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The Dissertation Committee for Sarah E. James Certifies that this is the approved version of the following dissertation:
Parent Stress and Child Anxiety in a Community Mental Health Center
Committee:
D. Gregory Allen, Supervisor
Rachel W. Robillard, Co-Supervisor
Kevin Stark
Tiffany Whittaker
Barbara L. Jones
Jennifer Felker
Parent Stress and Child Anxiety in a Community Mental Health Center
by
Sarah E. James, B.S. Psy.; B.A. Human Develop.; M.A.
Dissertation
Presented to the Faculty of the Graduate School of
The University of Texas at Austin
in Partial Fulfillment
of the Requirements
for the Degree of
Doctor of Philosophy
The University of Texas at Austin
May 2012
Dedication
This dissertation is dedicated to my husband, Jeff, for his constant support and occasional
nudging. Who knows how this would have turned out without him? It is dedicated to my
son, Ace, who put up with a cranky mommy at times but always managed to make me
smile. It is also dedicated to the families at Morrison Child and Family Services in
Portland, Oregon, without whose participation this dissertation would not exist. It was
always a pleasure to talk with them about their experiences.
v
Acknowledgements
Infinite thanks to Dr. Rachel W. Robillard for her support, encouragement,
mentoring, and friendship. I have learned so much from her about working in the mental
health field and keeping in mind what is really important. Special thanks to Dr. Greg
Allen for taking me on as a dissertation supervisee before he was even settled in. I could
not have done it without him. Additional thanks are deserved by Dr. Jeni Felker and Dr.
Joyce Ochsner at Morrison Child and Family Services for their support and
encouragement as I collected data and worked to get this thing put together. Finally, and
certainly not least, thanks to my family, who has given unending support and
encouragement throughout graduate school and the dissertation process. For them I am
lovingly grateful.
vi
Parent Stress and Child Anxiety in a Community Mental Health Center
Sarah E. James, Ph.D.
The University of Texas at Austin, 2012
Supervisors: D. Gregory Allen, Rachel W. Robillard
The primary focus of this study was to examine the relationship between parent
stress and child anxiety. In addition, differences in child anxiety by gender and ethnicity
were explored. Finally, data were evaluated to determine differences in types of anxiety
symptoms reported by children. Participants were 34 parent-child dyads from Morrison
Child and Family Services in Portland, Oregon. Children (20 females, 14 males) ranged
in age from 8 years to 12 years. The parent group (30 females, 4 males) included only
biological parents or legal guardians, with 23 parents reporting a single-caregiver home.
Results were not significant for correlations between parent stress or parent life stress and
child anxiety or for differences in child anxiety by gender or ethnicity. Results did
indicate that on the MASC, children reported significantly higher scores on the Harm
Avoidance scale than any other scale. Limitations and future directions are discussed.
vii
Table of Contents
List of Tables ......................................................................................................... ix
List of Figures ..........................................................................................................x
Chapter 1: Introduction ............................................................................................1
Chapter 2: Methods ..................................................................................................7 Project Approval .............................................................................................7 Participants ......................................................................................................7 Measures .........................................................................................................9 Procedure ......................................................................................................12
Chapter 3: Results ..................................................................................................13 Parent Stress and Child Anxiety ...................................................................13 Gender Differences in Reported Anxiety Symptoms ...................................15 Ethnicity Differences in Reported Anxiety Symptoms ................................15 Differences Between Symptoms of Anxiety .................................................16
Chapter 4: Discussion ............................................................................................18 Limitations and Future Research ..................................................................22
Appendix A: Literature Review .............................................................................27 Community Mental Health Services Overview ............................................27 Access To and Use of Mental Health Services by Low-Income Individuals and
Families ................................................................................................29 Barriers to Access and Utilization .......................................................30
Implementing Evidence-Based Treatment in Community Mental Health ...35 Parenting Stress .............................................................................................38
Parenting Stress in Low-Income Families ...........................................39 Anxiety Overview .........................................................................................41
Developmental Issues ..........................................................................48 Gender Differences ..............................................................................49
viii
Cultural Differences .............................................................................50 Theories of Anxiety ......................................................................................50
Cognitive Theories ...............................................................................50 Biological Bases ...................................................................................53 Genetics ................................................................................................56 Anxiety Sensitivity ..............................................................................57 Behavioral/Learning Theories .............................................................58 Attachment Theory ..............................................................................59 Integrative Model .................................................................................60 Family/Systems Theories .....................................................................62
Family Influences on Anxiety .....................................................64 Anxiety and the Parent-Child Relationship ................................65 Parent Stress and Child Adjustment ...........................................67
Effects of Anxiety on Daily Functioning ......................................................69 Anxiety and Social Functioning ...........................................................69 Anxiety and Activities of Daily Living ...............................................70 Anxiety and Academic Performance ...................................................71
Appendix B: Multidimensional Anxiety Scale for Children (MASC) Sample Questions.......................................................................................................73
Appendix C: Parenting Stress Index (PSI) Sample Questions ...............................74
References ..............................................................................................................75
ix
List of Tables
Table 1. Correlations between parenting stress and child anxiety .........................13
Table 2. Pairwise comparisons between MASC scale scores ................................17
Table 3. DSM-IV-TR Anxiety Disorders ..............................................................47
x
List of Figures
Figure 1. Correlation between parenting stress and child anxiety .........................14
Figure 2. Correlation between parent life stress and child anxiety .......................14
1
Chapter 1: Introduction
According to the National Center for Children in Poverty (NCCP), one in five
children has a diagnosable mental disorder, and one in ten have mental health problems
that are severe enough to interfere with daily functioning across environments, including
school, home, and in the community (NCCP, 2006). Children from low-income
households or children in the child welfare or juvenile systems are at greater risk for and
have higher proportions of mental health problems than the general population (McLearn,
Knitzer, Carter, 2007; Burns, Phillips, Wagner, Barth, Kolko, Campbell, & Yandserk
2004; Howell, 2004; Knitzer, 1996). Children in low-income households or households
below the poverty line, which account for 39% of children in the United States per NCCP
data collected in 2005, are likely to experience a number of barriers to care, including
fear of stigma, inaccessible facilities, lack of knowledge/parent education, lack of
funding, etc. (Bringewatt & Gershoff, 2010; Palmer, Courtot, & Howell, 2007; Gonzalez,
2005). Such barriers prevent access to even basic mental health treatment services. A
movement toward community-based care has seen the creation of community mental
health centers (Bringewatt & Gershoff, 2010), as well as provision of mental health
services in schools. It is believed that services provided in the community and schools
increases access to mental health services for individuals and families who would
typically be unlikely to access services elsewhere (Stephan, Weist, Kataoka, Adelsheim,
& Mills, 2007).
2
While prevalence rates for different mental health problems vary by study and
population, it is largely agreed upon that anxiety disorders are the most prevalent mental
health concerns among children and adolescents (Cartwright-Hatton, McNicol, &
Doubleday, 2006; Anderson, 1994). Anxiety disorders include a wide spectrum of
dysfunctional cognitions and behaviors that can negatively affect daily functioning.
Children with anxiety may, for example, refuse to go to school, often complain of
stomachaches or headaches, have unexpected reactions to “everyday” events (e.g., being
told to get ready for bed), be tearful or clingy, or demonstrate other undesirable
behaviors. In addition, they may have more internal signs such as constant worry,
inability to focus or intrusive thoughts that are difficult to control.
There are a number of factors identified as likely contributors to childhood
anxiety, including genetics, age, gender, biology (e.g., neurochemistry), and environment
(Bandura, 1969; Field, 2006; Gordon & Hen, 2004: Lesch, 2001; Ludwig & Schwarting,
2007). In addition, family dynamics literature draws attention to the interaction of parent
and child and how parent distress may relate to ultimate child outcome (Bonner, Hardy,
Guill, McLaughlin, Schweitzer, & Carter, 2006; Thompson & Gustafson, 1996). Several
studies of maternal depression have suggested that children of depressed mothers tend to
have more internalizing and externalizing symptoms than children of non-depressed
mothers (Campbell, Cohn & Meyers, 1995; Foster, Webster, Weisman, Pilowsky,
Wickmaratne, Rush, et al., 2008; Frankel & Harmon, 1996). Similarly, studies of anxiety
demonstrate that children whose parents have anxiety disorders are more likely to
develop an anxiety disorder than children whose parents are not maladaptively anxious
3
(Beidel & Turner, 1997; Low, Cui, & Merikangas, 2008; Nocon, Wittchen, Beesdo,
Brückl, Hofler, Pfister, Zimmermann, & Lieb, 2008; Stark, Humphrey, Crook, & Lewis,
1990).
The literature also demonstrates that social support (including that from family
members) may have beneficial effects in the treatment, recovery, and overall well-being
of children experiencing health and mental health problems (Campbell, 1993; Reinhardt,
Boerner & Horowitz, 2006). For children, parental support is a necessity for mental and
emotional well-being (Stice, Ragan, & Randall, 2004; Wickrama, Lorenz, & Conger,
1997); however, parents who experience significant stress or anxiety may have difficulty
providing adequate support and may, in fact, influence negative adjustment in their child
(Pellegrino, 2006). A parent who has difficulty coping with stressors of any kind may
be at risk for developing a number of mental health problems (Woodruff-Borden,
Morrow, Bourland & Cambron, 2002; Kazdin & Whitley, 2003), which may then affect
parenting and the parent-child relationship (Kochanska, Kucynski, Radke-Yarrow, &
Welsh, 1987; Sagrestano, Paikoff, Holmbeck, & Fendrick, 2003).
If anxiety is the most common mental health problem among children and
adolescents in general, it is reasonable to conclude it is also the most common problem
treated at community mental health centers. In fact, rates of anxiety being treated in the
community may be higher than average due to higher rates of mental health problems in
low-income families (McLearn, Knitzer, Carter, 2007; Burns, et al., 2004; Howell, 2004;
Knitzer, 1996), which is the target population of most community mental health centers.
Treatment within a community mental health center can focus on the family of the client
4
as well as on the client as an individual. This requires identification of factors within the
family in general, and between parent and child specifically, that may contribute to the
presenting problem. Factors are likely to vary not only from client to client, but also
from community to community.
There is a push to use evidence-based treatment in clinical practice, and a simple
internet search by this author revealed a number of funding sources for persons or clinics
implementing evidence-based mental health services. While evidenced-based treatment
is assumed to be generalizable and worthwhile to implement, it remains unclear how
effective it is across heterogeneous setting or clients (Lau, Chan, Li, & Au, 2010). In
fact, Messer (2004) points out several studies that included randomized clinical trials that
excluded a high number of potential subjects, or samples that included diagnoses that
were poorly represented in psychotherapy research literature, which brings to question
the generalizability of evidence-based treatment to typical clinical practice. Therefore, it
is important to evaluate local characteristics to determine if a specific evidence-based
treatment would be effective or even ethical to implement for a given client or
community (Stricker, 2007).
This study attempted to answer a number of questions. 1) Is there a relationship
between parenting stress and child reported symptoms of anxiety as it pertains to a
sample from a local community mental health center? Parenting is not easy, and stress
can make the job of a parent even more difficult. High levels of parental stress have been
associated with negative child outcomes, such as anxiety (Anderson, 2007), and negative
parent outcomes, such as limited ability to be sensitive to a child, which may influence
5
the child’s emotional development (Conger, Wallace, Sun, Simons, McLoyd & Brody,
2002; Smith, Oliver & Innocenti, 2001; Takeuchi, Williams & Adair, 1991). It was
hypothesized that parenting stress would be positively correlated with child anxiety
symptoms. 2) Are there differences in reported anxiety symptoms between male and
female clients? The literature gives evidence of gender differences in reported anxiety,
with females reporting anxiety more frequently and with greater intensity than males
(Breton, et al., 1999; Gullone & King, 1993; Ollendick, et al., 2002). It was hypothesized
that females would report more symptoms of anxiety than males. 3) Are there
differences between ethnic groups in reported symptoms of anxiety? There is a dearth of
cross-cultural literature on childhood anxiety, and conclusions from existing studies do
not give a clear picture regarding that relationship. This question is largely exploratory in
nature and may help elucidate cultural differences in anxiety for the population served at
the community mental health center where data was collected. 4) Is there a difference
between type of reported anxiety symptoms (e.g., social anxiety symptoms v. separation
anxiety symptoms)? This final question is also exploratory in nature and may serve to
inform education programs or interventions for clients and families who receive services
at community mental health centers. Programs or interventions may be developed that
target specific symptoms or sets of symptoms based on whether specific symptoms
appear to be more prominent in this sample.
This study is important for a number of reasons. It may contribute to general data
regarding childhood experience of anxiety and it may help increase understanding of the
relationship between parenting stress and child anxiety. It may identify factors within the
6
low-income/poverty population that contribute to parent stress or child anxiety that can
be addressed within a community mental health setting. Results from this study may help
identify the needs of clients at the specific community mental health center in which data
was collected. In addition, it may provide clinicians with information regarding parent
well-being, which may encourage parents to more readily engage in therapy. Such
information may not only inform the use of current evidence-based treatment, but may
also inform the development of new approaches or approaches targeted to the low-
income/poverty population. If evidence-based treatment is expected to be implemented in
clinical practice, it is most important, for the welfare of the client, to determine such
treatment’s efficacy and ethical implications for client and community.
7
Chapter 2: Methods
PROJECT APPROVAL
The proposed study is in compliance with the ethical issues and standards of
research delineated by the American Psychological Association (2002) and the Research
Review Committee at Morrison Child and Family Services (MCFS) in Portland, Oregon.
Approval for the study was granted by the Departmental Review Committee in the
Department of Educational Psychology, Institutional Review Board (IRB) of The
University of Texas at Austin, and the Research Review Committee at Morrison Child
and Family Services in Portland, Oregon.
PARTICIPANTS
Participants in this study were 34 caregivers and 34 children who receive services
at Morrison Child and Family Services in Portland, Oregon. Inclusion criteria were: the
child was a client at Morrison Child and Family Services, child was age 8-12, inclusive;
child and caregiver spoke English; caregiver and child had capacity to understand the
questions presented as determined by principal investigator; caregiver completing
measures was the legal guardian and the child had resided with that person for at least
one year. 3% (n=1) of the children were African American, 3% (n=1) Hispanic, 62%
(n=21) Caucasian, and 32% (n=11) reported being of mixed race or ethnicity. 59%
(n=20) of the children were female. 6% (n=2) of responding parents were African
American, 3% (n=1) Hispanic, 3% (n=1) Native American, 6% (n=2) Pacific Islander,
8
73% (n=25) Caucasian, and 9% (n=3) reported being of mixed race or ethnicity. 88%
(n=30) of responding parents were female. Median age of children was 10 years. 68%
(n=23) of parents reported being single parents.
Participants in this study reflect a homogeneous low-SES sample. All children at
MCFS qualify for and receive Medicaid, indicating family income does not exceed 133%
of the federal poverty level. The participants in this study experience significant financial
challenges that affect nearly every aspect of their lives, including access to mental health
care, and there is a culture of poverty that many people in the U.S. do not experience,
understand, or even know about. The families in this study often openly voiced the
stressors they faced on a daily basis and gave anecdotal evidence for how difficult it is for
them to access services of any kind. One of the most common comments reflected lack
of trust that “the system” could help, particularly when a parent had sought assistance
through several avenues to no effect. Parents reported trying to get help through their
doctor, through their children’s school, through the child welfare system and through
other social services with little to no success.
Some parents reported having a college education and were savvy in finding ways
to meet family needs, yet even they reported feeling at a loss when it came to finding help
for their child’s mental health or behavioral problems because they could not afford to
pay for care, could not pay to travel to appointments, could not miss work for
appointments, etc. Financial strain often resulted, for these families, in not seeking
mental health care or frequent missed appointments. Parents also voiced frustration at
not being able to meet their own mental health care needs, though many reported
9
preferring services at MCFS because they felt therapists listened to their needs as well as
the needs of the children. Some openly stated they had mental health challenges, but
many parents were reluctant to discuss the topic with the investigator out of fear that
child welfare could become involved with the family. There is a severe lack of trust that
the child welfare system has the best interest of the child and family in mind, especially
when unrealistic demands are placed on families to meet child welfare requirements.
One parent commented that her children had been removed from her care in the past and
that it took nearly two years to regain custody because she was expected to perform a
number of tasks that were nearly impossible for a person with no source of income or
transportation. She expressed frustration when recalling her caseworker expecting her to
find more suitable housing, which costs more money, but admonished her when she
sought employment because it would “take her focus away from the children.” While the
child welfare system was developed to help protect and help meet the needs of children, it
is seen as something to avoid in low-SES communities, and parents are reluctant to reveal
any information that could possibly be used by that agency as impetus remove their
children from the home.
MEASURES
The Parent Stress Index (PSI). The PSI (Abidin, 1995) is a “screening and
diagnostic assessment…designed to yield a measure of the relative magnitude of stress in
the parent-child system…” (Abidin, 1995). It has been demonstrated to be valid across
cultures including Chinese (Pearson & Chan, 1993), Latin American/Hispanic (Solis &
10
Abidin, 1991), and others (Abidin, 1995). The questionnaire contains Likert responses:
Strongly Agree, Agree, Not Sure, Disagree, Strongly Disagree and produces three
Domain Scores: Child Domain, Parent Domain, and Life Stress. The Child Domain
contains six subscales: Distractibility/Hyperactivity, Adaptability, Reinforces Parent,
Demandingness, Mood, and Acceptability. The Parent Domain contains seven subscales:
Competence, Isolation, Attachment, Health, Role Restriction, Depression, and Spouse.
The Child and Parent domain scores combine to create a Total Stress score, an overall
indication of the level of stress associated with parenting that does not include other life
stressors. The Life Stress scale is a measure of stress the parent experiences outside of
the parent-child relationship (e.g. loss of job); however, it may be indicative of need for
professional intervention if it is elevated as general life stress may affect parenting and
the parent-child relationship (Abidin, 1995)
Administration time is approximately 20 minutes and requires a fifth-grade
reading level. It is scored by hand and includes a Defensive Responding score. Low
scores on Defensive Responding suggest parents may have responded in an overly
guarded manner to items, and scores should be interpreted with caution; however, it is
possible for a highly competent parent in an economically advantaged situation to
produce a low score on this subscale (Abidin, 1995).
According to Abidin (1995), the PSI was normed on mothers (n = 2,633) recruited
from public and private pediatric clinics, day care centers, and public schools. Two
hundred fathers from the same recruitment pools were also included in the norming
process, and data suggests that fathers produce lower stress scores on many scales
11
compared to mothers. The samples were not stratified or randomized, and represent a
sample of convenience. The PSI has been demonstrated to have sufficient internal
consistency; ranging from .70 to .84 in the subscales of the Parent Domain, .70 to .83 in
the subscales of the Child Domain, and reliability for the two domains and Total Stress
was .90 or higher. Test-retest reliability for the Parent Domain was .91. It was.63 for the
Child Domain, and .96 for Total Stress.
Multidimensional Anxiety Scale for Children (MASC). The MASC is a 39-item
self-report measure designed to assess a variety of anxiety dimensions in children and
adolescents (March, 1997). Subjects rate how true an item is for them (0 = never, 1 =
rarely, 2 = sometimes, 3=often). Scores are distributed across four basic scales (Physical
Symptoms, Harm Avoidance, Social Anxiety, Separation/Panic), two major indices
(Anxiety Disorders, Inconsistency), and a Total Anxiety scale. The Inconsistency Index
determines probable careless or random responding, and Anxiety Disorders Index
identifies subjects who may benefit from more thorough assessment. Raw scores are
converted to T-scores, with T-scores 60-69 indicative of the at-risk range, and scores
above 70 in the clinically significant range. According to March (1997), the MASC was
normed on a sample of 2,698 children and adolescents aged 8-19. Internal consistency
ranges from .526 to .888 for males, and .500 to .878 for females across all scores. Test-
retest reliability ranges from .695 to .933 across all scores (March, 1997).
12
PROCEDURE
Recruitment fliers were posted in the waiting area of each clinic with instructions
on how to contact the principal investigator if interested in participating in the study.
This particular approach was not successful in recruiting participants, probably because it
required potential subjects to be proactive, and in a community that experiences a number
of highly stressful factors, reaching out to contact an unknown person to inquire about a
research study is not likely to be a priority. Consequently, the primary investigator also
recruited clients and parents as they arrived at the clinic for appointments. The
investigator spent a set number of hours each day at the various clinics at approximately
the same time of day (after school) in order to recruit as many participants as possible.
Parents and clients were informed about the purpose and procedures of the study, and that
there would be no consequence if they chose not to participate or chose to withdraw later.
Parents completed a packet containing information regarding informed consent and
confidentiality, the Parent Stress Index, and a form containing demographic information.
Child participants signed an assent form and completed the Multidimensional Anxiety
Scale for Children. Parents and children were compensated $5 each for their
participation. Most families who met inclusion criteria were interested in participating,
and those who declined stated it was due to time constraint. Some participants were
willing to arrange a different time to meet and completed the questionnaires in that way.
13
Chapter 3: Results
PARENT STRESS AND CHILD ANXIETY
Pre-analysis
Shapiro-Wilk tests indicated PSI_Total, PSI_LS and MASC_Total scores were
normally distributed. Boxplots revealed no significant outliers. Pearson’s correlation
coefficient indicated no significant relationship between PSI_Total and PSI_LS
(r(32)=.18, p=.31). Alpha level of .05 was used for all procedures.
Analysis
Evaluation of data was made to determine the relationship between parenting
stress (PSI_Total) and child anxiety (MASC_Total), as well as parent life stress (PSI_LS)
and child anxiety (MASC_Total). Analysis using Pearson’s correlation coefficient
indicated no significant correlation between PSI_Total and MASC_Total (r(32)=.08,
p=.66) or between PSI_LS and MASC_Total (r(32)=-.07, p=.69), indicating no
significant relationship between either parenting stress or parent life stress and child
anxiety. Visual inspection of data reveal no apparent trends. Post-hoc power analysis
revealed power was extremely low at 0.07 with n=34 for both correlations.
Table 1. Correlations between parenting stress and child anxiety
PSI_Total PSI_LS MASC_Total .08 -.07
14
Figure 1. Correlation between parenting stress and child anxiety
Figure 2. Correlation between parent life stress and child anxiety
15
GENDER DIFFERENCES IN REPORTED ANXIETY SYMPTOMS
Pre-analysis
Levene’s test for equality of variance was not significant (F(1,32)=.18, p=.68) and
homogeneity of variance was assumed. Shapiro-Wilk test indicated normal distribution
of data. Alpha level of .05 was used for all analyses.
Analysis
An independent-samples t-test was conducted to compare means of anxiety scores
(MASC_Total) between male (M=45.5, SE=4.09) and female (M=51.40, SE=3.72)
children. There was no significant difference in means of MASC_Total scores
(t(32)=.68, p=.30) between gender, suggesting there is no difference in reported anxiety
between male and female children. Post-hoc power analysis revealed power of 0.32 for
this t-test. Cohen’s d (d=.37) indicates a moderate practical significance for this
comparison despite low power. Coupled with insignificant differences in variance, it
appears that the results may truly reflect a lack of significant difference between gender
in reported anxiety symptoms.
ETHNICITY DIFFERENCES IN REPORTED ANXIETY SYMPTOMS
Pre-analysis
Demographics were originally collected to specify ethnicity; however, due to lack
of representation, children who indicated ethnicity as African American (n=1), Hispanic
(n=1), or Mixed (n=11) were grouped together as Non-Caucasian (n=13). The remainder
of the participants identified as Caucasian. Other ethnicities were not represented in the
16
sample. Levene’s test for equality of variance was not significant (F(1,32)=1.54, p=.25)
and homogeneity of variance was assumed. Shapiro-Wilk test indicated normal
distribution of data. Alpha level of .05 was used for all analyses.
Analysis
An independent samples t-test was conducted to compare means of anxiety scores
(MASC_Total) between Caucasian (M=50.19, SE=3.87) and non-Caucasian (M=47,
SE=3.77) groups. There was no significant difference in means of MASC_Total scores
(t(32)=.55, p=.58) between ethnicities, suggesting there is no difference in reported
anxiety between Caucasian and non-Caucasian children. Post-hoc power analysis
revealed power of 0.13 for this t-test.
DIFFERENCES BETWEEN SYMPTOMS OF ANXIETY
Pre-Analysis
Scale scores were initially transformed to averages as not all scores were based on
the same number of questions. Data for the Harm Avoidance scale violated normality
assumptions; however, there was no significant skew or kurtosis for this scale so the data
was used as-is. The remaining scale scores appeared normally distributed per Shapiro-
Wilk test. Greenhouse-Geisser corrections were also used (ε=.772) after Mauchly’s test
indicated a violation of sphericity (W=.66, χ2(5)=13.22, p<.05). Alpha level of .05 was
used for all procedures.
Analysis
Data was evaluated to determine if there was a difference in type of anxiety
17
symptoms reported by children on the MASC. Averages of MASC scale scores were
examined using a one-way repeated measures ANOVA. Mean scale scores are as
follows: Harm Avoidance (M=.2.0, SE=.09); Social Anxiety (M=1.28, SE=.13);
Separation Anxiety (M=.99, SE=.08); Physical Symptoms (M=.89, SE=.09). The
one-way repeated-measures ANOVA shows the scale scores are significantly different,
F(2.32, 76.39) = 13.13, p <.01, with moderate effect size (partial eta squared = .29).
Pairwise comparisons (Bonferonni correction) indicate significant differences between
Harm Avoidance and all other scale scores (p<.01), as well as significant differences
between Social Anxiety and Physical Symptoms (p<.01). These results suggest that
children rated symptoms on the Harm Avoidance scale significantly higher than all other
scales. Based on reported means, the next highest rated scale was Social Anxiety,
followed by Separation Anxiety then Physical Symptoms, with children rating Social
Anxiety significantly higher than Physical Symptoms.
Table 2. Pairwise comparisons between MASC scale scores
Physical Symptoms
Harm Avoidance
Social Anxiety
Separation Anxiety
Physical Symptoms - 1.13* -.39* -.11 Harm Avoidance - .74* 1.02* Social Anxiety - .28 Separation Anxiety - *p<.01
18
Chapter 4: Discussion
The purpose of this study was to examine the relationship between parent stress
and child anxiety, as well as to explore the child experience of anxiety. Results showed
no significant relationship between parenting stress or parent life stress and child anxiety,
which is contrary to current literature that suggests a strong relationship between
parenting stress and negative child mental health outcome (e.g., Anderson, 2007; Conger,
Wallace, Sun, Simons, McLoyd & Brody, 2002). This outcome was not altogether
surprising due to the small sample size, which severely limited power, and is likely
responsible for the lack of significant finding. Certain stressful factors, including
economic hardship (all children qualify for Medicaid) and single-parenthood, have been
demonstrated to negatively affect child adjustment (Antshel & Joseph, 2006;Conger, et
al., 2002), and such factors are both well represented in the sample from this study and
are characteristic of the population served in community mental health. It is probable
that a significant relationship between parent stress and child anxiety would be apparent
in a larger sample size.
Analysis also revealed no significant findings for differences in child anxiety
based on gender. It is important to note, however, that there was no significant difference
is variance for the two groups, indicating they were similar in their responses, and with a
moderate Cohen’s d, it appears more likely that the results reflect an accurate
representation of reported anxiety symptoms by gender despite low power. Numerous
studies have demonstrated a difference in reported anxiety between males and females
19
(e.g., Breton, Bergeron, Valla, Berthiaume, Gaudet, & Lambert, 1999; Gullone & King,
1993), including the standardization studies used in developing the MASC (March,
1997); however, more recent research indicates mixed results regarding gender
differences in anxiety. Brand, Wilhelm, Kossowsky, Holsboer-Trachsler, and Schneider
(2011), in exploring HPA axis activity through measurement of cortisol levels, found no
significant gender differences in a group of children with and without separation anxiety;
however, when comparing just the children with separation anxiety, they did find that
females had higher cortisol levels than males, which indicates there could be a difference
in the way males and females perceive or anticipate threat. A 2009 longitudinal study by
Olatunji and Cole indicated no gender differences in anxiety in elementary school
children, but they did report a gender by ethnicity interaction, further indicating the
importance of the role of ethnicity in anxiety.
Differences in child anxiety based on ethnicity were not significant, either. One
problematic issue involves how subjects were grouped together as “Caucasian” or “non-
Caucasian”, which does not truly represent the ethnic diversity of the sample. A number
of participants identified as being of mixed ethnicity, but there was no indication of what
those ethnicities were, which adds to the lack of clarity of the results. Power was also
extremely low due to small sample size; however, literature reveals little evidence for
differences in this area so it is not clear what one would expect to find given a larger
sample. A larger sample size would increase the likelihood of an ethnically diverse
sample that is more representative of the community that this mental health center serves.
The Portland area is home to a number of communities of color and immigrant
20
communities, and anecdotal evidence suggests that the various MCFS clinics’ clientele
well represents these communities. There may be other methods for data collection that
would improve the ethnic representation in future research, which is important if the site
is interested in using the MASC, or other measures, to identify specific needs of the
people they serve.
Results did suggest that children reported significantly more symptoms related to
harm avoidance than any other scale on the MASC. This corresponds with normative data
reported by March (1997) that indicated children in the 8-11 year old age range and the
12-15 year old age range had higher means for the Harm Avoidance scale than for other
scales. Harm avoidance in this instance includes behaviors such as perfectionism (e.g.,
trying hard to please others) and anxious coping (e.g., checking to be sure things are
safe), and is designed to help a child feel safe and less at risk for harm. These findings
may have clinical salience in the community mental health setting in general, and at the
data collection site more specifically. The children in this study live in an urban
environment that poses a number of risks to personal safety including violence (domestic
and non-domestic), exposure to drugs or alcohol, and gang activity to name a few. It is
not necessarily surprising that they would report Harm Avoidance as the highest scale of
symptoms. Some might argue that this particular scale may tap a unique aspect of
anxiety (Muris, Merckelbach, Ollendick, King, & Bogie, 2002), and it would be
beneficial information to use in therapy when helping children evaluate their thoughts or
beliefs and in developing appropriate coping skills, as well as to validate fear or worry
related to real dangers in the child’s environment. In addition, the Harm Avoidance scale
21
has been shown to predict instances of Generalized Anxiety Disorder (Wood, Piacentini,
Bergman, McCracken, & Barrios, 2002), which can be highly useful in differential
diagnosis in a clinical setting, as the measure is simple to administer and interpret.
Examination of the remaining scale scores indicated that children tended to rate
Social Anxiety as the next highest scale, followed by Separation Anxiety then Physical
Symptoms. It fits that Social Anxiety would be the second highest rated scale as the
mean age of children was 10 years old, with a mode of 10 and 11 years, ages when
children are becoming more socially aware and are engaging in more complex social
relationships. Peer acceptance becomes more desired during preadolescence, which
contributes to feelings of self-worth and identity development (Fullerton & Ursano,
1994), and social fears may begin developing around this age.
Examination of scales can help provide a clinical picture of the clients served at
this particular site, and may be a useful tool for other community mental health centers
looking for additional information for targeting client challenges. For example,
information gathered from the MASC may be particularly useful when developing group
interventions or deciding if a particular evidence-based program would be useful with a
group of children. It can help identify, for that group, which areas seem to be the most
challenging and which skills would most benefit from intervention. The therapist can
tailor the intervention based on actual evidence from the clients rather than making an
educated guess about client needs based on samples from other regions in the country,
different types of populations, different cultural representation, etc.
22
The MASC may also be a useful tool in the community mental health setting
where there tends to be a high turnover rate for therapists. New therapists are generally
well-educated and, being fresh from school, may focus on the “textbook” side of therapy
(e.g., deciding which techniques to use) and may overlook some of the more contextual
factors or specific phenotype. The MASC could be helpful in reminding the new
therapist in which areas the client struggles most and how contextual factors can be
addressed. More experienced therapists may use the tool in a similar manner, particularly
when caseloads become overwhelming and therapy for anxiety threatens to become a
one-size-fits-all routine rather than individualized treatment.
An additional use for the MASC is as an outcome measure. It can easily be used
at the beginning of therapy to help tailor treatment and used as an ongoing assessment
tool to quantify progress. It can be used on an individual or group basis, and data can be
used to support a specific treatment plan or group protocol. It is a practical and easy tool
to administer and interpret, and has been shown to not only differentiate between types of
symptoms, but may also help differentiate between diagnoses (e.g., anxiety versus
depression) (Dierker, Albano, Clarke, Heimberg, Kendall, Merikangas, et al., 2001).
LIMITATIONS AND FUTURE RESEARCH
There are some limitations to this study, some of which have already been
addressed. The most significant limitation is the small sample size, which resulted in
extremely low power for some analyses in this study. A larger sample size could help
demonstrate a relationship between parent stress and anxiety, as well as additional
23
information regarding the relationship between ethnicity and anxiety. It would likely
provide opportunity to further explore which aspects of parent stress (e.g., characteristics
of the parent or the child) are most related to child anxiety, how child anxiety affects
parent stress, and other more complex interactions that are undoubtedly present in the
parent-child relationship. A larger sample size would also increase the probability of an
ethnically diverse sample that reflects the true community served at the data collection
site. This is particularly important for community mental health centers as they tend to
cater to a highly diverse population.
A second limitation was the lack of ethnic diversity among respondents, which
was unexpected given the diversity of the clientele served at the data collection site, and
likely due to small sample size. In a sense, the sample was ethnically diverse as nearly
half responded as being multi-ethnic; however, there were very few respondents who
identified with a specific ethnicity other than “Caucasian”. Another limitation relates to
the nature of ethnicity versus race. The demographics questionnaire used in this study
utilized a model akin to the ubiquitous model of the U.S. Census, which asks about race
more than it does ethnicity. This is particularly salient at a community level when
implementing evidence-based treatment or studying the characteristics of a population at
a specific mental health center, especially urban sites, because there are likely to be
clients from many different countries or cultures who could identify as
“Hispanic/Latino”, “Black”, or other race. As Manson (2000) and May & Gossage
(2001) point out, it is important to remember that a culture is not a uniform structure, and
that beliefs or values can and do vary between people of the same culture or “race”.
24
Future research of this nature would be most beneficial if it can address the complexity of
ethnicity and culture in a useful way.
Another limitation that affected ability to truly explore anxiety among different
ethnicities was the inclusion of only English-speaking participants. At the time of this
study, the lead researcher had access only to English language questionnaires and, having
insufficient Spanish-speaking ability, was not able to communicate effectively with the
well-represented Spanish-speaking population served at the data collection site.
An important factor, which probably affected sample size, was the exclusion of
children in the foster care system. Most of the child participants in this study resided
with their biological parents, and those who did not resided with a family member who
was the legal guardian (e.g., a grandmother). This particular community mental health
center, which probably reflects other urban community mental health centers, serves
many children and families in the foster care system. Foster parents often do not know
much about the child’s history, may not have known the child for very long, cannot give
consent for child participation in studies such as this, and may not have the same kind of
stress that a biological parent or legal guardian may have. In addition, children who
reside with foster parents may have anxiety or other difficulties above and beyond those
experienced by children who have not been separated from their natural families.
Exclusion of this group of children limits the pool of available subjects, but was a
necessary exclusion in order to control for potential confounding factors that could be
introduced by participants who are involved in the foster care system. Future research
that targets children and foster parents would be highly beneficial at a local clinical level
25
considering how many children are served in the foster care system and how many seek
assistance at community mental health centers.
Age range of participants may have limited the accessible subject pool, though it
was deemed an important inclusion criteria due to developmental differences in anxiety.
Older children are likely to report different anxiety symptoms than younger children,
which, while useful, would certainly require not only a larger sample could be the focus
of a study on its own. By limiting the age range, this study was able to narrow its focus
in a useful, not limited, manner. At the data collection site, some clinics seemed to serve
more adolescents than children, and while data was collected during after-school hours in
attempt to catch school-age clients, some potential subjects with mid-day may have been
missed. On the other hand, set data collection times helped ensure sound methodology.
Future research can improve data collection by considering alternative methods for
recruiting participants and gathering information.. For example, it would be useful to
have all clients complete a questionnaire at the time of intake, and established clients
could complete a questionnaire a few minutes prior to scheduled appointments. Such data
collection requires well-organized collaboration among therapists and staff and could
prove to be an effective manner for gathering information.
While the results of this study did not demonstrate a relationship between parent
stress and child anxiety, anecdotal data would suggest otherwise. Continuing research in
this area is warranted as families served in the community mental health setting continue
to struggle with stresses commonly associated with low SES. Continued exploration of
the relationship between gender and anxiety is also warranted as current literature shows
26
mixed results with questions arising about what influences anxiety and how anxiety is
experienced across gender. The impact of ethnicity on anxiety is another area in which
additional research is much needed, particularly as the population served in the
community mental health setting becomes more diverse. Values and beliefs are core
components to a person’s overall identity and influence cognitive processes and
perceptions, which may influence mental health experiences and intervention. The
MASC has been shown to be a useful tool at a clinical level to aid in treatment planning
and development of intervention. Its ease of use makes it a worthwhile tool to implement
in order to provide the best possible mental health care to children and families in need.
27
Appendix A: Literature Review
COMMUNITY MENTAL HEALTH SERVICES OVERVIEW
Community mental health centers (CMCHs) and clinics have sprung up across the
country in effort to provide much needed mental health care to low-income individuals
and families (Bringewatt & Gershoff, 2010). In many states, CMHCs have become the
primary source of mental health care for individuals who cannot pay for services, and
have become the core for managed behavioral health care programs accepted by
Medicaid (Lambert, Hartley, Bird, Ralph, & Saucier, 1998). The focus of the treatment
populations has shifted over the years as responsibility of care has shifted between
federal and state government (Hartley, Bird, Lambert, & Coffin, 2002). Originally
implemented as a way to deinstitutionalize mental health care, CMHC’s were designated
to care for recently discharged state hospital patients and other individuals with serious
mental illness. Then, as now, mental health services for individuals were provided to
those who could pay or had insurance, which was, and is, a significant barrier to the
economically disadvantaged. The Community Mental Health Center Act of 1963 sought
to make mental health services available to all regardless of their ability to pay (Foley &
Sharfstein, 1983), as well as to integrate services for individuals returning to the
community from state hospitals.
Funding has also shifted as state versus federal control over mental health care
has shifted. The Community Mental Health Care Act of 1963 provided funding for
building clinics but did not provide continuing funding for staffing, which appears to be a
28
continuing problem in community mental health (Connery, Backstrom, Deener,
Friedman, Kroll, Marten, et al., 1968; Dorwart & Epstein, 1993). The Reagan
Administration returned responsibility for mental health care back to the state in 1981,
reinstating block grants (e.g., from the National Institute of Mental Health) and reducing
overall federal funding by 20% (Dorwart & Epstein, 1993; Hartley, et al., 2002). It is
common today for CMHCs to combine financial support from federal, state, and local
government to cover the cost of providing mental health care services to low-income and
uninsured people (Hartley, et al., 2002).
CMHCs remain the only viable option for low-income and uninsured individuals
to receive mental health care (Harley, et al., 2002). While Medicaid provides financial
access to mental health services for those poor enough to qualify, service availability has
become limited in the last twenty to thirty years, with community mental health centers
trying to meet local need and state priorities with limited staff and resources. There is
often a long wait for services at CMHCs, and sometimes individuals are turned away due
to the lack of funds for services. In this context, it is most important to understand the
needs of the local CMHCs to ensure that the most effective means of intervention are
being implemented. Even more important is understanding the needs of the CMHC
clients in order to provide the most effective forms of preventive care. The saying goes,
“An ounce of prevention is worth a pound of cure,” and it applies entirely to the context
of community mental health. In understanding the characteristics and needs of the clients
served in CMHCs, services can be tailored to intervene for those clients who need
29
intervention and to provide preventive services for clients in order to reduce the demand
for intervention.
ACCESS TO AND USE OF MENTAL HEALTH SERVICES BY LOW-INCOME INDIVIDUALS
AND FAMILIES
According to the 1999 Surgeon General’s report on mental health (United States
Department of Health and Human Services [DHHS], 1999), at least one tenth of children
suffer from mental health problems that in some way affect daily functioning. Children
at or below the federal poverty level tend to have more mental health problems than other
children (Costello, Compton, Keeler, & Angold, 2003), and more and more children are
becoming eligible for Medicaid and State Children’s Health Insurance Program (SCHIP)
(Dubay, Haley, & Kenney, 2002). The current federal poverty level, a loose term for the
poverty guidelines described by the federal government, is $23,505 for a family of 4
(Sebelius, 2012). Howell (2004) sites data analysis by the National Survey of America’s
Families (NSAF) that compared mental health problems in poor children living in
families below the federal poverty level, near-poor children living in families with
income between 100 and 200% of the federal poverty level, and non-poor children living
in families with income above 200% of the federal poverty level. The analysis showed
that poor children had significantly higher prevalence of mental health problems than
near-poor or non-poor children. Using the same data, Howell (2004) cites that out of a
sample of nearly 22,500 children who qualified for Medicaid or SCHIP, only 8.8%
utilized mental health services, and 39% of a sample of children with reported emotional
30
or behavior problems (n=1704) utilized mental health services. Children who were
uninsured, despite qualifying for Medicaid or SCHIP, showed dramatically less usage of
mental health services than children with any insurance (Howell, 2004). Howell (2004)
notes that while Medicaid and SCHIP may appear to improve access to mental health
care, many children continue to have inadequate access to and use of mental health
services.
Fairbrother, Kenney, Hanson, & Dubay (2005) analyzed data from the 1999
NSAF, reviewing measures of access to and use of health care. They reported that
insured children (public and private insurance) demonstrated greater access to and use of
health care services, and that children whose families were characterized as stressful were
less likely to have parents who were confident in the ability of family members to obtain
needed health care, and were less likely to have health care needs met, than other
children. Unfortunately, Fairbrother, et al. (2005) did not include data on mental health
care access and use in their analysis, although the enabling resources (e.g., insurance),
predisposing characteristics (e.g., ethnicity, SES) and need for care (e.g., illness severity)
may well affect access to and use of mental health services in much the same way they
affect medical service access and use.
Barriers to Access and Utilization
Several barriers to mental health service utilization have been identified,
including, but not limited to, stigma, lack of availability of services, and cost (DHHS,
1999). Pavuluri, Luk, & McGee (1996) reported that parents of preschoolers reported
31
their belief that they can handle their child’s behavior on their own or that the child
would outgrow the behaviors as common barriers to treatment. Parent attitude toward
mental health appears to be an important influence on their choice to seek help. Parents
who have a positive attitude toward mental health treatment and whose child’s behavior
problems are severe are more likely to seek treatment than, for example, a parent who
believes mental health services will not help (Gustafson, McNamara, & Jansen, 1994).
Thurston & Phares (2008) found that parents who perceived fewer barriers to mental
health care had a more positive attitude toward treatment, which supports literature that
demonstrates higher utilization of mental health services among individuals who perceive
fewer barriers to care, and that individuals with positive attitude tend to utilize mental
health care more than those with negative attitude toward mental health care (Cramer,
1999; Gustafson, et al., 1994; Thurston & Phares, 2008). Interestingly, Thurston &
Phares (2008) found that parents perceived significantly fewer barriers to and held more
positive attitudes toward mental health care for their children than they did for
themselves. This observation may be helpful in engaging parents to seek their own
mental health care via treatment for their children, particularly if treatment is geared
toward the child first followed by encouragement for parents to seek their own treatment.
Parent gender also appears to have significant influence on help-seeking
behaviors for mental health. It is well established that women access mental health
services more frequently than men (e.g., Mahalik, Good, & Englar-Carlson, 2003) and
that females tend to have more positive attitude toward help-seeking (Cohen, 1999).
Addis & Mahalik (2003) showed that males underutilize mental health services
32
regardless of age, race, or ethnicity; however, less is known about how gender affects
parents’ help-seeking for their children Most research depends on mother reports, with
fathers often not included in research, which may be a problem given that when both
parents are included, both appear to have significant influence on their children (Lamb,
2004). Thurston and Phares (2008) reported no difference between parent gender in
perceive mental health barriers for their children; however, they did find that mothers had
more positive attitude toward mental health care for themselves and for their children
than did fathers.
A third obstacle that has been well documented as a significant barrier to care is
race, with mental health care utilization by racial and ethnic minorities in the United
States extremely low (DHHS, 2001). The Surgeon General’s report indicates that mental
health services are less available to ethnic minorities, that they have less access to mental
health services, that they are less likely to receive care, and that they receive poor
treatment (DHHS, 1999). Service utilization by racial and ethnic minorities may also be
influenced by mistrust (Thompson, Bazile, & Akbar, 2004), fear, racism/discrimination,
language/communication barriers, and cultural barriers (Duran, Oetzel, Lucero, Jiang,
Novins, Manson, & Beals, 2005; Frazier, Abdul-Adil, Atkins, Gathright, & Jackson,
2007; Wong, Marshall, Schell, Elliott, Hambarsoomians, Chun, & Berthold, 2006).
Robin, Chester, Rasmussen, Jaranson, & Goldman (1997), in a study with Native
American adults, found a lifetime prevalence of nearly 86% for one or more psychiatric
disorders and that only 55% utilized mental health services. Cultural factors that affect
services utilization may include geographic isolation, discrimination, lack of employment
33
or lack of education (Duran & Duran, 1995; Whitebeck, Hoyt, McMorris, Chen, &
Stubben, 2001).
Duran, et al. (2005) reported that Native American individuals who received
tangible aid (e.g. food stamps) and perceived counselors to be useful were less likely to
report self-reliance as an obstacle (i.e., the belief they could solve their problems on their
own), and that the more useful individuals found family physicians to be, the less likely
they were to seek assistance from a specialist in mental health care. They also reported
that Native Americans who seek mental health treatment are twice as likely to endorse
self-reliance as a barrier than those seeking help for other problems (e. g., drug or alcohol
use). Another finding of the Duran, et al. (2005) study was that privacy or confidentiality
was a barrier for Native Americans in their study, who were concerned about receiving
serves at facilities where family or friends worked. Interestingly, they highlighted
heterogeneity among Native American tribes as an important piece in their study, as
tribes of the Northern Plains Indians were less concerned about privacy or confidentiality
and perceived higher quality of care than did Southwestern Indian tribes. This finding
demonstrates the importance of recognizing differences within a culture rather than
assuming a uniform population (Manson, 2000; May & Gossage, 2001).
In an interesting study involving Cambodian refugees to the United States, Wong,
et al. (2006) found that while cultural beliefs were somewhat a barrier to mental health
care services, the greater barriers were cost and language, as well as lack of transportation
and lack of knowledge of available services. These findings do not support long held
34
beliefs that shame, stigma or mistrust are primary barriers to care for Asian Americans
(DHHS, 2001; Sue & Sue, 1999; Wong, et al., 2006.)
Socioeconomic status (SES) is a mental health care barrier impossible to ignore
for many families. Financial difficulties pose a significant hindrance for parents seeking
help as they may not only be unable to pay for the cost of care, but they may have
difficulty paying for transportation, child care for other children at appointment time, and
parents may be unable to take time off from work because the loss of wages may be
detrimental to the family (Gonzales, 2005). A second, less acknowledged barrier for
families with low SES is that some children may not be eligible for public programs, yet
private insurance is unaffordable for their families (DHHS, 1999). As reported by
Howell (2004), uninsured children have some of the lowest rates of mental health service
utilization despite great need. In addition, many low-income parents may not only be
unaware of available services or of when to seek services (Huang, Stroul, Friedman,
Mrazek, Friesen, Pires, et al., 2005; Palmer, Courtot, & Howell, 2007), some parents may
not know whether their children are even in need of services (Palmer, et al., 2007).
Shortage of mental health providers is an additional barrier to care for low income and
low SES families, particularly in rural areas. The more rural a county or the more
families below the federal poverty level residing in a county, the fewer child mental
health specialists there are (Thomas & Holzer, 1999). Even if a parent does want mental
health assistance for their child, there may not be services readily available.
35
IMPLEMENTING EVIDENCE-BASED TREATMENT IN COMMUNITY MENTAL HEALTH
Use of evidence-based treatment (EBT) at the community level is encouraged by
funding agencies and government entities at all levels (Baker-Ericzén, Jenkins, &
Brockman-Frazee, 2010). Using treatment modalities that are shown to be effective
seems to be a good idea. The trouble with implementing EBT in a setting (e.g.,
community mental health centers) without first understanding the clientele is that EBT
which seems to be effective in a highly controlled, clinical research setting may be
impractical, costly, or ineffective in other settings (Hoagwood & Kolko, 2009). It is not
clear how generalizable EBTs are across settings and across clients (Lau, Chan, Li, & Au,
2010) or if they will meet the needs of clients outside of research. In fact, many clinical
research studies of EBTs exclude subjects who may represent typical clients at a
community mental health center (Messer, 2004). Hoagwood and Kolko (2009) suggest
that a more thorough understanding of community mental health clients and the contexts
of community services would allow clinicians to identify factors that may moderate or
mediate implementation of EBT, and then manipulate said treatments in a way that
potentially improves overall applicability of EBT in a community mental health care
setting.
In order for clinicians to provide good therapy, they must have good thinking and
problem-solving skills. They must be able to observe both objectively and subjectively
(Stricker & Trieweiler, 1995) and adapt empirical work to meet client needs. Depth and
breadth of observation of the client or local population allows a clinician to decide if
normative research conclusions are applicable or if the gap between science and the field
36
is too large to permit either efficacy or effective use of a particular EBT (Stricker &
Trieweiler 1995). This is not to say that well-controlled or laboratory studies are
unnecessary, because, in fact, they provide an orientation or a path for clinicians to
follow; however, EBT is only a partial solution that requires critical judgment and local
empirical support to make it a viable option in community mental health or other non-
research based settings (Stricker, 2007).
Parent and family characteristics are one of the most important contexts to
understand in community mental health services (Baker-Ericzén, et al., 2010). Parents
are most often the people who initiate mental health services for their child, and evidence
shows they are key players in the effectiveness of treatment for their child (Gunther,
Slavenburg, Feron, & Os, 2003; Kazdin & Whitley, 2003; Kazdin, 1998; Logan & King,
2001). Parent and family contextual factors, often defined as characteristics of parent
social, psychological or intellectual functioning (Baker-Ericzén, 2010), parent
competencies, attitudes and behaviors, and family dynamics are important in
implementing EBT, and many of these contextual factors may negatively affect treatment
engagement, compliance, or efficacy (Beauchaine, Webster-Stratton, & Reid, 2005;
Miller & Prinz, 2003; Reyno & McGrath, 2006). Parent involvement is crucial to
positive child outcome and is a main component of most EBT (Eyberg, Nelson, & Boggs,
2008), increasing the importance of positive parent contextual factors (such as parenting
stress).
A number of other contextual factors deserve attention. Substance abuse, parental
stress, parent mental health, domestic violence, family functioning, culture, ethnicity,
37
treatment expectations and socioeconomic status have all been shown to affect treatment
compliance, outcome and maintenance in EBT (Beauchaine, et al., 2005; Chronis,
Chacko, Fabiano, Wymbs, & Pelham, 2004; Eyberg, Funderburk, Hembree-Kigin,
McNeil, Anerido, & Hood, 2001; Fossum, Morch, Handegard, Grugli, & Larsson, 2009;
Friars & Mellor, 2009; Kazdin & Wassell, 1999; Kazdin 1995; Reyno & McGrath, 2006;
Webster-Stratton & Hammond, 1990). It remains unclear, however, which contextual
factors identified in EBT efficacy studies may affect treatment in a community setting,
and if there are other contextual factors that should be taken into account. Because of the
highly controlled conditions in EBT research, and because exclusion criteria common to
EBT research often ignores characteristics of populations served in community settings,
some clinicians may not be convinced of the importance of contextual factors identified
in EBT efficacy studies.
Baker-Ericzén, et al. (2010) suggest a critical role for both parent and clinician
perspective to understanding meaningful contextual factors in community based mental
health services. One study questioned families about factors influencing participation in
child mental health services, and results indicated that “family problems” were primary
reasons for stopping treatment (Attride-Stirling, Davis, Farrell, Groark, & Day, 2004).
These finding suggest that family contextual factors directly affect child treatment,
according to parents, which also supports previously identified contextual factors. Baker-
Ericzén, et al., (2010) identified factors reported as salient by both clinicians and parents
that mirrored factors identified in previous EBT efficacy research. In addition, they
identified seventeen other factors that may or may not be relevant to research sample. In
38
their study, Baker-Ericzén, et al., (2010) identified two parent-reported factors that
appear to have the highest impact on their child’s treatment—parent stress and inadequate
social support, and that parents would like attention paid to meeting those needs. Parents
report they are less likely to engage and participate in services for their children if their
own needs are not considered or if they feel they are not understood (Attride-Stirling, et
al., 2004; Levac, McCoy, Merka, & Reddon-Darcy, 2008).
PARENTING STRESS
Parents are expected to perform in highly demanding situations, often with few
personal or material resources, and some children are, by nature, difficult to parent. If the
child is out of control or parents do not handle a situation “well”, society sees them as
having failed. Parenting is hard work, and it undoubtedly comes with significant stress.
Parenting stress incudes not only daily hassles associated with being a parent, but also the
strain a parent experiences in his or her parenting role. That is, parenting stress is the
general distress a parent experiences after the parent appraises the benefits and harm that
he or she confronts in the role of a parent (Abidin, 1992). Parenting stress, for example,
comes from ensuring a child’s daily needs are met, that health and education needs are
met, as well as from tasks such as maintaining the home, employment, other relationships
in the family, etc. Theoretically, parent stress is a motivational factor that encourages
parents to use available resources to support them in parenting, such as social support and
coping skills. Abidin (1992), in his model of parenting stress, describes how a number of
variables influence parent stress at any given time in a transactional manner, such as
39
parent characteristics, child characteristics, life events and daily hassles, as well as,
parenting skills, social support, and material resources. Webster-Stratton (1990) notes
that, at the time of her article, little research had been done regarding parenting stress
[and children with conduct problems], perhaps because it is so difficult to define and
measure stress. A number of models have been proposed to help understand parenting
stress, its influences, and how it affects parent and child outcome (e.g., Abidin, 1990;
Belskey, Hertzog, & Rovine, 1986; Mash & Johnston, 1990; Belsky, 1984; Webster-
Stratton, 1990). They each address different variables that affect parenting stress and
reflect a transactional approach, indicating that the relationship between factors is
bidirectional and complex. Webster-Stratton (1990) specifies the importance of
examining the extra-familial and intra-familial factors that could potentially disrupt
parenting, which thereby affect child outcomes. Her model conceptualizes how extra-
familial factors, interpersonal factors, or child factors contribute to situations that force
parents to use coping skills, as few or as many as they may be (Webster-Stratton, 1990).
She goes on to explain how the effects of stressors on parent functioning and parent-child
interactions depend on parent psychological well-being and personal resources (e.g.,
social support), and that the impact of stress on children is indirect and mediated by
quality and sensitivity of parent-child interactions.
Parenting Stress in Low-Income Families
Parenting and family stress tends to be a chronic and significant issue in low-
income families. Based on 2010 data analyzed by DeNavas-Walt, Proctor, & Smith,
40
(2011), the poverty rate for children under age 18 (i.e., children in families whose income
falls below the federal poverty guidelines) is estimated to be 22%, with 16.4 million
children living in poverty. Constant financial strain is highly stressful to parents, which
may take a significant toll on family functioning and effective parenting (Ennis, Hobfoll,
& Schroder, 2000; Mistry, Low, Benner, & Chien, 2008). Living with economic
disadvantage has been linked to poor academic achievement and less than optimal parent-
child interactions (McLoyd, 1998), as well as with parenting practices and child
developmental outcome (Belsky, Woodworth, & Crnic, 1996; Dodge, 2001). Low family
income has also been related to less involved and less supportive parenting (Brody,
Murry, Kim, & Brown, 2002), and there appears to be increased rates of depression
among lower income individuals than higher income peers, which may also contribute to
hostile, coercive, or disengaged parenting (Blazer, Kesler, McGonagle, & Swartz, 1994;
Lorant, Deliege, Eaton, Robert, Philippot, & Ansseau, 2003; Lovejoy, Craczyk, O’Hare,
Neuman, 2000).
A family stress model proposed by Conger, Reuter, & Conger (2000) defines
economic pressure as difficulties dealing with stressful economic conditions, such as
inability to pay bills or meet basic needs (e.g., stable housing). The model suggests that
chronic financial disadvantage leads to daily struggles that are likely to contribute to
parent frustration, anger, and emotional distress. Emotional distress, in turn, disrupts or
diminishes effective parenting skills (Lee, Anderson, Horowitz, & August, 2009). In a
2002 study by Linver, Brooks-Gunn, and Kohen, it was demonstrated that family income
was indirectly related to parenting practices via maternal emotional distress. More
41
specifically, they showed that mothers with lower income experienced more stress, which
was associated with poorer parenting practices and more emotional distress.
Lazarus and Folkman (1984) describe a transactional model of stress in which
coping skills play an important role. Coping skills are strategies intended to manage
stressful events or circumstances (Lazarus & Folkman, 1984), and in low income
families, who experience chronic financial stress, it is likely that some parents are unable
to cope with the demands placed on them, including demands of the parent role (Maupin,
Brophy-Herb, Schiffman, & Bockneck, 2010; McKelvey, Fitzgerald, Schiffman, & von
Eye, 2002). In a 2010 study by Maupin, et al., greater use of coping skills was associated
with perception of adequate resources (e.g., financial assistance) and that parents who
used constructive coping strategies may perceive stress in a way that results in more
positive outcomes for both parent and child.
ANXIETY OVERVIEW
Anxiety is a normal and adaptive reaction that helps prepare us to respond to
events that are threatening and potentially dangerous. It may arise from internal or
external conflict, and is usually directed toward the future (e.g. anxiety about an
upcoming test) (Noyes & Hoehn-Saric, 1998). Anxiety is often confused with, or used
synonymously with, fear. While they are similar in that they are both reactions to
perceived threat or danger, fear is primarily directed toward a specific object or event
(e.g. spiders, dental procedures). Anxiety tends to be more general, and includes not only
an emotional response, but a behavioral and somatic response, as well (Bujiron, 2007).
42
Anxiety becomes problematic when its duration and intensity are disproportionate to the
precipitating event, or when it occurs without recognizable threat. In excess, or when
unmanaged, anxiety can become a debilitating factor, preventing an individual from
thinking clearly, making good decisions, and otherwise functioning successfully in day to
day activities. Anxiety may be related to temporary situational stress (state anxiety)
and/or it may be a personality or temperamental characteristic (trait anxiety).
Anxiety is recognized as the most common psychiatric disorder among adults,
adolescents, and children. Approximately 18.1% of the adult population in the United
States currently experiences an anxiety disorder, and approximately 25% of adults will
develop an anxiety disorder within their lifetime (Kessler, Chiu, Demler, &Walters,
2005). It is estimated that 5-18% of children and adolescents experience clinically
significant levels of anxiety (Puliafico & Kendall, 2006; James, Soler & Weatherall,
2005), and that 1 in 30 elementary school children have an anxiety disorder (Cartwright-
Hatton, McNicol & Doubleday, 2006). While there appears to be a substantial body of
research on adult anxiety, childhood anxiety has only become a focus for researcher over
the last ten to fifteen years.
There are a number of anxiety disorders described in the Diagnostic and
Statistical Manual of Mental Disorders-IV-TR (American Psychiatric Association [DSM-
IV-TR], 2000), including Social Phobia, Panic Disorder, Agoraphobia, Generalized
Anxiety Disorder, Obsessive-Compulsive Disorder (OCD), Posttraumatic Stress Disorder
(PTSD), Acute Stress Disorder, Anxiety Due to a Medical Condition, Anxiety Disorder,
Not Otherwise Specified (NOS), and Separation Anxiety. Panic attacks are not a specific
43
diagnosis, but are a key feature to several anxiety disorders. They are characterized as
sudden episodes of fear that are accompanied by physical symptoms such as headache,
heart palpitations, vertigo, thoughts of losing control, etc. Panic Disorder is diagnosed
when a person experiences recurrent unexpected panic attacks and at least one of the
attacks is followed by one month or more of one of the following: persistent concern
about having additional attacks, worry about implications of the attack or its
consequences (e.g. “going crazy”), and/or a significant change in behavior related to the
attacks. Panic attacks due to substance abuse or medication, or a general medical
condition do not qualify as a diagnosis for Panic Disorder. Agoraphobia is the fear of
having a panic attack or panic symptoms in a situation where escape would be very
difficult (e.g., amid a crowd). It may or may not be present in Panic Disorder, and it may
be diagnosed without a history of Panic Disorder. In this case, diagnostic criteria include
the presence of agoraphobia related to fear of developing panic-like symptoms with no
prior accounts of a panic attack, and the disturbance is not due to substance use or a
medical condition (or in excess of what would be expected for a given medical condition)
(DSM-IV-TR, 2000).
Specific Phobia is diagnosed when a person demonstrates marked and persistent
fear that is excessive or unreasonable, and that it is cued by the presence or anticipation
of a specific object or situation (e.g. getting a shot at the doctor’s office). The phobic
stimulus must provoke an immediate anxiety response that the person recognizes as
unreasonable or excessive (except in children, who may not have such a realization),
must result in avoidance of or intense distress in the presence of the stimulus, and
44
symptoms must interfere significantly with daily functioning (DSM-IV-TR, 2000).
Social Phobia is similar to Specific Phobia in that a marked and persistent fear exists, but
in this case the fear is focused on social or performance situations in which the person
may be exposed to scrutiny from others or may act in a way that would be humiliating or
embarrassing. Social situations must provoke extreme anxiety symptoms, and the person
must recognize that the fear is excessive or unreasonable (except in children). Avoidance
of social or performance situations must interfere significantly with daily functioning
(e.g., school refusal) (DSM-IV-TR, 2000).
Obsessive-Compulsive Disorder is characterized as recurrent and persistent
obsessions or compulsions that are intrusive and inappropriate. Obsessions are thoughts
or impulses beyond excessive worrying about real-life problems (e.g. exposure to germs),
are often ignored or suppressed with other thoughts or actions, and are recognized as a
product of the person’s mind. Compulsions are repetitive behaviors or mental acts (e.g.,
counting) that a person feels driven to perform in response to an obsession or to rigid
rules. Behaviors are aimed at preventing or reducing distress or preventing a dreaded
event, and are not usually connected in a realistic way with what they are designed to
prevent. Obsessions and compulsions significantly interfere with daily functioning, and
are recognized at some point during the disorder as unreasonable or excessive (DSM-IV-
TR, 2000).
Generalized Anxiety Disorder is diagnosed when a person demonstrates excessive
and difficult-to-control anxiety and worry almost every day about a number of events or
activities, and anxiety or worry is associated with three (or more) of the following:
45
restlessness, fatigue, difficulty concentrating or blank mind, irritability, muscle tension,
or sleep disturbance. Anxiety, worry, or physical symptoms interfere significantly with
daily functioning, and is not associated with a medical condition or substance use (DSM-
IV-TR, 2000).
Posttraumatic Stress Disorder (PTSD) is characterized by exposure to a traumatic
event in which the person experienced, witnessed, or was confronted with an event that
involved actual or threatened death or serious injury to self or others, and the response
involved intense fear, helplessness, or horror. The event must be re-experienced (e.g.,
nightmares, “flashbacks”), stimuli associated with the event are avoided (e.g.
conversation about the event), general numbing of responsiveness is present (e.g.,
detachment from others), persistent symptoms of increased arousal are present that were
not present prior to the event (e.g. hypervigilance), and the disturbance significantly
impairs daily functioning (DSM-IV-TR, 2000). Acute Stress Disorder, similar to PTSD,
is characterized by exposure to a traumatic event, but also requires that the individual
experience dissociative symptoms (e.g. being in a “daze”, inability to recall important
aspects of the event), and that the event be persistently re-experienced. Event-related
stimuli is avoided, presence of increased arousal or anxiety are noted, the disturbance
causes significant impairment in daily functioning, and the disturbance occurs for two to
four days within four weeks of the traumatic event (DSM-IV-TR, 2000).
Separation Anxiety Disorder is not typically diagnosed beyond childhood, and,
consequently, is listed as a disorder of childhood rather than an anxiety disorder in the
DSM-IV-TR (2000). It is diagnosed when a child demonstrates developmentally
46
inappropriate and excessive anxiety concerning separation from those to whom they are
attached or on whom they depend. Criteria include recurrent and excessive distress at
separation (e.g. tantrum) due to fear of losing an attachment figure, death or harm
befalling an attachment figure, or untoward events leading to separation (e.g.
kidnapping). A child may refuse to sleep away from home and may have nightmares
involving themes of separation. The disturbance must cause clinically significant distress
or impairment in daily functioning, and must last for at least four weeks with onset before
age 18 (DSM-IV-TR, 2000).
Anxiety may also be due to a medical condition and is diagnosed when prominent
anxiety, panic attacks, or obsessions or compulsions are evident in the clinical picture,
and there is evidence (e.g., from history and exam) that the disturbance is a direct
physiological consequence of the medical condition. Similarly, substance use may also
contribute to anxiety disorders, in which case Substance-Induced Anxiety Disorder is
diagnosed if it is not better explained by another psychiatric disorder or medical
condition (DSM-IV-TR, 2000). Anxiety Disorder, Not Otherwise Specified is diagnosed
when anxiety or phobic avoidance appears to significantly impair daily functioning, but
the individual does not meet criteria for a specific anxiety disorder (DSM-IV-TR, 2000).
47
Table 3. DSM-IV-TR Anxiety Disorders
Anxiety Disorder Description Panic Disorder Recurrent panic attacks that cause persistent worry of
continuing panic attacks.
Agoraphobia Fear of panic-like symptoms in a situation where escape is perceived to be difficult or impossible.
Specific Phobia Persistent and excessive fear cued by presence or anticipation of a specific object or situation.
Social Phobia Persistent and intense fear that focuses on social or performance situations.
Obsessive-Compulsive Disorder
Recurrent and persistent obsessions (thoughts) and/or compulsions (behaviors) that are intrusive and inappropriate.
Generalized Anxiety Disorder
Excessive and difficult-to-control anxiety and worry almost every day about a number of events.
Post-Traumatic Stress Disorder (PTSD)
Re-experiencing of a traumatic event accompanied by persistent hyper-arousal, emotional numbness, and avoidance of stimuli associated with traumatic event.
Acute Stress Disorder Symptoms similar to PTSD, including persistent dissociative symptoms, which occur within four weeks of the event.
Separation Anxiety Inappropriate and excessive anxiety concerning separation from those to whom they are attached or on whom they depend.
Anxiety Due to Medical Condition
Anxiety symptoms that are determined to be direct physiological consequences of a medical condition.
Substance-Induced Anxiety Disorder
Anxiety symptoms are associated with substance use and are not better explained by other psychiatric or medical disorders.
Anxiety Disorder, Not Otherwise Specified
Clinically significant anxiety symptoms that do not meet criteria for a specific anxiety disorder.
48
Developmental Issues
Nearly all children experience anxieties and fears at some point in their
development (Ollendick & Hirschfeld-Becker, 2002). Their anxieties are usually age-
related, transitory, of short duration, may vary in intensity and frequency, and are
generally adaptive (e.g. fear of strangers) (Morris & Kratochwill, 1998; Ollendick, et al.,
2002). Phobias, on the other hand, are maladaptive, are beyond voluntary control, are out
of proportion to the situation or stimulus, cannot be reasoned away, and are not age-or-
stage-related (Miller, Barrett & Hampe, 1974; Morris & Kratochwill, 1983, 1998).
Focus, form, and frequency of anxiety tend to change with age. For example, a toddler
may fear strangers or separation, but an elementary school-aged child may fear school-
related events or ghosts (Dadds & Barrett, 2001). Fears usually develop only after certain
maturational stages have been reached (e.g. separation anxiety develops after object-
permanence) (Muris, Merckelbach, de Jong, & Ollendick, 2002), which helps explain
why focus of fears and anxieties change as skills and cognitive abilities develop.
Developmental differences may also help account, in part, for the type of anxiety
commonly diagnosed at different ages. For example, social phobia, which is
characterized by fear of embarrassment in social situations or peer rejection, is not
typically diagnosed until adolescence (Dadds & Barrett, 2001), because children do not,
according to Piagetian theory, develop egocentricity and abstract thinking until late
childhood or early adolescence (Bjorklund, 2005). Barrios and O’Dell (1998) also report
that the number of fears and anxieties a child displays decreases over time, with younger
children (8-10 years old) reporting more fears than older children (11-13 years old) and
49
adolescents. The intensity of the anxiety may be more pronounced in older children and
adolescents than with younger children (Kendall, 1994). Other studies indicate intensity
diminishes with time; however, this may be more a reflection of ability to cope with, and
regulate expression of, anxiety rather than an actual decrease in intensity of symptoms
(Gullone, 2000).
Gender Differences
In general, females tend to report more anxiety than males (Ollendick, et al.,
2002). Females tend to report higher number of fears and higher level of intensity of
fears, and may be one and a half to two times more likely to have an anxiety disorder
than males (Breton, Bergeron, Valla, Berthiaume, Gaudet, & Lambert, 1999; Gullone &
King, 1993); however, Breton, et al. (1999) found an age-by-gender interaction in which
girls ages 9-14 had higher rates of anxiety than boys, but the interaction did not hold true
for the 6-8 year-old group. Gender differences may also be related to gender role
orientation or development of masculine or feminine traits (Ollendick, et al., 1995). For
example, expressing anxiety is more consistent with a feminine gender role whereas
expression of fear or anxiety is less tolerated in boys (Ginsburg & Silverman, 2000). It is
also possible that parents and teachers are more likely to attend to externalizing behaviors
exhibited by boys than to internalizing behaviors more frequently displayed by females
and, consequently, symptoms of anxiety may go unnoticed or be misinterpreted (Essau,
Sakano, Ishikawa, & Sasagawa, 2004).
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Cultural Differences
Limited cross-cultural studies have provided little information regarding cultural
differences in anxiety disorders. Last & Perrin (1993) found that Caucasian and African-
American children in their sample were similar in which disorders were most prevalent,
but that African-American children had higher rates of PTSD and Caucasian children had
higher rates of school refusal. Essau, et al., (2004) found significantly higher symptoms
of anxiety in German children compared to Japanese children, and Ollendick, Yang,
King, Dong, and Akande (1996) found that Nigerian and Chinese children reported
higher levels of social- and safety-related fears than American and Australian children.
Ginsburg and Silverman (1996) found that Hispanic and Caucasian children were
relatively similar in presentation of anxiety, with the only noted difference being higher
rates of separation anxiety disorder in Hispanic children.
THEORIES OF ANXIETY
A number of theories and approaches for explaining the development of anxiety
disorders have been formulated over the last few decades. They include cognitive,
learning, family and systems, and biological theories, as well as integrative models that
incorporate aspects from some or all of the mentioned approaches.
Cognitive Theories
Cognitive theories of anxiety are similar to those associated with depression,
which may partially explain the high comorbidity rate between depression and anxiety
51
and difficulties inherent with differential diagnosis. A 2001 meta-analysis by Beck and
Perkins demonstrated significant shared variance between anxiety and depression on
measures of depressogenic and anxious cognitions. A primary difference between
depression and anxiety is that cognitions for anxiety are primarily related to physical or
psychological threats and are future-oriented, while depressive cognitions are primarily
associated with negative self-, world-, and future-appraisal and are past-oriented (Beck &
Perkins, 2001). In addition, “catastrophizing” (assuming the worst outcome for future
events) seems to be specific to anxiety. Ghahramanlou-Holloway, Wenzel, Lour & Beck
(2007) demonstrated that individuals with Generalized Anxiety Disorder (GAD) were
more likely to anticipate anxiety associated with future worst outcomes, rather than the
outcome itself, suggesting that individuals with anxiety do not necessarily worry about
the actual outcome of an event, but of the future internal affective experience that future
events may produce. More specifically, their results demonstrated that individuals with
GAD were more likely to anticipate exacerbated anxiety and worry.
In cognitive schema theory, the individual develops a schema, or representation,
that “guides the screening, encoding, organizing, storing, and retrieving of information
(Beck & Clark, 1988).” For example, most people probably have a schema for “dog” that
includes four legs, furry, a wagging tail; however, the details within the schema may
create a different picture for different individuals. That is, one person may picture “dog”
as a short, black and tan, long-furred animal with a bow in its fur, while another person
may picture “dog” as a very tall, large-pawed, short furred, slobbery animal.
Consequently, perceptions are colored by schemas and may be quite different from
52
another’s perception of the same event. Beck and Clark (1988) posit that individuals
with maladaptive schemas (i.e., schemas that influence appraisal of situations as more
dangerous than they truly are) may be more vulnerable to developing anxiety disorders.
Ingram and Kendall (1987) added to cognitive schema theory by proposing that some
individuals (youth, specifically) experience a distorted thought process in which they
perceive situations as excessively dangerous or threatening and that they perceive
ambiguous situations to be more threatening or dangerous than non-anxious individuals
(Barrett, Rapee, Dadds, & Ryan, 1996; Bell-Dolan, 1995; Chorpita, Albano, & Barlow
1996).
Information-processing perspectives add to cognitive schema theory by proposing
that maladaptively anxious children experience cognitive distortions at different stages of
cognition. That is, children are likely to selectively attend to threat-related information
and interpret ambiguous information as threatening. Consequently, they expect negative
outcomes, and behave in a manner consistent with maintaining personal safety, which
leads to overemphasis of threat and consequent decision-making based on that
misperceived threat (Puliafico & Kendall, 2006). Because cognitive development is a
continuous process in childhood and adolescence, especially with regard to executive
functioning (e.g., planning and decision making), it makes sense that appraisals and
reactions will differ at various ages, and will be particularly different between children
and adults. This lends support to the observation that young children tend to experience
separation anxiety at a much higher rate than adolescents or adults, since adolescents and
53
adults are typically at a stage of healthy independence that does not include anxiety
associated with separation (Victor & Bernstein, 2009).
Biological Bases
The brain is composed of millions of neurons that are responsible for the
production, release, and uptake of neurotransmitters, the chemical messengers that help
direct every aspect of human functioning. Neurons are organized in networks based on
function to create a circuit within specified brain structures; the circuits communicate
with other nerve groups throughout the body. Dysfunction of neural circuits may result
in a number of symptoms including, but not limited to, those seen in anxiety (Bujiron,
2007). Gray (1987, 1988) suggests that trait anxiety, anxiety that has a temperamental
characteristic rather than a situational nature, is underpinned by a neural circuit or system
of circuits, commonly known as the behavioral inhibition system (BIS). The BIS is
thought to control the experience of anxiety in response to relevant cues. There may be
both a direct pathway between the BIS and anxiety, as well as an indirect pathway, via
attention bias (Field, 2006), which complements the cognitive models of anxiety and may
help explain the apparent multidimensionality of anxiety disorders.
A number of brain structures have been identified in imaging studies as being
involved in processing anxiety-producing stimuli. These include the amygdala,
hippocampus, hypothalamus, raphe nucleus, and various regions of the brainstem
(Charney & Drevets, 2002; Davis, Walker & Myers, 2003; LeDoux, 2000). The
involvement of these structures ranges from assisting in the synthesis of
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neurotransmitters, and providing primary activation sites for neurotransmitters, to
affective reactions and responses associated with anxiety (Davis, et al., 2003; Finn,
Rutledge-Gorman, & Crabbe, 2003; Sullivan, Coplan, Kent, & Gorman, 1999).
Several neurotransmitters and neural systems have also been identified in
processes of anxiety. Serotonergic and GABAergic systems are considered the two most
prominent systems affecting anxiety processing, regulation, and response (Gordon &
Hen, 2004). In fact, benzodiazepines and selective serotonin reuptake inhibitors
(SSRI’s), both of which affect the Serotonergic/GABAergic systems, are the most widely
prescribed classes of anxiolytic drugs (Gorman, Kent, & Coplan, 2002). GABA (γ-
aminobutyric acid) is an inhibitory neurotransmitter, meaning its primary function is to
inhibit responses from excitatory neurons in the central nervous system. It is thought that
during periods of high anxiety, certain excitatory neurons are engaging in high discharge
burst activity (i.e., firing frequently and rapidly), causing heightened physical and
emotional arousal (Haefely, 1990). Several studies have demonstrated that stress can
alter the functioning of excitatory neurons and can diminish levels of GABA (Biggio,
1983; Biggio, Concas, Mele & Corda, 1987; Concas, Serra, Astoggui & Biggio, 1988),
thus creating an environment in which excitatory neurons can function with little
regulation or inhibition, which can then result in symptoms of anxiety.
Serotonin is found throughout the body and is associated with a number of
functions including sleep regulation, body temperature, pain perception, as well as
gastrointestinal and cardiovascular functioning. Several types of serotonin have been
identified, with findings indicating it is able to act as both an inhibitory and excitatory
55
neurotransmitter, and is thought to both contribute to, and to help alleviate, anxiety
(Campbell & Merchant, 2003; Clement & Chapouthier, 1998; Handley & McBlane,
1993). The presence of one type of serotonin may have anxiogenic effects, while the
presence of another may have anxiolytic effects (Ludwig & Schwarting, 2007; Sommer,
Möller, Wiklund, Thorsell, Rimondini, et al., 2001). SSRI’s, a common treatment for
both depression and anxiety, can target specific types of serotonin, enabling anxiolytic
types of serotonin to remain longer within the synaptic cleft in order to inhibit excitatory
impulses that contribute to anxiety.
The noradrenergic system has also been implicated in anxiety, specifically in
panic disorder (Sullivan, et al., 1999). Norepinephrine (noradrenaline) is both a hormone
and a neurotransmitter. As a transmitter, it is excitatory in nature and triggers reactions
such as glucose release and increased heart rate and blood flow. During stressful events
it has been shown that norepinephrine levels in the hypothalamus, amygdala, and locus
coeruleus increase and may contribute, in part, to provocation of anxiety (Tanaka,
Yoshida, Emoto & Ishii, 2000). Consequently, norepinephrine may mediate autonomic
responses such as heart rate and respiration, which may explain symptoms seen in panic
disorder and the intense physiological responses experienced in high anxiety situations
(e.g. sweaty palms) (Stahl, 1996).
Finally, the adrenocortical system has been associated with anxiety and anxiety-
like behaviors (Clark & Kaiyala, 2003). Corticotrophin-releasing hormone (CRH) and
Adrenocorticotropin (ACTH) are two of the primary neurotransmitters in the
hypothalamus-pituitary-adrenal (HPA) axis and is frequently at elevated levels during
56
stressful situations. Stressful events trigger the release of CRH from the hypothalamus,
which then triggers the release of ACTH from the pituitary. ACTH then induces the
release of glucocorticoid stress hormones from the adrenal gland, which can result in the
“rush” one might experience during a stressful or exciting event (Gordon & Hen, 2004;
Miller & O’Callaghan, 2002). An increase in CRH may contribute, in part, to anxiety-
like behaviors, as it has been shown to do in some animal models (Heinrichs, Min,
Tamraz, Carmouche, Boehme, & Vale, 1997; van Gaalen, Stenzel-Poore, Holsboer,, &
Steckler, 2002).
Genetics
Heritability in anxiety has long been suspected; however, researchers have been
unsuccessful in determining a single predisposing gene for anxiety. What some studies
have shown, on the other hand, is that there are a number of genes that are required for
normal anxiety behaviors in animal models (Finn, Rutledge-Gorman, & Crabbe, 2003;
Lesch, 2001). This may suggest that a deletion or mutation in any one of those genes
may result in myriad phenotypes and, consequently, it would be near impossible to
identify with certainty, a specific genetic anomaly that leads to maladaptive anxiety
levels. Despite the lack of concrete genetic evidence of heritability of anxiety disorders,
a number of studies have shown that some people appear to have a predisposition toward
developing anxiety disorders, or a sensitivity to anxiety. This does not guarantee that a
person will develop a disorder, but they may be more likely to develop anxiety than a
person who does not have a predisposition.
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Anxiety Sensitivity
Anxiety sensitivity refers to a tendency to respond fearfully to symptoms of
anxiety and the belief that those symptoms signal further “catastrophic” consequences
such as physical illness, mental illness, increased anxiety, etc. (Reiss & McNally, 1985;
Silverman, Fleisig, Rabian, & Peterson, 1991). That is, anxiety sensitivity is a fear of
anxiety related sensation (e.g. heart palpitation, dizziness) (Taylor & Fedoroff, 1999).
Reiss, Peterson, Gursky and McNally (1986) suggested that, in an adult population,
anxiety sensitivity may be causally related to development of anxiety disorders, and in
several studies provide evidence that seems to support this claim (Donnell & McNally,
1989; Peterson & Reiss, 1992; Shostak & Peterson, 1989). In addition, adult studies have
confirmed that some anxiety disorders are associated with high anxiety sensitivity
(McNally & Lorenz, 1987; Reiss, et al., 1986; Taylor, Koch & McNally, 1992). In a
child study, Rabian, Peterson, Richters and Jensen (1993) demonstrated a significant
positive correlation between anxiety sensitivity and total number of reported anxiety
symptoms. These results are consistent with the adult literature and supports the Reiss, et
al. (1986) theory that increased anxiety sensitivity may predispose an individual to
developing an anxiety disorder. It is worthwhile to note that there may be a ceiling effect
for anxiety sensitivity, such that after a certain level of measured sensitivity, there is no
longer a reflected increase in anxiety level (Moore, Chung, Peterson, Katzman &
Vermani, 2009). Recent research has demonstrated the robustness of the anxiety
sensitivity construct across diverse populations (Chorpita & Daleidan, 2000; Muris,
Schmidt, Merckelback & Schoufen, 2001; Zinbarg, Brown, Barlow & Rapee, 2001;
58
Zvolensky, Kotov, Antipova, Leen-Feldner & Schmidt, 2005), which suggests its
measure may be useful in predicting future development of anxiety in multiple
populations.
Behavioral/Learning Theories
Behavioral and learning theories of anxiety emphasize the role of conditioning to
aversive stimuli and retardation of extinction in the development of anxiety disorders
(Bouton, Mineka & Barlow, 2001; Field, 2006; Grillon, 2002; Rachman, 1977). The
principal of conditioning, the learning process by which a subject develops an emotional
response to a previously neutral stimulus (the conditioned stimulus, CS) when it is paired
with an aversive stimulus (the unconditioned stimulus, US), is strongly implicated in
most behavioral/learning theories. Extinction of the conditioned response occurs when
the CS is no longer presented with the US and the conditioned response gradually
diminishes over repeated presentations of the CS alone; however, it is possible for a
conditioned response to reappear after extinction has been achieved (Waters, Henry &
Neumann, 2009). Lissek, Powers, McClure, Phelps, Woldehawariat, Grillon and Pine
(2005) recently reported in a meta-analysis of classical fear conditioning in adults with
anxiety that highly anxious adults not only demonstrated elevated responses to the initial
CS, but also tended to maintain higher levels of conditioned responding during extinction
compared to controls. In one of the few studies of conditioning in highly anxious
children (Liberman, Lipp, Spence & March, 2006), subjects exhibited a larger reaction to
the CS during extinction when compared to control subjects. In a second study, Waters,
59
et al. (2009) demonstrated that highly anxious children showed greater initial response to
the CS, but that arousal after extinction had subsided substantially. Thus far, the research
seems to reflect inconsistent results concerning conditioning and extinction with highly
anxious children, and there is a need for further investigation in this area.
Bandura (1969) presents a social learning theory in which an individual learns
through observation of others’ behaviors and their consequences. Bandura’s theory
posits that emotional responses can be conditioned vicariously and, thus, fear or anxiety
can be acquired by seeing another person hurt by or responding fearfully to a stimulus.
Two studies give supportive evidence for Bandura’s theory, with the successful use of
modeling behaviors to reduce maladaptive anxious and phobic reactions (Barrios &
O’Dell, 1998; Ollendick & King, 1998). In Barrios and O’Dell’s 1998 study, the more
the model (demonstrating successful regulation of anxiety) resembled the child in age,
fear level, and previous experience with the feared stimulus, the more positive the
outcome for the subject.
Attachment Theory
Attachment theory has played a significant role in the way many researchers,
particularly those taking a learning or family dynamics approach, view the development
of anxiety. Bowlby (1969, 1973) proposes that, evolutionarily speaking, genetic
selection favored those who demonstrated strong positive attachment behaviors because
they elicited caregiver proximity and greater chance of survival. Attachment behaviors
are often observed in children in times of stress or danger, and the availability and
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responsiveness of the caregiver (i.e., the mother) is paramount in reducing the child’s
fearfulness (Ainsworth & Wittig, 1969; Sorce & Emde, 1981). Bowlby’s primary thought
was that a child who could depend on the availability and protection of a caregiver would
be less anxious and that a child who was uncertain of availability, or who could not
depend on a positive affective reaction, would be more anxious. That is, a child who
develops a positive internal working model of the person on whom they depend being
physically and emotionally available, knows he or she can explore and return to that
person (a safe base) and will become securely attached. On the other hand, a child who
cannot depend on a caregiver, and develops a negative internal working model, is
generally considered to be insecurely attached. It should be noted that insecure
attachments are not responsible for, or equated with, poor mental health, although poor
mental health may be rooted in insecure attachment (Cassidy, Lichtenstein-Phelps,
Sibrava, Thomas, & Borkovec, 2009).
Integrative Model
Researchers have recently begun to integrate aspects of various theories to create
more comprehensive models of the development of anxiety. Brown, Chorpita and
Barlow (1998) argue for a model of anxiety that integrates several factors (e.g.,
environmental, personality) because previous models of anxiety (and other disorders) had
become so symptom specific that they may erroneously distinguish symptoms and
disorders that may, in fact, be variations or phenotypes of a broader underlying
syndrome. Brown, et. al. (1998) argue that earlier models of anxiety may be missing the
61
greater picture due to over-analysis of the details. This is particularly important in light
of the overlapping nature of symptoms of some disorders, such as anxiety and depression.
Lonigan, Vasey, Phillips, & Hazen (2004) propose an integration of cognition and
temperament as explanation for anxiety development. High negative affect is associated
with pre-attentive bias toward threat related information. This theory proposes that if a
person does not possess sufficient effortful control over cognitions and emotional
responses, and is unable to override the pre-attentive bias, the individual will selectively
attend to the threat related information and ignore contrary information (Puliafico &
Kendall, 2006).
Brown, Chorpita, and Barlow’s (1998) tripartite model of anxiety and depression
helps distinguish the two disorder and considers both disorders to consist of general
distress or negative affect, with anxiety specifically characterized by physiological
hyperarousal and depression characterized by absence of positive affect. Positive affect
reflects pleasurable interactions in the environment and the extent to which a person feels
active, alert and enthusiastic. Negative affect reflects unpleasurable environmental
interactions and high subjective distress. Because both anxiety and mood disorders share
a common diathesis (negative affect), it makes sense that they are frequently comorbid
and not always easily distinguishable (Brown, et al., 1998). Lonigan, Hooe, David and
Kistner (1999) examined the relation of positive and negative affect in children with an
anxiety or depressive disorder. Their findings suggest that positive and negative affect
are two separate dimensions and that, as part of a 2-factor model of affectivity, seem to fit
well in a population of children. Lonigan and colleagues (1999) also found that age
62
seemed to moderate the expression of symptoms of anxiety and depression. It appeared
that positive affect was significantly more correlated with depressive symptoms than
anxious symptoms in older children but no significant difference in positive affect was
found for anxious or depressive symptoms with younger children, a similar finding to a
previous study (Cole, Peeke, Martin, Truglio, & Serocynski, 1998) that demonstrated
significant differentiation between anxious and depressive symptoms in third-v. sixth-
graders.
Family/Systems Theories
One aspect that is not well covered in other integrative models is the influence of
the family system on the development and maintenance of anxiety. It seems necessary to
understand the basic concepts behind family dynamics and the complex interactions
within the family system, and how relationships within the system affect anxiety in order
to understand how it might manifest and be maintained at a maladaptive level in an
individual. Dialectical, dynamic, and systems theories emphasize the hierarchical nature
of families. Within a dialectical model, the individual is active, rather than reactive, and
must be understood as part of a family (i.e., a whole). Processes in a family (which
consists of relationships), and in the relationships (which consist of individuals), may be
clarified through notions of contradiction and opposites (Kuczynski & Parkin, 2007).
Contradictions and opposing thoughts, opinions, etc. arise frequently within a family.
From the opposing elements may emerge, ideally, a change that reflects resolution of
contradiction and restoration of homeostasis (balance within the family) (Schermerhorn
63
and Cummings, 2008). For example, an argument may arise between parents over any
number of issues, and the contradiction may be compounded by a child’s witnessing the
argument and worries about family cohesion. As the parents come to a compromise of
their differences, the conflict ends, and the child’s sense of family security returns.
Bronfenbrenner’s ecological systems model (1979) provides a foundation for
thinking of a family, not only as a system itself but as containing systems within, and as
part of a larger system without. The systems are fluid and are not merely an entity within
another entity, but include the processes and interactions between entities. Thelen and
Ulrich (1991) describe the family in dynamic terms of patterns of change rather than
outcomes, and repeated cycles of behaviors that contribute to stabilizing, destabilizing,
and self-regulating processes. For example, families may vary from a baseline level of
closeness, feeling highly cohesive at times, and distant at other times, but they generally
tend to return to the baseline level. From a family systems perspective, families are
conceptualized as interdependent subsystems that self-regulate and self-reorganize
according to changing environment (Cox & Paley, 1997, 2003; Minuchin, 1985). If a
primary caregiver (e.g., mother) becomes ill, for example, other family members (e.g.,
father) modify or change roles in order to fulfill caregiver duties. Dialectical, ecological,
and dynamic theories allow us to see how systems can fluctuate, stretch, and interrelate
without losing their overall identity and functioning.
Schermerhorn and Cummings (2008) present a comprehensive model of family
transactional dynamics that describes the mutual and multiple influence processes within
a family. Their theory has its roots in a number of models from varying aspects of
64
psychology, including developmental, dialectical, and systems, among others.
Schermerhorn and Cummings (2008) describe family processes as transactional—not
unidirectional—interactions that are continuously moving in both directions between the
individual and other family members over time. The focus is on how the individual
affects family relationships (e.g., marital) and vice versa, how family relationships affect
each other, and what other family-wide influences exist. Processes include intentional
and unintentional influential behaviors in moment-to-moment events (e.g., immediate
discipline) as well as over long periods of time (e.g., development of attachment).
Family Influences on Anxiety
Studies of family influences on depression are relatively common, with the
majority focusing on the parent-child relationship, specifically the mother-child dyad.
Maternal depression is associated with lower cohesion, warmth, and expressiveness and
higher conflict and affectionless control compared to “healthy” families (Cummings,
Keller & Davies, 2005; Goodman & Gotlib, 1999). Maternal depression is also
associated with higher maternal irritability, criticism, and control, and symptoms such as
sadness, irritability, and fatigue may negatively affect ability to create and maintain a
positive parent-child relationship (Foster, et al., 2008). It seems that an increasing
number of models of both depression and anxiety focus on not only the cognitive aspects
of the disorders, but on how early life experiences (i.e., family experiences) contribute to
poor mental health (Alloy, 2001; Barlow, 2002; Chorpita & Barlow, 1998; Ingram,
Miranda, & Segal, 1998). McGinn, Cukor and Sanderson (2005) propose that cognitive
65
style mediates the link between negative parenting and mental health outcome; however,
this would conflict with findings from recent studies that link negative early life events
(e.g., negative parenting) with development of dysfunctional cognitive style, which then
contributes to anxiety and depression (Gibb, Alloy, Abramson & Marx, 2003; Gibb,
Alloy, Abramson, Rose, Whitehouse, Donovan, et al., 2001; Hankin, Abramson, & Siler,
2001). This may be a topic in which research can demonstrate a relationship between
constructs, but may not be able to determine which comes first; does dysfunctional
cognitive style mediate negative life events or do negative life events contribute to
development of a dysfunctional cognitive style? From a therapeutic standpoint it may be
necessary to understand the temporal nature of this relationship; however, for the
purposes of this paper, it is enough to understand that negative life events and
dysfunctional cognitive style are consistently shown to be related.
Anxiety and the Parent-Child Relationship
It has frequently been reported that children whose parents have an anxiety
disorder have higher rates of anxiety disorders than the general population (Beidel &
Turner, 1997; Biederman, Rosenbaum, Bolduc, Faraone & Hirschfield, 1991;
Merikangas, Dierker & Szatmari, 1998). The literature estimates a lifetime prevalence
risk for developing any anxiety disorder is approximately 15 percent for first-degree
relatives of a control population (no previously diagnosed anxiety disorder) and 32-33
percent of first-degree relatives of individuals with agoraphobia and/or panic disorder
(Woodruff-Borden, et al., 2002). Other studies have demonstrated increased risk of
66
children developing anxiety disorders if parents have diagnosed problems with anxiety or
dysthymia (Turner, Beidel, & Costello, 1987), as compared to children whose parents
have no psychiatric diagnosis (Biederman, et al., 1991). Further, relatives of children
who have anxiety disorders were found to have higher rates of anxiety compared to
relatives of children with Attention Deficit/Hyperactivity Disorder with no other
psychiatric disorders (Last, Hersen, Kazdin, Orvaschel, & Perrin, 1991). Woodruff-
Borden, et al., (2002), also demonstrated that highly anxious parents were more
withdrawn and disengaged during a mildly stressful situation than non-anxious parents.
Dyadic interactions tended to be more negative, and anxious parents displayed more
control in response to negative affect from the children. This suggests that anxious
parents may tend to withdraw and leave children to cope or struggle on their own until
negative affect is expressed, at which time they exert control in attempt to alleviate the
negative affect which makes the parent feel uncomfortable. Consequently, the attention
shifts from the child to alleviating the parent’s discomfort (Pellegrino, 2006). In other
studies, mothers with panic disorder were less sensitive to infants (Warren, Gunnar,
Kagan, Anders, Simmens, Rones, et al., 2003), and anxious parents were less expressive
and cohesive (Turner, Beidel, Roberson-Nay, & Tervo, 2003) than non-anxious parents.
In a study by McClure, Brennan, Hammen, & LeBrocque (2001), maternal anxiety
predicted child anxiety but maternal depression did not, suggesting specificity in
transmission of anxiety.
Evidence suggests that parents treat their children differently based on child
characteristics (e.g., gender, age). For example, parents may grant certain privileges to
67
their first born son but not his younger brother (Tucker, McHale & Crouter, 2003). Other
studies have shown links between children and parents in terms of psychosocial
functioning. For example, level of autonomy granting among depressed mothers is a
function of both child behaviors and maternal negative mood (Kochanska & Kuczynski,
1991). In the other direction, conduct disordered children elicit more negative responses
from mothers (Anderson, Lytton, & Romney, 1986). Studies in temperament
demonstrate that the mother-child relationship may be more related to child emotionality
and mother personality than other dimensions of child temperament. Martini, Root and
Jenkins’ (2004) study produced evidence that maternal emotional regulation varied as a
function of child emotional state (e.g. happy, sad, angry) but not other aspects of
temperament.
Parent Stress and Child Adjustment
Parenting is not easy, and stress can make the job of a parent even more difficult.
Abidin (1995) proposes three sources of parental stress; these include child
characteristics, parent characteristics, and situational or life stress. Child characteristics
are child qualities that make it difficult for a parent to fulfill parental roles, such as
demandingness or moodiness. Parent characteristics are related to the parent’s
functioning, such as health or lack of support from a spouse or partner. Situational or life
stress includes variables beyond the parent’s control, such as loss of a job or a death in
the immediate family. High levels of parental stress have been associated with both
negative child outcomes (such as anxiety) (Anderson, 2007), and negative parent
68
outcomes such as limited ability to be sensitive to a child, which may influence the
child’s emotional development (Conger, Wallace, Sun, Simons, McLoyd & Brody, 2002;
Smith, Oliver & Innocenti, 2001; Takeuchi, Williams & Adair, 1991). Pianta and
Egeland (1990) found that mothers who were experiencing high levels of stress were
found to interact with their daughters in a severely maladaptive manner, and another
study found that mothers’ high stress was associated with externalizing behaviors in boys
and both externalizing and internalizing behaviors in girls (Pianta, Egeland & Sroufe,
1991).
Economic hardship generally leads to high parental stress, and a significant
relationship has been shown to exist between emotional distress of a caregiver due to
economic difficulties and child maladjustment (Conger, et al., 2002). Parent distress due
to divorce, remarried families (Hetherington, Bridges & Isabella, 1998), and single
parenthood (Antshel & Joseph, 2006) has also been shown to negatively affect child
maladjustment. Dong, Wang & Ollendick (2002) found that children from divorced
families had significantly higher levels of self-reported anxiety and depression, and
parents and teachers also reported significant levels of internalizing and externalizing
behaviors for these children. High stress may make it difficult for parents to be sensitive,
responsive and emotionally available to their children, which may contribute to poorly
developed attachment, which may then lead to further parent stress as the child grows. In
a study of domestic violence and young children’s functioning, parenting stress was
found to be the strongest predictor of children’s scores on a measure of internalizing and
69
externalizing behaviors (Zerk, Mertin & Proeve, 2009). In some cases, high parent stress
can be associated with abusive parenting (Whipple & Webster-Stratton, 1991).
EFFECTS OF ANXIETY ON DAILY FUNCTIONING
Anxiety can negatively affect daily functioning, in extreme cases to the point of
incapacitation (e.g. agoraphobia), and may cause disturbances in social functioning,
academic performance, and/or or activities of daily living. It is particularly salient to
understand how anxiety affects daily functioning in children, since childhood is the time
when skills are developed for functioning as an adult in social and professional arenas.
Anxiety and Social Functioning
The importance of childhood peer relationships and social interaction has long
been recognized by researchers in the field of child development. Early studies of
childhood social interaction focused on aggression or externalizing behaviors and peer
rejection (e.g. French, 1988); however, more recent research has examined the
relationship between internalizing problems and peer difficulties. There appears to be a
strong relationship between peer rejection and subsequent depression (Strauss, Frame and
Forehand, 1987) or anxiety (Hawker & Boulton, 2000; Kiesner, 2002), as well as other
problems such as loneliness, substance use, and academic difficulty (Ollendick, et al.,
2002, O’Neil, Welsh, Parke, Wang, & Strand, 1997). There is evidence that younger
children may ignore or neglect other children who seem socially inhibited or negative
(Younger, et al., 1993), and, as they become older, anxious children may be actively
70
rejected by peers (French, 1988; Rubin, Hymel, & Mills, 1989). There is also evidence
that these children engage in fewer constructive interactions (Morgan & Banerjee, 2006),
attain fewer social goals (Stewart & Rubin, 1995), and demonstrate poorer social
performance in novel situations (Spence, Donovan, & Brechman-Toussaint, 1999). In a
study by Verduin and Kendall (2008), children viewed a video-taped speech by a same-
age peer and rated the other child on likability. Their results suggest that children who
report feeling anxious are viewed as such by peers, and that peers preferred children
whom they rated as having lower anxiety as well as children who self-reported lower
social anxiety. After examining the data with regard to specific anxiety diagnoses,
however, the authors discovered that the above observations only held true for children
with social phobia, supporting previous research that has suggested a relationship
between social phobia and peer-liking and the importance of perception of anxiety in
others (Fordham & Stevenson-Hinde, 1999; Garber & Hollon, 1991; Grover, Ginsburg &
Ialongo, 2007; Parker & Asher, 1987).
Anxiety and Activities of Daily Living
Anxiety may also affect daily activities including, but not limited to, preparation
for the day ahead, school refusal, repetitive behaviors or routines that strain time
schedules (e.g., in the case of obsessive-compulsive disorder), forgetfulness or
distractibility, or sleep patterns. Interference of sleep may be important to consider as
good sleep is necessary for effective physical and mental functioning. Poor sleep is
likely to contribute to problems in daily functioning of highly anxious persons in
71
particular. Highly anxious children commonly experience difficulty with initial sleep,
nightmares, nonspecific nighttime fears, and difficulty sleeping away from home, all of
which contribute to poor sleep (Alfano, Ginsburg & Kingery, 2007). A 2007 study by
Alfano, Ginsburg, and Kingery reported that 88% of the anxious youth participants
suffered sleep problems and that the higher the level of anxiety, the more sleep problems
were experienced. Sleep deprivation may also account, in part, for the cognitive deficits
frequently seen in anxiety (e.g., impulsivity, poor problem-solving), which may
contribute to academic difficulties and social interaction problems.
Anxiety and Academic Performance
Anxiety is frequently associated with poor academic performance, as teachers
report higher school dysfunction and learning disabilities (Benjamin, Costello & Warren,
1990), poor motivation and school strategies (Gumora & Arsenio, 2002; Rabian &
Silverman, 2000), and early school drop-out among highly anxious children (Kessler,
Foster, Saunders & Stang, 1995; Van Ameringen, Mancini & Farvolden, 2002).
Cognitive and neurocognitive correlates may be responsible, in part, for poor academic
performance. Executive functioning also appears impaired in anxious children (Emerson,
Mollett & Harrison, 2004; Toren, Sadeh, Womer, Eldar, Koren, Weizman & Laor, 2000).
Executive functioning includes flexibility in thinking and problem-solving, shifting
attention, impulse control, organization, working memory and information processing
(Eysenk, 1990; Mathews, Mackintosh & Fulcher, 1997; Toren, et al., 2000; Vasey &
MacLeod, 2001).
72
Visu-Petra, Ciariano and Miclea (2006) propose a relationship between working
memory and anxiety, which may partially account for symptoms of Attention-Deficit
Hyperactivity Disorder commonly seen in anxiety, such that some memory resources are
depleted by task-irrelevant worry, reducing resources available for efficient processing
and consolidation of information (Eysenk & Calvo, 1992). Poor concentration or
attention due to distracting worries, coupled with limited working memory capacity,
would make learning in a classroom environment difficult. When such difficulties are
combined with poor problem-solving and poor impulse control, high levels of frustration,
possible acting out or refusal to complete tasks, and general academic problems are to be
expected. Tasks may take longer to accomplish, learning may appear delayed, and grades
are likely to suffer. Grover, Ginsburg and Ialongo (2007) demonstrated that low-income
African-American children who were highly anxious scored significantly lower on
measures of academic achievement and peer acceptance, and higher on measures of
depression and aggression, than children with low anxiety. After a seven-year follow up,
these same children scored significantly lower on measures of academic achievement,
aggression and peer acceptance, and higher on measures of anxiety and depression. In
fact, children who rated as having high levels of anxiety in first grade continued to have
problems with reading and mathematics achievement in eighth grade. When considering
the neurocognitive correlates of anxiety noted in previous sections, it is not surprising
that children with anxiety tend to have academic difficulties.
73
Appendix B: Multidimensional Anxiety Scale for Children (MASC)
Sample Questions
This questionnaire asks you how you have been thinking, feeling, or acting recently. For each item, please circle the word that shows how often the statement is true for you. Remember, there are no right or wrong answers, just answer how you have been feeling recently. I feel tense or uptight……………………….... Never Rarely Sometimes Often
I worry about other people laughing at me……Never Rarely Sometimes Often
I keep my eyes open for danger……………….Never Rarely Sometimes Often
I try to stay near Mom or Dad………………...Never Rarely Sometimes Often
I feel restless and on edge……………………..Never Rarely Sometimes Often
I try to do everything exactly right…………....Never Rarely Sometimes Often
74
Appendix C: Parenting Stress Index (PSI) Sample Questions
For each statement, please focus on the child you are most concerned about, and circle the response which best represents your opinion. SA=Strongly Agree; A=Agree; NS=Not Sure; D=Disagree; SD=Strongly Disagree
When my child wants something, my child usually keeps trying to get it.
SA A NS D SD
My child smiles at me much less than I expected
SA A NS D SD
I feel capable and on top of things when I am caring for my child.
SA A NS D SD
My child makes more demands on me than most children.
SA A NS D SD
I feel trapped by my responsibilities as a parent.
SA A NS D SD
For the following statements, choose Y for “Yes” and N for “No”.
During the last 12 months, have any of the following events occurred in your immediate
family?
Divorce Y N Death of a close family friend Y N
Pregnancy Y N Moved to a new location Y N
Promotion at work Y N Alcohol or drug problem Y N
75
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