Penn State Worry Questionnaire: Findings Form Normative and Clinical Samples in Denmark

Thinking about worry: A systematic review and meta-analysis on the assessment of metacognitions in children and adolescents

BACKGROUND

The metacognitive model of generalized anxiety disorder identifies three forms of metacognition: Positive metacognitive beliefs about worry (POS), negative metacognitive beliefs about worry (NEG), and meta-worry. Though this model was originally developed relying on adult samples, it has since been applied to children and youth in different studies, and results mostly support its validity for this group. As the roles of POS, meta-worry, and age-effects do not appear to be fully clarified for children and adolescents yet, an integration of studies on children and adolescents and the metacognitive model is both timely and worthwhile.

AIM

To summarize the current research on relationships, age-effects, and measurements for POS, NEG, and meta-worry in childhood and youth.

METHODS

We carried out a literature search in the electronic databases PsycINFO, PubMed, PSYNDEX, and ERIC in 2017 and updated in 2020. Empirical research in German or English language on metacognition was included with child and adolescent samples diagnosed with anxiety disorders or healthy controls if POS, NEG, or meta-worry were measured. Studies were included for meta-analysis if they reported correlations between these metacognitions and anxiety or worry. Consensus rating for eligibility was done for 20.89% of full-texts with 90.32% agreement. Risk of bias was assessed with the appraisal tool for cross-sectional studies and consensus rating of appraisal tool for cross-sectional studies for 20.83% of included studies attaining agreement of intraclass correlation = 0.898. Overall, correlations between metacognitions, anxiety and worry were calculated with RevMan 5.4.1, assuming random-effects models. Meta-regressions with mean age as the covariate were performed via the online tool MetaMar 2.7.0. PROSPERO-ID: CRD42018078852.

RESULTS

Overall, k = 763 records and k = 78 additional records were identified. Of those, k = 48 studies with 12839 participants were included and of those, k = 24 studies were included for meta-analysis. Most studies showed consistent NEG correlations with worry and anxiety, as well as higher values for clinical than for non-clinical samples. POS findings were less consistent. Meta-analysis revealed large effects for NEG correlating with worry and anxiety, small to medium effects for POS correlating with worry and anxiety, as well as small to medium effects for POS correlating with NEG. Meta-regressions did not reveal mean age as a significant covariate. Meta-worry was assessed in only one study. We identified eight questionnaires and one interview-format that assess metacognition about worry in children and adolescents.

CONCLUSION

POS and NEG are measurable from the age of seven upwards and correlate with anxiety and worry without influences by age. Meta-worry requires further investigation.

Development of the Perth Adolescent Worry Scale (PAWS)

Tools to assess worry among adolescents exist but do not capture the content of worries. This study reports on the development of a brief, psychometrically sound measure of worry for use with adolescents. Phase 1 involved identification of 27 potential items from existing instruments as well as item generation identified in interviews with students, teachers, school psychologists, and parents. In Phase 2, the candidate items were completed by 835 Australian adolescents (317 males, 508 females, 10 unspecified; Mean age = 13.55, SD = 1.31) from Grades 5 to 10. These data were randomly split in half, and an exploratory factor analysis on the first half identified a two-factor solution with 12 items: Peer Relationships (6 items) and Academic Success and the Future (6 items). On the second half of the data, confirmatory factor analyses supported the factor structure and supported strong invariance across age, socioeconomic status, and presence/absence of a diagnosed neurodevelopmental disorder. Weak invariance was evident across sex. Differences across groups are reported as are correlations with indicators of psychological wellbeing. In conclusion, the Perth Adolescent Worry Scale provides both applied professionals and researchers with a short, easy-to-administer, and psychometrically strong instrument to evaluate adolescents’ everyday worries.

"Why Isn't It Going Away?": A Qualitative Exploration of Worry and Pain Experiences in Adolescents with Chronic Pain

INTRODUCTION

The role of cognition is central to the fear avoidance (FA) model of chronic pain (CP), which emphasizes the importance of catastrophic pain interpretations and has been shown to be applicable to pediatric CP populations. However, while we know that pain catastrophizing plays a distinct role in influencing outcomes for children with CP, we know little about the specifics of how young people with CP experience catastrophizing and worry, as well as their general pain beliefs.

OBJECTIVE

To qualitatively explore beliefs about and experiences of worry and pain among a purposeful sample of adolescents with CP.

METHODS

Individual semistructured interviews with 12 adolescents (aged 12-17) with varying forms of CP attending an outpatient pain clinic in a general children's hospital. Relevant psychometric measures were administered orally to further inform the data. Data were analyzed using critical realist thematic analysis.

RESULTS

Three themes and one subtheme were identified. Themes were 1) the worry ripple: mind, body, and behavior (subtheme: worry content: personal competence and health); 2) the pain mystery: living in a "scribble of black"; and 3) the resist or avoid conundrum.

CONCLUSIONS

The findings highlight the need for psychological interventions targeting acceptance of uncertainty and also informing education on mind/body connections in adolescents with CP.

Psychometric Evaluation of the Intolerance of Uncertainty Scale for Children (IUSC): Findings From Clinical and Community Samples in Iran

OBJECTIVE

The present study examined the psychometric properties of a Persian version of the Intolerance of Uncertainty Scale for Children (IUSC; Comer et al, 2009).

METHOD

Participating youth (n = 346) 8 to 18 years of age were nonreferred community youth (n = 279) or youth who met diagnostic criteria for an anxiety disorder (n = 67) and their parents.

RESULTS

Across child- and parent-report data, confirmatory factor analysis supported a shortened 12-item version of the IUSC, and the confirmatory factor analysis also confirmed a theory-driven correlated two-factor structure of the IUSC-12. (i.e., prospective/inhibitory IU). Results further supported reliability and validity of parent- and child-reports of the Persian IUSC-12 via evidence of internal consistency, 4-week retest, significant associations with established measures of internalizing problems, and the ability of the measure to reliably distinguish the clinical sample from the community sample.

CONCLUSION

Findings demonstrate sound psychometric properties of the Persian version of the IUSC-12 and provide additional support for the reliability and validity of the measure and its use in non-Western cultures. Findings are discussed in terms of implications for assessment, treatment, and study of anxiety and related internalizing problems in Iranian youth.

Worry during the initial height of the COVID-19 crisis in an Italian sample

In the earliest months of 2020, the COVID-19 emergency reached a pandemic status of international concern. In this situation, people tended to think more about current difficulties and their negative consequences due to the fear of infection and changed daily life during quarantine. The aim of this study was to explore the severity of worry in relation to individual characteristics and emotions during COVID-19 outbreak in the Italian people. Socio-demographic questions and standardized self-report questionnaires were administered online. Results highlighted a moderate level of worry, anxiety and distress. People with higher perceptions of COVID-19 severity exhibited higher levels of worry in contrast to those who perceived a greater control over the possibility of infection. Multiple regression analysis indicated that coping styles, emotion regulation strategies and personality traits significantly contributed to explain the variance in worry scores. Findings supported that cognitive reappraisal, emotion-focused coping and extraversion were protective factors for worry, while expressive suppression, dysfunctional and problem-focused coping, and neuroticism were related to high worry. However, neuroticism and dysfunctional coping were particularly important predictors of worry. This paper also considers possible psychological interventions that might be implemented in order to deal with mental health issues emanating from the COVID-19 pandemic.

Assessment of the cognitive attentional syndrome in children: an adaptation of the CAS-1

BACKGROUND

Research suggests that the metacognitive model is applicable to clinical child populations. However, few measures related to the model are available for younger age groups. A key concept of the model is the cognitive attentional syndrome (CAS), which encompasses the individual's worry and rumination, maladaptive coping strategies, and metacognitive beliefs. While the CAS has been successfully measured in adults, this has not yet been attempted in children.

AIMS

The aim of this study was to adapt a measure of the CAS for use with children and investigate the measure's associations with anxiety, worry, depression and metacognitions.

METHODS

Our study included 127 children with anxiety disorders aged 7-13 years. The adult measure of CAS was adapted for use with children and administered at pre- and post-treatment. We examined the correlations between variables and the ability of the CAS measure to explain variance in anxious symptomatology, as well as the measure's sensitivity to treatment change.

RESULTS

The adapted measure, CAS-1C, displayed strong associations with overall anxiety, depression, worry and metacognitions. The CAS-1C explained an additional small amount of variance in anxiety and worry symptoms after accounting for metacognitions, which may be due to the measure also assessing thinking styles and coping strategies. Furthermore, the measure displayed sensitivity to treatment change.

CONCLUSIONS

The child measure of the CAS is a brief tool for collecting information on metacognitive beliefs and strategies that maintain psychopathology according to the metacognitive model, and it can be used to monitor treatment changes in these components.

Little things matter: a daily diary study of the within-person relationship between workplace incivility and work-related rumination

Workplace incivility is a low-intensity, counterproductive work behavior associated with negative health outcomes and organizational consequences (e.g., turnover intention). In the present study, I used a daily diary design to investigate the short-term within-person effects of workplace incivility on work-related rumination. Time pressure was included in the present study to underline the importance of workplace incivility for off-work ruminative thoughts beyond the known effects of a stressful workday. Additionally, I propose mood at the end of the workday as a mediator for the proposed relationships. The results of my study corroborate the existence of the daily within-person and the more stable weekly between-person effect of workplace incivility on off-work ruminative thoughts. These results suggest that the experience of short-term and fluctuating workplace incivility has an impact on off-work ruminative thinking even when controlling for the known effects of time pressure. With regard to my proposed mediational effect, my hypothesis was not confirmed. In an additional analysis, however, mediation was confirmed when time pressure was excluded from the model. Further, the within-person relationship between time pressure and work-related rumination was mediated by mood.

Sources of stress and worry in the development of stress-related mental health problems: A longitudinal investigation from early- to mid-adolescence

BACKGROUND AND OBJECTIVES

Stress and stress-related mental health complaints are common and increasing among adolescents, especially girls. Identifying typical sources of stress as well as central intervention targets is an important effort in the development of effective prevention and treatment protocols. This study investigated worry as potential mediator in the development of mental health problems in response to common stressors in adolescence. We also examined to what sources adolescents ascribe their stress over the years from the 7th through the 9th grade.

DESIGN

Prospective cohort study.

METHODS

Self-reported subjective stressor load, worry, anxiety and depressive symptoms were assessed in a sample of Swedish 7th graders (N = 1137; 46% girls, mean age 13.2) with follow-up assessments one and two years later.

RESULTS

School was the most common source of stress across all time-points, with girls reporting considerable more stress than boys. Worry mediated the relationship between overall stressor load and depressive symptoms and anxiety over time and was not moderated by gender.

CONCLUSIONS

Worry may be an important target in stress prevention and efforts to prevent stress-related problems would benefit from focusing on early adolescence as especially school stress is already relatively common in grade 7.

Development of a Shortened Version of the Adolescent Stress Questionnaire (ASQ-S): construct validity and sex invariance in a large sample of Swedish adolescents

Background

Stressor experience is an important topic of research concerning adolescent health and ill-health. For this, valid and reliable measures of adolescent stress are needed. The Adolescent Stress Questionnaire 2 was developed to tap into stressor domains specific for adolescence. Psychometric evaluations in Australian and European samples have indicated adequate psychometric properties. However, the ASQ-2 is quite extensive, which may render its use in large cohort studies, where several aspects of adolescent health are investigated, inconvenient and problematic.

Objective

To evaluate the psychometric properties of a short version of the ASQ-2 (ASQ-S) in terms of construct validity and factorial invariance across gender.

Method

The ASQ-2 was translated into Swedish and items were retained from nine of the ten scales based on factor loadings. One scale (stress of emerging adult responsibilities) was removed entirely due to low internal consistency and variance explained. The remaining 27 items were piloted and then included in an ongoing 5-year longitudinal study involving the participation of all students in the 7th and 8th grade in public schools from three Swedish municipalities (N = 2768, 47.5 % girls, mean age 13.64 years). For this study data from the first and second wave was used.

Results

A nine factor Confirmatory Factor Analysis (CFA) showed a good fit to the data and invariance across sexes was supported. The nine scales correlated positively with depressive symptoms, anxiety and worry and negatively with self-esteem. Girls reported higher stress levels than boys in eight of the nine scales. Stressors related to peer pressure predicted reported levels of anxiety and worry one year later, whereas stressors related to romantic relationships predicted depressive symptoms.

Conclusions

Overall this study suggests that the ASQ-S could be a valid measure of adolescent stressor experience and psychometrically equivalent to the full ASQ-2.

The efficacy of group metacognitive therapy for children (MCT-c) with generalized anxiety disorder: An open trial

Metacognitive therapy is an effective treatment for anxiety disorders in adults. Studies have demonstrated that the underlying theoretical model is also supported in children. It has therefore been suggested that metacognitive therapy for children may be effective. Our study is an open trial of metacognitive therapy for children with generalized anxiety as their primary disorder. Therapy was provided in groups. Families were interviewed with the Anxiety Disorders Interview Schedule - child/parent versions. They reported on the child's anxiety levels using the Revised Childrens Anxiety and Depression Scale - child/parent versions. Children reported on metacognitive beliefs using the Metacognitions Questionnaire for Children - 30 item version. Fourty-four children aged 7-13 years (50% girls) were enrolled, and one family dropped out during treatment. Fifty percent of the children had received counseling or psychological treatment for their anxiety disorder previously. Following treatment, 86.4% of the children were free of their primary disorder and 72.7% were free of all anxiety disorders, the corresponding figures were 75% and 65.9% at 6-months follow-up. The effect sizes were large for all measures and clinically significant improvements were obtained for 70% of the children at posttest and 77% at follow-up. Our study suggests that metacognitive therapy for children with generalized anxiety disorder may be a highly promising treatment approach.

The Penn State Worry Questionnaire for Children: Age, Gender and Clinical Invariance

The Penn State Worry Questionnaire for Children (PSWQ-C) is one of the most frequently used instruments to assess worry in children. The current study examines the measurement invariance of the PSWQ-C in a Romanian sample. Participants (n = 759) were recruited from both community and clinical populations. Our findings have replicated the good psychometric properties of the PSWQ-C and of the short PSWQ-C (the original scale with the negative items deleted). Multigroup confirmatory factor analysis has supported measurement invariance (configural, metric, scalar) across gender, age and clinical diagnosis. Convergent validity with other assessment measures has also been established. Finally, the implications of the use of the PSWQ-C in the assessment of anxiety in children and adolescents are discussed.

Exploring the relationships between maternal and child metacognitions and child anxiety

Research has shown that anxiety may be transmitted through verbal information pathways, for example, when parents share their anxious cognitions with their child. Less is known about the influence of parental metacognitions, that is, beliefs regarding thoughts, on child anxiety. We explored the relations between metacognitions in mothers and their children and anxiety in the children. Our study included 111 non-clinical children aged 8 to 12 years and their mothers. Children rated their metacognitions, worry and anxiety, and mothers rated their metacognitions. Results indicated agreement between maternal and child metacognitions. Maternal metacognitions were positively associated with children's anxiety symptoms and worry, and this relation was mediated by the children's metacognitions. Our results warrant further examination of the role of parental metacognitions in child anxiety.

Emotion Understanding in Clinically Anxious Children: A Preliminary Investigation

Children’s understanding of the nature, origins and consequences of emotions has been intensively investigated over the last 30–40 years. However, few empirical studies have looked at the relation between emotion understanding and anxiety in children and their results are mixed. The aim of the present study was to perform a preliminary investigation of the relationships between emotion understanding, anxiety, emotion dysregulation, and attachment security in clinically anxious children. A sample of 16 clinically anxious children (age 8–12, eight girls/boys) was assessed for emotion understanding (Test of Emotion Comprehension), anxiety (Screening for Child Anxiety Related Emotional Disorders-Revised and Anxiety Disorder Interview Schedule), emotion dysregulation (Difficulties in Emotion Regulation Scale) and attachment security (Security Scale). Children who reported more overall anxiety also reported greater difficulties in regulating their emotions, and were less securely attached to their parents. The results also showed that more specific symptoms of anxiety (i.e., OCD and PTSD) correlated not only with emotion dysregulation and attachment insecurity but also with emotion understanding. Finally, there were interrelations among emotion understanding, attachment security, and emotion dysregulation. The present results provide the first comprehensive evidence for a socio-emotional framework and its relevance to childhood anxiety.

Emotional reactivity and executive control: A pathway of risk for the development of childhood worry

Though risk factors associated with the development of anxiety have been examined, less is known about childhood worry. Current literature suggests that adult worriers may be more likely to avoid increases in negative affect (emotional contrast avoidance), and less likely to effectively regulate their emotions. The current study tested a mediational model to examine the role of emotional and attentional control in the relation between emotional reactivity and child worry. Participants were 99 children between 7 and 10 years old, and their parents, from a community sample. Parents completed measures of child temperament and executive function, and children completed a measure of worry. Overall the data supported the study hypotheses. Child temperaments rated as low in soothability were significantly related to higher worry symptoms. Attentional shift and emotional control acted as serial mediators in the relation between temperament and worry, and fully mediated the relation. These findings suggest a model for the development of childhood worry that combines emotional contrast avoidance and emotional dysregulation.

Worry in adolescents with visual impairment

We assessed worries of 162 German adolescents with visual impairment. Most adolescents reported low levels of worry. Nonetheless, about 25% showed moderate to high levels of worry related to a further decline of vision and not finding the right romantic partner. While adolescents with visual impairment reported lower levels of worry than an age- and gender-matched sample of sighted adolescents, adolescents with stronger visual impairment worried more than those with lower levels of visual impairment. In addition, higher levels of worry were associated with more depressive symptoms and, in part, with less optimism, negative changes of vision in recent years, higher age, and worse grades at school. Possible reasons for the inconsistent associations of visual impairment with levels of worry are discussed.

Meta-worry, worry, and anxiety in children and adolescents: relationships and interactions

The metacognitive model has increased our understanding of the development and maintenance of generalized anxiety disorders in adults. It states that the combination of positive and negative beliefs about worry creates and sustains anxiety. A recent review argues that the model can be applied to children, but empirical support is lacking. The aim of the 2 presented studies was to explore the applicability of the model in a childhood sample. The first study employed a Danish community sample of youth (n = 587) ages 7 to 17 and investigated the relationship between metacognitions, worry and anxiety. Two multiple regression analyses were performed using worry and metacognitive processes as outcome variables. The second study sampled Danish children ages 7 to 12, and compared the metacognitions of children with a GAD diagnosis (n = 22) to children with a non-GAD anxiety diagnosis (n = 19) and nonanxious children (n = 14). In Study 1, metacognitive processes accounted for an additional 14% of the variance in worry, beyond age, gender, and anxiety, and an extra 11% of the variance in anxiety beyond age, gender, and worry. The Negative Beliefs about Worry scale emerged as the strongest predictor of worry and a stronger predictor of anxiety than the other metacognitive processes and age. In Study 2, children with GAD have significantly higher levels of deleterious metacognitions than anxious children without GAD and nonanxious children. The results offer partial support for the downward extension of the metacognitive model of generalized anxiety disorders to children.