Discussion
Behavioral avoidance is a core component in the understanding and treatment of anxiety-related disorders. It is a critical maintenance factor of these disorders; while avoidance provides temporary relief, the fear is reinforced through such behavior, and dysfunctional beliefs are not refuted (e.g., Barlow,
2002; Kendall et al.,
2000; Mowrer,
1947). Additionally, behavioral avoidance leads to significant impairment in children’s daily lives, as they avoid activities or situations that might be important for their socioemotional development (e.g., Vasey & Ollendick,
2000). In line with this finding, the exposure technique is one of the most important and effective components of CBT for emotional disorders. Therefore, the availability of reliable measures to assess behavioral avoidance is critical not only to conduct future studies to deepen our understanding of the transdiagnostic mechanisms underlying emotional disorders but also to assess the efficacy of the exposure components in CBT interventions (namely, compared with other components, such as cognitive restructuring and mindfulness).
The CAMS and the CAMP are two eight-item parallel questionnaires that assess the behavioral avoidance of children from the child and parent perspectives, respectively. The current study aimed to determine the factor structure and psychometric properties of the CAMS and CAMP in clinical and nonclinical samples of Portuguese children and parents, thereby contributing to the study of the CAMS/CAMP in a culture in which it has not previously been studied, specifically a European culture, and providing Portuguese clinicians and researchers with a reliable and valid measure to assess children’s behavioral avoidance.
As expected, the one-factor structure of the CAMS and CAMP proposed by Whiteside et al. (
2013) was confirmed in both clinical and nonclinical samples. Additionally, as expected, in both samples, the CAMS and CAMP presented good internal consistency and item-total correlations above 0.30. Almost all the CAMS and CAMP items seem to contribute to the scales’ internal consistency, except for Item 2 on the CAMS (“
I try not to think about it”), which slightly reduced the Cronbach’s alpha of the scale. In addition, Item 2 had the lowest item-total correlation. One possible explanation is that all the other items are more strongly related to behavioral avoidance (e.g., “
I try not to go near it”), whereas Item 2 appears to be more strongly related to cognitive avoidance. Nevertheless, to retain the original factor structure of the CAMS, to enable comparison with other studies that employed the 8-item scale and considering that the correlation between Item 2 and the total score was above 0.30, we decided to retain this item in the scale (Ferketich,
1991).
The construct validity of the CAMS and CAMP was analyzed in the clinical sample by examining their associations with a measure of anxiety. As expected, higher levels of children’s behavioral avoidance in the CAMS were associated with higher levels of child’s anxiety symptoms (RCADS total anxiety score) and with higher scores of separation anxiety disorder, generalized anxiety disorder, panic disorder, social phobia, and obsessive-compulsive disorder (assessed by the RCADS subscales). These results are consistent with previous findings (Vasey & Ollendick,
2000; Whiteside et al.,
2013), as well as with theoretical and clinical perspectives, according to which children with higher anxiety levels are expected to engage in more avoidance behaviors.
Contrary to the expectations and results of the original validation study (Whiteside et al.,
2013), the CAMP was only significantly correlated with the separation anxiety disorder subscale, and this correlation was weak. This surprising result can be explained by the fact that parents might be more aware of avoidance behaviors in the context of the relationship with their children, as separation anxiety is the anxiety disorder that has the largest manifestations and impact on the parent‒child relationship. Most anxiety disorders are internalizing disorders, which can make it difficult for parents to recognize them and the associated avoidance behaviors. Additionally, research has shown that parents of anxious children are more likely to be overprotective (e.g., Clarke et al.,
2013), which may make them less likely to notice their children’s avoidance, thus potentially normalizing it in some way and discouraging the child’s independence and courageous behavior. These findings have important clinical and research implications, as they suggest that children with anxiety disorders can recognize their avoidant behaviors more effectively than their parents. In addition, these findings highlight the importance of providing psychoeducation and intervention for parents during the treatment of anxious children. However, it is also important to note that the CAMS and RCADS are both completed by children; therefore, higher correlations are expected between these measures than between the CAMP (parent report) and RCADS (child report).
Additionally, higher levels of children’s behavioral avoidance from the child’s perspective were significantly associated with higher levels from the parent’s perspective. However, this association was moderate, implying that there was only moderate agreement between the child’s and parent’s perspectives regarding the intensity of the child’s behavioral avoidance, which is consistent with the findings regarding the correlations between the CAMP and RCADS.
Additionally, as expected, the levels of children’s behavioral avoidance, according to both child and parent reports, were significantly higher in the clinical sample of anxious children than in the nonclinical sample of children and parents, with medium to large effect sizes. These findings may indicate that the CAMS and CAMP can discriminate between clinical and nonclinical populations.
Finally, and as expected, the CAMS and CAMP scores decreased significantly, with a large effect size, after an exposure-focused CBT intervention (the UP-C), demonstrating that these scales are sensitive to therapeutic change. This result is consistent with numerous studies that concluded that exposure-focused CBT is effective for treating emotional disturbances and reducing behavioral avoidance (e.g., Richard et al.,
2007; Schopf et al.,
2020), as is the UP-C (UP-C; Ehrenreich-May et al.,
2017a,
b).
Clinical and Research Implications and Future Studies
The present study has important clinical and research implications. First, this study can provide Portuguese clinicians and researchers with a valid instrument for assessing behavioral avoidance in children, which is a core aspect of many emotional disorders. Since behavioral avoidance is an observable variable, its assessment through the CAMS and CAMP may allow a more objective evaluation of the efficacy of psychological or psychopharmacological interventions, particularly their ability to reduce children’s levels of behavioral avoidance. Furthermore, assessing behavioral avoidance may provide a better understanding of its role in the development and maintenance of youth emotional disorders, as well as illuminating the mechanisms of change underpinning CBT.
Second, since the CAMS/CAMP provides a transdiagnostic assessment of behavioral avoidance, it can be applied to a wide range of disorders or difficulties, making this measure particularly useful. In light of the increased interest in transdiagnostic therapies (e.g., Brown & Barlow,
2009; Ehrenreich et al.,
2009), it is critical to have a psychometrically robust measure for assessing this construct. Moreover, in clinical settings, the CAMS/CAMP can be a useful instrument for determining children’s level of behavioral avoidance and, consequently, defining an appropriate therapeutic plan (e.g., gradual exposure). Furthermore, because of the discriminative capacity of this instrument, it may enable better identification of children at risk of developing emotional disorders. Finally, the CAMS/CAMP comprises only eight easy-to-understand items, which can facilitate its use in real-world clinical settings.
Because no other studies have been conducted to evaluate the factor structure and psychometric properties of the CAMS and CAMP, this study significantly contributes to the literature by supporting the psychometric robustness of both scales and by including clinical and nonclinical samples of children.
Despite these contributions, this study also has some limitations that should be noted and addressed in future studies. First, only children with anxiety or anxiety-related disorders were included in this study. Because behavioral avoidance is thought to be a transdiagnostic mechanism underlying emotional disorders, in future studies, it would be interesting to investigate the associations of the CAMS and CAMP scores with specific internalizing psychopathologies, including depression, which would require the recruitment of a larger sample of children with a variety of internalizing psychopathologies. Second, in the present study, the sample may not have been fully representative of the Portuguese population, as it was collected in only the central region of the country. Third, because the clinical sample of children was recruited in a therapeutic setting in which a change in behavioral avoidance was expected and because participants in the nonclinical sample answered the questionnaires only once, the test-retest reliability of the CAMS and CAMP could not be examined. Finally, the convergent validity of the scales was not assessed using other self- or other-report measures or subscales of behavioral avoidance.
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