Journal of Behavior Therapy and Experimental Psychiatry
Children's perception and interpretation of anxiety-related physical symptoms
Introduction
The understanding of emotions is an important prerequisite for effective self-regulation and competent social behavior (e.g., Shaffer, 1997). Developmental psychologists have found evidence indicating that preschool children already know a great deal about emotions. For example, most preschoolers have experienced and understand the basic human emotions. Their comprehension of positive emotions even shows strong resemblance to that of adults, although they are still not very good at interpreting the whole range of negative emotions that others may express. During the preschool period, children also acquire some understanding of the causes of emotions. By the age of 4, most of them know that emotions are elicited by what happens in a particular situation or by the outcome of that situation (Harris, 1994). During middle childhood, children learn to understand complex emotions such as guilt, shame, and pride (Ferguson, Stegge, & Damhuis, 1991). In addition, they are able to consider multiple aspects of an emotion-arousing situation. That is, children of this age know, for instance, that emotional experience not only depends on what happens to someone at the present time but also on what the person was previously thinking and feeling, including the person's expectations (see Lang (1987), Thompson (1991)).
Although, the above-mentioned research has provided insight in the development of understanding emotions, still little is known about children's perception and interpretation of physical symptoms, notwithstanding the fact that such symptoms are thought to be important concomitants of emotions. The latter seems particularly true for the emotion of anxiety. According to the three-system model of Lang (1968), emotions such as anxiety consist of three relatively independent components: a subjective component, a behavioral component, and a physiological component. Thus, anxiety is not only reflected in subjective feelings of apprehension and avoidance behavior but also accompanied by physical symptoms such as palpitations, sweating, trembling, shortness of breath, chest pain, nausea or abdominal distress, dizziness, chills and hot flushes. Of course, the experience of somatic symptoms is the key feature of panic disorder (American Psychiatric Association, 2000), although it should be borne in mind that such sensations are part and parcel of all other anxiety disorders (Rachman, 1998).
While it is clear that physical symptoms are an important by-product of anxiety psychopathology, it is also true that such symptoms are thought to play an important role in the continuation of subjective feelings of fear and apprehension. This is most evident in Clark's (1986) cognitive model of panic, which describes panic attacks as resulting from catastrophic misinterpretations of bodily sensations. Such catastrophic misinterpretations involve the perception of these sensations as far more threatening than they actually are. For example, palpitations may be interpreted as a sign of an impeding heart attack, trembling may be perceived as signaling loss of control, whereas difficulties with breathing may be seen as the cessation of breathing and death. In a similar vein, there seems to be individual differences in the extent to which people experience anxiety-related physical symptoms as aversive. This refers to the personality trait of anxiety sensitivity, which can be defined as the fear of anxiety-related bodily sensations that are interpreted as having potentially harmful somatic, psychological, or social consequences (e.g., Taylor, 1995). Studies have demonstrated that anxiety sensitivity plays a role in the aetiology and maintenance of anxiety disorders, in particular panic disorder (e.g., Rachman, 1998).
Clinical observations have shown that children as young as 8 years may suffer from panic attacks (e.g., Ballenger, Carek, Steele, & Cornish-McTighe, 1989; Vitiello, Behar, Wolfson, & Delaney, 1987), and researchers assume that the individual difference variable of anxiety sensitivity develops during middle childhood (e.g., Reiss, Silverman, & Weems, 2001). Yet, it should be borne in mind that there is actually little foundation for applying ‘adult’ physical-symptom-based theories and concepts to child populations. Nelles and Barlow (1988) were the first to raise this point in their critical review of panic disorder in children. These authors concluded that most panic attacks in children are linked to particular events, with catastrophic interpretations of bodily sensations playing a less prominent role (see also Ollendick, 1998). At least two requirements seem to be necessary for a child to develop a ‘real’ panic attack. First, the child must experience a clear-cut physical sensation. Second, the child must have the cognitive capacity to make a catastrophic interpretation of this physical sensation. A search in the psychological literature makes clear that there are virtually no studies that have examined children's perception and interpretation of (anxiety-related) physical symptoms.
An exception is an investigation by Mattis and Ollendick (1997), who examined cognitive interpretations of anxiety-related somatic symptoms in children from Grades 3, 6, and 9 (with mean ages of 8.6, 11.2, and 14.3 years). Children were asked to imagine experiencing the somatic symptoms of anxiety and to complete a brief checklist consisting of 12 items representing different types of cognitive attributions: external/non-catastrophic (e.g., “I’d think I was feeling that way because of the temperature or the weather”), external/catastrophic (e.g., “I’d think something or someone was trying to kill me”), internal/non-catastrophic (e.g., “I’d think I was worried about something”), or internal/catastrophic (e.g., “I’d think that I must be dying”). Results revealed no significant grade differences for the tendency to make internal vs. external and catastrophic vs. non-catastrophic attributions in response to anxiety-related somatic symptoms. More precisely, the data showed that children, regardless of age, made more internal and non-catastrophic attributions. Altogether, these findings demonstrate that at least in middle childhood, somatic symptoms are interpreted as a signal for anxiety. A limitation of Mattis and Ollendick's (1997) study is that these authors used a questionnaire for assessing children's interpretations of anxiety-related physical symptoms. This method may have prompted children to give anxiety-related interpretations of somatic symptoms. Furthermore, the youngest children in Mattis and Ollendick's study were on average almost 9 years old, and so it remains unclear whether younger children are capable of considering physical sensations as symptoms of anxiety. Several authors assume that children acquire this ability from the age of 7, when they enter the Piagetian cognitive stage of concrete operations, which increasingly enables them to link physical symptoms to psychological conditions such as anxiety (e.g., Bibace & Walsh, 1981; Nelles & Barlow, 1988).
With these issues in mind, the current study was undertaken. A group of primary school children aged 4–12 years (N=129) were presented with a series of brief scenarios describing situations that children might encounter in daily life. Scenarios described neutral situations in which the main character experienced an anxiety-related physical symptom (e.g., hands trembling, heart beating very fast). Children were asked to indicate which of five basic emotions (i.e., happy, sad, angry, fear, and pain) applied to the main character of the scenario. Children were allowed to select several emotions as long as they were able to substantiate their choice. Next, children were interviewed about their actual experiences with anxiety-related physical symptoms. In this way, it was determined whether children report such symptoms in daily life and to what extent these reflect symptoms of anxiety. Finally, children were explicitly asked what physical symptoms they experienced when feeling anxious. In this way, it was examined to what extent children of various ages are capable of relating physical symptoms to anxiety and fear, whether certain symptoms are more easily interpreted as a symptom of anxiety, and how frequently anxiety-related physical symptoms are experienced in daily life. As to the developmental pattern of the perception and interpretation of anxiety-related symptoms, it was hypothesized that older children (i.e., aged 7 years and above) would more frequently link a physical symptom to fear and more often experience anxiety-related somatic symptoms than younger children (i.e., aged 4–6 years).
Section snippets
Participants
Participants were 129 children (63 boys and 66 girls) recruited from a primary school in Utrecht, The Netherlands. Their mean age was 7.8 years (SD=2.4), with a range of 4–12 years. To study age effects, children were divided into three age groups: (1) children aged 4–6 years (n=47; 24 boys and 23 girls), (2) children aged 7–9 years (n=47; 22 boys and 25 girls), and (3) children aged 10–12 years (n=35; 17 boys and 18 girls). No information about the socioeconomic background of the children was
Emotion recognition
Before addressing the main research topics of the present investigation, it should be mentioned that most children were capable of correctly naming the emotions at their first attempt (i.e., before the experimenter provided help). Percentages of correctly named emotions were 99.2% for happy, 98.4% for sad, 98.4% for angry, 82.2% for fear, and 80.6% for pain. Chi-square comparisons revealed that there were no significant differences among the three age groups as to the identification of basic
Discussion
The current study examined children's perception and interpretation of anxiety-related physical symptoms in a sample of 4–12-year-old primary school children. The main results can be catalogued as follows. First, physical symptoms were associated with a broad range of emotions, including happiness, sadness, anger, fear, and pain. “Hands trembling”, “heart beating fast”, and “difficulties with breathing” were the only physical symptoms that were more frequently linked to fear than to any of the
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