the pathogenesis of childhood anxiety disorders: considerations from a developmental psychopathology...

8/13/2019 The pathogenesis of childhood anxiety disorders: Considerations from a developmental psychopathology perspective by Peter Muris (2006) - an article

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International Journal of Behavioral Development

2006, 30 (1), 511

http://www.sagepublications.com

2006 The International Society for the

Study of Behavioural Development

DOI: 10.1177/0165025406059967

Introduction

Anxiety phenomena such as fear, worry and scary dreams are

common in childhood (Muris, Merckelbach, Gadet, &

Moulaert, 2000). In most cases, these phenomena are short-

lived and dissipate within a brief period of time (see Craske,

1997). Initially, this has led many child psychologists to the

faulty conclusion that childhood anxiety should not be taken

too seriously, and as a result the phenomenon received little

research attention. During the past decade, this opinion has

changed as researchers have increasingly demonstrated that a

substantial minority of children do suffer from such high

anxiety levels that a diagnosis of an anxiety disorder is clearly

warranted (Muris, Meesters, Merckelbach, Sermon, &

Zwakhalen, 1998; Muris, Merckelbach, Mayer, & Prins, 2000;

Muris, Merckelbach, Ollendick, King, & Bogie, 2001). In fact,

epidemiological studies have shown that anxiety disorders are

among the most prevalent forms of psychopathology in youths

(Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Ford,

Goodman, & Meltzer, 2003).Moreover, there is evidence indi-

cating that a significant proportion of childhood anxiety

disorders have a chronic course and, although they may change

form, even last into adulthood (Keller, Lavori, Wunder, Beard-

slee, & Schwartz, 1992; Last, Perrin, Hersen, & Kazdin,

1996).

The understanding that childhood anxiety should be

viewed as a clinically relevant phenomenon has yielded a host

of studies on the pathogenesis of excessive anxiety in childrenand adolescents. While the majority of this research has

focused on single factors, it has become clear that an under-

standing of the pathways by which childhood anxiety

disorders develop, persist and remit is likely to require

consideration of a wide range of influences and, most impor-

tantly, their potential for complex, dynamic, transformationalinteractions (i.e., transactions) across development (Vasey &

Dadds, 2001, p. 3). Clearly, this notion fits nicely with the

major tenets of the developmental psychopathology perspec-

tive (Cicchetti & Cohen, 1995), which imply that (a) most

forms of psychopathology are the result of multiple causal

influences; (b) both successful and unsuccessful adaptation

are important for understanding the origins of psycho-

pathology; and (c) psychopathology occurs in a developing

organism, which is of course particularly relevant in child-

hood and adolescence, when developmental changes are most

pronounced.

The present article summarizes the main evidence that has

accumulated on the etiology of childhood anxiety disorders

during the past two decades. First, a number of vulnerability

and risk factors that are thought to play a role in the

development and maintenance of childhood anxiety

disorders will be described. Then it will be argued that

protective factors also play an important role in the develop-

ment of pathological anxiety in vulnerable children. More

precisely, children who have the disposal over protective

mechanisms are able to cope successfully with anxiety-

provoking situations, whereas those without such protective

mechanisms are prone to developing high and persistent levels

of fear and anxiety. Next, factors will be discussed which are

thought to play a role in the maintenance of childhood

anxiety disorders. Following this, developmental issues that

are relevant for understanding the pathogenesis of childhoodanxiety will be considered. The article will end with a

discussion in which the information is integrated and linked

to the earlier mentioned developmental psychopathology

perspective. Finally, some directions for future research in this

area will be pointed out.

The pathogenesis of childhood anxiety disorders: Considerations froma developmental psychopathology perspective

Peter Muris

Erasmus University, Rotterdam, The Netherlands

Anxiety disorders are among the most prevalent psychiatric problems in children and adolescents.

The present article summarizes the main evidence that has accumulated on the pathogenesis of child-

hood anxiety disorders during the past two decades. Various risk and vulnerability factors (e.g.,

genetics, behavioral inhibition, disgust sensitivity, negative life events, family influences), protective

factors (e.g., effortful control, perceived control), and maintaining factors (e.g., avoidance, cognitive

biases) will be discussed. The information will be described in terms of a developmental psycho-

pathology perspective, which assumes that (a) most forms of psychopathology are the result of

multiple causal influences; (b) both successful and unsuccessful adaptation are important for under-

standing the origins of psychopathology; and (c) psychopathology occurs in a developing organism.

Correspondence should be sent to Professor Peter Muris, Institute of

Psychology, Erasmus University Rotterdam, Burgemeester Oudlaan

50, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands; e-mail:

[email protected]


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Vulnerability and risk factors

Genetics

Behavioral-genetic research has yielded clear support for the

genetic transmission of childhood anxiety disorders. For

example, Stevenson, Batten, and Cherner (1992) obtained fear

scores in monozygotic and dizygotic twins aged between 8 and

16 years.Results showed that a twins level of fearfulness could

be predicted from a co-twins score. Also, the frequency offears was more similar in monozygotic than in dizygotic twin

pairs, yielding a significant heritability estimate of .29. Several

other studies have examined the genetic contribution to

anxiety phenomena in children and adolescents (Eley et al.,

2003; Legrand, McGue, & Iacono, 1999; Topolski et al.,

1997). These studies have provided further support for the

heritability of childhood anxiety. Genetic influences were

particularly prominent in the case of trait anxiety, with heri-

tability estimates as high as .50.

It is important to note that the genetic vulnerability to

anxiety disorders is represented in general and specific factors

(e.g., Taylor, 1998).The general genetic factor acts as a vulner-

ability factor to a wide range of anxiety disorders, while specific

factors only predispose to certain types of anxiety disorders.

The general genetic factor may constitute the biological

substrate of what is typically referred to as neuroticism,

which may manifest itself in children at a behavioral level as

behavioral inhibition (Craske, 1997).

Behavioral inhibition

Behavioral inhibition is a temperamental trait characterized by

the tendency to be unusually shy and to react with fear and

withdrawal in situations that are novel and/or unfamiliar

(Kagan, 1994). Research has shown that behaviorally inhibited

children and adolescents are at increased risk for developing

anxiety disorders. Noteworthy in this regard is a 3-year longi-

tudinal study by Biederman et al. (1993) who found that

children initially identified as behaviorally inhibited were

subsequently more likely to develop anxiety disorders

compared to control children (i.e., children who at study onset

were not classified as behaviorally inhibited). Further support

for a link between behavioral inhibition and anxiety in older

youths comes from a series of studies conducted by Muris and

colleagues (Muris, Meesters, & Spinder, 2003; Muris, Merck-

elbach, Schmidt, Gadet, & Bogie, 2001; Muris, Merckelbach,

Wessel, & Van de Ven, 1999; Van Brakel, Muris, & Bgels,

2004). In these studies, children, adolescents, and their parents

completed a questionnaire measuring childrens behaviorally

inhibited temperament. Results showed that children who wereidentified as high on behavioral inhibition displayed higher

levels of anxiety symptoms compared to children who were

classified as low on behavioral inhibition. All the above-

mentioned studies suggest that behavioral inhibition is associ-

ated with the development of a broad range of anxiety

symptoms and anxiety disorders (for reviews of studies on

behavioral inhibition and anxiety see Biederman, Rosenbaum,

Chaloff, & Kagan, 1995; Turner, Beidel, & Wolff, 1996).

As to the biological correlates of behavioral inhibition,

relevant parameters have been identified by Schmidt, Fox,

Rubin, and Sternberg (1997). These researchers noted that

behaviorally inhibited children exhibit relatively high morning

levels of the stress hormone cortisol.They speculated that high

levels of cortisol may sensitize subcortical arousal circuits (e.g.,

amygdala, hypothalamus) and this would make children more

prone to develop serious anxiety symptoms. Interestingly, work

on psychophysiological parameters that tap subcortical fear

responsivity (e.g., the eye blink startle reflex; Vrana, Spence,

& Lang, 1988) supports such an interpretation. For example,

Grillon, Dierker, and Merikangas (1997) measured startle

reflexes in children with a parental history of an anxiety

disorder (who often meet the criteria of behavioral inhibition)

and control children. It was found that the startle magnitude

was relatively elevated in children of parents with an anxiety

disorder. This is in agreement with the notion that anxiety-

prone (i.e., behaviorally inhibited) children have hyper-

excitable subcortical circuits that may promote fear and

anxiety.

Disgust sensitivity

Disgust sensitivity is a genetically based personality trait that

should be viewed as a specific vulnerability factor as it is only

relevant for certain types of anxiety disorders (Muris, Merckel-

bach, Schmidt, & Tierney, 1999). More precisely, disgust

sensitivity seems to be involved in the pathogenesis of child-hood phobias, and in particular animal phobias. Evidence for

this notion comes from a study by De Jong et al. (1997) who

assessed fear of spiders, disgust sensitivity, and spiders

disgust-evoking status in spider-phobic girls, non-phobic

controls, and the parents of both groups of children. Phobic

girls were tested twice, before and after behavioral treatment.

The idea that disgust is an important aspect of spider phobia

was supported by the following findings. First of all, compared

with non-phobic girls, spider-phobic girls exhibited higher

levels of disgust sensitivity and considered spiders per se as

more disgusting. Second, after treatment, the reduction in

spider fear was closely paralleled by a decline in spiders

disgust-evoking status. Third, mothers of spider-phobic girls

also more frequently attributed a high disgust-evoking status

to spiders, a finding that either points in the direction of

modeling experiences or the genetic transmission of disgust

sensitivity.

In a follow-up study by De Jong and Muris (2002), spider-

phobic and non-phobic girls were confronted with vignettes

describing potential encounters with spiders. Both groups of

girls then rated the subjective probability of spiders entering

their private living space, their tendency to approach and make

physical contact, and the probability of spiders doing physical

harm. In addition, all girls indicated their eagerness to eat a

favorite food item after a spider had contacted it. Results

showed that phobic girls reported relatively high ratings

concerning spiders tendency to enter their private living spaceand to approach and make physical contact, and low ratings of

eagerness to eat a spider-contaminated food item. This finding

seems to indicate that spider phobia results from the conver-

gence of disgust and the probability of physical contact. All

these results indicate that disgust plays a role in this type of

phobia.

Negative learning experiences

Besides general (e.g., neuroticism, behavioral inhibition) and

specific (e.g., disgust sensitivity) genetically based vulnerabil-

ity factors, it is clear that negative learning experiences also

play an important role in the pathogenesis of childhood anxiety

6 MURIS / THE PATHOGENESIS OF CHILDHOOD ANXIETY


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disorders. A useful framework for discussing these learning

experiences is Rachmans (1991) three-pathways theory.

Briefly, this theory posits that anxiety phenomena are acquired

in three ways: (a) classical conditioning, (b) observational

learning or modeling, and (c) negative information trans-

mission.

In their famous experiment, but questionable from an

ethical point of view, Watson and Rayner (1920) demonstrated

that classical conditioning is indeed involved in the develop-

ment of certain childhood anxiety disorders. They introduced

a white rat to an 11-month-old boy, Little Albert, who initially

showed no fear of the animal and appeared to want to play

with it. However, whenever Albert approached the rat, the

experimenters produced a loud noise (the UCS) by striking a

steel bar behind his head, causing him great fright (the UCR).

After five such experiences, Albert became very upset (the CR)

by the sight of the white rat, even without the presentation of

the loud noise. Obviously, the fear originally associated with

the loud noise had come to be elicited by the previously neutral

stimulus, the white rat (now the CS). Although some phobias

seem to be acquired by classical conditioning, it should be

borne in mind that current views of this learning mechanism

are more complicated and stress the importance of cognitiveprocesses (such as stimulus evaluation; Dadds, Davey, & Field,

2001).

Evidence for the role of observational learning in the origins

of childhood fear and anxiety was provided in an experimen-

tal study by Gerull and Rapee (2002). These authors investi-

gated the influence of modeling on the acquisition of fear and

avoidance toward novel, fear-relevant stimuli in a sample of

15- to 20-month-old toddlers. The toddlers were shown a

rubber snake and spider, which were alternately paired with

either negative or positive facial expressions by their mothers.

Both stimuli were presented after a brief delay, and fear and

avoidance reactions were assessed. Results clearly indicated

that children showed more fear and avoidance following

negative reactions from their mothers. Conversely, children

displayed less fear and more approach behavior when their

mothers responded positively to the stimuli.

Field, Argyrus, and Knowles (2001) carried out a prospec-

tive study on the role of negative information in the exacerba-

tion of childhood fear. Seven- to 9-year-old children received

either negative or positive information about an unknown

monster doll. Results showed that negative information signifi-

cantly increased childrens fear ratings, whereas after positive

information fear ratings slightly decreased. These results were

replicated by Muris, Bodden, Merckelbach, Ollendick, and

King (2003), who provided children with either negative or

positive information about an unknown, dog-like animal,

called the beast. This study demonstrated that information-induced fear effects endured over a 1-week follow-up period

and generalized to other stimuli, that is, children who became

more fearful of the beast after receiving negative information

also became more apprehensive of other dogs and predators.

Life events

Research has also found that there is a link between negative

life events such as parental divorce and death of significant

family members and childhood anxiety. For example, in a

recent study by Boer et al. (2002), anxiety-disordered children

were compared with non-clinical controls, and with their

nearest in age non-referred sibling on the number of parent-

reported stressful life events. Results indicated that anxiety-

disordered children differed significantly from healthy controls

in the number of negative life events reported by their parents

over their lifetime and the year preceding referral. Further-

more, anxiety-disordered children differed significantly from

their non-referred siblings in the number of negative life events.

Although Boer et al. also found some evidence indicating that

parents tended to appraise the impact of life events as more

negative for their anxious child than for their non-anxious

child, the conclusion that negative life events contribute to the

development of high levels of anxiety symptoms in youths was

still justified (see also Goodyer, Wright, & Altham, 1990).

Family factors

Family factors are also thought to be involved in the patho-

genesis of childhood anxiety disorders (e.g., Dadds & Roth,

2001). A factor that seems to be relevant in this context is

attachment.Research has, indeed, shown that early attachment

relationships are predictors of fear and anxiety in later child-

hood. For example, in their prospective study, Warren,

Huston, Egeland, and Sroufe (1997) examined whether

insecurely attached infants run greater risk for developinganxiety disorders than infants who are securely attached. At 12

months of age, infants were classified as either securely or

insecurely attached using the strange situation observation

procedure. When children reached 17.5 years of age, current

and past anxiety disorders were assessed by means of an inter-

view schedule. Results indicated that insecurely attached

children more frequently displayed anxiety disorders than

children who were securely attached (see also Muris, Meesters,

Van Melick, & Zwambag, 2001).

Other studies have examined the role of specific parental

rearing behaviors in the development of childhood anxiety. For

example, a number of studies focused on childrens perception

of their parents rearing behavior, and have reported signifi-

cant and positive relationships between anxious rearing,

parental control, and rejection, on the one hand, and anxiety

symptoms in youths, on the other hand (Grner, Muris, &

Merckelbach, 1999; Muris, Meesters, & Van Brakel, 2003;

Muris & Merckelbach, 1998).

Protective factors

Genetically based variables such as behavioral inhibition and

disgust sensitivity and other vulnerability and risk factors such

as negative learning experiences, stressful life events, and

adverse family factors will make children prone to develop

anxiety disorders. Fortunately, there are also protective influ-ences, which may serve to shield children and adolescents

against the development of an anxiety disorder. Although

several authors have carefully described the characteristics of

such resilience in children (Masten & Coatsworth, 1998), rela-

tively few attempts have been made to study protective factors

in relation to the development of anxiety problems in youths.

Effortful control

While behavioral inhibition is a temperament factor predispos-

ing to anxiety disorders, it is of interest to note that there are

also temperament variables that may buffer against the

emergence of such problems. These protective temperament

INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT, 2006, 30 (1), 511 7


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variables have been subsumed under the construct of effortful

control. Effortful control refers to regulative, executive func-

tioning-based processes, which include the focusing and

shifting of attention (i.e., attentional control) and the ability to

inhibit behavior when appropriate (i.e., inhibitory control;

Rothbart, Ellis, & Posner, 2004). While most research has

focused on the role of effortful control in the pathogenesis of

disruptive behavior disorders (e.g., Eisenberg et al., 2000),

several authors have recently noted that low levels of these

regulative temperament factors may also promote childrens

proneness to develop anxiety disorders (e.g., Lonigan &

Phillips, 2001; Muris, 2004).

A number of recent studies have examined the relation

between effortful control and anxiety symptoms in youths

(Meesters, Muris, & Van Rooijen, submitted; Muris, De Jong,

& Engelen, 2004; Muris, Meesters, & Rompelberg, sub-

mitted). Although these studies were cross-sectional in nature

and relied on non-clinical samples of children and adolescents,

results have indeed demonstrated that low levels of effortful

control are associated with high levels of anxiety symptoms in

youths of various ages. Further, some evidence emerged

showing that children are particularly prone to anxiety when

low levels of effortful control are combined with the presenceof certain vulnerability factors. For instance, the study by

Meesters et al. (submitted) demonstrated that low effortful

control was most strongly linked to anxiety in children with a

neurotic temperament.

Perceived control

According to Chorpita and Barlow (1998), there are clear indi-

vidual differences in perceived control that are formed as a

result of experiences during early childhood. More precisely,

early experiences with diminished control may foster a cogni-

tive style characterized by an increased probability of interpret-

ing and processing subsequent events as being out of ones

control, which may represent a psychological vulnerability for

anxiety. The other way around, early experiences of adequate

control may instill a cognitive style that is marked by certainty

about the ability to control ones environment, which may

serve as a buffer to anxiety. Support for these ideas comes from

studies showing that there is a negative link between perceived

control and symptoms of childhood anxiety. That is, children

who report high levels of perceived control generally display

lower levels of this negative emotion (e.g., Muris, Schouten,

Meesters, & Gijsbers, 2003; Weems, Silverman, Rapee, &

Pina, 2003). In passing, it should be mentioned that the litera-

ture lists several other protective factors that bear strong

resemblance to perceived control, such as self-esteem (Harter,

1993) and self-efficacy (Bandura, 1997), which are alsoinversely related to childhood anxiety (e.g., Muris, 2002;

Muris, Meesters, & Fijen, 2003).

Maintaining factors

Once children and adolescents have developed an anxiety

disorder, this condition is likely to be maintained, or even

intensified, by a variety of influences.The two-stage model of

Mowrer (1960) suggests that avoidance behavior is responsi-

ble for the maintenance of anxiety problems. More precisely,

avoidance would minimize direct and prolonged contact with

the fear-provoking stimulus or situation, and, hence, the

anxious child would not have the opportunity to learn that the

stimulus or situation is in fact harmless or safe. While the role

of avoidance behavior in the maintenance of anxiety disorders

seems self-evident (Ollendick, Vasey, & King, 2001), there are

also a number of cognitive distortions that promote continua-

tion of these psychopathological problems. Cognitive distor-

tions refer to cognitive processes that are biased and erroneous,

and therefore yield dysfunctional and maladaptive thoughts

and behaviors. Typically, in anxiety disorders, such distortions

reflect the chronic overactivity of schemas organized around

themes of danger and threat (Kendall, 1985).

Threat-perception biases

A good example of such cognitive distortion is interpretation

bias, which refers to anxious childrens tendency to dispropor-

tionally impose negative interpretations upon ambiguous situ-

ations. For example, in a study by Barrett, Rapee, Dadds, and

Ryan (1996), anxiety-disordered children and non-anxious

controls were confronted with ambiguous stories and

instructed to interpret them. Results indicated that anxiety-

disordered children were more likely to interpret ambiguous

situations in a threatening way compared to control children.Furthermore, it has been observed that in anxious children

even very minor threat cues may readily trigger subsequent

processing and consequently anxious responding, a phenom-

enon that has been labeled as Reduced Evidence for Danger

(RED) bias. Various studies have provided evidence for the

existence of RED bias in anxious children and adolescents

(e.g., Muris, Merckelbach, Schepers, & Meesters, 2003;

Muris, Rapee et al., 2003).The general outline of these studies

was as follows: Children were exposed to stories in which

ambiguous situations were described. They were told that

some of these stories were scary, i.e., these stories would have

a bad end, whereas other stories were not scary, i.e., these

stories would have a happy end. Children were instructed to

find out as quickly as possible whether the pertinent story was

scary or not scary. Stories were read aloud sentence by

sentence, and after each sentence children were asked whether

they thought that the story would be scary or not scary. Results

consistently indicated that highly anxious children needed to

hear fewer sentences before deciding a story to be threatening

compared to less anxious children.

Developmental issues

Research has shown that normal fear and anxiety follow a

predictable course: In infancy, children become fearful and

anxious of imaginary creatures (e.g., ghosts, monsters) andstimuli in their immediate environment, but as the child

matures these emotions begin to incorporate anticipatory

events and stimuli of an abstract nature (Gullone, 2000). It is

assumed that this developmental pattern of fear and anxiety

reflects everyday experiences and to an important extent is

mediated by childrens cognitive capacities (Marks, 1987).

Empirical evidence for this notion is, however, extremely

sparse. One exception is a study by Muris, Merckelbach,

Meesters, and Van den Brand (2002), who examined the

connection between cognitive development and worry.

Children were interviewed about the presence and content of

a personal worry. Furthermore, a worry elaboration score was

obtained by encouraging children to think up potential



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negative outcomes associated with a series of worry topics.

Finally, a number of Piagets (1970) conservation tasks were

administered in order to assess childrens level of cognitive

maturation. Results revealed a mediational model in which

increased age and, in its wake, cognitive development lead to

enhanced worry elaboration, which in turn increases the possi-

bility of a personal worry to emerge.The authors conclude that

worry becomes increasingly manifest in middle childhood

when children reach a certain level of cognitive maturation (see

also Vasey, Crnic, & Carter, 1994).

Another example involves a recent investigation by

Westenberg, Drewes, Goedhart, Siebelink, and Treffers

(2004). These researchers examined developmental patterns

in fears concerning physical danger and fears concerning

social evaluation in a large sample of children and adolescents.

In addition, participants level of sociocognitive maturation

was assessed. Results demonstrated that fears of physical

danger decreased with age, whereas fears concerning social

evaluation increased as children were older. Most importantly,

however, it was found that the age effect in social-evaluative

fears was entirely explained on the basis of developmental

differences in sociocognitive maturity. This led the authors to

the conclusion that the social fear and anxiety which frequentlyarise during adolescence are a corollary of sociocognitive

development.

Both studies seem to indicate that, in particular, cognitive

development plays a prominent role in the occurrence of

various normal anxiety phenomena, and may herald periods

in which vulnerable children are prone to develop high levels

of fear and anxiety or even anxiety disorders. Meanwhile, it is

also conceivable that greater cognitive capacity directly

promotes children and adolescents vulnerability to anxiety.

For example, according to the cognitive model, maladaptive

cognitions are the vehicle behind pathological anxiety (Beck &

Emery, 1985). More precisely, cognitive errors such as

catastrophizing (i.e., anticipating the worst possible outcome

for an event) lead to automatic negative thoughts, which guide

an individuals interpretation of internal and external events,

and eventually lead to feelings of anxiety and avoidance

behavior. It is generally assumed that such cognitive errors are

a function of childrens cognitive development (Alfano, Beidel,

& Turner, 2002), and there is indeed some recent evidence to

support this notion. Muris, Vermeer, and Horselenberg

(submitted) demonstrated that the catastrophic interpretation

of bodily sensations in most children occurs after the age of 7,

when they have reached Piagets concrete operational stage of

cognitive development.

Meanwhile, it should also be kept in mind that cognitive

development not only has a negative influence by enhancing

vulnerability to childhood anxiety, but it may also strengthenprotective mechanisms against this negative emotion. For

example, several studies have demonstrated that, under favor-

able circumstances, the increase of cognitive capacities may

also promote regulative processes such as perceived control,

effortful control, self-efficacy, self-esteem, and coping (Band &

Weisz, 1990; Daniels, 1993; Kochanska, Murray, & Harlan,

2000; Velder, 1985; Weisz, Southam-Gerow, & McCarty,

2001). Altogether, it is clear that developmental issues, such as

cognitive development, play a prominent role in the origins,

manifestation, and continuation of anxiety problems in

children and adolescents.

Discussion

During the past years, our knowledge of the factors that are

involved in the etiology of childhood anxiety disorders has

increased considerably. Not only a large number of vulnerabil-

ity factors have been identified, but we also have a good notion

of the protective influences that might play a role in the patho-

genesis of anxiety problems in youths. In the present article, I

summarized the evidence for the involvement of various

vulnerability, protective, and maintaining factors in the

development of anxiety disorders in children and adolescents.

As mentioned in the introduction, it is important to note that

these factors do not operate in isolation. Rather, we should

consider multifactorial models in which vulnerability and

protective factors interact with each other to produce an

adaptive or a maladaptive outcome (Craske, 1997; Manassis &

Bradley, 1994; Vasey & Dadds, 2001).

Clearly, this fits nicely with two of the major tenets of the

developmental psychopathology perspective. The first one

implies that mental disorders such as anxiety disorders are the

result of multiple causal influences. The second one pertains

to the fact that research of both successful and unsuccessful

adaptation is important for understanding the origins ofanxiety problems. That is, the study of unsuccessful adapta-

tion will primarily focus on vulnerability and risk factors,

whereas the investigation of successful adaptation will also call

attention to resilience and protective factors. The article also

stresses the importance of a third tenet of developmental

psychopathology, namely that developmental issues play an

important role in the pathogenesis of childhood anxiety. The

marked developmental changes during childhood and adoles-

cence seem to be involved in the manifestation of anxiety

phenomena and occasionally may promote vulnerability to

develop anxiety disorders (although such changes may also

strengthen protective mechanisms).

As mentioned earlier, most research on the etiology and

maintenance of childhood anxiety disorders has studied the

influence of isolated vulnerability and protective factors (see

Vasey & Dadds, 2001). As a result, we have little information

on the extent to which various factors overlap and play a

unique role in the pathogenesis of anxiety disorders.Moreover,

the precise dynamics between the various factors are far from

clear.While a number of recent studies have begun to examine

the additive and interactive effects of multiple factors in the

origins of childhood anxiety problems (e.g., Van Brakel,

Muris, Bgels, & Thomassen, submitted), it is obvious that

this issue requires more research attention.In particular, longi-

tudinal research including various vulnerability and protective

factors is greatly needed. Of course, such prospective studies

are not easy to conduct precisely because they are timeconsuming and difficult to get funded. However, only in this

way we will definitely learn more about the aetiological

antecedents of anxiety disorders in children and adolescents.

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