The development of anxiety disorders: considering the contributions of attachment and emotion regulation.

Anxiety disorders are among the most common psychiatric disorders in childhood. Nonetheless, theoretical knowledge of the development and maintenance of childhood anxiety disorders is still in its infancy. Recently, research has begun to investigate the influence of emotion regulation on anxiety disorders. Although a relation between anxiety disorders and emotion regulation difficulties has been demonstrated, little attention has been given to the question of why anxious individuals have difficulties regulating their emotions. The present review examines the evidence of the link between emotion regulation and anxiety. It also explores the unique contributions of attachment style and dysfunctional emotion regulation to the development of anxiety disorders.

Mothers' mental distress and parenting practices with infants and toddlers.

The purpose of this study was to examine whether maternal mental distress affects parenting practices related to monitoring activities (i.e. daily routines, enrichment activities). The nationally representative sample consisted of 1638 mothers. Maternal mental distress was assessed by the 5-item Mental Health Index (MHI). Logistic regression models were conducted, controlling for covariates (e.g. marital status, education level, etc.). Approximately 14% of the women reported high levels of mental distress and 25% of the women failed to engage in enrichment activities or consistent daily routines with their children. There was a significant adverse relationship between mental distress and routines, with women who were mentally distressed being more likely to not engage in daily routines. There was no significant relationship between mental distress and enrichment activities. Race differentials were evident among these relationships. These findings highlight the prevalence of maternal mental distress and its deleterious effects on select parenting behaviors.

What is the Revised Fear Survey Schedule for Children measuring?

The Fear Survey Schedule for Children-Revised (FSSC-R) is a widely used self-report questionnaire that purports to measure the number of fears and the overall level of fearfulness in children. A number of studies have shown that the ten most common childhood fears can be found on the Danger and Death subscale of the FSSC-R, with upwards of 50% of children endorsing such fears. However, some researchers (e.g., H. McCathie & S.H. Spence, 1991; Behaviour Research and Therapy, 29, 495-502) have questioned the validity of these findings, suggesting that these items do not reflect actual childhood fears that children have or experience on a daily or regular basis. Rather, they suggest that children are responding to these fear items as if they were actually occurring to them in the here and now. The current study examined the occurrence of five Danger and Death fears from the FSSC-R (i.e., "Not being able to breathe", "Being hit by a car or truck", "Falling from high places", "Bombing attacks or being invaded", and "Fire or getting burned") in a sample of normal school children aged eight to 12 years (N=102). More specifically, we used three different methods to asses these fears: (1). prevalence as determined by the standard FSSC-R procedure, (2). prevalence as determined by a fear list procedure, and (3). actual occurrence or prevalence of these fears in the past week, as determined by a diary method. Results indicated that while these fears ranked high when using the standard FSSC-R procedure, they were considerably less common when using the fear list procedure, and had a low probability of actual occurrence on a daily basis, as well as possessing a short duration and low intensity. Implications for the assessment of fears and the use of self-report measures like the FSSC-R are briefly discussed.

Self-reported anxiety in children and adolescents: a three-year follow-up study.

Anxiety may be more transient in children and adolescents than in adults. The present study involves a longitudinal design enabling the investigation of the continuity/discontinuity of self-reported anxiety in children and adolescents. A sample of 68 children was followed over 3 years. Results indicate that, on the whole, self-reported anxiety decreased over time. This was true for overall anxiety and its sub-types, with the exception of social concerns/concentration, which did not decrease over time. Consistent with past research involving normal fear, girls and younger children were found to score higher on anxiety than boys and older children did. However, those groups scoring higher at inception also demonstrated the most marked decreases over the 3-year period. In addition to the changes found over time, the data indicated continuity in anxiety such that levels of anxiety at inception were significant predictors of follow-up anxiety, although only a small amount of variance was shared. The authors concluded that adult models of anxiety cannot be applied to youth and that future research should investigate the contribution of contextual factors to the development of anxiety in children.

Empirically supported psychological interventions: controversies and evidence.

Efforts to increase the practice of evidence-based psychotherapy in the United States have led to the formation of task forces to define, identify, and disseminate information about empirically supported psychological interventions. The work of several such task forces and other groups reviewing empirically supported treatments (ESTs) in the United States, United Kingdom, and elsewhere is summarized here, along with the lists of treatments that have been identified as ESTs. Also reviewed is the controversy surrounding EST identification and dissemination, including concerns abou research methodology, external validity, and utility of EST research, as well as the reliability and transparency of the EST review process.

Children's nighttime fears: parent-child ratings of frequency, content, origins, coping behaviors and severity.

The present study investigated nighttime fears in normal school children aged 4 to 12 yr (N=176). Children and their parents were interviewed about the frequency, content, origins, coping behaviors and severity of children's nighttime fears. Results showed that 73.3% of the children reported nighttime fears, indicating that these fears are quite prevalent. Inspection of the developmental course of nighttime fears revealed that these fears are common among 4- to 6-year-olds, become even more frequent in 7- to 9-year-olds and then remain relatively stable in 10- to 12-year-olds. Inspection of the origins of nighttime fears revealed that most of the children (i.e., almost 80%) attributed their fear to negative information; conditioning and modeling were endorsed less frequently (25.6% and 13.2%, respectively). A substantial percentage of the children (24.0%) indicated that learning experiences had not played a role in the acquisition of their nighttime fears. Children reported a variety of coping strategies in order to deal with their nighttime fears and generally rated these strategies as helpful in reducing anxiety. Furthermore, children's nighttime fears were associated with moderate levels of anxiety. Moreover, in about 10% of the children, nighttime fears were related to one or more DSM-III-R anxiety disorders. Finally, parental reports of children's nighttime fears substantially deviated from children's reports. Most importantly, parents provided a marked underestimation of the frequency of nighttime fears, at least as reported by their children.

A cross-cultural and developmental analysis of self-esteem in Chinese and Western children.

In this review, we examine the construct of self-esteem from a cross-cultural perspective in Chinese and Western children and adolescents. We also explore the role of childrearing practices in the development of self-esteem in these different cultures. In doing so, we first review the concepts of emic (i.e., variations in patterns of behavior within a given culture) and etic research (i.e., variations in common patterns of behavior or activities across cultures). Then, we invoke Berry's notions of "imposed-etic" and "derived-etic" approaches (J. Berry, 1989) in understanding crucial cross-cultural differences that are evident in the literature. We pose basic questions such as: (1) What does self-esteem "look" like in Chinese children? (2) How do childrearing practices in China influence the development of self-esteem in children? And, (3) what are the limitations of cross-cultural research in understanding a phenomenon such as self-esteem? We suggest that self-esteem does not "mean" the same things across these collectivist and individualistic cultures. We conclude our discourse with specific recommendations for clinical theory, research, and practice.

Fear in children and adolescents: relations with negative life events, attributional style, and avoidant coping.

In this study, we explored relations among negative life events, negative attributional style, avoidant coping, and level of fear in 99 children who had survived residential fires. Overall, negative life events, negative attributional style, and avoidant coping were found to be predictive of levels of fear. However, the relation between negative life events and fear was moderated by mother's level of education such that this prediction was obtained only for those children whose mothers were low in education level. Age, ethnicity, and sex did not moderate these relations. In addition, negative attributional style and avoidant coping were related to levels of fear in those children whose mothers were high in education levels but not those whose mothers were low in education level. Results are discussed within a stress and coping framework.

Prevalence of anxiety and depression in Australian adolescents: comparisons with worldwide data.

Data from two Australian studies were combined so that the prevalence of anxiety and depression in a large, normative sample of Australian adolescents could be investigated. The combined sample comprised 1,299 adolescents randomly selected from metropolitan and country schools in Melbourne, a large Australian city. The data were examined in order to ascertain the percentages of adolescents who scored above the clinical cut-off on two self-report instruments--the Revised Children's Manifest Anxiety Scale (C. R. Reynolds & B. O. Richmond, 1985) and the Reynolds Adolescent Depression Scale (W. M. Reynolds, 1986). The results of these analyses were then compared with previously reported prevalence rates from studies worldwide. This comparison revealed striking differences in the prevalence of anxiety and depression across different countries and cultures. Limitations attributable to different self-report measures and imposed-etic approaches are discussed. Issues pertaining to social and political climate are also raised.

Treating sexually abused children with posttraumatic stress symptoms: a randomized clinical trial.

OBJECTIVE: To evaluate the efficacy of child and caregiver participation in the cognitive-behavioral treatment of sexually abused children with posttraumatic stress symptoms. METHOD: Thirty-six sexually abused children (aged 5-17 years) were randomly assigned to a child-alone cognitive-behavioral treatment condition, a family cognitive-behavioral treatment condition, or a waiting-list control condition. RESULTS: Compared with controls, children who received treatment exhibited significant improvements in posttraumatic stress disorder symptoms and self-reports of fear and anxiety. Significant improvements also occurred in relation to parent-completed measures and clinician ratings of global functioning. In general, parental involvement did not improve the efficacy of cognitive-behavioral therapy. Maintenance of improvement was evident at a 12-week follow-up assessment. CONCLUSIONS: Cognitive-behavioral treatment was useful, but further research is required on caregiver involvement.

Expanded school mental health services: assessing needs related to school level and geography.

We surveyed 62 school administrators from three midatlantic (MD, VA, WV) and one northeastern (CT) state on factors relevant to developing school-based mental health programs. Administrators were from schools that varied on education level (elementary, middle, and high) and geographic location (urban, suburban, and rural), with equivalent numbers in each subgroup. Administrators provided ratings to questions grouped in five categories: (a) Stressful Conditions, (b) Internalizing Behavioral Problems, (c) Externalizing Behavioral Problems, (d) Substance Abuse, and (e) Barriers to Mental Health Care, and provided open-ended comments on needs of youth and mental health programs for them. They rated behavioral and substance abuse problems as progressively more serious as students advanced in school level. Urban youth were reported to encounter higher stress and present more severe internalizing problems than suburban or rural youth. Suburban and rural schools provided more health and mental health services than urban schools. Across geographic locales, physical health services far outnumbered mental health services. Findings related to barriers to mental health care, and the viability of schools as delivery sites for comprehensive mental health services, are discussed.

Research on the cognitive-behavioral treatment of school refusal: a review and recommendations.

Cognitive-behavior therapy is frequently used in the treatment of school refusal, a challenging problem for mental health professionals and school authorities. We review the clinical and research support for the efficacy of cognitive-behavior therapy using recently published guidelines for determining the level of evidentiary support for psychosocial interventions. Although cognitive-behavior therapy appears to be a useful treatment for school refusal, further research is needed before it can be considered as having "well-established" empirical status. Several other important methodological and theoretical issues are emphasized.

Developmental theory and the practice of clinical child psychology.

Examined developmental theory and its relevance for the practice of clinical child psychology. Following a brief review of basic principles of developmental psychology and developmental psychopathology, implications of a developmental perspective are explored for the diagnosis, assessment, and treatment of childhood disorders. Although it is obvious that many developmental issues confront the clinical child psychologist and that we have learned much about translating developmental theory into clinical practice, we conclude we have a long way to go before we can assert that a true developmental-clinical child interface has been realized.

Cross-cultural aspects of fears in African children and adolescents.

The purpose of this study was to compare level and type of fears in Nigerian and Kenyan children using the Fear Survey Schedule for Children, Revised (FSSC-R; [Ollendick, T.H. (1983). Reliability and validity of the Revised Fear Survey Schedule for Children (FSSC-R). Behaviour Research and Therapy, 21, 685-692]). A total of 852 males and females between the ages of 8 and 17 were surveyed. Results indicated that Nigerian children reported significantly higher total fear than Kenyan children and that scores from both countries were higher than those found in the United States, Australia and China. This suggests that the cultures of Kenya and Nigeria may share a common variable that makes reporting of fears greater than that reported by children of other world cultures. In addition, Christian children in both countries reported higher levels of fear on several factors than Muslim children, indicating that Islamic beliefs may encourage children to report less fear or to deal with their fears better than Christian beliefs. Finally, children between the ages of 8 and 12 reported greater fear of the unknown than children between 13 and 17 years of age. Overall, these findings suggest that important cultural, religious and age differences exist for levels of childhood fears reported in Nigeria and Kenya.

Does anxiety mitigate the behavioral expression of severe conduct disorder in delinquent youths?

The purpose of this article is to examine the purported attenuating effects of comorbid anxiety on conduct disturbance in a sample of youths exhibiting severe Conduct Disorder (CD). Further, we examined the differential expression of CD and comorbid anxiety in male and female youths. Seventy-nine incarcerated youths between the ages of 12 and 19 were interviewed using the Diagnostic Interview Schedule for Children. Youths were identified who exhibited CD and CD plus an anxiety disorder. In contrast to previous findings with younger, less seriously disturbed male subjects, no overall differences were found between CD anxious and CD nonanxious youths in terms of age of first offense and overall number and severity of delinquent acts. Moreover, no differences were found between males and females, and gender did not moderate the effects of comorbidity anxiety on outcome measures. Findings suggest purported mitigating effects of anxiety on conduct disturbance may be attenuated in severe forms of CD and support the notion that comorbidity across internalizing and externalizing domains of child and adolescent psychopathology may differentially impact clinical presentation of disordered behavior depending on the severity of externalizing behavioral disturbance.

Panic disorder in children and adolescents: new developments, new directions.

Reviewed panic attacks and panic disorders in children and adolescents critically and highlighted new developments. It is concluded that panic attacks and panic disorder are common in adolescence and that they are responsive to cognitive-behavioral treatment regimens. It is also concluded that although panic attacks and panic disorder are less common in children, they are nonetheless present. It is important to note, however, that their expression in childhood may vary from the clinical features seen in adolescence and adulthood. Specifically, it is suggested that most panic attacks in childhood are associated with particular events and are not unexpected or "out of the blue." Moreover, noncatastrophic interpretations of the symptoms of panic prevail. A developmental model for the onset, course, and correlates of panic in children is put forth.

Empirically supported treatments for children with phobic and anxiety disorders: current status.

Reviews the empirically supported status of behavioral and cognitive-behavioral interventions in the treatment of childhood phobias and anxiety disorders. For childhood phobias, it is concluded that imaginal desensitization, in vivo desensitization, filmed modeling, live modeling, and cognitive-behavioral interventions that use self-instruction training are probably efficacious and that participant modeling and reinforced practice are well established. For anxiety disorders, only cognitive-behavioral procedures with and without family anxiety management (FAM) were found to be probably efficacious. However, much of the support for these procedures comes from analogue studies conducted in research laboratory or school settings, delivered in small-group format and, not infrequently, with nonclinically referred children. Additional research that examines high-strength interventions with clinic-referred children is recommended. Furthermore, research that examines the pathological processes involved in the onset and maintenance of phobic and anxiety disorders as well as the change processes used to treat these disorders is called for.

Etiology of childhood phobias: current status of Rachman's three pathways theory.

Despite advances in the assessment and treatment of childhood phobias, little is known about their etiology. Rachman has proposed that phobias are acquired through three different pathways: direct conditioning, modeling or instructions/information. We evaluate the empirical support for Rachman's theory in relation to the origins of childhood phobias. Although we find support for Rachman's theory, a number of methodological and theoretical issues are emphasized. For example, insufficient attention has been given to the reliability and validity of retrospective subject reports on the acquisition of childhood phobias. Also some findings on the origins of childhood fears and phobias are more consistent with a nonassociative account of phobia onset, thus providing an interesting challenge to Rachman's theory.

Utility of relaxation training with children in school settings: a plea for realistic goal setting and evaluation.

BACKGROUND: School-based relaxation training programmes are a popular means of helping children with anxiety problems such as headaches and test anxiety. AIMS: Our major objective is to evaluate the empirical status of school-based relaxation training programmes. CONTENTS: Focusing on progressive muscle relaxation training, we show how this adult training procedure has been modified for use with children. Several training issues are discussed including the questions of live versus recorded instruction and individual versus group instruction. We also discuss the evaluation of relaxation training programmes in school settings, highlighting issues of reliability and validity. CONCLUSIONS: Our review of studies examining the efficacy of school-based relaxation training shows that improvements are usually modest and of dubious clinical or educational significance. Consequently we suggest that when relaxation training is used with school children treatment goals should be more modest or, that if improvements in specific performance areas are sought, then more comprehensive treatment packages be developed which can influence the successful performance of children in target areas and reduce anxiety to normal levels.

Cognitive-behavioral treatment of school-refusing children: a controlled evaluation.

OBJECTIVE: To evaluate the efficacy of a 4-week cognitive-behavioral treatment program for children who refuse to go to school. METHOD: Thirty-four school-refusing children (aged 5 to 15 years) were randomly assigned to a cognitive-behavioral treatment condition or a waiting-list control condition. Treatment consisted of individual child cognitive-behavioral therapy plus parent/teacher training in child behavior management skills. Measures taken before and after treatment included school attendance, child self-report of emotional distress and coping, caregiver reports on emotional and behavioral problems, and clinician ratings of global functioning. RESULTS: Relative to waiting-list controls, children who received cognitive-behavioral therapy exhibited a significant improvement in school attendance. These children also improved on self-reports of fear, anxiety, depression, and coping. Significant improvements also occurred in relation to caregiver reports and clinician ratings. Maintenance of therapeutic gains was demonstrated at a 3-month follow-up assessment. CONCLUSIONS: Cognitive-behavioral treatment of school refusal was efficacious and acceptable. The relative contributions of child therapy and parent/teacher training require further study.