Está en la página 1de 7

Child and Adolescent Mental Health Volume **, No. *, 2018, pp. **–** doi:10.1111/camh.

12269

The direct and indirect effect of attachment


insecurity and negative parental behavior on anxiety
in clinically anxious children: it’s down to dad
Sonja Breinholst, Marie Tolstrup & Barbara Hoff Esbjørn
Center for Anxiety, Department of Psychology, University of Copenhagen, Oester Farimagsgade 2A, 1353 Copenhagen,
Denmark. E-mail: Sonja.breinholst@psy.ku.dk

Background: Theoretically, insecure attachment and negative parental behaviors are risk factors for childhood
anxiety. However, few empirical studies have examined their relative contribution including differences
between mothers and fathers. To date, only one study has examined a mediational model including these fac-
tors, albeit in a nonclinical sample. Method: This study ameliorates this limitation by investigating direct and
indirect relations between maternal and paternal attachment and behaviors, and clinical anxiety in children
(mean age 9.6 years). The study recruited 54 families. Anxiety symptoms were measured by the Spielberger
State-trait Inventory for Children, attachment relationships by the Security Scale, and parental behaviors using
the Rearing Behavior Questionnaire. Results: Neither insecure attachment relationship with mother nor
maternal negative behavior was a significant predictor of anxiety in children. However, insecure attachment
to father accounted for a significant proportion of variance in anxiety, and also fully mediated the relationship
between paternal rejection and anxiety. Conclusions: Our findings highlight the importance of assessing the
relative contribution of risk factors and the importance of including fathers when investigating the develop-
ment and maintenance of childhood anxiety.

Key Practitioner Message

• Fathers and mothers might play different roles regarding childhood anxiety.
• Paternal variables might need to be included in assessment of childhood anxiety and anxiety case formulation.
• Fathers might need to be included in the treatment of anxiety.

Keywords: Anxiety; parent-child interaction; attachment; mediation

approval, and responsiveness. It’s hypothesized that


Introduction
parental rejection may cause children to develop nega-
Anxiety is a highly prevalent and persistent psychiatric tive assumptions about themselves and their competen-
disorder in childhood and adolescence (Kessler & Wang, cies as well as negative/threatening expectations of the
2008). Approximately 10% of all children meet the diag- world, increasing the risk of developing anxiety (Cres-
nostic criteria for an anxiety disorder during childhood well, Murray, Stacey, & Cooper, 2011). Opposite to par-
(Copeland, Angold, Shanahan, & Costello, 2014). Conse- ental rejection, parental warmth and acceptance
quences of anxiety include negative influences on fami- behaviors signal that assistance is available, reducing
lies (Lebowitz et al., 2013) and societal financial burdens fear and anxiety (B€ogels & Brechman-Toussaint, 2006).
(Bodden, Dirksen, & B€ ogels, 2008), making identifying Theoretically, parental overprotection (rather than
risk factors leading to anxiety pivotal. This study investi- autonomy granting) minimizes experiences with unex-
gates the unique influence and mutual relation between pected or difficult situations, reducing children’s devel-
two risk factors well-established in the literature: inse- opment of self-efficacy and feelings of mastery and
cure attachment and negative parental behaviors. It also control. This is hypothesized to increase children’s
assesses these in relation to mothers and fathers, perceptions of threat and danger (B€ ogels & Brechman-
respectively. Toussaint, 2006). Finally, psychological control is
characterized by excessive parental vigilance and intru-
Negative parental behaviors and anxiety sion. Its interference with children’s experiences of
Risk factors such as negative parental behaviors have control is also considered to induce fear and anxiety
received theoretical and empirical attention. Rejection, (Thirlwall & Creswell, 2010).
overprotection, and psychological control are theoreti- Theoretical associations between negative parental
cally associated with childhood anxiety disorders behaviors and anxiety in children and adolescents have
(McLeod, Wood, & Avny, 2011). Parental rejection is been supported by three empirical reviews (McLeod,
characterized by reduced levels of parental warmth, Wood, & Weisz, 2007; Van der Bruggen, Stams, &

© 2018 Association for Child and Adolescent Mental Health.


Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA
2 Sonja Breinholst, Marie Tolstrup & Barbara Hoff Esbjørn Child Adolesc Ment Health 2018; *(*): **–**

B€ogels, 2008; Waite, Whittington, & Creswell, 2014). only, whereas Colonnesi et al. (2011), and Brumariu
Van der Bruggen et al. (2008) found moderate effect and Kerns (2010) also included questionnaires, projec-
sizes for negative parental behaviors, with the strongest tive task and interviews in children up to 18 years of age.
for overprotection (d = .93), psychological control Groh et al. (2012), and Madigan et al. (2013) only
(d = .52), rejection (d = .41). This study corroborated included mother-child attachment studies, while Colon-
previous findings of parental control as more strongly nesi et al. (2011), and Brumariu and Kerns (2010)
associated with anxiety than parental rejection (McLeod included studies on attachment to both parents, peers
et al., 2007). Waite et al. (2014) found consistent evi- and attachment figures in general. The association
dence for an association between anxiety and parental between internalizing symptoms and attachment in the
control in primarily nonclinical adolescent samples, meta-analysis by Groh et al. (2012) was smaller than
whereas evidence for a relationship between anxiety and previously reported (d = .15) and was explained by inse-
parental rejection was less consistent. Despite theoreti- cure avoidant attachment (d = .17). Madigan et al.
cal emphasis on negative parental behaviors as an (2013) corroborated this finding. Both studies contradict
important contributing factor in childhood anxiety, the the findings by Brumariu and Kerns (2010), who
overall association between childhood anxiety and nega- reported that the effect of avoidant attachment disap-
tive parental behaviors is modest, explaining only 4% of peared when analyses included disorganized attach-
variance in anxiety (McLeod et al., 2007). Consequently, ment. A final limitation in the reviews is that most
attention has turned to other factors within the participants included in the analyses were nonclinically
parent-child relationship, for example, child-parent anxious, for example, four of 61 studies in the analysis
attachment. by Madigan et al. (2013), and six studies out of 55 in the
review by Brumariu and Kerns (2010) were clinical,
Insecure attachment and anxiety disorder thus, potentially reducing the validity of findings for clin-
According to attachment theory, the quality of the par- ically anxious children. Inconsistent findings and
ent-child attachment relationship more likely impacts diverse methods therefore warrant further investigation.
the psychological development of the child (Bowlby,
1973; ¸ Cassidy & Berlin, 1994). Children’s susceptibility The interaction between negative parental
to fear and anxiety is hypothesized to depend on the behaviors and attachment
physical/emotional availability and sensitivity of their Parental behaviors in the child’s first year will lead to the
caregiver (Bowlby, 1973). A secure attachment relation- child displaying a specific pattern in the attachment
ship is considered pivotal for a healthy development. It is behavior (Cassidy & Berlin, 1994). Hence, parental dis-
formed by caregivers’ consistent sensitivity to children’s play of neglectful behavior may cause children to either
attachment behaviors, serving as a secure base from withdraw or increase attempts at proximity to the par-
which children can explore their surroundings, and a ent. Both behaviors indicate insecure attachment (Van
safe haven to which children can return when dis- IJzendoorn, 1995). Similarly, parental over-control may
tressed. However, in insecure attachment relationships, reduce openness to children’s needs and emotional
the caregiver is unable or unwilling to consistently and expressions, triggering dependency from the child due to
sensitively react to these behaviors. The absence of the low self-efficacy or withdrawal in order to gain control.
caregiver’s availability may cause chronic anxiety Theoretically associated with insecure attachment, this
(Bowlby, 1973; Cassidy & Berlin, 1994). Thus, insecure may be an antecedent to anxiety (Van IJzendoorn,
attachment is supposedly associated with fear and anxi- 1995). Empirical testing of these suggestions requires a
ety (Bosquet & Egeland, 2006; Bowlby, 1958). model testing the indirect relationship between attach-
Recently, empirical evidence for the theoretical link ment relationship and parental behavior.
between insecure attachment and anxiety has been eval- Although theoretical models of childhood anxiety
uated in four reviews (Brumariu & Kerns, 2010; Colon- often include multiple risk factors, few studies have
nesi et al., 2011; Groh, Roisman, van IJzendoorn, empirically investigated relative contributions of nega-
Bakermans-Kranenburg, & Fearon, 2012; Madigan, tive parental behaviors and insecure attachment. One
Atkinson, Laurin, & Benoit, 2013). An association study investigated the influence of different risk factors
between insecure attachment and higher anxiety levels like maternal behavior, mother-child attachment and
in children and adolescents was found, but results were maternal anxiety on the development of anxiety disor-
mixed and inconsistent. These inconsistencies might be ders in 202 (102 behaviorally inhibited, 100 behaviorally
due to methodological differences such as which type of noninhibited) children aged 4–9 years (Hudson & Dodd,
insecure attachment was included, and how attachment 2012). Mother-child attachment was measured with the
was measured. Furthermore, the reviews differed with preschool version of the Strange Situation Procedure
regard to whether anxiety symptoms, anxiety disorders, (Cassidy & Marvin, 1992) and maternal behavior
or internalizing disorders were investigated. Last, differ- through a speech preparation task, a 5-Min Speech
ent age groups were investigated in the different reviews. Sample (Hudson & Rapee, 2001), and the Parent Protec-
Colonnesi et al. (2011) assessed only secure and inse- tion Scale (Thomasgard, Metz, Edelbrock, & Shonkoff,
cure ambivalent attachment and anxiety symptoms in 1995). The authors reported that maternal over-involve-
children, finding effect sizes to be moderate (r = .30). ment – but not negativity or insecure attachment – at
Brumariu and Kerns (2010), Groh et al. (2012), and 4 years of age, significantly predicted anxiety diagnoses
Madigan et al. (2013) investigated ambivalent, avoidant, at 9 years of age. No moderation effects were found
and disorganized attachment and internalizing symp- between these variables (Hudson & Dodd, 2012). A limi-
toms, not anxiety symptoms specifically. Groh et al. tation was that fathers were not included. This is very
(2012), as well as Madigan et al. (2013) measured common in those types of studies. Since fathers are as
attachment in infancy through observational studies pivotal attachment figures as mothers (Lieberman,

© 2018 Association for Child and Adolescent Mental Health.


doi:10.1111/camh.12269 Parental behavior, attachment and childhood anxiety 3

Doyle, & Markiewicz, 1999), this study cannot exclude maternal and paternal variables and their influence on
attachment with fathers as a potential mechanism influ- childhood anxiety disorders.
encing anxiety development.
In general, few studies on attachment as well as on
anxiety include fathers. The limited number of studies Method
on father-child attachment, and their rather broad cate- Participants, procedure, and ethical considerations
gorization of potential associated problems in children Fifty-nine families were eligible for the present cross-sectional
(e.g., depression, externalizing disorders), have resulted study. Five declined; they were offered nonresearch-related
in these studies being excluded from two out of four treatment elsewhere. Ultimately, 54 families participated. Of
reviews on the topic (Groh et al., 2012; Madigan et al., these, 28 (51.9%) were boys. Mean age was 9 years, 6 months
2013). Results of the few studies on attachment and the (SD = 1 year, 7 months). All the families were self-referred but
some of them were informed about the clinic and encouraged to
broader child problem behavior, which have included
attend by their general practitioners, school psychologists, tea-
fathers alongside mothers, are mixed. For example, a cher etc. All the children met diagnostic criteria for either gener-
study by Fagot (1995) found nothing particularly regard- alized anxiety disorder, separation anxiety disorder, specific
ing fathers. Rothbaum, Rosen, Pott, and Beatty (1995) phobia or social phobia as the primary diagnosis using Anxiety
found that only maternal acceptance and maternal Disorders Interview Schedule for Children – Child and Parent
attachment security was significant for child wellbeing, versions ADIS C/P (Silverman, Albano, & Barlow, 1996). Chil-
and that only maternal attachment predicted later prob- dren’s full-scale IQ needed to be higher than or equal to 70
(WISC-III; Wechsler, 1991), and at least one parent was a native
lems in children. Most of the studies including fathers Danish speaker. Written consents from the parents were
alongside mothers, report on a combined parental received.
result, or fail to find anything special regarding the dif- The families participated in intake assessment procedures
ference between the parents (please see the reviews by from March 2009 to September 2010 at the University Clinic,
Groh et al., 2012; Madigan et al., 2013 for further where all the questionnaires were administered by trained clini-
details). cal psychologists or clinically trained students receiving ongo-
Overall, the paucity of literature calls for empirical ing supervision. Families received cognitive behavioral therapy
free of charge.
studies on interactions between parental behaviors and
Children met criteria for these primary diagnoses: Separation
attachment including fathers. To our knowledge, the Disorder 46.3% (25), Generalized Anxiety Disorder 22.2% (12),
only study examining this with both parents is a study Specific Phobia 25.9% (14), and Social Phobia 5.3% (3). Of the
using a sample of nonclinical children (Breinholst, 54 children, 41 (75.9%) met criteria for a secondary diagnosis,
Esbjørn, & Reinholdt-Dunne, 2015). The study tested and 20 (37%) met criteria for a tertiary diagnosis, most of which
whether insecure attachment mediated the association were comorbid anxiety disorders. The participating families
between negative parental behaviors and anxiety. were rather homogenous, primarily Caucasian, well-educated
with 13% of the sample having an household income of
Results indicated that insecure attachment and negative
300,000–5000,000 Danish Kroner, 22.2% of the sample having
parental behaviors accounted for a small and unique a household income of 500,000–750,000 Danish Kroner, and
proportion of variance in anxiety symptoms. In contrast 38.9 earning more than 750,000 Danish Kroner, hence, a gen-
to the findings by Hudson and Dodd (2012), examining erally low risk sample.
the distinctive influence of mothers’ and fathers’ behav- The study complied with all ethical standards regarding
iors revealed significance only in maternal behavior. The research conducted using children and was approved by the
relation between anxiety symptoms and both maternal Institutional Ethical Review Board, Department of Psychology,
University of Copenhagen. Written informed consent from all
rejection and maternal psychological control was par-
participating parents – and assent from all participating chil-
tially mediated by the child’s report of insecure attach- dren – was obtained.
ment to the mother (Breinholst et al., 2015). However,
methodological differences between studies may help
explain this difference.
Questionnaires
Questionnaires were translated to Danish using a translation/
This study aimed to expand existing empirical knowl-
back-translation procedure (Brislin, 1970). Original question-
edge regarding the unique contribution of insecure paren- naires were translated to Danish by a staff member, after which
tal attachment and negative behavior on childhood a second staff member, who hadn’t read the original question-
anxiety disorders and the interaction between these risk naire, performed the back-translation. The back-translations
factors regarding mothers and fathers, given the field is were approved by the original questionnaire authors.
relatively unexplored but still important in understand-
ing/preventing anxiety in children and understanding State-trait anxiety inventory for children. The trait scale of
their social world, which includes influences from both Spielberger State-Trait Inventory for Children, STAICtrait (Spiel-
berger, Edwards, Lushene, Montuori, & Platzek, 1973) is a
parents. The study attempted to reproduce findings by
widely used self-report measure of anxiety. Children rated 20
Breinholst et al. (2015) in a clinical sample, so that items on a 3-point scale. Higher scores indicated higher anxiety
insight may be found concerning anxiety disorders; prior levels. An example item is “I feel like crying.” The child reports
studies have only been conducted using normative sam- whether this happens “almost never,” “sometimes,” or “often.”
ples, and consequently aren’t applicable to anxiety dis- The STAIC displays sound psychometric properties with regard
orders. Based on the literature, these hypotheses were to both reliability and validity (Spielberger et al., 1973). In our
assessed: (a) attachment insecurity and negative paren- study, Cronbach’s alpha was .91.
tal behaviors each account for a significant and unique
proportion of variance in childhood anxiety, (b) attach- Security scale. The Security Scale (SEC) measures children’s
perception of the attachment relationship with their mother or
ment insecurity mediates the relation between negative
father in middle childhood (Kerns, Aspelmeier, Gentzler, & Gra-
parental behaviors and anxiety disorders in children. bill, 2001; Kerns, Klepac, & Cole, 1996). It is a self-report mea-
Due to contradictory findings in previous studies, no sure consisting of 15 items scored on a 4-point scale. Higher
hypotheses were made regarding differences between scores indicate greater security. The child is presented with

© 2018 Association for Child and Adolescent Mental Health.


4 Sonja Breinholst, Marie Tolstrup & Barbara Hoff Esbjørn Child Adolesc Ment Health 2018; *(*): **–**

information about two types of children: “Some kids find it easy analyses were only conducted on paternal variables as
to trust their mom” BUT “Other kids find it difficult to trust their these yielded a significant model fit in the previous anal-
mom.” The child decides which of the statements is most like ysis. Analyses were conducted separately for each pater-
them. Second, the child indicates whether the statement is “very
much true” or “somewhat true.” The scale holds good psycho-
nal RBQ scale (rejection, overprotection, psychological
metric properties with good internal consistency and test-retest control). OLS regressions were used to assess the extent
reliability (Kerns et al., 2001). In this study, children’s percep- to which the criteria for mediation in the causal step
tions of their attachment to both their mother and father were strategy were met (Baron & Kenny, 1986).
assessed separately, which has been done in prior studies of The hypothesis was partially supported; the causal
self-competence (Diener, Russell, Behunin, & Wong, 2007). In step analysis revealed no mediation regarding paternal
our study, Cronbach’s alpha was .76 and .92 for mothers and
overprotection and psychological control. However, a full
fathers, respectively.
mediational effect of insecure attachment was found
between paternal rejection and anxiety, as the signifi-
Rearing behavior questionnaire. The Rearing Behavior cant association between anxiety disorder and paternal
Questionnaire (RBQ) measures perceptions of parental rearing
rejection disappeared when accounting for insecure
behaviors. In this study, we assessed mothers’ and fathers’ per-
ceptions of their rearing behaviors independently (B€ ogels & attachment to father (Figure 1).
Melick, 2004). It consists of 33 items loading on three subscales:
psychological control (“I am always telling my child how it should
behave”), granting of autonomy versus overprotection (“I encour-
Discussion
age my child to make its own decisions” vs. “I am overprotective of This study set out to replicate findings from a previous
my child”), and acceptance versus rejection (“I enjoy being with
study investigating the direct and indirect relationship
my child” vs. “I do not like to have my child around the house”).
Each item is rated on a 4-point scale ranging from “not true at all” between parent-child attachment and negative parental
to “very true.” Psychometric properties are reported as satisfac- behaviors separately for mothers and fathers in a clini-
tory (B€
ogels & Melick, 2004; Verhoeven, B€ ogels, & van der Brug- cally anxious sample.
gen, 2012). In our study, Cronbach’s alpha for the subscales We hypothesized that attachment insecurity and neg-
(psychological control, granting of autonomy vs. overprotection ative parental behaviors would directly and indirectly
and acceptance vs. rejection) were .81, .54, and .69, respectively, influence clinically anxious children’s self-reported anxi-
for mothers and .85, .75, and .39 for fathers.
ety levels. These hypotheses were partially supported.
The maternal variables model did not yield a significant
Results model fit. Child-reported attachment to mother and
mothers’ report of their behavior did not significantly
SPSS version 22 software was used for analysis. We exam- explain the variance in child-reported anxiety. The lack
ined age and gender effects on our target variables (STAIC, of significant influence of maternal insecure attachment
SEC and all RBQ). A median split between younger chil- and negative behavior on child anxiety matches findings
dren (7–9 years) and older children (10–12 years) was per- by Hudson and Dodd (2012), although the lack of influ-
formed prior to independent sample t-tests. We found no ence of overprotection contradicts their findings. In our
age difference for anxiety, though we found older children study, only the paternal variables model was significant.
reported more secure attachment to mothers than younger This contrasts with findings by Breinholst et al. (2015).
children (M (SD) = 3.4 (0.3) vs. 3.1 (0.5); t (49) = 3.4, They found insecure attachment to mothers but not
p = .002). Fathers of older children also reported being fathers, as well as perceptions of negative maternal but
more overprotective than fathers of younger children (M not paternal behavior, contributed significantly to child
(SD) = 39 (4.6) vs. 36 (3.2); t (37) = 2.4; p = .021). Age anxiety. Our study also found that child-reported inse-
was therefore included in the main analyses. No significant cure attachment to father fully mediated between
gender differences were found. fathers’ report on rejection and child-reported anxiety
levels.
Contribution of attachment and parental We offer two explanations for the difference in results
behaviors to child anxiety between the current and earlier study: first, it may be
Two multiple regression analyses were run to test our due strictly to methodological differences regarding the
hypothesis that attachment and parental behaviors informant level. Our study applied multiple informants
would account for a unique proportion of variance in with parental self-report for parental behaviors and child
child anxiety. One model included maternal variables, report on anxiety and attachment to minimize the risk of
the other paternal variables. Age, SEC, and RBQ sub- single-informant bias. The previous study applied only
scales were entered as independent variables with STAIC
as the dependent variable. The hypothesis was partially
supported; the maternal variables model did not provide
a significant model fit, but, the paternal variables model Insecure
was significant and explained 28.9% of the variance in a = .36* Attachment b = –.42*
child anxiety. Child-reported attachment to fathers was
the only significant contributor (B = 5.6; SE B = 2.2;
b = .39; p = .02). Rejection Anxiety

Insecure attachment as a mediator between c = .38* (c ´ = –.16)


negative parental behaviors and anxiety
Our second hypothesis was that attachment insecurity Figure 1. Standardized regression coefficients for the relation-
would mediate the relation between negative parental ship between rejection and anxiety as mediated by attachment
behaviors and anxiety disorders in children. Mediational insecurity

© 2018 Association for Child and Adolescent Mental Health.


doi:10.1111/camh.12269 Parental behavior, attachment and childhood anxiety 5

child report on all variables (Breinholst et al., 2015). It is der Bruggen et al., 2008). This prohibits direct compar-
possible that the magnitude of associations was inflated ison of effects of maternal and paternal variables.
because of shared method variance. Findings may also Overall, these limitations and the findings from this
have been influenced by the level of anxiety. Clinically study highlight the need for further studies assessing
anxious children endorse cognitive distortions that may the unique roles of mothers and fathers concerning both
contribute to perceiving, for instance, their parent’s attachment and parental behaviors, as well as their
behavior overly negatively (Van Brakel, Muris, B€ ogels, & reciprocal relationship and potential interactions.
Thomassen, 2006). Furthermore, many studies have
reported low agreement between parental and child Strengths and limitations
report on parenting behavior (B€ ogels & Melick, 2004; Our study provides new insight on the relationship
B€ogels, van Oosten, Muris, & Smulders, 2001), with chil- between two well-established risk factors for child-
dren reporting lower levels of positive parental behav- hood anxiety disorders. Strengths of the study are
iors. Therefore, maternal rearing behavior might not the use of a clinical sample of anxious children and
have been as negative and crucial for clinical anxiety the inclusion/comparison of the role of mothers and
levels, as suggested by the previous study. Future fathers, seeking to bridge the gap in the present
research could apply partner reports instead of child body of research. However, our study is not without
and parental reports on parental behaviors to solve this limitations, the most critical being the cross-sectional
issue. B€ ogels and Melick (2004) have argued for this design. This prohibits us from offering conclusions
solution as spouses’ reports on each other were more regarding cause and effect in relationships of attach-
highly correlated with children’s reports than parental ment, parental behaviors, and child anxiety. Future
self-report. studies should include longitudinal designs or experi-
The second explanation is that our study recruited a mental manipulations before our model may be con-
sample of clinically anxious children, whereas the firmed. An additional limitation is our relatively small
previous study recruited typically developing youth. Sev- sample; it limits our statistical power and examina-
eral studies have found that maternal behavior and tion of complicated models (Fritz & MacKinnon,
mother-child attachment predicts anxiety symptoms in 2007), as well as reliance on self-report measures.
non-clinical samples (Brown & Whiteside, 2008; Muris, Future studies should incorporate multiple infor-
Meesters, Merckelbach, & H€ ulsenbeck, 2000), in line mants on the same variables. The measures used
with Breinholst et al. (2015). In relation to clinical anxi- were also chosen specifically to accommodate the age
ety levels, Hudson and Dodd (2012) found that maternal and developmental phase of the children, which
overprotection but neither negativity nor mother-child might make it difficult to generalize into other ages
attachment predicted anxiety disorders. This finding is and phases. Furthermore, it is a typical two-parent,
partly corroborated by our study, where child attach- middle-class Caucasian sample; caution must be
ment to mother did not predict clinical anxiety. However, taken before generalizing results to other samples.
as we included fathers, significant results emerged with Low alphas on some of the RBQ constructs are
father-child attachment predicting clinical levels of anxi- another concern. A minor limitation concerning mea-
ety. The different results may indicate that parents offer sures is that attachment was assessed using a
different contributions depending on their child’s level of dimensional rather than categorical approach. It was
difficulties; a suggestion the literature supports (B€ ogels therefore impossible to distinguish between different
& Phares, 2008). It is possible that biology and society classifications of insecure attachment regarding anxi-
render parents to treat their children differently, result- ety. However, some attachment categories are rela-
ing in mothers and fathers promoting different risk and tively rare; very large samples are required to prevent
protective factors for children (B€ ogels & Phares, 2008). reducing power. Therefore, the majority of studies
However, it’s critical to note that very few studies exam- within this field report results on secure versus inse-
ine the role of paternal behaviors, and even fewer exam- cure attachment (Lubiewska & van de Vijver, 2013).
ine children’s attachment to fathers. In a meta-analysis Overall, limitations and findings from this study high-
of observational studies of parental behaviors in child light the need for further studies assessing the unique
anxiety, only one of 22 studies included fathers, and only roles of mothers and fathers concerning both attach-
eight included mixed father/mother samples, with an ment and parental behaviors, as well as their reciprocal
overrepresentation of mothers (Van der Bruggen et al., relationship and potential interactions. The implications
2008). Some of the few studies including fathers show for doing this are that fathers and mothers might play
that paternal behavior – especially control – may influ- different roles regarding childhood anxiety and, based
ence confidence of socially anxious children, moreso on this knowledge, paternal variables might need to be
than maternal behavior. However this is reversed in included in the assessment of childhood anxiety and
samples of normal or low socially anxious children, with case formulation, as well as that fathers might need to
maternal behavior being more influential than paternal be included in the treatment of anxiety.
(e.g., B€
ogels, Stevens, & Majdandzic, 2011; Greco & Mor-
ris, 2002). Findings that there are differences between Acknowledgement
maternal and paternal influence depending on the clini-
cal anxiety level is similar to findings in this study. How- This study was made possible by funding from Helse Founda-
ever, a further problem is that most studies on fathers tion (Grant number 2008A438) and Egmont Foundation (Grant
number 831‐2205). The authors would like to thank participat-
don’t distinguish between children with clinical anxiety, ing children and parents, as well as all students and staff at
children with anxiety symptoms, and children display- Center for Anxiety who helped to collect data. They are also
ing internalizing disorders (B€ ogels & Phares, 2008; Van grateful for statistical guidance from Associate Professor

© 2018 Association for Child and Adolescent Mental Health.


6 Sonja Breinholst, Marie Tolstrup & Barbara Hoff Esbjørn Child Adolesc Ment Health 2018; *(*): **–**

Mathias Gondam. The authors have declared that they have no Diener, M. L., Russell, I. A., Behunin, M. G., & Wong, M. S.
competing or potential conflicts of interest. (2007). Attachment to mother and fathers during middle
childhood. Associations with child gender, grade, and compe-
tence. Social Development, 17, 84–101.
References Fagot, B. I. (1995). Classification of problem behaviors in young
children: A comparison of four systems. Journal of Applied
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator
developmental Psychology, 16, 95–106.
variable distinction in social psychological research: Concep-
Fritz, M. S., & MacKinnon, D. P. (2007). Required sample size to
tual, strategic, and statistical considerations. Journal of Per-
detect the mediated effect. Psychological science, 18, 233–
sonality and Social Psychology, 51, 1173–1182.
239.
Bodden, D. H., Dirksen, C. D., & B€ ogels, S. M. (2008). Societal
Greco, L. A., & Morris, T. L. (2002). Paternal child-rearing style
burden of clinically anxious youth referred for treatment: A
and child social anxiety: Investigation of child perceptions
cost-of-illness study. Journal of Abnormal Child Psychology,
and actual father behavior. Journal of Psychopathology and
36, 487–497.
Behavioral Assessment, 24, 259–267.
B€
ogels, S. M., & Brechman-Toussaint, M. L. (2006). Family
Groh, A. M., Roisman, G. I., van IJzendoorn, M. H., Bakermans-
issues in child anxiety: Attachment, family functioning, par-
Kranenburg, M. J., & Fearon, R. (2012). The significance of
ental rearing and beliefs. Clinical Psychology Review, 26,
insecure and disorganized attachment for children’s internal-
834–856.
izing symptoms: A meta-analytic study. Child Development,
B€
ogels, S. M., & Melick, M. V. (2004). The relationship between
83, 591–610.
child-report, parent self-report, and partner report of per-
Hudson, J. L., & Dodd, H. F. (2012). Informing early interven-
ceived parental rearing behaviors and anxiety in children and
tion: Preschool predictors of anxiety disorders in middle
parents. Personality and Individual Differences, 37, 1583–
childhood. PLoS ONE, 7, e42359.
1596.
Hudson, J. L., & Rapee, R. M. (2001). Parent–child interactions
B€
ogels, S., & Phares, V. (2008). Fathers’ role in the etiology, pre-
and anxiety disorders: An observational study. Behaviour
vention and treatment of child anxiety: A review and new
Research Theraphy, 39, 1411–1427.
model. Clinical Psychology Review, 28, 539–558.
Kerns, K. A., Aspelmeier, J. E., Gentzler, A. L., & Grabill, C. M.
B€
ogels, S., Stevens, J., & Majdandzi c, M. (2011). Parenting and
(2001). Parent-child attachment and monitoring in middle
social anxiety: Fathers’ versus mothers’ influence on their
childhood. Journal of Family Psychology, 15, 69–81.
children’s anxiety in ambiguous social situations. Journal of
Kerns, K. A., Klepac, L., & Cole, A. (1996). Peer relationships
Child Psychology and Psychiatry, 52, 599–606.
and preadolescents’ perceptions of security in the child-
B€
ogels, S. M., van Oosten, A., Muris, P., & Smulders, D. (2001).
mother relationship. Developmental Psychology, 32, 457–
Familial correlates of social anxiety in children and
466.
adolescents. Behaviour Research and Therapy, 39, 273–
Kessler, R. C., & Wang, P. S. (2008). The descriptive epidemi-
287.
ologv of commonly occurring mental disorders in the United
Bosquet, M., & Egeland, B. (2006). The development and main-
States.
tenance of anxiety symptoms from infancy through adoles-
Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L.,
cence in a longitudinal sample. Development and
Dauser, C., Warnick, E., . . . & Vitulano, L. A. (2013). Family
Psychopathology, 18, 517–550.
accommodation in pediatric anxiety disorders. Depression
Bowlby, J. (1958). The nature of the child’s tie to his mother.
and Anxiety, 30, 47–54.
International Journal of Psycho-Analysis, 39, 350–373.
Lieberman, M., Doyle, A. B., & Markiewicz, D. (1999). Develop-
Bowlby, J. (1973). Attachment and Loss. Vol. 1: Attachmen. Lon-
mental patterns in security of attachment to mother and
don: Basic Books.
father in late childhood and early adolescence: Associations
Breinholst, S., Esbjørn, B. H., & Reinholdt-Dunne, M. L. (2015).
with peer relations. Child development, 70, 202–213.
Effects of attachment and rearing behavior on anxiety in nor-
Lubiewska, K., & van de Vijver, F. J. R. (2013). Attachment types
mal developing youth: A mediational study. Personality and
or dimensions: Evidence from adult attachment scale across
Individual Differences, 81, 155–161.
three generations. Symposium at 6th International Attach-
Brislin, R. W. (1970). Back-translation for cross-cultural
ment Conference, 2013, Pavia, Italy.
research. Journal of cross-cultural psychology, 1, 185–216.
Madigan, S., Atkinson, L., Laurin, K., & Benoit, D. (2013).
Brown, A. M., & Whiteside, S. P. (2008). Relations among per-
Attachment and internalizing behavior in early childhood: A
ceived parental rearing behaviors, attachment style, and
meta-analysis. Developmental Psychology, 49, 672.
worry in anxious children. Journal of Anxiety Disorders, 22,
McLeod, B. D., Wood, J. J., & Avny, S. B. (2011). Parenting and
263–272.
child anxiety disorders. In D. McKay & E. A. Storch (Eds.),
Brumariu, L. E., & Kerns, K. A. (2010). Parent-child attachment
Handbook of child and adolescent anxiety disorders (pp. 213–
and internalizing symptoms in childhood and adolescence: A
228). New York: Springer.
review of empirical findings and future directions. Develop-
McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007). Examin-
ment and Psychopathology, 22, 177–203.
ing the association between parenting and childhood anx-
Cassidy, J., & Berlin, L. J. (1994). The insecure/ambivalent pat-
iety: A meta-analysis. Clinical Psychology Review, 27,
tern of attachment: Theory and research. Child development,
155–172.
65, 971–991.
Muris, P., Meesters, C., Merckelbach, H., & H€ ulsenbeck, P.
Cassidy, J., & Marvin, R. S. (1992). Attachment organization in
(2000). Worry in children is related to perceived parental rear-
preschool children: Procedures and coding manual. University
ing and attachment. Behaviour Research and Therapy, 38,
of Virginia: Unpulished manuscript.
487–497.
Colonnesi, C., Draijer, E. M., Stams, G. J., Van der Bruggen, C.
Rothbaum, F., Rosen, K. S., Pott, M., & Beatty, M. (1995). Early
O., Bogels, S. M., & Noom, M. J. (2011). The relation between
parent-child relationships and later problem behavior: A lon-
insecure attachment and child anxiety: A meta-analytic
gitudinal study. Merill-palmer Quarterly, 41, No. 2, 133–151.
review. Journal of Clinical Child and Adolescent Psychology,
Silverman, W. K., Albano, A. M., & Barlow, D. H. (1996). Manual
40, 630–645.
for the ADIS-IV-C/P. New York: Psychological Corporation.
Copeland, W. E., Angold, A., Shanahan, L., & Costello, E. J.
Spielberger, C. D., Edwards, C. D., Lushene, R. E., Montuori, J.,
(2014). Longitudinal patterns of anxiety from childhood to
& Platzek, D. (1973). State-Trait Anxiety Inventory for Children:
adulthood: The great smoky mountains study. Journal of the
Professional manual. Redwood City, CA: Mind Garden, Inc.
American Academy of Child & Adolescent Psychiatry, 53, 21–
Thirlwall, K., & Creswell, C. (2010). The impact of maternal con-
33.
trol on children’s anxious cognitions, behaviours and affect:
Creswell, C., Murray, L., Stacey, J., & Cooper, P. (2011). Parent-
An experimental study. Behaviour Research and Therapy, 48,
ing and child anxiety. Anxiety disorders in children and
1041–1046.
adolescents, 2, 299–322.

© 2018 Association for Child and Adolescent Mental Health.


doi:10.1111/camh.12269 Parental behavior, attachment and childhood anxiety 7

Thomasgard, M., Metz, W., Edelbrock, C., & Shonkoff, J. P. analysis on the predictive validity of the Adult Attachment
(1995). Parent-child relationship disorders: I. Parental over- Interview. Psychological bulletin, 117, 387–403.
protection and the development of the Parent Protection Verhoeven, M., B€ogels, S. M., & van der Bruggen, C. C. (2012).
Scale. Developmental Behavior Pediatrics, 16, 244–250. Unique roles of mothering and fathering in child anxiety;
Van Brakel, A. M., Muris, P., B€ogels, S. M., & Thomassen, C. moderation by childs age and gender. Journal of Child and
(2006). A multifactorial model for the etiology of anxiety in Family Studies, 21, 331–343.
non-clinical adolescents: Main and interactive effects of Waite, P., Whittington, L., & Creswell, C. (2014). Parent-child
behavioral inhibition, attachment and parental rearing. Jour- interactions and adolescent anxiety: a systematic review. Psy-
nal of Child and Family Studies, 15, 568–578. chopathology Review, 1, 51–76.
Van der Bruggen, C. O., Stams, G. J. J., & B€
ogels, S. M. (2008). Wechsler, D. (1991). WISC-III: Wechsler intelligence scale for
Research review: The relation between child and parent anxi- children. San Antonio, TX: Psychological Corporation.
ety and parental control: A meta-analytic review. Journal of
Child Psychology and Psychiatry, 49, 1257–1269.
Van IJzendoorn, M. (1995). Adult attachment representations, Accepted for publication: 6 February 2018
parental responsiveness, and infant attachment: A meta-

© 2018 Association for Child and Adolescent Mental Health.