Thinking about worry: Investigation of the cognitive components of worry in children

Metacognitive Transmission Between Parents and Children in the Context of Anxiety Disorders

One in ten children is affected by an anxiety disorder. Current state of research shows that transgenerational transmission as well as positive (POS) and negative (NEG) metacognitive beliefs are relevant in the context of anxiety disorders in youth. We investigated whether transgenerational transmission is also evident in conjunction with POS and NEG and cross-sectionally surveyed POS, NEG, anxiety symptoms and worry in 8-16-year-old children and adolescents with anxiety disorders (n = 71) and non-clinical controls (n = 40) and one of their parents. Our results revealed significant transgenerational correlations for NEG in both samples, and for POS in the non-clinical sample only. Mediation analysis showed that children's NEG did at least partly mediate the relationship between parents' NEG and children's anxiety and worry. Children's and parents' POS did not correlate in either sample with children's anxiety and worry. Further research on the transgenerational transmission of metacognition and longitudinal data is needed.

Relationships between metacognitive beliefs and anxiety and depression in children and adolescents: A meta-analysis

BACKGROUND

As hypothesized in the Self-Regulatory Executive Function (S-REF) model, metacognitive beliefs are associated with anxiety and depression in adults. An important question is the extent to which such effects are present in children and adolescents, with the implication that the model may also apply to young people. The aim of this meta-analysis was to synthesize results on the nature and magnitude of associations between metacognitive beliefs and anxiety and depression in children and adolescents.

METHODS

Systematic searches were conducted to identify studies that investigated: (1) group differences in metacognitive beliefs in clinical compared to non-clinical samples or (2) correlations between metacognitive beliefs and symptoms of anxiety and depression.

RESULTS

Forty papers were identified comprising a total sample of 9,887 participants aged 7-18 years. Meta-analyses revealed that clinical samples endorsed significantly elevated metacognitive beliefs on four out of the five domains measured (i.e., negative beliefs about worry, cognitive confidence, need for control, and cognitive self-consciousness, with the only exception being positive beliefs about worry) compared to non-clinical samples with a small to large effect (Hedges' gs = 0.45-1.22). Moreover, all five domains of metacognitive beliefs were significantly and positively correlated with symptoms of anxiety and depression of a small to large effect (rs = .24-.53). Negative beliefs about worry showed the strongest relationship with clinical status and the magnitude of symptoms.

LIMITATIONS

The number of studies did not allow for an evaluation of metacognitive beliefs at a disorder-specific level.

CONCLUSIONS

In line with the S-REF model, our findings provide evidence of robust cross-sectional relationships between metacognitions and both anxiety and depression in childhood and adolescence.

Intolerance of Uncertainty in Pediatric Chronic Pain: Dyadic Relationships Between Youth and Parents

The current study used a dyadic analytic approach (actor-partner interdependence models) to assess the stability and interrelationships of intolerance of uncertainty (IU) among a cohort of youth with chronic pain and their parents (n = 156 dyads). Relationships between parent and youth IU, parent and youth pain interference, and parent and youth internalizing mental health symptoms were examined. At baseline and follow-up, youth and parents completed psychometrically-sound questionnaires to assess their respective IU, pain characteristics, and clinical outcomes (pain interference, anxiety, depressive, and posttraumatic stress symptoms). Our findings support the construct stability of IU over time, as well as intrapersonal (ie, actor) effects of IU on follow-up youth pain interference and mental health symptoms and parents' mental health symptoms (but not parent pain interference). There were no interpersonal (ie, partner) effects over time between youth and parent IU or between youth and parent IU and pain interference or mental health symptoms. These findings align with previous research evidencing IU as a transdiagnostic risk factor for a range of mental health concerns and extend previous findings by showing the stability of parent and youth IU over time and its potential predictive relevance to outcomes in a clinical sample of youth with chronic pain. PERSPECTIVE: This article presents dyadic analyses assessing intrapersonal and interpersonal associations between intolerance of uncertainty (IU) and pain and mental health symptoms in youth with chronic pain and their parents. Analyses evidenced short-term construct stability of IU and intrapersonal (but not interpersonal) effects of IU on pain and mental health symptoms.

Thinking about worry: A systematic review and meta-analysis on the assessment of metacognitions in children and adolescents

BACKGROUND

The metacognitive model of generalized anxiety disorder identifies three forms of metacognition: Positive metacognitive beliefs about worry (POS), negative metacognitive beliefs about worry (NEG), and meta-worry. Though this model was originally developed relying on adult samples, it has since been applied to children and youth in different studies, and results mostly support its validity for this group. As the roles of POS, meta-worry, and age-effects do not appear to be fully clarified for children and adolescents yet, an integration of studies on children and adolescents and the metacognitive model is both timely and worthwhile.

AIM

To summarize the current research on relationships, age-effects, and measurements for POS, NEG, and meta-worry in childhood and youth.

METHODS

We carried out a literature search in the electronic databases PsycINFO, PubMed, PSYNDEX, and ERIC in 2017 and updated in 2020. Empirical research in German or English language on metacognition was included with child and adolescent samples diagnosed with anxiety disorders or healthy controls if POS, NEG, or meta-worry were measured. Studies were included for meta-analysis if they reported correlations between these metacognitions and anxiety or worry. Consensus rating for eligibility was done for 20.89% of full-texts with 90.32% agreement. Risk of bias was assessed with the appraisal tool for cross-sectional studies and consensus rating of appraisal tool for cross-sectional studies for 20.83% of included studies attaining agreement of intraclass correlation = 0.898. Overall, correlations between metacognitions, anxiety and worry were calculated with RevMan 5.4.1, assuming random-effects models. Meta-regressions with mean age as the covariate were performed via the online tool MetaMar 2.7.0. PROSPERO-ID: CRD42018078852.

RESULTS

Overall, k = 763 records and k = 78 additional records were identified. Of those, k = 48 studies with 12839 participants were included and of those, k = 24 studies were included for meta-analysis. Most studies showed consistent NEG correlations with worry and anxiety, as well as higher values for clinical than for non-clinical samples. POS findings were less consistent. Meta-analysis revealed large effects for NEG correlating with worry and anxiety, small to medium effects for POS correlating with worry and anxiety, as well as small to medium effects for POS correlating with NEG. Meta-regressions did not reveal mean age as a significant covariate. Meta-worry was assessed in only one study. We identified eight questionnaires and one interview-format that assess metacognition about worry in children and adolescents.

CONCLUSION

POS and NEG are measurable from the age of seven upwards and correlate with anxiety and worry without influences by age. Meta-worry requires further investigation.

National Parent Survey 2017: Worries, hopes, and child well-being

Sociopolitical events impact population health; parents' perspective of such events crosses demographics, geography, and generations. We elicited changes in U.S. parents' hopes and worries for their children 1 year after the 2016 election via an online survey of school climate, discrimination against child, family health care and security, and macrolevel/future concerns (e.g., environment, postsecondary options). Among n = 1189 respondents, national security (39%), the environment (30.5%), and "continued place in America" (25.7%) were most worrisome. In general linear mixed models, employment buffered against social and material stressors such as discrimination (odds ratio [OR] = 0.67; 95% confidence interval [CI] = 0.49-0.92), and family health care/security (OR = 0.62; 95% CI = 0.45-0.86) while being of a dominant religion and ethnicity buffered future macrolevel (Christianity, OR = 70; 95% CI = 0.54-0.92/non-Hispanic, OR = 59; 95% CI = 0.39-0.90) and existential "continued place in America" (Christianity, OR = 69; 95% CI = 0.51-0.94/non-Hispanic, OR = 56; 95% CI = 0.36-0.88) worries. Qualitative comments underscored macrolevel worries. Parents represent a unique vantage for gauging how sociopolitical events impact health and well-being.

Days of worry: Emotional intelligence and social support mediate worry in the COVID-19 pandemic

This study tested a model accounting for worries among 275 adults during the height of the COVID-19 pandemic in Israel. The main hypothesis posited that psychological and instrumental social support will mediate the association between emotional intelligence and worry, controlling for the level of exposure to the virus risk and demographics. The results showed that social support mediated the above association: social support showed a negative association with worries while instrumental support showed a positive one. The results are discussed in light of existing findings and theories.

How do anxious children attempt to regulate worry? Results from a qualitative study with an experimental manipulation

OBJECTIVE

The objective of this study was to explore how anxiety-disordered children attempt to regulate their worry.

DESIGN

An experimental manipulation was applied, followed by a qualitative interview.

METHODS

Thirty children aged 7-13 were enrolled in this study. Each child was presented with a black mystery box, was told that shortly he/she would have to feel what was inside the box, and was then left alone for 4 min, prior to commencing the task. The purpose of the experimental manipulation was to induce slight levels of worry in the child, so that he/she could better report on worry regulation strategies. Afterwards, an interview about how the child had regulated worry during the experimental manipulation and in everyday life was undertaken. The interviews were coded using thematic analysis.

RESULTS

Five main themes were uncovered. These were (1) internal regulation of worry, for example, thinking about something else and self-reassurance talk, (2) external regulation of worry, for example, behavioural avoidance and distraction, (3) perceived effect of strategies, (4) shifting between strategies, and (5) absence of a strategy.

CONCLUSIONS

Our results demonstrate that anxious children use a variety of behavioural and cognitive strategies to regulate worry. They use these strategies in combination, they generally perceive them as ineffective, and they sometimes do not report any strategy for attempting to regulate their worry. These results indicate that clinicians should be curious about which strategies anxious children use to regulate their worry, how these strategies interact with each other, and how they are implemented by the child.

PRACTITIONER POINTS

Using an experimental manipulation followed by an interview, this study sought to investigate how anxious children seek to regulate their worries. Anxious children attempt to regulate their worry with use of behavioural regulation strategies, such as avoidance and distraction, and with use of cognitive regulation strategies, including thinking about something else, self-reassurance talk, and thought suppression. Sometimes, however, anxious children are not able to report a regulation strategy for a specific worry episode, suggesting that they may not always have a strategy or that they lack the introspective ability to report what they did. Clinicians should be aware that anxious children may use internal (cognitive) regulation strategies while at the same time using behavioural regulation strategies, such as avoidance.

Intolerance of uncertainty in youth: Psychometrics of the Intolerance of Uncertainty Index-A for Children

Intolerance of uncertainty (IU) is a cognitive vulnerability for pathological anxiety. The current study adapted the Intolerance of Uncertainty Index-A for Children (IUI-A-C), and created a single-item Intolerance of Uncertainty Clinician-Rated Index (IUCR), both of which assess a youth's general inability to endure uncertainty. Psychometric properties of these two measures were evaluated. Participants were 146 youth aged 7-17 years seeking treatment for anxiety. The IUI-A-C evidenced individual item performance (i.e., correlations between each item and the total remainder score > .40, ps <.001), internal consistency, convergent validity with the IUCR and self-report measures of anxiety and functional impairment, divergent validity with ADHD severity, and retest reliability with a mean interval of over four weeks. The IUCR also evidenced convergent validity with the IUI-A-C and self-report measures of anxiety and functional impairment and divergent validity with ADHD severity. The IUI-A-C predicted composite principal diagnosis severity but did not predict composite GAD diagnosis severity. The IUI-A-C and IUCR have utility as measures of IU in youth. The role of IU in specific anxiety disorders and future research are discussed.

A Cognitive Model of Pathological Worry in Children and Adolescents: A Systematic Review

Worry is common in children and adolescents, yet some youth experience excessive worries that persist over time and cause significant distress. Whilst the literature on worry and generalised anxiety disorder (GAD) in adults is well established, relatively less is known about the cognitive mechanisms underlying child and adolescent worry. An influential cognitive model of adult pathological worry (Hirsch and Matthews in Behav Res Therapy 50:636–646, 10.1016/j.brat.2012.06.007, 2012) proposes that negative information-processing biases, reduced executive functions, and verbal worry are critical in the aetiology of GAD in adults. The current systematic review investigated whether this cognitive model of worry could be extended to understand child and adolescent worry. Following a systematic search of the literature and screening for eligibility, 30 studies were identified. Evidence indicates that negative information-processing biases and reduced executive functions play an important role in worry and GAD in children and adolescents. However, evidence that children and adolescents experience verbal worry is inconclusive. Building upon Hirsch and Matthews' cognitive model (Behav Res Therapy 50:636–646, 10.1016/j.brat.2012.06.007, 2012), we propose a model of child and adolescent worry to provide a guiding framework for future research. We conclude that cognitive models of worry should incorporate a developmental framework in order to provide greater insight into the mechanisms uniquely associated with worry in children and adolescents and help to identify the cognitive processes to target for early interventions and treatments.

The Metacognitions Questionnaire and Its Derivatives in Children and Adolescents: A Systematic Review of Psychometric Properties

Background: The Metacognitions Questionnaire (MCQ) and its derivatives have been instrumental in research examining the Self-Regulatory Executive Function Model in adults. Studies testing whether findings are applicable to children and adolescents have been increasing and several different measures adapting the MCQ for younger populations have been developed. The current study aimed to systematically review the psychometric properties of MCQ measures or derivatives used in young people (aged 18 or less), to help assess current findings in this population and to guide future research in this growing area of investigation. Method: Systematic searches were carried out on PubMed and PsycINFO of studies published up to June 2018. Additional studies were identified through Google Scholar and article references. Validity, reliability, range and responsiveness of measures were examined as well as analyses of age and gender differences on scores. Results: Forty-five articles were identified. The total sample consisted of 7,803 children and adolescents (6,922 non-clinical, 881 clinical) aged 7-18. Studies used one of seven versions of the questionnaire, five adapted from the MCQ for younger populations: (1) The Metacognitions Questionnaire-Adolescent version; (2) The Metacognitions Questionnaire-Child version; (3) The Metacognitions Questionnaire-Child Version-Revised; (4) The Metacognitions Questionnaire-Child-30; and (5) The Metacognitions Questionnaire-65 Positive Beliefs Scale Revised; and two adult versions used without adaptation: (1) The Metacognitions Questionnaire-30 and (2) The Cognitive Self Consciousness Scale-Expanded. The validity and reliability of the Metacognitions Questionnaire-Adolescent version had the most extensive support. Other questionnaires had either mixed psychometrics or promising initial findings but more limited data. Conclusions: It is recommended that studies using adolescents (age 12-18) consider using the Metacognitions Questionnaire-Adolescent version. Based on initial data, it is suggested studies using younger populations should consider the Metacognitions Questionnaire-Child-30 but further psychometric research into this and other measures is needed.

A Preliminary Investigation of Cognitive Features Associated With Worry Among African American Youth

Although knowledge of the cognitive factors that place children at risk for worry has grown, little is known about these processes within African American youth. The present study investigated cognitive factors associated with worry in a sample of 47 African American children, ages 8 to 13. Participants completed self-report measures of worry, intolerance of uncertainty, positive and negative beliefs about worry, and negative problem orientation. Results supported the hypothesis that cognitive factors demonstrated significant positive associations with worry. Based on a model predicting worry from all cognitive factors, negative beliefs about worry emerged as the only individual predictor. This is the first study to examine cognitive factors associated with worry in an African American sample of children and provides initial support for the applicability of these cognitive factors in future examinations of worry within this population. Future research should continue to explore cognitive as well as other factors that predispose African America children to worry.

A systematic review of the role of parents in the development of anxious cognitions in children

Anxious cognitions and parental behavior are important in the development of child anxiety. The current review aims to appraise the literature on the relationship between parental factors and chid anxious cognitions. Online database searches of PsycInfo, Scopus, ProQuest Dissertations and Web of Science were systematically searched using key terms related to 'parent', 'child', 'anxiety' and 'cognitions'. Included studies (N = 13) were quality assessed and study findings were appraised in line with cognitive behavioral frameworks of the parental pathways to the development of anxious cognitions in children. Reviewed studies confirmed that parental factors have a role in the development of their children's anxious cognitions by modelling fearful responses, reducing their child's autonomy, and indirectly via their own expectations about their child. Limitations of the literature are considered, including issues of measurement. Future research should consider multi-modal assessment of parental factors and examine parental behavior and child anxious cognitions in the context of real-life threatening events.

Intolerance of Uncertainty, anxiety, and worry in children and adolescents: A meta-analysis

BACKGROUND

Intolerance of uncertainty (IU) has been implicated in the development and maintenance of worry and anxiety in adults and there is an increasing interest in the role that IU may play in anxiety and worry in children and adolescents.

METHOD

We conducted a systematic review and meta-analysis to summarize existing research on IU with regard to anxiety and worry in young people, and to provide a context for considering future directions in this area of research. The systematic review yielded 31 studies that investigated the association of IU with either anxiety or worry in children and adolescents.

RESULTS

The meta-analysis showed that IU accounted for 36.00% of the variance in anxiety and 39.69% in worry. Due to the low number of studies and methodological factors, examination of potential moderators was limited; and of those we were able to examine, none were significant moderators of either association. Most studies relied on questionnaire measures of IU, anxiety, and worry; all studies except one were cross-sectional and the majority of the studies were with community samples.

LIMITATIONS

The inclusion of eligible studies was limited to studies published in English that focus on typically developing children.

CONCLUSIONS

There is a strong association between IU and both anxiety and worry in young people therefore IU may be a relevant construct to target in treatment. To extend the existing literature, future research should incorporate longitudinal and experimental designs, and include samples of young people who have a range of anxiety disorders.