Cognition in childhood anxiety: conceptual, methodological, and developmental issues
Introduction
For the past 30 years, the predominant conceptual model of anxiety disorders has been considered to consist of three components: somatic or physical reactivity, subjective distress, and behavioral avoidance (e.g., Lang, 1968). Over the ensuing years, the term subjective distress has become equated with cognition, cognitive schemata, and the presence of anxious thoughts. Increasingly, models of etiology, maintenance, and treatment of anxiety disorders have suggested a need to attend to the cognitive dimension and, in some cases, the “cognitive model” has been proposed as a primary model for anxiety disorders (e.g., Clark & Beck, 1988). As usually occurs, models of disorders, as they exist in adults, are adopted as the initial basis for understanding these same disorders in children and, thus, there has been a marked increase in cognitive-behavioral research aimed at anxiety disorders in youth. Growing amounts of empirical data address the “cognitive factors” associated with childhood anxiety (e.g., Bogels & Zigterman, 2000, Houston et al., 1984, Kendall & Chansky, 1991, King et al., 1995, Messer & Beidel, 1994, Prins, 1986, Prins & Hanewald, 1999, Zatz & Chassin, 1983, Zatz & Chassin, 1985) and, although a substantial literature on cognition and childhood anxiety disorders exists, much of it is conflictual in nature. Thus, the purpose of this review is to present and evaluate this literature and propose areas for future investigation.
Understanding cognition in childhood anxiety disorders requires attention to conceptual, methodological, and developmental considerations. As such, this review presents some issues that have received inadequate attention thus far. First, with respect to conceptual issues, there are competing definitions of the term “cognition.” For example, within the childhood anxiety literature, the term cognition broadly refers to both actual thoughts reported (e.g., cognitive product; Kendall & Ingram, 1987) and to a basic underlying schema organized around a theme of threat (e.g., cognitive structure; Kendall & Ronan, 1990). For purposes of clarity, we shall refer to the former simply as cognitive content and the latter as cognitive process. In the first part of this review, the literature on both cognitive content and process in anxious children will be examined. To date, most research has focused solely on cognitive content including assessing negative vs. positive cognitions, determining cognitive errors (inaccurate beliefs), evaluating cognitive distortions, and determining state-of-mind ratios (SOM; ratio of positive to negative thoughts). Additionally, we examine whether there is cognitive content specific to childhood anxiety as opposed to a more general cognitive style associated with various affective states. Following the review of cognitive content, research on cognitive process is presented. Specifically, we review the results of investigations that have examined anxious children's interpretations, attributions, and expectancies in relation to specific events, including research examining the role of familial factors (e.g., transmission of information) in maintaining a specific cognitive style among anxious children. Finally, we consider the role of emotional understanding in children's report of cognition. Specifically, research suggesting that young children may not understand the links between cognition and emotion is reviewed, and implications for assessment are considered.
This review also addresses available research examining cognitive change in the context of treatment outcome. Based on a marked increase in cognitive-behavioral treatments aimed at childhood anxiety disorders within recent years, there remains a growing need for a better understanding of the changes (if any) associated with specific treatment components. For example, despite the lack of clear evidence that children with anxiety disorders have “distorted” cognitions, many researchers and clinicians have included cognitive interventions as part of their treatment packages. Thus, we have seen a proliferation of treatments designed to alter cognitions in the absence of understanding cognitive content and process, and in the absence of cohesive explanations that meet the usual criteria of theory. In this section, data addressing cognitive change as a result of behavioral and cognitive-behavioral interventions are evaluated.
Finally, important methodological considerations such as the suitability of various assessment methods for use with children are addressed. The vagaries of the various assessment methods are relevant for understanding the current, and often conflicting, state of the assessment literature. Conflicting results from various studies of negative cognition in anxiety disorders may be the result of different assessment methods, the specific time at which the assessment occurred, or from the wholesale adoption of adult assessment models for use with children. Without further attention to these issues, the confused and conflicting nature of the literature is likely to continue. Moreover, the role of cognitive development and its impact upon specific methodologies is discussed. Although basic developmental abilities have clear and direct implications for examining cognition in anxious children, few investigations have adequately considered the impact of differences in cognitive maturation when adopting methods of child assessment. Thus, recommendations for future research in these areas also are proposed.
Section snippets
Conceptual considerations
Anxiety disorders are characterized by an internal process of excessive worry, apprehensive expectation, and/or rumination about possible negative outcomes (DSM-IV; American Psychiatric Association, 1994). This internal process has become known as “cognition,” but in actuality, cognition has been defined in a myriad of ways. Thus, the literature on the cognitive aspects of anxiety now includes research on terms such as cognitive distortions, cognitive biases, anxious self-talk, cognitive style,
Methodological considerations
The clinical assessment literature is characterized by lack of agreement in terms of how to approach the measurement of cognitive phenomena. One contributing factor is that most methods were originally developed for adults (e.g., Burgio et al., 1981, Hollon & Kendall, 1980), and no reliability and validity data for children have been firmly established. Some researchers have reported the successful use of cognitive assessment strategies with children as young as 7 years (e.g., Barrett et al.,
Conclusions and future directions
Overall, research on the cognitive aspects of childhood anxiety has produced divergent and sometimes confusing findings. Although some data indicate significant differences in terms of the types of cognitions reported by clinically anxious children, many of the findings have been difficult to interpret due to methodological differences and issues related to statistical vs. clinical significance. Nonetheless, these results have implications for future research in this area. Specifically, the
Acknowledgements
This manuscript was supported in part by NIMH Grants 53703 and 60332 awarded to the second and third authors.
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