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NORMAL AND ABNORMAL FEAR AND ANXIETY IN CHILDREN AND ADOLESCENTS FM-I045073.indd i FM-I045073.indd i 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM FM-I045073.indd ii FM-I045073.indd ii 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM NORMAL AND ABNORMAL FEAR AND ANXIETY IN CHILDREN AND ADOLESCENTS PETER MURIS AMSTERDAM • BOSTON • HEIDELBERG • LONDON NEW YORK • OXFORD • PARIS • SAN DIEGO SAN FRANCISCO • SINGAPORE • SYDNEY • TOKYO FM-I045073.indd iii FM-I045073.indd iii 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM Elsevier 30 Corporate Drive, Suite 400, Burlington, MA 01803, USA 525 B Street, Suite 1900, San Diego, California 92101-4495, USA 84 Theobald’s Road, London WC1X 8RR, UK This book is printed on acid-free paper. Copyright © 2007, Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Science & Technology Rights Department in Oxford, UK: phone: (+44) 1865 843830, fax: (+44) 1865 853333, E-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (, by selecting “Support & Contact” then “Copyright and Permission” and then “Obtaining Permissions.” Library of Congress Cataloging-in-Publication Data Muris, Peter. Normal and abnormal fear and anxiety in children and adolescents/ Peter Muris. p. ; cm.—(BRAT series in clinical psychology) Includes index. ISBN-13: 978-0-08-045073-5 (alk. paper) ISBN-10: 0-08-045073-3 (alk. paper) 1. Anxiety in children. 2. Anxiety in adolescence. 3. Fear in children. I. Title. II. Series. [DNLM: 1. Anxiety Disorders—etiology. 2. Adolescent. 3. Anxiety—psychology. 4. Anxiety Disorders. 5. Child. 6. Fear—psychology. WM 172 M977n 2007] RJ506.A58M87 2007 618.92'8522—dc22 2007006299 British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library. ISBN 978-0-08-045073-5 For information on all Elsevier publications visit our Web site at Printed in the United States of America 07 08 09 10 9 8 7 6 5 4 3 2 1 Working together to grow libraries in developing countries | | FM-I045073.indd iv FM-I045073.indd iv 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM To my beautiful daughters, Jip and Kiki, who so far have developed without serious anxiety problems FM-I045073.indd v FM-I045073.indd v 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM FM-I045073.indd vi FM-I045073.indd vi 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM Table of Contents Preface ix Introduction xi 1. Normal and Abnormal Fear and Anxiety in Children and Adolescents 1 2. Genetically Based Vulnerability 31 3. Environmental Influences 61 4. Protective Factors 99 5. Maintaining Factors 129 6. The Aetiology of Childhood Phobias and Anxiety Disorders: A Dynamic Multifactorial Model 163 7. Assessment of Fear and Anxiety in Children and Adolescents 193 8. Treatment and Prevention of Childhood Anxiety 225 Appendix Questionnaires 267 References 299 Index 373 FM-I045073.indd vii FM-I045073.indd vii 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM FM-I045073.indd viii FM-I045073.indd viii 5/17/2007 1:45:29 PM 5/17/2007 1:45:29 PM Preface In the Behaviour Research and Therapy (BRAT) Series in Clinical Psychology, Craske (2003) wrote her monograph “Origins of phobias and anxiety disorders: Why more women than men?” in which she provided an excellent overview of current theories on the aetiology of phobias and anxiety disorders. Although the emphasis of Craske’s book is mainly on adults, it is also clear that she assumes that the foundation of these problems is already laid during childhood. In the past decades, the research domain of childhood phobias and anxiety disorders has made an enormous progress, as evidenced by a massive amount of empirical articles in scientific journals. This book provides an overview of the accumulating knowledge on the pathogenesis of fear and anxiety in youths. The main target will be to give the reader an idea of the factors that are thought to be involved in the development of abnormal fear and anxiety in children and adolescents, and to integrate this knowledge in a comprehensive model. An additional purpose will be to provide an update of current assessment methods as well as empirically supported intervention strategies for fear and anxiety problems in young people. In the Appendix, the reader will find a number of instruments that can be employed for research (and eventually clinical) purposes. Admittedly, many good books have been published that deal with the domain of child- hood fear and anxiety (see Weems, 2005). Most books are more predominantly concerned with the phenomenology and treatment of various phobias and anxiety disorders in children and adolescents (e.g., Essau & Petermann, 2001; Morris & March, 2004; Ollendick & March, 2004) and only partially cover the aetiology of this type of child psychopathology. Exceptions are the volumes edited by Vasey and Dadds (2001; “The developmental psy- chopathology of anxiety”) and Silverman and Treffers (2001; “Anxiety disorders in children and adolescents”), which both give an in-depth coverage of the multiple factors involved in the origins of phobias and anxiety disorders in youths. However, having appeared more than five years ago, the field seems ready for a new update of this rapidly expanding and intriguing research area. Peter Muris FM-I045073.indd ix FM-I045073.indd ix 5/17/2007 1:45:30 PM 5/17/2007 1:45:30 PM FM-I045073.indd x FM-I045073.indd x 5/17/2007 1:45:30 PM 5/17/2007 1:45:30 PM Introduction “My dear professor, I am sending you a little more about Hans—but this time, I am sorry to say, material for a case history. As you will see, during the last few days he has developed a nervous disorder, which has made my wife and me most uneasy, because we have not been able to find a means of dissipating it. I shall venture to call upon you tomorrow, . . . but in the meantime . . . I enclose a written record of the material available. “No doubt the ground was prepared by sexual overexcitation due to his mother’s tender- ness, but I am not able to specify the actual exciting cause. He is afraid a horse will bite him in the street, and this fear seems somehow to be connected with his having been fright- ened by a large penis. As you know from a former report, he had noticed at a very early age what large penises horses have, and at that time he inferred that as his mother was so large she must have a widdler like a horse. “I cannot see what to make of it. Has he seen an exhibitionist somewhere? Or is the whole thing simply connected with his mother? It is not very pleasant for us that he should begin setting us problems so early. Apart from his being afraid of going into the street and from his being in low spirits in the evening, he is in other respects the same Hans, as bright and cheerful as ever.” (Freud, 1909/1955; p.22) The preceding quotation was taken from a letter written to Sigmund Freud by the father of a five-year-old boy at the beginning of the 20th century. It is clear that the boy, also known as Little Hans, was troubled by fear and anxiety, and apparently these negative emotions were so intense that his parents decided to seek help from a psychiatrist. Freud was of course interested in the case, carefully documented it as the “Analysis of a phobia in a five-year-old boy,” and he used this case history to further illustrate his theoretical notions on the genesis of neurotic behavior. Due to Freud, Little Hans became the subject of one of the most famous case studies in psychological history. However, the symptoms displayed by the boy are certainly not exceptional, as it is a well-known fact that many children and adolescents suffer from fear and anxiety complaints at some point of time during their development to adulthood. In such a way, fear and anxiety have long been considered as normal developmental phenomena, and as a result little research effort was made to properly understand these emotions in youths. Since the early 1980s, this situation has gradually changed. Clinicians, and in their wake researchers, gradually came to the conclusion that although fear and anxiety are transitory in most children, in some of the youths these symptoms may become so severe that they do significantly interfere with daily functioning and clearly warrant the diagnosis of an anxiety disorder. This insight has resulted in a host of empirical studies examining the phenomenology, prevalence, aetiology, persistence, assessment, and treatment of anxiety symptoms and disorders in youths. FM-I045073.indd xi FM-I045073.indd xi 5/17/2007 1:45:30 PM 5/17/2007 1:45:30 PM This book is titled Normal and Abnormal Fear and Anxiety in Children and Adolescents, and as such it covers many aspects of these internalizing symptoms in youths. However, another focus of the book is What Was Really Wrong with Little Hans? That is, many of the sections in this book discuss why some children develop serious fear and anxiety prob- lems. In Freud’s (1909/1955) opinion, Little Hans was afraid of horses because he suffered from a so-called Oedipus complex. That is, Hans wanted to have sex with his mother and therefore expected to be punished by his father. As a result, Hans became afraid of his father. However, this was considered as unacceptable by his Ego, and therefore the fear was displaced to another object, resulting in a phobia of horses. From a scientific point of view, Freud’s analysis of the case is of course unacceptable, as the main concepts of his account (i.e., Oedipus complex, Ego) cannot be validated empirically (Eysenck, 1985). Moreover, after a reanalysis of the case, Wolpe and Rachman (1960) rightly indicated that there was no convincing connection between Little Hans’s sexual behavior and his phobia of horses. Further, these authors pointed at a number of negative learning experiences (e.g., Hans witnessed a horse crashing on the street), which likely played a more plausible role in the aetiology of Hans’s phobic symptoms. This book makes no attempt to reconstruct the aetiology of the phobia of Little Hans’s in detail. Instead, a general theoretical framework will be described that may help clinicians and researchers to understand the pathogenesis of excessive anxiety in youths. It has become clear that an “understanding of the pathways by which childhood anxiety disorders develop, persist, and remit is likely to require consideration of a wide range of influences and, most importantly, their potential for complex, dynamic, transformational interactions (i.e., trans- actions) across development” (Vasey & Dadds, 2001; p.3). Clearly, this notion fits nicely with the major tenets of the developmental psychopathology perspective (Cicchetti & Cohen, 1995), which imply that (1) most forms of psychopathology are the result of multiple causal influences, (2) both successful and unsuccessful adaptation are important for under- standing the origins of psychopathology, and (3) psychopathology occurs in a developing organism, which is of course particularly relevant in childhood and adolescence, when developmental changes are most pronounced. As such, the framework that is explicated in this book emphasizes multicausality, includes vulnerability as well as protective factors, and stresses the importance of developmental transitions. The main perspective of the book is psychological, although in some chapters biological processes (genetics, brain processes) are also discussed. After an introductory chapter, in which the basic phenomena of normal and abnormal fear and anxiety in children and adolescents are described, following chapters of the book will extensively discuss various vulnerability (Chapters 2 and 3), protective (Chapter 4), and maintaining (Chapter 5) variables that are involved in the pathogenesis of phobias and other anxiety disorders. In Chapter 6, this information will be integrated and a dynamic, multifactorial model for the aetiology of pathological fear and anxiety will be presented. In this chapter, an attempt will be made to analyze the case of Little Hans in terms of this model and to provide an answer to the question that was posed in the case of Little Hans. Chapter 7 will give an overview of empirically validated assessment instruments that can be used for measuring normal and abnormal fear and anxiety in youths. Finally, Chapter 8 describes psychological and pharmacological interventions that are employed for children and adolescents with anxiety problems, and summarizes the research that has demonstrated their effectiveness. xii Introduction FM-I045073.indd xii FM-I045073.indd xii 5/17/2007 1:45:30 PM 5/17/2007 1:45:30 PM