon that is also known as the “ontogenetic parade,” which is thought to be largely determined by children’s development (see Chapter 1). As the current model assumes that normal and abnormal fear and anxiety lie on a continuum, the developmental pattern in normal fear and anxiety should also be reflected in the prevalence of phobias and anxiety disorders in children and adolescents across various ages. There is some empirical support for this idea. For example, in nonclinical youths, Weems and Costa (2005) have observed that symptoms of separation anxiety are most prevalent among younger children and then gradually decline with age. A reversed pattern was observed for symptoms of social phobia: These symptoms occur in childhood but clearly become more prominent during adolescence. Indeed, this normal pattern is also echoed in clinical data (see Ferdinand, Bongers, Van der Ende et al., 2006). That is to say, the prevalence of separation anxiety disorder seems to be higher in childhood than in adolescence (e.g., Kashani & Orvashel, 1990), whereas social phobia is more common among adolescents than among children (e.g., Essau, Conradt, & Petermann, 1999). As a related point, the symptom picture of specific anxiety disorders may
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also differ across various developmental stages. For example, young children with separation anxiety disorder more frequently report nightmares involving separation themes than adolescents. Further, while the majority of children with this anxiety disorder display excessive distress when separated from their caregivers, very few adolescents continue to demonstrate this particular symptom (e.g., Silverman & Dick-Niederhauser, 2004). Similar developmental variations have been observed for the content of obsession and compulsions (Geller, Biederman, Faraone et al., 2001). In addition, research has also demonstrated the physiological and cognitive symptoms of anxiety disorders change systematically during the course of development. That is, the number of physical symptoms that accompany generalized anxiety disorder in youths has been found to increase with age (Kendall & Pimentel, 2003) and a similar developmental rise has been observed for anxious cognitions (see Beidel, Morris, & Turner, 2004). Furthermore, the progression of cognitive development seems particularly relevant as it is hypothesized to have an impact on various aspects of the model (see Figure 6.5). Evidence for this notion comes from a number of sources. First, as discussed before, results of some studies seem to indicate that shifts in cognitive development herald periods in which vulnerable children are more prone to develop high levels of fear and anxiety (Muris, Merckelbach, Meesters, & Van den Brand, 2002; Westenberg, Drewes, Siebelink, & Treffers, 2004). Second, according to the cognitive model, maladaptive cognitions are the vehicle behind pathological anxiety (Beck, Emery, & Greenberg, 1985). More precisely, cognitive errors such as catastrophizing (i.e., anticipating the worst possible outcome for an event) lead to automatic negative thoughts, which guide an individual’s interpretation of internal and external events, and eventually lead to feelings of anxiety and avoidance behavior. It has been proposed that such processes are a function of children’s cognitive development (Alfano, Beidel, & Turner, 2002). There is indeed some recent evidence indicating that the catastrophic interpretation of bodily sensations in most children occurs after the age of 7, when they have reached Piaget’s (1970) concrete operational stage of cognitive development (Muris, Vermeer, & Horselenberg, submitted). Third, cognitive development not only has a negative influence by enhancing vulnerability to childhood anxiety, it may also strengthen children and adolescents’ resilience against this negative emotion. For example, research has shown that with increasing age and the progression of cognitive capacities, regulative processes such as perceived control, self-efficacy, self-esteem, and coping continually mature in the average child population (Band & Weisz, 1990; Daniels, 1993; Velder, 1985; Weisz, Southam-Gerow, & McCarty, 2001). Finally, as noted by Rapee and Spence (2004), age and the associated developmental stage may also determine to what extent certain fear and anxiety symptoms really interfere with daily functioning and ultimately enshrine whether such symptoms reflect a clinically significant disorder. An example from clinical practice may illustrate this point: A girl who was really afraid of traveling on public transportation experienced little interference as long as she visited primary school that was just a few blocks away from home. However, during early adolescence, the change to high school made it necessary to travel by bus, and this was the moment that her fear started to cause her serious problems and so could be qualified as a phobic disorder. Taken together, the proposed model hypothesizes that, in some youths, normal fear and anxiety radicalize to a phobia or an anxiety disorder due to a complex of multiple,
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interacting variables in which vulnerability clearly exceeds protection. Factors in the model may vary from one child to another, and the equilibrium between vulnerability and protection continuously changes as a result of experience and development. Obviously, such a model accounts best for the inter- and intra-individual variation in the development of pathological fear and anxiety.
Some Empirical Evidence for the Model The preceding model seems plausible but does not have the qualities of a scientific model in the strict sense of the word. Most important, the precise dynamics between various vulnerability and protective factors are far from clear. It is good to see that in the past few years, an increasing number of studies have begun to address this important issue and in the current section, some examples of such research are presented. The focus will be on the role of children’s temperament in the aetiology of anxiety problems, not per se because this factor plays a more prominent role than other variables but simply because a range of studies can be found in the literature that have demonstrated how temperament interacts with other variables to produce high levels of fear and anxiety symptoms in youths. Several investigations have found evidence showing that children’s temperamental vulnerability interacts with negative environmental influences. For instance, in an interesting study by De Rosnay, Cooper, Tsigaras, and Murray (2006), 12- to 14-month-old infants first observed their mother interacting with a stranger and then had to interact with the stranger themselves. There were two experimental conditions: In the first condition, the mother was instructed to interact with the stranger in a normal, nonanxious way, whereas in the second condition, the mother received the instruction to interact with the stranger in a socially anxious manner. The results showed that infants who had observed their mother behaving socially anxious were more fearful and avoidant during their own interaction with the stranger than infants who had observed their mother interacting nonanxiously. Interestingly, the effect of the experimental manipulation was modified by children’s temperament. As can be seen in Figure 6.6, infants with a high-anxious temperament were more avoidant in the socially anxious condition than infants with a low-anxious temperament, whereas no such difference was observed in the normal, nonanxious condition. Apparently, the observation of mothers’ anxious modeling behavior had a more negative impact on children who had a stronger temperamental disposition to become anxious. Another example of a study showing that temperament interacts with environment was recently provided by Brozina and Abela (2006). These researchers examined the relationship between temperamental vulnerability (i.e., behavioral inhibition) and anxious symptoms within a diathesis-stress framework, using a short-term prospective design. Briefly, it was hypothesized that the diathesis, a behaviorally inhibited temperament, would be associated with the development of anxiety symptoms but only when children experienced high levels of stress. To examine this issue, a large sample of children aged 8 to 13 years (N = 384) completed self-report scales for measuring behavioral inhibition, anxiety symptoms, and depression. Six weeks later, these scales were completed for a second time, this time together with a measure of daily hassles, which assessed children’s stressful experiences during the past six weeks (e.g., parents fighting, being teased at school, and being punished
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4
3 Mother nonanxious 2
Mother socially anxious
1
0 Low-anxious temperament
High-anxious temperament
Figure 6.6: Mean avoidance scores of temperamentally low- and high-anxious infants during the interaction with a stranger after observing mother behaving either nonanxious or socially anxious with that stranger. Based on: De Rosnay, Cooper, Tsigaras, & Murray (2006). 8 6 4 High stress
2
Low stress
0 –2 –4 Inhibited
Noninhibited
Figure 6.7: Changes in anxiety symptoms scores during a six-week period as a function of temperament (behaviorally inhibited versus behaviorally noninhibited) and stress (high versus low stress). Based on: Brozina & Abela (2006).
for something they didn’t do). The results revealed the expected interaction effect of behavioral inhibition and stress. That is, only behaviorally inhibited children who had also experienced high levels of stress exhibited an increase of anxiety symptoms (see Figure 6.7). Furthermore, it is important to note that no such pattern was observed for depression symptoms, which indicates that behavioral inhibition should be considered as a specific vulnerability factor to anxiety symptoms.
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There is also evidence indicating that temperament interacts with parental insensitivity, and in its wake attachment insecurity, in the formation of anxiety problems in youths. For example, Warren and Simmens (2005) collected prospective data to examine predictors of anxiety and depression symptoms in a large sample of 2- and 3-year-old toddlers (N = 1226). Mothers and caregivers completed a questionnaire to measure children’s difficult temperament (including features of behavioral inhibition) during the first 6 months of life. In addition, trained observers scored the insensitivity of the mothers by means of videotapes of mother-child interactions that were obtained when children were 6 and 15 months. Anxiety and depression symptoms were rated by mothers and other caregivers when children were 2 and 3 years of age. The results demonstrated that a difficult temperament of the child and insensitivity of the mother both made a unique contribution to children’s anxiety and depression symptoms at ages 2 and 3. Interestingly, when predicting anxiety and depression symptoms at age 2, a significant interaction of children’s difficult temperament and insensitivity of the mother was found. As shown in Figure 6.8, anxiety and depression symptoms were highest in children who had both a difficult temperament and a mother that was highly insensitive. In a similar vein, Shamir-Essakow, Ungerer, and Rapee (2005) examined the relationship between behavioral inhibition, insecure attachment, and anxiety disorders in an at risk sample of preschool children aged 3 to 4 years. All children and their mothers were subjected to an extensive laboratory assessment in order to establish their behavioral inhibition (i.e., inhibited versus uninhibited) and attachment (i.e., insecure versus secure) status. In addition, the mothers were interviewed to assess DSM-defined anxiety disorders of the children using a standardized, structured interview. It was found that behavioral inhibition and insecure attachment each made an independent and significant contribution to children’s anxiety. Furthermore, the highest level of anxiety disorders was observed for children who were both behaviorally inhibited and insecurely attached (although the interaction
0,5 0,4 0,3 0,2
Low difficult temperament
0,1 0
High difficult temperament
–0,1 –0,2 –0,3 –0,4 –0,5 Low insensitivity of mother
High insensitivity of mother
Figure 6.8: Standardized anxiety and depression symptoms scores for 2-year-old children with varying levels of difficult temperament and maternal insensitivity. Based on: Warren & Simmens (2005).
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2 Behaviorally uninhibited Behaviorally inhibited
1
0 Securely attached
Insecurely attached
Figure 6.9: Mean number of children’s anxiety disorders as a function of behavioral inhibition and attachment status. Based on: Shamir-Essakow, Ungerer, & Rapee (2005).
failed to reach statistical significance; (see Figure 6.9)). Finally, Schieche and Spangler (2005) found evidence to indicate that the combination of behavioral inhibition and insecure attachment is associated with a less favorable physical adaptation to stressful circumstances. During an experiment, 22-month-old toddlers were exposed to a challenging problemsolving task. Before and after the task, salivary cortisol was measured. The results demonstrated that toddlers who were low on behavioral inhibition showed an adequate physiological adaptation during the stressful task (as evidenced by decreasing cortisol levels) that was independent of their attachment status. However, in toddlers who were high on behavioral inhibition this physiological adaptation was less convincing, and this was particularly true in children who also had an insecure attachment status (see also Nachmias, Gunnar, Mangelsdorf, Parritz, & Buss, 1996). Altogether, these and other results (e.g., Bohlin, Hagekull, & Andersson, 2005; Mannassis et al., 1995; Muris & Meesters, 2002b) demonstrate that an inhibited temperament and insecure attachment both play a unique role in the development of anxiety problems and that the joint presence of these two vulnerability factors further increases the risk for this type of psychopathology (Manassis & Bradley, 1994). To complicate the picture even further, temperament and attachment may in turn interact with still other variables. An example of this idea was provided in a recent investigation by Van Brakel, Muris, Bögels, and Thomassen (2006), who examined the reciprocal connections among temperament, attachment, and parental rearing behaviors, and their unique and interactive relations to anxiety symptoms in a large sample of nonclinical adolescents aged 11 to 15 years (N = 644). The results indicated that behavioral inhibition, insecure attachment, and a controlling/anxious parental rearing style were all positively associated with each other. Further, all these vulnerability factors accounted for a unique and significant proportion of the variance in anxiety disorders symptoms. Interactive effects were also found (although they only explained a rather small proportion of the variance). First, there was a significant interaction of behavioral inhibition and attachment: Adolescents
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Anxiety
20 Low control
15
High control
10 5 0 Uninhibited/secure Uninhibited/insecure
Inhibited/secure
Inhibited/insecure
Figure 6.10: Visual presentation of the higher-order interaction effect of behavioral inhibition, attachment, and parental control on adolescents’ anxiety symptoms. Based on: Van Brakel, Muris, Bögels, & Thomassen (2006).
characterized by a combination of high behavioral inhibition and insecure attachment displayed the highest levels of anxiety symptoms (see supra). Second, a higher-order interaction of behavioral inhibition, attachment, and control was found. As shown in Figure 6.10, this effect was due to the fact that in some youths (i.e., uninhibited/secure and inhibited/ insecure), high levels of this rearing style were associated with higher anxiety levels, whereas in other children (i.e., inhibited/secure), high control was related to lower anxiety levels. Van Brakel et al. noted, “These divergent effects of parental control on anxiety can be explained when one adopts the notion that this rearing factor has multiple faces. On the one hand, control may be associated with extreme strictness, which has the negative consequence of reducing the development of autonomy. On the other hand, control has the positive consequence of structuring the child’s environment. When looking at our data, it can be suggested that on the condition that inhibited children have parents who are sensitive and responsive (in such a way that caregiver and child are securely attached), a highly controlling parenting style may have a positive influence on the anxiety symptoms of these children. That is, in this group of children, highly controlling parents offer just the structure these children need to help them navigate through their daily lives, and hence reduce anxiety. However, when children do not need assistance (i.e., the uninhibited/secure group) or when children do need guidance but their parents cannot provide it (i.e., the inhibited/ insecure group), control may manifest itself in its negative overprotective way and thus enhance anxiety” (p.577). These results point out that it is important to develop specific and unambiguous instruments for assessing vulnerability (and protective) variables in the study of the origins of anxiety pathology. Further, the findings indicate that the direction of influence of certain vulnerability factors may depend on the precise constellation of other variables. Recent attempts to examine the role of temperament in the aetiology of childhood anxiety are particularly promising as researchers have begun to not only pay attention to temperament factors that make children and adolescents vulnerable but also to temperamental variables that protect youths against the development of such symptoms (see Lonigan & Phillips, 2001; Muris & Ollendick, 2005; Nigg, 2006). The evidence summarized in
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24 23 22 High effortful control
21
Low effortful control
20 19 18 High neuroticism
Low neuroticism
Figure 6.11: Main and interactive effects of neuroticism and effortful control on DSMdefined anxiety symptoms in young adolescents. Based on: Muris (2006b).
Chapters 2 and 4 has indicated that neuroticism (and its derivates) have a positive influence on the development of childhood fear and anxiety, whereas effortful control (and in particular attention control) appears to play a buffering role against the emergence of these negative emotions. Several studies have demonstrated that neuroticism and effortful control each have a unique influence on child psychopathology, although it should be noted that most of this research has focused on the broad category of internalizing symptoms (e.g., Eisenberg, Cumberland, Spinrad et al., 2001; Eisenberg, Fabes, Guthrie et al., 1996; Eisenberg, Sadovsky, Spinrad et al., 2005; Oldehinkel, Hartman, De Winter, Veenstra, & Ormel, 2004). The few studies that have been investigating the role of neuroticism and effortful control on anxiety in youths have yielded highly similar results (Meesters, Muris, & Van Rooijen, in press; Muris, De Jong, & Engelen, 2005; Muris, Meesters, & Rompelberg, 2007). Interestingly, some of this research has shown that in particular a combination of high neuroticism and low effortful control seems to make youths most prone to display high levels of anxiety symptoms. For example, in a recent study by Muris (2006b), nonclinical adolescents aged 12 to 15 years (N = 173) completed self-report questionnaires for measuring neuroticism, effortful control, and DSM-defined psychopathology, including symptoms of anxiety disorders. Results showed that both neuroticism and effortful control made a unique contribution to youths’ anxiety symptoms, with the former having a positive effect and the latter having a negative influence. Most importantly, an interactive effect of neuroticism and effortful control on anxiety symptoms emerged. As shown in Figure 6.11, it was in particular the combination of high levels of neuroticism and low levels of effortful control that yielded highest levels of anxiety symptoms. A similar interacting effect of neuroticism and effortful control has been observed by Lonigan, Vasey, Phillips, and Hazen (2004), who investigated the effects of temperament on children’s attentional bias regarding threat-related stimuli. In their study, a large sample of children was screened to identify four temperament groups: (1) children with high neuroticism and high effortful control, (2) children with high neuroticism and low effortful control, (3) children with low neuroticism and high effortful control, and (4) children with
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182 50 40 30 20 10 0
High neuroticism/low High neuroticism/high Low neuroticism/low effortful control effortful control effortful control
Low neuroticism/high effortful control
Figure 6.12: Mean attentional bias toward threat scores for children in various temperament groups. Based on: Lonigan, Vasey, Phillips, & Hazen (2004). low neuroticism and low effortful control. All children were tested with a dot probe detection task that measures attentional bias for threat (see Chapter 5). It is important to note that the presentation interval used in this task was relatively long (i.e., 1250 sec.) in order to make it possible for the children to exert willful control over their attention. Results demonstrated that in particular children with high neuroticism and low effortful control displayed an attentional bias toward threat (see Figure 6.12), which suggests that it was the combination of high reactivity and low regulation that promoted this anxiety-related cognitive distortion. As an aside, it seems plausible that the interactive effect of neuroticism and effortful control on fear and anxiety also manifests itself on a biological level. In Chapter 2, it was noted that anxiety-prone (or neurotic) children and adolescents have hyperexcitable subcortical brain circuits that promote fear and anxiety. At the same time, it has been proposed that frontal brain areas are responsible for the regulation of negative emotion (Chapter 4). Thus, from a biological point of view, it can be assumed that youths who have a combination of hypersensitive subcortical brain circuits and poor functioning of the frontal brain areas display difficulties to control and regulate fear and anxiety and hence are more vulnerable to develop abnormal variants of these emotions (e.g., Fox, Henderson, Marshall, Nichols, & Ghera, 2005). Clearly, the further exploration of the brain regions/circuits associated with the expression and regulation of fear and anxiety warrants further research (see Kalin, Shelton, Fox, Oakes, & Davidson, 2005; Kalish, Wiech, Herrmann, & Dolan, 2006). The current section has listed empirical evidence on the role of temperament in the development of childhood fear and anxiety with the purpose to illustrate interactive influences of vulnerability and protective variables. A number of remarks can be made to qualify the information provided in this section. First of all, examples were given of how temperament may have direct and indirect effects on the emergence of pathological fear and anxiety in youths. However, it should be kept in mind that current theorists assume that temperament is not only biologically based but also affected by environmental variables or even levels of psychopathology (see Rothbart & Bates, 1998). The latter possibility is described
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as the scarring model and essentially assumes that “the manifestation of anxiety strengthens the vulnerability to anxiety” (Craske, 2003; p.33). Second, although it is widely accepted that temperament plays an important role in the aetiology of pathological fear and anxiety in youths, it should be stressed that there may be different paths to anxiety disorders, some of which do not involve temperament factors. For example, Hayward, Wilson, Lagle, Killen, and Taylor (2004) examined the role of various vulnerability factors in the aetiology of adolescent panic attacks and noted that whereas a neurotic temperament seems to play a prominent role in a substantial proportion of the youths, there were multiple other pathways to this type of psychopathology, which nicely illustrates the principle of equifinality. Finally, as emphasized by Craske (2003), there are marked differences between boys and girls regarding their temperamental vulnerability to anxiety. That is, girls display higher levels of neuroticism and in its wake exhibit a different way of responding to negative affect. According to Craske, these temperamental differences start to emerge from age 2 and then become even more prominent during the transition from childhood to adolescence. It seems important to learn more about the development of these gender differences. Furthermore, most studies on the aetiology of abnormal fear and anxiety in youths have simply collapsed the data of both genders. It may be worthwhile to explore more systematically whether different pathways to childhood phobias and anxiety disorders exist for boys and girls.
Clinical Application of the Model: A Case Study The proposed dynamic multifactorial model of childhood phobias and anxiety disorders is not only interesting from a scientific point of view but certainly has relevance for clinical practice. Most importantly, it may help clinicians to pay attention to the wide variety of vulnerability, protective, and maintaining factors that play a role in this type of psychopathology, and to take into account the developmental aspects that are involved. The identification of various child-, family-, or environment-related difficulties and strengths may be helpful to make (more) optimal decisions about the most appropriate intervention strategy. To illustrate this point, a clinical case will be discussed and analyzed in terms of the model. The case involves Julia, a girl born with a harelip, who applied for psychological treatment in a general hospital when she was 10 years old. The main reason for seeking help was a severe blood-injection-injury phobia, which was at that time extremely disturbing, as she had to undergo medical surgery to further correct her lip, jaw, and teeth. She had always been fearful of doctors, dentists, hospitals, injections, and so on, which was not very surprising given the aversive and often painful procedures that she already had to undergo from birth on. The male therapist was young and inexperienced, and he immediately focused on what seemed to be the most important problem: Julia’s fear of medical affairs. An anxiety hierarchy was made and exposure exercises were rapidly started. However, after a few sessions, the therapist discovered that the specific phobia was not the only anxiety problem of Julia. This happened when he was called away for a few moments at a beginning of an exposure session and had left Julia alone in the therapy room. When the therapist returned, he found Julia crying and completely in panic. This made him decide to plan more extensive diagnostic interviews (which he should have done in the first place)
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Physical problems: Harelip
Hospitalization and medical procedures
Medical fear
Initially rejected by parents
Insecure attachment
Rejected/victimized by peers
Grandmother deceased
Behavioral inhibition
Anxious mother
Separation anxiety
Overprotected by mother
Figure 6.13: Schematic representation of the variables that, according to the cognitivebehavior therapist, were involved in the aetiology of Julia’s anxiety problems. Note: The gray ovals indicate variables that were initially neglected during the diagnostic process.
with Julia and her parents. These interviews indicated that the girl also suffered from a separation anxiety disorder. Being a cognitive-behavior therapist, he summarized his idea about the origins of Julia’s anxiety in a macroanalysis (also known as a holistic theory; (see Figure 6.13)). As can be seen, Julia’s medical problems were clearly associated with the fact that she had a harelip. Shortly after birth, is was necessary that she stay in the hospital, where she underwent surgery to close her upper lip and palate. When she was almost 2 years old, a new operation was necessary. At that time, she was already very scared of doctors and nurses. In the following years, she visited the dentist regularly and underwent the checkups with moderate levels of fear. She avoided having a tooth filled because she feared this procedure, although she denied her feelings by saying, “This is only a milk tooth and I will lose it anyway!” The upcoming surgery at age 10, which had to be carried out to correct her growing lips and jaw, reintensified her medical fears. Additional interviews with Julia and her parents revealed a number of vulnerability factors that, as mentioned earlier, were initially neglected by the therapist. First of all, the fact that Julia had a harelip not only caused Julia to undergo aversive medical procedures but also had some other negative consequences. That is, father and mother admitted that, in the beginning, they were very upset about the appearance of their newborn daughter. Mother even acknowledged that she initially avoided physical contact with Julia because
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she found it so grisly to hug her. In combination with the recurrent hospitalizations during the early years of life, Julia might have become insecurely attached to her parents. Some evidence for this idea came from the observation that Julia showed marked difficulties in separation situations. For example, when she was brought to primary school, it took almost three months before mother could leave her behind without Julia having a fit of crying. Further, in times of stress (for example, when she was afraid of something), it was really difficult to comfort Julia: She wanted to be physically close to mother, but at the same time she was frustrated and refused advice or help to deal with the stressful situation. In the third class of primary school, she was victimized by some boys in her class who called her names (because of her harelip) and pushed her onto the ground. In this period, Julia showed a clear resurgence of school-related distress. In the mornings, she refused to get out of bed. She complained about being sick, but her father gently forced her to go to school. After only a few months, the school teacher discovered the victimization, and the perpetrators were punished. Julia was relieved but refused to talk about it anymore. It may well be that these negative social experiences further lowered her trust in other people, thereby fortifying her insecure attachment style. Second, the therapist noticed that Julia’s mother was shy and inhibited; she was anxious about meeting unfamiliar people. Being a housewife, this anxiety did not really interfere with her daily functioning, and as such these symptoms could not be qualified as a social phobia. Julia’s personality strongly resembled that of mother. She was also shy, and this was the case with adults as well as children, even if they were quite familiar to her. Nevertheless, she struck up two very close friendships with girls from her class. Some other signs of a behaviorally inhibited temperament were also present. For example, when she was young, she did not dare to fully explore the large climbing frame in the garden, and currently she still does not dare to go on the roller-coaster at an amusement park. Third, in contrast to father who has a no-nonsense rearing style, mother had translated her anxious attitude into an overprotective style. Whenever Julia showed distress, mother was quick to help her, even though Julia was frequently too annoyed to accept this support. Fourth and finally, one year ago, Julia’s grandmother died. The family visited the grandmother only once a month, but nevertheless Julia had a very warm and close relationship with her. As shown in Figure 6.13, the cognitive-behavior therapist assumes that negative learning experiences, Julia’s inhibited temperament and insecure attachment style, mother’s overprotective rearing behavior, and the death of her grandmother all played a role in the origins of her anxiety complaints. An additional element should be noted in Julia’s recent personal history that the therapist considered as less important but nevertheless may have had a significant impact on Julia’s anxiety problems at age 10. That is, father recently accepted a new job. On first sight, this seemed indeed less relevant. However, because his new job was very busy and he had to travel a lot, his participation in the upbringing of the children was significantly reduced. This had a specific impact on Julia, as father was less able to encourage Julia in anxiety-provoking situations and to compensate the anxiety-promoting rearing behaviors of mother. The therapist’s schematic overview of the factors involved in the origins of Julia’s anxiety problems has one particular strong point in that it demonstrates that multiple factors are involved in her psychopathology. However, several other features seem less in accordance with a developmental psychopathology account. To begin with, as is the case with many clinicians, the therapist mainly focused on vulnerability factors. Protective factors were
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neglected, but it is good to keep in mind that even in a vulnerable child like Julia various protective factors can be identified. For example, Julia’s family was quite involved and supportive, father encouraged his daughter to expose herself to anxiety-provoking situations, she had a lot of fun with her two friends, and she was quite intelligent (as she generally experienced few problems with the lessons at school). In the second place, cause-effect relations in the therapist’s model were only conceptualized as main effects. Although it may well be the case that the therapist did this in order to keep his overview simple, it is clear that various types of interactions can be introduced in his model. For example, it seems most plausible to view the origins of Julia’s medical anxiety in terms of a diathesis-stress account. That is, it may well be that the combination of Julia’s temperamental vulnerability (i.e., behavioral inhibition) and the early hospitalization and medical procedures that she had to undergo installed her fear of medical affairs. Further, it seems very likely that various vulnerability factors in the model (i.e., behavioral inhibition, insecure attachment, and overprotection by her mother) have strengthened each other, and gradually intensified Julia’s fears and anxiety. In the third place, there is no place for developmental aspects in the therapist’s model, which makes it rather difficult to understand why anxiety problems become really prominent at certain points-in-time. Figure 6.14 displays a developmental psychopathology analysis of Julia’s anxiety problems. Note that the key features of the proposed dynamic multifactorial model are all
Separation anxiety
School refusal
Fear of dentist
SAD, Blood injection-injury phobia
Anxiety level
Time 6 years V≥P
7 years V≥P
8 years V=P
9 years V≥P
10 years V>P
Vulnerability: • Life event: going to primary school
Vulnerability: • Life event: being victimized at school
Vulnerability:
Vulnerability: • Life events: visits to dentist (problem teeth) ∞
Vulnerability: • Life events: surgery, grandmother deceased, father change of work
Protection:
Protection:
Protection:
• Harelip • Behavioral inhibition • Insecure attachment • Overprotective/ anxious mother Protection:
Protection: • Supporting mother • Intelligence • Friends at school
• Supporting family • Rearing style father • Intelligence • Friends at school
• Friends at school
Figure 6.14: Developmental psychopathology analysis of Julia’s anxiety problems. Note: SAD = Separation Anxiety Disorder, V = Vulnerability, P = Protection, V = P: vulnerability and protection are reasonably in balance, V ≥ P: vulnerability tends to prevail over protection (but not strongly enough to produce pathological anxiety), V > P: vulnerability clearly predominates protection, and this results in pathological anxiety.
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present: (1) normal and abnormal fear and anxiety are part of one and the same continuum, (2) although not visually depicted in the figure, it is clear that vulnerability and protective factors are continuously in dynamic interaction with each other to determine the anxiety level at each point in time, and (3) development has an important influence: This is illustrated by the fact that the balance between vulnerability and protection continuously changes during the course of development. Furthermore, in this vulnerable child, normal developmental challenges (such as going to primary school) seem to herald a difficult period in which related anxiety symptoms (e.g., separation anxiety/school phobia) become more intense. Two additional remarks regarding the analysis as shown in Figure 6.14 are in order. To begin with, time frames of one year were used in order to keep the figure orderly. However, it is clear that this approach allows a more detailed and refined analysis of the origins of anxiety problems as long as the exact points in time for certain life events are known. Further, the model is of course far from complete. That is, no information was available for other vulnerability and protective factors that play a role in the aetiology of childhood phobias and anxiety disorders. This points out that in order to fully understand the origins of the anxiety problems of a specific child, it is important for clinicians to have a good overview of all the factors that may be involved.
What Was Really Wrong with Little Hans? Little Hans was an almost 5-year-old boy who was so afraid of horses that he did not dare to go out on the street anymore. Freud (1909/1955) postulated that these complaints originated from a so-called Oedipus complex: Hans wanted sex with his mother and therefore expected to be punished by his father. As a result, Hans came to fear his father. However, this was considered as unacceptable by his Ego, and therefore his fear was shifted to another object: horses. As a result of his fear of horses, Hans no longer went out of the house. According to Freud, these agoraphobic complaints helped him to achieve his main goal: staying at home with his beloved mother. As already pointed out by Wolpe and Rachman (1960), there is absolutely no empirical evidence for the Freudian interpretation of Little Hans’s case. However, Wolpe and Rachman identified various factors in Freud’s description of the case that may have been relevant for understanding the aetiology of the phobia in this 5year-old boy. Briefly, these authors assume that negative learning experiences with horses have played an important role in the origins of Hans’s horse phobia. First of all, they note a number of events that may have enhanced the boy’s susceptibility to become fearful of horses. In Wolpe and Rachman’s (1960) words, Hans had gone through “two unpleasant incidents with horses prior to the onset of the phobia. It is likely that these experiences had sensitized Hans to horses, or in other words, he had already been partially conditioned to fear horses. These incidents occurred at Gmunden [a small village in Austria where Hans and his family went for the summer holidays]. The first was the warning given by the father of Hans’s friend to avoid the horse lest it bite, and the second when another of Hans’s friends injured himself (and bled) while they were playing horses” (p.146). Obviously, the first incident involves negative information transmission, while the second event can be qualified as a vicarious learning experience. Second, the onset of Hans’s phobia probably
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occurred when the boy witnessed a horse in front of a carriage falling on the street. Hans himself pointed at this incident when his father asked him about where his fear of horses came from: “I only got it [the phobia] then. When the horse in the bus fell down, it gave me such a fright, really! That was when I got the nonsense [father and Hans use this word to refer to Hans’s horse phobia]” (Freud, 1909/1955; p.192). This incident can be viewed as a classical conditioning experience, and although the event from an adult’s point of view can be regarded as rather mild, it was severe enough for Hans to display intense fear of horses immediately afterward. Besides these negative learning experiences, a number of other variables can be identified in the case history of Little Hans that may also be relevant in the context of the origins of his phobic complaints. To begin with, questions can be posed concerning the rearing behaviors of Hans’s parents. Father impresses as a real adept of Freud’s theoretical notions of psychopathology, and obviously had a clear view of what was wrong with his son. He really seemed to make a lot of fuss about Hans’s problem and talked a lot with him about the presupposed (sexual) origins but actually did little to help the boy to cope with his fears. Little is known about Hans’s mother. We only know that she was a former patient of Freud, and that she threatened Hans when she found him with his hand to his penis when he was 3 years old: “If you do that, I shall send for Dr. A. to cut off your widdler!,” which gives us the impression that she may have not been particularly suitable for dealing with the intense fears of her son. Further, a number of stressful life experiences occurred in the year before the onset of his phobia, which may have enhanced Hans’s vulnerability to develop anxiety complaints. First of all, his sister was born, and as in many young children, Hans initially was rather jealous about the new arrival in the family. Further, the boy got influenza and even underwent an operation during which his tonsils were removed. Clearly, these experiences introduced stress in Hans’s life and as a consequence he may have felt less secure. Admittedly, the information about Hans’s parents and these negative life events is rather meager, and hence one could argue that the role of all these factors in the aetiology of Hans’s fears is rather speculative. However, even psychoanalysts themselves have noted these factors and tried to incorporate them in a reformulation of the case. For example, Ornstein (1993) offered a self-psychological perspective on the origins of Hans’s horse phobia, and concluded that the problem probably emerged because of the child’s separation anxiety and an increasingly insecure attachment to his mother. However, there is no need for new psychoanalytic speculations, because Little Hans’s case can be perfectly analyzed in terms of a developmental psychopathology account (see Figure 6.15). While we know little about protective variables, it can be assumed that several factors enhanced Hans’s vulnerability to develop an anxiety problem, including the stressful life events, the way his parents dealt with his fear, and the negative learning experiences with horses (of which the mild conditioning event of the horse falling on the street probably caused his fear to gain phobic properties). Important in this account is the fact that Hans is only 5 years old. At this age, fantasy is a significant aspect in children’s perception and thinking. From the description of Freud’s case, it becomes clear that Hans indeed tended to magnify the danger of horses. For example, he viewed the halter as a muzzle, which prevented the horse from biting. In his perception, horses were quite large animals and from his point of view, the incidents with horses were rather impressive and really frightening
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5-year-old boy
Pathological anxiety
Protection
?
Vulnerability
Normal anxiety
Anxiety-promoting rearing behaviors of parents Stressful life events: newborn sister, tonsillectomy Negative learning experiences with horses
Figure 6.15: Analysis of Little Hans’s case in terms of a developmental psychopathology perspective.
for him. It seems doubtful, however, that these events would have exerted a similar impact if Hans had been 10 years of age. Finally, Little Hans’s case is also a nice illustration of the fact that normal and abnormal fears are part of one and the same dimension. More precisely, at its climax, Hans’s fear of horses certainly exhibited phobic characteristics. In terms of the current diagnostic criteria of a specific phobia (American Psychiatric Association, 2000), there was a marked fear of a clearly discernable and circumscribed object (i.e., horses), exposure to this stimulus invariably provoked an anxiety response, and the stimulus was avoided to such an extent that it interfered with Hans’s daily functioning (i.e., he did not dare to go out on the street anymore). However, there is one important DSM-criterion that Hans’s “phobia” did not fulfill: in youths, the duration of the phobic complaints should at least be six months, and this was obviously not the case. According to the original case description, the phobia broke out in January 1908, whereas Freud’s (one-session) therapy ended in May of that year (Freud, 1909/1955). In other words, it seems most plausible to view the “phobia” of Little Hans as a significant but short-lasting increase of fear in a 5-year-old boy in which the vulnerability factors briefly exceeded the protective potential. The weight of these vulnerability factors seemed to be partly determined by the developmental level of Hans: His restricted experience with and knowledge about horses as well as his rich fantasy may have created a good soil for developing a fear of these animals.
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Conclusion This chapter conceptualized the aetiology of phobias and anxiety disorders in youths in terms of a dynamic multifactorial model. The model incorporates a wide range of vulnerability, maintaining, and protective variables that have been identified as relevant for the origins of anxiety problems in youths. The basic idea is that normal and abnormal fear and anxiety are situated on a continuum and that at each point in time, while taking into account the developmental level of the individual child or adolescent, vulnerability and protective factors operate in dynamic interaction with each other to produce a certain level of fear or anxiety. If protection is greater or equal to vulnerability, fear and anxiety levels will remain within acceptable limits. However, when vulnerability clearly exceeds protection, fear and anxiety may become so frequent and intense that the young person experiences significant interference in his daily routine and functioning. In the latter case, fear and anxiety are no longer normal but acquire the status of a phobia or an anxiety disorder. Development is considered as an important moderating variable in the model; for example, the child’s developmental level may determine the type of fear (phobia) or anxiety (disorder) from which the child comes to suffer or may have an impact on the precise symptomatology of the disorder. Admittedly, the hypothesized model does not have all the qualities of a scientific model. Clearly, many issues need to be investigated. To begin with, this account implies that the aetiology of the anxiety problem may be totally different for each individual child. This does not mean, however, that it is an important issue for researchers to examine whether there are common pathways to pathological anxiety in youths. Researchers have begun to identify such trajectories for various types of child psychopathology (e.g., Broidy, Nagin, Tremblay et al., 2003; Kim & Cicchetti, 2006; Mulvaney, Lambert, Garber, & Walker, 2006; Shaw, Lacourse, & Nagin, 2005), and it seems important to examine this issue for childhood phobias and anxiety disorders. Further, the precise dynamics and interactions among various vulnerability and protective factors that figure in the model are far from clear. The recent past has seen the emergence of studies that examine the contributions of multiple factors to childhood fear and anxiety, but it is clear that more research is required to establish the overlap among these variables and to study interactive effects, in particular between vulnerability and protective factors. Finally, the role of development needs careful consideration. So far, in most studies, development (in most studies: age) has been predominantly treated as a confounding variable, and as a consequence most researchers have simply partialled out its influence in their statistical analyses. It seems important to thoroughly examine the influence of development on the emergence of normal and abnormal fear and anxiety. In this research, age might be employed as a proxy of development. However, it would certainly be an improvement to employ more direct indices of social, cognitive, and emotional development. Obviously, all these issues preferably require longitudinal prospective studies that include various parameters. Of course, such complex prospective studies are not easy to conduct, precisely because they are time consuming and difficult to get funded. However, only in this way we can further expand our knowledge on the aetiology of this highly prevalent type of psychopathology, which is a burden to many of our youths and inherently a silent threat to the future adult generation.
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Although the focus of this book is on the aetiology of phobias and anxiety disorders in youths, the following two chapters are concerned with assessment and treatment. More precisely, Chapter 7 provides a thorough overview of various types of empirically validated measures that can be employed to assess normal and abnormal manifestations of fear and anxiety in children and adolescents. Finally, in Chapter 8 various interventions methods that are used for treating pathological fear and anxiety in youths will be described. Again, science will be our guide, which means that only those intervention methods will be discussed that have demonstrated efficacy in controlled outcome research.
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Chapter 7
Assessment of Fear and Anxiety in Children and Adolescents
Introduction Freud made little effort to assess the fears and anxiety of Little Hans in a systematic way. Instead, he mainly relied on observations of the boy’s father to gather information about the case (Freud, 1909/1955). In current psychological setting, it is common practice to employ some kind of psychological test to quantify and qualify children’s fear and anxiety complaints. While it is true that projective tests like the Columbus (Langeveld, 1981) and the Children’s Apperception Test (Bellak, 1993) are still frequently used and certainly may provide interesting information on children’s fear and anxiety, various other instruments can be employed to measure these negative emotions in a more standardized manner. This chapter provides an overview of empirically validated assessment instruments that may be helpful for assessing fear and anxiety in youths. First, a wide range of general and specific self-report questionnaires of childhood fear and anxiety will be reviewed. Next, a number of clinician rating scales will be discussed. Then, various interview instruments will be described that can be employed to classify childhood anxiety disorders in terms of current nosologic constructs as described in the DSM. Finally, a number of assessment methods will be described that rely on the direct observation of fearful and anxious behaviors in children and adolescents.
Self-Report Questionnaires In both research and clinical practice, self-report instruments for measuring childhood anxiety symptoms are frequently used. This type of measure is easy to administer, requires a minimum of time, and captures information about anxiety symptoms from the child’s point of view (Strauss, 1993). The latter is particularly important as fear and anxiety belong to the so-called internalizing problems, which are frequently less observable, even to people in youths’ direct environment. Although self-report instruments appear to assess children’s anxiety directly, these measures are not without limitations. As Stallings and March (1995) rightly remarked, social factors may influence the veracity of reporting. That is, some children tend to underreport fear and anxiety symptoms, simply because they want to present a more favorable evaluation of themselves or to avoid treatment. Further, when a questionnaire is used, one has to take into account the child’s ability to read and to understand the
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items, which of course determine the validity of responses. In spite of these limitations, self-reports represent an important source of information on fear and anxiety symptoms in youths. A wide range of instruments are available, of which the most important will be discussed in the following sections of the chapter.
Traditional Fear and Anxiety Scales The three most widely used self-report scales for measuring childhood anxiety are the StateTrait Anxiety Inventory for Children (STAIC; Spielberger, 1973), the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978), and the Revised Fear Survey Schedule for Children (FSSC-R; Ollendick, 1983). All these instruments are agedownward versions of adult questionnaires and were been developed more than 20 years ago. As such, it is not surprising that these scales do not use the current diagnostic constructs that are employed by many contemporary researchers and clinicians, which has led some authors to label them as “traditional” childhood anxiety questionnaires (Muris, Merckelbach, Ollendick, King, & Bogie, 2002). The STAIC is a widely used questionnaire, which consists of a state scale (20 items) that measures present-state and situation-linked anxiety, and a trait scale (20 items) that addresses temporally stable anxiety across situations. From a clinical perspective, the trait anxiety version of the STAIC (STAIC-T; item examples are “I am scared,” “I feel troubled,” and “I get a funny feeling in my stomach”) is more relevant than the state anxiety version because in most cases the assessor will be interested in assessing more chronic anxiety symptoms in children. The RCMAS resembles the STAIC-T in that this scale also attempts to assess more general anxiety levels in youths. Briefly, the RCMAS is a 37-item self-report rating scale that contains three anxiety-related subscales: physiological manifestations of anxiety (e.g., “Often I have trouble getting my breath”), worry and oversensitivity (e.g., “I worry a lot of the time”), and problems with fear and concentration (e.g., “Others seem to do things easier than I can”; Reynolds & Paget, 1983). Research has indicated that the STAIC-T and the RCMAS are reliable instruments (e.g., Varela & Biggs, 2006). However, there are questions about the validity of both instruments. As both questionnaires include items referring to mood rather than anxiety problems (see Szabó & Lovibond, 2006), several authors have argued that the STAIC-T and the RCMAS can best be considered as measures of “general distress, with the accent on anxiety” (Greco & Morris, 2004; Stallings & March, 1995, p.134). The FSSC-R primarily focuses on fears and phobic symptoms, and simply asks children and adolescents to rate how much fear they experience in response to specific stimuli or situations. In this way, information can be obtained on the number, severity, and types of fears. Factor analysis has consistently demonstrated that the FSSC-R contains five factors: fear of danger and death (e.g., “being hit by a car or truck”), fear of failure and criticism (e.g., “looking foolish”), fear of the unknown (e.g., “going to bed in the dark”), fear of small animals (e.g., “snakes”), and medical fears (e.g., “getting an injection from the nurse or doctor”; Ollendick, 1983; Ollendick, King, & Frary, 1989; Ollendick, Yule, & Ollier, 1991; see also Schaefer, Watkins, & Burnham, 2003). Interestingly, over the years, several authors have made an attempt to update the scale in such a way that it includes the new threats of
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contemporary society (e.g., “school violence,” “terrorists,” “AIDS,” “sexual assaults”; Fisher, Schaefer, Watkins, Worrell, & Hall, 2006; Gullone & King, 1992; Muris & Ollendick, 2002; Shore & Rapport, 1998). The psychometric properties of the FSSC-R are generally satisfactory, although Perrin and Last (1992) noted that the scale failed to discriminate between youths with either anxiety disorders, ADHD, or no psychiatric diagnosis. However, a more recent study by Weems, Silverman, Saavedra, Pina, and Lumpkin (1999) found evidence to suggest that the FSSC-R may be useful in differentiating among children with various types of phobias. Although the FSSC-R clearly seems to have its niche for assessing fears and fearfulness in youths (Myers & Winters, 2002), it should be mentioned that several authors have questioned the validity of this scale. For example, based on the observation that fears of danger and death (e.g., “not being able to breathe,” “bombing attacks or being invaded,” “being hit by a car or truck”) in FSSC-R studies typically belong to the most prevalent fears reported by children, McCathie and Spence (1991; p.495–496) noted: “Whereas it is perhaps sensible to suggest that these events would be extremely fear-producing if they were to occur, they are not highly probable events. Given such a low probability of occurrence, it seems unlikely that children frequently worry about these events or engage in avoidance behavior in order to prevent their occurrence.” A diary study of children’s fears indeed seemed to confirm this notion (Muris, Merckelbach, Ollendick et al., 2002). In that study, it was found that frequent FSSC-R danger and death fears have a low prevalence rate in daily life and, even when they do occur, elicit fairly low levels of fear. On the basis of these findings, it can be concluded that various FSSC-R items do not assess the frequency of actual fearful behavior, but rather the negative affective responding to the thought of occurrence of these specific events. In spite of their obvious limitations, it can be concluded that traditional scales such as the STAIC-T, RCMAS, and FSSC-R provide useful information on childhood fear and anxiety. Greco and Morris (2004) rightly remarked that these scales are good measures of global, anxiety-related distress. Some authors note this as a shortcoming of these questionnaires and have argued that these scales are more suitable for measuring general psychopathology-related distress rather than specific anxiety problems (Perrin & Last, 1992). Further, as these measures are not closely linked to the most recent diagnostic taxonomy of childhood anxiety, it can be concluded that their clinical utility is restricted. Fortunately, recent times have seen the emergence of modern self-report instruments, which intend to assess anxiety symptoms in youths in terms of current classification systems such as the DSM.
Modern, Multidimensional Questionnaires Over the past few years, a number of new questionnaires have been developed in an attempt to measure the various aspects of childhood anxiety in terms of the nosologic constructs that are currently employed by researchers and clinicians. In this context, three scales should be mentioned, namely the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997), the Spence Children’s Anxiety Scale (SCAS; Spence, 1998), and the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher, Khetarpal, Brent et al., 1997).
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The MASC was constructed to assess four theoretically meaningful domains of childhood anxiety symptoms: affective, physical, cognitive, and behavioral. Items selected to represent these domains were subjected to factor analysis. Results, indeed, revealed four factors, yet the content of these factors deviated somewhat from the hypothesized anxiety domains. More precisely, the MASC seems to tap the following four dimensions of childhood anxiety: physical symptoms (e.g., “I feel tense”), social anxiety (e.g., “I am worried about others laughing at me”), separation anxiety (e.g., “I am scared when my parents go out”), and harm avoidance (e.g., “I avoid things that upset me”). These psychometrically derived dimensions have been found consistently in normal and clinical samples (March et al., 1997; March, Sullivan, & Parker, 1999; March, Conners, Arnold et al., 1999; Olason, Sighvatsson, & Smami, 2004). The psychometric properties of the MASC appear to be adequate with good internal consistency and test-retest stability (March et al., 1997; March et al., 1999). Furthermore, there is evidence for the concurrent and discriminant validity of this scale. For example, the MASC correlates significantly with traditional and other modern anxiety scales (Muris et al., 2002), and most MASC dimensions show specific convergence with their corresponding anxiety disorder as measured with a diagnostic interview (Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). Finally, the scale differentiates reasonably well between anxious children, normal children, and children with other types of psychopathology (see March et al., 1999; Rynn, Barber, Khalid-Khan et al., 2006). The SCAS is a DSM-based questionnaire that measures youths’ perceptions of the frequency with which they experience symptoms related to generalized anxiety disorder (e.g., “I worry about things”), separation anxiety disorder (e.g., “I would feel afraid of being on my own at home”), social phobia (e.g., “I feel afraid that I will make a fool of myself in front of people”), panic and agoraphobia (e.g., “I suddenly feel as if I can’t breathe when there is no reason for this”), physical injury fears (which replace specific phobias—e.g., “I am scared of dogs”), and obsessive-compulsive disorder (e.g., “I can’t seem to get bad or silly thoughts or pictures out of my head”). The psychometric properties of the SCAS are strong. That is, the scale possesses good internal consistency, sufficient test-retest reliability (Spence, 1998; Spence, Barrett, & Turner, 2003), and satisfactory validity as evidenced by its correlations with concurrent anxiety scales (Essau, Muris, & Ederer, 2002; Mellon & Moutavelis, 2007; Muris, Schmidt, & Merckelbach, 2000). Further, the SCAS discriminates between youths with and without anxiety disorders, and within youths suffering from different anxiety disorders (Spence, 1998). It should be mentioned that Chorpita, Yim, Moffitt, Umemoto, and Francis (2000) undertook a revision of the SCAS. Physical fear items were removed, generalized anxiety disorder items were changed (focusing more on excessive worry, which seems to be the key feature of DSM-IV-defined generalized anxiety disorder), and depression items were added, resulting in the Revised Child Anxiety and Depression Scale (RCADS). Available evidence indicates that the psychometric qualities of the RCADS are good (Chorpita, Moffitt, & Gray, 2005; Chorpita et al., 2000; De Ross, Gullone, & Chorpita, 2002; Muris, Meesters, & Schouten, 2002). Just like the SCAS, the SCARED is a questionnaire for measuring anxiety symptoms in terms of DSM-classifications. The original SCARED (Birmaher, Ketharpal, Brent et al., 1997) consists of 38 items that can be allocated to five anxiety subscales. Four of these subscales represent anxiety disorders as described in the DSM—namely, separation
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anxiety disorder, generalized anxiety disorder, panic disorder, and social phobia. The fifth subscale is school phobia, which according to some authors can best be considered as a separate childhood anxiety disorder (see Blagg & Yule, 1994). The original SCARED has good internal consistency, test-retest reliability, and discriminant validity, both between anxiety and other psychiatric disorders and within anxiety disorders (Birmaher et al., 1997). In a follow-up study, Birmaher, Brent, Chiapetta et al. (1999) modified the SCARED by adding three items in order to strengthen the social phobia scale. This 41-item version of the SCARED displayed similar satisfactory psychometrics as the original version. The MASC, SCAS, and SCARED are modern measures of childhood anxiety that are closely related to current nosologic constructs as described in the DSM. The researchers that developed these scales were well aware of the problems with traditional scales, and have succeeded in constructing more anxiety-specific questionnaires. This becomes particularly evident in the discriminant validity of these scales. That is, even within clinical samples, MASC, SCAS, and SCARED scores are able to distinguish between anxiety and other disorders (Birmaher et al., 1997; Spence, 1998; Wood et al., 2002).
Screen for a Broad Range of Anxiety Symptoms The MASC, SCAS, and SCARED are certainly an improvement as compared to the more traditional scales. However, from a clinical point of view, it may be a disadvantage that each of these questionnaires is limited to assess symptoms of a restricted number of anxiety problems. With this issue in mind, Muris, Merckelbach, Schmidt, and Mayer (1999) revised the SCARED in three ways. First of all, school phobia items were joined to the separation anxiety disorder subscale. This was done because the DSM (see especially the DSM-III-R; APA, 1987) views school phobia as a symptom of separation anxiety disorder. Second, 15 new items were added in an attempt to index symptoms of specific phobia. The latest editions of the DSM (APA, 1994, 2000) distinguish three main subtypes—namely, animal phobia, situational-environmental phobia, and blood-injection-injury phobia (see Frederikson, Annas, Fischer, & Wik, 1996; Muris, Schmidt, & Merckelbach, 1999). Because specific fears and phobias are highly prevalent among children (e.g., Ollendick, King, & Muris, 2002), items of all three subtypes were included in the revised version of the SCARED. Third, although obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are relatively rare, an extra 13 items were added so that it is also possible to tap symptoms of these disorders with the revised SCARED. Thus, the final 66-item revised version of the SCARED (i.e., SCARED-R; see Appendix) purports to measure symptoms of the entire anxiety disorders spectrum that, according to the DSM, may occur in children and adolescents. Previous studies have shown that the SCARED-R possesses adequate internal consistency (e.g., Muris et al., 1999), test-retest stability (Muris, Merckelbach, Van Brakel, & Mayer, 1999), and good validity—that is, the scale correlates substantially with other childhood anxiety measures (Muris, Merckelbach, Mayer et al., 1998; Muris et al., 2000) and discriminates between children with and without subclinical anxiety disorders (Muris, Merckelbach,
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Kindt et al., 2001; Muris, Merckelbach, Mayer, & Prins, 2000). A recent study by Muris, Dreessen, Bögels, Weckx, and Van Melick (2004) underlined the clinical utility of the SCARED-R. In a large sample of 242 clinically referred youths, SCARED-R scores were found to be significantly correlated with internalizing problems (as indexed by the Child Behavior Checklist; Achenbach, 1991) but not with externalizing problems. Further, within the group of children and adolescents who suffered from anxiety disorders, SCARED-R scores were negatively associated with children’s daily functioning on the Global Assessment of Functioning (GAF) scale (APA, 1994). In other words, higher levels of anxiety symptoms were accompanied by greater dysfunction in daily life. Finally, SCARED-R scores had satisfactory discriminant validity (both between anxiety disorders and other problems and within anxiety disorders) and, most importantly, had reasonable value for predicting specific anxiety disorders. Research has also evaluated the utility of specific SCARED-R subscales. For example, Muris, Merckelbach, Körver, and Meesters (2000) examined the validity of the SCARED-R PTSD subscale. Children who scored high on this subscale (i.e., the trauma group) and control children (matched for gender, age, and educational level) were interviewed about their most aversive life event. Results showed that children in the trauma group more frequently reported life events that independent judges considered as “potentially traumatic” than did control children. Further, children in the trauma group also reported to have experienced more traumatic incidents and displayed higher scores on PTSD-related questionnaires as compared to control children. All in all, these findings seem to support the validity of PTSD subscale of the SCARED-R. The SCARED-R possesses good psychometric qualities that are similar to those documented for other DSM-based questionnaires such as the MASC, SCAS, and original SCARED. The main advantage of this scale, however, is that it taps the full range of anxiety disorders symptoms in youths.
Choosing an Anxiety Self-Report When selecting a self-report questionnaire for measuring anxiety symptoms in youths, one should of course take the purpose of the assessment into consideration. For example, if one is interested in measuring children’s global level of anxiety-related distress, the researcher or clinician may choose the STAIC-T or the RCMAS, although the total scores of the MASC, SCAS, and SCARED(-R) are also suitable for this purpose. When one wants to evaluate frequency of various anxiety disorders symptoms—for example, in the process of a clinical evaluation—modern multidimensional questionnaires like the MASC, SCAS, and SCARED(-R) are preferable. In their comprehensive review of childhood anxiety measures, Stallings and March (1995; p.127) noted, “Ideally, instruments to assess anxiety in young persons should (1) provide reliable and valid ascertainment of symptoms across multiple symptom domains; (2) discriminate symptom clusters; (3) evaluate severity; (4) incorporate and reconcile multiple observations, such as parent and child ratings; and (5) be sensitive to treatment-induced change in symptoms.” Table 7.1 summarizes how various child anxiety questionnaires score on these parameters.
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As Table 7.1 shows, childhood anxiety scales generally perform satisfactorily on these parameters. That is, all questionnaires appear to possess good reliability and seem to be appropriate for measuring the severity of anxiety-related complaints. For most scales, a parent version is available, of which the psychometric properties have been investigated in at least one empirical study (e.g., Birmaher et al., 1997; Cole, Hoffman, Tram, & Maxwell, 2000; Muris et al., 2004; Nauta, Scholing, Rapee et al., 2004; Southam-Gerow, Flannery-Schroeder, & Kendall, 2003). Traditional scales like the STAIC-T, RCMAS, and FSSC-R are less suitable for assessing clinically relevant symptom clusters—that is, these questionnaires are unidimensional (STAIC-T) or assess symptom clusters that are less clearly linked to the anxiety disorders as described in the DSM. Relatedly, traditional scales often lack discriminative power, which means that they do not distinguish very well between children with anxiety disorders and children suffering from other psychiatric disorders, in particular mood disorders, and among children with different types of anxiety disorders (Perrin & Last, 1992; see Seligman, Ollendick, Langley, & Bechtoldt Baldacci, 2004). Available research has demonstrated that modern, multidimensional scales like the MASC, SCAS, and SCARED(-R) perform much better on this important aspect (e.g., Birmaher et al., 1997, 1999; Muris et al., 2004; Muris & Steerneman, 2001; Spence, 1998). On the other hand, the STAIC-T, RCMAS, and FSSC-R are found to possess good treatment sensitivity, which means that they are able to tap reductions in anxiety or anxietyrelated distress following successful psychological and pharmacological treatment (see for a review, Silverman & Ollendick, 2005). This aspect is less established for the modern, multidimensional scales, although such evidence is rapidly emerging (Barrington, Prior, Richardson, & Allen, 2005; Muris, Merckelbach, Gadet, Moulaert, & Tierney, 1999; Muris, Meesters, & Van Melick, 2002; Walkup, Labellarte, Riddle et al., 2002). There are some indications that the new questionnaires are even better in tapping treatment effects than the traditional scales. For example, in a study by Muris, Mayer, Bartelds, Tierney, and Bogie (2001), 36 anxiety disordered children were treated with cognitive-behavioral therapy. Treatment effects were documented with a traditional scale, the STAIC-T, and a modern questionnaire, the SCARED-R. On both scales, anxiety scores were significantly reduced after the intervention. Results further showed that the treatment effect as measured by the SCARED-R remained significant while controlling for STAIC prepost-treatment change scores. In contrast, when covarying SCARED-R change scores, the STAIC no longer tapped a significant treatment effect. This finding indicates that the SCARED-R explained variance in treatment effects over and above the STAIC-T. Altogether, for the assessment of general, anxiety-related distress, the STAIC-T and RCMAS can be used. However, if one likes to select a more specific anxiety scale for measuring symptoms in terms of the nosologic constructs as defined in the DSM, the MASC, SCAS, and SCARED(-R) are better options (Brooks & Kutcher, 2003). The MASC, SCAS, and original SCARED are relatively short and hence economic, and as such may be the instruments of choice in research. The SCARED-R is longer as it taps symptoms of the full range of anxiety problems that occur in youths and therefore may be the most useful selfreport instrument in clinical settings. In spite of its shortcomings, the FSSC-R remains the tool of choice for assessing fears and phobic tendencies, although the specific phobia scales of the SCARED-R can also be used for this purpose (Muris et al., 1999).
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Questionnaire STAIC-T (Spielberger, 1973)
Goal, description, other features Temporally stable anxiety 20 items 3-point scale 10 minutes 8- to 18-year-olds
RCMAS (Reynolds & Richmond, 1978)
Manifest anxiety 37 items 2-point scale 15 minutes 7- to 18-year-olds
FSSC-R (Ollendick, 1983)
Fears and fearfulness 80 items 3-point scale 20 minutes 7- to 18-year-olds
MASC (March, 1997)
Multiple domains of anxiety symptoms 39 items 4-point scale 20 minutes 8- to 18-year-olds
Psychometrics General evaluation: ± Internal consistency: + Test-retest reliability: + Convergent and divergent validity: ± Discriminant validity: ± General evaluation: ± Internal consistency: + Test-retest reliability: + Convergent and divergent validity: ± Discriminant validity: ± General evaluation: ± Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: ± General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: +
Symptom clusters
Evaluate severity
Multiple observations
Treatment sensitivity
−
+
+ Parent version
+
± 3 empirically derived factors: Physiological worryoversensitivity, fear-concentration
+
+ Parent version
+
± 5 empirically derived factors: Danger and death, unknown, small animals, failure and criticism, medical fears
+
+? Parent version
+
+ 4 empirically derived factors, partly related to the DSM: Physical symptoms, social anxiety, separation anxiety, harm avoidance
+
+ Parent version
+?
Unidimensional
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Table 7.1 Summary of the practical parameters and psychometric properties of the most important self-report anxiety questionnaires for children and adolescents
DSM-defined anxiety symptoms 38 items 4-point scale 20 minutes 8- to 18-year-olds
General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: +
SCARED (Birmaher et al., 1997, 1999)
DSM-defined anxiety symptoms 38–41 items 3-point scale 20 minutes 8- to 18-year-olds DSM-defined anxiety symptoms 66 items 3-point scale 30 minutes 8- to 18-year-olds
General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: + General evaluation: + Internal consistency: + Test-retest reliability: + Convergent and divergent validity: + Discriminant validity: +
SCARED-R (Muris et al., 1999)
+ 6 DSM-defined anxiety clusters: Separation anxiety disorder, generalized anxiety disorder, social phobia, panic and agoraphobia, obsessivecompulsive disorder, physical injury fears + 4 DSM-defined anxiety clusters and school phobia: Separation anxiety disorder, generalized anxiety disorder, social phobia, panic + 9 DSM-defined anxiety clusters: Separation anxiety disorder, generalized anxiety disorder, social phobia, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, 3 types of specific phobia
+
+ Parent version
+?
+
+ Parent version
+?
+
+ Parent version
+?
Note. STAIC-T = Trait version of the State-Trait Anxiety Inventory for Children, RCMAS = Revised Children’s Manifest Anxiety Scale, FSSC-R = Revised Fear Survey Schedule for Children, MASC = Multidimensional Anxiety Scale for Children, SCAS = Spence Children’s Anxiety Scale, SCARED = Screen for Child Anxiety Related Emotional Disorders, SCARED-R = Revised version of the Screen for Child Anxiety Related Emotional Disorders. − Not satisfactory, ± Moderately satisfactory, + Satisfactory and well established in research, +? Probably satisfactory, but more empirical evidence is needed.
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SCAS (Spence, 1998)
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Specific Fear and Anxiety Measures Traditional scales like the RCMAS, STAIC-T, and FSSC-R tap more general levels of fear and anxiety symptoms, whereas modern, multidimensional scales such as the MASC, SCAS, and SCARED(-R) tap symptoms of a variety of anxiety disorders. There are also scales that specifically measure the symptoms of one type of anxiety problem. Examples of such instruments can be found for all childhood anxiety disorders. Social Phobia. There are a number of questionnaires specifically developed for measuring symptoms of social phobia in youths. The Social Anxiety Scale for Children–Revised (SASC-R; La Greca & Stone, 1993) is a self-report measure that has been developed to assess social anxiety symptoms in children aged 8 to 13 years. The scale consists of 18 items that can be allocated to three subscales: fear of negative evaluation from peers (e.g., “I worry about what other kids say about me”), social avoidance and distress specific to new situations (e.g., “I get nervous when I talk to new kids”), and generalized social avoidance and distress (e.g., “I feel shy even with kids I know very well”). The psychometric properties of the SASC-R are satisfactory: Internal consistency and test-retest reliability are sufficient to good (La Greca, Dandes, Wick, Shaw, & Stone, 1988; La Greca & Stone, 1993). Furthermore, support has been found for the discriminant validity of the scale: In a sample of children with anxiety disorders, scores on the SASC-R differentiated children with and without a social-based anxiety disorder (Ginsburg, La Greca, & Silverman, 1998). La Greca and Lopez (1998) modified the language of the SASC-R to make the scale appropriate for adolescents. The resulting Social Anxiety Scale for Adolescents (SAS-A) has highly similar psychometric qualities as compared to the SASC-R: The original threefactor structure of the scale was retained, internal consistency and test-retest reliability are found to be good, and the validity is also satisfactory (Inderbitzen-Nolan & Walters, 2000; La Greca & Lopez, 1998; Myers, Stein, & Aarons, 2002). An alternative questionnaire for measuring social anxiety in youths is the Social Phobia and Anxiety Inventory for Children (SPAI-C; Beidel, Turner, & Morris, 1995), which can be employed in young people from age 8. The SPAI-C was empirically developed to assess cognitive (e.g., “When with others, I think scary thoughts”), physiological (e.g., “In a social situation, I feel [physical symptoms]”), and behavioral symptoms (e.g., “I avoid social situations”) of social phobia in children and adolescents as defined in the DSM. Items were generated on the basis of clinical interviews of children with social phobia and their mothers, daily diaries of stressful situations, and an adult questionnaire, the Social Phobia and Anxiety Inventory (Turner, Beidel, Dancu, & Stanley, 1989). The SPAI-C has excellent internal consistency and sufficient test-retest stability (Beidel et al., 1995), good convergent validity, and satisfactory discriminant validity with nonclinical controls and disruptive behavior disorders (Beidel, Turner, & Fink, 1996). Finally, a study by Beidel, Turner, Hamlin, and Morris (2000) demonstrated that the SPAI-C successfully distinguishes between socially phobic children and children with other anxiety disorders. Recent studies that directly compared the psychometrics of the SASC-R/SAS-A and the SPAI-C have demonstrated that both instruments seem to tap related but relatively independent constructs of social phobia and anxiety, and so both provide valuable information on this
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anxiety disorder (Storch, Masia-Warner, Dent, Roberti, & Fisher, 2004). When predicting social phobia in terms of the DSM, it was found that the SPAI-C was somewhat more sensitive than the SAS-A (Inderbitzen-Nolan, Davies, & McKeon, 2004). Separation Anxiety Disorder. Separation anxiety disorder is a relatively prevalent childhood anxiety disorder, and according to the latest edition of the DSM (DSM-IV-TR; APA, 2000) the only anxiety disorder that specifically occurs in youths. As such, it is somewhat surprising to note that questionnaires for specifically measuring symptoms of separation anxiety in youths are extremely sparse. Most of these instruments are grounded in the attachment theory, which is plausible as Bowlby (1973) described separation anxiety in older children as one of the signs indicating insecure attachment relationships. An example is the Separation Anxiety Test (SAT; see Richard, Fonagy, Smith, Wright, & Binney, 1998; Wright, Binney, & Smith, 1995), which assesses children’s responses to photographs depicting separations from parents (e.g., “Mum is going to the hospital to have a serious operation,” “Dad is leaving home after an argument,” and “This young person is going on a school trip for two weeks. He/she is saying good-bye to mum and dad”). For each separation situation, children and adolescents are asked how they would feel in that situation, why they would feel so, and what they would do in the pertinent situation. Responses are coded to yield one of three attachment classifications: secure, avoidant, and ambivalent. The ambivalent classification is most relevant for those interested in anxiety, as this category is indicative for children’s anxious responding to separation situations (Scott Brown & Wright, 2001, 2003). Generalized Anxiety Disorder. The key feature of generalized anxiety disorder is excessive worry (APA, 2000). The Penn State Worry Questionnaire (Meyer, Miller, Metzger, & Borkovec, 1990) is the most widely used scale for measuring worry in adults (see also Brown, Anthony, & Barlow, 1992). The age-downward version of the scale, the Penn State Worry Questionnaire for Children (PSWQ-C; Chorpita, Tracey, Brown, Collica, & Barlow, 1997; see Appendix) consists of 14 items that measure the tendency of youths to engage in generalized and uncontrollable worry (e.g., “I worry all the time,” “Once I start worrying, I can’t stop”). Research has demonstrated the PSWQ-C to be unifactorial and to possess good reliability in terms of internal consistency and test-retest reliability. Furthermore, evidence was found for the convergent and divergent validity of the scale. That is, in both samples of normal and clinically referred children, PSWQ-C scores correlated in a theoretically meaningful way with scores on measures of anxiety and depression. Finally, PSWQ-C scores of children with generalized anxiety disorder were found to be significantly higher than those of children with other anxiety disorders and nonclinical controls, thus yielding support for the discriminant validity of the scale (Chorpita et al., 1997). Similar favorable psychometric properties have been reported by Muris, Meesters, and Gobel (2001), although these authors advise that it is preferable to discard the three reversely scored items from the PSWQ-C when using the measure in younger (i.e., 8- to 12-year-old) children. Panic Disorder. Anxiety sensitivity refers to the fear of anxiety-related bodily sensations (e.g., Taylor, 1995) and has been proposed to play an important role in the aetiology and
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maintenance of panic disorder (e.g., Rachman, 1998). In children and adolescents, anxiety sensitivity is measured by means of the Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991; see Appendix), which is an age-downward modification of the Anxiety Sensitivity Index (Reiss, Peterson, Gursky, & McNally, 1986), the most frequently employed instrument for assessing anxiety sensitivity in adults. The CASI consists of 18 items such as “It scares me when I feel shaky,” “It scares me when my heart beats fast,” and “It scares me when I feel nervous.” Previous studies have consistently shown that the CASI is a reliable and valid questionnaire for measuring anxiety sensitivity in both clinical and nonclinical samples of children and adolescents (e.g., Chorpita, Albano, & Barlow; 1996a; Lambert, Cooley, Campbell, Benoit, & Stansbury, 2004; Muris, Schmidt, Merckelbach, & Schouten, 2001a; Rabian, Embry, & MacIntyre, 1999; Silverman et al., 1991; Silverman, Ginsburg, & Goedhart, 1998a; Van Widenfelt, Siebelink, Goedhart, & Treffers, 2002; Weems, Hammond-Laurence, Silverman, & Ginsburg, 1998). In an attempt to tap the underlying factor structure of anxiety sensitivity in a more adequate way, Muris (2002a) developed a revised version of the CASI (i.e., CASI-R). The CASI-R is lengthier than the original version and contains 31 items that can be allocated to four factors—namely, fear of cardiovascular symptoms (e.g., “When my heart is skipping a beat, I worry that something might be seriously wrong”), fear of publicly observable anxiety symptoms (e.g., “When I tremble in the presence of others, I fear what people think of me”), fear of cognitive dyscontrol (e.g., “When I feel strange, I worry that I might go crazy”), and fear of respiratory symptoms (e.g., “When my chest feels tight, I am scared that I cannot breathe properly”). The CASI-R has been shown to be a reliable scale in terms of internal consistency. Furthermore, CASI-R scores were substantially related to levels of anxiety sensitivity as measured by the CASI, and to symptoms of anxiety disorders—in particular, panic disorder. Finally, some evidence was found for the divergent validity of the CASI-R factor scores. That is, all factors convincingly loaded on symptoms of panic disorder, whereas the factor “fear of publicly observable anxiety reactions” was also strongly associated with symptoms of social phobia. Although these results with the CASI-R are encouraging, the original CASI remains the instrument of choice for measuring this panicrelated anxiety construct. More research with the expanded scale is necessary to demonstrate its incremental value as compared to the original index. Obsessive-Compulsive Disorder. The only currently available self-report scale for measuring symptoms of obsessive-compulsive disorder in youths is the Leyton Obsessional Inventory for Children (LOI-C; Berg, Whitaker, Davies, Flament, & Rapoport, 1988). This brief 20-item scale taps symptoms of OCD in children and adolescents aged 8 to 18 years. Examples of items are “Do you have to check things several times?,” “Are you fussy about keeping your hands clean?,” and “Do you move or talk in just a special way to avoid bad luck?” Research on the psychometric properties has indicated that the LOI-C is reliable in terms of internal consistency (Berg et al., 1988). Furthermore, Flament and colleagues (1988) have found that the scale has acceptable sensitivity for identifying adolescents with OCD, although its specificity was rather poor (i.e., high false-positive rate). March and Mulle (1998) advise that the LOI-C can best be used as a screening tool for initial evaluation.
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Posttraumatic Stress Disorder. Several scales can be employed for obtaining information in children who have (possibly) been traumatized. The Childhood Trauma Questionnaire (Bernstein, Ahluvalia, Pogge, & Handelsman, 1997) and the Self-Reported Post-Traumatic Symptomatology (March, Amaya-Jackson, Terry, & Costanzo, 1997) are two scales that may be particularly helpful for identifying the traumatic events that children have experienced. Both questionnaires ask children to indicate whether they ever have experienced frightening events such as violence, accidents, sexual abuse, severe illness and death, war, and natural disasters. A number of scales can be used for measuring the presence and severity of posttraumatic stress symptoms in children and adolescents. For example, the Child version of the PostTraumatic Stress Disorder Reaction Index (CPTSD-RI; Frederick, Pynoos, & Nader, 1992) measures trauma-related symptoms in three domains: reexperiencing (e.g., “When I think back on this event, I get scared”), avoidance and numbing of general responsiveness (e.g., “It seems that I am less in contact with other people since the event”), and hyperarousal (e.g., “I am nervous and jumpy”). Support has been obtained for the psychometric qualities of the CPTSD-RI. That is, the instrument has good internal consistency, interrater and testretest reliability, and correlates in a meaningful way with other measures of posttraumatic stress (Muris et al., 2000; Nader, Pynoos, Fairbanks, & Frederick, 1990; Pynoos & Nader, 1989; Shannon, Lonigan, Finch, & Taylor, 1994). The Impact of Event Scale (IES; Horowitz, Wilner, & Alvarez, 1979) is a 15-item scale that measures two important aspects of posttraumatic symptomatology—namely, intrusive thinking (e.g., “I think about it when I don’t mean to”) and cognitive avoidance of traumatic intrusions (e.g., “I try to remove it from memory”). The IES is currently the most widely used instrument in research on PTSD in adults. Yule and colleagues (1990, 1991) have used the scale with children aged 8 to 16 years. These authors concluded that children who had survived a sea disaster found the IES questions meaningful and reported scores as high as those of traumatized adults. Dyregrov, Kuterovac, and Barath (1996) found the IES to possess good psychometric properties in children exposed to warfare. Further evidence on the reliability and validity of the IES in children and adolescents has been provided in a recent study by Perrin, Meiser-Stedman, and Smith (2005), who demonstrated that the scale can be effectively used to identify youths with or without PTSD. Although scores on the CPTSD-RI and IES provide useful information of PTSD-related symptoms in youths, both scales do not fully cover the criteria as listed in the DSM. The Child PTSD Symptom Scale (CPSS; Foa, Johnson, Feeny, & Treadwell, 2001) certainly is an improvement in this respect. This measure is designed to assess PTSD diagnosis and symptom severity in children and adolescents aged 8 to 18 years, and consists of 24 items referring to symptoms of reexperiencing (e.g., “Upsetting thoughts about the event”), avoidance (e.g., “Trying not to talk about the event”), and hyperarousal (e.g., “Being irritable since the event”), as well as trauma-related functional impairment across various domains of daily functioning (e.g., relationships with friends, schoolwork). Preliminary support has been found for the reliability and validity of the CPSS. That is, internal consistency, testretest reliability, and concurrent validity with other PTSD scales are satisfactory. Moreover, the scale has been demonstrated to possess excellent discriminant validity (Foa et al., 2001). Although more research with the CPSS is certainly required, the good psychometrics and
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the full coverage of PTSD symptoms as defined in the DSM seem to make this instrument most suitable for assessing PTSD symptomatology in youths. Specific Phobias and Other Anxiety(-Related) Problems. Specific phobias refer to a wide variety of distinct fears, and perhaps for this reason few attempts have been made to develop specific scales for assessing this type of childhood anxiety disorder. In most cases, assessment is confined to the aforementioned FSSC-R, which includes most stimuli and situations for which youths may typically develop a specific phobia (King, Muris, & Ollendick, 2005). Spider phobia certainly is one of the most prevalent phobias in youths (e.g., Muris, Merckelbach, & Collaris, 1997), and because this phobia has been used as an exemplary model to study the aetiology, maintenance, and treatment of pathological anxiety (De Jong, 1993), it is not surprising that researchers have developed a self-report scale for measuring this type of fear in children and adolescents. The Spider Phobia Questionnaire for Children (SPQ-C; Kindt, Brosschot, & Muris, 1996; see Appendix) consists of 29 items for assessing fear of spiders (e.g., “I avoid being in gardens or parks because spiders might be there,” “Even a toy spider in my hand scares me a bit,” and “If I see a spider, I feel tense”). The internal consistency and test-retest reliability of the SPQ-C are very good. Further, SPQ-C scores predict performance on a behavioral approach test, during which children engaged in a stepwise procedure to approach a real spider in a closed jar, some three meters in front of them. Finally, a shortened version of the SPQ-C has been demonstrated to possess excellent treatment sensitivity (Muris, Merckelbach, Van Haaften, & Mayer, 1997; Muris, Merckelbach, Holdrinet, & Sijsenaar, 1998). Given the increased emphasis on children’s school performance in most Western countries, it makes sense that various instruments have been developed to measure school-related fear and test anxiety. For example, the School Refusal Assessment Scale (SRAS; Kearney, 2002; Kearney & Silverman, 1993) is a rating scale that can be completed by children and/or their parents to identify the primary function of a child’s school refusal behavior. Of course, avoidance of stimuli and situations that provoke fear, anxiety, or sadness is one of the main reasons why children refuse to go to school, which is therefore included in the SRAS as a subscale with items such as “How often do you have bad feelings about going to school because you are afraid of something related to school (e.g., tests, school bus, teacher, fire alarm)?” and “How often do you feel worse at school (e.g., scared, nervous, sad) compared to how you feel at home with friends?” Escape from aversive social and evaluative situations may be a second important reason for school refusal and as such also incorporated in the SRAS (e.g., “How often do you stay away from school because it is hard to speak with the other kids at school” and “How often do you stay away from school because you do not have many friends there?”). The psychometric qualities of the SRAS are satisfactory (Higa, Daleiden, & Chorpita, 2002; Kearney, 2006), and although the questionnaire taps various other reasons of school refusal (such as the pursuit of attention and tangible rewards), the scale can also be employed for measuring school-related fear and anxiety. Another school phobia-related scale, the Visual Analogue Scale for Anxiety-Revised (VAA-R), was developed by Bernstein and Garfinkel (1992). Interestingly, this scale uses pictorial visual analogues scales to help the children to rate the degree of anxiety elicited by school-related situations such as “Starting school in the fall” and “Thinking about going
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to school on Monday morning.” While internal consistency reliability is good and correlations with other anxiety scales support its convergent validity, the measure has not been extensively used in research. The Test Anxiety Inventory (TAI; Spielberger, 1980) is a brief 20-item scale for measuring specific symptoms of anxiety before, during, and after examinations. Two major components of test anxiety are addressed in the TAI: worry, which refers to cognitive concerns about consequences of failure (e.g., “Thoughts of doing poorly interfere with my concentration on tests”), and emotionality, which pertains to reactions of the autonomic nervous system that are evoked by evaluative stress (e.g., “I feel my heart beating very fast during important tests”). Although originally developed to measure test anxiety in adolescent and adult students, the TAI has also proved to be a reliable and useful instrument for assessing this type of anxiety in children (Peleg-Popko, 2004; Zeidner & Nevo, 1992).
Scales for Measuring Anxious Cognition With the rise of the cognitive-behavioral theory of psychopathology and its application to the treatment of children (see Chapter 8), a number of instruments have been constructed that intend to measure the negative thought content of disordered youths. In the context of anxiety, three instruments are particularly worthy of note. The first instrument is the Negative Affect Self-Statement Questionnaire (NASSQ; Ronan, Kendall, & Rowe, 1994), which asks for the occurrence of anxious and depressive thoughts in children aged between 7 and 15 years. Research with the NASSQ has demonstrated that there are indeed specific selfstatements related to either anxiety or depression and this is even the case in pre-adolescent youths (7- to 10-year-olds; Ronan et al., 1994). Further, the NASSQ is reliable in terms of internal consistency and test-retest reliability, correlates in a theoretically meaningful way with concurrent measures of anxiety and depression (see also Lerner, Safren, Henin et al., 1999; Muris, Merckelbach, Mayer, & Snieder, 1998), and discriminates between anxious and nonanxious youths (Rietveld, Prins, & Van Beest, 2002; Ronan et al., 1994). Finally, it has been found that the reduction in distress after successful treatment of anxietydisordered children, was predominantly mediated by the decline in negative self-statements (Treadwell & Kendall, 1996). The latter finding not only demonstrates that the NASSQ possesses treatment sensitivity but also seems to support the main premise of cognitive therapy—namely, that a diminution of faulty cognition yields an improvement of mental health. The second instrument is the Children’s Automatic Thoughts Scale (CATS; Schniering & Rapee, 2002), which purports to measure negative self-statements in four domains: physical threat, social threat, personal failure, and hostility. The first two domains would refer to the automatic negative thoughts of anxious children, whereas the third and fourth domains would pertain to the negative thinking of children with, respectively, mood and disruptive behavior disorders. So far, only one study has examined the reliability and validity of the CATS (Schniering & Rapee, 2002). In that study, this scale was demonstrated to possess excellent reliability in terms of both internal consistency and test-retest stability. Most important, CATS domains effectively discriminated between control children and adolescents and clinically referred youths, and showed reasonable discriminant validity across
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various clinical groups. More precisely, clinically referred youths clearly displayed higher levels of negative automatic thoughts as compared to their nonclinical counterparts. Moreover, the pattern of scores on the CATS subscales was largely as predicted—that is, anxious youths displayed the highest scores on the domains of physical and social threat, depressed youths exhibited the highest scores on the personal failure domain, whereas youths with behavior disorders clearly showed the highest scores on the hostility domain. The third and final scale is the Children’s Thought Questionnaire (CTQ; Marien & Bell, 2004). Briefly, the CTQ consists of 10 vignettes, each followed by a series of corresponding negative and positive thought and mood rating items. Half of the vignettes pertain to anxious themes and are concerned with potential threat to the physical or psychological well-being of the child (e.g., trouble breathing in gym class), whereas the other half refer to depressive themes of loss and social rejection (e.g., not being invited to a party). Preliminary evaluation of the CTQ has yielded promising results. More precisely, higher levels of anxious thoughts uniquely predicted anxiety symptoms, while higher levels of depressive thoughts were most convincingly linked to symptoms of depression. Finally, positive thoughts were only negatively related to depression and unrelated to anxiety. Altogether, there seem to be reliable and valid self-report instruments for measuring negative thought processes in youths, it seems to be the case that relatively few researchers and clinicians are employing such measures in spite of the fact that anxious cognition is generally viewed as an important concomitant of childhood anxiety disorders and is thought to play a role in the continuation of such problems.
An “Anxiety Control” Scale All of the preceding interviews and questionnaires intend to measure the frequency, intensity, and severity of fear and anxiety symptoms and anxiety-related cognitions, and as such these instruments focus on the negative, problematic side of these phenomena. Interestingly, Weems, Silverman, Rapee, and Pina (2003) developed a scale that takes a more positive perspective, as it measures children’s perception of control over anxiety-related feelings and events. This Anxiety Control Questionnaire for Children (ACQ-C) can be completed by children aged 8 years and over, and consists of 14 items designed to assess perceived control over “external” threats (e.g., “When something scares me, there is always something I can do,” “I would be able to get away from a scary or frightening place,” and “I am good at getting along with people who bug me”) and 16 items for assessing control over negative “internal” emotional and bodily reactions associated with anxiety (e.g., “When I am in a place that gets me nervous or afraid, I can take charge over and control my feelings,” “If I begin to shake or tremble, I can stop myself,” and “When I am anxious or nervous, I can still think about things other than my feelings of anxiety”). Research has provided some preliminary support for the reliability and validity of the scale. That is, Weems et al. (2003) found that the ACQ-C had good internal consistency, correlated negatively with selfreported anxiety levels, and differentiated between children with and without an anxiety disorder. Furthermore, it was found that even when controlling for self-reported anxiety levels, ACQ-C scores were still predictive of anxiety disorder status. The latter finding is
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particularly important as it demonstrates that the ACQ-C is not just the inverse of an anxiety scale but indeed seems to tap a unique anxiety-related characteristic of children and adolescents.
Instruments for Assessing Fear and Anxiety in Young Children Some self-report questionnaires (e.g., RCMAS, FSSC-R) can be reliably used in children aged 7 years and over (see Stallings & March, 1995). For younger children, this type of instrument does not seem suitable because the questionnaire items and response format are too abstract. For this reason, the assessment of fear and anxiety in preschool children has been confined to interviews in which children are simply asked to report the stimuli and situations that they fear or worry about (e.g., Lentz, 1985; Muris, Merckelbach, Gadet, & Moulaert, 2000; Stevenson-Hinde & Shouldice, 1995). While this method has yielded interesting information regarding the content of young children’s fear and anxiety, such an approach is less precise with regard to the frequency and intensity of these negative emotions. In her review on a century of research on normal childhood fears, Gullone (2000) concludes that the lack of standardized self-report questionnaires has hindered systematic research of fears and fearfulness in young children (i.e., children aged 6 years or under). Nevertheless, it is worthy of note that there have been a few attempts to develop measures of anxiety that can be used with children in the preschool age. For example, Ialongo and colleagues (1994, 1995) used an interview version of the RCMAS employing symbols (i.e., pictures of shapes and objects) to help children to find the correct place on the answer sheet. The authors concluded that in this way “a reliable and valid assessment of anxiety in children as young as five or six is quite possible” (Ialongo et al., 1995; p.436). A further interesting line of research was instigated by Valla, Bergeron, Berube, Gaudet, and St-Georges (1994), who developed the Dominic questionnaire. The Dominic is a pictorial interviewbased scale to assess mental disorders in childhood, designed with the cognitive immaturity of young children in mind. The Dominic depicts a child named “Dominic” facing various situations in the daily life. In fact, the pictures illustrate the emotional and behavioral content of various childhood disorders including a number of anxiety disorders (i.e., specific phobias, separation anxiety, and generalized anxiety). So far, the Dominic has been psychometrically tested in children as young as six (see for a review, Valla, Bergeron, & Smolla, 2000), but given its content, the questionnaire might also be applicable to younger children. The Koala Fear Questionnaire (KFQ; Muris, Meesters, Mayer et al., 2003; see Appendix) is a standardized self-report instrument for assessing fears and fearfulness in children below the age of 7 years. This scale consists of 31 potentially fear-provoking stimuli and situations that are all illustrated with pictures. Children rate the intensity of their fear of these stimuli by using a visual scale that depicts koala bears expressing various degrees of fear (no fear, some fear, a lot of fear). The use of pictures and the visual fear scale makes the KFQ suitable for younger children. Muris et al. (2003) have reported on a series of studies examining the psychometric properties of the KFQ in pre- and primary school children. The results of this research can be summarized as follows. To begin with, it was demonstrated that the visual
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fear scales of koala bears as employed in the KFQ are highly comparable to the standard Likert scales that are used in other childhood fear measures such as the FSSC-R. Further, the KFQ was found to posses good internal consistency and test-retest stability, and this appeared also true for children aged 4 to 6 years. Additional studies provided support for the concurrent validity of the KFQ in schoolchildren. That is, the scale correlated significantly with alternative measures of childhood fear and anxiety, such as the FSSC-R, STAICT, and SCAS (older children), and a picture-based fear and anxiety interview (young children). Finally, in a study carried out on Sint-Maarten (Saint Martin), the Netherlands Antilles, which is a small island in the Carribean (Muris, 2002b), KFQ scores were substantially correlated among children with a high relevant of fear—namely, fear of storms and hurricanes. Altogether, available evidence indicates that the KFQ might be a reliable and valid scale for assessing fears and fearfulness in children aged 4 years and over, although it is clear that further research is necessary to investigate the psychometrics (e.g., reliability, discriminant validity, treatment sensitivity) of the KFQ in clinically referred children.
General Behavior Rating Scales Besides specific anxiety instruments, researchers and clinicians also use general behavior rating scales to measure symptoms of anxiety in youths. The Achenbach (1991) scale is without doubt the most widely employed instrument for this purpose. The scale consists of 118 items addressing two broad domains of psychopathology: One is externalizing, which reflects behavioral problems, and the other is internalizing, which refers to emotional problems. The latter domain is of particular importance in the case of anxiety, because it contains an anxious-depressed subscale, which refers to anxiety and mood problems. A further strong point of this measure is that there are versions for multiple informants (i.e., child, parent, and teacher), which makes it possible to evaluate children’s (anxiety) problems from various perspectives. However, although the psychometric properties of the scales are well established, it has been noted that neither the internalizing nor the anxious-depressed scales of this instrument are suitable for specifically measuring anxiety symptoms (e.g., Aschenbrand, Angelosante, & Kendall, 2005; Kasius, Ferdinand, Van den Berg, & Verhulst, 1997; Seligman et al., 2004). Even a reconstruction of the Achenbach scale in terms of DSM categories could not improve its correspondence with anxiety disorders symptoms (Van Lang, Ferdinand, Oldehinkel, Ormel, & Verhulst, 2005). The recently developed Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) is also a rating scale that can be employed to assess children’s emotional and behavioral problems. The SDQ is a reliable and valid scale that can be completed by youths, parents, and teachers (Goodman, 2001; Muris, Meesters, & Van den Berg, 2003). The measure consists of 25 items that cover the most important domains of child psychopathology— namely, emotional symptoms, conduct problems, hyperactivity-inattention, and peer problems, as well as personal strengths (i.e., prosocial behavior). In particular, the emotional symptoms subscale is relevant in the context of anxiety, as it includes items such as “I worry a lot” and “I have many fears. I am easily scared.” However, just like the Achenbach scales, the SDQ emotional symptoms scale lacks specificity as it also taps symptoms of mood problems.
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A behavior rating scale that seems to be an improvement in this regard is the Child Symptom Inventory-4 (CSI-4; Gadow & Sprafkin, 1994). This parent- and teachercompleted instrument assesses symptoms of childhood disorders in terms of the DSM-IV. Besides various disruptive behavior disorders, mood disorders, schizophrenia, and pervasive developmental disorders, the CSI-4 also includes scales for measuring the main symptoms of various types of anxiety disorders, such as generalized anxiety disorder, separation anxiety disorder, social phobia, specific phobia, and obsessive-compulsive disorder. Each CSI-4 item closely resembles a symptom/criterion as listed in the DSM. For each disorder, symptoms are summed, and if this score is equal to the number of symptoms specified in the DSM as being necessary for a diagnosis, the child or adolescent receives a “screening” (i.e., probability) diagnosis. Of course, this diagnosis does not signify a clinical diagnosis because the CSI-4 does not include additional diagnostic criteria (e.g., impairment of functioning). Nevertheless, research has indicated that CSI-4 ratings as obtained from parents can successfully discriminate youths with and without various DSM-IV disorders (Sprafkin, Gadow, Salisbury, Schneider, & Loney, 2002). Unfortunately, in the case of anxiety symptoms, such discriminant validity was only established for generalized anxiety disorder, and so it remains to be seen whether these positive validity findings can also be found for the other anxiety disorders tapped by the CSI-4.
Clinician Rating Scales Besides self-report questionnaires and their parent-rated equivalents, there are also clinician rating scales for evaluating anxiety symptoms in youths. The Hamilton Anxiety Rating Scale (HARS; Hamilton, 1959) is an example of such an instrument. Originally, the HARS was developed for assessing the severity of anxiety disorders in adults, but the scale also has been frequently employed with adolescents. Unfortunately, there is only one study evaluating the psychometric properties of the HARS in a youth sample, and so overall one has to conclude that “the HARS’s suitability, utility, and appropriateness for teenagers remain unclear” (Myers & Winters, 2002). The Pediatric Anxiety Rating Scale (PARS; Research Units of Pediatric Psychopharmacology Anxiety Study Group, 2002) is another clinician rating scale that does not have this problem because this instrument has been specifically developed for children and adolescents aged 6 to 18 years. Briefly, the PARS consists of a checklist of 50 items that can be grouped into the following categories: social phobia, separation anxiety, generalized anxiety, specific phobia, physical anxiety signs and symptoms, and other symptoms (e.g., “Temper tantrums when in anxiety-provoking situations”). On the basis of an interview with the child and the parent, the clinician rates each of the symptoms as being absent or present during the previous week. Next, additional information about the symptoms is gathered from interviews with both the child and the parents. Endorsed symptoms are then collectively rated on seven dimensions of severity: (1) number of symptoms, (2) frequency, (3) severity of distress associated with anxiety symptoms, (4) severity of physical symptoms, (5) avoidance, (6) interference at home, and (7) interference out of home. A 5-point rating scale is used for this purpose, with 1 = minimal severity and 5 = maximal severity. A score on each of these scales would indicate a clinically significant level of frequency, severity, and
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interference. The psychometric qualities of the PARS have been examined in a sample of 128 children, aged 6 to 17 years, with a current diagnosis of social phobia, separation anxiety disorder, and/or generalized anxiety disorder, based on a semistructured diagnostic interview of the child and his/her parent (Research Units of Pediatric Psychopharmacology Anxiety Study Group, 2002). Results demonstrated that the PARS was a reliable instrument in terms of internal consistency, test-retest reliability, and interrater agreement. Further, the scale showed good convergent and divergent validity as established through correlations with, respectively, measures of internalizing and externalizing problems. Finally, PARS scores appeared to be sensitive to treatment and paralleled change on other anxiety measures. These results are certainly encouraging, but further data are needed to establish whether this clinician-rated scale can successfully discriminate between nonclinical, clinical nonanxious, and anxious youths. Whereas the HARS and PARS can be used to evaluate a broad range of anxiety symptoms in youths, there are also clinician rating scales for assessing specific childhood anxiety problems. A good example is the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Goodman, Price, Rasmussen et al., 1989b), which is considered as the primary instrument for assessing OCD symptomatology in youths aged 6 to 17 years (March & Mulle, 1998). The CY-BOCS basically is a semistructured interview with child and parent(s), during which the clinician first identifies the most severe obsessions and compulsions of the child and then rates their severity in terms of (1) time occupied by obsessive thoughts and spent on performing compulsive behaviors, (2) level of interference, (3) level of distress, (4) degree of resistance against the obsessions and compulsions, and (5) degree of control over such thoughts and behaviors. In this way, the CY-BOCS yields three scores: the obsessions severity score, the compulsions severity score, and a total score, which provides a general index of the severity of obsessive-compulsive symptoms. Research has demonstrated that the scale has good internal consistency and interrater reliability, and fair convergent and dicriminant validity (Goodman, Price, Rasmussen et al., 1989a; McKay, Piacentini, Greisberg et al., 2003; Scahill, Riddle, McSwiggin-Hardin et al., 1997; Storch, Murphy, Geffken et al., 2005) and even possesses satisfactory psychometrics when completed by children and adolescents and their parents (Storch, Murphy, Adkins et al., in press). Other clinician-rated scales can be found in the domain of social anxiety. The Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA; Masia-Warner, Storch, Pincus et al., 2003) and the Kutcher Generalized Social Anxiety Disorder Scale for Adolescents (K-GSADS-A; Brooks & Kutcher, 2004) are recently developed scales for measuring social phobia symptoms and their associated severity and impairment. Psychometric evaluations of these scales have yielded promising results (e.g., Storch, Masia-Warner, Heidgerken et al., 2006), but clearly more research is required to further establish their clinical usefulness. The recently developed Child Stress Disorders Checklist (CSDC; Saxe, Chawla, Stoddard et al., 2003) is an observer-report measure of PTSD (that can be completed by clinicians and parents) which is particularly useful for the assessment of anxiety-related stress responses in acutely traumatized youths (i.e., acute stress disorder). This checklist measures symptoms in four domains: reexperiencing (e.g., “Child reports uncomfortable memories of the event”),
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increased arousal (e.g., “Child startles easily. For example, he/she jumps when hearing sudden or loud noises”), avoidance (e.g., “Child avoids doing things that remind him/her of the event”), and numbing/dissociation (e.g., “Child seems ‘spaced out’ or in a daze”), as well as impairment in functioning. Preliminary evidence has indicated that the CSDC seems to possess reliable and valid psychometric properties. In sum, clinician rating scales represent an informative source of information and seem particularly relevant for assessing anxiety symptoms in clinical settings and treatment outcome research.
Diagnostic Interviews With the rise of the medical, disease-oriented model in psychology and psychiatry, the classification of child psychopathology in terms of the DSM has become common practice in many clinical settings. Clearly, the DSM is a categorical system and thus neglects the fact that there is still debate whether psychopathology can best be defined in terms of a categorical, dimensional, or mixed model (with categories for some disorders—e.g., schizophrenia—and dimensions for others—e.g., anxiety disorders). Nevertheless, a big advantage of the categorical DSM-system is that, compared to previous practice, both clinicians and researchers can communicate more easily about diagnostic entities with at least some expectation that the disorders are the same, or at least similar, across various settings (McClellan & Werry, 2000). The clinical interview still remains the main assessment tool for clinicians and researchers to reach a DSM-diagnosis. Nevertheless, Angold and Fisher (1999) have rightly remarked that diagnoses based on a standard clinical interview are liable to various biases, such as (1) the tendency to determine diagnoses before all relevant information is collected, (2) the tendency to collect information selectively when confirming a diagnosis and/or to ignore information that rules out a diagnosis, (3) the lack of a systematic approach for combining various types of information, and (4) the tendency to make diagnoses or judgments based on what is most familiar to the clinician. Even when clinicians employ the same diagnostic criteria, disagreement may occur for several reasons: There may be differences in wording and questions asked by the clinicians, in how clinicians interpret the responses, and in responses that respondents make to different interviewers or at different times. With these problems of the clinical interview in mind, semistructured and structured interviews have been developed, which enable clinicians to gather information concerning various mental disorders in a more systematic way, thereby reducing the variability in how interviews are conducted and improving the reliability and validity of the collected information (McClellan & Werry, 2000). In the field of childhood anxiety, several diagnostic interviews can be employed to classify the anxiety problems of youths in terms of the DSM. Briefly, these instruments can be divided into two broad categories: highly structured interviews during which the interviewer asks a fixed set of questions using specified wording, and semistructured interviews, which allow interviewers to use their own questions and to incorporate other sources of information to reach a classification of the disorder.
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Highly Structured Interviews The Children’s Interview of Psychiatric Syndromes (ChIPS; Weller, Weller, Teare, & Fristad, 1999) is a highly structured diagnostic interview, which is suitable for children and adolescents aged 6 to 18 years. The instrument can be administered to youths, but there is also a version for interviewing children’s parents. The ChIPS is based on DSM-IV criteria and screens for various Axis I disorders, including the following anxiety disorders: specific phobia, social phobia, separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, acute stress disorder, and posttraumatic stress disorder. The instrument also contains two sections addressing the psychosocial stressors of abuse and neglect. During the interview, for each disorder, the most essential DSM features are checked. If these key symptoms are not applicable to the child, the interviewer proceeds to the next section, which covers another disorder. The ChIPS was originally developed for children aged 6 to 12 years, and this has resulted in a number of strong points— namely, its brief duration (<45 minutes) and the simple language and short sentence structure. Few studies have examined the psychometrics of this interview instrument. While there is evidence for the concurrent validity of the ChiPS as classifications obtained with this instrument show reasonable overlap with diagnoses based on another interview schedule as well as clinicians’ diagnoses (Fristad, Cummins, Verducci et al., 1998; Fristad, Glickman, Verducci et al., 1998; Fristad, Teare, Weller, Weller, & Salmon, 1998; Teare, Fristad, Weller, Weller, & Salmon, 1998a, 1998b), so far no study has established the test-retest reliability of this interview (see for a review Weller, Weller, Fristad, Rooney, & Schecter, 2000). Another example of a very structured interview is the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule for Children (DISC; Shaffer, Fisher, Dulcan, & Davies, 1996). The latest version of this instrument was designed to address more than 30 psychiatric diagnoses in children and adolescents, including all DSM-IV-defined anxiety disorders. The DISC can be used to interview youths aged 9 to 17 years or the parents of children aged 6 to 17 years. The complete interview consists of almost 3000 questions; 358 of these are “stem” questions, which cover the most essential aspect of a symptom in general terms. When a stem question is endorsed affirmatively, a number of “contingent” questions follow, which are used to determine whether the endorsed stem symptom meets the frequency, duration, and intensity criteria as described in the DSM. Finally, when essential criteria for a given diagnosis are met, additional questions follow that ask about the impairment associated with the symptoms, as interference with daily functioning is a crucial characteristic of most clinical disorders. Several studies have been carried out to examine the reliability and validity of the DISC. Research has generally demonstrated that the testretest reliability of the anxiety disorder diagnoses is moderate, whereas the validity is acceptable (Breton, Bergeron, Valla, Berthiaume, & St-Georges, 1998; Piacentini, Shaffer, Fisher et al., 1993; Roberts, Solovitz, Chen, & Casat, 1996; Schwab-Stone, Fisher, Piacentini et al., 1998; Shaffer, Schwab-Stone, Fisher et al., 1993). While most of these studies have been carried out using previous versions of the instrument, a recent study has indicated that the latest DSM-IV-based DISC version possesses similar qualities (Bravo, Ribera, Rubio-Stipec et al., 2001; Lewczyk, Garland, Hurlburt, Gearity, & Hough, 2003; see Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000).
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The Child and Adolescent Psychiatric Assessment (CAPA; Angold, Prendergast, Cox et al., 1995) also is a structured psychiatric interview that gathers data on the onset, duration, frequency, and intensity of a wide range of psychiatric diagnoses according to the DSM-III-R and DSM-IV, including most of the anxiety disorders. The CAPA provides a detailed definition of symptoms and then lists a series of questions that guide the interviewer to decide whether various symptoms are present. Three types of questions are used in the CAPA. First, screening questions are asked, which serve as entry points for a group of symptoms that are related to a single psychopathological phenomenon. Once a symptom area has been entered, mandatory (i.e., questions that must be asked to all subjects who enter the section) and discretionary probes (i.e., questions that provide further guidance for the clarification process) are asked to quantify the severity and interference associated with the pertinent symptom. The psychometric properties of the CAPA have been investigated in two large epidemiological samples and are generally found to be rather favorable, although again little is known about the reliability of the anxiety disorder diagnoses obtained with this instrument (Angold & Costello, 1995, 2000).
Semistructured Interviews Whereas the original version of the Diagnostic Interview for Children and Adolescents (DICA; Herjanic & Reich, 1982) was highly structured, follow-up versions of this instrument are considered as semistructured as interviewers are in some cases, especially with younger children, allowed to deviate from the interview and to ask questions in their own words (Reich, 2000). The latest edition of the DICA is polydiagnostic and covers a wide range of disorders in terms of DSM-III-R as well as DSM-IV diagnoses in children and adolescents aged 6 to 18 years. Unlike many of the other interview instruments, the DICA assesses lifetime diagnoses. The interview itself resembles the DISC, but as mentioned before, the interviewer is allowed to formulate his own questions. Of course, in the latter case, at least some clinical expertise is required. Psychometric evaluations of the DICA are sparse: Available studies indicate that the test-retest reliability is moderate, whereas there is emerging evidence for the validity of this interview instrument (De la Osa, Ezpeleta, Oomenech, Navarro, & Losilla, 1997; Ezpeleta, De la Osa, Judez et al., 1997; Welner, Reich, Herjanic, Jung, & Amado, 1987). The Schedule for Affective Disorders and Schizophrenia for school-age children (KSADS; see Ambrosini, 2000) is an interview schedule that covers the most important DSMIII-R and DSM-IV classifications that may occur in youths, including the full range of anxiety disorders. The K-SADS is semistructured, which means that it offers questions to assist the interviewer to check the presence of symptoms. However, the interviewer can ask as many additional questions to clarify the presence and severity of the symptom, and then makes a clinical judgment about the assignment of a diagnosis. There are currently three editions of the K-SADS: (1) an epidemiological version, which can be used to classify current and lifetime diagnoses as well as to obtain severity ratings of current symptoms; (2) a present and lifetime version (Kaufman, Birmaher, Brent et al., 1997), which can be employed to classify current and lifetime diagnoses and symptoms; and (3) a present state version, which scores severity and frequency of all symptoms, current and during the last
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12 months. There is support for the reliability and validity of the K-SADS (e.g., Ambrosini, Metz, Prabucki, & Lee, 1989; Hodges, McKnew, Burbach, & Roebuck, 1987), although it has to be noted that data on the test-retest reliability are limited and only pertain to a small set of the (anxiety) diagnoses that are covered by this instrument (Ambrosini, 2000). The Interview Schedule for Children and Adolescents (ISCA; Kovacs, 1997) is another semistructured symptom-oriented psychiatric interview that is suitable for youths from age 8. The ISCA can be used to examine the presence and severity of a number of “major” psychiatric symptoms, including depressed, manic, and hypomanic mood, anxiety, cognitive problems, problems in neurovegetative functioning, dysregulated behavior and conduct, as well as developmental difficulties. Symptoms and severity ratings can be combined in DSMbased current and lifetime diagnoses by an experienced interviewer who is also allowed to use behavioral observations and clinical impressions. The interrater reliability of the ISCA is good, but there is little evidence for the test-retest reliability of DSM-classifications based on this interview instrument. Further, more research is needed to establish the validity of the ISCA (Sherrill & Kovacs, 2000). The Pictorial Instrument for Children and Adolescents (PICA; Ernst, Godfrey, Silva, Pouget, & Welkowitz, 1994) was developed to assess DSM-III-R psychiatric disorders in children aged 6 to 16 years. Instead of gathering information about children’s mental condition by asking verbal questions, this instrument employs pictures that depict the emotions, behaviors, thought content, thought processes, and vegetative signs relevant for each of the disorders. The PICA can be used to establish the presence of various symptoms, but also measures the severity of these symptoms. Thus, the PICA yields categorical DSM-diagnoses as well as a dimensional evaluation of child psychopathology. The psychometric properties of the PICA can be labeled as promising: The internal consistency of most subscales is good, the scale seems to possess sufficient discriminative power for detecting diagnoses, and is a sensitive index for measuring treatment effects (see Ernst, Cookus, & Morayec, 2000). However, no study can be found that examined the test-retest reliability of this interview instrument. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions (ADIS C/P; Silverman & Albano, 1996) is a semistructured interview developed specifically to assess child and adolescent anxiety disorders as well as a number of frequent comorbid disorders (e.g., mood disorders, disruptive behavior disorders). During separate interviews, children and parents are questioned about the presence of various symptoms. Further, for endorsed symptoms, severity is checked as well as the level of interference in areas that include school, family life, and peers. The psychometric properties of the ADIS C/P are good, with excellent interrater agreement, sufficient test-retest reliability, even in younger children (although this quality has not been established for all anxiety disorders), and good concurrent validity (e.g., Grills & Ollendick, 2003; Rapee, Barrett, Dadds, & Evans, 1994; Silverman & Eisen, 1992; Silverman & Nelles, 1988; Silverman & Rabian, 1995; Silverman, Saavedra, & Pina, 2001; Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). It is clear that semistructured and structured interviews can be employed to obtain detailed information about anxiety symptoms and anxiety disorder diagnoses in children and adolescents. Compared to a standard clinical interview, these types of interviews guide the interviewer systematically across various DSM diagnoses and ensure that no relevant classifications are missed. In most cases, semistructured and structured interviews yield better
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interrater agreement as compared to the clinical interview. However, there are also a number of problems with these interviews. To begin with, the wording of questions may be too abstract and difficult, especially for young children (e.g., Breton, Bergeron, Valla et al., 1995). Further, most interviews are rather lengthy and exceed the attention span of most children, which of course makes it impossible for the child to stay focused during the entire interview. Finally, robust evidence for the psychometric qualities of these interview instruments is generally lacking. In particular, support for the most robust indicator of reliability—that is, the test-retest reliability—is meagre for most interviews (see Table 7.2) and is frequently based on small samples and only pertains to a restricted range of anxiety diagnoses. In view of the former shortcomings, the PICA seems to be a particularly interesting instrument. This interview is relatively short and uses pictures to explain various symptoms to the children. Although more studies are needed to establish its psychometric qualities, these features make this PICA an attractive instrument for interviewing children about their anxiety complaints. Of the more verbally oriented interviews, the ADIS C/P seems to be the most optimal choice for classifying anxiety disorders. This instrument is specifically developed for this type of psychopathology, has been demonstrated to possess good psychometric properties (especially in comparison with other interview instruments), and possesses good clinical utility, and is therefore currently considered as the “gold standard” interview for assessing anxiety disorders in youths (Greco & Morris, 2004).
Direct Assessment of Fearful and Anxious Behavior Questionnaires, rating scales, and interviews certainly provide useful information about symptoms of fear and anxiety in youths. However, it is also clear that such assessment procedures suffer from various weaknesses (see Kendall & Flannery-Schroeder, 1998). For example, especially younger children have limited metacognitive capacity, which may hinder them to provide valid responses to the questions raised in interviews and questionnaires. Further, it is a well-known fact that, in particular, anxious children are susceptible to response bias and social desirability (e.g., Dadds, Perrin, & Yule, 1998). In Kendall and Chansky’s (1991) words: “Anxious children—consistent with their desire to please—may tend to ‘fake good’ and overestimate their ability to cope with problem situations. Placed in an in vivo exposure situation, however, these same children are often afraid to ask an adult confederate as simple a question as ‘What time is it?’ ” (p.179). The latter observation makes clear that it may be important to also incorporate behavioral observations in the assessment of anxious youths.
Behavioral Observation Behavioral observation comprises a first method that can be used to quantify children’s anxiety and fear responses during stressful situations. This type of assessment has been typically employed with younger children, probably because most interviews and questionnaires are not suitable for this age group. For example, Glennon and Weisz (1978) describe
Table 7.2 youths
Summary of practical parameters and reliability of diagnostic interviews that can be used for assessing anxiety disorders in Anxiety disorders covered
ChIPS (Weller et al., 1999)
Highly structured DSM-IV-based interview for youths and parents (6–18 years). Trained lay interviewers; <45 minutes.
DISC (Shaffer et al., 1996)
Highly structured DSM-III-R- and DSM-IV-based interview for youths (9–18 years) and parents (6–18 years). Trained lay interviewers; 90 minutes.
CAPA (Angold et al., 1995)
Structured DSM-III-R- and DSMIV-based interview for youths and parents (8–18 years; parent version for preschoolers 3–6 years available). Trained interviewers with at least bachelor-level degree; 60 minutes. Semistructured or structured DSM-III-R- and DSM-IVbased interview for children, adolescents, and parents (6–18 years). Trained lay interviewers although clinical experience is necessary when using DICA as semistructured interview; 60– 120 minutes.
Specific phobia, social phobia, separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, acute stress disorder, and posttraumatic stress disorder Specific phobia, social phobia, separation anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, selective mutism, panic disorder, agoraphobia Specific phobia, social phobia, avoidant disorder, separation anxiety disorder, generalized anxiety disorder, overanxious disorder, obsessive-compulsive disorder, selective mutism, panic disorder, agoraphobia
DICA (see Reich, 2000)
Simple phobia, social phobia, avoidant disorder, separation anxiety disorder, generalized anxiety disorder, overanxious disorder, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder
Reliability of anxiety diagnoses (kappa) Not examined
Child SP: .41–.68 SOP: .25–.44 SAD: .27–.59 GAD: .28–.43 PD/AGO: −.04–.20 Child OAD/GAD: .74–.79
Child SP: .65 SAD: .60 GAD: .55 Adolescent SAD: .75 GAD: .72
Parent SP: .55–.96 SOP: .33–.75 SAD: .44–.72 GAD: .34–.65 PD/AGO: .27
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Instrument
Semistructured DSM-III-R- and DSM-IV-based interview for youths and parents (6–18 years). Trained clinical interviewer; 90 minutes.
ISCA (Kovacs, 1997)
Semistructured DSM-III-R- and DSM-IV-based interview for youths and parents (8–18 years). Trained clinical interviewer; >60 minutes (child), >120 minutes (parent).
PICA (Ernst et al., 1994)
Semistructured DSM-III-R-based interview for youths (6–16 years). Trained clinical interviewer; <60 minutes.
ADIS C/P (Silverman & Abano, 1996)
Semistructured DSM-IV-based interview for youths and parents (7–18 years). 90 minutes.
Simple phobia, social phobia, avoidant disorder, separation anxiety disorder, generalized anxiety disorder, overanxious disorder, obsessive-compulsive disorder, posttraumatic stress disorder, panic disorder, agoraphobia Phobic disorders, obsessivecompulsive disorder, adjustment disorder with anxious mood, anxiety disorder NOS, avoidant disorder, generalized anxiety disorder, overanxious disorder, panic disorder, separation anxiety disorder Agoraphobia, avoidant disorder, overanxious disorder, obsessive-compulsive disorder, separation anxiety disorder, simple phobia Separation anxiety disorder, social phobia, specific phobia, panic disorder, agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic and acute stress disorder
Combined SAD: .72–.80 GAD: .78
Combined SAD: .81 GAD: .82
Not examined
Child SP: .47–.84 SOP: .57–.72 SAD: .63–.78 GAD: .43–.71
Parent SP: .51–.73 SOP: .71–.92 SAD: .84–.88 GAD: .51–.78
219
Note. ChIPS = Children’s Interview of Psychiatric Syndromes, DISC = Diagnostic Interview Schedule for Children, CAPA = Child and Adolescent Psychiatric Assessment, DICA = Diagnostic Interview for Children and Adolescents, K-SADS = Schedule for Affective Disorders and Schizophrenia for school-age children, ISCA = Interview Schedule for Children and Adolescents, PICA = Pictorial Instrument for Children and Adolescents, ADIS C/P = Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions. SP = Specific Phobia, SOP = Social Phobia (including Avoidant Disorder), SAD = Separation Anxiety Disorder, GAD = Generalized Anxiety Disorder (including Overanxious Disorder), PD/AGO = Panic Disorder and Agoraphobia.
Assessment of Fear and Anxiety in Children and Adolescents
K-SADS (see Ambrosini, 2000)
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the development of the Preschool Observation Scale of Anxiety (POSA) that can be used to assess behavioral indicators of anxiety (e.g., nail biting, fearful facial expression, crying) in 2- to 4-year-old children using a time-sampling observation procedure. It was demonstrated that the POSA possessed satisfactory interrater reliability in particular for anxious behaviors that occurred frequently. Further, POSA scores correlated significantly with parent and teacher ratings of children’s anxiety. Finally, POSA scores were significantly higher when children’s mothers were absent as compared to when mothers were present, which can be taken as support for the predictive validity of this observation scale. Kendall and colleagues (1994, 1997) used the POSA as the basis for a behavioral observation in their large-scale research evaluating the effects of cognitive-behavioral therapy in anxiety-disordered youths. Children were requested to tell about themselves in front of a video camera for a five-minute period. During ten 30-second periods, children’s videotaped performance was coded for the following behavior categories: gratuitous verbalization (e.g., stating a physical complaint, dislike for the task), gratuitous body movements (e.g., leg kicking or shaking, biting lips), trembling voice (e.g., shaking speech, stuttering), avoiding task (e.g., leaving the room, not talking), absence of eye contact (e.g., not looking at the camera for the entire observational period), and fingers in mouth (e.g., biting nails, moving hand to lips). Interrater reliability for various behavior categories was very good, and it was also found that the total behavioral observation score significantly differentiated between treated and untreated groups, which demonstrates that this type of assessment is sensitive to treatment effects. Instead of actually coding children’s responses to stressful situations in behavior categories, one can also ask independent observers to provide an overall rating of children’s anxiety level during such situations. A nice illustration of this type of anxiety assessment has been provided by Beidel, Turner, and Morris (2000), who observed socially anxious children during two socially provocative tasks. The first task involved a series of socially relevant role-plays with a same-age peer (e.g., starting a conversation with an unfamiliar child, offering to help another child, and receiving a compliment). The second task implied reading aloud a story in front of a small group of children. During both tasks, observers rated children’s effectiveness of performance and anxiety levels using five-point Likert scales (with high ratings indicating higher levels of ineffectiveness and anxiety). Interrater reliability for this type of assessment was high, and these behavioral observation ratings also proved to be sensitive to measure the effects of a successful intervention. Taken together, behavioral observation generally yields reliable and valid information on children’s level of anxiety and anxiety-related impairment. An advantage is that this method is applicable to a broad range of anxiety disorders. A disadvantage, however, is that behavior observation is often time consuming and thus costly, and this is probably the reason why this type of assessment has somewhat fallen out of favor (Vasey & Lonigan, 2000).
Behavioral Approach Tests Whereas behavioral observation can be used to assess general anxiety levels in children and adolescents, behavioral approach tests might be informative to measure youths’ fearful and anxious responding to one particular stimulus or situation. Typically, during a behavioral approach test, children are asked to approximate and deal with the feared stimulus or situa-
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tion in a stepwise manner. The idea is that anxious children do not dare to come close to this stimulus and situation, and as such this type of test yields information about children’s actual avoidance behavior (which explains why this test is also known as the “behavioral avoidance test”). A typical example of a behavioral approach test was described by Muris et al. (1998), who used this method for assessing fear of spiders in a sample of phobic girls. The procedure of this test was as follows: Children entered a room in which a table was located approximately three meters in front of them. A closed jar containing a medium-size living spider was placed on the table. Then children were asked to approach the spider in a stepwise manner (i.e., in 10 steps). Performance of the children was scored on a 10-point scale that corresponds with the steps to be taken during the test, ranging from 1 = spider still at threemeter distance to 10 = spider walking on the hand (see also Öst, Svensson, Hellström, & Lindwall, 2001). Similar procedures have been used for measuring children’s avoidance responses to a wide range of phobic stimuli and situations, including blood (Van Hasselt, Hersen, Bellack, Rosenblum, & Lamparski, 1979), darkness (King, Cranstoun, & Josephs, 1989), heights (Van Hasselt et al., 1979), and medical procedures (Melamed & Siegel, 1975). Evidence for the reliability and validity of behavioral approach tests is sparse. As to the reliability of behavioral approach tests, it is not possible to examine internal consistency because this assessment is typically expressed in one figure that simply reflects the subject’s level of performance. Test-retest reliability can be investigated, but this has been rarely done. One exception is a study by Hamilton and King (1991), who examined the temporal stability over one week of a 14-step behavioral approach test for assessing dog phobia in 2- to 11-year-old children. Test-retest reliability was extremely high (r = .97). In fact, most children obtained an identical approach score on both occasions, whereas others only showed minimal change over the one-week period. Thus, the result of this study indicates that behavioral approach tests can be highly reliable across time. Further, Kindt et al. (1996) found evidence indicating that performance on a behavioral approach test concerning spiders was inversely related to children’s self-reported levels of spider fear. In other words, as expected, high spider-fearful children performed less well on the behavioral approach test. This finding indicates that the behavioral approach test is a valid index of spider fear. Finally, several studies have demonstrated that behavioral approach tests are sensitive to tap the effects of treatment. More precisely, performance on these tests significantly improves following a successful intervention, and closely parallels the effects found on other therapy outcome measures (e.g., self-report scales; see Muris et al., 1998; Öst et al., 2001). A strong point of behavioral approach tests is that they provide useful information on children’s actual fear and anxiety levels. A disadvantage is that these tests are not suitable for more general anxiety problems, but only can be employed for measuring anxiety disorders characterized by high levels of avoidance behavior (i.e., specific phobias, social phobia).
Monitoring and Self-Monitoring of Anxiety Monitoring and self-monitoring are assessment procedures that are frequently employed in clinical settings—in particular in the context of a cognitive-behavioral treatment. It is clear
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that this assessment procedure may also be helpful for measuring real-life fluctuations in fear and anxiety symptoms among youths. Typically, during monitoring, a parent (or another observer) is asked to record a child’s actual fearful and anxious behavior in a diary. In this way, the therapist collects information about the frequency and intensity of the child’s fear and anxiety, the specific situations that elicit these emotions, how the child tries to cope with negative affect, and how the environment responds to the anxious child. Self-monitoring might yield additional information, as the child can also be asked to record physiological and cognitive symptoms he/she experiences when confronted with threatening stimuli or situations. Whereas monitoring can be employed in children and adolescents of all ages, self-monitoring is only appropriate in older youths. Although this type of assessment does not circumvent the problem of response bias and social desirability, it is clear that less metacognitive capacity is required when children and adolescents immediately record their fearful and anxious behavior whenever it occurs. A study by Henker, Whalen, Jamner, and Delfino (2002) even demonstrated the incremental value of self-monitoring as compared to selfreport by means of a questionnaire. More specifically, it was found that a stratification on the basis of adolescents’ records in electronic diaries yielded a sharper differentiation among anxiety subgroups in terms of negative and positive moods, energy level, daily activities, and urges and intake (e.g., eating, smoking) than a stratification based on adolescents’ scores on the RCMAS. Few examples can be found of studies that examined the psychometric merits of monitoring and self-monitoring. Silverman and Ollendick (2005) noted that the test-retest reliability of these assessment procedures is generally modest (e.g., Beidel, Neal, & Lederer, 1991), which is not that surprising as events listed in the diaries likely show actual, real-life fluctuations. Furthermore, these authors rightly observed that it would be important to study the agreement between parents’ and children’s monitoring activities, which of course would provide information on the validity of such diary records. Finally, although research has shown that (self-)monitoring is sensitive to document treatment effects in single case studies (e.g., Eisen & Silverman, 1998; Ollendick, 1995), it remains to be seen whether treatment sensitivity can be established in large-scale therapy outcome studies, which typically involve the evaluation of group changes from pre- to posttreatment assessment. In sum, then, behavioral observation, behavioral approach tests, and (self-)monitoring may yield important and interesting information about childhood fear and anxiety. Nevertheless, in their review of performance-based measures of childhood anxiety, Vasey and Lonigan (2000) rightly conclude that “despite their clinical utility, none of [these] assessments of childhood anxiety possess sufficient documented clinical utility to warrant their dissemination for clinical use” (p.505). Clearly, more research is required to establish their psychometric qualities and to demonstrate the incremental utility of these measures above other assessment methods of childhood fear and anxiety.
Conclusion A wide range of standardized psychological assessment instruments can be employed to index symptoms of fear and anxiety in youths of various ages. Current researchers and clini-
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cians have at their disposal questionnaires and interview instruments that classify and quantify symptoms of anxiety disorders in terms of the prevailing diagnostic system: the DSM. While there is certainly critique on this system (e.g., Weems & Stickle, 2005), a clear advantage is that this taxonomy facilitates the communication about these problems. It is good to observe that child researchers even have taken the lead in some assessment domains. For example, whereas it was common practice to use age-downward versions of adult scales for the assessment of fear and anxiety symptoms in youths, recent times have seen the rise of modern, multidimensional rating scales for measuring childhood anxiety problems. Currently, we are still awaiting the development of such questionnaires for adults. As mentioned by Greco and Morris (2004; p.98): “The reliable and valid assessment of child and adolescent anxiety faces numerous challenges, including high comorbidity within anxiety disorder categories and between anxiety and depression.” The present overview of assessment instruments that can be used to index fear and anxiety symptoms in youths indicates that researchers have succeeded to develop new and up-to-date questionnaires and interviews (such as the SCARED-R and ADIS C/P) that for the greatest part adequately deal with these problems. A positive point is that such instruments include child as well as parent versions, which is important given the low agreement among child and parent reports that has been observed for childhood anxiety problems (e.g., Choudhury, Pimentel, & Kendall, 2003; Comer & Kendall, 2004; see Grills & Ollendick, 2002). While it is certainly true that self-report is essential for measuring the internal and subjective nature of fear and anxiety, parents, clinicians, and other observers (e.g., teachers) may provide additional and cross-validational information on these types of problems. As such, it is advised to use a multi-informant/multimethod approach for the assessment of fear and anxiety symptoms in youths.
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Chapter 8
Treatment and Prevention of Childhood Anxiety
Introduction In the case of Little Hans, the therapist, Sigmund Freud himself, had only one therapeutic session with the anxious boy (Gay, 1988). After this single session, Hans’s fear of horses quickly disappeared, and this is why many have questioned whether the boy really suffered from a phobia and argued that Hans just displayed the signs of a normal developmental fear (see Chapter 6). However, advocates of psychodynamic therapy have pointed out that it was Freud’s intervention that was highly effective. For example, in his biography of Freud, Jones (1955) states that the “brilliant success of child analysis” (p.289) was “indeed inaugurated by the study of this very case” (p.292; see Wolpe & Rachman, 1960). This claim seems to be supported by a review of 352 records from the Anna Freud center of children who were, retrospectively, diagnosed with DSM-III-R (American Psychiatric Association, 1987) disorders, and in particular anxiety disorders and depression. All these children underwent psychoanalysis or psychodynamic therapy, and the results indicated that 72% of the youngsters displayed improvement in adaptation (see Bernstein & Kinlan, 1997). Although it has been concluded that this therapeutic approach may be useful in the treatment of childhood anxiety disorders (American Academy of Child and Adolescent Psychiatry, 1997), there are few controlled therapy outcome studies, which means that the empirical status of this type of intervention is meagre (see for an exception, Muratori, Picchi, Apicella et al., 2005). A completely different picture emerges when considering the effectiveness of cognitivebehavioral and pharmacological treatments of anxiety disorders in children and adolescents. In the past decades, a host of controlled therapy outcome studies has appeared examining the efficacy of these interventions. In this chapter, the results of this research are summarized. First, the focus will be on the cognitive-behavioral treatment of phobias and anxiety disorders in children and adolescents. The content of an exposure therapy for phobias and a cognitive-behavioral intervention protocol for more generalized anxiety problems will be described, and studies demonstrating their short-term and long-term effectiveness are discussed. Second, the issue will be addressed of whether the effectiveness of a cognitivebehavioral intervention can be enhanced by including the family in this type of treatment. Third, other psychological approaches for treating phobias and anxiety disorders in youths are discussed. Fourth, an overview of the psychopharmacological treatment of childhood anxiety problems will be provided, and empirical trials evaluating their effectiveness are presented. Finally, the current status of the psychological and pharmacological treatment of
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childhood anxiety disorders will be critically discussed, developmental issues will be addressed, and an attempt will be made to link both types of intervention to the multifactorial, aetiological model that was described earlier (see Chapter 6).
Cognitive-Behavioral Treatment of Childhood Anxiety Cognitive-behavior treatment (CBT) essentially represents a fusion of behavior therapy and cognitive interventions (Kendall & Panichelli-Mindel, 1995). The behavior therapy component has evolved within learning theory and is based on the assumption that behavior, which has been acquired via classical and/or operant conditioning, can be corrected and changed (e.g., Wolpe, 1958). The cognitive component is grounded on the increasingly accepted notion that all normal and abnormal human behavior is mediated by cognitive processes (Beck, 1995). The two components are often combined in treatment, and differences between behavior and cognitive therapists simply seem to pertain to the strategy that is initially chosen to deal with the problematic behavior. That is, behavior therapists work with patients to change behaviors and thereby reduce distressing feelings and thoughts, whereas cognitive therapists first try to change thoughts and feelings, with improvements in functional behavior following in turn (see Compton, March, Brent et al., 2004). In order to get an impression of CBT interventions with youths, two examples of such treatments are given in the following paragraphs. The first example is an exposure-based therapy for childhood phobias. This one-session therapy was developed by Öst (1989) and essentially consists of a series of behavioral exercises, during which the child or adolescent is instructed to approach the phobic stimulus (see Table 8.1). The exposure is gradual in two respects. First, the child starts with a phobic stimulus that elicits relatively low levels of fear and anxiety, and ends up with the stimulus that is feared most. Second, each stimulus is approached in a stepwise manner: The child first carefully observes the phobic object and then gets closer to the stimulus, touches it indirectly with another object (for example, a pencil or a long stick), and eventually makes direct physical contact. During the exposure, the therapist continuously monitors the child’s subjective anxiety level, and the rule of thumb is that before one proceeds to the next step
Table 8.1 Possible hierarchy for a one-session exposure in vivo therapy of spider phobia Exposure-exercises
Possible steps within each exercise
1. 2. 3. 4. 5. 6.
1. 2. 3. 4. 5. 6.
Pictures of spiders Toy spider Small spider Medium-size spider Large house spider Tarantula
Watch the spider from a distance Gradually approach the spider Touch the spider with a pencil Touch the spider with a finger Let the spider walk on the hand Catch a spider
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or stimulus, there should be at least a 50% decline in anxiety level. The therapist first demonstrates each step (modeling) and then encourages the child to perform the exercise. A one-session exposure therapy can best be viewed as an example of behavior therapy. No active cognitive therapy is carried out during the treatment session, although the therapy aims at correcting the false beliefs that a child has in regard to the phobic stimulus (e.g., in case of a spider phobia, the belief that the spider will approach and attack). In other words, “The hallmark, then, of one-session treatment is a graduated, systematic, prolonged exposure to the phobic stimulus combined with the active dissuading and repair of faulty cognitions” (Ollendick, Davis, & Muris, 2004; p.293). The second example is the “Coping Koala (Cat),” a CBT program for anxiety disordered children and adolescents (Kendall, 1990, 2000), of which many variants have appeared (e.g., “Coping Koala,” Heard, Dadds, & Rapee, 1991; “Friends,” Barrett, Lowry-Webster, & Turner, 2000; “Cool Kids,” Rapee, Wignall, Hudson, & Schniering, 2000). The basic elements of this program are shown in Table 8.2. As can be seen, the core feature of the program is the so-called FEAR-plan which helps the child or adolescent (1) to recognize anxious feelings and the physical symptoms of fear and anxiety, (2) to identify anxious thoughts and self-talk in potentially threatening situations, (3) to think up a plan to deal with threatening events, and (4) to evaluate one’s behavior and to reinforce oneself for coping effectively with fear- and anxiety-provoking stimuli and situations. Obviously, the active correction of negative cognition clearly is an important component of the “Coping Koala (Cat)” program, and as such this type of treatment can certainly be regarded as cognitively oriented (Hudson, Hughes, & Kendall, 2004). Nevertheless, it is important to note that exposure exercises are also a very important component of this treatment. In sessions 9 through 11, the child or adolescent is encouraged to apply his/her newly acquired skills in real-life threatening situations. In addition, the “Coping Koala (Cat)” also contains a number of other therapeutic elements that may help to reduce fear and anxiety, including psychoeducation and relaxation training. Taken together, the “Coping Koala (Cat)” contains a mixture of cognitive-behavioral strategies, which make it possible to use this program with a variety of childhood phobias and anxiety disorders.
Effectiveness of CBT in Childhood Phobias and Anxiety Disorders From early on, CBT has been strongly embedded in research tradition. This explains why CBT probably is the best evaluated treatment approach for psychological disorders. The same conclusion can be drawn regarding the treatment of childhood phobias and anxiety disorders. As soon as clinicians and researchers started to realize that these disorders should be regarded as serious clinical problems, a host of controlled treatment outcome studies have appeared investigating the effectiveness of exposure programs, CBT protocols, and other cognitive-behavioral interventions in phobic and anxiety disordered youths. Exposure-Based Treatment of Phobias While exposure is assumed to be an essential element of an intervention for almost every anxiety disorder, it is generally regarded as the treatment of choice for phobias. In Antony
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Table 8.2 The 12 sessions of the “Coping Koala” (the Australian version of the “Coping Koala (Cat)”), a cognitive-behavioral program for children with anxiety disorders Session
Title in workbook
1
Introduction
2
Recognizing feelings
3 4
How does my body react? Relax!
5
What do I think?
6
What can I do?
7
How am I doing?
8
The FEAR-plan
9
Start to exercise
10
It’s getting more difficult Look what I am doing! You did it!
11 12
Main content Acquaintance and providing an overview of the treatment. To help the child to identify anxious and worried feelings and to differentiate these from other feelings. To identify the physical symptoms that accompany fear and anxiety. To introduce relaxation training and to teach the child to use it as a strategy for controlling the physical symptoms that are associated with fear and anxiety. To explain the function of personal thoughts and their impact on the child’s behavior. To teach the child to recognize anxious self-talk in (potentially) threatening situations. To teach the child to change anxious self-talk into coping self-talk and to alter fearful into brave behavior. To teach the child to evaluate his/her behavior and to rate and reward performance. To introduce the FEAR-plan, which integrates the elements that were learned in previous sessions. The FEAR-plan is a 4-step approach for dealing with fear- and anxiety-provoking situations: 1. Feeling frightened? (awareness of physical symptoms of anxiety); 2. Expecting bad things to happen? (recognition of anxious self-talk); 3. Attitudes and actions that will help (problemsolving and coping); and 4. Results and rewards (self-evaluation and self-reward for effort). To apply the FEAR-plan in mildly threatening situations. To apply the FEAR-plan in moderately threatening situations. To apply the FEAR-plan in highly threatening situations. Closure and award of the anxiety certificate.
Based on: Heard, Dadds, & Rapee (1991).
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and Barlow’s (2002) words: “Almost all experts agree that exposure to feared objects and situations is both necessary and sufficient for treating the vast majority of the patients with this condition” (p.408). Although this statement was made with regard to the treatment of phobias in adults, there is no reason to assume that this is not true for childhood phobias (King, Heyne, & Ollendick, 2005; King, Muris, & Ollendick, 2005; King, Muris, Ollendick, & Gullone, 2005; Ollendick, Davis, & Muris, 2004). In fact, the literature contains many case studies that describe exposure as an important element in the treatment of phobic children (e.g., Nelissen, Muris, & Merckelbach, 1995; Nock, 2002; Saavedra & Silverman, 2002; Sturges & Sturges, 1998). Moreover, controlled treatment outcome research has indicated that exposure-based treatments are indeed effective in reducing fear and anxiety in phobic youths. Exposure treatment of childhood phobias has been conducted in many ways. Based on the idea that two emotional states cannot occur simultaneously, Wolpe (1958) developed the treatment approach named “systematic desensitization,” during which fear and anxiety elicited by a phobic stimulus are terminated by a previously learned relaxation response. Briefly, Wolpe assumed that a response antagonistic to anxiety (e.g., physiological relaxation) inhibits the emotional fear response (a phenomenon known as “reciprocal inhibition”). Various studies have demonstrated that systematic desensitization yields positive effects when treating phobic youths, and this is especially true when real-life exposure to the phobic stimulus is used to provoke fear and anxiety during the therapeutic procedure. For example, Ultee, Griffoen, and Schellekens (1982) divided 24 water phobic children aged between 5 and 10 years in three groups: (1) an in vitro desensitization group in which children received gradual imaginal exposure to fear-evoking stimuli plus relaxation, (2) an in vivo desensitization group in which children were treated with gradual real-life exposure in combination with relaxation, and (3) a no-treatment control group. The results of behavioral observation tests and reports by the swimming teachers indicated that both desensitization procedures were effective in reducing children’s fear of water, whereas no such effect could be observed in the no-treatment condition. Further, evidence was found showing that the in vivo exposure procedure yielded better treatment effects than the in vitro exposure procedure. In spite of the fact that various other studies have documented positive effects of systematic desensitization in the treatment of childhood phobias (e.g., Miller, Barrett, Hampe, & Noble, 1972), this type of intervention seems somewhat outdated. This is because research has demonstrated that Wolpe’s (1958) basic ideas about the underlying mechanism of systematic desensitization are not correct. In fact, there is clear evidence showing that the relaxation component of this treatment is not necessary to achieve the positive effects of the intervention (see Emmelkamp, 1982). Although the therapeutic procedure of systematic desensitization is less frequently employed nowadays, it is of interest to note that there is an age-downward variant that may still be feasible to apply, in particular when working with younger children. This technique has been described as “emotive imagery,” and was first defined by Lazarus and Abrahamson (1962) as “those classes of imagery which are assumed to arouse feelings of self-assertion, pride, affection, mirth, and similar anxiety-inhibiting responses” (p.191). An important feature of the emotive imagery procedure is that the child identifies himself with a “personal hero” (usually a person or cartoon character seen on television) and then makes up a narrative, in which the phobic stimulus is gradually introduced (see for an example,
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Table 8.3 Transcript from an emotive imagery therapy session with a 5-year-old boy who had a phobia of darkness Therapist
Child Therapist Child Therapist Child Therapist
Child Therapist
Child
Close your eyes. Now I want you to imagine that you are sitting in the lounge room watching TV with your family. You are dressed for bed and the last program before bedtime has finished. Your mother tells you that it is time for bed, but just then Batman appears out of nowhere and sits down next to you. Think about it as best as you can. Can you see Batman in your head? Yes. Can you tell me what Batman is wearing? What color are his clothes? He’s got black and red clothes, big shoes, and a gun. Oh, you can see him with a gun? Yeah, he needs it for the Joker. That’s terrific! Now I want you to imagine that Batman tells you he needs you on his mission to catch robbers and other bad people, and he has appointed you as his special agent. However, he needs you to get your sleep in your bedroom, and he will call on you when he needs you. You are so lucky to have been chosen to help him. Yes. Now your mother puts you in bed and leaves a small light on. Batman is also there, looking as strong as he always does. Think about it as clearly as you can. Can you see it? Yes. I can see Mummy and Batman in my room.
From: King, Molloy, Heyne et al. (1998).
Table 8.3). After the imaginal exposure, during which the child—supported by the personal hero—effectively deals with the phobic stimulus, he/she is encouraged to apply these newly learned skills in real-life situations (King, Heyne, Gullone, & Molloy, 2001; King, Molloy, Heyne, Murphy, & Ollendick, 1998). In an attempt to examine the effectiveness of emotive imagery, King, Cranstoun, and Josephs (1989) treated three children (aged 6, 8, and 11 years old) with nighttime fears in a multiple baseline design. All three children showed marked improvements on a behavioral test for darkness toleration. Further, parents observed fewer nighttime disturbances for two of the children and reported to be satisfied with emotive imagery as a fear-reduction procedure. More systematic research was conducted by Cornwall, Spence, and Schotte (1996) who assigned 24 clinically referred 7- to 10-yearold children with a severe darkness phobia to either emotive imagery treatment or a waitinglist control condition. The results demonstrated that children in the emotive imagery group showed significant reductions in darkness fear and anxiety and clear improvement on a darkness tolerance test, whereas no such effects were observed in the waiting-list control group (see Figure 8.1). Another way to conduct an exposure treatment in phobic youths is “reinforced practice,” which is also known as “contingency management.” In line with his operant conditioning
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Fear of darkness 6 5 4 3 2 1 0 Pretreatment
Posttreatment Emotive imagery
Follow-up (3 months) Waiting-list
Darkness tolerance 180 160 140 120 100 80 60 40 20 0 Pretreatment
Posttreatment
Follow-up
Figure 8.1: Mean scores on a self-report questionnaire (fear of darkness) and a behavioral test (darkness tolerance) in the emotive imagery and the waiting-list control groups at pretreatment, posttreatment, and 3-month follow-up. Based on: Cornwall, Spence, & Schotte (1996).
theory, Skinner (1988) assumed that a phobia essentially is “a reduced probability of moving toward a feared object and a heightened probability of moving away from it” (p.172). During reinforced practice, an attempt is made to weaken the negative associations with the phobic stimulus that results in avoidance behavior by strengthening positive associations through reinforcement of approach behavior. This is achieved via exposure exercises during which successful approaches of the phobic stimulus are reinforced by means of rewards. There is ample evidence supporting the efficacy of reinforced practice in treating phobic children and adolescents. For example, Silverman, Kurtiness, Ginsburg et al. (1999) treated 33 6- to 16-year-old youths with either specific phobia, social phobia, or agoraphobia by means of a reinforced practice program during which children had to perform increasingly difficult exposure tasks that were reinforced by their parents every time they completed a task successfully. Results revealed that this treatment program was equally effective in reducing fear and anxiety levels as a cognitive-behavioral intervention. Further, it was found that the positive treatment effects of reinforcement practice were largely maintained at a one-year
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follow-up. In terms of clinical significant improvement, it was found that more than half of the youths (55%) no longer met the diagnostic criteria of a phobic disorder after the completion of the treatment. Yet another option is to make children observe a nonphobic person who approaches the phobic stimulus and successfully copes with it without displaying fear. This procedure of modeling, which has also been described as vicarious learning (Bandura, 1969), can be employed in various ways. The first way is filmed modeling, during which the child watches a film in which a model interacts with the phobic stimulus. The second way is live modeling: The phobic child observes a real model interacting and dealing with the phobic stimulus. Finally, during participant modeling, the child and the model work together: The model demonstrates how to approach and deal with the phobic stimulus, and then instructs the child to imitate this behavior. Research has indicated that participant modeling clearly is more effective than the other modeling variants (Ollendick et al., 2004). For example, Menzies and Clarke (1993) assigned 3- to 8-year-old children with water phobia to various interventions involving exposure, live modeling, or a combination of these two procedures. Most important, this study demonstrated that modeling merely yielded significant treatment effects when combined with exposure exercises. Clearly, this finding can be taken as support for the notion that participant modeling is far more effective than live modeling only. A final exposure-based approach that can be chosen to treat childhood phobias is the aforementioned one-session therapy (Öst, 1989). A number of studies can be found in the literature demonstrating that this type of intervention is particularly effective for reducing phobic complaints in youths. A first study by Muris, Merckelbach, Van Haaften, and Mayer (1997) compared the efficacy of one-session therapy with that of eye-movement desensitization and reprocessing (EMDR, Shapiro, 1995; see Box 8.1) in the treatment of 22 spiderphobic girls aged 9 to 14 years. A crossover design was used in which half of the children were first treated with exposure and then with EMDR, whereas the other half received the
Box 8.1
Eye-movement desensitization and reprocessing
Eye-movement desensitization and reprocessing (EMDR) is a therapeutic technique that has been proposed as a treatment for posttraumatic stress disorder (PTSD; Shapiro, 1995). During EMDR, the therapist induces rapid, lateral eye movements while the patient imaginally exposes him- or herself to aversive memories. After each set of eye movements, the patient briefly reports his or her images, feelings, and/or thoughts. This procedure is repeated until the negative affect associated with the traumatic or aversive memory habituates. Furthermore, the therapist encourages cognitive restructuring. That is, the patient is prompted to change negative cognitions about him- or herself or about the traumatic event into more functional cognitions. While the EMDR-procedure in itself is unique (because of the employment of the eye movements), it is clear that this treatment is essentially based on the key elements of cognitive-behavioral therapy (i.e., exposure and cognitive restructuring). Based on: Muris & Merckelbach (1999b).
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treatments in reversed order. Treatment outcome was evaluated by means of self-report questionnaires and a behavioral approach test (during which children had to approach a real-life house spider in a stepwise manner), which were administered before treatment, after treatment 1, and after treatment 2. The results indicated that one-session therapy was superior to EMDR. More precisely, the one-session therapy yielded a significant reduction of subjective fear and a clear improvement on the behavioral approach test, whereas the EMDR intervention only produced some positive effects on the self-report scales. Similar findings were obtained in a follow-up study by Muris, Merckelbach, Holdrinet, and Sijsenaar (1998), who compared the effects of one-session therapy, EMDR, and computerized exposure in 26 8- to 17-year-old girls with a spider phobia. The one-session therapy resulted in significant improvements on all outcome measures, EMDR only yielded a significant improvement on self-reported spider fear, whereas computerized exposure did not produce any improvement. Further research by Öst, Svensson, Hellström, and Lindwall (2001) tested the effectiveness of one-session therapy in a large sample of children and adolescents (N = 60) with various types of specific phobias. For this purpose, youths were randomly assigned to (1) regular one-session therapy, (2) one-session therapy with one of the child’s parents present, or (3) a waiting-list control group. Various outcome measures were used including self-report inventories, independent assessor ratings, a behavioral approach test, and physiological indexes (e.g., blood pressure, heart rate), most of which were obtained at pretreatment, posttreatment, and one-year follow-up. The results consistently showed that one-session therapy produced significantly better results than the waiting-list control condition. Further, both variants of the one-session therapy did equally well on most outcome measures, indicating that the presence of a parent did neither promote nor hinder the treatment effects. Finally, the treatment effects of one-session therapy were maintained at a follow-up of one year (see Figure 8.2). Altogether, this type of intervention seems highly effective for treating phobias in children and adolescents. In sum, then, exposure-based interventions have shown to be effective for treating phobias in children and adolescents. In their systematic review article, Ollendick and King (1998) provide an overview of the empirical status of treatments for youths with phobias, thereby using the guidelines as provided by the American Psychological Association (Task Force on Promotion and Dissemination of Psychological Procedures, 1995; see Chambless & Ollendick, 2001). With regard to the treatment of phobias in youths, these authors conclude that “participant modeling and reinforced practice enjoy a well-established status” (p.162), which implies that multiple studies have shown that these interventions are more effective than other treatments. A more recent review by Davis and Ollendick (2005) has indicated that one-session therapy by now also meets the criteria for a well-established treatment. These interventions all share that they try to enhance approach behavior to reallife phobic stimuli, which seems to be an essential element for the treatment of (childhood) phobias (Muris, 2005). As a final note it should be mentioned that CBT programs like the “Coping Koala (Cat)” have also been successfully employed to treat phobias in children and adolescents (see Silverman et al., 1999). However, this type of intervention seems more suitable for treating those childhood anxiety disorders (e.g., separation anxiety disorder, generalized anxiety disorder, and social phobia) in which dysfunctional cognitions play a more prominent role. In the next section, empirical evidence on the effectiveness of CBT programs for anxietydisordered youths will be discussed in detail.
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5 4
One-session therapy + parent
3
One-session therapy
2 1 0
Pretreatment Posttreatment Follow-up
Figure 8.2: Severity of phobia scores as rated by independent assessors for youths in the one-session therapy groups and the waiting-list control group. Based on: Öst, Svensson, Hellström, & Lindwall (2001).
CBT Programs for Childhood Anxiety Disorders Since the introduction of the “Coping Koala (Cat),” a series of studies has appeared that examined the effectiveness of such CBT programs for treating anxiety disorders in children and adolescents. In a multiple-baseline evaluation of four 9- to 13-year old children diagnosed with generalized anxiety disorder, Kane and Kendall (1989) were among the first to demonstrate that this CBT program has potential for treating anxious youths. Kendall (1994) then performed the first randomized clinical trial to evaluate the effectiveness of the “Coping Koala (Cat)” program more systematically. In this study, 47 children with anxiety disorders (i.e., generalized anxiety disorder, separation anxiety disorder, and social phobia) were assigned to the CBT intervention or a waiting-list control condition. Outcome was evaluated using child self-report, parent report, teacher report, and behavioral observation. The results of a number of these outcome measures are displayed in Figure 8.3. As can be seen, there were significant pre- to posttreatment changes in the CBT intervention group, whereas the waiting-list control group remained relatively unchanged. More precisely, the CBT intervention resulted in substantial reductions of self-reported anxiety symptoms, parent-reported internalizing symptoms, and observable anxious behavior, as well as significant improvement of self-rated coping abilities. Furthermore, it is important to note that these positive effects of CBT were retained at a one-year follow-up assessment. Finally, many of the treated children (64%) no longer met the diagnostic criteria for an anxiety disorder at posttreatment, which indicated that the observed treatment effects were also clinically significant. In a following study (Kendall, Flannery-Schroeder, Panichelli-Mindel et al., 1997) with 94 anxiety-disordered children, these results were largely replicated. Again, the CBT intervention resulted in substantial improvements at posttreatment, whereas no such effects occurred in the waiting-list control condition. Due to treatment, anxiety levels of the majority of children returned within nondeviant limits, and this was still the case at a one-year follow-up.
Self-reported anxiety 60 55 50 CBT
45
Waiting-list
40 35 30
Pretreatment Posttreatment
Follow-up
Parent-reported internalizing symptoms 75 70 65 60 55 Pretreatment Posttreatment
Follow-up
Observation of anxious behavior 1,5 1,3 1,1 0,9 0,7 0,5
Pretreatment Posttreatment
Follow-up
Self-reported coping 6
5
4
3 Pretreatment
Posttreatment
Follow-up
Figure 8.3: Changes on various outcome measures for children treated with the CBT program and children in the waiting-list control group. Based on: Kendall (1994).
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Further research has been conducted to examine whether these CBT programs yield equally positive results when administered in a group format. For example, Silverman, Kurtiness, Ginsburg et al. (1999) evaluated the therapeutic efficacy of a group CBT in 56 children and adolescents (aged between 6 and 16 years) with social phobia, generalized anxiety disorder, or separation anxiety disorder. Results showed that group CBT was very effective in reducing anxiety symptoms. That is, youths treated with group CBT showed significant improvement from pre- to posttreatment on all outcome measures, and these effects were largely maintained at 3-, 6-, and 12-months follow-up (see also Lumpkin, Silverman, Weems, Markham, & Kurtines, 2002). About 75% of the children and adolescents did no longer fulfill the diagnostic criteria of the anxiety disorder for which they had received the treatment. In contrast, children and adolescents in a waiting-list condition did not show any improvement: These youths did not show spontaneous recovery and remained highly anxious. Although this study suggests that group CBT is also effective for treating youths with anxiety disorders, it should be noted that this intervention was supported by a parent intervention. More precisely, parents were instructed to encourage and reinforce the exposure exercises of their children. In other words, it is not clear to what extent the positive effects observed in the treated youths were caused by the group CBT program or by the parent intervention. A more clear-cut picture on the effects of group CBT was provided by Hayward, Varady, Albano et al. (2000), who randomly assigned 35 female adolescents to a treatment or a notreatment control group. The treatment group received group CBT without any parental involvement. All participants were assessed at pretreatment, posttreatment, and one-year follow-up by means of standardized self-report questionnaires and a structured diagnostic interview. The results showed that the group CBT intervention resulted in a significant decline of social phobia symptoms, whereas no such effect was observed in the no-treatment control group. At posttreatment, a substantial proportion of the treated adolescents (i.e., 55%) still met the criteria of social phobia, although this percentage was substantially lower than in the control group (96%). At the one-year follow-up, the differences between adolescents who had received group CBT and those who were untreated seemed to disappear: In the treatment condition 40% continued to have social phobia, whereas in the no-treatment condition this percentage was 56%. However, this state of affairs changed when comorbid depression was taken into account. As noted by Hayward et al. (2000), “Much of the improvement in the group CBT compared to the untreated group was maintained when social phobia and major depression were combined as the outcome” (p.724; (see Figure 8.4)). Taken together, although the group CBT yielded positive results, the effects seemed somewhat less impressive than those observed in previous studies by Kendall and colleagues (1994, 1997). However, it should be kept in mind that the youths in the Hayward et al. (2000) study were substantially older, and so it may well be the case that the anxiety problems were simply more chronic and severe than those of the younger children in Kendall et al.’s studies. Of course, only a direct comparison between individual and group CBT programs can provide an answer to the question of whether both types of treatment are equally effective in reducing anxiety symptoms in youths. Flannery-Schroeder and Kendall (2000) carried out an investigation in which this issue was addressed. Thirty-seven anxiety disordered children were randomly assigned to three conditions: individual CBT, group CBT, and waiting-list
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100 80 60
Group CBT No treatment
40 20 0 Pretreatment Posttreatment
Follow-up
Figure 8.4: Percentage of female adolescents with either social phobia or depression in the group CBT and the no-treatment control condition at pretreatment, posttreatment, and 1-year follow-up. Based on: Hayward, Varady, Albano et al. (2000).
control. Results showed that individual and group CBT were equally effective and superior to the waiting-list control condition. For example, after treatment, percentages of diagnosisfree children were 73% in the individual CBT condition, 50% in the group CBT condition versus only 8% in the waiting-list control condition. However, it is important to note that in both CBT interventions, several sessions with parents were included in order to enhance therapeutic effects. Thus, although the results of the Flannery-Schroeder and Kendall (2000) study seem to indicate that the effects of individual CBT and group CBT are comparable, it may well be the case that the parental involvement in both interventions has overshadowed differential treatment effects. A similar remark can also be made with regard to a study by Manassis, Mendlowitz, Scapillato et al. (2002). These researchers compared the effectiveness of individual and group CBT, both with parental involvement, in treating 78 anxiety disordered children aged 8 to 12 years. Both treatment formats yielded significant and largely comparable treatment gains. Nevertheless, some indications were found showing that high socially anxious children responded more favorably to the individual treatment format. A final investigation by Muris, Mayer, Bartelds, Tierney, and Bogie (2001) also made a comparison of the effects of individual and group CBT in a nonreferred sample of 36 8- to 13-year-old school children who fulfilled the diagnostic criteria of social phobia, generalized anxiety disorder, and/or separation anxiety disorder. Treatment was solely targeted at the children, which makes it possible to compare the “pure” effects of individual and group CBT. No differences were observed between both treatment formats—that is, levels of anxiety disorder symptoms were relatively stable from baseline to pretreatment (i.e., waiting-list period) but substantially decreased from pre- to posttreatment, and this pattern was identical for both CBT formats (see Figure 8.5). Altogether, it can be concluded that CBT programs have proven to be very successful in treating youths with anxiety disorders (see Dadds & Barrett, 2001). Further, research seems to suggest that a group format CBT is just as effective as an individual CBT intervention (James, Soler, & Weatherall, 2005). This finding seems to warrant the conclusion that the
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Individual CBT
50
Group CBT
40 30 Baseline
Pretreatment Posttreatment
Figure 8.5: Mean levels of anxiety disorders symptoms in the individual CBT and the group CBT conditions at the baseline (6 months before the intervention), pretreatment, and posttreatment assessments. Based on: Muris, Mayer, Bartelds, Tierney, & Bogie (2001).
group treatment format is preferable simply because it is more cost- and time-efficient. However, the results of the aforementioned study by Manassis et al. (2002) seem to suggest that individual treatment may still be necessary for some children. For instance, children with extremely high levels of social phobia may profit little from a group CBT simply because it is too difficult for them to participate adequately in the group sessions. As another example, severely traumatized youths may find it difficult to discuss their experiences, fears, and anxieties in front of other children. Finally, the individual format also seems to be preferable for children suffering from comorbid ADHD. Although children with ADHD may certainly profit from a group CBT intervention, it has also been observed that these children regularly disturb the group interactions with their hyperactive and impulsive behaviors (Muris et al., 2001; see Manassis & Monga, 2001).
Combining CBT with a Family Intervention Based on the observation that family factors play a role in the aetiology and maintenance of childhood anxiety disorders (see Chapter 3), many clinicians are convinced that it is important to involve parents in the CBT intervention (e.g., Kendall, MacDonald, & Treadwell, 1995). One of the first studies that examined whether family CBT yields positive effects in the treatment of youths with anxiety disorders was carried out by Howard and Kendall (1996). In a multiple-baseline design, six children aged 9 to 13 years who were diagnosed with an anxiety disorder received a CBT treatment in which at least one of the parents was present during the sessions. Besides the normal child-focused protocol, parents were encouraged to gain better understanding of their children’s anxiety symptoms and the role of the family in these problems, and to help and support their offspring to carry out the homework exposure exercises. Results clearly revealed changes on various types of outcome measures indicating meaningful treatment-related improvements. In the FRIENDS program, Barrett and co-workers (2000) have worked out a more systematic plan for helping parents to deal effectively with their anxious offspring. Besides the
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CBT sessions for the children, this program incorporates a parent component that consists of four 1½-hour sessions (that can eventually be split up into multiple sessions of shorter duration) during which parents are taught to recognize and deal with their own anxiety, to reinforce their child’s courageous behavior, to help their children employ cognitive techniques in order to challenge dysfunctional thoughts, and to communicate effectively and to support each other within the family (see Table 8.4). Shortt, Barrett, and Fox (2001) evaluated the efficacy of this family group CBT program. Seventy-one anxiety disordered
Table 8.4 Content of the parent sessions of the FRIENDS program Session 1
2
3
4
Aim General introduction of the program. Normalize the emotion of anxiety during childhood. Introduce Step 1 (Feeling worried?) and Step 2 (Relax and feel good). Introduce Step 3 (Inner thoughts) and Step 4 (Explore plans).
Introduce Step 5 (Nice work, so reward yourself!) Teach parents operant conditioning principles to reinforce desirable behaviors. Introduce Step 6 (Don’t forget to practice) and Step 7 (Stay calm). Promote positive family skills and outline strategies to maintain gains.
Based on: Shortt, Barrett, & Fox (2001).
Main content Psychoeducation about anxiety. Explanation of the rationale behind the program. Parents are taught to identify (their child’s) physical symptoms of anxiety and how to employ progressive muscle relaxation to deal with these symptoms. Parents are taught to identify dysfunctional thoughts of themselves and their children. Parents are taught how to combat such dysfunctional thinking and how to assist their child in doing so. Parents are taught how to apply a problem-solving plan and to employ this to help their children to solve problems. Parents are informed about the main learning principles (observation, reinforcement). Parents are taught to behave as a positive role model for their child and to praise and reward for (partial) successful behavior of their child in difficult situations. Parents are taught how they can support each other and encouraged to plan family activities. Parents are instructed to engage other persons (e.g., teachers) to deal more effectively with child’s anxiety. Strategies for maintaining gains and potential future difficulties are discussed, and plans for continuation of the FRIENDS program are made.
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children aged between 6 and 10 years were assigned to the FRIENDS treatment or a waiting list. Results showed that 69% of the children who had received the FRIENDS program were anxiety disorder-free after treatment as compared to only 6% in the waiting-list control condition. The positive effects of the intervention were maintained over a longer time period with 68% of the treated children being still diagnosis-free at a one-year follow-up. Similar findings were reported in a recent study by Bögels and Siqueland (2006), who also treated children and adolescents with a family CBT program. It was found that this intervention was more effective than a waiting-list period: That is, none of the youths improved during the waiting period, whereas of the treated children and adolescents 41% were free of diagnosis at posttreatment, 57% at three-month follow-up, and 71% at one-year follow-up. Altogether, these findings indicate that family CBT is an effective treatment for youths with anxiety disorders (see also King, Tonge, Heyne et al., 1998; Siqueland, Rynn, & Diamond, 2005; Thienemann, Moore, & Tompkins, 2006). A number of controlled therapy outcome studies have been conducted to examine whether a CBT plus family intervention is more effective than a CBT intervention that is only targeted at the child. A first study was conducted by Barrett, Dadds, and Rapee (1996), who randomly allocated 79 anxiety disordered children aged between 7 and 14 years to three treatment conditions: (1) regular CBT: Children were treated with a 12-session Australian variant of Kendall’s (1990) program (i.e., the “Coping Koala (Cat)”), (2) CBT plus family management, in which the child’s CBT session was shortened and combined with a family anxiety management session. During these family sessions, the parents were trained to reward courageous behavior and to extinguish the anxiety of their child, to communicate in a more optimal way, and to deal with their own emotions and model problem-solving responses in potentially fearful situations, or (3) a waiting-list control condition. The effectiveness of the interventions was assessed at posttreatment and at 6- and 12-month follow-up. Results first of all indicated that treatments produced better outcome than the waiting list. For example, of the children who had received CBT or family CBT, 70% no longer fulfilled the diagnostic criteria for an anxiety disorder, compared with 26% of the children in the waiting-list control condition. Most important, indications were found that demonstrated that family CBT was somewhat more effective than regular CBT: At a 12-month follow-up, 96% of the children in the family CBT group appeared diagnosis-free versus 70% in the child-alone CBT group. The added benefits of family CBT were also found when other therapy evaluation measures (i.e., self-report scales and clinician ratings) were employed. Further research was conducted by Barrett (1998), who evaluated the effectiveness of a group CBT intervention plus family management. In this study, 60 children aged between 7 and 14 years with generalized anxiety disorder, separation anxiety disorder, and social phobia were allocated to three treatment conditions: (1) group CBT, (2) group CBT plus family management, or (3) a waiting-list control condition. The effectiveness of the interventions was examined at posttreatment and 12-month follow-up. Results indicated that at posttreatment 56% of the children in the group CBT and 71% in the group CBT plus family management no longer met the criteria for an anxiety disorder as compared with 25% in the waiting-list control condition. At the 12-month follow-up, 65% of the children in the group CBT and 85% of youths in the group CBT plus family management were anxiety disorder-free. Although these figures seem to indicate an advantage for the group CBT plus family intervention, statistical tests could not substantiate this impression.
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Various other studies have compared the effectiveness of CBT programs with or without parental involvement. Mendlowitz, Manassis, Bradley et al. (1999) randomly assigned 7- to 12-year-old children to one of three group CBT conditions: a combined parent-child intervention, a child-only intervention, and a parent-only intervention. Compared to a waitinglist control condition, all CBT variants produced significant treatment gains. Some indications were found indicating that children in the combined parent-child intervention profited somewhat more from treatment. More specifically, at posttreatment, children in this treatment condition used more active coping strategies and (according to their parents) displayed greater improvement in emotional well-being than children in the other two conditions. A similar result was obtained by Wood, Piacentini, Southam-Gerow, Chu, and Sigman (2006), who also compared the effectiveness of a family- and a child-focused CBT intervention in 40 clinically anxious youths aged 6 to 13 years. Although both interventions were found to be effective in reducing children’s anxiety symptomatology, “family CBT was associated with greater improvement on independent evaluators’ ratings and parent reports of child anxiety [and thus] may provide additional benefit over and above child-focused CBT” (Wood et al., 2006; p.314). A study by Spence, Donovan, and Brechman-Toussaint (2000) randomly distributed 50 7- to 14-year-old youths with social phobia across child-focused CBT, CBT plus parent involvement, and a waiting-list control condition. CBT interventions were a combination of social skills training, graded exposure, and cognitive restructuring. The results demonstrated that both treatment groups displayed a significantly greater decrease of self-reported social anxiety and an increase of parent-rated social skills as compared to the control group, and these positive effects of CBT were retained at a one-year follow-up. Further, although CBT plus parental involvement produced somewhat better results than child-focused CBT, this difference did not reach statistical significance. Further research by Heyne, King, Tonge et al. (2002) evaluated the relative effectiveness of child CBT, caregiver (i.e., parent/teacher) CBT, and the combination of these two interventions in 61 children and adolescents aged 7 to 14 years who displayed anxiety-based school refusal (see King, Tonge, Heyne, & Ollendick, 2000). All youths were assessed at pretreatment, posttreatment, and four-month follow-up by means of school attendance records, self-report, parent, and clinicianratings. All interventions yielded statistically and clinically significant treatment results. At posttreatment, child-focused CBT was somewhat less effective in increasing school attendance as compared to the other two interventions. However, at the follow-up assessment, this difference had disappeared, and data essentially showed that all interventions were equally effective. Finally, Nauta, Scholing, Emmelkamp, and Minderaa (2003) also evaluated the effectiveness of a CBT program for children and adolescents with anxiety disorders and the additional value of a cognitive parent training program, addressing the parents’ behavior and thoughts regarding their anxious child. Children and adolescents aged 7 to 18 years were randomly assigned to a CBT intervention or a waiting-list control condition. In half of the youths who received active treatment, the cognitive parent training was added to the intervention. The results indicated that CBT was more effective in reducing anxiety symptoms than the waiting-list condition. Further, in contrast with previous research (Barrett et al., 1996; Mendlowitz et al., 1999; Wood et al., 2006), no differences in outcome were observed between the two CBT treatment conditions. That is, all children improved equally whether or not additional parent training was offered.
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Taken together, a number of randomized control trials have sought to examine whether the effects of a CBT intervention can be enhanced by an adjunctive parent component. In a review of this research, Barmish and Kendall (2005) conclude that although the effect sizes of CBT plus parent interventions seem somewhat larger than those reported for childfocused CBT, this research is far from conclusive. To begin with, these authors note that there has been quite some variability across the content and number of the parent sessions that were added to the CBT protocol, which of course make it difficult to make a good comparison across the effectiveness of the treatments provided in various studies. Further, the children treated in various studies vary considerably with respect to age, and there are some indications that the inclusion of a parent component may be more useful in younger children than in adolescents (Barrett et al., 1996; see also Barrett, 2000, 2001). Finally, the measures that have been used to evaluate treatment outcome are also important in this regard. That is, some studies have documented fairly large effect sizes on parent report measures in the case of family CBT. Of course, such a finding may simply reflect demand— that is, parents who were actively involved in the treatment reported that their children did well after this intervention. Interestingly, the results of a study by Cobham, Dadds, and Spence (1998) have suggested that it may be useful to add a parent component to a CBT intervention but only in the case that parents suffer from anxiety problems themselves. In this study, 67 children aged 7 to 14 years who fulfilled the criteria for an anxiety disorder were assigned to two treatment conditions: child-focused CBT or child-focused CBT plus parental anxiety management. As can be seen in Figure 8.6, the effectiveness of the interventions at posttreatment was dependent on the anxiety status of the parents. In children of whom the parents did not display anxiety problems, child-focused CBT was equally effective as child-focused CBT
90 80 70 60 50
CBT CBT + PAM
40 30 20 10 0
Child anxiety only
Child + parental anxiety
Figure 8.6: Percentage of youths who were anxiety disorder-free after being treated with either child-focused CBT or child-focused CBT plus parental anxiety management (PAM). Based on: Cobham, Dadds, & Spence (1998).
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plus parental anxiety management. However, in children who had one or more anxious parents, child-focused CBT clearly yielded less favorable results than the CBT plus parental anxiety management intervention (see also Toren, Wolmer, Rosental et al., 2000). Thus, although it intuitively makes sense to include the parents of youths with anxiety disorders in the treatment, more evidence is needed to substantiate this intervention strategy. A recent meta-analysis by In-Albon and Schneider (2006), including 24 therapy outcome studies, clearly indicated that “the active treatment condition was cognitive-behavioral” and “that no differences in outcome were observed between child- and family-focused treatments” (p.15). Based on this observation and the results of her own randomized clinical trial, Bögels (2006) concludes that given the extra time and therapeutic effort that is invested in a CBT plus family/parent component intervention, a child-focused CBT is even preferable in terms of cost-effectiveness.
Long-Term Effectiveness of CBT Interventions CBT interventions have proven to be highly effective in the short term (see reviews by Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004; Compton et al., 2004; Dadds & Barrett, 2001; Hudson, 2005; James et al., 2005). Most studies evaluating the effectiveness of CBT with anxiety disordered youths have included follow-up assessments until one year after treatment, and these data have shown that the positive effects of CBT are largely maintained over such a time period (e.g., Barrett, 1998; Kendall, 1994). The question is whether effects of CBT are preserved over longer intervals of time. So far, a number of studies have addressed this issue. A first investigation by Kendall and SouthamGerow (1996) reexamined 36 of the 47 children who were treated in Kendall’s (1994) original study between two and five years after they had finished treatment. On all outcome measures, the treatment gains obtained at the one-year follow-up were continued, with no observable deterioration. A further study by Barrett, Duffy, Dadds, and Rapee (2001) also evaluated the long-term effectiveness of CBT for childhood anxiety disorders. Fifty-two participants (aged between 14 and 21 years) who had completed treatment on average more than six years earlier were reassessed using diagnostic interviews, clinician ratings, and self- and parent-report questionnaires. Results demonstrated that 86% of the participants were still anxiety disorder-free. On most of the other outcome measures, immediate treatment effects were maintained at the long-term follow-up. Interestingly, the data also showed that child-directed CBT and CBT plus family anxiety management were equally effective (see Figure 8.7), which substantiates the earlier formulated conclusion that an additional focus on the anxious child’s family is not really necessary to achieve positive treatment results. Another investigation by Garcia-Lopez, Olivares, Beidel et al. (2005) obtained longterm (i.e., five-year) follow-up data for a group of adolescents who were treated with three types of CBT-based interventions that all included social skills training and exposure, potentially supplemented with cognitive restructuring. All treatment conditions produced significant reductions in social anxiety. Most importantly to the present discussion, these positive treatment effects were still present at the five-year follow-up. Similar positive longterm effects were documented by King, Tonge, Heyne et al. (2001), who followed a sample of youths that had received CBT for anxiety-based school refusal. Their findings indicated
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1-year follow-up
6-year follow-up
Self-reported fear 140 130 120 CBT
110
CBT+ FAM
100 90 80 Pretreatment
1-year follow-up
6-year follow-up
Parent-reported internalizing 75 70 65 60 55 50 45 40 Pretreatment
1-year follow-up
6-year follow-up
Figure 8.7: Long-term changes on a number of outcome measures in youths who had been treated with child-focused CBT or CBT with family anxiety management. Based on: Barrett, Duffy, Dadds, & Rapee (2001).
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that 3 to 5 years after termination of treatment, children still showed maintenance of the improvements in school attendance and school adjustment that were observed just after the intervention. A final study on the long-term effects of CBT for anxiety disorders in youths was conducted by Kendall, Safford, Flannery-Schroeder, and Webb (2004). Children and adolescents who had received a 16-week CBT intervention for an anxiety disorder were examined after a mean follow-up period of 7.4 years (range: 5.5 to 9.3 years). The assessments showed that for the majority of the participants, the significant improvements in anxiety symptoms were retained at the long-term follow-up. Further, the data also indicated that positive responders to the CBT intervention had a reduced risk for developing substance use problems (i.e., the regular use of alcohol, cigarettes, and drugs) than less positive responders. Finally, a substantial proportion of the participants in this study (50%) had received additional treatment after the CBT program, including outpatient therapy, hospitalization (a very small percentage), or medication (see also Manassis, Avery, Butalia, & Mendlowitz, 2004). This indicates that some youths with anxiety disorders clearly need more intensive treatment and/or booster sessions in order to achieve and/or retain the desired treatment goals. Obviously, this issue is related to the observation that 30% to 40% of the anxious youths do not respond very well to a CBT protocol. In order to optimize the treatment of these children and adolescents, it is important to study the characteristics of these “nonresponders,” which is a topic that will be addressed in following section.
Predictors of Outcome in CBT for Anxious Youths Various factors have been put forward as relevant for predicting the outcome of a CBT intervention in children and adolescents with anxiety disorders. Several child and family characteristics have been studied in this context. For example, in an early study on this topic, Treadwell, Flannery-Schroeder, and Kendall (1995) examined sensitivity to a CBT intervention across gender and ethnicity (i.e., European American versus African American) in 81 children aged 9 to 13 years with anxiety disorders. These researchers observed that the CBT intervention produced similar reductions in anxiety symptoms and the presence of anxiety disorders irrespective of gender and ethnic background. A similar conclusion was reached by Pina, Silverman, Fuentes, Kurtines, and Weems (2003), who compared the CBT outcome of 131 Hispanic/Latino and European-American youths aged 6 to 16 years. Results indicated that Hispanic/Latino and European-American children and adolescents responded similarly to the CBT intervention, and this was still the case at a one-year follow-up. Both studies seem to indicate that demographic variables such as gender and ethnicity are not very important predictors of treatment outcome in anxiety-disordered youths. Comorbidity is another factor that has been related to CBT outcome. Anxiety disorders are highly comorbid with other disorders including depression and disruptive behavior disorders (see Chapter 1) and one might expect that such concurrent psychopathology influences the ability of children and adolescents to gain from treatment of their anxiety disorder. However, there is very little empirical evidence for this notion. For instance, Kendall, Brady, and Verduin (2001) treated 165 children aged between 8 and 13 years with a standardized CBT protocol. Twenty-one percent of the children were diagnosed with only one anxiety disorder, while other children either suffered from multiple anxiety disorders (52%) or an
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anxiety disorder plus a comorbid externalizing disorder. Pretreatment comorbidity was not found to be associated with differences in treatment outcome. That is, 65% of the noncomorbid children were free of their primary anxiety disorder versus 71% in the comorbid group. Further, no differences were observed between children with a comorbid anxiety disorder or a comorbid externalizing disorder. This led Kendall et al. (2001) to the conclusion that “the cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders” (p.787; see also Flannery-Schroeder, Suveg, Safford, Kendall, & Webb, 2004; Rapee, 2003). Further research has indicated that a number of child and family characteristics do matter when studying responsiveness to CBT interventions. Southam-Gerow, Kendall, and Weersing (2001) classified a large sample of 7- to 15-year-old children and adolescents who had completed a CBT for their anxiety problems in one of two groups: poor treatment responders and good treatment responders. By means of a discriminant function analysis, a wide range of child- and family-variables were evaluated as possible predictors of group status. The results indicated that higher levels of internalizing symptoms at pretreatment, an older age of the child, and higher levels of maternal depression were associated with poor treatment outcome. In other words, when a child’s problems are severe and perhaps may have become more chronic and if the mother of the child has serious problems of her own, response to a CBT intervention for childhood anxiety disorders seems to be less favorable (see also Berman, Weems, Silverman, & Kurtiness, 2000; Crawford & Manassis, 2001). Altogether, it can be concluded that, although some relevant factors have been identified, research on the determinants of responsiveness to CBT interventions for anxiety disorders in youths has generally yielded disappointing results. This means that it is still largely unknown what factors predict poor or good response to this type of treatment. In a discussion of this topic, Pina, Silverman, Weems, Kurtiness, and Goldman (2003) note that investigators need to move beyond the types of sociodemographic and clinical variables that were studied so far in this type of research. In their words, “Although these variables were reasonable ones to initially select, especially given that the first generation of child clinical trials was designed mainly to evaluate whether positive outcome could be produced, the next generation of clinical trials is well posed to evaluate other [variables] . . . . These variables include stressors and obstacles that compete with treatment attendance, treatment demands and issues, perceived relevance of treatment, relationship with the therapist, time and effort concern” (p.703). Interestingly, in recent years, a number of studies have begun to examine such factors. For example, Creed and Kendall (2003) explored the specific behaviors of the therapists who delivered the CBT intervention to anxious youths, and the contribution of such behaviors to children’s perception of the therapeutic alliance (which has been shown to be a significant predictor of therapy outcome; e.g., Shirk & Karver, 2003). It was found that “collaboration” (i.e., the therapist presents the treatment as a team effort and builds a sense of togetherness with words like “we,” “us,” and “let’s”) and “not being overly formal” (i.e., the therapist makes the relationship with the child relaxed and comfortable) contributed positively to the building of a therapeutic alliance, whereas “pushing the child to talk” (i.e., the therapist too strongly pressures the child to talk about his/her anxiety) and “finding common ground” (i.e., things that the therapist does to make the child feel special and connected to the therapist, which may be perceived by the child as insincere especially in the beginning of the therapy) were negatively associ-
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ated with the formation of an alliance between child and therapist. A further study by Chu and Kendall (2004) examined whether children’s involvement in the CBT program is associated with therapy outcome. Independent coders viewed a number of audiotaped therapy sessions and then completed a rating scale for measuring children’s involvement in therapy (e.g., “Does the child initiate discussion or introduce new topics?,” “Does the child demonstrate enthusiasm in therapy-related tasks?”). Results indicated that child involvement was significantly associated with therapy gains: Higher levels of involvement, measured at midtreatment (just prior to the exposure exercises), were predictive of treatment outcome. More precisely, children who had shown a substantial increase of involvement by midtreatment were likely to have a more than four times greater chance of being anxiety disorderfree at posttreatment. These findings are promising, and it may be interesting to study whether similar findings can be obtained when assessing involvement in later therapy sessions when children have to do homework assignments during which they expose themselves to increasingly threatening situations (Hudson & Kendall, 2002). Finally, Panichelli-Mindel, Flannery-Schroeder, Kendall, and Angelosante (2005) examined whether the degree to which children disclose distress during therapy has influence on the effectiveness of a CBT intervention. The idea was that children who are “open” to the therapist about their problems, fears, and anxieties will eventually profit more from CBT. The findings indeed demonstrated that the level of disclosure moderated therapy outcome. That is, children high on distress disclosure profited more from treatment than children low on distress disclosure. Clearly, more of these types of studies are needed to further explore the issue of predicting responsiveness to CBT for anxiety-disordered youths.
CBT for Specific Anxiety Disorders A CBT protocol like Kendall’s (1990) “Coping Koala (Cat)” program contains a variety of cognitive-behavioral elements (e.g., exposure, cognitive restructuring, psychoeducation, relaxation), and as such it is not surprising that this type of intervention is suitable for treating various types of childhood anxiety disorders. However, a number of anxiety disorders have such unique features that it may be advisable or even necessary to apply a more specific therapeutic approach. Obsessive-Compulsive Disorder. As described in Chapter 1, obsessive-compulsive disorder (OCD) in effect consists of two components: obsessions, which refer to intrusive anxiety- or distress-provoking thoughts or impulses, and compulsions, which pertain to the repetitive behaviors or mental acts that are conducted in order to prevent or reduce distress and anxiety. According to the cognitive-behavioral perspective, compulsions play a prominent role in the continuation of OCD as they result in an immediate reduction of anxiety and distress, thereby negatively reinforcing these ritualistic behaviors, which increasingly interfere with the patient’s daily routine (see Salkovskis, 1985). As such, it is clear that response prevention, which intends to block any type of compulsive behavior, is regarded as an important ingredient of a CBT intervention for OCD (e.g., Salkovskis, 1999). March and Mulle (1998) were the first to systematically apply this knowledge to the treatment of OCD in youth populations. These authors developed a detailed 20-sessions
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Table 8.5 Summary of a CBT program for treating childhood OCD Session 1 2 3–18 18–19 20
Aims To provide general information on OCD. To explain to the child the basic principles of cognitive theory of OCD. To clarify what the OCD of this particular child looks like. To teach the child some techniques to apply cognitive restructuring. To teach the child “exposure plus response prevention.” To advise the child on relapse prevention and to close the treatment. Booster session: To check how the child is doing some 4 weeks after the end of treatment.
Note. Parent sessions can be added to the program, in particular in the beginning and at the end of treatment and during the “exposure plus response prevention” sessions when parents may be needed as cotherapists. Based on: March & Mulle (1998).
CBT protocol for treating children and adolescents with OCD. As shown in Table 8.5, a substantial proportion of this intervention consist of “exposure plus response prevention” (sessions 3 through 18): Children expose themselves to stimuli and situations that elicit the obsessional thoughts, and then try to prevent the occurrence of the compulsive behavior (or when this is too difficult, to delay, shorten, or modify the ritual). In the beginning of the treatment, the therapist or parents may help the child to expose himself to the anxietyprovoking stimuli and situations and to provide support in preventing the compulsions from occurrence. Eventually, the child has to learn to apply “exposure plus response prevention” on his own and to employ this technique to cope with the OCD in real life. Several studies have demonstrated that a CBT protocol incorporating “exposure plus response prevention” is successful in treating childhood OCD. For example, a number of open trials have shown that such a CBT intervention either provided individually or in a group format yields clinically significant improvement in 25% to 70% of the cases (Fischer, Himle, & Hanna, 1998; Franklin, Kozak, Cashman et al., 1998; Knox, Albano, & Barlow, 1996; March, Mulle, & Herbel, 1994; Martin & Thienemann, 2005; Piacentini, Bergman, Jacobs, McCracken, & Kretchman, 2002; Piacentini, Gitow, Jaffer, Graae, & Whitaker, 1994; Scahill, Vitulano, Brenner, Lynch, & King, 1996; Valderhaug, Larsson, Götestam, & Piacentini, 2007; Waters, Barrett, & March, 2001; Wever & Rey, 1997). More recently, a number of controlled treatment outcome studies have also appeared. De Haan, Hoogduin, Buitelaar, and Keijsers (1998) randomly assigned 22 children and adolescents (aged between 8 and 18 years) to CBT or drug treatment (clomipramine; see following). Significant improvement was obtained with both types of interventions, although on some of the outcome measures CBT produced better a outcome than drug treatment. The largest controlled trial on the effectiveness of CBT in youths with OCD has been conducted by Barrett, Healy-Farrell, and March (2004). Seventy-seven youths aged between 7 and 17 years were randomly distributed across three conditions: individual CBT, group CBT, or a waiting-list control condition. Treatment outcome was evaluated by means of diagnostic interviews and standardized rating scales. Outcome data showed that both CBT interventions were highly
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Severity of OCD-symptoms 10 8 Waiting-list
6
Individual CBT Group CBT
4 2 0 Pretreatment Posttreatment 12-month follow-up
18-month follow-up
Figure 8.8: Mean clinician-rated severity of OCD-symptoms in the two CBT groups and the waiting-list control condition. Based on: Barrett, Healy-Farrell, & March (2004) and Barrett, Farrell, Dadds, & Boulter (2005).
effective in eliminating OCD symptomatology as compared to the waiting-list control condition for which symptoms remained fairly stable (see Figure 8.8). Follow-up assessments indicated that the treatment gains of the CBT interventions were maintained up to 18 months after treatment (Barrett, Farrell, Dadds, & Boulter, 2005). These positive results were also clinically significant. Directly after treatment, 88% of the youths in the individual CBT condition and 76% in the group CBT condition were without a diagnosis of OCD versus 0% in the waiting-list control condition. At 18-months follow-up, 78% of the youths treated with one of the two CBT interventions were still diagnosis-free. Altogether, these results have provided further support for the notion that CBT is a highly recommended intervention for OCD in children and adolescents (March, Frances, Carpenter, & Kahn, 1997). Posttraumatic Stress Disorder. In posttraumatic stress disorder (PTSD), traumatic experiences play a central role. Although some clinicians fear the use of CBT, because during this treatment youths are repeatedly re-exposed to the trauma (see King, Tonge, Mullen et al., 1999), available evidence suggests that children and adolescents benefit remarkably from such an intervention. More precisely, there are a number of randomized clinical trials which have demonstrated that CBT is effective for treating traumatized youths. For example, Deblinger and colleagues (Deblinger, Lippmann, & Steer, 1996; Deblinger, Steer, & Lippmann, 1999) assigned 100 sexually abused children aged 7 to 13 years, of whom threequarters fulfilled the criteria of PTSD, to four treatment conditions: child CBT, mother CBT, child plus mother CBT, and a community control condition. Symptoms of PTSD and other emotional and behavioral problems were assessed at pretreatment, posttreatment, and various follow-up moments until two years after termination of treatment. As shown in Figure 8.9, while PTSD symptoms decreased in all groups, it is clear that the CBT groups showed greater reductions of such symptoms. Initially, somewhat greater reductions in
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12
PTSD symptoms
10 Child CBT
8
Mother CBT
6
Child + mother CBT
4
Community control
2 0 Pretreatment Posttreatment 3-month follow-up
6-month follow-up
1-year follow-up
2-year follow-up
Figure 8.9: Mean combined child/parent ratings of PTSD symptoms of sexually abused children in the four treatment conditions. Based on: Deblinger, Steer, & Lippmann (1999).
symptoms were achieved in the CBT conditions that incorporated child participation (i.e., the child CBT and the child plus mother CBT groups; Deblinger et al., 1996). However, these effects disappeared during the (long-term) follow-up assessments. King, Tonge, Mullen et al. (2000) also evaluated the efficacy of CBT for sexually abused children and adolescents (aged 5 to 17 years). These researchers randomly distributed 36 youths over a child-alone CBT condition, a family CBT condition, and a waiting-list control condition. Results demonstrated that both CBT interventions produced significant improvement in caregiver-reported PTSD symptoms and self-reported fear and anxiety as compared to the waiting-list control condition. Child-focused and family CBT were equally effective, which indicated that parental involvement did not improve the efficacy of the CBT intervention. Further research, also involving sexually abused youths, has been conducted by Cohen, Mannarino, and colleagues. Interestingly, this research group carried out a set of randomized controlled trials in which the effects of CBT were compared with those of an alternative intervention—namely, nondirective supportive therapy, which was mainly based on clientcentered principles (Cohen & Mannarino, 1996; Cohen, Deblinger, Mannarino, & Steer, 2004). The results consistently showed that the CBT intervention resulted in significantly more improvement with regard to PTSD, depression, behavior problems, and abuse-related attributions than nondirected supportive therapy, and these differences in outcome were still present at a one-year follow-up (Cohen & Mannarino, 1997; Cohen, Mannarino, & Knudsen, 2005). To get an impression of the specific content of a CBT intervention for traumatized youths, Table 8.6 displays the Multi-Modality Trauma Treatment protocol as described by March, Amaya-Jackson, Murray, and Schulte (1998). Notice that there is clear overlap with the regular CBT protocol for childhood anxiety disorders (Kendall, 1990) but that there is also a clear focus on the trauma. March et al. (1998) evaluated the effectiveness of this protocol in a small sample of 10- to 15-year-old children and adolescents who had been exposed to a single stressor (e.g., car accident, gunshot injury, fire). Clear reductions of PTSD symptoms were observed in the youths that were treated with this CBT program, with, respectively, 57% and 86% being free of diagnosis at posttreatment and a 6-month follow-up.
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Table 8.6 An outline of a CBT group protocol for traumatized youths Session
Main content
1–2
Introduction
3–5
Anxiety management training
6–7
Anger coping
8–9 10–15
Cognitive training Exposure
16
Right beliefs
17–18
Closure
To provide an overview of treatment, to give information on PTSD, to map the symptoms of the children, to define rules for the group. To learn progressive muscle relaxation and to employ this technique when experiencing trauma-related distress. To teach children to cope with feelings of anger by means of interpersonal problem solving. To help children to develop positive self-talk. To provide the rationale for exposure, to construct a hierarchy of trauma-related stimuli and situations, and to gradually expose children to these stimuli by means of narrative exposure or exposure in vivo while applying the techniques learned in the earlier sessions. To correct PTSD-induced dysfunctional beliefs or schemas. To advise children on relapse prevention and to close the treatment.
Based on: March, Amaya-Jackson, Murray, & Schulte (1998).
A final note on the cognitive-behavioral treatment of PTSD is devoted to EMDR (see Box 8.1). EMDR has been primarily developed for treating adults with PTSD and other trauma-related anxiety problems. Although EMDR has been criticized because of its weak empirical foundation (e.g., McNally, 1999), randomized clinical trials have demonstrated that, at least in adults with PTSD, this type of intervention clearly yields positive effects. For example, on the basis of a meta-analysis of studies examining the effects of EMDR, Davidson and Parker (2001) conclude that this treatment, when applied to PTSD or traumatic memories, produces significant effects on various outcome measures (e.g., subjective, behavioral, physiological). However, these authors also noted that EMDR was not significantly better than regular exposure techniques, which is not surprising, given the observation that the incremental therapeutic effect of the eye movements is nil (Muris & Merckelbach, 1999a). Nevertheless, various studies have shown that EMDR can be applied to youths with PTSD symptoms (e.g., Chemtob, Nakashima, & Carlson, 2002; Jaberghaderi, Greenwald, Rubin, Oliaee Zand, & Dolatabadi, 2004; Muris & De Jongh, 1996; Tufnell, 2005), but clearly more controlled outcome research is necessary to demonstrate whether this exposure-based intervention has any additional value in the treatment of traumatized children and adolescents. Altogether, research in the past 10 to 15 years has yielded indisputable evidence indicating that CBT interventions are effective in treating phobias and anxiety disorders in children
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1
0 CBT pre- to posttreatment
Waiting-list control
CBT short-term CBT long-term follow-up follow-up
Figure 8.10: Mean pre- to posttreatment, short-term (<1 year) and long-term (>3 years), follow-up effect sizes for CBT with anxious youths. Mean effect sizes for waiting-list control conditions are added for reasons of comparison. Based on: In-Albon & Schneider (2006).
and adolescents (Velting, Setzer, & Albano, 2004). The meta-analysis by In-Albon and Schneider (2006) on controlled treatment outcome studies of childhood anxiety disorders revealed a mean effect size of .86, indicating a large treatment effect. Follow-up data demonstrated that these treatment gains were maintained at short-term (mean effect size = 1.36) and long-term (mean effect size = .92) follow-up (see Figure 8.10). In terms of clinical significance, 69% of all children and adolescents who completed treatment showed recovery and hence no longer met the criteria of their principal pretreatment anxiety disorder. When applying more stringent criteria (i.e., taking into account dropouts), it can be concluded that 55% of those who start with a CBT eventually will recover (see also Cartwright-Hatton et al., 2004). When comparing these figures to those of general child and adolescent psychotherapy (Weisz, Weiss, Han, Granger, & Morton, 1995), it can be concluded that the effects of CBT for anxious youths are quite favorable (see Butler, Chapman, Forman, & Beck, 2006 who draw a similar conclusion for the efficacy of CBT in anxious adults). A number of comments can be made regarding the treatment of childhood anxiety disorders with CBT. First of all, it should be mentioned that most CBT interventions for anxious youths contain a variety of behavioral and cognitive therapeutic techniques such as cognitive restructuring, coping self-talk, in vivo exposure, modeling, role-play, and relaxation training. In their review article on the current status of treatments for anxiety disordered children, Ollendick and King (1998) rightly pointed out that an important avenue for future research will be dismantling studies in which the critical components of CBT-based treatment packages are established. Although some preliminary attempts have been made in this direction (Muris, Meesters, & Gobel, 2002), more studies should be conducted to compare the unique effects of the separate components of CBT interventions. Such research may have to take into account that childhood anxiety disorders differ in terms of their symptomatology and that it may be important to tune the intervention to the specific expression of the disorder.
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For example, anxious children and adolescents who clearly report somatic symptoms may profit more from relaxation training, whereas anxious youths with prominent faulty cognition may benefit more from cognitive restructuring (e.g., Eisen & Silverman, 1998). In a similar vein, it may be useful to address specific features of various anxiety disorders during the CBT intervention. For example, recent attempts have been made to target specific cognitive features of generalized anxiety disorder (i.e., intolerance of uncertainty; Léger, Ladouceur, Dugas, & Freeston, 2003) and obsessive-compulsive disorder (i.e., metacognition; Simons, Schneider, & Herpertz-Dahlmann, in press), but it remains to be established whether such a focused CBT intervention is more effective than regular CBT. A second and related issue pertains to the fact that the precise working mechanism of CBT is still largely unknown. In other words, it is unclear what factors change as a result of the CBT intervention and ultimately produce the symptomatic improvement (e.g., Ollendick & King, 1998). Prins and Ollendick (2003) have suggested two factors that may be important in this respect. Briefly, they assume that CBT may correct faulty cognition and/or enhance nonavoidant coping, but they note that more research is necessary to evaluate the mediational role of these variables in treatment gains observed in CBT. A third point is that so far CBT for anxiety disordered youths has been mainly compared to waiting-list control conditions. Although this research has shown that CBT is clearly more effective than no treatment (see also Figure 8.10), more studies should compare the effects of CBT with those of other interventions. Notably, studies that made such a comparison have yielded rather mixed results. Some studies have shown that CBT is no more active than an attention-placebo control condition (Last, Hansen, & Franco, 1998; Silverman et al., 1999), whereas other investigations have indicated that CBT is far more effective than emotional disclosure (Muris, Meesters, & Van Melick, 2002), bibliotherapy (Rapee, Abbott, & Lyneham, 2006), or another active but nonspecific intervention (Beidel, Turner, & Morris, 2000). More research is needed to understand why “placebo” interventions sometimes yield such positive treatment results. It may be the case that when delivered with a strong and straightforward rationale, even a nondirective placebo intervention may produce positive therapeutic change. Furthermore, it seems also important to compare CBT to other psychological interventions (e.g., psychodynamic therapy, non-cognitive-behavioral family therapy) and psychopharmacologic therapy (see following). A fourth issue is concerned with developmental considerations regarding CBT for childhood anxiety disorders. The treatment of fear and anxiety in very young children may require specific therapeutic techniques. Besides the aforementioned procedure of emotive imagery, other therapeutic aids may be viable. For example, Muris, Verweij, and Meesters (2003) employed an “antimonster letter” (see Box 8.2) to help 4- to 6-year-old children overcome their nighttime fears. Further, at least some degree of cognitive maturation must be present before children are able to use cognitive restructuring techniques for combating negative cognitions. This means that in children of a younger age, behavioral strategies (in particular exposure) are more appropriate, whereas in older children cognitive techniques may be increasingly added to the intervention (Barrett, 2000). Developmental level may also be an important determinant of the type of parental involvement in a CBT intervention of anxious youths. For example, in younger children, parents need to provide a secure environment in which youths can form a secure attachment relationship and gain a proper sense of control over the environment. However, in older youths, parents not only need to
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Box 8.2 The “antimonster letter,” which can be used to help young children with nighttime fears Dear monsters, ghosts, witches, and other beasts. Please read this message at the very least. With this “antimonster letter,” I am feeling good and even better. And I will use this letter for ever and ever so that I am not afraid of you spooky thing, never and never! Based on: Muris, Verweij, & Meesters (2003).
provide support to their offspring but also should encourage autonomy and independence (Dadds & Barrett, 2001). Future research should take such developmental differences into account when delivering CBT interventions to anxious youths of various ages. A fifth point is concerned with the dissemination of CBT programs that are developed in a research clinic to practitioners working in regular health service (see Kendall & Southam-Gerow, 1995). Research has shown that youths with anxiety disorders who were treated in a community clinic were quite different from youths with anxiety disorders treated in a university research setting. That is, anxious children and adolescents who apply for treatment in a community clinic generally display more comorbid externalizing problems and more frequently come from low-income and single parent families (Southam-Gerow, Weisz, & Kendall, 2003). Yet, it should be mentioned that CBT protocols allow therapists to be quite flexible in their application of the treatment manual (Kendall & Chu, 2000), which may help to employ this type of intervention with multiproblem youths. As such it is not surprising that CBT has been found to be just as effective for treating anxiety disorders of youths in a community clinic as for treating youths in a university research setting (Barrington, Prior, Richardson, & Allen, 2005). More effort should be put in the transportation of CBT protocols to community settings, so that more children and adolescents with phobias and anxiety disorders will profit from these effective interventions (Collins, Westra, Dozois, & Burns, 2004). Many youths are still treated with traditional forms of psychotherapy, which have not demonstrated to be very effective (Weiss, Catron, Harris, & Phung, 1999). A sixth and final issue has to do with the fact that although anxiety disorders are highly prevalent among youths, these problems often remain unrecognized and untreated (e.g., Chavira, Stein, Bailey, & Stein, 2005). In order to circumvent barriers to treatment, researchers have begun to transport CBT interventions for childhood anxiety disorders into schools (see Spence, 2001; Spence & Dadds, 1996). In a first study, Dadds, Spence, Holland, Barrett, and Laurens (1997) screened a total of 1786 7- to 14-year-olds for anxiety problems using teacher nominations and children’s self-report. After this recruitment, high-risk children were randomly assigned to a 10-week school-based CBT intervention (plus parental anxiety management) or a monitoring condition. The results indicated that immediately after the intervention/monitoring period, anxiety problems significantly improved in both conditions. However, at a 6-month follow-up, this improvement was only maintained in the CBT inter-
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Children with an anxiety disorder 100 80 60
CBT Monitoring
40 20 0 Pre
Post
6-month follow-up
Children at risk but no anxiety disorder 100 80 60
CBT Monitoring
40 20 0 Pre
Post
6-month follow-up
Figure 8.11: Percentages of children with an anxiety disorder diagnosis at pretreatment, posttreatment, and 6-month follow-up in the CBT intervention and the monitoring groups. The top panel displays the children who at study onset already met the criteria for an anxiety disorder, the bottom panel displays at-risk children who at the beginning of the study did not meet the full criteria of an anxiety disorder. Based on: Dadds, Spence, Holland, Barrett, & Laurens (1997).
vention condition: These children still displayed reduced rates of anxiety disorders and also developed less new anxiety problems (see Figure 8.11). These and other findings (Masia, Klein, Storch, & Corda, 2001; Masia-Warner, Klein, Dent et al., 2005; Mifsud & Rapee, 2005) make clear that it is feasible and useful to implement CBT protocols into school programs as they may help youths with anxiety problems and prevent the development of new disorders (Spence & Dadds, 1996). As a final note, while implementation in schools may be a viable approach, Rapee, Kennedy, Ingram, Edwards, and Sweeney (2005) developed an intervention program for even younger children. Based on research showing that behavioral inhibition is one of the best predictors of later anxiety problems, these researchers selected withdrawn/inhibited children in preschool (aged 3 to 5 years) and provided the parents of these youngsters with a brief six-session parent intervention program (see also
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Box 8.3 Some basic knowledge for understanding the working mechanisms of psychopharmacologic drugs In the brain, information is passed from one neuron (nerve cell) to another via a synapse, which is a small gap between the cells. The neuron that sends the information releases neurotransmitters (such as norepinephrine, dopamine, and serotonin) into that gap. The neurotransmitters are then recognized and received by receptors on the surface of the postsynaptic cell, which upon this stimulation, in turn, relays the signal. After this action has taken place, a substantial proportion of the neurotransmitters is released from the receptors and taken up again by the presynaptic cell, a process called reuptake. Psychopharmacologic medication is thought to influence this process of physiological information-processing in various ways. For example, these drugs can (1) increase the amount of neurotransmitters in the synaptic cleft by stimulating the production of certain neurotransmitters, preventing their destruction, or blocking their reuptake; (2) diminish the amount of neurotransmitters via similar but reversed ways; (3) directly bind to the postsynaptic receptors, thereby stimulating the cell to pass on the signal. Based on: Information from Wikipedia, the free encyclopedia (www.wikepedia.org).
Rapee, 2002). This intervention appeared to produce a significant reduction of children’s anxiety problems, and thus seems to indicate that prevention programs for childhood anxiety disorders can start at a very early age.
Pharmacological Treatment of Childhood Anxiety Disorders Almost a decade ago, researchers and clinicians were rather reserved to use drugs for treating anxiety disorders in children and adolescents (see Bernstein & Kinlan, 1997). The most important reason for this reluctance was that solid scientific evidence for the employment of medication in this type of psychopathology was still lacking (e.g., Kearney & Silverman, 1998). In their review published in 1999, Labellarte, Ginsburg, Walkup, and Riddle conclude, “Several controlled studies of cognitive-behavioral therapy (CBT) demonstrate efficacy for paediatric anxiety disorders. In contrast, no controlled psychopharmacology studies have demonstrated efficacy in children and adolescents with anxiety disorders, except obsessive-compulsive disorder” (p.1567), which nicely illustrates the prevailing view at that point-in-time. However, this state of affairs has gradually changed since the appearance of a number of large, methodologically sound treatment outcome trials evaluating the effects of psychopharmacologic drugs in youths with anxiety disorders. This section contains a comprehensive review of the effects of pharmacotherapy in anxiety disordered youths, but first an overview of various psychopharmacologic drugs and their supposed working mechanisms is provided (see also Box 8.3).
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Anxiolytic Drugs Various types of psychopharmacologic drugs have an anxiolytic effect and can be applied to treat anxiety disorders in children and adolescents. These include benzodiazepines, buspirone, tricyclic antidepressants (TCAs), and selective serotonin-reuptake inhibitors (SSRIs; see Velosa & Riddle, 2000). Table 8.7 summarizes a number of important features for each of these drug categories. Benzodiazepines (also known as minor tranquilizers) bind at benzodiazepine or gammaaminobutyric acid (GABA) receptor membrane chloride channel complexes, which are mainly situated in the cortex and the limbic system. Through this action, these drugs enhance and facilitate the transmission of GABA, which is the most important inhibitory neurotransmitter in the brain. The net effect is that the general neuronal activity of the brain is dampened. Because they work quickly, benzodiazepines are often used for short-term relief of severe disabling anxiety. Main side effects of these drugs are sedation and concentration and memory problems. Further, benzodiazepines are considered to be moderately to highly addictive, which explains why prolonged use of these drugs is usually discouraged. Buspirone is a nonbenzodiazepine anxiolytic, which is thought to act by binding to serotonin (5HT1A) receptors in the brain. As a result, there would be less spontaneous firing of serotonergic neurons in subcortical brain regions, which would be the basis for the anxiolytic effect of this drug. It takes some time before the anxiety-reducing effects of buspirone become visible. This medication has no sedative effects and does not cause dependence, but it has a number of physical side effects, including dizziness, headaches, sleeping problems, and gastrointestinal troubles. Beta-blockers hinder the action of endogenous cathecholamines, in particular adrenaline (epinephrine) and noradrenaline (norepinephrine), on β-adrenergic receptors, which are part of the peripheral sympathetic nervous system and are an important mediator of the fightflight response. The blocking of these receptors in the heart, lungs, muscles, and so on directly inhibits the physiological symptoms of anxiety (e.g., palpitations, increased respiration, trembling) and secondarily also reduces subjective and cognitive symptoms. It is generally thought that TCAs work because they inhibit the reuptake of noradrenaline, dopamine, and serotonin by the presynaptic cells, causing these neurotransmitters to stay longer in the synaptic cleft, which enhances the chance that they will be received by the postsynaptic cell, which can eventually be fully stimulated. In this way, the activity of the brain systems involving these neurotransmitters will be normalized, resulting in a decrease of all kinds of psychopathological symptoms, including anxiety. TCAs also block cholinergic, histaminic, and adrenergic receptors, which explains their massive side effects, including a dry mouth, blurred vision, nausea, dizziness, weight gain, and even cardiac problems (in some youths, TCAs may even cause sudden death; see Riddle, Geller, & Ryan, 1993). SSRIs are an improvement in this respect: These drugs selectively inhibit the reuptake of serotonin, which leads to an increase of this neurotransmitter in the synaptic cleft and eventually results in a normalization of the serotonergic neurotransmission. Because SSRIs have little impact on other neurotransmitter systems, they have fewer and weaker side effects and are considered as safer than TCAs (although some have observed that these drugs may enhance suicidal ideation; Labellarte, Walkup, & Riddle, 1998).
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Most important drugs that can be employed for treating anxiety disorders in children and adolescents
Drug Benzodiazepines
Drug names Alprazolam Diazepam Oxazepam
Buspirone
Supposed working mechanism Enhance and facilitate the transmission of GABA Serotonin receptor agonist
Beta-blockers
Atenolol Propanolol
Block peripheral β-adrenergic receptors
Tricyclic antidepressants (TCAs)
Clomipramine Desipramine Imipramine
Selective serotonin reuptake inhibitors (SSRIs)
Fluoxetine Fluvoxamine Paroxetine Sertraline
Inhibit the reuptake of the neurotransmitters noradrenaline, dopamine, and serotonin Selectively inhibit the reuptake of serotonin
Primary effects Immediate anxiolytic effect, tranquilizer, sedative effect Anxiolytic effect after a few weeks Immediate effect: reduction of physical symptoms, no general sedative effect Antidepressant effect, secondary anxiolytic effect after several weeks Antidepressant effect, secondary anxiolytic effect after several weeks
Side effects Addiction
No sedative or addictive effects, mild to moderate physical complaints Cold hands and feet, tiredness, and sleep disturbance Serious side effects: physical problems such as blurred vision, dry mouth, constipation, and so on Less serious side effects than TCAs
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Table 8.7
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Effectiveness of Pharmacologic Treatment of Anxious Youths This section summarizes the empirical evidence that has accumulated on the efficacy of pharmacotherapy in children and adolescents with anxiety disorders (see for reviews, Walkup, Labellarte, & Ginsburg, 2002; Waslick, 2006). First, studies on the pharmacologic treatment of OCD will be summarized. Then, research on this type of intervention with other childhood anxiety disorders will be reviewed. It should be mentioned that the effects of benzodiazepines, buspirone, and beta-blockers are seriously understudied in youth populations (see Walkup et al., 2002). Most controlled outcome studies in this relatively young research area are concerned with TCAs and SSRIs, and therefore the focus will be on these two psychopharmacologic drugs.
OCD OCD is the anxiety disorder that has received most attention from investigators seeking efficacious pharmacologic treatment in children and adolescents. This research started in the 1980s with studies evaluating the effects of TCAs in youths with this anxiety disorder. For example, Leonard, Swedo, Rapoport et al. (1989) compared the effects of clomipramine and desipramine (both are TCAs, but the former is thought to have more potential for blocking the reuptake of serotonin) using a double-blind crossover design in 45 children and adolescents (aged 7 to 19 years) with severe OCD. Results indicated that in particular clomipramine was effective in reducing OCD symptoms, suggesting that in particular TCAs with a serotonergic effect are suitable for this type of anxiety disorder. The positive effects of clomipramine for treating OCD in youths were also documented by DeVaugh-Geiss, Moroz, Biederman et al. (1992), who conducted a double-blind multi-center trial to compare the effects of clomipramine versus placebo in a sample of 54 10- to 17-year-olds with OCD. Outcome was measured with an age-downward version of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen et al., 1989a). At the end of the eight-week treatment period, youths treated with clomipramine displayed a mean reduction of 37% on the Y-BOCS, whereas those in the placebo condition only showed an improvement of 8%. However, these studies have also demonstrated that youths suffer from substantial side effects that are typical for this type of medication. As such it is not surprising that more recent studies have mainly concentrated on studying the effects of SSRI in youths with OCD because this type of drug is safer and has considerably less adverse side effects. In one of the first studies evaluating this intervention in youths with OCD, Riddle, Scahill, King et al. (1992) treated 14 children and adolescents aged 8 to 15 years with fluoxetine in a 20-week randomized, double-blind, placebo-controlled trial. The results showed that fluoxetine was well tolerated by the youths and significantly reduced the severity of OCD symptoms. A similar conclusion was reached in a clinical trial conducted by Geller, Hoog, Heiligenstein et al. (2001), who assigned 103 patients aged 7 to 17 years to a fluoxetine or placebo condition. Treatment outcome was evaluated with the child version of the Y-BOCS and various other self-report, parent, and clinician rating scales. Results indicated that across various outcome measures fluoxetine yielded significantly greater reductions in OCD symptoms than the placebo control intervention (see also Liebowitz, Turner, Piacentini et al., 2002).
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Sertraline
Fluvoxamine
Fluoxetine
Placebo
0 –2 –4 * –6 –8 –10
Figure 8.12: Mean short-term decline in self-reported OCD symptoms (as indexed by the Children’s Yale-Brown Obsessive-Compulsive Scale) after being treated with various types of selective serotonin reuptake inhibitors (SSRIs) or a placebo intervention. * Mean decrease across various studies; in all cases, significantly smaller than the effect of the SSRI. Based on: Geller, Hoog, Heiligenstein et al. (2001); Geller, Wagner, Emslie et al. (2004); March, Biederman, Wolkow et al. (1998); Riddle, Reeve, Yaryura-Tobias et al. (2001).
Other types of SSRIs such as paroxetine, sertraline, and fluvoxamine have yielded highly comparable findings. These drugs not only produced a statistically significant decline of OCD symptoms within a time frame of 8 to 12 weeks (see Figure 8.12) but also yielded clinically significant improvement in about half of the youths treated for this anxiety disorder (e.g., Geller, Wagner, Emslie et al., 2004; March, Biederman, Wolkow et al., 1998; Riddle, Reeve, Yaryura-Tobias et al., 2001). Interestingly, a study by Cook, Wagner, March et al. (2001), who evaluated the safety and long-term effectiveness of sertraline in 132 children and adolescents with OCD, indicated that youths further improved when the administration of this SSRI was continued for 1 year: 67% showed clinically significant improvement at the end point of treatment, with no differences being observed between children (aged 6 to 12 years) and adolescents (aged 13 to 18 years).
Other Anxiety Disorders After the positive effects of pharmacotherapy in childhood OCD, researchers have a renewed interest in examining whether drugs can be a useful intervention for other anxiety disorders as well. However, the first controlled trial for treating childhood anxiety problems with a TCA was already published more than three decades ago, when Gittelman-Klein and Klein (1971) randomly assigned 6- to 14-year-old children and young adolescents with a school phobia to two treatment conditions: an imipramine plus CBT intervention and a placebo plus CBT intervention. Results demonstrated that the imipramine plus CBT intervention yielded significantly better results than the placebo plus CBT intervention. For example,
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81% of the youths in the imipramine condition returned to school within six weeks after the beginning of treatment versus only 47% of the youths in the placebo condition. Two further studies have made an attempt to replicate these promising findings. In a first replication study by Klein, Koplewicz, and Kanner (1992), no evidence was obtained showing that imipramine was better than placebo in a relatively small sample of 6- to 15-year-olds with separation anxiety disorder. In contrast, a more recent investigation by Bernstein, Borchardt, Perwien et al. (2000) again provided support for the efficacy of imipramine in youths with anxiety problems. More specifically, these researchers compared the effects of imipramine plus CBT versus placebo plus CBT in the treatment of school-refusing adolescents with comorbid anxiety and depressive disorders. Like in the Gittelman-Klein and Klein (1971) study, imipramine plus CBT produced a better outcome than the placebo plus CBT intervention, with mean school attendance rates of respectively 70% versus 28% during the last week of treatment. However, follow-up data of this sample (Bernstein, Hektner, Borchardt, & McMillan, 2001) showed that one year after treatment, many of the youths again met the criteria of an anxiety disorder or a depression (respectively, 64% and 33%), indicating relapse in a substantial proportion. Thus, while initially promising, evidence on the effectiveness of TCAs for treating anxiety disorders in youths is still meagre, as studies have generally yielded mixed results. Given the fact that SSRIs are safer than TCAs and have been found to produce better effects in childhood mood disorders (e.g., Keller, Ryan, Strober et al., 2001), researchers and clinicians have shifted toward SSRIs as the primary medication for childhood anxiety disorders (see Seidel & Walkup, 2006). Besides a number of open trials that explored the potential effectiveness of SSRIs in youths with non-OCD anxiety disorders (e.g., Birmaher, Waterman, Ryan et al., 1994; Chavira & Stein, 2002; Compton, Grant, Chrisman et al., 2001; Dummit, Klein, Tancer, Asche, & Martin, 1996; RUPP Anxiety Study Group, 2002), a number of randomized placebo-controlled studies have emerged. In an early study, Black and Uhde (1994) evaluated the efficacy of treatment with fluoxetine in reducing symptoms associated with selective mutism. Sixteen patients aged 5 to 16 years were treated with placebo for 2 weeks. The 15 placebo nonresponders were then assigned to a double-blind treatment with fluoxetine or continued placebo for an additional 12 weeks. Significant improvements in clinician, parent, and teacher ratings of symptoms were observed in both fluoxetine- and placebotreated youths. However, the parental measures indicated that children treated with fluoxetine were significantly more improved than the placebo-treated controls. In a placebo-controlled trial by the RUPP Anxiety Study Group (2001), 128 children and adolescents (aged between 6 and 17 years) with separation anxiety disorder, generalized anxiety disorder, and/or social phobia were randomly allocated to a treatment with fluvoxamine or placebo for 8 weeks. Outcome was evaluated using clinician ratings of anxiety symptoms and global improvement. Results indicated that the decline in anxiety symptoms was more than three times larger in the fluvoxamine treatment group as compared to the placebo group. In addition, in the fluvoxamine group 76% of the youths responded favorable to the intervention versus 29% in the placebo group. Finally, it is worthy of note that the fluvoxamine was tolerated rather well: Only 8% of the children and adolescents discontinued treatment because of adverse side-effects (as compared to 2% in the placebo group). Rynn, Siqueland, and Rickels (2001) compared the efficacy of sertraline versus placebo in the treatment of a small sample of 5- to 17-year-old children and adolescents (N = 22)
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with generalized anxiety disorder. On the main outcome measure, the Hamilton Anxiety Scale (completed by children and parents), the results clearly indicated that the sertraline treatment was superior in reducing anxiety symptoms as compared to the placebo intervention. A multi-center, randomized, double-blind, placebo-controlled trial by Wagner, Berard, Stein et al. (2004) evaluated the effectiveness of paroxetine in 319 youths aged 8 to 17 years with social phobia. After 16 weeks of treatment, clinicians observed significantly greater improvement in the youths treated with paroxetine (78%) than in youths who received the placebo (38%). The difference in improvement between the two groups was confirmed by self-reports of social anxiety as completed by the children and adolescents. A final randomized study was carried out by Birmaher, Axelson, Monk et al. (2003) who compared the effects of fluoxetine versus placebo in 7- to 17-year-old children and adolescents with separation anxiety disorder, generalized anxiety disorder, and social phobia. Results indicated that fluoxetine was more effective in reducing anxiety symptoms and improving general functioning than placebo. For example, on self- and parent-report measures of anxiety symptoms, fluoxetine-treated youths displayed larger reductions than their placebo-treated counterparts. Further, 61% of the children and adolescents taking fluoxetine showed much to very much improvement versus only 35% of the youths taking placebo. Interestingly, the participants of this study were followed for one year in an open trial (Clark, Birmaher, Axelson et al., 2005). During this open trial, four groups were studied: (1) youths who had received fluoxetine during the randomized trial who continued to take this medication, (2) youths who had received fluoxetine during the randomized trial and stopped taking this medication, (3) youths who had received placebo during the randomized trial and now received fluoxetine, and (4) youths who had received placebo during the randomized trial and still did not receive any medication. The results of the study are shown in Figure 8.13, which displays the mean change in clinician-rated severity of anxiety disorders symptoms for each of the four groups. As can be seen, the largest reduction in severity was observed
FluoxetineRCT/Fluoxetine
PlaceboFluoxetine-RCT/No Placebo-RCT/No RCT/Fluoxetine medication medication
0,4 0,2 0 –0,2 –0,4 –0,6 –0,8 –1 –1,2
Figure 8.13: Mean change in clinician-rated severity of anxiety disorders symptoms in the four treatment groups. RCT = Randomized Controlled Trial. Based on: Clark, Birmaher, Axelson et al. (2005).
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in the group who had received placebo during the randomized trial followed by fluoxetine in the follow-up period. A substantial reduction was also observed for the group who continued the fluoxetine medication during the follow-up period. The groups who received no medication during the follow-up year did not display noteworthy change: The group receiving placebo during the randomized trial followed by no medication during the follow-up period even showed a slight increase in symptom severity. In conclusion, then, pharmacotherapy is increasingly accepted as a viable treatment of childhood anxiety disorders. The review above indicates that in particular SSRIs yield positive effects in treating OCD and other anxiety disorders in youths. As noted by Seidel and Walkup (2006), SSRIs have become “the pharmacologic treatment of choice for paediatric anxiety disorders” (p.171). These drugs have clear-cut anxiolytic effects and are welltolerated by most children and adolescents. Although there is a small but significant increased risk for suicide, the magnitude of the improvement produced by the SSRIs in anxietydisordered youths makes the benefit/risk ratio is acceptable. A number of remarks can be made with regard to the pharmacologic treatment of childhood anxiety disorders. First of all, most randomized placebo-controlled trials have focused on OCD, separation anxiety disorder, generalized anxiety disorder, and social phobia. While it is clear that psychopharmacologic drugs are not really an option in the case of specific phobias (Stein & Seedat, 2004), SSRIs may be useful in the treatment of panic disorder and PTSD, and it is clear that this issue needs proper investigation (Waslick, 2006). Second, 50% to 70% of the children and adolescents appear to respond favorably to an SSRI (Scott, Mughelli, & Daes, 2005): These youths display a reduction of anxiety symptomatology and show a significant improvement of general functioning. In terms of effect size, the effects produced by SSRIs in anxious youths are quite robust. For example, in the randomized controlled trials on SSRIs in non-OCD anxiety disorders (see supra), effect sizes across various outcome measures ranged between 1.45 and 2.68, indicating large treatment effects. Third, it is important to get insight in the factors that either moderate or mediate the outcome of pharmacotherapy in anxious youths. A preliminary study of the RUPP Anxiety Study Group (2003) showed that severity of the anxiety disorder and the presence of a social phobia (and possibly a behaviorally inhibited temperament) were predictive of a less favorable outcome, but it is clear that this issue requires more research. Fourth, the administration of a placebo in the randomized controlled trials was also frequently accompanied by substantial decreases of anxiety symptoms and improvement in functioning. This underlines that nonspecific therapeutic effects (e.g., attention from a clinician, belief that the treatment works) are important determinants of the outcome of any treatment, including medicationbased interventions. Recently, Olfson, Marcus, Weissman, and Jensen (2002) described trends in the use of psychotropic medications by children and adolescents in the United States. These researchers did not specify the medication use for anxiety disorders but noted that the use of antidepressants, which are commonly employed for this type of problem, had clearly increased between 1987 and 1996. More precisely, in the age categories 6 to 14 years and 15 to 18 years, the use of these drugs had grown from, respectively, .30 and .50 per 100 children in 1987 to 1.06 and 2.12 per 100 children in 1996. While there seems to be increasing support for this type of intervention, it should be borne in mind that research so far has only demonstrated short-term efficacy of pharmacotherapy in childhood anxiety disorders. More
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research is required to study the long-term effects and the consequences of prolonged use of these drugs in youth populations (Seidel & Walkup, 2006).
Conclusion The past decade has seen a steady increase of methodologically sound (see Kendall & Flannery-Schroeder, 1998) treatment outcome studies evaluating the effectiveness of psychological and biological interventions for youths with phobias and anxiety disorders. This research has demonstrated that CBT and pharmacotherapy are effective in reducing anxiety symptoms in children and adolescents of various ages. Given that the empirical evidence for CBT is more substantial than that for pharmacotherapy, cognitive-behavioral therapy should still be regarded as the treatment of choice for childhood anxiety disorders. However, pharmacotherapy (in particular SSRIs) can be employed during the acute phase of treatment (when symptoms are very severe) or when children or adolescents do not respond adequately to a CBT intervention (see also American Academy of Child and Adolescent Psychiatry, 1997). Such treatment algorithm is nicely in keeping with parents’ perception of the most optimal treatment for their anxious child. More precisely, Brown, Deacon, Abramowitz, Dammann, and Whiteside (2007) recently found that although CBT and pharmacotherapy are both viewed as acceptable interventions for childhood anxiety disorders, most parents rate CBT as more acceptable, believable, and effective than a pharmacologic intervention (see also Young, Beidel, Turner et al., 2006). Meanwhile, it is of interest to note that a randomized control trial (Pediatric OCD Treatment Study (POTS) Team, 2004) has indicated that the combination of CBT and medication may yield the most optimal treatment outcome. In that study, children and adolescents with OCD from various academic treatment centers (N = 112) were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or a placebo. As shown in Figure 8.14, the CBT alone and sertraline
25
Sertraline CBT
20
Sertraline + CBT 15
Placebo
10 Pretreatment
Posttreatment
Figure 8.14: Mean OCD-symptoms scores for youths in various intervention groups before and after the 12-week treatment period. Based on: Pediatric OCD Treatment Study (POTS) Team (2004).
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alone treatments were significantly better than the placebo intervention in reducing youths’ symptoms of OCD, but it is also clear that the combined CBT and sertraline treatment produced the most optimal effects. These findings are interesting and need further replication, especially in other types of childhood anxiety disorders. A number of developmental issues are relevant for the treatment of anxiety disorders in children and adolescents. As mentioned earlier, the precise content of a CBT intervention may depend on the developmental level of the child. In their interesting review article, Dadds and Barrett (2001) have pointed out that each developmental stage has its own characteristics and poses the child for new risks and challenges, which have implications for the content of a CBT intervention (see also Hudson, Kendall, Coles, Robin, & Webb, 2002). During infancy, the main focus should be on training the parents to be responsive to their child in order to foster a secure attachment relationship and a predictable/controllable environment. As children grow older, problem-solving training, exposure, and cognitive strategies become the main targets of the child-based CBT intervention. During early and middle childhood, parents should be trained to model effective cognitive and behavioral coping to their child and to manage behavior avoidance. Finally, during adolescence, the approach of the child largely remains the same, although it may be useful to focus more on the interaction with peers during treatment. Parent training during this stage is more concerned with finding a balance between autonomy/independence and family support. In the case of pharmacotherapy, development and age seem less important as most studies have demonstrated equal responsiveness to drug treatment for children and adolescents (e.g., RUPP Anxiety Study Group, 2003; Wagner et al., 2004). However, it should be borne in mind that the use of such medication on a younger age may have consequences for the maturation of the brain. For example, animal studies have demonstrated detrimental effects of chronic use of SSRIs on the development of frontal and subcortical brain areas (e.g., Norrholm & Ouimet, 2001; Wegerer, Moll, Bagli et al., 1999). These observations have made some authors reserved about the (chronic) employment of SSRIs and other anxiolytic medication in young children (Pine, 2002). The theoretical basis for CBT and pharmacotherapy seems sound, although a lot of research is still necessary to reveal the precise working mechanisms of both types of intervention. In terms of the multifactorial aetiological model that was described in Chapter 6, it can be argued that both types of interventions aim at decreasing children’s vulnerability. For example, any CBT interventions contains elements of emotion regulation (SouthamGerow & Kendall, 2002), which seem to target soothing the reactive temperament/personality factor of neuroticism. However, it is equally plausible to assume that these programs promote protective factors of children. More precisely, during a typical CBT program, youths are prompted to carefully analyze the stimuli and situations that cause their anxious feelings, to think about what is going on in their head, and to eventually choose a more adaptive behavioral response instead of avoidance. In other words, CBT teaches children to inhibit their maladaptive behaviors and to regulate their attention, thereby improving their effortful control (Muris & Ollendick, 2005). A similar line of reasoning can be made regarding the presumed working mechanism of pharmacologic interventions. On the one hand, these drugs decrease the activity and arousability of subcortical brain circuits, which would directly reduce feelings of fear and anxiety. On the other hand, this medication may ameliorate the regulative function of the frontal lobes, so that children and adolescents are better
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able to control too intense manifestations of these emotions. Interestingly, some authors have suggested that CBT and pharmacotherapy result in comparable modifications of brain processes, suggesting that the effects produced by both therapeutic approaches are not as dissimilar as previously thought (Linden, 2006; O’Neill & Schwartz, 2004; Schwartz, 1999). In conclusion, the information in this final chapter shows that research has not only made considerable progress in the study of the aetiology and maintenance of childhood anxiety disorders but also indicates clear advances in the treatment of this type of psychopathology in youths. This is certainly positive news for children and adolescents who, just like Little Hans, are in need of an intervention for their anxiety problems.
Appendix
Questionnaires that can be used for research purposes
Attachment Questionnaire for Children (AQ-C) Choose the description that fits you the most. Remember: You are allowed to choose only one of the descriptions below.
I find it easy to become good friends with others. I feel comfortable when I am able to trust them and they are able to trust me. I am almost never scared of being deserted or that someone becomes really close friends with me. I don’t feel entirely comfortable when I am close friends with others. I find it difficult to trust them completely. I find it difficult to be depended by them. I am nervous when someone wants to be friends with me. It often occurs that friends want more from me than I find pleasant. I find that others don’t want to be close friends with me as much as I would like to. I worry that my best friend doesn’t like me and will end our friendship. I personally would like to do everything with my best friend. I notice that as a result I sometimes scare others away.
Scoring Description 1 = Secure Attachment Description 2 = Avoidant Attachment Description 3 = Ambivalent Attachment Key references Muris, P., Mayer, B., & Meesters, C. (2000). Self-reported attachment style, anxiety, and depression in children. Social Behavior and Personality, 28, 157–162. Muris, P., Meesters, C., Van Melick, M., & Zwambag, L. (2001). Self-reported attachment style, attachment quality, and symptoms of anxiety and depression in young adolescents. Personality and Individual Differences, 30, 809–818. Note The AQ-C is an age-downward version of Hazan and Shaver’s single-item measure of attachment style. See: Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52, 511–524.
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Attentional Control Scale for Children (ACS-C)
1. It’s very hard for me to concentrate on a difficult lesson if there is a lot of noise in the class. 2. If I have to concentrate and solve a difficult math problem, I have trouble focusing my attention. 3. When I am working hard on something, I still get distracted by things going on around me. 4. My concentration is good, even when somebody turns the music on.* 5. When I concentrate myself, I do not notice what is happening in the room around me.* 6. When I am reading in the classroom, I am easily disturbed by other children talking to each other. 7. When I try to concentrate myself, I find it difficult not to think about other things. 8. I find it difficult to concentrate myself when I am excited about something. 9. When I am concentrating, I do not notice that I am hungry or thirsty.* 10. When I am doing something, I can easily stop and switch to some other task.* 11. When I have to start a new task, it takes me a while to get really involved in it. 12. When the teacher explains something, I find it difficult to understand and write down at the same time. 13. When it is necessary, I can become interested in a new topic very quickly.* 14. It is easy for me to read or write while I am also talking to someone on the telephone.*
1 Almost never
2 Sometimes
3 Often
4 Always
(To be continued)
Appendix: Questionnaires
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Attentional Control Scale for Children (ACS-C) (Continued)
15. I have trouble having two conversations at the same time. 16. I find it difficult to come up quickly with new ideas. 17. After being interrupted or distracted, I can easily shift my attention back to what I was doing before.* 18. When I am daydreaming or having distracting thoughts, it is easy for me to switch back to the work I have to do.* 19. It is easy for me to switch back and forth between two different tasks.* 20. I find it difficult to let go of my own way of thinking about something and to look at it in a different way.
1 Almost never
2 Sometimes
3 Often
4 Always
Scoring *Reversed items. A total attentional control score can be obtained by summing across all items (after recoding reversed items). Higher scores are indicative of lower levels of attentional control. Items 1, 2, 3, 4 (R), 5 (R), 6, 7, 8, and 9 (R) = Attentional focusing Items 10 (R), 11, 12, 13 (R), 14 (R), 15, 16, 17 (R), 18 (R), 19 (R), and 20 = Attentional shifting Key references Muris, P., De Jong, P.J., & Engelen, S. (2004). Relationships between neuroticism, attentional control, and anxiety disorders symptoms in non-clinical children. Personality and Individual Differences, 37, 789–797. Muris, P., Meesters, C., & Rompelberg, L. (2007). Attention control in middle childhood: Relations to psychopathological symptoms and threat perception distortions. Behaviour Research and Therapy, 45, 997–1010. Note The ACS-C is an age-downward version of the Attentional Control Scale. See: Derryberry, D., & Reed, M.A. (2002). Anxiety-related attentional biases and their regulation by attentional control. Journal of Abnormal Psychology, 111, 225–236.
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Behavioral Inhibition Instrument (BII) Part 1: Behavioral Inhibition Scale (BIS)
1. I am shy when I have to talk to an unfamiliar person. 2. I talk easily to an unfamiliar person.* 3. I feel nervous when I have to talk to an unfamiliar person. 4. I feel good and I am able to laugh when I talk to an unfamiliar person.*
1 Never
2 Sometimes
3 Often
4 Always
Scoring *Reversed items. Total score can be obtained by summing ratings on all items (after recoding reversed items). Scores vary between 4 (not at all behaviorally inhibited) and 16 (extremely behaviorally inhibited).
Part 2: Behavioral Inhibition Categories Choose the description that fits you the most. Remember: You are allowed to choose only one of the descriptions below.
As long as I remember, I am shy when I have to talk to an unfamiliar person. On such occasions, I am nervous, I am not able to laugh, and I do not know what to say. As long as I remember, I talk easily to an unfamiliar person. On such occasions, I feel good, I am able to laugh, and I know precisely what I have to say. I am someone falling in between these two descriptions.
Scoring Description 1 = High Behavioral Inhibition Description 2 = Low Behavioral Inhibition Description 3 = Medium Behavioral Inhibition Key references Muris, P., Meesters, C., & Spinder, M. (2003). Relationships between child- and parent-reported behavioural inhibition and symptoms of anxiety and depression in normal adolescents. Personality and Individual Differences, 34, 759–771. Muris, P., Merckelbach, H., Schmidt, H., Gadet, B., & Bogie, N. (2001). Anxiety and depression as correlates of self-reported behavioural inhibition in normal adolescents. Behaviour Research and Therapy, 39, 1051–1061. Muris, P., Merckelbach, H., Wessel, I., & Van de Ven, M. (1999). Psychopathological correlates of self-reported behavioural inhibition in normal children. Behaviour Research and Therapy, 37, 575–584. Note The items of the BIS were based on the scale described by Gest, S.D. (1997). Behavioral inhibition: Stability and associations with adaptation from childhood to early adulthood. Journal of Personality and Social Psychology, 72, 467–475.
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Big Five Questionnaire for Children (BFQ-C)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.
26. 27. 28. 29. 30.
I like to meet with other people. I share my things with other people. I do my job with care and attention. I get nervous for silly things. I know many things. I am in a bad mood. I work hard and with pleasure. I argue with others with excitement. I like to compete with others. I have a great deal of fantasy. I behave correctly and honestly with others. I easily learn what I study at school. I understand when others need my help. I like to move and to do a lot of activity. I easily get angry. I like to give gifts. I quarrel with others. When the teacher asks questions, I am able to answer correctly. I like to be with others. I engage myself in the things I do. If someone commits an injustice to me, I forgive her/him. During class I concentrate on the things I do. I can easily say to others what I think. I like to read books. When I finish my homework, I check it many times to see if I did it correctly. I say what I think. I treat my peers with affection. I respect the rules and the order. I easily get offended. When the teacher explains something, I understand immediately.
1 Never
2 Seldom
3 Sometimes
4 Often
5 Always
(To be continued)
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Big Five Questionnaire for Children (BFQ-C) (Continued)
31. 32. 33. 34. 35. 36. 37. 38. 39.
40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57.
I am sad. I treat others with great kindness. I like scientific TV shows. If I make an engagement, I keep it. I do something not to get bored. I like to watch TV news and to know what happens in the world. My room is in order. I am polite when I talk to others. If I want to do something, I am not capable of waiting and I have to do it immediately. I like to talk to others. I am not patient. I am able to convince someone of what I think. I am able to create new games and entertainment. When I start to do something, I have to finish it at all costs. If a classmate has some difficulty, I help her/him. I am able to solve mathematics problems. I trust others. I like to keep all my school things in great order. I easily lose my calm. When I speak, the others listen to me and do what I say. Even people I do not like are treated kindly by me. I like to know and learn new things. I play only when I have finished my homework. I do things with agitation. I like to joke. It is unlikely that I divert my attention. I easily make friends.
1 Never
2 Seldom
3 Sometimes
4 Often
5 Always
(To be continued)
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Big Five Questionnaire for Children (BFQ-C) (Continued) 1 Never
2 Seldom
3 Sometimes
4 Often
5 Always
58. I weep. 59. I would like very much to travel and to know the habits of other countries. 60. I think other people are good and honest. 61. I worry about silly things. 62. I understand immediately. 63. I am happy and lively. 64. I let other people use my things. 65. I do my own duty.
© Claudio Barbaranelli. Reproduced with permission. Scoring Items 1, 9, 14, 19, 23, 26, 35, 40, 42, 50, 55, 57, and 63 = Energy/extraversion Items 2, 11, 13, 16, 21, 27, 32, 38, 45, 47, 51, 60, and 64 = Agreeableness Items 3, 7, 20, 22, 25, 28, 34, 37, 44, 48, 53, 56, and 65 = Conscientiousness Items 4, 6, 8, 15, 17, 29, 31, 39, 41, 49, 54, 58, and 61 = Emotional instability Items 5, 10, 12, 18, 24, 30, 33, 36, 43, 46, 52, 59, and 62 = Intellect/openness Key references Barbaranelli, C., Caprara, G.V., Rabasca, A., & Pastorelli, C. (2003). A questionnaire for measuring the Big Five in late childhood. Personality and Individual Differences, 34, 645–664. Muris, P., Meesters, C., & Diederen, R. (2005). Psychometric properties of the Big Five Questionnaire for Children (BFQ-C) in a Dutch sample of young adolescents. Personality and Individual Differences, 38, 1757–1769.
BIS/BAS Scales for Children
1. I usually get very tense when I think something unpleasant is going to happen. 2. I feel excited and full of energy when I get something that I want. 3. When I want something, I usually go all the way to get it.
0 Not true
1 Somewhat true
2 True
3 Very true
(To be continued)
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BIS/BAS Scales for Children (Continued)
4. I often do things for no other reason than that they might be fun. 5. I worry about making mistakes. 6. When I am doing well at something, I like to keep doing it. 7. I do everything to get the things that I want. 8. I have a great need for excitement and new sensations. 9. I am hurt when people scold me or tell me that I did something wrong. 10. I get thrilled when good things happen to me. 11. When I see a chance to get something that I want, I go for it right away. 12. I am always willing to try something new if I think it will be fun. 13. I feel pretty upset when I think that someone is angry with me. 14. I do not become fearful or nervous, even when something bad happens to me.* 15. I get very excited when I might win a contest. 16. Nobody can stop me when I want something. 17. I often do things on the spur of the moment. 18. I feel worried when I think I have done poorly at something. 19. I get really excited when I see an opportunity to get something I like. 20. I am very fearful compared to my friends.
0 Not true
1 Somewhat true
2 True
3 Very true
Scoring *Reversed item. Items 1, 5, 9, 13, 14 (R), 18, and 20 = Behavioral inhibition system (BIS) Items 2, 3, 4, 6, 7, 8, 10, 11, 12, 15, 16, 17, and 19 = Behavioral activation system (BAS)
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Key reference Muris, P., Meesters, C., De Kanter, E., & Eek Timmerman, P. (2005). Behavioural inhibition and behavioural activation system scales for children: Relationships with Eysenck’s personality traits and psychopathological symptoms. Personality and Individual Differences, 38, 831–841. Note The BIS/BAS Scales for Children are an age-downward version of the Carver and White (1994) BIS/BAS Scales. See: Carver, C.S., & White, T.L. (1994). Behavioral inhibition, behavioral activation, and affective responses to impending reward and punishment. Journal of Personality and Social Psychology, 67, 319–333.
Children’s Anxiety Sensitivity Inventory (CASI)
1. I don’t want other people to know when I feel afraid. 2. When I cannot keep my mind on my schoolwork, I worry that I might be going crazy. 3. It scares me when I feel “shaky.” 4. It scares me when I feel I am going to faint. 5. It is important for me to stay in control of my feelings. 6. It scares me when my heart beats fast. 7. It embarrasses me when my stomach growls (makes noises). 8. It scares me when I feel like I am going to throw up. 9. When I notice that my heart is beating fast, I worry that there might be something wrong with me. 10. It scares me when I have trouble getting my breath. 11. When my stomach hurts, I worry that I might be really sick. 12. It scares me when I can’t keep my mind on my schoolwork. 13. Other kids can tell when I feel shaky. 14. Unusual feelings in my body scare me. 15. When I am afraid, I worry that I might be crazy. 16. It scares me when I feel nervous. 17. I don’t like to let my feelings show. 18. Funny feelings in my body scare me.
0 None
1 Some
2 A lot
© Wendy K. Silverman. Reproduced with permission. Scoring A total anxiety sensitivity score can be obtained by summing across all items.
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Key reference Silverman, W.K., Fleisig, W., Rabian, B., & Peterson, R.A. (1991). Childhood anxiety sensitivity index. Journal of Clinical Child Psychology, 20, 162–168. Note The CASI is an age-downward version of the Anxiety Sensitivity Index. See: Reiss, S., Peterson, R.A., Gursky, D.M., & McNally, R.J. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1–8.
Children’s Anxiety Sensitivity Inventory-Revised (CASI-R)
1. When I feel like I am not getting enough air, I get scared that I might suffocate. 2. It is important for me not to appear nervous. 3. When I feel a strong pain in my stomach, I worry that it might be cancer. 4. When I feel strange, I worry that I might go crazy. 5. It scares me when I have a feeling of choking. 6. I believe it would be awful if I had to vomit in public. 7. When my head is pounding, I worry that I could have a stroke. 8. When my heart beats fast, I worry that something is wrong. 9. It scares me when I am short of breath. 10. I think it would be horrible to faint in public. 11. When my face feels numb, I worry I might be having a stroke. 12. When my thoughts speed up, I worry that I might go crazy. 13. When my chest feels tight, I get scared that I cannot breathe properly. 14. I worry that other people will notice my anxiety. 15. When I feel pain in my chest, I worry that I am going to have a heart attack. 16. When I have trouble with thinking clearly, I worry that something is wrong with me. 17. When my throat feels tight, I get scared that I could choke to death. 18. It scares me when my heart beats fast. 19. When I tremble in the presence of others, I fear what people think of me.
0 Not true
1 Somewhat true
2 Very true
(To be continued)
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Children’s Anxiety Sensitivity Inventory-Revised (CASI-R) (Continued)
20. When I feel dizzy, I worry that something is wrong with my brain. 21. When my stomach is upset, I worry that I might be seriously ill. 22. When my heart is skipping a beat, I worry that something serious is going to happen to me. 23. When I cannot keep my mind on my schoolwork, I worry that I might go crazy. 24. When my breathing is irregular, I fear that something bad will happen. 25. When I have trouble with swallowing, I worry that I could choke. 26. When I start to sweat in the presence of others, I get scared that people will think negatively of me. 27. It scares me when I blush in front of people. 28. It scares me when I feel like I have to throw up. 29. It scares me when I feel tingling or prickling sensations in my hands. 30. It scares me when I cannot keep my mind on the task. 31. When my mind goes blank, I worry that something is terribly wrong with me.
0 Not true
1 Somewhat true
2 Very true
Scoring A total anxiety sensitivity score can be obtained by summing across all items. Items 3, 7, 8, 11, 15, 18, 20, 21, 22, and 29 = Fear of cardiovascular and digestive symptoms Items 2, 6, 10, 14, 19, 26, 27, and 28 = Fear of publicly observable anxiety reactions Items 4, 12, 16, 23, 30, and 31 = Fear of cognitive dyscontrol Items 1, 5, 9, 13, 17, 24, and 25 = Fear of respiratory symptoms Key reference Muris, P. (2002). An expanded Childhood Anxiety Sensitivity Index: Its factor structure, reliability, and validity in a non-clinical adolescent sample. Behaviour Research and Therapy, 40, 299–311. Note The CASI-R consists of 8 items from the original Child Anxiety Sensitivity Index (items 2, 8, 9, 18, 21, 23, 28, and 30; Silverman et al., 1991). The other items were taken from the Anxiety Sensitivity Index-Revised (Taylor & Cox, 1998) but modified and simplified for use with youths. See: Silverman, W.K., Fleisig, W., Rabian, B., & Peterson, R.A. (1991). Childhood anxiety sensitivity index. Journal of Clinical Child Psychology, 20, 162–168; and Taylor, S., & Cox, B.J. (1998b). An expanded anxiety sensitivity index: Evidence for a hierarchic structure in a clinical sample. Journal of Anxiety Disorders, 12, 463– 484.
Disgust Sensitivity Questionnaire for Children (DSQ-C) 3 4 Pretty Very disgusting disgusting
5 Very much disgusting
(To be continued)
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1. How disgusting would you find that soup if you had to eat it from a poorly washed soup bowl? 2. How disgusting would you find that soup if you had to eat it from a brand-new dog bowl? 3. How disgusting would you find that soup if you had to eat it from a washed dog bowl? 4. How disgusting would you find that soup if you had to eat it from a soup bowl after it has been stirred with a carefully washed fly swatter? 5. How disgusting would you find that soup if you had to eat it from a soup bowl after it had been stirred with a brand new fly swatter? 6. How disgusting would you find that soup if you had to eat it from a soup bowl after it has been stirred with a just used fly swatter? 7. How disgusting would you find that soup if you had to eat it from a soup bowl after it had been stirred with a carefully washed comb? 8. How disgusting would you find that soup if you had to eat it from a soup bowl after it had been stirred with a brand new comb? 9. How disgusting would you find that soup if you had to eat it from a soup bowl after it had been stirred with a just used comb? 10. How disgusting would you find that soup if you had to eat it from a soup bowl while there is a dead grasshopper lying on the bottom of the bowl? 11. How disgusting would you find that soup if you had to eat it from a soup bowl after the grasshopper has been removed?
1 2 Not at all Somewhat disgusting disgusting
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What is your favorite soup? My favorite soup is . . . . . . . . . . . . . . . . . . . . . . . . . . .
What is your favorite soft drink? My favorite soft drink is . . . . . . . . . . . . . . . . . . 12. How disgusting would you find that soft drink if you had to drink it from a glass while there is a leaf from a nonpoisonous plant lying on the bottom of the glass? 13. How disgusting would you find that soft drink if you had to drink it from a glass after we have removed the leaf ? 14. How disgusting would you find that soft drink if you had to drink it from a poorly washed glass?
What is your favorite cookie? My favorite cookie is . . . . . . . . . . . . . . . . . . . . . . . .
3 4 Pretty Very disgusting disgusting
5 Very much disgusting
1 2 Not at all Somewhat disgusting disgusting
3 4 Pretty Very disgusting disgusting
5 Very much disgusting
Scoring A total disgust score can be obtained by summing ratings on all items. Scores vary between 18 (extremely low disgust sensitivity) and 90 (extremely high disgust sensitivity).
Note The DSQ-C is an age-downward version of Rozin et al.’s (1984) questionnaire. See: Rozin, P., Fallon, A., & Mandell, R. (1984). Family resemblance in attitudes to food. Developmental Psychology, 20, 309–314.
279
Key reference Muris, P., Merckelbach, H., Schmidt, H., & Tierney, S. (1999). Disgust sensitivity, trait anxiety, and anxiety disorders symptoms in normal children. Behaviour Research and Therapy, 37, 953–961.
Appendix: Questionnaires
15. How disgusting would you find that cookie after a good friend has taken a bite from it? 16 How disgusting would you find that cookie after another child of your class has taken a bite from it? 17. How disgusting would you find that cookie after a waiter in a restaurant has taken a bite from it? 18. How disgusting would you find that cookie after it has fallen to the ground during a picnic?
1 2 Not at all Somewhat disgusting disgusting
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Modified Version of the EMBU-C (My Memories of Upbringing)
1. When you come home, you have to tell your parents what you have been doing. 2. When you are unhappy, your parents console you and cheer you up. 3. Your parents want you to reveal your secrets to them. 4. Your parents tell you that they don’t like your behavior at home. 5. Your parents like you just the way you are. 6. Your parents worry about what you are doing after school. 7. Your parents play with you and are interested in your hobbies. 8. Your parents treat you unfairly. 9. Your parents are afraid that something might happen to you. 10. Your parents listen to you and consider your opinion. 11. Your parents wish that you were like somebody else. 12. Your parents want to decide how you should be dressed or how you should look. 13. Your parents worry about you getting into trouble. 14. Your parents blame you for everything that goes wrong. 15. Your parents punish you for no reason. 16. Your parents tell you what you should do after school hours. 17. Your parents want to be with you. 18. Your parents worry about you doing dangerous things. 19. Your parents show that they love you.
1 No, never
2 Yes, but seldom
3 Yes, often
4 Yes, most of the time
(To be continued)
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Modified Version of the EMBU-C (My Memories of Upbringing) (Continued)
20. Your parents criticize you in front of others. 21. Your parents know exactly what you are allowed to do and what not. 22. Your parents worry about you making a mistake. 23. You feel disappointed because your parents don’t give you what you want. 24. Your parents allow you to decide what you want to do.* 25. Your parents take care that you behave by the rules. 26. Your parents are afraid when you do something on your own. 27. Your parents and you like each other. 28. Your parents are mean and grudging toward you. 29. Your parents are anxious people, and therefore you are not allowed to do as many things as other children. 30. When you have done something stupid, you can make it up with your parents. 31. Your parents watch you very carefully. 32. Your parents think that they have to decide everything for you. 33. Your parents give you compliments. 34. If something happens at home, you are the one who gets blamed for it. 35. Your parents warn you of all possible dangers. 36. Your parents help you when you have to do something difficult. 37. Your parents are worried when they don’t know what you are doing.
1 No, never
2 Yes, but seldom
3 Yes, often
4 Yes, most of the time
(To be continued)
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Modified Version of the EMBU-C (My Memories of Upbringing) (Continued) 1 No, never
2 Yes, but seldom
3 Yes, often
4 Yes, most of the time
38. Your parents keep a check on you. 39. Your parents beat you for no reason. 40. Your parents want to keep you from all possible dangers.
Scoring *Reversed item. Items 1, 3, 12, 16, 21, 24 (R), 25, 31, 32, and 38 = Control/overprotection Items 2, 5, 7, 10, 17, 19, 27, 30, 33, and 36 = Emotional warmth Items 4, 8, 11, 14, 15, 20, 23, 28, 34, and 39 = Rejection Items 6, 9, 13, 18, 22, 26, 29, 35, 37, and 40 = Anxious rearing Key publication Muris, P., Meesters, C., & Van Brakel, A. (2003). Assessment of anxious rearing behaviors with a modified version of the “Egna Minnen Beträffande Uppfostran” (EMBU) questionnaire for Children. Journal of Psychopathology and Behavioral Assessment, 25, 229–237. Note Control/overprotection, emotional warmth, and rejection items were derived from Castro et al.’s (1993) EMBU version for Children. Anxious rearing items were added by Grüner et al. (1999). See: Castro, J., Toro, J., Van der Ende, J., & Arrindell, W.A. (1993). Exploring the feasibility of assessing perceived parental rearing styles in Spanish children with the EMBU. International Journal of Social Psychiatry, 39, 47–57, and Grüner, K., Muris, P., & Merckelbach, H. (1999). The relationship between anxious rearing behaviours and anxiety disorders symptomatology in normal children. Journal of Behavior Therapy and Experimental Psychiatry, 30, 27–35.
Koala Fear Questionnaire (KFQ)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Frightening movie Rats or mice Ghosts Witches Telling something in front of a group of children Being teased by other kids Lions Getting sick Getting lost and not seeing your parents anymore Being hit by a car Hearing my parents arguing
1 No fear
2 Some fear
3 A lot of fear
(To be continued)
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Koala Fear Questionnaire (KFQ) (Continued)
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.
High in the sky Snakes Being in the dark A man who wants to take you away (a kidnapper) A burglar breaking into your house Thunderstorms Birds Roller-coaster Scary dreams Flying in an airplane Chickens Fire Dogs War Spiders Death Getting a shot Crocodiles Blood Parents getting divorced
1 No fear
2 Some fear
3 A lot of fear
Scoring A total fear score can be obtained by summing the ratings across all items. Key references Muris, P. (2002). The Koala Fear Questionnaire: Its relationship with fear of storms and hurricanes in 4- to 14-year-old Antillean children. Journal of Psychopathology and Behavioral Assessment, 24, 145–150. Muris, P., Meesters, C., Mayer, B., Bogie, N., Luijten, M., Geebelen, E., Bessems, J., & Smit, C. (2003). The Koala Fear Questionnaire: A standardized self-report scale for assessing fears and fearfulness in pre-school and primary school children. Behaviour Research and Therapy, 41, 597–617. Note Accompanying pictures can be obtained from Professor Muris. KFQ stimuli and situations are based on self-reported top intense fears (“free option” fears) among 4- to 12-year-old children (Muris et al., 1997, 2000). Stimuli and situations were only included in the KFQ when they were also featured in the Revised Fear Survey Schedule for Children (Ollendick, 1983) or a contemporary version of this scale. See: Muris, P., Merckelbach, H., Meesters, C., & Van Lier, P. (1997). What do children fear most often? Journal of Behavior Therapy and Experimental Psychiatry, 28, 263–267, Muris, P., Merckelbach, H., Gadet, B., & Moulaert, V. (2000). Fears, worries, and scary dreams in 4- to 12year-old children: Their content, developmental pattern, and origins. Journal of Clinical Child Psychology, 29, 43–52, and Ollendick, T.H. (1983). Reliability and validity of the Revised Fear Survey Schedule for Children (FSSC-R). Behaviour Research and Therapy, 21, 685–692.
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Penn State Worry Questionnaire for Children (PSWQ-C) 0 1 Not at all Somewhat true true 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
My worries really bother me. I don’t really worry about things.* Many things make me worry. I know I shouldn’t worry, but I just can’t help it. When I am under pressure, I worry a lot. I am always worrying about something. I find it easy to stop worrying when I want.* When I finish one thing, I start to worry about everything else. I never worry about anything.* I have been a worrier all my life. I notice that I have been worrying about things. Once I start worrying, I can’t stop. I worry all the time. I worry about things until they are all done.
2 Most times true
3 Always true
© Bruce F. Chorpita. Reproduced with permission. Scoring *Reversed items. A total worry score can be obtained by summing ratings on all items (after recoding reversed items). Key publications Chorpita, B.F., Tracey, S.A., Brown, T.A., Collica, T.J., & Barlow, D.H. (1997). Assessment of worry in children and adolescents: An adaptation of the Penn State Worry Questionnaire. Behaviour Research and Therapy, 35, 569–581. Muris, P., Meesters, C., & Gobel, M. (2001). Reliability, validity, and normative data of the Penn State Worry Questionnaire in 8- to 12-year-old children. Journal of Behavior Therapy and Experimental Psychiatry, 32, 63–72. Note The PSWQ-C is an age-downward version of the Penn State Worry Questionnaire for adults. See: Brown, T.A., Anthony, M.M., & Barlow, D.H. (1992). Psychometric properties of the Penn State Worry Questionnaire in a clinical anxiety disorders sample. Behaviour Research and Therapy, 30, 33–37.
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Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R)— Child Version Instruction Below you will find a number of statements that refer to children’s fears and anxiety. Please read each statement carefully and indicate how frequently you have experienced that symptom during the last 3 months: never or almost never, sometimes, or often.
1. When I feel frightened, it is hard to breathe. 2. I am afraid of heights. 3. I get headaches or bellyaches when I am at school. 4. I don’t like to be with unknown people. 5. When I see blood, I get dizzy. 6. I want things to be in a fixed order. 7. I get scared when I sleep away from home. 8. I worry about others not liking me. 9. When I get frightened, I feel like passing out. 10. I think that I will be contaminated with a serious disease. 11. I am nervous. 12. I have strange thoughts that frighten me. 13. I follow my mother or father wherever they go. 14. People tell me that I look nervous. 15. I feel nervous with people I don’t know well. 16. I am afraid to visit the doctor. 17. I don’t like going to school. 18. When I get frightened, I feel like I am going crazy. 19. I worry about sleeping alone. 20. I am afraid to visit the dentist. 21. I worry about being as good as other kids. 22. I am afraid of an animal that is not really dangerous. 23. I get scared when there is thunder in the air. 24. I do things more than twice in order to check whether I did it right. 25. I have frightening dreams about a very aversive event I once experienced. 26. I want things to be clean and tidy.
0 Never or almost never
1 Sometimes
2 Often
(To be continued)
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Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R)— Child Version (Continued) 0 Never or almost never
1 Sometimes
2 Often
27. When I get frightened, it feels like things are not real. 28. I would feel scared if I had to fly in a plane. 29. I have nightmares about something bad happening to my parents. 30. I worry about going to school. 31. I perform rituals that help me to get less scared of my thoughts. 32. When I feel frightened, my heart beats fast. 33. I am scared when I get an injection. 34. I’m afraid of getting a serious disease. 35. I feel weak and shaky. 36. I have nightmares about something bad happening to me. 37. I am so scared of a harmless animal that I do not dare to touch it. 38. I worry about things working out for me. 39. I doubt whether I really did something. 40. When I get frightened, I sweat a lot. 41. I am a worrier. 42. I feel scared when I watch a medical operation on TV. 43. I try not to think about a very aversive event I once experienced. 44. Suddenly I get really frightened for no reason at all. 45. I am afraid to be alone in the house. 46. I get scared when I think back to a very aversive event I once experienced. 47. It is hard for me to talk with unfamiliar people. 48. When I get frightened, I feel like I am choking. 49. People tell me that I worry too much. 50. I don’t like to be away from my family. 51. I am afraid of having anxiety (or panic) attacks. 52. I worry that something bad might happen to my parents.
(To be continued)
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Screen for Child Anxiety-Related Emotional Disorders-Revised (SCARED-R)— Child Version (Continued) 0 Never or almost never
1 Sometimes
2 Often
53. I feel shy with people I don’t know well. 54. I have unwanted thoughts about hurting other people. 55. I worry about what is going to happen in the future. 56. When I get frightened, I feel like throwing up. 57. I worry about how well I do things. 58. I am scared to go to school. 59. I worry about things that happened in the past. 60. When I feel frightened, I get dizzy. 61. I get scared in small, closed places. 62. I have scary strange thoughts that I prefer not to have. 63. I am afraid of the dark. 64. I have unbidden thoughts about a very aversive event I once experienced. 65. I am afraid of an animal that most children do not fear. 66. I don’t like being in a hospital. 67. I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport). 68. I feel nervous when I am going to parties, dances, or anyplace where there will be people that I don’t know well. 69. I am shy.
Scoring A total anxiety symptoms score can be obtained by summing the ratings across all items. Items 1, 9, 14, 18, 27, 32, 35, 40, 44, 48, 51, 56, and 60 = Panic disorder Items 2, 23, 28, 61, and 63 = Specific phobia, situational/environmental type Items 3, 17, 30, and 58 = School phobia Items 4, 15, 47, 53, 67, 68, and 69 = Social phobia Items 5, 16, 20, 33, 34, 42, and 66 = Specific phobia, blood-injection-injury type Items 6, 10, 12, 24, 26, 31, 39, 54, and 62 = Obsessive-compulsive disorder Items 7, 13, 19, 29, 36, 45, 50, and 52 = Separation anxiety disorder Items 8, 11, 21, 38, 41, 49, 55, 57, and 59 = Generalized anxiety disorder Items 22, 37, and 65 = Specific phobia, animal type Items 25, 43, 46, and 64 = Acute or posttraumatic stress disorder
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Key publications Muris P., Dreessen, L., Bögels, S.M., Weckx, M., & Van Melick, M. (2004). A questionnaire for screening a broad range of DSM-defined anxiety disorder symptoms in clinically referred children and adolescents. Journal of Child Psychology and Psychiatry, 45, 813–820. Muris, P., Merckelbach, H., Körver, P., & Meesters, C. (2000). Screening for trauma in children and adolescents: The validity of the Traumatic Stress Disorder scale of the Screen for Child Anxiety Related Emotional Disorders. Journal of Clinical Child Psychology, 29, 406– 413. Muris, P., Merckelbach, H., Mayer, B., Van Brakel, A., Thissen, S., Moulaert, V., & Gadet, B. (1998). The Screen for Child Anxiety Related Emotional Disorders and its relationship to traditional childhood anxiety measures. Journal of Behavior Therapy and Experimental Psychiatry, 29, 327–339. Muris, P., Merckelbach, H., Schmidt, H., & Mayer, B. (1999). The revised version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-R): Factor structure in normal children. Personality and Individual Differences, 26, 99–112. Muris, P., & Steerneman, P. (2000). The revised version of the Screen for Child Anxiety Related Emotional Disorders (SCARED-R): First evidence for its reliability and validity in a clinical sample. British Journal of Clinical Psychology, 40, 35– 44. Note The subscales panic disorder, social phobia, school phobia, separation anxiety disorder, and generalized anxiety disorder were taken with permission from Birmaher et al.’s (1999) original SCARED. See: Birmaher, B., Brent, D., Chiappetta, L., Bridge, J., Monga, S., & Baugher, M. (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1230–1236.
Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R)— Parent Version Instruction Below you will find a number of statements that refer to children’s fears and anxiety. Please read each statement carefully and indicate how frequently your child has displayed that symptom during the last 3 months: never or almost never, sometimes, or often. Please respond to all statements as well as you can, even if some of them do not seem to concern your child.
1. When my child feels frightened, it is hard for him/her to breathe. 2. My child is afraid of heights. 3. My child gets headaches or bellyaches when he/she is at school. 4. My child doesn’t like to be with unknown people.
0 Never or almost never
1 Sometimes
2 Often
(To be continued)
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Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R)— Parent Version (Continued)
5. When my child sees blood, he/she gets dizzy. 6. My child wants things to be in a fixed order. 7. My child gets scared when he/she sleeps away from home. 8. My child worries about others not liking him/her. 9. When my child gets frightened, he/she feels like passing out. 10. My child thinks that he/she will be contaminated with a serious disease. 11. My child is nervous. 12. My child has strange thoughts that frighten him/her. 13. My child follows me wherever I go. 14. People tell me that my child looks nervous. 15. My child feels nervous with people he/she doesn’t know well. 16. My child is afraid to visit the doctor. 17. My child doesn’t like going to school. 18. When my child gets frightened, he/she feels like he/she is going crazy. 19. My child worries about sleeping alone. 20. My child is afraid to visit the dentist. 21. My child worries about being as good as other kids. 22. My child is afraid of an animal that is not really dangerous. 23. My child gets scared when there is thunder in the air. 24. My child does things more than twice in order to check whether he/she did it right. 25. My child has frightening dreams about a very aversive event he/she once experienced. 26. My child wants things to be clean and tidy. 27. When my child gets frightened, he/she feels like things are not real. 28. My child would feel scared if he/she had to fly in a plane.
0 Never or almost never
1 Sometimes
2 Often
(To be continued)
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Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R)— Parent Version (Continued)
29. My child has nightmares about something bad happening to his/her parents. 30. My child worries about going to school. 31. My child performs rituals that help him/her to get less scared of his/her thoughts. 32. When my child feels frightened, his/her heart beats fast. 33. My child is scared when he/she gets an injection. 34. My child is afraid of getting a serious disease. 35. My child feels weak and shaky. 36. My child has nightmares about something bad happening to him/her. 37. My child is so scared of a harmless animal that he/she does not dare to touch it. 38. My child worries about things working out for him/her. 39. My child doubts about whether he/she really did something. 40. When my child gets frightened, he/she sweats a lot. 41. My child is a worrier. 42. My child feels scared when he/she watches a medical operation on TV. 43. My child tries not to think about a very aversive event he/she once experienced. 44. Suddenly my child gets really frightened for no reason at all. 45. My child is afraid to be alone in the house. 46. My child gets scared when he/she thinks back to a very aversive event he/she once experienced. 47. It is hard for my child to talk with unfamiliar people. 48. When my child gets frightened, he/she feels like he/she is choking. 49. People tell me that my child worries too much. 50. My child doesn’t like to be away from his/her family.
0 Never or almost never
1 Sometimes
2 Often
(To be continued)
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Screen for Child Anxiety Related Emotional Disorders-Revised (SCARED-R)— Parent Version (Continued)
51. My child is afraid of having anxiety (or panic) attacks. 52. My child worries that something bad might happen to his/her parents. 53. My child feels shy with people he/she doesn’t know well. 54. My child has unwanted thoughts about hurting other people. 55. My child worries about what is going to happen in the future. 56. When my child gets frightened, he/she feels like throwing up. 57. My child worries about how well he/she does things. 58. My child is scared to go to school. 59. My child worries about things that happened in the past. 60. When my child feels frightened, he/she gets dizzy. 61. My child gets scared in small, closed places. 62. My child has scary, strange thoughts that he/she prefers not to have. 63. My child is afraid of the dark. 64. My child has unbidden thoughts about a very aversive event he/she once experienced. 65. My child is afraid of an animal that most children do not fear. 66. My child doesn’t like being in a hospital. 67. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport).* 68. My child feels nervous when he/she is going to parties, dances, or anyplace where there will be people that he/she doesn’t know well. 69. My child is shy. * For scoring, see SCARED-R Child Version.
0 Never or almost never
1 Sometimes
2 Often
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Self-Efficacy Questionnaire for Children (SEQ-C)
1. How well can you get teachers to help you when you get stuck on schoolwork? 2. How well can you express your opinions when other classmates disagree with you? 3. How well do you succeed in cheering yourself up when an unpleasant event has happened? 4. How well can you study when there are other interesting things to do? 5. How well do you succeed in becoming calm again when you are very scared? 6. How well can you become friends with other children? 7. How well can you study a chapter for a test? 8. How well can you have a chat with an unfamiliar person? 9. How well can you prevent becoming nervous? 10. How well do you succeed in finishing all your homework every day? 11. How well can you work in harmony with your classmates? 12. How well can you control your feelings? 13. How well can you pay attention during every class? 14. How well can you tell other children that they are doing something that you don’t like? 15. How well can you give yourself a pep-talk when you feel low? 16. How well do you succeed in understanding all subjects in school? 17. How well can you tell a funny event to a group of children? 18. How well can you tell a friend that you don’t feel well? 19. How well do you succeed in satisfying your parents with your schoolwork? 20. How well do you succeed in staying friends with other children? 21. How well do you succeed in suppressing unpleasant thoughts? 22. How well do you succeed in passing a test?
1 Not at all
2
3
4
5 Very well
(To be continued)
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Self-Efficacy Questionnaire for Children (SEQ-C) (Continued)
23. How well do you succeed in preventing quarrels with other children? 24. How well do you succeed in not worrying about things that might happen?
1 Not at all
2
3
4
5 Very well
Scoring A total self-efficacy score can be obtained by summing across all items. Items 1, 4, 7, 10, 13, 16, 19, and 22 = Academic self-efficacy Items 2, 6, 8, 11, 14, 17, 20, and 23 = Social self-efficacy Items 3, 5, 9, 12, 15, 18, 21, and 24 = Emotional self-efficacy Key publications Muris, P. (2001). A brief questionnaire for measuring self-efficacy in youths. Journal of Psychopathology and Behavioral Assessment, 23, 145–149. Muris, P. (2002). Relationships between self-efficacy and symptoms of anxiety disorders and depression in a normal adolescent sample. Personality and Individual Differences, 32, 337–348. Note Three items of this questionnaire were taken from Bandura et al. (1999). See: Bandura, A., Pastorelli, C., Barbaranelli, C., & Caprara, G.V. (1999). Self-efficacy pathways to childhood depression. Journal of Personality and Social Psychology, 76, 258–269.
Spider Phobia Questionnaire for Children (SPQ-C) 0 1 Not true True 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
I avoid being in gardens or parks because spiders might be there. Even a toy spider in my hand scares me a bit. Whenever I see a spider on television I close my eyes. I dislike looking at pictures of spiders. When there is a spider above my bed, I am only able to sleep if somebody takes the spider away. I enjoy looking at spiders weaving webs.* The thought of touching a spider scares me. Whenever somebody tells me that there are spiders near me, I start looking around and get nervous. If I think there are spiders in the closet, I keep the door of the closet closed. If I am about to put my shoes on, I would feel very uneasy if a spider would creep out of one of them. If I see a spider, I feel tense.
(To be continued)
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Spider Phobia Questionnaire for Children (SPQ-C) (Continued) 0 1 Not true True 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.
I enjoy reading a story about spiders.* It makes me feel sick when I see a spider. Spiders can be seen as useful because they eat flies.* Thinking of spiders makes me shiver. Some spiders are quite funny to watch.* I think all children are always a bit scared of grabbing a spider. The way spiders walk is an ugly sight. I even do not dare to touch a spider with a stick. If I encounter a spider while playing, I would probably run away. Spiders scare me more than any other animal. I would like to stay away from countries where there are a lot of poisonous spiders. I am careful when picking fruit because there might be spiders in between the fruit. I stay calm if there are spiders around.* When the teacher speaks of spiders I would like to leave the classroom. Spider webs are very beautiful.* I stop reading a story if it is about spiders. If I think that I will run into a spider on my way to school, I will take another route, even if this makes me late for school. I am scared of spiders and also of centipedes and caterpillars.
© Merel Kindt. Reproduced with permission. Scoring *Reversed items. Total score can be obtained by summing ratings on all items (after recoding reversed items). Scores vary between 0 (not at all fearful of spiders) and 29 (extremely fearful of spiders). Key publication Kindt, M., Brosschot, J.F., & Muris, P. (1996). Spider phobia questionnaire for children (SPQ-C): A psychometric study and normative data. Behaviour Research and Therapy, 34, 277–282.
Thought-Action Fusion Questionnaire for Adolescents (TAFQ-A) 1 2 Not at all Somewhat true true 1. You are with a friend. Suddenly without any reason you think that your friend is a stupid person.
3 Rather true
4 Very true
(To be continued)
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Thought-Action Fusion Questionnaire for Adolescents (TAFQ-A) (Continued) 1 2 Not at all Somewhat true true
2.
3.
4.
5.
6.
7.
Question: Having this thought is almost as bad as really saying to your friend that he/she is stupid. Suddenly without any reason you have the thought that you are dying. Question: Having this thought increases the risk that you really are going to die. You are alone in a church, standing in front of a large statue of Jesus. Suddenly you have the thought of spitting on the statue. Question: Having this thought is almost as bad as really spitting on the statue. Suddenly without any reason you have the thought that your father is laid off and that there are financial problems at home. Question: Having this thought increases the risk that your father really will be laid off. You meet a classmate. Suddenly without any reason you think of a term of abuse for this person. Question: Having this thought is almost as bad as abusing this person. Suddenly without any reason you have the thought that you are hit by a car. Question: Having this thought increases the risk that you really will be hit by a car. You are sitting in the classroom. All your classmates are quietly working. Suddenly you have the thought of shouting at the top of your voice.
3 Rather true
4 Very true
(To be continued)
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Thought-Action Fusion Questionnaire for Adolescents (TAFQ-A) (Continued) 1 2 Not at all Somewhat true true
8.
9.
10.
11.
12.
Question: Having this thought is almost as bad as really shouting at the top of your voice in the silent class. Suddenly without any reason you have the thought that you fall seriously ill. Question: Having this thought increases the risk that you really will fall seriously ill. In a silent street, you meet a younger child. Suddenly without any reason you think of pushing the child down. Question: Having this thought is almost as bad as really pushing the child down. Suddenly without any reason you have the thought of your father being in a car accident. Question: Having this thought increases the risk that your father really will have a car accident. You walk on the street and you meet an unfamiliar person. Suddenly you have the thought of making an obscene gesture to this person. Question: Having this thought is almost as bad as really making the obscene gesture to this person. Suddenly without any reason you have the thought that your mother is dying. Question: Having this thought increases the risk that your mother really is going to die sometime soon.
3 Rather true
4 Very true
(To be continued)
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297
Thought-Action Fusion Questionnaire for Adolescents (TAFQ-A) (Continued) 1 2 Not at all Somewhat true true 13. You have heard that the parents of one of your classmates are getting a divorce. Suddenly you have the thought of teasing this classmate with this information. Question: Having this thought is almost as bad as really teasing your classmate with this information. 14. Suddenly without any reason you have the thought that you have to stay back a class. Question: Having this thought increases the risk that you really will stay back a class. 15. You come across your mother’s purse. Suddenly you have the thought of stealing some money from the purse. Question: Having this thought is almost as bad as really stealing money from the purse.
3 Rather true
4 Very true
Scoring Items 1, 3, 5, 7, 9, 11, 13, and 15 = Thought-action fusion—Morality Items 2, 4, 6, 8, 10, 12, and 14 = Thought-action fusion—Likelihood Key reference Muris, P., Meesters, C., Rassin, E., Merckelbach, H., & Campbell, J. (2001). Thought-action fusion and anxiety disorders symptoms in normal adolescents. Behaviour Research and Therapy, 39, 843–852.
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Index
A Abuse panic disorder and, correlation between, 64–65 posttraumatic stress disorder secondary to, 64 Academic self-efficacy, 115 Achenbach scale, 210 ACQ-C. See Anxiety Control Questionnaire for Children Acute stress disorder, 16t Adaptation, 99–100 ADIS C/P. See Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions β-Adrenergic receptors, 257 Adrenocorticotropic hormone, 52 Aetiological models. See Etiological models Age anxiety disorder and, correlation between, 22, 175 genetic influences affected by, 35 Agoraphobia features of, 16t panic disorder and, comorbidity between, 25 prevalence of, 18f Alprazolam, 258t Ambivalent attachment, 85 Amygdala anxiety-related vulnerability and, 48–49 evolutionary influences, 83 fear and, 2, 83 fear conditioning, 48–49 preattentive processing of threatening information by, 49 sensitivity differences in, 49–50 startle reflex and, 50 Anger/frustration temperament, 45 Antenatal stress, 72
Anxiety abnormal, 14–18, 19–22 antenatal, 72 cultural differences, 95–97 definition of, 1–4 description of, 1 developmental patterns in, 6–9 fear vs., 2–3 gender differences in, 12–13 maternal, 72 neuroticism and, 43 normal, 4–6, 9t, 29 prevalence of, 5–6 self-esteem and, 113 severity of, 13–14 societal increase in, 61 three-pathways theory of, 76–79 vulnerability to. See Vulnerability Anxiety Control Questionnaire for Children, 208–209 Anxiety disorder—not otherwise specified, 15 Anxiety disorders. See also specific disorder age and, 22, 175 arousal theory of, 46–47 asthma and, 52 attachment problems as cause of, 85 attention control and, 105 behavioral inhibition levels and, 38–41 biological theory of, 48–52 changeability of, 22 classical conditioning of, 74 cognitive development and, 166 comorbidities. See Comorbidities course of, 19–22 daily functioning impairments secondary to, 22–23 depression and, 27–28 developmental influences on, 22, 174
374
Index
disgust sensitivity and, 57–58 DSM classification of, 14, 26–27 in ethnic minorities, 95 family studies of, 31–37 fear correlated with, 15t fearful temperament and, 45 gender differences in, 18–19 global assessment of functioning scores in youth with, 23, 24f heritability of, 33–37 IQ scores and, 100–101 multifactorial model of, 29–30, 30f onset of, 20 pathogenetic model of, 30f persistence from youth into adulthood, 20–21 posttraumatic stress disorder and, 64–66 prevalence of, 17, 18f prognosis for, 19–22 self-efficacy levels and, 115 shyness and, 42 substance abuse and, 28 substance-induced, 15 suffocation fear and, 52 traumatic events as cause of, 65–66 types of, 16t Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent versions, 216–217, 219t Anxiety sensitivity attentional bias and, 134 definition of, 53, 203 depression and, 55 panic disorder and, 53–55, 203–204 summary of, 170t Anxiety Sensitivity Index for Children, 53 Anxiety symptoms developmental differences in expression of, 7 environmental influences on, 33–34 genetic influences on, 33–34 recurrence of, 13–14 types of, 6t Anxiolytic drugs, 257, 258t Anxious cognition, 207–208 Anxious rearing, 88–89, 111 Arousal theory, 46–47 Assessments behavior rating scales, 210–211 behavioral approach tests, 220–221 behavioral observation, 217, 220
clinician rating scales, 211–213 description of, 193 diagnostic interviews. See Diagnostic interviews monitoring, 221–222 self-monitoring, 221–222 self-report questionnaires. See Self-report questionnaires summary of, 222–223 Asthma, 52 Atenolol, 258t Attachment “ambivalent,” 85 anxiety disorders and, 85 “avoidant,” 85 behavioral inhibition and, 179–180 definition of, 85 insecure, 85–87, 165, 171t patterns of, 85 “secure,” 85 temperament and, 179 Attention control definition of, 103 internalizing symptoms and, 104–105 Attentional bias anxiety sensitivity and, 134 definition of, 130 dot probe paradigm for measuring, 133–135 emotional Stroop test, 130–131 encoding of threatening material and, 130 experimental tasks for, 135–137 modified Stroop task for measuring, 131–133 Autism spectrum disorder, 10 Avoidance behavior, 129 Avoidant attachment, 85 Avoidant disorder, 14 Awareness, 120 B Behavior rating scales, 210–211 Behavioral approach system, 47 Behavioral approach tests, 220–221 Behavioral inhibition anxiety disorders and, correlation between, 38–41 definition of, 37 description of, 165 genetic basis of, 46–52 insecure attachment and, 179–180
Index
neuroticism and, 42–43 prevalence of, 37 social aspects of, 41–42 studies of, 37–42 summary of, 169t Behavioral inhibition system, 47, 109, 169t Behavioral observation, 217, 220 Benzodiazepines, 257, 258t Beta-blockers, 257, 258t Bias attentional. See Attentional bias covariation, 146–147 interpretation, 137–138 memory, 142–143 probability, 147–150 reduced evidence for danger, 139–142 Biopsychosocial model of pain, 161 Boys, 12–13 Brain amygdala. See Amygdala arousal theory, 46–47 behavioral approach system of, 47 behavioral inhibition system, 47 fight-flight system, 47 limbic circuits of, 48–49, 49f Brain stem, 50 Bullying, 71 Buspirone, 257, 258t C Cancer, 63 CAPA. See Child and Adolescent Psychiatric Assessment Case studies, 183–189 CASI. See Childhood Anxiety Sensitivity Index CASI-R. See Childhood Anxiety Sensitivity Index-Revised Catastrophes, 63 Catastrophizing definition of, 154, 175 negative thoughts and, 175 pain, 161 CATS. See Children’s Automatic Thoughts Scale Child and Adolescent Psychiatric Assessment, 215, 218t Child Stress Disorders Checklist, 212–213 Child version of the Post-Traumatic Stress Disorder Reaction Index, 205
375
Childhood Anxiety Sensitivity Index, 53–56, 204 Childhood Anxiety Sensitivity Index-Revised, 204 Childhood Trauma Questionnaire, 205 Children’s Automatic Thoughts Scale, 207–208 Children’s Interview of Psychiatric Syndromes, 214, 218t Children’s Manifest Anxiety Scale, 61 Children’s Negative Cognitive Error Questionnaire, 154, 155t Children’s Thought Questionnaire, 208 Children’s Yale-Brown Obsessive-Compulsive Scale, 212 ChIPS. See Children’s Interview of Psychiatric Syndromes Chronic disease anxiety reactions to, 67–68 posttraumatic stress disorder and, 63 stress caused by, 68 Chronic stress, 68 Classical conditioning, 74 Clinician rating scales, 211–213 Clomipramine, 258t Cognitive avoidance, 2 Cognitive development anxiety disorders and, 166 fear and anxiety manifestations, 9–11 panic and, 11 progression of, 175 vulnerability and, 30 worry and, 10 Cognitive distortions attentional bias. See Attentional bias definition of, 129, 150 dysfunctional thinking secondary to, 150–151 interpretation bias, 137–138 memory bias, 142–143 negative thinking secondary to, 150–151 regulative mechanisms that affect, 149 Cognitive errors, 151, 154–156, 175 Cognitive restructuring, 253 Cognitive-behavioral treatment in community settings, 254 comorbidity and, 245–246 components of, 226 “Coping Koala,” 227, 228t, 233 developmental considerations, 253 effectiveness of, 227, 241, 243–245
376
Index
exposure-based therapy, 226–233 family intervention with, 238–243 group, 236–237, 240 long-term effectiveness of, 243–245 mechanisms of, 265 obsessive-compulsive disorder treated with, 247–249 outcome of, 245–247, 264 with parental involvement, 241–242 pharmacological treatment and, 260–262 post-traumatic stress disorder treated with, 249–256 programs for, 234–238, 254 research recommendations for, 252–253 responsiveness to, 246 in school settings, 254–255 summary of, 252–256 Comorbidities cognitive-behavioral treatment and, 245–246 depression, 27 description of, 23, 25, 245 panic disorder and agoraphobia, 25 posttraumatic stress disorder, 25 prevalence of, 25 Conditioning classical, 74 fear, 48–49, 74–75 summary of, 170t Congenital hypoventilation syndrome, 52 Contingency management. See Reinforced practice Contingency-competence-control model, 111 Control parental, 90–92, 109, 110f perceived. See Perceived control sense of, during development, 109 Coping definition of, 116 dimensions of, 117 disengagement, 117–118 emotion-focused, 117 engagement, 117–118 maladaptive, 124 perspectives on, 117 problem-focused, 117–118 situational factors that affect, 118 summary of, 124, 172t “Coping Koala,” 227, 228t, 233 Corticotropin releasing hormone, 52
Cortisol, 52, 72 Covariation bias, 146–147 CPTSD-RI. See Child version of the PostTraumatic Stress Disorder Reaction Index CSDC. See Child Stress Disorders Checklist CTQ. See Children’s Thought Questionnaire Cultural differences, 95–97 CY-BOCS. See Children’s Yale-Brown Obsessive-Compulsive Scale D Defense mechanisms, 120–122, 124, 172t Depression anxiety disorders and, comorbidity between, 27–28 anxiety sensitivity as predictor of, 55 neuroticism and, 54 Desipramine, 258t Development anxiety disorders affected by, 174 genetic influences correlated with, 35 normal fear and anxiety based on, 8–9 patterns of, 6–9 perceived control importance influenced by, 111 rituals and, 8 sense of control during, 109 treatment considerations, 265 Developmental psychopathology, 167–168 Diagnostic Interview for Children and Adolescents, 215, 218t Diagnostic Interview Schedule for Children, 214, 218t Diagnostic interviews description of, 213 highly structured, 214–215 semistructured, 215–217 Diazepam, 258t DICA. See Diagnostic Interview for Children and Adolescents Disasters, 63 DISC. See Diagnostic Interview Schedule for Children Disengagement coping, 117–118 Disgust sensitivity, 57–58, 170t Disruptive behavior disorders anger/frustration temperament and, 45 characteristics of, 104
Index
Dissociation, 121–122 Distal threat, 2 Dominic questionnaire, 209 Dot probe paradigm, 133–135 Dynamic multifactorial model case study of, 183–187 description of, 168–176 empirical evidence for, 176–183 schematic diagram of, 173f Dysfunctional thinking cognitive distortions as cause of, 150–151 summary of, 171t worry, 151–153 E Educational achievement, 23 Effortful control description of, 103–107, 172t neuroticism and, 181–182 Ego development, 22 Ego-control, 101 Ego-resilience, 101 EMDR. See Eye-movement desensitization and reprocessing Emotion(s) expressed, 92 negative low self-esteem and, 113 three-factor model of, 3 tripartite model of, 27–28 self-regulation of, 122–123 Emotion regulation, 122–124, 172t, 265 Emotional reasoning, 144–145 Emotional self-efficacy, 115 Emotional Stroop test, 130–131 Emotion-focused coping, 117 Emotive imagery, 229–230, 230t Engagement coping, 117–118 Environmental influences anxiety symptoms, 33–34 conditioning experiences, 74–76 cultural differences, 95–97 gender role orientation, 93–95, 171t negative life events, 66–70 overview of, 61 peer victimization, 70–72, 170t present-day society and, 61, 97 summary of, 67 temperament and, 176–177
377
traumatic events, 62–66 twin studies of, 33 Ethnic minorities, 95 Etiological models behavioral inhibition, 165 description of, 163–167 developmental psychopathology perspective, 167–168 dynamic multifactorial. See Dynamic multifactorial model insecure attachment, 165 Manassis and Bradley’s, 166 of phobias, 164–165 summary of, 190–191 temperament, 180–181 Evolutionary influences, 83 Executive functioning, 103, 105 Exposure-based therapy description of, 226, 229 reinforced practice, 230–232 summary of, 233 systematic desensitization, 229–230 Expressed emotion, 92 Externalizing symptoms, 43, 45 Eye-movement desensitization and reprocessing, 232–233, 251 Eysenck’s theory, 47 F False beliefs, 158–159 Family influences insecure attachment, 85–87, 165, 171t parental rearing behaviors. See Parental rearing behaviors Family interventions with cognitive-behavioral treatment, 238–243 Fear(s) abnormal, 14–18 anxiety vs., 2–3 cultural differences, 95–97 definition of, 1–4 description of, 1 developmental patterns in, 6–9 evolutionary influences, 83 gender differences in, 12–13 genetic influences on, 33 negative information and, 80–82, 97 normal, 4–6, 9t, 29 of pain, 161
378
Index
preparedness theory, 83–85 recurrence of, 13–14 severity of, 13–14 three-pathways theory of, 76–79 types of, 4 Fear conditioning amygdala’s role in, 48–49 model of, 75f studies of, 74–75 Fear Frequency and Avoidance Survey Schedule for Children, 13 Fear of suffocation, 51 Fearful temperament, 45 Fight-flight system, 47 Filmed modeling, 232 Fluoxetine, 258t, 262 Fluvoxamine, 258t Freud, Sigmund, 187–189, 225 FRIENDS program, 238–240, 239t FSSC-R. See Revised Fear Survey Schedule for Children G Gamma-aminobutyric acid receptors, 257 Gender anxiety and, 12–13 anxiety disorders and, 18–19 fear and, 12–13 genetic influences affected by, 35 phobias and, 18 social support benefits and, 125 Gender role orientation, 93–95, 171t General genetic factors behavioral inhibition. See Behavioral inhibition description of, 37 neuroticism. See Neuroticism trait anxiety, 46, 169t Generalized anxiety disorder course of, 21 depression and, 27 features of, 16t heritability of, 34 intolerance of uncertainty associated with, 158 perfectionism in, 158–159 prevalence of, 5, 18f psychosocial maturity and, 22 self-report questionnaires for, 203
twin studies of, 34–35 Genetic influences anxiety sensitivity. See Anxiety sensitivity anxiety symptoms, 33–34 behavioral inhibition. See Behavioral inhibition description of, 37 development and, correlation between, 35 disgust sensitivity, 57–58, 170t general genetic factors. See General genetic factors neuroticism. See Neuroticism specific genetic factors, 37, 53–56 studies to support, 31–37 summary of, 169t trait anxiety, 46, 169t twin studies, 33 vulnerability, 37 Girls anxiety disorders in, 18–19 fear levels in, 12–13 phobias in, 18 Global assessment of functioning scores, 23, 24f, 198 H Hamilton Anxiety Rating Scale, 211–212 HARS. See Hamilton Anxiety Rating Scale Heritability, 33–37. See also Genetic influences Highly structured interviews, 214–215 Hippocampus, 50 Hypochondriasis, 17 Hypothalamic-pituitary-adrenal axis description of, 52 stress effects on, 72 in traumatized individuals, 72–73 I IES. See Impact of Event Scale Imipramine, 258t, 260–261 Impact of Event Scale, 205 Impulsive behavior, 47 Indirect learning experiences, 170t Information-processing abnormalities attentional bias. See Attentional bias covariation bias, 146–147 description of, 130 emotional reasoning, 144–145 interpretation bias, 137–138
Index
memory bias, 142–143 probability bias, 147–150 reduced evidence for danger bias, 139–142 regulative factors that affect, 149 research of, 149 summary of, 162, 171t Inhibitory control, 103 Insecure attachment behavioral inhibition and, 179–180 description of, 85–87, 165 summary of, 171t Internalizing symptoms attention control and, 104–105 cognitive errors and, 154–155 effortful control and, 104 neuroticism and, 43, 45 peer victimization and, 70 positive life events effect on, 125 stressful life events effect on, 125 Interpretation bias, 137–138 Interview Schedule for Children and Adolescents, 216, 219t Interviews description of, 213 highly structured, 214–215 semistructured, 215–217 Intolerance of uncertainty, 158 Inventory of Parent and Peer Attachment, 85 IQ, 100–101 ISCA. See Interview Schedule for Children and Adolescents K Koala Fear Questionnaire (KFQ), 209–210 K-SADS. See Schedule for Affective Disorders and Schizophrenia for school-age children L Learning experiences modeling, 79–80 negative information, 80–82, 97 three-pathways theory, 76–79 Leyton Obsessional Inventory for Children, 204 Liebowitz Social Anxiety Scale for Children and Adolescents, 212 Life-threatening events, 62–63 Limbic brain circuits amygdala. See Amygdala
379
hippocampus, 50 hyperexcitability of, 51 periaqueductal gray areas, 50 septum, 50 Live modeling, 232 Locus of control, 107 LOI-C. See Leyton Obsessional Inventory for Children LSAS-CA. See Liebowitz Social Anxiety Scale for Children and Adolescents M Maintaining factors attentional bias. See Attentional bias covariation bias, 146–147 description of, 129, 130 emotional reasoning, 144–145 interpretation bias, 137–138 memory bias, 142–143 probability bias, 147–150 reduced evidence for danger bias, 139–142 regulative factors that affect, 149 research of, 149 summary of, 162 Maladaptive coping, 124 Maladaptive schemas, 155–156 MASC. See Multidimensional Anxiety Scale for Children Maternal anxiety, 72 Memory bias, 142–143 Metacognition, 160–161 Modeling anxiety disorders and, 79–80 bias formation and, 149 phobias treated with, 232 Modified Stroop task, 131–133 Monitoring, 221–222 Motivational model of emotion, 116 Multidimensional Anxiety Scale for Children, 195–196, 200t N NASSQ. See Negative Affect Self-Statement Questionnaire Negative affect, 27 Negative Affect Self-Statement Questionnaire, 207 Negative affectivity, 44–45
380
Index
Negative emotions low self-esteem and, 113 three-factor model of, 3 tripartite model of, 27–28 Negative information, 80–82, 97 Negative learning experiences, 187–188 Negative life events anxiety disorders and, 125 description of, 66–70, 69t phobias and, 73 summary of, 170t Negative self-evaluation, 156–158 Negative self-speech, 153–154 Negative thinking cognitive errors, 154–156 description of, 150–151 scales for measuring, 207–208 summary of, 171t Neurotic anxiety, 120 Neuroticism anxiety and, 43, 181 arousal theory of, 47 behavioral inhibition and, 42–43 behavioral inhibition system and, 47 child psychopathology and, 42–46 definition of, 42 depression and, 54 disgust sensitivity and, 57 effortful control and, 181–182 etiology of, 164 externalizing symptoms and, 44 fight-flight system and, 47 general genetic component and, 37 genetic basis of, 46–52 internalizing symptoms and, 43 lower-order traits of, 45 summary of, 169t Nonassociative fear acquisition, 84–85 O Obsessive-compulsive disorder cognitive theory of, 159 cognitive-behavioral treatment for, 247–249 features of, 16t metacognition in, 160–161 obsessions commonly present in, 129 pharmacological treatment of, 259–260, 264 rituals, developmental-based studies of, 8
self-report questionnaires for, 204 thought-action fusion in, 159–160, 162 Oedipus complex, 187 “Ontogenetic parade,” 8, 174 Operant conditioning, 167 Outcome contingency, 111 Overanxious disorder, 14 Overcontrolled personality type, 101–102 Overgeneralizing, 154 Oxazepam, 258t P Pain, fear of, 161 Panic, 11 Panic attacks anxiety sensitivity and, 54 phobias and, 51 Panic disorder agoraphobia and, comorbidity between, 25 anxiety sensitivity and, 53–55, 203–204 family studies of, 31–32 features of, 16t genetic influences, 31–32 selective serotonin reuptake inhibitors for, 263 self-report questionnaires for, 203–204 sexual abuse and, 64–65 symptoms of, 144 traumatic events as precipitant of, 64 Parental care, 92–93 Parental control, 90–92, 109, 110f Parental divorce, 67 Parental insensitivity, 178 Parental rearing behaviors anxious rearing, 88–89, 111 description of, 88 expressed emotion, 92 parental care, 92–93 parental control, 90–92, 109, 110f perceived control and, 109–110 summary of, 171t Parental rejection, 93 Paroxetine, 258t PARS. See Pediatric Anxiety Rating Scale Pediatric Anxiety Rating Scale, 211–212 Peer victimization, 70–72, 170t Penn State Worry Questionnaire, 203 Perceived control anxiety levels and, 107–108
Index
components of, 111 definition of, 107 developmental influences on role of, 111 diminishments in, 108 outcome contingency and, 111 parental rearing behaviors’ effect on, 109–110 personal competence and, 111 summary of, 172t Perfectionism, 158–159 Periaqueductal gray areas, 50 Personal competence, 111 Personalizing, 154 Pervasive developmental disorder, 10 Pharmacological treatment anxiolytic drugs, 257, 258t cognitive-behavioral treatment and, 260–262 description of, 256 mechanisms of, 265–266 of obsessive-compulsive disorder, 259–260 outcome studies of, 264 trends in, 263–264 Phobias arousal theory of, 46–47 conditioning experiences, 74 covariation bias and, 146 disgust sensitivity and, 57 etiological models of, 163–167 exposure-based therapy for description of, 226, 229 reinforced practice, 230–232 summary of, 233 systematic desensitization, 229–230 fear as expression of, 14 gender differences in, 18 negative life events and, 73 panic attacks and, 51 preparedness theory, 83–84 prevalence of, 17 social. See Social phobia specific. See Specific phobia three-pathways theory, 76–79 types of, 16t Physical harm cognitive development and, 10 fear of, 7–8 Physiological hyperarousal, 27–28
381
PICA. See Pictorial Instrument for Children and Adolescents Pictorial Instrument for Children and Adolescents, 216–217, 219t POSA. See Preschool Observation Scale of Anxiety Positive affect, 28 Posttraumatic stress disorder anxiety disorders with, 64–66 cancer and, 63 catastrophes as cause of, 63 cognitive-behavioral treatment for, 249–256 comorbidities, 25 disasters as cause of, 63 dissociation and, 121–122 eye-movement desensitization and reprocessing for, 251 features of, 16t IQ scores and, 101 life-threatening events and, 62–63 motor vehicle trauma and, 64 prevalence of, 18f selective serotonin reuptake inhibitors for, 263 self-report questionnaires for, 205–206 sexual abuse and, 64 symptoms of, 62 traumatic events and, 62–64 Preparedness theory, 83–85 Preschool Observation Scale of Anxiety, 220 Probability bias, 147–150 Problem-focused coping, 117–118 Propranolol, 258t Protective factors coping, 117–120, 124 defense mechanisms, 120–122, 124, 172t description of, 99 effortful control, 103–107, 172t emotion regulation, 122–124, 172t, 265 relationship among, 126 resilience, 99–102 self-efficacy. See Self-efficacy self-esteem. See Self-esteem social support, 124–126 summary of, 126–127, 172t vulnerability factors and, interactions between, 29, 126 Psychopathology defense mechanisms and, 120–121
382
Index
developmental, 167–168 dysfunctional emotion regulation and, 123 effortful control and, 103–104 neuroticism and, 42–46 personality correlates of, 44 Psychosocial maturity, 22 R Rating scales behavior, 210–211 clinician, 211–213 RCMAS. See Revised Children’s Manifest Anxiety Scale Rearing behaviors anxious rearing, 88–89, 111 description of, 88 expressed emotion, 92 parental care, 92–93 parental control, 90–92 perceived control and, 109–110 summary of, 171t Reciprocal inhibition, 229 Reduced evidence for danger bias, 139–142 Regulative temperament factors, 103–107 Reinforced practice, 230–232 Resilience, 99–102 Revised Children’s Manifest Anxiety Scale, 194–195, 199, 200t, 209 Revised Fear Survey Schedule for Children, 4, 194–195, 199, 200t Rituals, 8 S SAS-A. See Social Anxiety Scale for Adolescents SASC-R. See Social Anxiety Scale for Children–Revised SAT. See Separation Anxiety Test SCARED. See Screen for Child Anxiety Related Emotional Disorders SCAS. See Spence Children’s Anxiety Scale Schedule for Affective Disorders and Schizophrenia for school-age children, 215–216, 219t School functioning, 13 School Refusal Assessment Scale, 206 Screen for Child Anxiety Related Emotional Disorders, 105, 195–197, 201t
Screen for Child Anxiety Related Emotional Disorders-Revised, 197–198, 201t SDQ. See Strengths and Difficulties Questionnaire Secure attachment, 85 Selective abstraction, 154 Selective mutism, 17 Selective serotonin reuptake inhibitors description of, 257, 258t obsessive-compulsive disorder treated with, 259–260 panic disorder treated with, 263 post-traumatic stress disorder treated with, 263 Self-efficacy academic, 115 anxiety disorders and, 115 definition of, 112, 114 emotional, 115 function of, 114 social, 114 summary of, 172t Self-esteem anxiety and, 113 definition of, 112 development of, 112 mental health and, 112–113 peer victimization and, 72 shyness effects on, 42 social support effects on, 112 societal increases in, 113–114 summary of, 172t terror management theory, 113 well-being and, 112–113 Self-monitoring, 221–222 Self-report questionnaires description of, 193–194 generalized anxiety disorder, 203 Multidimensional Anxiety Scale for Children, 195–196, 200t obsessive-compulsive disorder, 204 panic disorder, 203–204 posttraumatic stress disorder, 205–206 Revised Children’s Manifest Anxiety Scale, 194–195, 199, 200t Revised Fear Survey Schedule for Children, 4, 194–195, 199, 200t Screen for Child Anxiety Related Emotional Disorders, 195–197, 201t
Index
Screen for Child Anxiety Related Emotional Disorders-Revised, 197–198, 201t selection of, 198–199, 200t–201t separation anxiety disorder, 203 social phobia, 202–203 specific phobias, 206–207 Spence Children’s Anxiety Scale, 195–196, 201t State-Trait Anxiety Inventory for Children, 194–195, 199, 200t summary of, 223 for young children, 209–210 Self-speech, negative, 153–154 Semistructured interviews, 215–217 Separation anxiety disorder age of patient, 22 course of, 21 developmental influences, 175 DSM classification of, 14 features of, 16t genetic influences, 31–32 heritability of, 22 prevalence of, 18f psychosocial maturity and, 22 self-report questionnaires for, 203 twin studies of, 34–35 Separation Anxiety Test, 203 Septum, 50 Sertraline, 258t, 261 Sexual abuse panic disorder and, correlation between, 64–65 posttraumatic stress disorder secondary to, 64 Shyness, 41–42 Social Anxiety Scale for Adolescents, 202 Social Anxiety Scale for Children–Revised, 202 Social norms, 96 Social phobia behavioral inhibition and, correlation between, 41 comorbidities, 27 features of, 16t negative self-evaluation in, 156–158 prevalence of, 5, 18f self-report questionnaires for, 202–203 social skill deficits in, 156–158
383
Social Phobia and Anxiety Inventory for Children, 202 Social self-efficacy, 114 Social skill deficits, 156–158 Social support anxiety and, 124–125 self-esteem affected by, 112 stressor severity and, 125 summary of, 172t Social-evaluative fears, 10–11 SPAI-C. See Social Phobia and Anxiety Inventory for Children Specific genetic factors anxiety sensitivity, 53–56 description of, 37 Specific phobia covariation bias and, 146 features of, 16t prevalence of, 18f self-report questionnaires for, 206–207 Spence Children’s Anxiety Scale, 195–196, 201t Spider Phobia Questionnaire for Children, 206 SPQ-C. See Spider Phobia Questionnaire for Children SRAS. See School Refusal Assessment Scale STAIC. See State-Trait Anxiety Inventory for Children Startle reflex, 50 State-Trait Anxiety Inventory for Children, 46, 194–195, 199, 200t Strengths and Difficulties Questionnaire, 210 Stress antenatal, 72 chronic, 68 chronic disease as cause of, 68 negative life events as cause of, 66–67 neurobiological consequences of, 72–74 social support effects on adjustment to, 125 summary of, 170t Subcortical arousal, 51 Subcortical brain circuits, 169t Substance abuse, 28 Substance-induced anxiety disorder, 15 Suffocation fear anxiety disorders and, 52 description of, 51 Suppression, 122 Systematic desensitization, 229–230
384
Index
T TAI. See Test Anxiety Inventory Teasing, 71 Temperament attachment and, 179 brain systems that affect, 47 empirical evidence regarding, 176–183 environmental influences and, 176–177 etiological role of, 180–181 fearful, 45 parental insensitivity and, 178 Temperament model, 106f Terror management theory, 113 Test Anxiety Inventory, 207 Thought processes negative self-evaluation, 156–158 perfectionism, 158–159 scales for measuring, 207–208 social skill deficits, 156–158 Thought-action fusion, 159–160, 162 Threat(s) distal, 2 fear and, 2 new types of, 4 preattentive processing of, 49 Threat imminence model, 2 Threat perception abnormalities, 150 Trait anxiety, 46, 169t Traumatic events anxiety disorders secondary to, 65–66 catastrophes, 63 definition of, 62 disasters, 63 neurobiological consequences of, 72–74 panic disorder and, correlation between, 64 posttraumatic stress disorder and, 62–64 summary of, 170t Treatment cognitive-behavioral. See Cognitivebehavioral treatment developmental considerations, 265 outcome studies of, 264–266 overview of, 225–226 pharmacological. See Pharmacological treatment Tricyclic antidepressants, 257, 258t, 259
U Uncertainty, intolerance of, 158 Undercontrolled personality type, 101–102 V VAA-R. See Visual Analogue Scale for Anxiety-Revised Vicarious learning, 232 Viscero-cortical circuit, 47 Visual Analogue Scale for Anxiety-Revised, 206–207 Vulnerability amygdala and, 48–49 cognitive development periods and, 30, 175 frontal brain asymmetries and, 51 genetic influences, 37, 58. See also Genetic influences overview of, 29 Vulnerability factors anxiety sensitivity, 53 behavioral inhibition as, 38 insecure attachment, 85–87, 165, 171t interactions among, 179–180 neuroticism. See Neuroticism protective factors and, interactions between, 29, 126 summary of, 169t–172t, 174 W Worry adaptive benefits of, 151 anxiety disorders and, 15t, 152–153 cognitive development and, 10 definition of, 151 developmental pattern of, 7 false beliefs about, 158–159 functions of, 2 intolerance of uncertainty and, 158 Penn State Worry Questionnaire, 203 studies of, 151–152 Y Yale-Brown Obsessive-Compulsive Scale, 259 Young Schema Questionnaire, 156
