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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 1

Anxiety Symptoms in Children and Their Parents:

Where are the Connections?

Jeanine Baartmans (10633456)

24-4-2017

Supervised by:

Dr. F.J.A. van Steensel

Research internship / Thesis 1

Research Master Child Development and Education Graduate School of Child Development and Education Faculty of Social and Behavioral sciences

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 2

Abstract

Family factors are supposed to play a central role in the development and maintenance of anxiety disorders. The current study investigated the relation between anxiety in children and their parents at a symptom level using a network analysis approach. Parents of 1287 clinically referred children completed questionnaires on anxiety symptoms in their children and

themselves. Results demonstrated that the symptom relations within persons were more intertwined than the symptom relations between family members. Moreover, between person relations were found among similar symptoms. Paternal and maternal anxiety symptoms were differently related to childhood anxiety symptoms, but the general feeling of being fearful was found to be a central node in all family members (fathers, mothers, and children). Contrary to the extensive evidence for intergenerational relations in anxiety problems, the results suggest that intrapersonal factors may be more important in childhood anxiety than interpersonal factors in a family.

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 3

Anxiety Symptoms in Children and Their Parents: Where are the Connections?

Anxiety disorders are among the most common psychological disorders in children. Around 5% of all children meet the criteria for an anxiety disorder at any given point in time (Anderson, 1994; Merinkangas et al. 2010; Rapee, Schniering, & Hudson, 2009), and up to 19% of children and adolescence will suffer from an anxiety disorder before adulthood (Costello, 2005). Anxiety disorders are characterized by excessive fear and anxiety and related behavioral disturbances, which are interfering with daily functioning. (American Pychiatric Association [APA], 2013). Childhood anxiety disorders can persist into

adolescence and adulthood if left untreated and they are associated with increased risk of later depression and substance abuse (Keller et al., 1992). So far, various treatments for childhood anxiety disorders are available. The preferred treatment for anxiety disorders besides

medication is Cognitive Behavioral Therapy (CBT) (Antony & Stein, 2009). This intervention combines the reappraising of negative cognitions with examining behavior related to the anxiety and preventing the avoidance of anxiety provoking situations (O'Donohue, Fisher, & Hayes, 2004). Especially this and other treatments for childhood anxiety disorders have a good efficacy, but clear limitations remain. That is, at least 40% of children remain having an anxiety diagnosis after treatment (James, James, Cowdery, Solar, & Choke, 2013). Several attempts – like involving parents - to improve the efficacy of treatments for childhood anxiety have failed to improve treatment outcomes (Rapee et al., 2009; Arendt, Thastum, &

Hougaard, 2015). Therefore, the current study aims to get more insight into the basic

characteristics of various child anxiety symptoms and its reciprocal relationships with parental anxiety symptoms to generate starting points for developing targeted improvements for

childhood anxiety treatments.

There is substantial evidence that anxiety symptoms and disorders in children should be investigated at a family level, since there is a large overlap between anxiety disorders in

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 4 family members (Biederman, Rosenbaum, Bolduc, Faraone, & Hirschfeld, 1991; Nauta, Scholing, Emmelkamp, & Minderaa, 2003). That is, it is found that (1) when one or both parent(s) suffer from an anxiety disorder, the offspring has an heightened chance of suffering from an anxiety disorder (Beidel & Turner, 1997) and (2) the heritability of sensitivity for anxiety problems is around 45%, meaning that the variance in sensitivity for anxiety problems can approximately be explained for this percentage by genetics. However, more than only sensitivity for anxiety is needed for a child to develop an anxiety disorder (Stein, Jang, & Livesley, 1999), and other family factors - next to genetics - need to be investigated. Bögels and Brechman-Toussaint (2006) describe in their review article four groups of family variables that can contribute to the development of anxiety problems. The first is attachment of the children and the parents. Studies indicate that insecure attachment in parents and in children can be associated with child anxiety. Additionally, there is some preliminary evidence that attachment can predict childhood anxiety disorders and that improving the parent-child attachment relationship may help treat childhood anxiety disorders. Second, family dysfunction seems associated with parental and children’s anxiety symptoms. That is, for instance low family cohesiveness and adaptability or dysfunctional interactive processes among family members. Thirdly, there is considerable evidence for a relation between parenting styles and child anxiety. Parents can transmit anxiety to their children by their parenting style, when they act overprotective in their parenting or force their children to encounter anxious situations (McLeod, Wood, & Weisz, 2007; Tak, Bosch, Begeer, & Albrecht, 2014). Also high levels of negativity in parents might provoke anxiety (Krohne, 1990, 1992). And fourth, the beliefs that parents hold about their children’s anxious thoughts and behavior, and parental beliefs on their own control, are found to be associated with parental and children’s anxiety symptoms (Bögels & Brechman-Toussaint, 2006). In addition, to the four family factors identified by Bögels and Brechman-Toussaint, two other family

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 5 factors have been associated with childhood anxiety: anxious modelling and parental support. That is, children may copy anxious behavior both explicitly and implicitly from their parents and perceive or interpret situations as threatening (Muris, Merckelbach, Jong, & Ollendick, 2002; Muris, Steerneman, Merckelbach, & Meesters, 1996); and, if parents suffer from an anxiety disorder they might be less available for supporting their children (Biringen & Easterbrooks, 2012a, 2012b) which may lead to their children being more likely to develop anxiety problems (Ainsworth, Belhan, Waters, & Wall, 1978).

Based on the above, it is clear that there is a relationship between family factors, parental anxiety and child anxiety. However, studies so far are limited because most studies examined the relation between anxiety in children and parents at a syndrome level when either parents or children suffer from an anxiety disorders. Also, most studies only studied the relation between anxiety in mother and children, and did not include fathers. Some studies that did include fathers suggested that fathers with anxiety disorders are more controlling to their children and are more influential when it comes to indicating threat than mothers suffering from anxiety disorders (Bögels, Barnelis & van der Bruggen, 2008; Bögels &

Perotti, 2011, Möller et al., 2016). Moreover, the role of parental and/or family factors may be overestimated. That is, Rapee (2012) described that the role family factors play in the

development and maintenance of childhood anxiety disorders is not as big as in other forms of psychopathology. Particularly for the role of parents in the treatment of childhood anxiety disorders is limited empirical evidence which is somewhat surprising given the well-established relation between childhood anxiety and parental anxiety. These somewhat contradictory conclusions stress the importance of further investigating anxiety in a family context.

The current study aims to get a clearer view of anxiety in children and parents by investigating the relations among anxiety symptoms within and between family members

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 6 (children, mothers, fathers) with a network analysis approach. This method enables

researchers to create a graphic representation of relations between multiple symptoms for studying multiple relations between symptoms as a whole (Borsboom, 2008). The relations between the anxiety problems in families are studied in a clinical sample with various types of psychopathology, since anxiety problems (which do not necessarily meet the criteria for an anxiety disorder) are frequently present in clinical samples (Brown, Campbell, Lehman, Grisham, & Mancill, 2001; Costello et al., 2005). We examined what type of anxiety symptoms in children and parents connect with each other, and how paternal and maternal anxiety symptoms relate to their children’s anxiety symptoms. Based on the extensive literature on the relation between parental and childhood anxiety, it was expected that the strength of the interpersonal relations is comparable to the intrapersonal relations in childhood anxiety. In addition, it was examined in this study which anxiety symptoms play a central role in anxiety problems, and whether this is similar for children, mothers and fathers.

Methods Participants

Participants of the study were parents of 1287 children who were referred to an academic treatment center for mental health care problems. All children were aged between 6 and 18 years old (M = 11.57, SD = 3.03) and 60.3% (N = 776) of the children were boys. Of the 1287 children, 1231 mothers and 961 fathers participated in the study. The average age of the mothers was 45.17 (SD = 5.72) and the average age of the fathers was 47.43 (SD = 6.08). The children were primary diagnosed with attention deficit disorder (36.9%, N = 475), anxiety disorders (22.8%, N = 294), pervasive developmental disorders (11.2%, N = 144), and mood disorders (2.2%, N = 28), behavioral problems (1.4 %, N = 18), and 13.4% (N = 172) of the children had another diagnosis. 23.5% (N = 303) of all children had a comorbid diagnosis. All diagnoses were determined by the multidisciplinary team of the mental health care center and

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 7 were based on questionnaires, structured clinical interviews, psychiatric evaluations, and/or neuropsychological assessments. An inclusion criterium for referral to the academic treatment center is that children had at least a below average level of cognitive functioning (i.e., IQ > 70) as indicated by their school performance. For the current study, parents were excluded when their children were younger than 6 years old or older than 18 years. Further descriptive statistics on the included families are presented in table 1.

Table 1

Family descriptive statistics

N Percentage (%)

Living situation of the child

With both parents 718 55.8

Mainly with mother 213 16.6

Mainly with father 3 .2

With mother and new partner 45 3.5

With father and new partner 3 .2

Different living situation 117 9.1

(Missing information) 188 14.6 Number of siblings None 221 17.2 One 621 48.3 Two 285 22.1 Three or more 96 7.9 (Missing information) 64 5.0

Mother's relation to the child

Biological mother 1185 96.3

Adoptive mother 11 89.4

Stepmother 5 40.6

Foster mother 2 2.3

(Missing information) 28 2.3

Father's relation to the child

Biological father 911 94.8

Adoptive father 12 1.3

Stepfather 19 2.0

Foster father 5 0.5

(Missing information) 14 1.5

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 8

Univerisity 754 34.4

Applied university 681 31.1

Community college 279 12.7

Secondary or primary school 375 17.1

(Missing information) 103 4.7

Measures

Child Behavior Checklist 6-18 (CBCL/6-18). The CBCL/6-18 is a questionnaire for

parents to investigate problem behavior in their children. The questionnaire consist of 113 items for which parents have to indicate on a three-point scale how much the statements applied to their child in the past six months (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true). The CBCL has good internal consistency (Achenbach et al., 2008). In a Dutch sample, the CBCL also had good reliability and validity (De Groot, Koot, & Verhulst, 1994). The internal consistency in our sample for the CBCL total score was

excellent (mothers: α = .94, fathers: α = .94). In our sample, mothers reported clinical total for 50.8% of the children and subclinical scores for 8.1% of the children (M = 50.14, SD = 24.02,

range = 0 - 159). Fathers reported clinical scores on the anxiety scale for 42.5% of the

children and subclinical scores for 15.2% of the children (M = 43.99, SD = 23.27, range = 2 - 120).

In the current study, the DSM-anxiety scale of the CBCL was used. This scale consists of the following items: ‘clings to adults or too dependent’, ‘fears certain animals, situations, or places, other than school’, ‘fears going to school’, ‘nervous, high strung, or tense’, ‘too fearful or anxious’, and ‘worries’, and has an acceptable internal consistency (α = .79) (Nakamura, Ebesutani, Bernstein, & Chorpita, 2009). The internal consistency of the DSM-anxiety scale of the CBCL in the current sample was also acceptable (mothers: α = .75, fathers: α = .74). Mothers reported clinical scores on the anxiety scale for 16.0% of the

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 9 Fathers reported clinical scores on the anxiety scale for 11.1% of the children and subclinical scores for 7.1% of the children (M = 3.12, SD = 2.55, range = 0 - 11).

Adult Self-Report (ASR). The ASR is a questionnaire with 126 items for measuring

problem behavior in adults during the past six months. Participants had to indicate for each item on a three-point scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often true) how much the statements applied to them. The ASR has a good test-retest reliability and a good internal consistency (Achenbach, Newhouse, & Rescorla, 2004). The internal consistency of the ASR in the current study was excellent (mothers: α = .95, fathers: α = .94). 5.9% of the mothers had a clinical total score on the ASR and 6.1% had a subclinical total score (M = 32.67, SD = 23.38, range = 0 - 166). 3.7% of the fathers had a clinical score on the ASR and 3.3% a subclinical score (M = 29.54, SD = 21.65, range = 0 - 127).

The DSM-anxiety scale consisting of seven items of the ASR was used for the analysis in the current study. The items of the scale are ‘I worry about my future’, ‘I am afraid of certain animals, situations or places’, ‘I am nervous or tense’, ‘I am too fearful or anxious’, ‘Heart pounding or racing’, ‘I worry about my family’, and ‘I worry a lot’. The DSM-anxiety scale of the ASR has a good reliability (α = .86; Achenbach et al., 2004). The internal

consistency of this scale in the current sample was acceptable (mothers: α = .76, fathers: α = .77). 6.3% of the fathers had a clinical score and 3.4% had a subclinical score on the anxiety subscale (M = 4.07, SD = 2.67, range = 0 - 14). In the mothers, 11.4% had a clinical score and 6.1% had a subclinical score on the anxiety subscale (M = 3.05, SD = 2.46, range = 0 - 14).

Procedure

The current study was part of a larger study investigating the effectiveness of treatments provided at the academic treatment center. All parents of children who sought treatment were asked to complete a set of questionnaires, among which the CBCL and ASR,

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 10 before the treatment started. The questionnaires were sent to the participants by email. When parents came for intake they were asked whether their reports could be used for research purposes. If parents agreed, they signed informed consent. Ethical approval for the study was provided by the Faculty of Social and Behavioral Sciences from the University of

Amsterdam. The data was collected between July 2010 and February 2016.

Data analysis

A network analysis approach was used to study the data. A network is a graphic representation of correlations. Usually, this approach is used to study relations between psychopathology symptoms within persons for understanding comorbidity between disorders (e.g. Borsboom, Cramer, Schmittmann, Epskamp, & Waldrop, 2011). However, in the current study, the approach was used to investigate the relations both within and between persons; i.e., fathers’ and mothers’ reports on anxiety symptoms in themselves and their children were analyzed in one network on a symptom level. The knots represent the symptoms and the lines between the knots represent the significant partial correlations. Symptoms closely related to each other (with multiple reciprocal relations) are presented closely to each other. In addition, Thicker lines between symptoms correspond with stronger relations (Borsboom, 2008). In order to identify the anxiety symptom(s) that played a central role among all anxiety symptoms, a centrality plot was used. This plot gives insight in the betweenness, closeness, and strength of the symptoms. A symptom is central, important, and influential when it has many connections, is close to other symptoms, and when it connects to other symptoms (Epskamp, Cramer, Waldorp, Schmittmann, & Borsboom, 2012). In the current study, relations between symptoms were only interpreted when they were bigger than 0.3, representing a medium effect size (Cohen, 1992). Data analysis was conducted with the package Qgraph (Version 1.3.2; Epskamp et al., 2012) in RStudio (Version 1.0.136; RStudio Team, 2016).

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 11

Results

Figure 1 presents the full network of the anxiety symptoms in fathers, mothers and their children. All significant correlations are presented. The attachment contains a table with all correlations. In total, 269 correlations (in total 325 correlations) were bigger than 0.1, and 100 correlations were bigger than 0.3. All of these correlations were significant at α = 0.05. Visually, it can be seen that the network shows a pattern with three rather separate clusters where the symptoms of one family member are more closely related to each other than the symptoms between family members. In addition, there were more and stronger relations within family members (ticker lines) than between family members (thinner lines). The results between and within family members are discussed in more detail next.

Figure 1. Full network

Note. M1 = mother worrying about future, M2 = mother specific phobia, M3 = mother

nervousness, M4 = mother fearful, M5 = mother heart pounding, M6 = mother worrying about family, M7 = mother general worrying, F1 = father worrying about future, F2 = father specific phobia, F3 = father nervousness, F4 = father fearful, F5 = father heart pounding, F6 = father worrying about family, F7 = father general worrying, C1m = mother reported child dependency, C2m = mother reported child specific phobia, C3m = mother reported child fears

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 12 school, C4m = mother reported child nervousness, C5m = mother reported child fearful, C6m = mother reported child general worrying, C1f = father reported child dependency, C2f = father reported child specific phobia, C3f = father reported child fears school, C4f = father reported child nervousness, C5f = father reported child fearful, C6f = father reported child general worrying

Between person relations

There were nine correlations between family members bigger than 0.3. In total, there were three correlations between maternal and child anxiety symptoms, four between paternal and child symptoms, and two between maternal and paternal anxiety symptoms bigger than 0.3 (see table 2). As can also be seen from Table 2, the correlations between the different family members were all found for the same symptoms.

Table 2

Between person symptom correlations bigger than 0.3

Mother Father Child Correlation

Specific phobia Specific phobia .31

Fearful Fearful .34

General worrying Worrying .30

Nervousness Nervousness .37

Fearful Fearful .35

General worrying Worrying .34

Worrying family Worrying .30

Worrying future Worrying future .31

Worrying family Worrying familiy .34

Within person relations

All within person correlations for father-anxiety symptoms, mother-anxiety symptoms, child father-reported symptoms, and child mother-reported symptoms were 0.3 or higher. The correlations between father-reported and mother-reported child-anxiety symptoms were all

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 13 between 0.2 and 0.8 (see Appendix 1: Correlations between all anxiety symptoms in fathers, mothers and their children).

Figure 2 shows a centrality plot of the anxiety symptoms in fathers, mothers, and children. Based on the betweenness, closeness and strength, and the within person networks (figure 3, 4, and 5) it can be concluded that the symptom ‘fearful’ (m4, f4, C5m, C5v in Figure 2) had a central role in all family members.

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 14

Figure 3. Maternal anxiety symptoms network

Note. M1 = mother worrying about future, M2 = mother specific phobia, M3 = mother

nervousness, M4 = mother fearful, M5 = mother heart pounding, M6 = mother worrying about family, M7 = mother general worrying

Figure 4. Paternal anxiety symptoms network

Note. F1 = father worrying about future, F2 = father specific phobia, F3 = father nervousness,

F4 = father fearful, F5 = father heart pounding, F6 = father worrying about family, F7 = father general worrying

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 15

Figure 5. Child anxiety symptoms network reported by fathers and mothers

Note. C1m = mother reported child dependency, C2m = mother reported child specific

phobia, C3m = mother reported child fears school, C4m = mother reported child nervousness, C5m = mother reported child fearful, C6m = mother reported child general worrying, C1f = father reported child dependency, C2f = father reported child specific phobia, C3f = father reported child fears school, C4f = father reported child nervousness, C5f = father reported child fearful, C6f = father reported child general worrying

Discussion

The aim of the current study was to investigate the relations between anxiety symptoms in children and their parents. More specifically, it was studied how strong the between person correlations were compared to the within person correlations. It was found that (1) there were multiple relations between anxiety symptoms within and between family members, however, there were more and stronger relations within family members than between family members. (2) Significant relations were found between mother and child, father and child, but also between mother and fathers, and the relations between fathers and their children and between mothers and their children were slightly different. (3) The

strongest relations between family members were among similar symptoms. (4) The general feeling of being fearful had a central role in paternal, maternal and childhood anxiety.

The current study indicated that the within person relations between anxiety symptoms are more important than the between person relations in a family which suggests that internal

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 16 anxiety symptoms – and how they relate and are intertwined with each other - are more important in the expression of childhood anxiety than family factors are, or at least than the role of parents own anxiety symptoms. This finding may be viewed in slight contrast with the general idea of the (relatively large) importance of parental transmission of anxiety (Beidel & Turner, 1997; Bögels & Brechman-Toussaint, 2006). However, also note, that while the parental transmission on an anxiety symptom-level was not as much evident as was expected in the current study, these findings do not necessarily mean that parental transmission of anxiety is to be neglected (i.e., evidence of significant interpersonal relations on a symptom-level was found in the current study). This finding is in line with the general idea that anxiety problems develop as a result of an interaction between temperament and environmental risk factors (Degnan, Almas, & Fox, 2010).

The anxiety symptoms in fathers were slightly different related to the child anxiety symptoms than the anxiety symptoms in mothers; i.e., specific phobia was stronger related between mother and child than between father and child, and nervousness was stronger related between father and child than between mother and child. From previous studies investigating possible differences between the roles of fathers and mothers in de etiology, maintenance, or treatment of childhood anxiety, we know that fathers are more focused on play and challenges in their parenting, while mothers are more focused on care and protection (Bögels & Phares, 2008). When fathers have symptoms of nervousness themselves it could be that they are less challenging in their parenting, which in turn could elicit nervousness in their children. With regard to specific phobia, it is known that vicarious learning is involved in the development of specific fears (Merckelbach, de Jong, Muris, & van Den Hout, 1996) and it can be hypothesized that as mothers are (usually) the primary caregivers, the child and mother may share more (anxious) events and/or the child gets exposed more by the mother’s specific fear (reaction).

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 17 Another important finding was that the strongest relations between anxiety symptoms in family members were found among similar symptoms. A possible explanation for this finding could be that these symptoms are transmitted from parents to children by a specific genetic component or through parenting styles or modelling. However, it is thought that intergenerational relations of anxiety disorders are not disorder specific (Eley, 2001; Rapee, 2002). Our finding could also possibly be explained by the use of parent report on both the parental and childhood anxiety symptoms. When parents experience certain anxiety

symptoms themselves, it could be that they more easily recognize similar symptoms in their children and/or that they think that their child is suffering from the same symptoms (biased perception) (see also Rapee & Heimberg, 1997). For instance, Bögels and van Melick (2004) found that parents’ report on questionnaires about anxiety themselves and in their children was strongly correlated, while the relations between parent’s report about their child’s anxiety and children’s report about their own anxiety did not reach significance.

Finally, it was found in the current study that for all family members, the general feeling of being fearful had a central role in the expression of anxiety. This findings seems argumentative, since the general feeling of being fearful relates to the core symptoms of all types of anxiety disorders (American Psychiatric Association [APA], 2013). This advocates for the robustness of the centrality of the general feeling of being fearfull in individuals from a different sex or with a different age.

A strength of the current study was that it examined the relation between anxiety in fathers, mothers, and children at a symptom level in a large heterogenetic sample while previously studies mostly only looked at relations at a syndrome level, did not include fathers, or focused only on parents or children with anxiety disorders. This study therefore provides a more broad perspective on the relation between child and parental anxiety, and their

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 18 members) In addition, the use of a network analysis approach enabled us to more intensely investigate the relations between psychopathology symptoms of the different family members. Still, limitations of the study also need to be noted. First, although the use of a clinical

heterogeneous sample has its strength (more variance in responding), it also has it back drawings. That is, offspring of parents with psychopathology are not only at risk for similar disorders but also for other different forms of psychopathology (Beidel & Turner, 1997), thus children of anxious parents are also at risk for others types of (internalizing) disorders (Fisak, Grills-Taquechel, 2007). In future studies it could therefore be interesting to study the

relations between anxiety symptoms in children and their parents using different clinical samples as well as a typically developing sample, and exploring these relations both on a symptom as well as a disorder level. A second remark about the current study is that the current sample included parents from different family and living situations and parents with different relations to the child, even though family functioning is important in

intergenerational relations between anxiety problems (McLeod, Wood, & Weisz, 2007). In future studies it could be interesting to compare the relations between anxiety symptoms in families with living together parents and separated parents, or other type of family structures as it is found that family functioning and family structure can be related to the development of psychopathology in children (Cohen & Brook, 1987; Gotlib & Avison, 1993). Furthermore, it would be interesting to include anxiety symptoms in siblings in the network analyses. This way, it would not only be possible to study the relations between anxiety symptoms among siblings, but also it would be possible to investigate possible differences between parents and different children living in the same family. Siblings often have common risk factors for the development of psychopathology and psychopathology in one child can influence the family functioning (Burt, 2009; Kelvin, Goodyer, & Altham, 1996). A third limitation of the study was that parents reported on their children’s anxiety symptoms. These parental reports could

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 19 be biased because of parent’s own anxiety symptoms. In future studies it would be useful to use child reports on their own anxiety symptoms instead of parent reports on their children’s symptoms or use other measures – like observations, behavioral assessments or implicit measures – in addition to the questionnaires. Lastly, with the network analysis approach it is not possible to draw conclusions about causality between symptoms, meaning that it remains unclear if the parental symptoms lead to anxiety symptoms in children and/or the other way around. All described relationships between parental and childhood anxiety were

correlational.

This study showed that childhood anxiety is at a symptom level related to parental anxiety, but not as strong as we expected based on studies relating childhood and parental anxiety at a syndrome level (i.e. Beidel & Turner, 1997; Biederman et al., 1991). Besides, there were multiple relations between anxiety symptoms within persons and the general feeling of being fearful played a central role within fathers, mothers, and children. These findings stress the importance of mainly focusing on internal factors in the treatment of childhood anxiety, instead of focusing on family factors. Additionally, these findings might suggest that different types of anxiety problems are strongly related to each other and that treating general anxious feelings – for instance by learning to tolerate and accepts this feeling through exposure or mindfulness exercises (Abramowitz, Deacon, & Whiteside, 2012; Hofmann, Sawyer, Witt, & Oh, 2010) - might cause other anxiety symptoms to decrease.

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 20

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 27

Appendix 1

Correlations between all anxiety symptoms in fathers, mothers and their children

Note. M1 = mother worrying about future, M2 = mother specific phobia, M3 = mother nervousness, M4 = mother fearful, M5 = mother heart

pounding, M6 = mother worrying about family, M7 = mother general worrying, F1 = father worrying about future, F2 = father specific phobia, F3 = father nervousness, F4 = father fearful, F5 = father heart pounding, F6 = father worrying about family, F7 = father general worrying, C1m = mother reported child dependency, C2m = mother reported child specific phobia, C3m = mother reported child fears school, C4m = mother reported child nervousness, C5m = mother reported child fearful, C6m = mother reported child general worrying, C1f = father reported child dependency, C2f = father reported child specific phobia, C3f = father reported child fears school, C4f = father reported child nervousness, C5f = father reported child fearful, C6f = father reported child general worrying

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RUNNING HEAD: ANXIETY SYMPTOMS IN CHILDREN AND THEIR PARENTS 28 C1m C2m C1m C2m C1m C2m M1 M2 M3 M4 M5 M6 M7 C1f C2f C1f C2f C1f C2f F1 F2 F3 F4 F5 F6 F7 C1m C2m .436 C1m .378 .387 C2m .295 .328 .415 C1m .495 .678 .565 .465 C2m .320 .374 .496 .509 .561 M1 .101 .093 .114 .149 .091 .181 M2 .148 .311 .133 .207 .289 .119 .306 M3 .135 .123 .115 .278 .182 .258 .537 .401 M4 .152 .220 .217 .264 .352 .249 .512 .676 .685 M5 .091 .136 .128 .215 .144 .149 .391 .354 .485 .530 M6 .135 .113 .242 .244 .142 .282 .506 .315 .473 .397 .327 M7 .096 .150 .240 .213 .179 .306 .597 .341 .623 .572 .416 .685 C1f .526 .299 .309 .214 .408 .296 .054 .021 .085 .101 -.024 .133 .098 C2f .308 .588 .218 .259 .492 .278 .081 .174 .087 .164 .096 .129 .119 .448 C1f .288 .212 .771 .285 .465 .401 .075 -.013 .084 .059 -.015 .279 .176 .352 .287 C2f .202 .208 .280 .539 .283 .328 .111 .082 .133 .073 .076 .165 .179 .391 .353 .385 C1f .366 .503 .395 .316 .694 .412 .093 .220 .110 .249 .116 .164 .155 .507 .628 .488 .477 C2f .219 .225 .380 .339 .399 .578 .082 .088 .130 .124 .066 .194 .157 .351 .363 .430 .475 .533 F1 .082 .072 -.032 -.014 -.001 .094 .309 .031 .097 .093 .104 .190 .153 .101 .100 .104 .128 .124 .162 F2 .112 .123 .103 .094 .074 .109 .217 .233 .205 .217 .207 .212 .110 .156 .263 .183 .135 .228 .217 .368 F3 .080 .104 .135 .155 .127 .159 .248 .154 .209 .201 .141 .247 .230 .176 .238 .183 .369 .273 .296 .523 .475 F4 .158 .129 .068 .089 .156 .118 .274 .0701 .201 .221 .159 .223 .166 .206 .280 .160 .255 .346 .256 .512 .704 .721 F5 .097 .058 .063 .081 .128 .077 .077 .094 .097 .080 .055 .124 .062 .107 .294 .169 .155 .205 .233 .378 .404 .493 .527 F6 .130 .117 .179 .198 .106 .155 .220 .117 .131 .113 .138 .338 .235 .216 .157 .222 .276 .261 .303 .518 .398 .449 .390 .360 F7 .035 -.026 .051 .066 -.006 .124 .216 .049 .107 .114 .132 .212 .130 .122 .101 .155 .213 .202 .345 .695 .490 .635 .661 .433 .673

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