The Koala Fear Questionnaire: a standardized self-report scale for assessing fears and fearfulness in pre-school and primary school children

The link between anxiety and theory of mind in children: A meta-analysis

BACKGROUND

The ability to reason about someone else's mental states, an ability known as theory of mind, is essential to help children navigate social life. However, not all children are socially skilled. Given socialisation is key for healthy development in children, finding what might exacerbate these difficulties is important. Emerging research suggests a potential link between anxiety and theory of mind abilities in children. This meta-analysis aims to characterise that link.

METHOD

Four electronic databases were systematically searched to identify relevant studies. Search terms included variations of terms for theory of mind, anxiety, and children. Studies were screened with inclusion and exclusion criteria for eligibility and identified papers were appraised on quality.

RESULTS

The search returned 3674 papers of which 20 were included in the analysis. These included a total of 3110 participants, aged 4-19. Overall, it was found that anxiety had a negative relationship with theory of mind and this appeared to be more pronounced in theory of mind processes related to affective states. There were no differences in the negative relationship between subtypes of anxiety or between studies with autistic and neurotypical children.

CONCLUSION

The findings suggest that anxious children may have difficulties using theory of mind abilities. Heterogeneity was substantial in the data, which limits the confidence in conclusions. Quality appraisal identified that the quality of theory of mind and anxiety measures varied between studies.

Development and validation of a test instrument for the assessment of perceived basic motor competencies in first and second graders: the SEMOK-1-2 instrument

Both actual motor competencies (AMC) and perceived motor competencies (PMC) play an important role in motor development research and children's physical and psychological development. PMC refer to children's perceptions of their motor competencies. To assess the PMC of first and second grade children (aged 6-9 years), the SEMOK-1-2 instrument was developed. The instrument is aligned to the validated MOBAK-1-2 instrument which assesses AMC in the competence areas "object movement" and "self-movement" Accounting for possible reading difficulties in younger children, the motor tasks and answer options were illustrated and explained verbally. The purpose of this study was to test and validate the SEMOK-1-2 instrument and investigate the associations between the constructs AMC, PMC and physical activity (PA), whereby PA was measured by the participation in team and individual sports. Data from N = 404 pupils in the German-speaking part of Switzerland from first and second grades (M = 7.8 years, SD = 0.69, 49% boys) were analyzed. Confirmatory factor analyses were conducted to test the factorial validity of the SEMOK-1-2 instrument. Structural equation models were used to investigate the association between the constructs. The analyses confirmed a two-factor structure with the factors PMC "object movement" and PMC "self-movement", corresponding to the factors existing in the MOBAK-1-2 instrument. Latent correlations between AMC factors and the corresponding PMC factors were r = 0.79 for "object movement" and r = 0.76 for "self-movement". Associations with external criteria and covariates, such as sex, were associated with both AMC and PMC. Analyses also revealed that children who participated more often in individual and team sports showed higher levels in both AMC and PMC. The confirmation of the two-factorial structure of the SEMOK-1-2 instrument and the associations between AMC and PMC as well as external criteria indicate construct and criterion validity. The SEMOK-1-2 instrument can be economically utilized for assessing PMC and is also suitable for the monitoring of PMC in the context of Physical Education.

Research on Alleviating Children’s Nighttime Fear Using a Digital Game

Nighttime fear is common among children and may negatively affect their growth. Given the positive role of digital games in regulating children’s emotions, in this study, we proposed principles for the design of a digital game to alleviate children’s nighttime fears and developed a game prototype based on a survey of children and their parents. In order to verify whether digital games can reduce children’s fears, the Koala Fear Questionnaire (KFQ) was used to assess the effectiveness of the game prototype in an experiment. We adopted a quasi-experimental design with non-randomized samples, including 47 subjects in the experimental group (EG) and 49 subjects in the control group (CG). The results of the analysis show that the children in the EG displayed an obvious decrease in their fear of the objects that appeared in the game. Moreover, for some children with a moderate level of fear, playing digital games could significantly reduce their fear. Therefore, this preliminary study suggests that digital games have a positive effect on alleviating children’s nighttime fears.

Wie gelingt die Prävention psychischer Beschwerden?

Hintergrund

Emotionale und Verhaltensprobleme in der Kindheit haben oft weitreichende Folgen für die soziale, emotionale und kognitive Entwicklung, sodass ihrer Prävention ein hoher Stellenwert zukommt. Dennoch ist die Inanspruchnahme von Präventionsmaßnahmen im Kindesalter gering.

Ziel

In einer versorgungsepidemiologischen Implementationsstudie wird untersucht, inwiefern durch ein systematisches Screening eingebettet in U‑Untersuchungen die Identifikation von Risikokindern und die Zuweisung zu Präventionsprogrammen gelingt.

Methoden

Dazu ist ein Screening mittels „Strengths and Difficulties Questionnaire“ während der regulären Gesundheitsuntersuchungen (U9–U11) von ca. 3500 Kindern im Alter von 5 bis 10 Jahren in ca. 53 Arztpraxen in Dresden und 20 km Umkreis geplant. Die Eltern erhalten von der Fachkraft für Kinderheilkunde eine Rückmeldung zu den Ergebnissen und im Falle von grenzwertigen Werten auf den Subskalen „Emotionale Probleme“ und/oder „Verhaltensprobleme“ eine Empfehlung für ein indikatives Präventionsprogramm. Zu vier Messzeitpunkten werden Familien mittels standardisierter und projektspezifischer Fragebogen befragt. Zusätzlich erfolgen leitfadengestützte Interviews mit Leistungserbringern und Familien.

Ergebnisse und Schlussfolgerung

Es werden die Machbarkeit, Nützlichkeit und Akzeptanz eines Screenings für emotionale und Verhaltensauffälligkeiten bei Kindern und Präventionsempfehlungen in Kinderarztpraxen im Prä‑/Post-Vergleich und nach 12 Monaten evaluiert. Förderliche und hemmende Faktoren für die Inanspruchnahme werden bestimmt, um Empfehlungen für die Implementation von Präventionsangeboten in die Regelversorgung abzuleiten, um emotionale und Verhaltensauffälligkeiten frühzeitig zu erkennen und der Entwicklung psychischer Störungen vorzubeugen.

Pictorial Assessment of Health-Related Quality of Life. Development and Pre-Test of the PictoQOL Questionnaire

The aim of the present study was to develop a pictorial questionnaire for the assessment of health-related quality of life (PictoQOL) and to examine its content validity and usability across three exemplary population groups of different origin residing in Germany (non-migrants, Turkish migrants and Arabic-speaking migrants). A mixed-methods design combining qualitative and quantitative methods was used, comprising 6 focus group discussions with a total of 17 participants, 37 cognitive interviews and a quantitative pretest with 15 individuals. The PictoQOL consists of a pictorial representation of a total of 15 different situations. Using a visual Likert scale, respondents indicate how much each situation applies to them. Some representations proved to be culturally sensitive and were adapted. Respondents found the use of an additional graphic layer in the form of symbols in addition to pictures helpful for interpretation. The PictoQOL is considered to allow a more accessible assessment and better comparability of HRQOL across different population groups regardless of their literacy level. It is therefore considered to be superior to existing instruments for routine use in health research and practice. Future studies need to examine its convergent and factorial validity.

Pictorial Scales in Research and Practice

Abstract. The present article is concerned with the theoretical foundations and practical aspects of developing pictorial scales. It aims to assess the potential of pictorial scales compared to verbal scales. The article provides a review of existing pictorial scales with a view to identifying suitable methodological approaches for developing such scales. The review showed that the development and especially validation of many pictorial scales did not follow a stringent methodological approach. A category system is proposed, which allows the classification of different types of pictorial scales. Finally, we present a first draft of a theoretical framework, which can provide guidance for the future development of pictorial scales. The present work carries the implication that a specific methodological approach is needed, which focuses more strongly on the particular needs of designing pictorial scales (e.g., testing the comprehensibility of pictures).

The Nighttime Fears Scale: Development and psychometric evidence of a standardized self-report scale to assess nighttime fears in children

Nighttime fears are highly prevalent in children and are linked to children's distress and internalizing problems, especially childhood anxiety. Although its assessment may be critical, there is a lack of available standardized self-reports. This study aimed to describe the development and psychometric evaluation of the Nighttime Fears Scale (NFS), a new standardized self-report for assessing nighttime fears in school-aged children. The construction of the scale was based on prior relevant research and involvement of researchers and clinicians, experts in childhood anxiety, and fears. A total of 794 Spanish-speaking children (51.1 % girls) aged 8-12 years completed the NFS along with measures of anxiety, sleep problems, internalizing and externalizing problems, and positive behaviors. Exploratory and confirmatory factor analyses supported a four-factor structure of the NFS, consisting of 21 items measuring a range of potentially fear-provoking stimuli at nighttime. Strong internal consistency (alphas ranging from .87 to .94), adequate test-retest reliability, and evidence of convergent, divergent and incremental validity was found. This study provides initial support for the use of the NFS by clinicians and researchers, suggesting that it is a promising tool for a rapid and easily-administered assessment to identify the presence and intensity levels of a set of common children's nighttime fears.

Designing and psychometric evaluation of disease-related fear scale (D-RFS) in adults with epilepsy: A sequential exploratory mixed methods design

BACKGROUND

Disease-related fear is one of the important diagnoses of healthcare providers in caring for people with epilepsy whose conceptual dimensions should be discovered and investigated. To this end, it is necessary to provide healthcare providers with appropriate tools to assess fears related to the disease in accordance with the sociocultural milieu of each community.

AIM

The purpose of this study was to design and psychometrically evaluate the disease-related fear scale (D-RFS) in adults with epilepsy.

METHODS

This study was of a sequential exploratory mixed methods design conducted in Iran in 2019. In the item generation phase, inductive (face-to-face, semi-structured interviews with 14 adult patients with epilepsy) and deductive (literature review) were used. In the item reduction, integration of qualitative and literature reviews and scale evaluation were performed. For the scale evaluation, face validity, content validity, construct validity [exploratory factor analysis (EFA) (n = 367) and confirmatory factor analysis (CFA) (n = 250)], and convergent and divergent validity and reliability (internal consistency and stability) were investigated.

RESULTS

After the qualitative phase and literature review, 40 items were codified. After investigation of the qualitative and quantitative face validity, 7 items were deleted. Two items were deleted due to content validity ratio (CVR) of less than 0.56 and one item due to content validity index (CVI) of less than 0.78. Finally, a 30-item scale was obtained, and its construct validity was assessed. Kaiser-Meyer-Olkin (KMO) index was 0.85, and Bartlett's test of sphericity was 7237.504, P < 0. 001. The results of CFA showed that the bivariate model of the D-RFS (fear of seizure consequences and fear of the disease's long-term consequences) had the most appropriate fitness to the data. Convergent and divergent validity results showed that the values of composite reliability (CR) and average variance extracted (AVE) for the two factors were greater than 0.7 and 0.5, respectively, and the AVE for each factor was greater than CR. Internal consistency of the first and second factors were obtained 0.891 and 0.910, respectively. Cronbach's alpha coefficient for the total scale was obtained 0.921. The results of test-retest reliability showed that there was a significant agreement between the scores of the test and retest (P < .001).

CONCLUSION

The D-RFS has an acceptable factorial structure, and its internal consistency was confirmed by different approaches. This scale is a valid and reliable tool for assessing disease-related fear in patients with epilepsy. The simplicity of the items and the appropriate time to complete the scale can be considered as its strengths.

Mapping the frequency and severity of anxiety behaviors in preschool-aged children

Although anxiety can be early-emerging, impairing, and persistent, behaviors relevant to anxiety mirror typical development in early childhood. To better understand the spectrum of typical to problematic behavior, this study characterizes the range of frequency and severity of separation and social anxiety behaviors and associated impairment in preschool-aged children using a novel daily diary method. Primary caregivers of 291 3-5-year-old children reported the frequency of children's daily separation and social anxiety behaviors and related impairment for 14 days. Frequencies of each separation and social anxiety behavior were computed and item response theory analyses revealed the specific frequencies at which the behavior was considered psychometrically severe/rare. Patterns varied across items; for example, worry that caregiver would not return and shyness with familiar adults had to occur at least 3-4 times over 14 days for the behavior to be considered severe/rare, whereas shyness around peers and new people were not severe at any frequency. In addition, behaviors were associated with impairment. To our knowledge, these data are the first to delineate empirical, dimensional information about the frequency and severity of anxiety behaviors and associated impairment in early childhood. Such data could be useful for clinical practice to enhance empirically-driven assessment of anxiety.

Assessing anxiety disorders in children and adolescents

BACKGROUND

Given the relatively high prevalence of anxiety problems among young people and their adverse consequences if left untreated, it is important that clinicians and researchers have access to reliable and valid assessment tools to facilitate early detection, case formulation, treatment design and evaluation of outcomes.

METHOD

This paper presents the findings of a pragmatic review of the literature regarding the assessment of anxiety in young people in multiple contexts, including mental health services, school-based screening and research trials.

RESULTS

Commonly used diagnostic interviews, questionnaire measures and alternative assessment methods are described, along with psychometric properties and practical issues. The review indicates the complexities of assessing anxiety problems given the high level of comorbidity between anxiety disorders and with depression. It also highlights the different approaches required for assessment across different age groups, the need for multiple informants and issues relating to the lack of agreement between reporters. There is a strong evidence-base for several diagnostic instruments and anxiety scales, although the accuracy of youth and parent report scales in forming clinical diagnoses is not sufficiently strong to justify their use in isolation for diagnostic purposes.

CONCLUSIONS

The assessment of youth anxiety should ideally include a multiinformant, multimethod approach, with measures tailored to the age of the child, and the purpose of the evaluation. There is now a sufficiently strong research base to enable clinicians and researchers to ensure that they select evidence-based instruments.

The Interactive Child Distress Screener: Development and Preliminary Feasibility Testing

Background

Early identification of child emotional and behavioral concerns is essential for the prevention of mental health problems; however, few suitable child-reported screening measures are available. Digital tools offer an exciting opportunity for obtaining clinical information from the child’s perspective.

Objective

The aim of this study was to describe the initial development and pilot testing of the Interactive Child Distress Screener (ICDS). The ICDS is a Web-based screening instrument for the early identification of emotional and behavioral problems in children aged between 5 and 12 years.

Methods

This paper utilized a mixed-methods approach to (1) develop and refine item content using an expert review process (study 1) and (2) develop and refine prototype animations and an app interface using codesign with child users (study 2). Study 1 involved an iterative process that comprised the following four steps: (1) the initial development of target constructs, (2) preliminary content validation (face validity, item importance, and suitability for animation) from an expert panel of researchers and psychologists (N=9), (3) item refinement, and (4) a follow-up validation with the same expert panel. Study 2 also comprised four steps, which are as follows: (1) the development of prototype animations, (2) the development of the app interface and a response format, (3) child interviews to determine feasibility and obtain feedback, and (4) refinement of animations and interface. Cognitive interviews were conducted with 18 children aged between 4 and 12 years who tested 3 prototype animated items. Children were asked to describe the target behavior, how well the animations captured the intended behavior, and provide suggestions for improvement. Their ability to understand the wording of instructions was also assessed, as well as the general acceptability of character and sound design.

Results

In study 1, a revised list of 15 constructs was generated from the first and second round of expert feedback. These were rated highly in terms of importance (mean 6.32, SD 0.42) and perceived compatibility of items (mean 6.41, SD 0.45) on a 7-point scale. In study 2, overall feedback regarding the character design and sounds was positive. Children’s ability to understand intended behaviors varied according to target items, and feedback highlighted key objectives for improvements such as adding contextual cues or improving character detail. These design changes were incorporated through an iterative process, with examples presented.

Conclusions

The ICDS has potential to obtain clinical information from the child’s perspective that may otherwise be overlooked. If effective, the ICDS will provide a quick, engaging, and easy-to-use screener that can be utilized in routine care settings. This project highlights the importance of involving an expert review and user codesign in the development of digital assessment tools for children.

Play-Modified One-Session Treatment for Young Children with a Specific Phobia of Dogs: A Multiple Baseline Case Series

The one-session treatment (OST) approach for SPs is deemed well-established, and has been found to be highly effective for older children and adults; however, has not yet been trialled with very young children. The present study examines the preliminary effectiveness of play-modified OST for young children with a SP of dogs, using a multiple baseline controlled case series design. Treatment involved play modified one-session of intensive cognitive-behavioural therapy (OST plus Play) which was followed by brief telephone delivered maintenance calls over the 3 weeks immediately following treatment. Four young children (4 years of age) participated and symptoms were assessed at pre-treatment, across a 1-3 week baseline phase, immediately following the OST plus Play, and at 1 and 3 months follow-up. Visual inspection provided evidence for stability of symptoms across the baseline phase, followed by reductions in symptoms over the course of treatment and follow-up. Non-parametric analyses offered further support, with significant improvements in following the intensive OST plus Play intervention.

Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial

BACKGROUND

Half of all lifetime anxiety disorders emerge before age 12 years; however, access to evidence-based psychological therapies for affected children is poor. We aimed to compare the clinical outcomes and cost-effectiveness of two brief psychological treatments for children with anxiety referred to routine child mental health settings. We hypothesised that brief guided parent-delivered cognitive behavioural therapy (CBT) would be associated with better clinical outcomes than solution-focused brief therapy and would be cost-effective.

METHODS

We did this randomised controlled trial at four National Health Service primary child and mental health services in Oxfordshire, UK. Children aged 5-12 years referred for anxiety difficulties were randomly allocated (1:1), via a secure online minimisation tool, to receive brief guided parent-delivered CBT or solution-focused brief therapy, with minimisation for age, sex, anxiety severity, and level of parental anxiety. The allocation sequence was not accessible to the researcher enrolling participants or to study assessors. Research staff who obtained outcome measurements were masked to group allocation and clinical staff who delivered the intervention did not measure outcomes. The primary outcome was recovery, on the basis of Clinical Global Impressions of Improvement (CGI-I). Parents recorded patient-level resource use. Quality-adjusted life-years (QALYs) for use in cost-utility analysis were derived from the Child Health Utility 9D. Assessments were done at baseline (before randomisation), after treatment (primary endpoint), and 6 months after treatment completion. We did analysis by intention to treat. This trial is registered with the ISCRTN registry, number ISRCTN07627865.

FINDINGS

Between March 23, 2012, and March 31, 2014, we randomly assigned 136 patients to receive brief guided parent-delivered CBT (n=68) or solution-focused brief therapy (n=68). At the primary endpoint assessment (June, 2012, to September, 2014), 40 (59%) children in the brief guided parent-delivered CBT group versus 47 (69%) children in the solution-focused brief therapy group had an improvement of much or very much in CGI-I score, with no significant differences between groups in either clinical (CGI-I: relative risk 1·01, 95% CI 0·86-1·19; p=0·95) or economic (QALY: mean difference 0·006, -0·009 to 0·02; p=0·42) outcome measures. However, brief guided parent-delivered CBT was associated with lower costs (mean difference -£448; 95% CI -934 to 37; p=0·070) and, taking into account sampling uncertainty, was likely to represent a cost-effective use of resources compared with solution-focused brief therapy. No treatment-related or trial-related adverse events were reported in either group.

INTERPRETATION

Our findings show no evidence of clinical superiority of brief guided parent-delivered CBT. However, guided parent-delivered CBT is likely to be a cost-effective alternative to solution-focused brief therapy and might be considered as a first-line treatment for children with anxiety problems.

FUNDING

National Institute for Health Research.

Preschool Fantasy-Reality Discrimination: Influences of Trait and Primed Fearfulness

Distinguishing between fantasy and reality is an important developmental milestone, achieved in the preschool years, that has been linked to children's cognitive capabilities and emotional knowledge. The authors examined the influence of both trait and prime fearfulness on preschoolers' ability to differentiate between fantastic and real situations. Forty 3-5-year-old preschoolers were administered a fearfulness assessment, a standard theory-of-mind task, and a fantasy-reality discrimination task (with or without a fear prime). When primed to experience fear, participants who were high in trait fearfulness made more mistakes distinguishing between fantastic and real events than did participants who were low in trait fearfulness. In the absence of a fear prime there was no difference in performance between these two groups. These findings were independent of participants' age, gender, and theory of mind abilities and suggest that preschoolers who are high in trait fearfulness are more prone to difficulty in discriminating between fantasy and reality when actively experiencing fear. This study illuminates important factors that contribute to the errors in fantasy-reality judgments frequently seen in preschoolers.

Cognitive Behavioral Therapy in a One-Session Treatment for a Preschooler With Specific Phobias

Anxiety disorders among preschool-aged children are as prevalent as in older children, yet younger children are even less likely to receive treatment for these frequently impairing childhood disorders (Egger & Angold, 2006). Specific phobias (SPs) are often the earliest form of anxiety to onset, affect 2.3% of preschoolers (Egger & Angold, 2006), and tend to be stable from 3 years of age to at least 6 years of age (Bufferd, Dougherty, Carlson, Rose, & Klein, 2012). Recently, our group developed and piloted a modified intensive one-session treatment (OST) incorporating play therapy for preschoolers with SP (Farrell, Kershaw, & Ollendick, in press). Given that highly fearful young children may find concentrated, rapid exposure therapy highly confronting, we integrated play therapy into the commencement of this treatment to (a) assist with rapid rapport building with the therapist and (b) enhance the child's motivation through engaging them with play. An initial, controlled, baseline case series (N = 4) provided preliminary evidence of the feasibility, acceptability, and effectiveness of this innovative one-session (3 hours) therapy-POP! Pre-schoolers Overcoming Phobias (POP; Farrell et al., in press). The approach combines child-centered, nondirective play therapy (during Hour 1) and empirically supported OST (during Hours 2 and 3), with 4-year-old preschool children with clinical SPs of dogs. This article presents a case description of POP, describing the assessment approach, cognitive-behavioral case formulation, and intensive treatment of a 4-year-old girl who presented with a severe SP of dogs, along with various other comorbid SPs.

Treating nighttime fears in young children with bibliotherapy: evaluating anxiety symptoms and monitoring behavior change

OBJECTIVE

Children's nighttime fears are a normal part of child development and are transient for most children, but result in considerable distress for others. The present study evaluated a 4-week bibliotherapy intervention designed to treat young children with persistent and interfering nighttime fears utilizing a multiple baseline design.

METHOD

Nine children between 5 and 7 years of age with specific phobia diagnoses were randomized into one of three baseline control conditions (1, 2, or 3 weeks). The treatment protocol involved parents reading Uncle Lightfoot, Flip that Switch: Overcoming Fear of the Dark, Academic Version (Coffman, 2012) with their children over 4 weeks while engaging in activities prescribed in the book. Assessments took place at baseline, post treatment, and 1 month following treatment. Daily and weekly tracking of nighttime behaviors was also obtained.

RESULTS

Pre-post group analyses revealed that eight of the nine children demonstrated clinically significant change in anxiety severity. In addition, decreases in child-reported nighttime fears were observed, as were parent-reported decreases in separation anxiety and increases in the number of nights children slept in their own bed.

CONCLUSIONS

The present study provides initial support for the use of bibliotherapy in the treatment of nighttime fears. Further replication and evaluation are needed to determine appropriate length of treatment and long-term effects. Implications of the findings are discussed.

[Pathological nighttime fears in children: Clinical specificities and effective therapeutics]

OBJECTIVE

Pathological nighttime fears in children have been little studied. However, this disorder is commonly encountered in medical consultations and is discomforting and dysfunctional for both the child and the family. Most nighttime fears are part and parcel of normal development, and emanate from increasingly sophisticated cognitive development in the growing child. Thus, most children report a variety of coping strategies generally helpful in reducing their anxiety, which resolves spontaneously in the growing child. Nevertheless, in about 10% of children, nighttime fears are related to one or more anxiety disorders according to Diagnostic and Statistical Manual of Mental Disorders criteria. Then, it is estimated that severe nighttime fears and sleep problems occur in 20-30% of children. This problem is not transient and has to be treated. This study aims to review clinical features of nighttime fears and possible treatments for these patients and their families.

METHOD

This systematic review follows the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. Two databases (Medline and Web of Science) were searched combining the search terms: nighttime fears AND children. English and French languages were imposed. There were no publication date or publication status limitations.

RESULTS

Pathological nighttime fears are responsible for emotional (crying, panic, tantrums at bedtime, loss of confidence, self-disparaging negative statements, and feeling of social embarrassment) and behavioral (wandering alone in the house at night, calls for parental or sibling comfort, bed sharing with parents or siblings, light source at night, refusal to go to the toilet alone at night) disturbances. This leads to a poor quality of sleep interfering with school learning, and also affects social development and family functioning. A full assessment has to be made to eliminate organic causes, have a baseline functioning, and search for comorbid anxiety diseases. The treatments which have proved effective are some cognitive-behavioral techniques: systematic desensitization (with relaxation or emotive imagery), reinforcement (gain of points and techniques of self statement), and cognitive techniques (reinforcing self-statements, reducing the aversive aspects of being in the dark, involving reality-testing statements, and active control are preferred in children older than 6 years, whereas the "anti-monster letter" and the techniques using a doll are preferred in children under 6 years old). The modelling technique seems to be appropriate at any age.

CONCLUSION

We have explained the clinical features of pathological nighttime fears and the way to assess this disease, and we have pointed out the treatments whose effectiveness has been evaluated in this indication.

The maternal adversity, vulnerability and neurodevelopment project: theory and methodology

OBJECTIVE

To describe the theory and methodology of the multi-wave, prospective Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) study. The goal of MAVAN is to examine the pre- and postnatal influences, and their interaction, in determining individual differences in mental health.

METHOD

MAVAN is a community-based, birth cohort study of pregnant Canadian mothers and their offspring. Dyads are assessed longitudinally, with multiple assessments of both mother and child in home and laboratory across the child's development. Study measures, including assessments of cognitive and emotional function, are described. The study uses a candidate gene approach to examine gene-environment interdependence in specific developmental outcomes. Finally, the study includes measures of both brain-based phenotypes and metabolism to explore comorbidities associated with child obesity. One of the unique features of the MAVAN protocol is the extensive measures of the mother-child interaction. The relation between these measures will be discussed.

RESULTS

Evidence from the MAVAN project shows interesting results about maternal care, families, and child outcomes. In our review, preliminary analyses showing the correlations between measures of maternal care are reported. As predicted, early evidence suggests that maternal care measures are positively correlated, over time.

CONCLUSIONS

This review provides evidence for the feasibility and value of laboratory-based measures embedded within a longitudinal birth cohort study. Though retention of the samples has been a challenge of MAVAN, they are within a comparable range to other studies of this nature. Indeed, the trade-off of somewhat greater participant burden has allowed for a rich database. The results yielded from the MAVAN project will not only describe typical development but also possible targets for intervention. Understanding certain endophenotypes will shed light on the pathogenesis of various mental and physical disorders, as well as their interrelation.

Cognitive bias in action: evidence for a reciprocal relation between confirmation bias and fear in children

BACKGROUND AND OBJECTIVES

Some cognitive models propose that information processing biases and fear are reciprocally related. This idea has never been formally tested. Therefore, this study investigated the existence of a vicious circle by which confirmation bias and fear exacerbate each other.

METHODS

One-hundred-and-seventy-one school children (8-13 years) were first provided with threatening, ambiguous, or positive information about an unknown animal. Then they completed a computerized information search task during which they could collect additional (negative, positive, or neutral) information about the novel animal. Because fear levels were repeatedly assessed during the task, it was possible to examine the reciprocal relationship between confirmation bias and fear.

RESULTS

A reciprocal relation of mutual reinforcement was found between confirmation bias and fear over the course of the experiment: increases in fear predicted subsequent increases in the search for negative information, and increases in the search for negative information further enhanced fear on a later point-in-time. In addition, the initial information given about the animals successfully induced diverging fear levels in the children, and determined their first inclination to search for additional information.

LIMITATIONS

As this study employed a community sample of primary school children, future research should test whether these results can be generalized to clinically anxious youth.

CONCLUSIONS

These findings provide first support for the notion that fearful individuals may become trapped in a vicious circle in which fear and a fear-related confirmation bias mutually strengthen each other, thereby maintaining the anxiety pathology.

Nighttime fears of preschool children: a potential disposition marker for anxiety?

OBJECTIVE

To examine if children who suffer from significant Nighttime Fears (NF) experience higher degree of general fears and behavioral problems and to explore whether effortful control mediates NF association with internalizing problems.

METHODS

One-hundred and nine preschool children (64 boys) between the ages 4 and 6years suffering from significant NF and 30 healthy children (16 boys) were evaluated using parental reports of behavioral problems [Child Behavior Checklist (CBCL)], parental and child report of fears [Fear Survey Revised for Parents (FSS-PC), Koala Fear Questionnaire (KFQ)], and a measure of effortful control derived from the Child Behavior Questionnaire (CBQ).

RESULTS

Children with severe NF also suffer from an increased level of a wide variety of fears other than NF, and exhibit more behavioral problems than controls both on parental and children's measures of general fears, and main CBCL scale scores (Internalizing, Externalizing, Total score). Additionally, children with NF had lower abilities of effortful control (as manifested in CBQ attention and inhibitory control scales). Attention control mediated NF association to internalizing problems scale.

CONCLUSIONS

NF may serve as a marker for anxiety vulnerability, and this vulnerability might be mediated by abnormal attentional control. Our finding also highlights the need for a more comprehensive assessment of behavioral problems, fears and anxiety phenomena among children referred with NF.

Structure of the Italian Fear Survey Schedule for Children (FSSC-IT)

Psychometric properties of the Italian Fear Survey Schedule for Children (FSSC-IT) were examined in a large community sample of children aged 6 to 10 years. PCA and CFA yielded and confirmed a six correlated factor model, named FSSC-IT54. Internal consistency estimates of the FSSC-IT54 total score and of most of its factors were acceptable. Analyses of variance were carried out considering gender and age sub-groups and confirmed findings in the extant literature. Convergent validity of the FSSC-IT54 scores was supported by its positive correlations with a measure of childhood anxiety, the Spence Children's Anxiety Scale.

Nighttime fears and fantasy-reality differentiation in preschool children

Nighttime fears are very common in preschool years. During these years, children's fantasy-reality differentiation undergoes significant development. Our study was aimed at exploring the links between nighttime fears and fantasy-reality differentiation in preschool children. Eighty children (aged: 4-6 years) suffering from severe nighttime fears were compared with 32 non-fearful controls. Fears were assessed using child and parental reports. Children viewed images depicting fantastic or real entities and situations, and were asked to report whether these were imaginary or could occur in real life. The results revealed that children with nighttime fears demonstrated more fantasy-reality confusion compared to their controls. These differences in fantasy-reality differentiation were more pronounced in younger children. Additional significant associations were found between fantasy-reality differentiation and age and specific characteristics of the stimuli. These preliminary findings, suggesting a developmental delay in fantasy-reality differentiation in children with nighttime fears, have significant theoretical and clinical implications.

Parent-directed cognitive behavioral therapy for young anxious children: a pilot study

Anxiety in children age 8 years and above has been successfully treated with cognitive behavioral therapy (CBT). However, the efficacy of CBT for anxious children ages 4-7 years has not, to date, been fully investigated. This paper piloted a CBT intervention targeting child anxiety that was delivered exclusively to parents of 26 children with anxiety symptoms ages 4-7 years. The intervention consisted of four 2-hour group sessions of four to six parents (couples). These group sessions were followed by four individual telephone sessions, once per week across a 4-week period. The pre- and postintervention assessment involved measures of multiple constructs of child anxiety (anxiety symptoms, children's fears, behavioral inhibition, and internalizing symptoms) from multiple informants (parents, children, and teachers). Parents also reported parenting strategies they were likely to use to manage their children's anxiety pre- and postintervention. Results indicated a significant decrease in child anxiety and behavioral inhibition as reported by parents and teachers. Furthermore, mothers reported significant increases in their use of positive reinforcement, and modeling and reassurance, and a significant decrease in their use of reinforcement of dependency directly after treatment. Taken together, parent-directed CBT appears to be an effective approach for treating children ages 4-7 years with anxiety symptoms. Limitations of the current research are discussed.

The “Anti-monster Letter” as a Simple Therapeutic Tool for Reducing Night-time Fears in Young Children

The current study examined the effects of the “anti-monster letter” as a simple tool for reducing night-time fears in young children. One hundred and forty-two children aged 4 to 6 years were randomly assigned to either an experimental condition in which children and parents were provided with an “anti-monster letter” or a control condition in which no intervention was carried out. Results indicated that the “anti-monster letter” yielded positive effects. That is, child report data showed that night-time fears substantially decreased in the intervention condition as compared with the control condition. In parents, such positive effects could not be substantiated by standardised assessments, although some parents indicated that they considered the intervention as helpful.

The Picture Anxiety Test (PAT)

This study extends prior research on the Picture Anxiety Test (PAT; Dubi & Schneider, 2009 ) in clinical samples, by examining psychometric properties and acceptance in a community sample of 153 4–8-year-old children. Children completed the PAT and the RCMAS, a well-established questionnaire measuring anxiety. Parents and teachers completed questionnaires on anxiety and externalizing behavior. In addition, a panel of psychologists and psychiatrists evaluated the PAT for quality and utility. Results indicated high internal consistencies for the subscales and composite scale, very high interrater reliability, and moderate to high test-retest reliability. Substantial correlations between the PAT and the RCMAS indicated good convergent validity. Sex and age differences were found for some subscales. Agreement between children and their parents and teachers was generally low. Children reported high acceptance of the PAT, and the panel of psychologists and psychiatrists rated the PAT as high in both quality and utility. Results were consistent with prior research on the PAT in clinical samples and indicate reliability and validity for assessing anxiety in a subclinical community sample.

The impact of maternal control on children's anxious cognitions, behaviours and affect: an experimental study

Controlling parenting is associated with child anxiety however the direction of effects remains unclear. The present study implemented a Latin-square experimental design to assess the impact of parental control on children's anxious affect, cognitions and behaviour. A non-clinical sample of 24 mothers of children aged 4-5 years were trained to engage in (a) controlling and (b) autonomy-granting behaviours in interaction with their child during the preparation of a speech. When mothers engaged in controlling parenting behaviours, children made more negative predictions about their performance prior to delivering their speech and reported feeling less happy about the task, and this was moderated by child trait anxiety. In addition, children with higher trait anxiety displayed a significant increase in observed child anxiety in the controlling condition. The pattern of results was maintained when differences in mothers' levels of negativity and habitual levels of control were accounted for. These findings are consistent with theories that suggest that controlling parenting is a risk factor in the development of childhood anxiety.

The Fear Survey Schedule for Children-Revised: Normative Developmental Data in Italy

The aim of the study was to explore children's fear content. Using the Italian Fear Survey Schedule for Children, an Italian-language version of Ollendick's Fear Survey Schedule for Children–Revised (1983), the study assessed the reliability of the survey and reported intensity, prevalence, and content of fears in children aged six to 10 years, using this questionnaire. 1,845 school children (931 girls, 914 boys; M age = 8.3 yr., SD = 1.4) were asked to complete the survey, indicating what they thought were their fears, and the intensity of those fears. Sex and age differences were also examined. Girls endorsed significantly higher fearfulness than did boys. Few age differences were found, with seven-year-olds appearing more fearful than 10- to 11-year-old children. Results were interpreted in relation to developmental changes. Cross-national comparisons were discussed.

Children's internal attributions of anxiety-related physical symptoms: age-related patterns and the role of cognitive development and anxiety sensitivity

The present study examined age-related patterns in children's anxiety-related interpretations and internal attributions of physical symptoms. A large sample of 388 children aged between 4 and 13 years completed a vignette paradigm during which they had to explain the emotional response of the main character who experienced anxiety-related physical symptoms in a variety of daily situations. In addition, children completed measures of cognitive development and anxiety sensitivity. Results demonstrated that age, cognitive development, and anxiety sensitivity were all positively related to children's ability to perceive physical symptoms as a signal of anxiety and making internal attributions. Further, while a substantial proportion of the younger children (i.e., <7 years) were able to make a valid anxiety-related interpretation of a physical symptom, very few were capable of making an internal attribution, which means that children of this age lack the developmental prerequisites for applying physical symptoms-based theories of childhood anxiety.

The Relation Between Cognitive Development and Anxiety Phenomena in Children

We examined the relation between cognitive development and fear, anxiety, and behavioral inhibition in a non-clinical sample of 226 Dutch children aged 4-9 years. To assess cognitive development, children were tested with Piagetian conservation tasks and a Theory-of-Mind (TOM) test. Fears were measured by means of a self-report scale completed by the children, while anxiety symptoms and behavioral inhibition were indexed by rating scales that were filled out by parents. Significant age trends were observed for some anxiety phenomena. For example, younger children displayed higher fear scores, whereas older children exhibited higher levels of generalized anxiety. Most importantly, results of regression analyses (in which we controlled for age) indicated that cognitive development, and in particular TOM ability, made a unique and significant contribution to various domains of behavioral inhibition. In all cases, higher levels of TOM were associated with lower levels of behavioral inhibition. In general, percentages of explained variance were rather small (i.e., <6%), indicating that the role of cognitive development in various anxiety phenomena is limited.

The Picture Anxiety Test (PAT): a new pictorial assessment of anxiety symptoms in young children

This study examines the psychometric properties of a newly developed pictorial anxiety assessment, the Picture Anxiety Test (PAT), designed for young children. A sample of 71 5-7-year-old children (clinically anxious and healthy controls) participated in an assessment comparing the PAT to other, established anxiety measures. Children's ratings were also compared to parent ratings of internalizing and externalizing problems. The PAT demonstrated favorable psychometric properties in this sample, including moderate to high internal consistency, high convergent validity with related constructs, and high discriminant validity between diagnostic groups and across pre- and post-treatment. Initial findings suggest that the PAT is a psychometrically sound instrument for assessing child anxiety and avoidance in young children and a valuable addition to existing diagnostic instruments for clinicians working with anxious children.

Children's fears: a survey of Italian children ages 6 to 10 years

The aim of this study was to explore children's fears. The article reports on average factor scores of a study carried out in Italy using the Fear Survey Schedule for Children (here, the "Fear Survey"; Ollendick, 1983) with normal 6- to 10-yr.-old children (931 girls, 914 boys). Participants were 1,845 children, recruited in mainstream classrooms. Respondents were asked to complete the schedule indicating their fears and the intensity of such fears. A principal components analysis yielded a four-factor structure (1: Death and Danger, 2: Injury and Animals, 3: Failure and Criticism, 4: Fear of the Unknown). Average factor scores showed significant differences across the factors and according to sex and age. Girls reported significantly higher fearfulness than boys. Age differences were found on some factors.

Mood assessment via animated characters: a novel instrument to evaluate feelings in young children with anxiety disorders

We evaluated a novel, computerized feelings assessment instrument (MAAC) in 54 children with anxiety disorders and 35 nonanxious children ages 5 to 11. They rated their feelings relative to 16 feeling animations. Ratings of feelings, order of feeling selection, and correlations with standardized anxiety measures were examined. Positive emotions were rated more highly and visited earlier by nonanxious children. Children with anxiety disorders explored fewer emotions. MAAC ratings on several positive emotions showed inverse correlations with state anxiety. Although needing further evaluation, MAAC may facilitate feelings assessment in young children and may distinguish children with anxiety disorders from nonanxious children.

Development and validation of the Child Post-Traumatic Cognitions Inventory (CPTCI)

BACKGROUND

Negative trauma-related cognitions have been found to be a significant factor in the maintenance of post-traumatic stress disorder (PTSD) in adults. Initial studies of such appraisals in trauma-exposed children and adolescents suggest that this is an important line of research in youth, yet empirically validated measures for use with younger populations are lacking. A measure of negative trauma-related cognitions for use with children and adolescents, the Child Post-Traumatic Cognitions Inventory (CPTCI), is presented. The measure was devised as an age-appropriate version of the adult Post-Traumatic Cognitions Inventory (Foa et al., 1999).

METHODS

The CPTCI was developed and validated within a large (n = 570) sample, comprising community and trauma-exposed samples of children and adolescents aged 6-18 years.

RESULTS

Principal components analysis suggested a two-component structure. These components were labelled 'permanent and disturbing change' and 'fragile person in a scary world', and were each found to possess good internal consistency, test-retest reliability, convergent validity, and discriminative validity. The reliability and validity of these sub-scales was present regardless of whether the measure was completed in the acute phase or several months after a trauma. Scores on these sub-scales did not vary with age.

CONCLUSIONS

The CPTCI is a reliable and valid measure that is not specific to the type of trauma exposure, and shows considerable promise as a research and clinical tool. The structure of this measure suggests that appraisals concerning the more abstract consequences of a trauma, as well as physical threat and vulnerability, are pertinent factors in trauma-exposed children and adolescents, even prepubescent children.

Cognitive development and the interpretation of anxiety-related physical symptoms in 4-13-year-old non-clinical children

The present study examined developmental patterns in children's interpretation of anxiety-related physical symptoms and emotional reasoning (i.e., the tendency to infer danger on the basis of physical response information). A sample of 171 children aged between 4 and 13 years were interviewed after listening to a number of vignettes in which the presence and absence of physical symptoms was systematically varied. Results revealed the expected developmental pattern for anxiety-related interpretations of physical symptoms. More precisely, from age 7, children were increasingly capable of linking physical symptoms to the emotion of anxiety. Furthermore, support was obtained for an emotional reasoning effect. That is, children rated vignettes with physical symptoms as more dangerous than vignettes without such symptoms. While the emotional reasoning effect was present in children of all ages, this phenomenon was more salient among older children. Finally, cognitive development as measured by Piagetian conservation tasks appeared to influence children's anxiety-related interpretations of physical symptoms and emotional reasoning. Altogether, these findings are relevant for researchers who are interested in "physical symptoms-based" theories of childhood anxiety.

Anxious and nonanxious children’s recall of a repeated or unique event

The current study examined 4- and 5-year-olds' memory for an event that was experienced once or was the first in a sequence of four similar events. The event was private swimming lessons for beginners that, because of natural variation in fear of water, were experienced as stressful for some children and not stressful for others. Consistent with much previous research, there was evidence that repeat-event children remembered less than did single-event children. There was some evidence for a beneficial influence of stress on resistance to suggestions. No other effects of stress were found in either the single- or repeat-event children. Implications for the debate on the influence of stress on memory and for children's testimony are discussed.

Death understanding and fear of death in young children

The purpose of this study was to test whether the developmental acquisition of a mature concept of death, that is, understanding death as a biological event, affects young children's fear of death. Ninety children between the ages of 4 and 8 participated in an interview study in which their understanding of death and their fear of death were both assessed. Levels of general anxiety were also measured via parent report. A regression analysis indicated that more mature death understanding was associated with lower levels of death fear, when age and general anxiety were controlled. These data provide some empirical support for the widely held belief that discussing death and dying in biological terms is the best way to alleviate fear of death in young children.

Theory-of-mind, cognitive development, and children's interpretation of anxiety-related physical symptoms

The present study investigated developmental patterns in children's interpretation of anxiety-related physical symptoms and emotional reasoning, and to what extent these phenomena are influenced by children's level of cognitive development. A large sample of 4-13-year-old children (N=358) were exposed to vignettes in which the presence and absence of physical symptoms was systematically varied. In addition, children completed a series of conservation tasks and a theory-of-mind-test. Results demonstrated that from the age of 7, children were increasingly able to link physical symptoms to anxiety. Furthermore, cognitive development appeared to enhance children's ability to interpret physical symptoms as a sign of anxiety. Further, children's tendency to infer danger from vignettes with physical symptoms (i.e., emotional reasoning) was already prominent in 4-6-year-olds. The implications for physical symptom-based theories of childhood anxiety are briefly discussed.

When disaster becomes commonplace reaction of children and adolescents to prolonged terrorist attacks in Israel

The aim of this study was to examine, in conditions of prolonged terror, the possible influences of yet another terrorist attack as an additional traumatic event on children's reactions in the emotional, behavioral, and cognitive spheres, and to identify any mediating factors. The sample included 747 students in junior high schools in three Israeli cities. None of the participants was directly exposed to terrorist attacks, but they all lived with the possibility of daily terror. The research focused on fear as the most common and widespread reaction to terror and war. Short-term and long-term symptoms of fear were studied. It was found that an additional terrorist attack had no significant influence on children's emotional, cognitive, or behavioral spheres. Terror that has become habitual becomes negligible. Children learn to adjust to loss without experiencing grief.

Evaluation and treatment of anxiety disorders in the general pediatric population: a clinician's guide

This article provides an overview of research on the recognition, assessment, and treatment of children and adolescents who have anxiety disorders and emphasizes practical issues facing clinicians. Discussion includes an overview of the prevalence and consequences of anxiety and reviews assessment tools, maintenance factors, and evidence-based approaches to treatment. Topics also include developmental considerations, approaches to informant discrepancy, predictors of treatment outcome, and recent innovative approaches to treatment that may potentially improve dissemination to the general pediatric population.

Relations between parent- and teacher-reported behavioral inhibition and behavioral observations of this temperamental trait

This study examined the relation between the Behavioral Inhibition Scale (BIS), a measure that was specifically developed for assessing behavioral inhibition, and behavioral observations of this trait. Children ages 6 to 10 years participated in a series of experimental tasks assessing behavioral features of the inhibited temperament. The parents and teachers of these children completed the BIS. Results showed that the BIS (in particular the parent version) was significantly related to the observational index of behavioral inhibition. An additional aim of the study was to examine the relation between behavioral inhibition as indexed by the BIS and observations, on the one hand, and measures of anxiety symptoms, fear, and behavioral symptoms, on the other hand. As expected, significant correlations between behavioral inhibition indexes and symptoms of anxiety and withdrawal were observed. The BIS is found to be a brief and easy-to-administer instrument, which seems to provide a meaningful first impression of children's level of behavioral inhibition, and this is particularly true when using the parent version of the BIS.