The Features of Childhood Anxiety

Anxiety refers to heightened distress and withdrawal from perceived threats (Pine, 2007). There is a sense of fear and helplessness that is coupled with a somatically aroused central nervous system, which leads the danger detection system to be maladaptively engaged, making it difficult to regulate emotional responses to potentially threatening stimuli (Chua and Dolan, 2000). This brain response is a basic emotion already present in infancy and childhood, with expressions falling on a continuum from mild to severe (Beesdo, Knappe and Pine, 2009). Generally, anxiety is not considered pathological as it is adaptive in many scenarios when it facilitates avoidance of danger. However, while fears, especially social evaluative fears, are quite normal across all age levels, it can lead to disorder when it is out of proportion to the challenge or stress, or when it results in significant distress and impairment (Trivedi and Gupta, 2010). Childhood is the core risk phase for the development of anxiety symptoms which may range from transient mild symptoms to full-blown anxiety disorders (Beesdo, Knappe and Pine, 2009).

Anxiety is the earliest of all forms of child psychopathology and is one of the most pervasive psychiatric problems experienced by children (Rapee, Schniering and Hudson, 2009). Hence, the role of anxiety has been considered central to the understanding of entire range of childhood psychopathology (Kashani and Orvaschel, 1990). Anxiety may appear in different forms including separation anxiety, specific phobia, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder. Separation anxiety and specific phobias have the earliest average onset, followed by social phobia, generalized anxiety, and panic disorder (Kessler et al., 2012).

Clinical anxiety is one of the most common psychiatric problems that is experienced by school-aged children (Schniering, Hudson and Rapee, 2000). Prevalence estimates for anxiety disorders in children and adolescents have varied across studies, due in part to different informants and measures, and populations. Despite these differences, the median prevalence rate of all anxiety disorders in a recent review (Merikangas, Nakamura and Kessler, 2009) was 8% with an extremely wide range of estimates (2% to 24%). A much more recent meta-analysis (Polanczyk, Salum, Sugaya, Caye and Rohde, 2015) of prevalence of mental disorders in children and adolescents reported worldwide prevalence of any anxiety disorder to be 6.5%.

In India, comprehensive data on the prevalence of anxiety disorders among children is lacking. Although various older epidemiological studies on children and adolescents have reported prevalence of anxiety disorders to range from 1.3% to 5% (Srinath et al., 2005; Hackett, Hackett, Bhakta and Gowers, 1999; Sidana, Bhatia and Choudhary, 1998; Chadda, 1994), a more recent study (Nair et al., 2013) using DSM-IV criteria reported it to be 14.4%. Such high prevalence of anxiety disorder in India and their associated negative consequences, render them major health priorities.

Anxiety has clinical importance not only as a distinct set of disorders, but also because it exerts an effect on other domains of functioning. The effect can be particularly damaging if anxiety first emerges in childhood because this has been linked to increases in both the severity and longevity of the disorder (Pine, Cohen, Gurley, Brook and Ma, 1998). Untreated anxiety can have both short- and long-term deleterious consequences in children. Long-term consequences of anxiety include difficulties in academic, vocational and social domains of functioning, and can even reach into adulthood (Rapee, Schniering and Hudson, 2009). Further, presence of anxiety symptoms may also act as a risk factor for the development of various types of psychiatric disorders in adulthood, including depression and substance use disorders (Essau, Lewinsohn, Olaya and Seeley, 2014).

There have been several strands of research attempting to understand the development of child anxiety. Similar to many psychiatric illnesses, anxiety disorders run in families, and etiological models of child anxiety have identified vulnerability factors such as genetic and various environmental factors, including parenting styles and child temperament (Akinsola and Udoka, 2013; Drake and Ginsburg, 2011; Degnan, Almas and Fox, 2010; Murray, Creswell and Cooper, 2009). However, although the problem is widespread and affects children throughout childhood and adolescence, the cause, maintenance and long-term consequences of childhood anxiety are complex and not well understood.

According to ecological system theory by Bronfenbrenner (1977), child development is shaped by reciprocal interactions between the individual and those in the immediate environment. He postulated that the microsystem consisting of parents, peers and teachers has direct interaction with the child, thus having the greatest impact on child’s developmental outcome. Drawing from Bronfenbrenner’s theory, several researchers have posited that the child’s temperament and child-parent relationship have a direct interaction with child’s anxiety (Hudson, Dodd and Bovopoulos, 2011; Shamir-Essakow, Ungerer and Rapee, 2005). Consistent with this framework, empirical evidence supports multiple influences on childhood anxiety, including child temperament, parenting style, parent characteristics, sociodemographic characteristics, family environment, and community factors (Karevold, Røysamb, Ystrom and Mathiesen, 2009; Marakovitz, Wagmiller, Mian, Briggs-Gowan and Carter, 2011; Vasey and Dadds, 2001).

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Parents play a significant role in shaping children’s emotional health, especially during the early years of childhood. Parenting style is a general pattern of caregiving that provides a context for specific episodes of parental childrearing behaviors, and are determined by patterns of control, responsiveness, warmth, and punishment that parents use most often, across contexts and over time, to manage their children’s behavior. Based on parental behaviors, Baumrind (1971) categorized parenting style into three types, namely authoritative, authoritarian, and permissive parenting styles. Later, permissive parenting style was differentiated into neglectful and indulgent styles (Maccoby and Martin, 1983). Parenting style exerts a significant influence on the development of their child’s present and future emotional health, well-being, and social and cognitive development (Baumrind, 1978). Theoretical models describing the development, maintenance and transmission of childhood anxiety disorders have highlighted the central role of parenting style. For example, Craske (1999) proposed a theoretical model that helps specify the roles that parenting may play in the development and maintenance of childhood anxiety. Drawing on emotion theory and learning theory, this model suggests that parenting may be related to childhood anxiety in at least two ways. First, general parenting across contexts, i.e., parenting style, provides an environmental context that influences the development of trait anxiety. For instance, frequent parental criticism could increase a child’s wariness and influence perceptions of self and the world in a negative manner. Second, among children with high trait anxiety, specific parenting practices or behaviors that promote or reinforce children’s experiences of anxiety in specific situations, contribute to the development of a particular anxiety disorder by centering beliefs about threat and physiological arousal upon a specific theme or class of stimuli. Consistent with this theory, research has demonstrated clear associations between specific parenting strategies and various child outcomes (Wood, McLeod, Sigman, Hwang and Chu, 2003). Studies suggest that parental rejection, anxious rearing, high control, over protection and modeling of anxious behaviors are associated with children's manifestations of anxiety (Orgilés, Penosa, Morales, Fernández-Martínez and Espada, 2018; Mousavi, Low and Hashim, 2016; Rapee, 2012; Beesdo, Pine, Lieb and Wittchen, 2010; Wood, McLeod, Sigman, Hwang and Chu, 2003; McLeod, Wood and Weisz, 2007). Given the major influence of parenting style on the development of the child in general, and child anxiety in particular, the current study was designed to examine parenting styles of children diagnosed with anxiety disorder.

Belsky’s (1984) Process Model suggests that parent’s behavior or parenting style is determined by different factors, including parent characteristics such as parental personality. Personality refers to individual differences in characteristic patterns of thinking, feeling and behaving. When it comes to personality, there is relative consensus on five-factor structure of personality, which has been described as Five Factor Model of Personality (Costa and McCrae, 1989). According to the Big-Five Model of personality, individual differences in personality maybe sufficiently described using five main factors: neuroticism, extraversion, openness, agreeableness and conscientiousness. Parent’s personality is considered the most important determinant of parenting, and parent’s interactions and relationships with their children depends on their own personality and psychopathology (Belsky, 1984; Hong et al., 2015). Further, parental personality traits may influence psychopathological outcomes in their children (Oliveira et al., 2017), and specific personality traits may promote healthy development into adulthood (Schofield et al., 2012). Huver, Otten, de Vries and Engels (2010) also reported that parental personality traits play an important role in parenting behaviors as well as in children’s behavioral outcomes. However, there are only a handful of empirical studies detailing the developmental interplay between specific personality characteristics of parents, parenting styles and children’s problem behaviors, and this constitutes a major knowledge gap. Further, studies reporting the effects of personality characteristics measured by instruments consistent with the comprehensive Five Factor Model are lacking in India. Hence the current study was designed to examine parental personality and its association with parenting styles and child outcome.

Belsky (1984) also suggested that child temperament plays an important role in dictating parental behavior. He proposed that parental personality is associated with parenting directly but this association also interacts with such child characteristics as temperament. While parent's personality predisposes parents to certain parenting behaviors, outcomes are dependent on many factors, including the child's temperament. Hence, it appears that child temperament moderates the relationship between parental personality and parenting style (Kornienko and Dmitriy, 2016). Temperament refers to biologically influenced individual difference in emotional, motor and attentional reactivity to stimulation and its regulation, and is the antecedent and fundament of adult personality (Rothbart and Bates, 2006). Thomas and Chess (1977) delineated nine different characteristics that make up a child's temperament: activity level, sensitivity, intensity of reaction, adaptability, distractibility, inhibition, negative emotionality, persistence, and regularity. Children high or low in these areas are usually described by parents as being difficult children or presently challenging behaviors.

Certain temperament poses as a risk factor for psychopathology. For example, the presence of behavioral inhibition in early childhood has been shown to be a risk factor for anxiety in childhood (Hirshfeld et al., 1992; Dougherty et al., 2013). There are various theoretical models of relationships between temperamental traits and anxiety. In the Vulnerability Model, a child’s temperamental traits predispose them to the development of an anxiety disorder. In the Complication Model, the onset of an anxiety disorder influences a child’s temperament or causes a permanent change in temperament. In the Pathoplastic Model, temperamental traits modify the manifestation, severity, and/or course of anxiety. In the Common Cause Model, a genetic or environmental factor influences temperament as well as anxiety disorder development. These theories and research findings suggest that temperament traits are risk factors, or at least a marker of risk, for anxiety disorders. Studying temperament along with parenting style is necessary because of bi-directionality of effects, and its outcome on the child. Thomas and Chess (1997) also hypothesized a Goodness-of-Fit model of temperament, according to which, a poor fit of children’s characteristics with their environment leads to poor child developmental outcomes, whereas a good fit lead to optimal developmental outcomes. Hence children with different kinds of temperaments would benefit from different kinds of parenting. These theoretical underpinnings suggest that because temperament is early appearing, the construct may help outline early risk factors, even before a disorder is visibly manifested. Identifying difficult temperament early on, and training parents to handle them may help in preventing behavioral problems in children, and was therefore included in the study.

Fathers have come to be recognized as important contributors to the social and emotional development of their children (Marsiglio, Amato, Day and Lamb, 2000). However, very few studies have examined how the father-child relationship or paternal parenting styles are associated with child outcomes in India. The role of fathers is of particular concern considering the trend of increased father involvement in children’s lives among two-parent families (Cabrera, Tamis‐LeMonda, Bradley, Hofferth and Lamb, 2000). For a traditional country like India, the emergence of active involvement of fathers in parenting is becoming popular (Bhattacharyya and Pradhan, 2015), and middle-class fathers in urban India are increasingly becoming actively involved in their children’s lives (Roopnarine, Talukder, Jain, Joshi and Srivastav, 1990). One of the major limitations of past work on parenting style is that most studies focus exclusively on maternal parenting style, and not on the role of fathers in parenting and its subsequent influence on the child. Knowledge about the role of fathers in the development of anxiety in early childhood is limited. Therefore, the present study was designed to examine both maternal and paternal parenting styles.

Most of the studies on parenting styles and its effect on the child are conducted in the West, and literature available focuses on Western cultural beliefs and images about parenting and family life, with the assumption that the meaning of parenting is similar across cultures. However, numerous research studies carried out with different cultures have shown that the relationship between parenting practices and child outcome varies widely (Bornstein, 2012; Bornstein, Putnick and Lansford, 2011; Hofferth, 2003). Therefore, even though research has indicated that authoritative parenting yields the most stable child in Western cultures, it is possible that it may not have the same effects across different cultures and norms (Wang and Leichtman, 2000). There are very few published studies that have looked at parenting styles in India, and the effects of parenting on child has not been adequately researched in India, and hence the need for the present study was felt necessary.

In summary, children with anxiety have unique issues, and suffer from impairment in various life domains such as in school, leisure-time activities, and peer-interaction, which can disrupt and hamper their social functioning as they try to avoid anxiety-provoking situations such as schools, games, social situations, etc. Child anxiety can have a longitudinal course and progress into adult psychopathology. Identifying and treating children with anxiety disorders would reduce the burden of this disorder, and may help in better management of the co-morbid conditions in these patients. Understanding the factors associated with anxiety can be used to predict, prevent or integrate the knowledge into interventional strategies. Given how much work in the area of developmental psychology focuses on the importance of parenting (Belsky and de Haan, 2011; Rueger, Katz, Risser and Lovejoy, 2011), the relative lack of research in India on parenting practices, factors that influence parenting styles, and child outcome, constitutes a major lacuna. Therefore, the current study was designed to examine the influence of parental personality, parenting styles and child temperament in children with anxiety disorders in comparison to children who do not have anxiety disorders. The findings can help develop interventions for children with anxiety as well as in devising parent training programs for vulnerable children.