Copyright

by

Sarah E. James

2012

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).

50

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

54

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.

57

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

60

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

References

Abidin, R. (1990). Parenting Stress Index/Short Form. Lutz, Fl: Psychological Assessment Resources, Inc.

Abidin, R. (1992). The determinants of parenting behavior. Journal of Clinical Child Psychology, 21, 407-412.

Abidin, R. (1995). Parenting Stress Index Professional Manual (3rd Ed.). Lutz, FL: Psychological Assessment Resources, Inc.

Addis, M. & Mahalik, J. (2003). Men, masculinity, and the contexts of help seeking. American Psychologist, 58, 5-14.

Ainsworth, M. & Wittig, B. (1969). Attachment and exploratory behavior of one-year-olds in a strange situation. In Foss, B. (Ed.), Determinants of Infant Behavior IV (pp. 111-136). London: Methuen.

Alfano, C., Ginsburg, G. & Kingery, J. (2007). Sleep-Related Problems Among children and Adolscents with Anxiety Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(2), 224-232.

Alloy, L. A. (2001). The developmental origins of cognitive vulnerability to depression: Negative interpersonal context leads to personal vulnerability. Cognitive Therapy and Research, 25(4), 349–351.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington DC: Author.

Anderson, K., Lytton, H., & Romney, D. (1986). Mother’s interactions with normal and conduct-disordered boys: Who affects whom? Developmental Psychology, 22, 604-609.

Anderson, J.C. (1994). Epidemiological issues. In T.T. Ollendick, N.J. King, & W. Yule (Eds.), International handbook of phobic and anxiety disorders in children and adolescents (pp. 43-65). New York: Plenum Press.

Anderson, N. (2007). The Relationship Between Mothers’ Stress Level and Anxiety Ratings of Their Children. Retrieved July 11, 2009, from PsycINFO database.

Antshel, K.M., & Joseph, G.R. (2006). Maternal stress in nonverbal learning disorder: A comparison with reading disorder. Journal of Learning Disabilities, 39, 194-205.

Attride-Stirling, J., Davis, H., Farrell, L. Groark, C., & Day, C. (2004). Factors influencing parental engagement in a community child and adolescent mental health service: A qualitative comparison of completers and non-completers. Clinical Child Psychology and Psychiatry, 9(3), 347-361.

Baker-Ericzén, M., Jenkins, M., & Brookman-Frazee, L. (2010). Clinician and Parent Perspectives on Parent and Family Contextual Factors that Impact Community Mental Health Services for Children with Behavior Problems. Child Youth Care Forum, 39, 397-419.

Bandura, A. (1969). Principles of Behavior Modification. New York: Holt, Rinehart, and Winston, Inc.

76

Barlow, D. H. (2002). Anxiety and its disorder (2nd ed.). New York: Guilford. Barrett, P. M., Rapee, R. M., Dadds, M. R., & Ryan, S. M. (1996). Family enhancement

of cognitive style in anxious and aggressive children: Threat bias and the FEAR effect. Journal of Abnormal Child Psychology 24, 187–203.

Barrios, B.A., & O’Dell, S.L. (1998). Fears and anxieties. In E.J. Mash & R.A.Barkley, (Eds.), Treatment of childhood disorders (2nd ed., pp.249-337). New York: Guilford Press.

Beauchaine, T. P., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and predictors of 1-year outcomes among children treated for early-onset conduct problems: A latent growth curve analysis. Journal of Consulting and Clinical Psychology, 73(3), 371-388.

Beck, A. & Clark, D. (1988). Anxiety and Depression: An information processing perspective. Anxiety Research, 1(1), 23-36.

Beck, R. & Perkins, T. (2001). Cognitive content-Specificity for Anxiety and Depression: A Meta-Analysis. Cognitive Therapy and Research, 25(6), 651-663.

Beidel, D. & Turner, S. (1997). At risk for anxiety: Psychopathology in the offspring of anxious parents. Journal of American Academy of Child and Adolescent Psychiatry, 36, 918-924.

Bell-Dolan, D. J. (1995). Social cue interpretation of anxious children. Journal of Clinical Child Psychology 24, 1–10.

Belsky, J., Hertzog, C., & Rovine, M. (1986). Causal analyses of multiple determinants of parenting: Empirical and methodological advances. In M. E. Lamb, A. L., Brown, & B. Rogoff (Eds.), Advances in developmental psychology (pp. 153-202). New York: Pergamon.

Belsky, J., Woodworth, S., & Crnic, K. (1996). Trouble in the second year: Three questions about family interaction. Child Development, 67, 556-578.

Belsky, J. (1984). The determinants of parenting: A process model. Child Development, 55, 83-96.

Benjamin, R. S., Costello, E. J., & Warren, M. (1990). Anxiety disorders in a pediatric sample. Journal of Anxiety Disorders, 4(4), 293-316. Biederman, J., Rosenbaum, J. F., Bolduc, E. A., Faraone, S. V., & Hirschfield, D. R.

(1991). A high risk study of young children of parents with panic disorder and agoraphobia and without comorbid major depression. Psychiatry Research, 37, 333−348.

Biggio, G. (1983). The actions of stress, β-carbolines, diazepam, and Ro-15-1788 on GABA receptors in the rate brain. In G. Biggio and E. Costa (Eds.) Benzodiazepine Recognition Site Ligands: Biochemistry and Pharmacology (pp. 105-117). New York: Raven Press.

Biggio, G., Concas, A., Mele, S., & Corda, M. (1987). Changes in GABAergic transmission induced by stress, anxiogenic and anxiolytic β-carbolines. Brain Research Bulletin, 19, 301-308.

Bjorklund, D.F. (2005). Children’s thinking: Cognitive development and individual differences (4th ed.). Belmont, CA: Wadsworth.

77

Blazer, D., Kessler, R., McGonagle, A., & Swartz, M. (1994). The prevalence and distribution of mahor depression in a national community sample: The National Comorbidity Study. American Journal of Psychiatry, 151, 979-986.

Bonner, M., Hardy, K., Guill, A., McLaughlin, C., Schweitzer, & Carter, K. (2006). Development and validation of the Parent Experience of Child Illness. Journal of

Pediatric Psychology, 31(3), 310-321. Bouton, M., Mineka, S., & Barlow, D. (2001). A contemporary learning theory

perspective on the etiology of panic disorder. Psychological Review, 108, 4–32. Bowlby, J. (1969). Attachment and Loss: Volume 1 Attachment. New York: Basic

Books. Bowlby, J. (1973). Attachment and loss: Vol 2. Separation. New York: Basic Books. Brand, S., Wilhelm, F. H., Kossowsky, J., Holsboer-Trachsler, E., & Schneider, S.

(2011). Children suffering from separation anxiety disorder (SAD) show increased HPA axis activity compared to healthy controls. Journal of Psychiatric Research, 45(4), 452-459.

Breton, J.J., Bergeron, L., Valla, J.P., Berthiaume, C., Gaudet, N., Lambert, J., et al. (1999). Quebec Child Mental Health Survey: Prevalence of DSM-III-R mental health disorders. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 375-384.

Bringewatt, E. & Gershoff, E. (2010). Falling through the cracks: gaps and barriers in the mental health system for America’s disadvantaged children. Children and Youth Services Review, 32, 1291-1299.

Brody, G., Murry, V., Kim, S., & Brown, A. (2002). Longitudinal pathways to competence and psychological adjustment among African American children living in rurual single-parent households. Child Development, 73, 1505-1516.

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.

Brown, T. A., Chorpita, B. F., & Barlow, D. H. (1998). Structural relations among dimensions of the DSM-IV anxiety and mood disorders and dimensions of negative affect, positive affect, and autonomic arousal. Journal of Abnormal Psychology, 107, 179-192.

Burijon, B. (2007). Biological Basis of Clinical Anxiety. New York: W. W. Norton and Company.

Burns, B., Phillips, S., Wagner, H., Barth, R., Kolko, D., Campbell, Y., & Yandsverk, J. (2004). Mental health need and access to mental health services by youths involved with child welfare: A national survey. Journal of the American Academy of Child and Adolescent Psychiatry, 43(8), 960-970.

Campbell, B. M., & Merchant, K. M. (2003). Serotonin 2C receptors within the basolateral amygdala induce acute fear-like responses in an open-field environment. Brain Research, 993(1-2), 1-9.

Campbell, S., Cohn, J., & Meyers, T. (1995). Depression in first-time mothers: Mother-infant interaction and depression chronicity. Developmental Psychology, 31, 349-357.

78

Campbell, T. (1993). Families after a heart attack. Family Systems Medicine, 11(1), 105-110.

Cartwright-Hatton, S., McNicol, K., & Doubleday, E. (2006). Anxiety in a neglected population: Prevalence of anxiety disorders in pre-adolescent children. Clinical Psychology Review, 26, 817-833.

Cassidy, J., Lichtenstein-Phelps, J., Sibrava, N., Thomas, C. & Borkovec, T. (2009). Generalized Anxiety disorder; Connections with Self-Reported Attachment.

Behavior Therapy, 40, 23-38. Charney DS, & Drevets WC. 2002. The neurobiological basis of anxiety disorders. In

Davis KL, Charney DS, Coyle JT, Nemeroff C. (Eds.). (2002). Neuropsychopharmacology: The Fifth Generation of Progress, (pp. 901-930). Philadelphia: Lippincott Williams and Wilkins.

Chorpita, B., Albano, A., & Barlow, D. H. (1996). Cognitive processing in children: Relationship to anxiety and family influences. Journal of Clinical Child

Psychology 25, 170–176. Chorpita, B. F., & Barlow, D. H. (1998). The development of anxiety: The role of control

in the Early environment. Psychological Bulletin, 124(1), 3–21. Chorpita, B., & Daleiden, E. (2000). Properties of the childhood anxiety sensitivity

index in children with anxiety disorders: Autonomic and nonautonomic factors. Behavior Therapy, 31, 327-349.

Chronis, A. M., Chacko, A., Fabiano, G. A., Wymbs, B. T., & Pelham, W. E., Jr. (2004). Enhancements to the behavioral parent training paradigm for families of children with ADHD: Review and future directions. Clinical Child and Family Psychology Review, 7(1), 1-27.

Clark M., & Kaiyala, K. (2003). Role of corticotropin-releasing factor family peptides and receptors in stress-related psychiatric disorders. Seminar in Clinical Neuropsychiatry, 8, 119–136.

Clement, Y., & Chapouthier, G. (1998). Biological bases of anxiety. Neuroscience and Biobehavioral Reviews, 22(5), 623-633.

Cohen, B. (1999). Measuring the willingness to seek help. Journal of Social Service Research, 26, 67-82.

Cole, D., Peeke, L., Martin, J., Truglio, R., & Serocynski, A. (1998). A longitudinal look at the relation between depression and anxiety in children and adolescents. Journal of Consulting and Clinical Psychology, 66, 451-460.

Concas, A., Serra, M., Astoggiu, T., & Biggio, G. (1988). Foot shock stress and anxiogenic β-carbolines increase 35S-TBPS binding in the rate cerebral cortex, and effect opposite to anxiolytics and GABE mimetics. Journal of Neurochemistry, 51, 1868-1876.

Conger, K., Reuter, M., & Conger, R. (2000). The role of economic pressure in the lives of parents and their adolescents: The family stress model. In L. J. Crockett & R. J. Silbereisen (Eds.), Negotiating adolescence in times of social change (pp. 201-223). Cambridge, UK: Cambridge University Press.

79

Conger, R.D., Wallace, L.E., Sun, Y., McLoyd, V.C., & Brody, G.H. (2002). Economic pressure in African American Families: A replication of the family stress model. Developmental Psychology, 38, 179-193.

Connery, R., Backstrom, C., Deener, D., Friedman, J., Kroll, M., Marden, R., et al. (1968). The Politics of Mental Health: Organizing Community mental Health in Metropoilitan Areas. New York: Colombia University Press.

Costello, E., Compton, S., Keeler, G., & Angold, A. (2003). Relationships between Poverty and Psychopathology. Journal of the American Medical Association, 290(15), 2020-2064.

Cox, M. and Paley, B. (1997). Families as systems. Annual Review of Psychology, 48, 243-267.

Cox, M. and Paley, B. (2003). Understanding families as systems. Current Directions in Psychological Science, 12, 193-196.

Cramer, K. (1999). Psychological antecedents to help-seeking behavior: A reanalysis using path modeling structures. Journal of Counseling Psychology, 46, 381-387.

Cummings, E. M., Keller, P. S., & Davies, P. T. (2005). Towards a family process model of maternal and paternal depressive symptoms: Exploring multiple relations with child and family functions. Journal of Child Psychology and Psychiatry, 46, 479–489.

Dadds, M.R., & Barrett, P.M. (2001). Practitioner review: Psychological management of anxiety disorders in childhood. Journal of Child Psychology and Psychiatry, 42,99-1011.

Davis M., Walker D., & Myers K. (2003). Role of the amygdala in fear extinction measured with potentiated startle. Annals of the New York Academy of Science, 985, 218–232.

DeNavas-Walt, C., Proctor, B., & Smith, J. (2011). Income, poverty, and health insurance coverage in the United States: 2010. U.S. Census Bureau, Current Population Reports. Washington, DC: US.

Dierker, L. C., Albano, A., Clarke, G. N., Heimberg, R. G., Kendall, P. C., Merikangas, K. R., et al. (2001). Screening for anxiety and depression in early adolescence. Journal Of The American Academy Of Child & Adolescent Psychiatry, 40(8), 929-936.

Dodge, K. (2001). The Science of Youth Violence Prevention: Progressing from Developmental Psychopathology to Efficacy to Effectiveness to Public Policy. American Journal of Preventive Medicine 20, 63-70.

Dong, Q., Wang, Y., & Ollendick, T.H. (2002). Consequences of divorce on the adjustment of children in China. Journal of Clinical Child and Adolescent Psychology, 31, 101-110.

Donnell, C. & McNally, R. (1989). Anxiety sensitivity and history of panic as predictors of response to hyperventilation. Behavior, Research and Therapy, 27, 325-332.

Dorwart, R. A., & Eptstein, S. S. (1993). Privatization and mental health care: A fragile balance. Westport, CT: Auburn House.

80

Duran, E. & Duran, B. (1995). Native American postcolonial psychology. New York: State University of New York Press.

Duran, B., Oetzel, J., Lucero, J., Jiang, Y., Novin, D., Manson, S., & Beals, J. (2005). Obstacles for Rural American Indians Seeking Alcohol, Drug, or Mental Health Treatment. Journal of Consulting and Clinical Psychology, 73(5), 819-829.

Dubay, L., Haley, J., & Kenney, G. (2002). Children’s Eligibility for Medicaid and SCHIP: A View from 2000. Washington, DC: The Urban Institute.

Emerson, C. S., Mollet, G. A. & Harrison, D. W. (2004). Anxious-depression in boys: an evaluation of executive functioning. Archives of Clinical Neuropsychology, 20(4),

539-46. Ennis, N., Hobfall, S., & Schroder, K. (2000). Money doesn’t talk, it swears: How

economic stress and resistance resources impact inner city women’s depressive mood. American Journal of Community Psychology, 28, 149-173.

Essau, C.A., Sakano, Y., Ishikawa, S., & Sasagawa, S. (2004). Anxiety symptoms in Japanese and in German children. Behaviour Research and Therapy, 42, 601-612.

Eyberg, S. M., Funderburk, B. W., Hembree-Kigin, T., L., Mcneil, C. B., Querido, J. G., & Hood, K. K. (2001). Parent-child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child and Family Behavior Therapy, 23(4), 1-20.

Eyberg, S., Nelson, M., Boggs, S. (2008). Evidence-based psychosocial treatment for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37(1), 215-237.

Eysenck, H. J. (1990). Biological dimensions of personality. In L. A. Pervin (Ed.), Handbook of personality: Theory and research (pp. 244-276). New York:

Guilford. Eysenck, M. W., & Calvo, M. G. (1992) Anxiety and performance: The Processing Efficiency Theory. Cognition and Emotion, 6, 409-434. Fairbrother, G., Kenney, G., Hanson, K., & Dubay, L. (2005). How Do Stressful Family

Environments Relate to Reported Access and Use of Health Care by Low-Income Children? Medical Care Research and Review, 62(2), 205-230.

Field, A. (2006). The Behavioral Inhibition System and the Verbal Information Pathway to Children’s Fears. Journal of Abnormal Psychology, 115(4), 742-752.

Finn, D., Rutledge-Gorman, M., & Crabbe, J. (2003). Genetic animal models of anxiety. Neurogenetics, 4,109–35. Foley, H., & Sharftsein, S. (1983). Madness and Government: Who Cares for the

Mentally Ill? Washington, DC: American Psychiatric Press. Fordham K., & Stevenson-Hinde J. (1999). Shyness, friendship quality, and adjustment

during middle childhood. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40,757–768.

Fossum, S., Morch, W. T., Handegard, B. H., Drugli, M., & Larsson, B. O. (2009). Parent training for young Norwegian children with ODD and CD problems: Predictors and mediators of treatment outcome. Scandinavian Journal of Psychology, 50(2), 173-181.

81

Foster, C., Webster, M., Weissman, M., Pilowsky, D., Wickramaratne, P., Rush, A., et al. (2008). Course and severity of maternal depression: Associations with family functioning and child adjustment. Journal of Youth and Adolescence, 37(8), 906-916.

Frankel, K. & Harmon, R. (1996). Depressed Mothers: they don’t always look as bad as they feel. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 289-298.

Frazier, S., Abdul-Adil, J., Atkins, M., Gathright, T., & Jackson, M. (2007). Can’t have one without the other: Mental health providers and community parents reducing barriers to services for family in urban poverty. Journal of Community Psychology, 35(4), 435-446.

French, D. C. (1988). Heterogeneity of peer-rejected boys: Aggressive and non-aggressive subtypes. Child Development, 59, 976–985.

Friars, P., & Mellor, D. (2009). Drop-out from parenting training programmes: A retrospective study. Journal of Child and Adolescent Mental Health, 21(1), 29-38.

Fullerton, C., & Ursano, R. 91994). Preadolescent Peer Friendships: A Critical Contribution to Adult Social Relatedness? Journal of Youth and Adolescence, 23(1), 43-63.

Garber, J., & Hollon, S. D. (1991). What can specificity designs say about causality in psychopathology research? Psychological Bulletin, 110, 129–136. Ghahramanlou-Holloway, M., Wenzel, A., Lou, K. & Beck, A. (2007). Differentiating Cognitive Content Between Depressed and Anxious Outpatients. Cognitive

Behaviour Therapy, 36(3), 170-178. Gibb, B., Alloy, L., Abramson, L., Rose, D., Whitehouse, W., Donovan, P., et al. (2001).

History of childhood maltreatment, negative cognitive styles, and episodes of depression in adulthood. Cognitive Therapy and Research, 25(4), 425–446.

Gibb, B. E., Alloy, L. B., Abramson, L. Y., & Marx, B. P. (2003). Childhood maltreatment and maltreatment-specific inferences: A test of Rose and Abramson’s (1992) extension of the hopelessness theory. Cognition and Emotion, 17(6), 917–931.

Ginsburg, G.S., & Silverman , W.K. (1996). Phobic and anxiety disorders in Hispanic and Caucasian youth. Journal of Anxiety Disorders, 10, 517-528.

Ginsburg, G.S., & Silverman, W.K. (2000). Gender role orientation and fearfulness in children with anxiety disorders. Journal of Anxiety Disorders, 14, 57-67.

Gonzalez, M. J. (2005). Access to mental health services: the struggle of poverty affected urban children of color. Child and Adolescent social Work Journal, 22, 245-256.

Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission. Psychological Review, 106, 458–490.

Gordon, J. & Hen, R. (2004). Genetic Approaches to the Study of Anxiety. Annual review of Neuroscience, 27, 193-222.

82

Gorman J., Kent J., & Coplan J. (2002). Current and emerging therapeutics of anxiety and stress disorders. In Davis, KL, Charney DS, Coyle JT, Nemeroff C. (Eds.). (2002). Neuropsychopharmacology: The Fifth Generation of Progress, (pp. 967-980). Philadelphia: Lippincott Williams and Wilkins.

Gray, J. A. (1987). Perspectives on anxiety and impulsivity: A commentary. Journal of Research in Personality, 21, 493–509.

Gray, J. A. (1988). The psychology of fear and stress (2nd edition). Cambridge: Cambridge University Press. Grillon, C. (2002). Startle reactivity and anxiety disorders: Aversive conditioning,

context, and neurobiology. Biological Psychiatry, 52, 958–975. Grover, R., Ginsburg, G. & Ialongo, N. (2007). Psychosocial outcomes of anxious first graders: a seven-year follow-up. Depression and Anxiety, 24, 410-420. Gullone, E., & King, N. J. (1993). The fears of youth in the 1990s: Contemporary

normative data. The Journal of Genetic Psychology, 154, 137-153. Gullone, E. (2000). The development of normal fear: A century of research. Clinical

Psychology Review, 20, 429-451 Gumora G., & Arsenio W. F. (2002). Emotionality, emotion regulation, and school performance in middle school children. Journal of School Psychology, 40, 395–

413. Gunther, N., Slavenburg, B., Feron, F., & Os, J. V. (2003). Childhood social and early

developmental factors associated with mental health service use. Social Psychiatry and Psychiatric Epidemiology, 38, 101-108.

Gustafson, K., McNamara, J., & Jensen, J. (1994). Parents’ informed consent decisions regarding psychotherapy for their children: Consideration of therapeutic risks and benefits. Professional Psychology: Research and Practice, 25, 16-22.

Haefely, W. (1990). GABA-Benzodiazepine receptor complex and anxiety. In N. Sartorious (Ed.) Anxiety: Psychobiological and Clinical Perspectives (pp. 23-36). New York: Hemisphere Publishing Corporation.

Handley, S. L., & McBlane, J. W. (1993). 5HT drugs in animal models of anxiety. Psychopharmacology, 112(1), 13-20.

Hankin, B. L., Abramson, L. Y., & Siler, M. (2001). A prospective test of the hopelessness theory of depression in adolescence. Cognitive Therapy and Research, 5, 607–632.

Hartley, D., Bird, D., Lambert, D., & Coffin, J. (2002). The Role of Community Mental Health Centers as Rural Safety Net Providers (Working Paper #30). Portland, ME: Maine Rural Health Research Center.

Hawker, D. S. J., & Boulton, M. J. (2000). Twenty years’ research on peer victimization and psychosocial maladjustment: A meta-analytic review of cross-sectional studies. Journal of Child Psychology and Psychiatry and Allied Disciplines, 41, 441–455.

Hetherington, E., Bridges, M., & Insabella, G. M. (1998). What matters? What does not? Five perspectives on the association between marital transitions and children's adjustment. American Psychologist, 53(2), 167-184.

83

Heinrichs S., Min H., Tamraz S., Carmouche M., Boehme, S., & Vale W. (1997). Anti-sexualand anxiogenic behavioral consequences of corticotropin-releasing factor overexpressionare centrally mediated. Psychoneuroendocrinology, 22, 215–224.

Hoagwood, K., & Kolko, E. (2009). Introduction to the special section on practice contexts: A glimpse into the nether world of public mental health services for children and families. Administration and Policy in Mental Health and Mental Health Services Research, 39(1), 35-36.

Howell, E. (2004). Access to children’s mental health services under Medicaid and SCHIP. Washington, D.C.: Urban Institute.

Huang, L., Stroul, B., Friedman, R., Mrazek, P., Friesen, B., Pires, S., et al. (2005). Transforming mental health care for children and their families. American Psychologist, 60, 615-627.

Ingram, R. E., & Kendall, P. C. (1987). The cognitive side of anxiety. Cognitive Therapy and Research, 11: 523–536.

Ingram, R. E., Miranda, J., & Segal, Z. V. (1998). Cognitive vulnerability to depression. New York: Guilford.

James, A., Soler, A., & Weatherall, R. (2005). Cognitive behavioural therapy for anxiety disorders in children and adolescents. [Art. No. CD004690.pub2]. The Cochrane Database of Systematic Reviews, 4. Art.No.:

CD004690. doi:10.1002/14651858.CD004690.pub2. Kazdin, A. E., & Wassell, G. (1999). Barriers to treatment participation and therapeutic

change among children referred for conduct disorder. Journal of Clinical Child Psychology, 28(2), 160-172.

Kazdin, A. & Whitley, M. (2003). Treatment of Parental Stress to Enhance Therapeutic Change Among Children Referred for Aggressive and Antisocial Behavior. Journal of Consulting and Clinical Psychology, 71(3), 504-515.

Kazdin, A. E. (1995). Scope of child and adolescent psychotherapy research: Limited sampling of dysfunctions, treatments, and client characteristics [Special issue: Methodological issues in clinical psychology research]. Journal of Clinical Child Psychology, 24(2), 125-140.

Kazdin, A. E. (1998). Research design in clinical psychology (3rd Ed.). Needham Heights, MA: Allyn & Bacon.

Kendall, P.C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 62, 100-110.

Kessler, R., Chiu, W., Demler, O., & Walters, E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IVdisorders in the National Comorbidity Survey Replication (NCS- R), Archives of General Psychiatry, 62(6), 617-627.

Kessler, R. C., Foster, C. L., Saunders, W. B., & Stang, P. E. (1995). Social consequencesof psychiatric disorders: Educational attainment. American Journal of Psychiatry, 152, 1026–1032.

Kiesner, J. (2002). Depressive symptoms in early adolescence: Their relations with classroom problem behavior and peer status. Journal of Research on Adolescence, 12, 463–478.

84

Knitzer, J. (1996). Meeting the mental health needs of young children and their families. In B. A. Strout (Ed.), Children’s mental health: Creating systems of care in a changing society (pp. 553-572). Baltimore, MD: Paul H. Brookes Publishing Co.

Kochanska, G., Kuczynski, L., Radke-Yarrow, M., & Welsh, J. (1987). Resolutions of control episodes between well and affectively ill mothers and their young. Journal of Abnormal Child Psychology, 15, 441-456.

Kochanska, G., & Kuczynski, L. (1991). Maternal autonomy granting: Predictors of normal and depressed mothers' compliance and noncompliance with the requests of five-year-olds. Child Development, 62(6), 1449-1459.

Kuczynski, L., & Parkin, C. (2007). Agency and bidirectionality in socialization: Interactions transactions and relational dialectics. In J. E. Grusec and P. D. Hastings (Eds.), Handbook of socialization: Theory and research (pp. 259-283). New York: Guilford.

Lambert, D., Hartley, D., Bird, D., Ralph, R., & Saucier, P. (1998). Medicaid Mental Health Carveouts: Impact and Issues in Rural Areas (Working Paper #9). Portland, ME: Maine Rural Health Research Center.

Lamb, M. (2004). The role of the father in child development (4th ed.). Hoboken, NJ: Wiley.

Last, C. G., Hersen, M., Kazdin, A. E., Orvaschel, H., & Perrin, S. (1991). Anxiety disorders inchildren and their families. Archives of General Psychiatry, 48, 928-934.

Last, C.G., & Perrin, S. (1993). Anxiety disorders in African-American and white children. Journal of Abnormal Child Psychology, 21, 153-164.

Lau, W., Chan, C. K., Li, J. C., & Au, T. K. (2010). Effectiveness of group cognitive behavioral therapy for childhood anxiety in community clinics. Behaviour Research and Therapy, 48, 1067-1077.

Lazarus, R., & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer. LeDoux J. (2000). Emotion circuits in the brain. Annual Review of Neuroscience,

23,155–184. Lee, C. S., Anderson, J. R., Horowitz, J. L., & August, G. J. (2009). Family income and

parenting: The role of parental depression and social support. Family Relations, 58(4), 417-430.

Lesch, K. (2001). Mouse anxiety: the power of knockout. Pharmacogenomics Journal, 1, 187–92.

Levac, A. M., McCay, E., Merka, P., & Reddon-Darcy, M. L. (2008). Exploring parent participation in parent training program for children’s aggression: Understanding and illuminating the mechanisms of change. Journal of Child and Adolescent Psychiatric Nursing, 21(2), 78-88.

Liberman, L. C., Lipp, O. V., Spence, S. H., & March, S. (2006). Evidence for retarded extinction of aversive learning in anxious children. Behaviour Research and Therapy, 44, 1491–1502.

85

Linver, M., Brooks-Gunn, J., & Kohen, D. (2002). Family processes as pathways from income to young children’s development. Developmental Psychology, 38, 719-734.

Lissek, S., Powers, A., McClure, E., Phelps, E., Woldehawariat,G., Grillon, C., & Pine, D. (2005). Classical fear conditioning in the anxiety disorders: A meta-analysis.

Behaviour Research and Therapy, 43, 1391–1424. Logan, D. E., & King, C. A. (2001). Parental facilitation of adolescent mental health

utilization: A conceptual and empirical review. Clinical Psychology: Science & Practice, 8(3), 313-333.

Lonigan, C., Hooe, E., David, C., & Kistner, J. (1999). Positive and negative affectivity in children; Confirmatory factor analysis of a two-factor model and its relation to symptoms of anxiety and depression. Journal of Consulting and Clinical Psychology 67, 374-386.

Lonigan, C., Vasey, M., Phillips, B., & Hazen, R. (2004). Temperament, Anxiety, and the Processing of Threat-Relevant Stimuli. Journal of Clinical Child and Adolescent Psychology, 33(1), 8-20.

Lorant, V., Deliège, D., Eaton, W., Robert, A., Philippot, P., & Ansseau, M. (2003). Socioeconomic inequalities in depression: a meta-analysis. American Journal of Epidemiology, 157(2), 98-112.

Lovejoy, M., Graczyk, P., O’Hare, E., & neuman, G. (2000). Maternal depression and parenting behavior. A meta-analytic review. Clinical Psychology Review, 20, 561-592.

Low, N., Cui, L., & Merikangas, K. (2008). Specificity of familial transmission of anxiety and comorbid disorders. Journal of Psychiatric Research, 42(7), 596-604.

Ludwig, V. and Schwarting, R. K. (2007). Neurochemical and behavioral consequences of striatal injection of 5,7-dihydroxytryptamin. Journal of Neuroscience Methods, 162(1-2), 108-118.

Mahalik, J., Good, G., & Englar-Carlson, M. (2003). Masculinity scripts, presenting concerns, and help seeking: Implications for practice and training. Professional Psychology: Research and Practice, 34, 123-131.

Manson, S. M. (2000). Mental health services for American Indians and Alaska Natives: Need, use and barriers to effective care. Canadian Journal of Psychiatry, 45, 617-626.

March, J. (1997). Multidimensional Anxiety Scale for Children (MASC) Technical Manual. Toronto: Multi-Health Systems Inc.

Martini, T., Root, C., & Jenkins, J. (2004). Low and middle income mothers’ regulation of negative emotion: Effects of children’s temperament and situational emotional responses. Social Development, 13, 515-530.

Mash, E. & Johnston, C. (1990). Determinants of Parenting Stress: Illustrations from Families of Hyperactive Children and Families of Physically Abused Children. Journal of Clinical child Psychology, 19(4), 313-328.

Mathews, A., Mackintosh, B. & Fulcher, E. P. (1997). Cognitive biases in anxiety and attention to threat. Trends in Cognitive Sciences, 1, 340-345.

86

Maupin, A. N., Brophy-Herb, H. E., Schiffman, R. F., & Bocknek, E. L. (2010). Low-income parental profiles of coping, resource adequacy, and public assistance receipt: Links to parenting. Family Relations: An Interdisciplinary Journal of Applied Family Studies, 59(2), 180-194.

May, P. & Gossage, P. (2001). New data on the epidemiology of adult drinking and substance use among American Indians of the northern states: Male and female data on prevalence, patterns, and consequences. American Indian Alaska Native Mental Helath Research, 10, 1-26.

McClure, E. B., Brennan, P. A., Hammen, C., & Le Brocque, R. M. (2001). Parental anxiety disorders, child anxiety disorders, and the perceived parent-child relationship in an Australian high-risk sample. Journal of Abnormal Child Psychology, 29, 1-10.

McGinn, L., Cukor, D. & Sanderson, W. (2005). The Relationship Between Parenting Style, Cognitive Style,, and Anxiety and Depression: Does Increased Early Adversity Influence Symptom Severity Through the Mediating Role of Cognitive Style? Cognitive Therapy and Research, 29(2), 219-242.

McKelvey, L. M., Fitzgerald, H. E., Schiffman, R. F., & Von Eye, A. (2002). Family stress and parent-infant interaction: The mediating role of coping. Infant Mental Health Journal, 23(1-2), 164-181.

McLearn, K. T., Knitzer, J., and Carter, A. S. (2007). Mental health: A neglected partner in the healthy development of children. In J. L. Aber, S. J. bishop-Josef, S. M. Jones, K. T. McLearn, & D. A. Phillips (Eds.), Child development and social policy: Knowledge for action (pp. 233-248). Washington, DC: American Psychological Association.

McLoyd, V. (1998). Socioeconomic disadvantage and child development. American Psychologist, 53, 185-204.

McNally, R. & Lorenz, M. (1987). Anxiety sensitivity in agoraphobic. Journal of Behavior therapy and Experimental Psychiatry, 18, 3-11.

Merikangas, K. R., Dierker, L. C., & Szatmari, P. (1998). Psychopathology among offspring of parents with substance abuse and/or anxiety disorders: A high risk study. Journal of Child Psychology and Psychiatry, 37, 711−720.

Messer, S. (2004). Evidence-Based Practice: Beyond Empirically Supported Treatment. Professional Psychology: Research and Practice, 35(6), 580-588.

Miller, L.C., Barrett, C.L., & Hampe, E. (1974). Phobias of childhood in a prescientificera. In A. Davids (Ed.), Child personality and psychopathology: Current topics(pp. 89-134). New York: Wiley.

Miller, D. B., & O’Callaghan, J. P. (2002). Neuroendocrine aspects of the response to stress. Metabolism, 51, 5-10.

Miller, G. E., & Prinz, R. J. (2003). Engagement off families in treatment for childhood conduct problems. Behavior Therapy, 34(4), 517-534.

Minuchin, P. (1985). Families and individual development: Provocations from the field of family therapy. Child Development, 56, 289-302.

87

Mistry, R., Lowe, E., Benner, A., & Chien, N. (2008). Expanding the family economic stress model: Insights from a mixed methods approach. Journal of Marriage and Family, 70, 196-209.

Moore, P., Chung, E., Peterson, R., Katzman, M., & Vermani, M. (2009). Information integration and emotion: How do anxiety sensitivity and expectancy combine to

determine social anxiety? Cognition & Emotion, 23(1), 45-68. Morgan, J., & Banerjee, R. (2006). Social anxiety and self-evaluation of social

performance in anonclinical sample of children. Journal of Clinical Child and Adolescent Psychology, 35, 292–301.

Morris, R.J., & Kratochwill, T.R. (1983). Treating children’s fears and phobias: A behavioral approach. New York: Pergamon Press. Morris, R.J., & Kratochwill, T.R. (1998). Childhood fears and phobias. In R.J. Morris and T.R. Kratochwill, (Eds.), The practice of child therapy (3rd ed., pp. 91-131). Needham Heights, MA: Allyn & Bacon. Muris, P., Merckelbach, H., de Jong, P.J., & Ollendick, T.H. (2002). The etiology of

specific fears and phobias in children: A critique of the non-associative account. Behaviour Research and Therapy, 40, 185-195.

Muris, P., Merckelbach, H., Ollendick, T. King, N., & Bogie, N. (2002). Three traditional and three new childhood anxiety questionnaires: Their reliability and validity in a normal adolescent sample. Behaviour Research and Therapy, 40, 753-772.

Muris, P., Schmidt, H., Merckelbach, H., & Schouten, E. (2001). Anxiety sensitivity in adolescents: Factor structure and relationships to trait anxiety and symptoms of

anxiety disorders and depression. Behavior Research and Therapy, 39, 89-100. National Center for Children in Poverty. (2006). Children’s mental health: Facts of

policymakers. Retrieved from http://www.nccp.org/publications/pub_687.html June 20, 2011.

Nocon, A., Wittchen, H., Beesdo, K., Brückl, T., Hofler, M., Pfister, H., Zimmerman, P. & Lieb, R. (2008). Differential familial liability of panic disorder and agoraphobia. Depression and Anxiety, 25(5), 422-434.

Noyes, R. & Hoehn-Saric, R. (1998). The Anxiety Disorders. Cambridge: Cambridge University Press.

Olatunji, B. O., & Cole, D. A. (2009). The longitudinal structure of general and specific anxiety dimensions in children: Testing a latent trait–state–occasion model. Psychological Assessment, 21(3), 412-424.

Ollendick, T.H., & Hirshfeld-Becker, D.R. (2002). The developmental psychopathology of social anxiety disorder. Biological Psychiatry, 51, 44-58.

Ollendick, T.H., & King, N.J. (1998). Empirically supported treatments for children with phobic and anxiety disorders: Current status. Journal of Clinical Child Psychology, 27, 156-167.

Ollendick, T. H., Yang, B., Dong, Q., & Xia, Y. (1995). Perceptions of fear in other children and adolescents: The role of gender and friendship status. Journal Of Abnormal Child Psychology, 23(4), 439-452.

88

Ollendick, T.H., Yang, B., King, N.J., Dong, Q., & Akande, A. (1996). Fears in American, Australian, Chinese, and Nigerian children and adolescents: A cross-cultural study. Journal of Child Psychology and Psychiatry, 37, 213-220.

O’Neil, R., Welsh, M., Parke, R. D., Wang, S., & Strand, C. (1997). A longitudinal assessment of the academic correlates of early peer acceptance and rejection. Journal of Clinical Child Psychology, 26, 290–303.

Palmer, L., Courtot, B., & Howell, E. (2007). Are children accessing and using needed mental health care services? The case of the San Mateo County Healthy Kids Program (Health Policy Briefs No. 23). Washington, DC: The Urban Institute.

Parker, J. G., & Asher, S. R. (1987). Peer relations and later personal adjustment: Are low accepted children at risk? Psychological Bulletin, 102, 357–389.

Pavuluri M., Luk S., & McGee R. (1996). Help-seeking for behavior problems by parents of preschool children: A community Study. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 215-222.

Pearson, V., & Chan, T. W. (1993). The relationship between parenting stress and social support in mothers of children with learning disabilities: A Chinese experience. Social Science & Medicine, 37(2), 267-274.

Pellegrino, M. (2006). Maternal anxiety, parenting, and the emergence of child anxiety among young children with and without developmental delay. Retrieved September 5, 2008, from PsycINFO database.

Peterson, R. & Reiss, S. (1992). Anxiety Sensitivity Revised Test Manual. Worthington, Ohio: IDS Publishers.

Phillips, B. N., Pitcher, G. D., Worsham, M. E., & Miller, S. C. (1980). Test anxiety and the school environment. In I. G. Sarason (Ed.). Test anxiety: Theory, research and applications (pp. 327-346). Hillsdale, NJ: Lawrence Erlbaum.

Pianta, R.C. & Egeland, B. (1990). Life stress and parenting outcomes in a disadvantaged sample: Results of the mother-child interaction project. Journal of Clinical Child Psychology, 19, 329-336.

Pianta, R.C., Egeland, B., & Sroufe, L.A. (1991). Maternal stress and children’s development: Prediction of school outcomes and identification of protective factors. In J. Rolf, A. Masten, D. Cicchetti, K.H. Nuechterlein, & S. Weinraud (Eds.), Risk and protective factors in the development of psychopathology (pp.215-235). New York: Cambridge University Press.

Puliafico, A. & Kendall, P. (2006). Threat-Related Attentional Bias in Anxious Youth: A Review. Clinical Child and Family Psychology Review, 9(3/4), 162-180.

Rabian, B., Peterson, R. A., Richters, J., & Jensen, P. (1993). Anxiety sensitivity among anxious children. Journal of Clinical Child Psychology, 22, 441-146.

Rabian, B., & Silverman, W. K. (2000). Anxiety disorder. In M. Hersen & R. T. Ammerman (Eds.), Advanced abnormal child psychology (pp. 271-289). London: Lawrence Erlbaum Associates.

Rachman, S. (1977). The conditioning theory of fear acquisition: A critical examination. Behaviour Research and Therapy, 15, 375–387.

89

Reinhardt, J., Boerner, K., & Horowitz, A. (2006). Good to have but not to use: Differential impact of perceived and received support on well-being. Journal of Social and Personal Relationships, 23(1), 117-129.

Reiss, S. & McNally, R. (1985). The Expectancy Model of Fear. In Reiss, S. and Bootzin, R. (Eds.) Theoretical Issues in Behavior Therapy (pp. 107-132). New York. Academic.

Reiss, S., Peterson, R., Gursky, D. & McNally, R. (1986). Anxiety sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour, Research, & Therapy,

24, 1-8. Reyno, S. M., & McGrath, P. J. (2006). Predictors of parent training efficacy for child

externalizing behavior problem: A meta-analytic review. Journal of Child Psychology and Psychiatry, 47(1), 99-111.

Robin, R., Chester, B., Rasmussen, J., Jaranson, J., & Goldman, D. (1997). Facts influencing utilization of mental health and substance abuse services by American Indian men and women. Psychiatric Services, 48, 826-32.

Rubin, K. H., Hymel, S., & Mills, R. S. L. (1989). Sociability and social withdrawal in childhood: Stability and outcomes. Journal of Personality, 57, 237–255. Sagrestano, L., Paikoff, R., Holmbeck, G., & Fendrick, M. (2003). A longitudinal examination of familial risk factors for depression among inner-city African

American adolescents. Journal of Family Psychology, 17, 108-120. Schermerhorn, A. & Cummings, M. (2008). Transactional Family Dynamics: A New Framework for Conceptualizing Family Influence Processes. In Kail, R. (Ed.),

Advances in Child Development and Behavior, (pp. 187-250). Amsterdam. Elselvier.

Sebelius, Kathleen. (2012). 2012 Poverty Guidelines. Federal Register, 77(17), 4034-4035. Retrieved from http://aspe.hhs.gov/poverty/12fedreg.shtml March 8, 2012.

Shostak, B. & Peterson, R. (1989). Effects of anxiety sensitivity on emotional response to a stress task. Behavior Research and Therapy, 28, 513-521.

Silverman, W., Fleisig, W., Rabian, B., & Peterson, R. (1991). Childhood Anxiety Sensitivity Index. Journal of Clinical Child Psychology, 20(2), 162-168.

Smith, T., Oliver, M., & Innocenti, M. (2001). Parenting stress in families of children with disabilities. American Journal of Orthopsychiatry, 71(2), 257-261.

Solis, M. L., & Abidin, R. R. (1991). The Spanish version Parent Stress Index: A psychometric study. Journal of Clinical Child Psychology, 20, 372-378.

Sommer, W., Möller, C., Wiklund, L., Thorsell, A., Rimondini, R., Nissbrandt, H., & Heilig, M. (2001). Local 5,7-dihydroxytryptamine lesions of rat amygdala: Release of punished drinking, unaffected plus-maze behavior and ethanol consumption. Neuropsychopharmacology, 24(4), 430-440.

Sorce, J. & Emde, R. (1981). Mother’s presence is not enough: Effect of emotional availability on infant explorations. Developmental Psychology, 17, 737-745. Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (1999). Social skills, social

outcomes, and cognitive features of childhood social phobia. Journal of Abnormal Psychology, 108, 211–221.

90

Stahl, S. (1996). Anxiolytics and Sedative-hypnotics. In S. Stahl (Ed.) Essential psychopharmacology: Neuroscientific basis and practical applications. (pp. 167-

215). Cambridge: Cambridge University Press. Stark, K., Humphrey, L., Crook, K. & Lewis, K. (1990). Perceive Family Environments

of Depressed and Anxious Children: Child’s and Maternal Figure’s Perspective. Journal of Abnormal Child Psychology, 18(5), 527-547.

Stephan, S. H., Weist, M., Kataoka, S., Adelsheim, S., & Mills, C. (2007). Transformation of children’s mental health services: the role of school mental health. Psychiatric Services, 58, 1330-1338.

Stewart, S. L., & Rubin, K. H. (1995). The social problem-solving skills of anxious-withdrawn children. Development and Psychopathology, 7, 323–336.

Stice, E., Ragan, J., & Randall, P. (2004). Prospective Relations Between Social Support and Depression: Differential Direction of Effects for Parent and Peer Support? Journal of Abnormal Psychology, 113(1), 155-159.

Strauss, C., Frame, C. & Forehand, R. (1987). Psychosocial Impairment Associated with Anxiety in Children. Journal of clinical child Psychology, 16(3), 235-239.

Stricker, G. & Trierweiler, S. (1995). The local clinical scientist: A bridge between science and practice. American Psychologist, 50, 995-1002.

Stricker, G. (2007). The Local clinical Scientist. In Hofman, S. & Weinberger, J. (Eds.), The Art and Science of Psychotherapy. (pp. 85-99). New York: Routledge.

Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd ed.). New York: Wiley.

Sullivan G., Coplan J., Kent, J., & Gorman, J. (1999). The noradrenergic system in Pathological anxiety: a focus on panic with relevance to generalized anxiety and

phobias. Biological Psychiatry, 46, 1205–1218. Tanaka, M., Yoshida, M., Emoto, H., & Ishii, H. (2000). Noradrenaline systems in the hypothalamus, amygdala and locus coeruleus are involved in the provocation of

anxiety: basic studies. European Journal of Pharmacology, 405, 397-406. Takeuchi, D., Williams, D., & Adair, R. (1991). Economic stress in the family and

children's emotional and behavioral problems. Journal of Marriage & the Family, 53(4), 1031-1041.

Taylor, S., & Fedoroff, I. C. (1999). The expectancy theory of fear, anxiety, and panic: A conceptual and empirical analysis. In S. Taylor, S. Taylor (Eds.), Anxiety sensitivity: Theory, research, and treatment of the fear of anxiety (pp. 17-33). Mahwah, NJ US: Lawrence Erlbaum Associates Publishers.

Taylor, S., Koch, W., & McNally, R. (1992). How does anxiety sensitivity vary across the anxiety disorders? Journal of Anxiety Disorders, 6, 249-259.

Thelen, E. & Ulrich, B. (1991). Hidden skills: A dynamic systems analysis of treadmill stepping during the first year. Monographs of the Society for Research in Child Development, 56, v-103.

Thomas, C. & Holzer, C. (1999). National distribution of child and adolescent psychiatrists. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 9-15.

91

Thompson, V., Bazile, A., & Akbar, M. (2004). African Americans’ perceptions of psychotherapy and psychotherapists. Professional Psychology: Research and Practice, 35, 19-26.

Thompson, R. & Gustafson, K. (1996). Adaptation to chronic childhood illness. Washington, D.C. American Psychological Association.

Thurston, I. & Phares, V. (2008). Mental Health Service Utilization Among African American and Caucasian Mothers and Fathers. Journal of Consulting and Clinical Psychology, 76(6), 1058-1067.

Toren, P., Sadeh, M., Wolmer, L., Eldar, S., Koren, S., Weizman, R., & Laor, N. (2000). Neurocognitive correlates of anxiety disorders in children: A preliminary report.

Journal of Anxiety Disorders, 14(3), 239–247. Tucker, C., McHale, S., & Crouter, A. (2003). Dimensions of mothers’ and fathers’

differential treatment of siblings: Links with adolescents’ sex-typed personal qualities. Family Relations, 52, 82-89.

Turner, S. M., Beidel, D. C., & Costello, A. (1987). Psychopathology in the offspring of anxiety disorders patients. Journal of Consulting and Clinical Psychology, 55, 191-202.

Turner, S. M., Beidel, D. C., Roberson-Nay, R., & Tervo, K. (2003). Parenting behaviors in parents with anxiety disorders. Behaviour Research and Therapy, 41, 541-554.

United States Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockvill, MD: Author.

United States Department of Health and Human Services. (2001). Mental Health: Culture, Race and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockvill, MD: Author.

van Ameringen, M., Mancini, C., & Farvolden, P. (2002). The impact of anxiety disorderson educational achievement. Anxiety Disorders, 433, 1–11.

van Gaalen M., Stenzel-Poore M., Holsboer, F., & Steckler T. (2002). Effects of transgenicoverproduction of CRH on anxiety-like behaviour. European Journal of Neuroscience, 15, 2007–2015.

Vasey, M. W., & MacLeod, C. (2001). Information-processing factors in childhood anxiety: A review and developmental perspective. In M. W. Vasey & M. R. Dadds (Eds.), The developmental psychopathology of anxiety (pp. 253-277). Oxford, England: Oxford University Press.

Verduin, T. & Kendall, P. (2008). Peer Perceptions and Liking of Children with Anxiety Disorders. Journal of Abnormal Child Psychology, 36, 459-469.

Victor, A. M., & Bernstein, G. A. (2009). Anxiety disorders and posttraumatic stress disorder update. Psychiatric Clinics of North America, 32(1), 57-69.

Visu-Petra, L., Ciairano, S. & Miclea, M. (2006). Neurocognitive correlates of child Anxiety: A review of working Memory Research. Cognition, Brain and Behavior, 10, 517-541.

Warren, S. L., Gunnar, M. R., Kagan, J., Anders, T. F., Simmens, S. J., Rones, M., Wease, S.,Aron, E., Dahl, R. E., & Sroufe, L. A., (2003). Maternal panic disorder:

92

Infanttemperament, neurophysiology, and parenting behaviors. Journal of the AmericanAcademy of Child and Adolescent Psychiatry, 42, 814-825.

Waters, A., Henry, J., & Neumann, D. (2009). Aversive Pavlovian Conditioning in Childhood Anxiety Disorders: Impaired Response Inhibition and Resistance to Extinction. Journal of Abnormal Psychology, 118 (2), 311-321.

Webster-Stratton, C., & Hammond, M. (1990). Predictors of treatment outcome in parent training for families with conduct problem children. Behavior Therapy, 21(3), 319-337.

Webster-Stratton, C. (1990). Stress: A Potential Disruptor of Parent Perceptions and Family Interactions. Journal of Clinical Child Psychology, 19(4), 302-312.

Whipple, E., & Webster-Stratton, C. (1991). The Role of Parental Stress in Physically Abusive Families. Child Abuse and Neglect, 15, 279-291.

Whitebeck, L., Hoyt, D., McMorris, B., Chen, X., & Stubben, J. (2001). Perceived discrimination and early substance abuse among American Indian children. Journal of Health and Social Behavior, 42, 405-424.

Wickrama, K., Lorenz, F., & Conger, R. (1997). Parental support and adolescent physical health status: A latent growth-curve analysis. Journal of Health and Social Behavior, 38(2), 149-163.

Wong, E., Marshall, G., Schell, T., Elliott, M., Hambarsoomians, K., Chun, C., & Berthold, S. M.. (2006). Barriers to Mental Health Care Utilization for U.S. Cambodian Refugees. Journal of Consulting and Clinical Psychology, 74(6), 1116-1120.

Woodruff-Borden, J., Morrow, C., Bourland, S., & Cambron, S. (2002). The behavior to child. Journal of Clinical Child and Adolescent Psychology, 31, 364-374.

Wood, J., Piacentini, J., Bergman, R., McCracken, J., & Barrios, V. (2002). Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: child and Parent Versions. Journal of Clinical Child and Adolescent Psychology, 31, 335-342.

Younger, A. J., Gentile, C., & Burgess, K. (1993). Children’s perceptions of withdrawal: Changes across age. In K. H. Rubin & J. Asendorpf (Eds.) Social withdrawal, inhibition, and shyness in childhood (pp 215–236). Hillsdale, NJ: Erlbaum.

Zerk, D., Mertin, P., & Proeve, M. (2009). Domestic Violence and Maternal Reports of Young Children’s Functioning. Journal of Family Violence, 24, 423-432.

Zinbarg, R., Brown, T., Barlow, D., & Rapee, R. (2001). Anxiety sensitivity, panic, and depressed mood: A reanalysis teasing apart the contributions of the two levels in the hierarchical structure of the Anxiety Sensitivity Index. Journal of Abnormal Psychology, 110(3), 372-377.

Zvolensky, M., Kotov, R., Antipova, A., Leen-Feldner, E., & Schmidt, N. (2005). Evaluating anxiety sensitivity, exposure to aversive life conditions, and problematic drinking in Russia: A test using an epidemiological sample. Addictive Behaviors, 30, 567-570.