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

https://doi.org/10.1016/j.janxdis.2019.01.006Get rights and content

Highlights

  • Severity of child separation and social anxiety behaviors was assessed via daily diary.

  • Good model fit for both separation and social anxiety behaviors was found.

  • Frequencies of anxiety behaviors that were considered severe were identified.

  • Behaviors such as shyness with peers and new people were developmentally normative.

  • Anxiety behaviors were associated with demographic characteristics and impairment.

Abstract

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.

Introduction

Anxiety disorders are among the most prevalent, impairing, and persistent conditions that typically onset during childhood (Beesdo, Knappe, & Pine, 2009; Bufferd, Dougherty, Carlson, & Klein, 2011; Costello, Egger, & Angold, 2005; Franz et al., 2013; Whalen, Sylvester, & Luby, 2017; Wichstrom et al., 2012) and predict a variety of psychiatric disorders in childhood (Bufferd, Dougherty, Carlson, Rose, & Klein, 2012; Bufferd et al., 2018), adolescence (Bittner et al., 2007; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003), and adulthood (Pine, Cohen, Gurley, Brook, & Ma, 1998; Shear, Jin, Ruscio, Walters, & Kessler, 2006). In addition, many adults report that their anxiety disorders began in childhood (Kessler et al., 2005; Kim-Cohen et al., 2003). However, compared to older children and adolescents, less is known about anxiety during the preschool period (Egger & Angold, 2006). This limited focus is problematic given that earlier onset of internalizing difficulties may contribute to long-term impairment and chronicity (Weissman et al., 1999). In addition, early childhood offers a developmental window for prevention or early intervention before school entry (Anticich, Barrett, Silverman, Lacherez, & Gillies, 2013; Kennedy, Rapee, & Edwards, 2009; Lau & Rapee, 2011). Therefore, it is critical to clarify the nature of anxiety during the preschool period to minimize the impact of these problems.

The limited evidence suggests that up to 20% of preschoolers meet criteria for anxiety diagnoses (Bufferd et al., 2011; Egger & Angold, 2006; Franz et al., 2013; Wichstrom et al., 2012). Separation anxiety and social anxiety are particularly common anxiety disorders identified in preschool-aged children (Bufferd et al., 2011; Franz et al., 2013). However, given that a certain degree of separation anxiety and social fear reflect typical developmental behaviors of early childhood (Gullone, 2000; Muris, Merckelbach, Gadget, & Moulaert, 2000; Muris, 2010; Ollendick, King, & Frary, 1989), it is necessary to better understand the particular level of such behaviors that may be clinically significant by characterizing the spectrum of typical to problematic behavior (Bufferd, Dyson, Hernandez, & Wakschlag, 2016). The goal of the present study is to examine the daily frequency of behaviors relevant to common anxiety difficulties, separation anxiety and social anxiety, in preschool-aged children using a parent-report daily diary assessment.

One challenge in identifying behaviors in young children relevant to risk for psychopathology is that the behaviors associated with psychopathology (e.g., noncompliance, inattention, irritability) are developmentally normative in early childhood. Fear and anxiety are especially common in young children and are often expressed as separation and social anxiety (Gullone, 2000; Muris et al., 2000; Muris, 2010; Ollendick et al., 1989). As behaviors relevant to anxiety can be both evolutionarily adaptive and developmentally appropriate, determination of potentially problematic levels is especially challenging.

Anxiety and fear are evolutionarily advantageous as these emotions permit rapid detection of threat to enhance survival (Öhman & Mineka, 2001; Sloman, Farvolden, Gilbert, & Price, 2006). Separation and social anxiety in particular confer adaptive advantages given protection associated with resistance to separation from a caregiver and/or hesitation around new people, respectively. Separation anxiety can also activate attachment needs, signal potential abandonment, and create arousal that enhances motivation to seek reunion/safety; social anxiety can signal potential rejection and create arousal that enhances motivation to avoid unsafe individuals (Öhman, 2009). Further, anxiety is associated with withdrawal and avoidance, which can also be adaptive as a way to preserve resources and minimize exposure to threat in the short-term (Sloman et al., 2006). Findings that identify common patterns of development of fear and anxiety across cultures and primates support the adaptive value of a threat orientation (Gullone, 2000; Marks, 1987).

Moreover, for most typically developing children, normative emotional development in early childhood involves increasing social engagement (Bufferd et al., 2016; Rubin, Coplan, Chen, Buskirk, & Wojslawowicz, 2005) and typically some degree of separation/individuation from parents/caregivers. Socially, most young children are shifting from solitary and parallel play to more interactive play with peers; these shifts require the development of a variety of skills, such as social communication, empathy, problem-solving, and reciprocity (Martin, Fabes, Hanish, & Hollenstein, 2005; Rubin et al., 2005). Expectations for social engagement with others and separation from parents typically increase during the preschool period as children enter more formal schooling. Therefore, the preschool period is an ideal time in development to investigate these emotional processes as identification of disruptions may suggest potential prevention of worsening difficulties (Bufferd et al., 2016).

Given that behaviors relevant to anxiety are both evolutionarily adaptive and developmentally appropriate yet also contribute to clinically significant distress and impairment in functioning, it is necessary to better understand anxiety behaviors in early childhood that may contribute to risk for psychopathology. Efforts have been made to theoretically map the variation in young children’s anxiety from normative to problematic (Bufferd et al., 2016), but to date, empirical advances have only included externalizing behavior (Wakschlag et al., 2014; Wakschlag, Choi et al., 2012), irritability (Wakschlag et al., 2015), and depressive symptoms (Bufferd, Dougherty, & Olino, 2017). The empirical range of the frequency of separation and social anxiety behaviors in preschool-aged children that identify the levels of behavior that may suggest difficulty is unknown. As anxiety can be early-emerging, distressing/impairing, and contribute to long-term symptoms and associated difficulties, it is worthwhile to improve identification of problematic levels of anxiety in early childhood.

In addition, although valuable findings have resulted from the development and use of reliable and valid parent-report diagnostic interviews (Egger, Ascher, & Angold, 1999; Ezpeleta, de la Osa, Granero, Domenech, & Reich, 2011; Scheeringa & Haslett, 2010) and symptom scale (Andrijic, Bayer, & Bretherton, 2013; Achenbach & Rescorla, 2000; Edwards, Rapee, Kennedy, & Spence, 2010; Gadow & Sprafkin, 2000) measures to assess anxiety in preschool-aged children, some features of these measures limit the mapping of all behaviors relevant to anxiety. First, as per the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2013), diagnostic assessment requires identifying whether anxious behaviors are “persistent” and “excessive”; without empirical guidelines, determining whether a child exhibits behavior in a sufficiently persistent and/or excessive manner is a challenging, subjective, and potentially fallible endeavor. Second, children’s behavior is typically only documented when meeting these thresholds; other behaviors that may be impairing and relevant to risk for psychopathology are not documented at sub-threshold levels. Third, checklist measures require parents to determine the frequency of the behavior based on their own judgement (e.g., whether the behavior happens “sometimes” or “often”) and to compare their children’s behavior to similarly-aged children; as parents have varying degrees of exposure to children and potentially limited knowledge of developmental norms, their judgements may be biased. Finally, both diagnostic and checklist assessment methods rely on potentially questionable retrospective report over a period of one month or more. Therefore, a method that detects behaviors along the full spectrum of relevant behavior is needed (Bufferd et al., 2016; Egger & Angold, 2006; Wakschlag, Henry et al., 2012) in a manner that reduces parents’ subjective judgement and the period of retrospective recall.

One method that may address these limitations is the use of a parent-report daily diary. Several researchers have examined parental daily diary reports of anxiety in anxious and healthy comparison school-age children and adolescents, typically to characterize the phenomenology of anxiety in older youth or assess the impact of an intervention (Allen, Blatter-Meunier, Ursprung, & Schneider, 2010; Beidel, Neal, & Lederer, 1991; Beidel, Turner, & Morris, 1999; Beidel, Turner, & Morris, 2000; Eisen, Raleigh, & Neuhoff, 2008). These studies demonstrated the feasibility of daily assessment of children’s anxiety. However, to our knowledge, this method has not been used to assess parents' reports of behaviors relevant to anxiety in a community sample of preschool-aged children, nor has this method been used to characterize normative to non-normative anxiety behaviors in young children.

The goal of the present study is to employ a 14-day parent-report daily diary method to assess the frequency and severity of the full range of daily behaviors relevant to separation and social anxiety in young children. Data collected using this novel approach will capture the daily variations in behaviors relevant to anxiety, minimize biases in parents’ retrospective reporting, and enable documentation of the full range of normative behaviors that are relevant to anxiety in young children, rather than limiting data collection to behaviors that only meet clinical symptom thresholds in diagnostic interviews. We hypothesized that theoretically high base rate anxiety behaviors (e.g., shyness around new adults) will occur at greater frequencies to be considered psychometrically severe, whereas theoretically non-normative anxiety behavior (e.g., worry about separation due to natural disaster) will occur less frequently to be considered severe. These hypotheses reflect speculative predictions: although there have been some efforts to examine normative and clinical levels of fears in young children (e.g., Bufferd et al., 2016; Gullone, 2000; Muris et al., 2000), the specific anxiety behaviors that will be more or less severe are not known. In addition, we also hypothesized that severity/frequency of behaviors would be associated with children’s and parents’ distress, and children’s impairment in psychosocial functioning and relationships. Empirical, developmentally sensitive information about the frequency and severity of behaviors relevant to anxiety in the preschool period is essential to delineate the level at which normative behaviors may reflect clinically significant risk.

Section snippets

Participants

As part of a larger study to assess behaviors relevant to mood and anxiety in young children (Bufferd et al., 2017), 300 parents of 3-5-year-old children without medical or developmental disabilities enrolled in the study; nine parents only completed baseline measures and never started the diary measures, so the final sample included 291 parents (see Table 1). Participants were recruited from a twenty-mile radius around two universities: California State University San Marcos and University of

Results

Table 2 shows the frequencies of each separation and social anxiety behavior across the 14-day period within each category. The percentile and frequency categories correspond such that children within each percentile group were reported to demonstrate the behavior within the range of frequency presented. For example, youth up to the 50th percentile demonstrated distress when anticipating separation from a caregiver zero times; youth between the 50th and 80th percentiles demonstrated this

Discussion

The goal of the present study was to illustrate the spectrum of behavior relevant to separation and social anxiety to determine the frequency and psychometric severity of these behaviors in young children. The study included a novel parent-report daily diary method that minimized retrospective recall as well as measured the full range of frequencies of relevant behavior rather than limiting data collection to behaviors that meet clinical symptom thresholds in diagnostic interviews or requiring

Funding

This work was supported by a National Institute of Mental Health (Bufferd) grant R15 MH106885, a California State University San Marcos (CSUSM) Grant Proposal Seed Money Award (Bufferd), a CSUSM University Professional Development Award (Bufferd), the University of Maryland (UMD) College of Behavioral and Social Sciences Dean’s Research Initiative Award (Dougherty), and the UMD Research and Scholars Award (Dougherty).

Declarations of interest

None.

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