توسعه گزارش اقدامات کودک و پدر و مادر اجتناب رفتاری مربوط به اختلالات اضطرابی دوران کودکی

The current report describes 3 studies conducted to develop 8-item child- and parent-report measures to further the understanding of the role of behavioral avoidance in the development, maintenance, and treatment of childhood anxiety disorders. Participants included both clinical (N = 463; ages 8 to 12) and community (N = 421; ages 7 to 18) samples of children and their parents from primarily Caucasian intact families. Follow-up data were collected from 104 families in the community sample. Overall, the measures were internally consistent and related to anxiety, distress, and alternative measures of avoidance in both samples. Parent report of children’s behavioral avoidance evidenced the strongest psychometric properties, differentiated among clinical and community populations, and most importantly, predicted children’s anxiety at least 8 months later over and above initial anxiety ratings. Moreover, decreases in avoidance were associated with successful exposure therapy. These results are consistent with the role of behavioral avoidance in the development of anxiety and provide an efficient tool for assessing the role of avoidance in clinical and research settings.

In childhood, fears and anxiety are normative (Ollendick, Matson, & Helsel, 1985), but at elevated levels cause significant distress and interference in activities and development due to avoidance and escape from anxiety-provoking stimuli (Vasey & Ollendick, 2000). Because anxiety disorders impact functioning across many domains (e.g., social, occupational, medical, academic) and often persist into adulthood, research improving the understanding, identification, prevention, and treatment of childhood anxiety disorders is of great importance (Mendlowicz and Stein, 2000, Merikangas and Avenevoli, 2002 and Quilty et al., 2003). In service of these goals, it is imperative to assess all aspects of anxiety that may impact suffering and indicate the need for intervention from both the child’s and the parents’ perspectives. Behavioral avoidance may be a particularly fruitful area of assessment given its prominence in theories of anxiety; the centrality of techniques to address avoidance in the treatment of anxiety disorders (i.e., exposure); and the fact that it may be a particularly observable, measureable, and accessible target for assessment and intervention (Barlow, 2002, Beidel et al., 2000, Clark, 1999, Davis and Ollendick, 2005, Foa and Kozak, 1986, Hayes et al., 1996, Kendall et al., 2005, Marks, 1969, Mowrer, 1960, Rapee, 2002 and Salcioglu et al., 2007). Specifically, one of the earliest and most persistent models of anxiety indicates the role of avoidance in negatively reinforcing anxious arousal and cognition, thus maintaining anxiety disorders (Mowrer). Even in children with generalized anxiety disorder (GAD), arguably the most cognitive of the anxiety disorders, avoidance in the form of worry is thought to play a central role in maintaining anxiety (for review see Mineka & Zinbarg, 2006). Additionally, there is evidence that avoidance in children may be further complicated by the involvement of parents. Parental reinforcement of avoidance (e.g., promoting avoidant coping strategies or consoling in times of anxious avoidance) may contribute to the development of anxiety disorders (Dadds, Barrett, Rapee, & Ryan, 1996). For example, when parents help children to avoid or escape from feared situations, often referred to as parental accommodation, anxiety symptoms worsen and children frequently become more impaired ( Benito and Freeman, 2011, Storch et al., 2007 and Storch et al., 2010). Thus, it is particularly important to assess avoidance from both the child’s and the parents’ perspective. Despite the centrality of avoidance in models of childhood anxiety disorders, the amount of direct evidence supporting the role of behavioral avoidance in the development, maintenance, and treatment of childhood anxiety disorders is limited by the lack of convenient measures to assess this construct in children. Inspection of the three primary measures of childhood anxiety disorders (per Muris, Merckelbach, Ollendick, King, & Bogie, 2002)—the Spence Children’s Anxiety Scale (SCAS; Spence, 1998), the Multidimensional Anxiety Scale for Children (MASC; March, 1997), and the Screen for Child Anxiety Related Emotional Disorders (SCARED; Birmaher et al., 1997)—reveals few items assessing avoidance. The majority of the items cover somatic/emotional symptoms (66%, SCAS; 51%, MASC; 54%, SCARED), such as “I feel scared when I have to take a test,” or cognitive/worry symptoms (21%, SCAS; 10%, MASC; 23%, SCARED), such as “I worry about things.” Each measure, particularly the MASC, includes behavioral items (13%, SCAS; 38%, MASC; 15%, SCARED) covering a wide variety of actions, such as compulsive rituals, rule following, and vigilance. However, only the MASC contains items directly referring to avoidance (i.e., “avoid” or “stay away”) and these three items are spread across two scales and intermingled with other items. McCathie and Spence (1991) adapted the Revised Fear Survey Schedule for Children (Ollendick, 1983) to create the Fear Frequency and Avoidance Survey Schedule for Children, which assesses the impact of specific fears, including avoidance. However, this measure is lengthy and did not successfully disentangle avoidance from the affective components of anxiety. In terms of domain-specific scales, there is at least one measure designed to independently assess anxious cognitions [the Children’s Automatic Thoughts Scale (Schniering & Rapee, 2002) and somatic symptom (the State-Trait Anxiety Inventory for Children (STAIC; Spielberger, 1973)]. However, existing measures that include avoidance subscales tend to be specific to a single disorder [e.g., Social Anxiety Scale for Children–Revised (SASC-R; La Greca, 1999), Mobility Inventory for Agoraphobia (Chambless, Caputo, Jasin, Gracely, & Williams, 1985)]. As such, a measure specifically capturing behavioral avoidance broadly applicable to anxiety disorders would be a strong complement to the existing measures of somatic and cognitive symptoms. The most common method of measuring avoidance in children is through behavioral approach tests (BATs), which are laboratory tasks that involve creating an environment in which to present the individual’s fear and measuring the individual’s approach toward that feared item. These tasks, most commonly used for children and adults with specific phobias, involve asking an individual to approach an object (e.g., a spider) and measuring the physical distance they accomplish toward it (e.g., Field et al., 2008 and Klein et al., 2011). Variations of BATs have been used with social phobia (e.g., Beidel, et al., 2000) and obsessive-compulsive disorder (e.g., Najmi, Tobin, & Amir, 2012). Although BATs are sensitive to change and can be useful for guiding treatment (Barlow, 2002, Barrett et al., 2003, Craske et al., 1988 and McGlynn, 1988), they are limited by the range of situations that can feasibly be assessed, are often impractical for clinical use, and are typically unstandardized (Barrett et al., 2003). Specifically, a clinician would need to have a wide variety of stimuli (e.g., different animals, social interactions, sources of contamination, public places) immediately available, as well as a standardized method for measuring the degree of avoidance that indicated psychopathology. Other widely used measures of anxiety symptoms, such as structured interviews or questionnaires (e.g., Silverman and Albano, 1996 and Spence, 1998), include questions relating to avoidance but do not include separate avoidance scales. In addition to convenience, questionnaires have other advantages over laboratory tasks. Because they ask the reporter to reflect on behavior over time and in a variety of situations, questionnaires can be more reliable and can provide a more complete assessment of the behavior than a one-time laboratory-based task. Given the importance of multi-informant report for childhood behavioral assessment (see Haynes & O’Brien, 2000), the current project sought to create and validate child- and parent-report measures of behavioral avoidance related to childhood anxiety disorders. The development of a measure to specifically assess behavioral avoidance has the potential to elucidate the role of behavioral avoidance in the development and maintenance of childhood anxiety disorders, better identify children at risk for developing anxiety disorders, and enhance our understanding of the mechanism of treatment. It is hypothesized that a measure of avoidance will positively correlate with anxiety symptoms, dysfunction related to anxiety, and avoidance specific to social phobia. (Social phobia was chosen because the measure includes one of the only existing questionnaire scales of behavioral avoidance.) Additionally, it is predicted that elevated scores on the avoidance measure will predict worsening of anxiety symptoms over time and that scores will be greater in a clinical sample of anxious children compared to a community sample.