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R E V I E W P A P E R
Parental Contributions to Child Anxiety Sensitivity: A Review and Recommendations for Future Directions
Sarah E. Francis • Valerie Noël
Published online: 25 May 2010 � Springer Science+Business Media, LLC 2010
Abstract Anxiety sensitivity (AS) is defined as the fear of anxiety-related symptoms (e.g., a fast beating heart) and the consequences that may follow from these symptoms
(e.g., a heart attack). Recently, child AS has been examined in relation to parental AS and
parental anxiety to elucidate potential parental contributions. Given inconsistent findings to
date, this review was intended to identify parental factors that are significant contributors
to child AS. Two key findings from this review included the absence of a significant
relationship between parental anxiety and child AS and the determination that the parent–
child AS association is conditional upon the child reporter, the parent reporter, and the
specific dimensions of AS being tested. Recommendations for future directions include
examining specific facets of AS, studying parental contributions amongst anxiety-disor-
dered youth, and employing sufficiently large samples to allow for between child group
comparisons.
Keywords Anxiety sensitivity � Child � Adolescent � Parent � Transmission
Anxiety sensitivity (AS) is often defined as a fear of anxiety based primarily upon the
belief that the experience of anxiety symptoms is harmful for the individual [1–4].
Researchers have concluded that the construct of AS encompasses multiple components,
including being fearful of physical symptoms (such as a grumbling stomach or a fast
beating heart), concern about mental well being (such as losing one’s mind), and concerns
that others might notice symptoms of anxiety (such as trembling or appearing emotional)
[5–7]. For example, an individual with heightened levels of AS might be fearful of an
inability to concentrate on a task, and might perceive this lack of concentration as indic-
ative of ‘‘going crazy’’, whereas an individual with low AS might instead recognize that
difficulty concentrating often occurs when one is anxious or worried and is not a sign of
other harmful consequences.
S. E. Francis (&) � V. Noël Department of Psychology, Memorial University of Newfoundland, St. John’s, NL A1B 3X9, Canada e-mail: [email protected]
123
Child Psychiatry Hum Dev (2010) 41:595–613 DOI 10.1007/s10578-010-0190-5
Anxiety sensitivity has been significantly correlated with symptoms of anxiety in adult
[4, 8] and child populations [9]. Similarly, AS is a significant predictor of anxious symp-
tomatology and has been noted to act as a vulnerability factor with respect to the subsequent
development of an anxiety disorder [10–12]. Among both adults and children, AS is uniquely
predictive of anxiety symptoms, suggesting that AS is an important risk factor in the
development of anxiety among both children and adults [4, 9].
Similarly, among both youths and adults, support has been yielded for the notion that
AS is a construct unique from anxiety [13–19]. Specifically, several investigators, using
hierarchical regression analyses, have demonstrated that AS accounts for a significant
proportion of the variance in anxiety disorder diagnoses beyond that accounted for by
measures of trait anxiety alone [4, 19]. Such findings suggest that AS has predictive power
with respect to anxiety symptoms above and beyond that yielded by measures of trait
anxiety. More specifically, this research yields support for the notion that AS is a mea-
surable construct that is not only distinct from anxiety, but that possesses clinical utility in
the assessment and conceptualization of anxious symptomatology.
Adult twin-studies have suggested that although there is a heritable component to AS,
environmental factors also play a significant role in its development [20, 21]. The extent to
which genetic and environmental factors influence the presentation of AS, however, differs
across sex, as well as across the different facets of AS [21]. The notion that specific
learning experiences might differentially influence specific AS concerns [22], as well as
findings indicating that beliefs about the harmful nature of anxiety can be transmitted from
parent to child [23], suggests the importance of examining the role of parental contribu-
tions to child AS. However, amongst the studies to date that have tested the relationship
between parental AS or anxiety and child AS, little consensus appears to have emerged
with respect to the role parental anxiety-related variables might play in the risk for or later
development of child AS.
Specifically, several investigators have examined the contribution of parental AS to
child AS. These efforts have yielded mixed findings such that in some samples parental AS
is significantly related to child AS [23], whereas in others it is not [24, 25]. Moreover,
parental anxiety disorders generally do not appear to confer a risk upon the child of
experiencing heightened levels of AS [26, 27]. The absence of a demonstrable relationship
between parental anxiety and child AS suggests that parents who are themselves diagnosed
with an anxiety disorder do not transmit AS to the child. However, initial evidence has
suggested that parental diagnostic status moderates the relationship between child AS and
anxious symptomatology in the child such that children of an anxious parent tend to have a
higher degree of association between AS and symptoms of anxiety [27].
Collectively, the discrepant findings reported in the literature to date suggest that careful
consideration is required when studying parental contributions to child AS, both with
respect to the methodology employed by a given study, as well as with respect to the
specific research question under examination. Accordingly, the primary aims of this paper
are to review those published studies that have investigated parental contributions to child
AS, provide a unified summary of these findings, and offer specific suggestions for future
research in this area.
Measuring Child Anxiety Sensitivity
The majority of studies cited in this review have employed a single measure of child AS
when studying samples of youth aged 7 and older: the Childhood Anxiety Sensitivity Index
596 Child Psychiatry Hum Dev (2010) 41:595–613
123
(CASI) [30]. The CASI is an 18-item self-report measure designed to assess the construct
of AS in youth aged 6–17 years [19]. The CASI is a downward extension of the adult
Anxiety Sensitivity Index (ASI) [4], which was revised to include language more acces-
sible to youth, as well as two items that are not included on the ASI (‘‘It scares me when
my heart beats fast’’ and ‘‘When I am afraid, I worry that I might be crazy’’). All CASI
items include a 1 to 3 response scale (ranging from ‘‘none’’ to ‘‘a lot’’) with total scores
ranging from 18 to 54 and higher scores indicating greater levels of AS. In both clinical
and non-clinical samples the CASI has demonstrated good psychometric properties,
including a 1 week test–retest reliability coefficient of .76 in a nonclinical sample and .79
in a clinical sample, and an alpha coefficient of .87 in both a nonclinical and clinical
sample [15]. Scores on the CASI have also been found to distinguish between anxious
youth and youth without a clinical diagnosis [28].
With respect to the factor structure of the CASI, inconsistent findings have been yielded,
although there appears to be general support for a hierarchical factor structure with a single
higher order factor and multiple lower order factors. Specifically, various studies have
yielded support for a two-factor structure (autonomic and non-autonomic) [29]; a three-
factor structure (physical concerns, mental incapacitation concerns, and concerns about
publicly observable symptoms) [7, 30]; and a four-factor solution (disease concerns,
unsteady concerns, mental incapacitation concerns, and social concerns) [30]. A more
recent study [5] has yielded additional support for the three-factor structure identified by
Silverman et al. [24].
In the past two decades, the CASI has emerged as the predominant measure of child-
hood AS. Indeed, the majority of studies of child AS employ the CASI and virtually all of
the studies of parental contributions to child AS also use this instrument to assess child AS.
Despite its widespread use, however, this instrument is not without certain limitations that
might hinder the interpretation of studies employing the CASI. Specifically, inconsistent
evidence has been yielded with respect to the factor structure of the CASI. The existence of
multiple factor structures can lead to varied explanations and conclusions with respect to
the facets of AS that might be related to parental factors, suggesting caution when inter-
preting specific findings regarding parental contributions to child AS. Additionally, some
researchers have questioned whether the CASI measures AS as distinct from anxiety in
young children [13]. Finally, very few studies have employed other modes of assessing AS
(e.g., [31]), thus making the construct validity of this instrument challenging to interpret.
Review of Specific Studies
This review will pertain specifically to those 10 published empirical studies that have
examined parental contributions to child AS. The research questions examined in these
studies can be broken down into four types: (1) those examining the relationship between
parental anxiety and child AS, (2) those examining the relationship between parental AS
and child AS, (3) those examining the relationship between parental cognitions and
behaviors and child AS, and (4) those testing moderational or mediational models
involving child AS and some measure of parental psychopathology or behavior. Most of
the studies reviewed here fall into multiple categories, given that multiple research
questions were addressed in the context of a single study. Of the studies conducted to date
falling within each of the four categories mentioned above, variation can be noted with
respect to the sample employed (clinical versus non-clinical), the age of the offspring
studied (ranging from childhood to undergraduate), and the parent reporter (see Table 1).
Child Psychiatry Hum Dev (2010) 41:595–613 597
123
The methodology and measures used, specific results, study conclusions, and effect sizes
are detailed in Tables 2 and 3. Each of the studies comprising the four areas referenced
above will be reviewed below.
Parental Anxiety as a Predictor of Child AS
Six published studies have reported on the association between parental anxiety and child
AS [23, 25–27, 32, 33]. With respect to those studies that examined parents with a
diagnosis of an anxiety disorder, Mannuzza et al. [26] reported that levels of child AS did
not vary across parental diagnostic group when parental anxiety disordered groups were
compared with other parental diagnoses and a no-diagnosis control group. Across all of the
two-group contrasts conducted, parental diagnostic status accounted for less than 2% of the
variance in child AS scores, suggesting that neither parental anxiety (in particular panic
disorder) nor mood disorders are predictive of child AS. Similarly, Pollock et al. study [27]
reported similar adolescent scores on the ASI between groups considered high and low risk
for anxiety disorders. Consistently, van Beek et al. [25] found no differences between child
Table 1 Demographic characteristics of studies examining parental contributions to child anxiety sensitivity
Study Sample N Reporter Child age % female Parent assessed
Drake and Kearney [32]
Non-clinical 157 Child/ parent
7–18 years M = 11.9 years,
SD = 2.6
59 82% mothers
East et al. [34] Non-referred 138 Child M = 20.6 years, SD = 3.6
77 52.2% both mother and father
Mannuzza et al. [26]
Clinical/non- clinical
340 Child/ parent
6–17 years M = 11.5 years,
SD = 3.5
54 Not available
Muris et al. [35]
Non-clinical 52 Child 12–14 years M = 12.3 years,
SD = 0.5
56 Not applicable
Ollendick and Horsch [33]
Clinic-referred/ non-clinical
156 Child/ parent
7–15 years M = 10.8 years,
SD = 2.5
35 100% mothers
Pollock et al. [27]
Clinic-referred/ non-referred
121 Child/ parent
12–17 years Not available
Not available
Scher and Stein [36]
Non-clinical 249 Child 17–54 years M = 19.6 years,
SD = 3.7
83 Not applicable
Silverman and Weems [24]
Clinic-referred/ non-clinical
144 Child/ parent
6–17 years Not available
Not available
Tsao et al. [23]
Non-clinical 207 Child/ parent
8–18 years M = 12.3 years
50 85% mothers
van Beek et al. [25]
Clinical/non- clinical
136 Child/ parent
6–17 years M = 11.9 years,
SD = 2.9
45 Panic sample: 75% mothers control sample: 82% mothers
598 Child Psychiatry Hum Dev (2010) 41:595–613
123
T a b
le 2
A ss
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(7 .4
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Child Psychiatry Hum Dev (2010) 41:595–613 599
123
T a
b le
2 c o
n ti
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S tu
d y
Q u
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P o
ll o c k
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a l.
[2 7 ]
A S
I C
M A
S S
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S K
-S A
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in a d o le
sc e n ts
w it
h h ig
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m il
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fo r
a n
x ie
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o le
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it h
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fa m
il ia
l ri
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ty
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) v
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[3 6 ]
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m s
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n e
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S il
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s [2
4 ]
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N o
n e
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c a b
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T sa
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[2 3 ]
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A S
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C L
-9 0 -R
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b o
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) \
1 ,
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4 )
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B e e k
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C A
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D
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I; D
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M e a n
c h
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A S
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h P
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a l
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.3 )
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.5 ),
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st ic
In te
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ts ,
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v e
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a n
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c h
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n ia
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E I
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in g
E x p e ri
e n c e s
In te
rv ie
w ,
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I M
in i
In te
rn a ti
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a l
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ro p
sy c h
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ic In
te rv
ie w
, P
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a s
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fo rm
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lt P
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e je
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P T
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n t
T h
re a t
In v
e n
to ry
, S
C A
R E
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c re
e n
fo r
C h
il d
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x ie
ty R
e la
te d
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o ti
o n a l
D is
o rd
e rs
, S
C ID
S tr
u c tu
re d
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n ic
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In te
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w fo
r th
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S M
-I V
, S
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IC S
ta te
-T ra
it A
n x ie
ty In
v e n to
ry fo
r C
h il
d re
n
600 Child Psychiatry Hum Dev (2010) 41:595–613
123
T a
b le
3 S
u m
m a ry
st a ti
st ic
s a n d
e ff
e c t
si z e s
S tu
d y
V a ri
a b
le s
S u
m m
a ry
R e su
lt s
E ff
e c t
si z e
D ra
k e
a n
d K
e a rn
e y
[3 2 ]
C h
il d
A S
; p
a re
n t
A S
; c h
il d
a n
x ie
ty ;
p a re
n t
p sy
c h o
p a th
o lo
g y ;
fa m
il y
e n
v ir
o n
m e n
t
P a re
n ta
l a n
x ie
ty is
re la
te d
to so
m e
fa c e ts
o f
c h
il d
A S
— C
A S
I d
is e a se
c o
n c e rn
s, C
A S
I u
n st
e a d
y c o
n c e rn
s, C
A S
I so
c ia
l c o
n c e rn
s
rs =
.2 2
, .2
1 .,
.1 8
, p \
.0 5
R 2
= .0
5 ,
.0 4
, .0
3
S o
m e
fa c e ts
o f
p a re
n ta
l A
S a re
si g
n ifi
c a n
tl y
c o
rr e la
te d
w it
h so
m e
fa c e ts
o f
c h
il d
A S
;
rs =
.1 9
– .2
6 ,
p \
.0 5
R 2
= .0
4 –
.0 7
N o
t a
st ro
n g
re la
ti o
n sh
ip b
e tw
e e n
p a re
n ta
l A
S a n
d c h
il d
a n
x ie
ty rs
= .0
2 –
.1 8
R 2 \
.0 1
– .0
3
C h il
d A
S m
e d
ia te
s re
la ti
o n sh
ip b
e tw
e e n
p a re
n t
p sy
c h o
p a th
o lo
g y
a n
d c h
il d
a n
x ie
ty
U n
c o
n st
ra in
e d
m o
d e l
fi t:
C F
I =
0 .9
2 7
; IF
I =
0 .9
2 8
; R
M S
E A
= 0
.0 8 0
; v
2 =
9 1
.9 7
–
E a st
e t
a l.
[3 4 ]
P a re
n t
A S
; o
ff sp
ri n
g A
S ;
a n
x ie
ty ;
m o
o d
d is
o rd
e rs
; su
b st
a n
c e
u se
d is
o rd
e r;
d e p
re ss
io n
; st
re ss
F a th
e r
A S
(& n
o t
m o
th e r
A S
) p
o si
ti v
e ly
re la
te d
to o
ff sp
ri n g
A S
r =
.2 4
, p
\ .0
5 R
2 =
.0 6
F a th
e r
A S
(& n
o t
m o
th e r
A S
) p
o si
ti v
e ly
re la
te d
to o
ff sp
ri n g
a n
x ie
ty
r =
.3 9
, p
\ .0
1 R
2 =
.1 5
M a n
n u
z z a
e t
a l.
[2 6 ]
C h
il d
A S
; a n
x ie
ty ,
d e p
re ss
io n
, P
D P
a re
n ta
l a n
x ie
ty n
o t
re la
te d
to c h
il d
A S
– R
2 \
.0 1
– .0
2
M u
ri s
e t
a l.
[3 5 ]
C h
il d
A S
; le
a rn
in g
e x
p e ri
e n c e s
fr o m
p a re
n ts
, p
a re
n ta
l re
in fo
rc e m
e n t,
o b
se rv
a ti
o n
a l
le a rn
in g
P a re
n ts
’ id
e a
o f
a n
x ie
ty sy
m p
to m
s p
o te
n ti
a ll
y b
e in
g d
a n
g e ro
u s
re la
te d
to c h il
d A
S
r =
.2 8
, p
\ .0
5 R
2 =
.0 8
P a re
n ts
’ id
e a
o f
p a in
sy m
p to
m s
p o
te n
ti a ll
y b
e in
g d
a n
g e ro
u s
re la
te d
to c h il
d A
S
r =
.3 7
, p
\ .0
1 R
2 =
.1 4
O ll
e n
d ic
k a n d
H o
rs c h
[3 3
] C
h il
d A
S ;
m a te
rn a l
p h
o b ic
a n
x ie
ty ;
m a te
rn a l
o v
e r-
c o
n tr
o l;
c h
il d
fe a r;
a g
e ;
se x
M a te
rn a l
p h
o b ic
a n
x ie
ty n
o t
re la
te d
to c h il
d A
S o
r c h
il d
fe a r
r =
.0 3
, n
.s .
R 2 \
.0 1
Child Psychiatry Hum Dev (2010) 41:595–613 601
123
T a
b le
3 c o
n ti
n u
e d
S tu
d y
V a ri
a b le
s S
u m
m a ry
R e su
lt s
E ff
e c t
si z e
P o
ll o c k
e t
a l.
[2 7 ]
C h
il d
A S
; a n x
ie ty
; d
e p
re ss
io n
; p
a re
n t
p sy
c h o
p a th
o lo
g y
P a re
n ta
l a n
x ie
ty n
o t
si g n
ifi c a n
tl y
re la
te d
to c h
il d
A S
N o
n -s
ig n
ifi c a n
tl y
d if
fe re
n t
g ro
u p
m e a n s
–
P a re
n ta
l a n
x ie
ty m
o d
e ra
te s
re la
ti o
n sh
ip b
e tw
e e n
c h
il d
A S
a n
d a n
x ie
ty
D R
2 =
.0 3
(p \
.0 5
) D
R 2
= .0
3
S c h
e r
a n d
S te
in [3
6 ]
A S
; a n
x ie
ty ;
d e p
re ss
io n
; p
a re
n t
b e h
a v
io rs
P a re
n t
th re
a te
n in
g b
e h
a v
io rs
p re
d ic
t A
S F
(1 ,
1 7
9 )
= 1
2 .5
4 ,
p \
.0 1
R 2
= .0
7
A S
m e d ia
te s
re la
ti o n sh
ip b e tw
e e n
p a re
n t
th re
a te
n in
g b
e h
a v
io r
a n
d a n
x ie
ty
z =
3 .2
4 ,
p \
.0 1
–
S il
v e rm
a n
a n
d W
e e m
s [2
4 ]
P a re
n t
A S
; p
a re
n t
d e p
re ss
io n
; c h
il d
A S
; c h
il d
d e p
re ss
io n
P a re
n ta
l A
S n
o t
si g
n ifi
c a n
tl y
re la
te d
to c h
il d
A S
N o
t re
p o
rt e d
–
T sa
o e t
a l.
[2 3 ]
C h
il d
A S
; p
a re
n t
A S
; p
a re
n t
a n
x ie
ty ;
p a re
n t
d e p
re ss
io n
P a re
n t
a n x
ie ty
n o
t si
g n
ifi c a n
tl y
re la
te d
to c h
il d
A S
r =
.0 4
, n
.s .
R 2 \
.0 1
P a re
n t
p h
o b ic
a n
x ie
ty n
o t
si g n
ifi c a n
tl y
re la
te d
to c h
il d
A S
r =
.0 3
, n
.s .
R 2 \
.0 1
S ig
n ifi
c a n t
a ss
o c ia
ti o n
b e tw
e e n
c h il
d A
S a n
d p
a re
n ta
l A
S r
= .1
5 ,
p \
.0 5
R 2
= .0
2
v a n
B e e k
e t
a l.
[2 5 ]
C h
il d
A S
; p
a re
n t
A S
; p
a re
n t
P D
P D
p a re
n t
g ro
u p :
p a re
n ta
l A
S n
o t
si g n
ifi c a n
tl y
re la
te d
to c h
il d
A S
r =
.0 4
, n
.s .
R 2 \
.0 1
N o n -c
li n ic
a l
p a re
n t
g ro
u p :
p a re
n ta
l A
S n
o t
si g n
ifi c a n
tl y
re la
te d
to c h
il d
A S
r =
.1 5
, n
.s .
R 2
= .0
2
A S
A n
x ie
ty se
n si
ti v
it y
, P
D P
a n
ic d
is o
rd e r
602 Child Psychiatry Hum Dev (2010) 41:595–613
123
AS scores in the parent-panic disordered group and the healthy parent group. Collectively,
these studies suggest that parental anxiety disorders, and parental panic disorder in par-
ticular, do not confer a risk for elevated child or adolescent AS.
With respect to studies that assessed anxiety as a continuous variable, Ollendick and
Horsch [33] reported no correlation between maternal phobic anxiety and child AS.
Similarly, Tsao et al. [23] reported low and non-significant correlations between parental
general anxiety and child AS as well as between parental phobic anxiety and child AS.
These correlations were both corrected for child sex and age. These authors also reported
that for both boys and girls, parental anxiety did not account for additional variance in
child AS after parental AS was controlled for. Together, these two studies provide
corroborating evidence with the three previously discussed studies to suggest that
parental anxiety, whether measured categorically or dimensionally, is not associated with
child AS.
However, a third study in which parental anxiety was measured dimensionally did find
some significant associations between parental anxiety and child AS. Specifically, Drake
and Kearney [32] reported finding significant associations between parental general anxiety
and three CASI scales (disease concerns, unsteady concerns, and social concerns), as well
as between parental phobic anxiety and the unsteady concerns scale. However, non-sig-
nificant correlations were observed between general parental anxiety and the CASI mental
incapacitation scale, as well as between parental phobic anxiety and the disease concerns,
mental incapacitation concerns, and social concerns scales. This study, unlike the two
previously mentioned investigations evaluating parental anxiety dimensionally, examined
the CASI by subscale, rather than relying on an overall estimate of child AS from this
measure. However, all studies employed a relatively large sample of children and exam-
ined this relationship across broad child age ranges.
Summary
In sum, five of the six published studies examining the contribution of parental anxiety to
child AS failed to demonstrate a significant relationship between parental anxiety and child
AS. The one study that did indicate a significant relationship between these two variables
reported significant correlations between parental anxiety and only certain facets of child
AS, and suggested that the variance accounted for in child AS by parental anxiety was
relatively small (R2s ranging from .03 to .05). However, the findings yielded from this one study suggest the potential importance of examining individual components of AS, rather
than testing the construct of AS as a whole.
With respect to the remainder of the studies reviewed in this section, the observed
relationship between parental anxiety and child AS was consistently low across studies that
varied in key methodological ways, lending confidence to the generalizability of these
findings to multiple participant groups. Specifically, the relationship between these two
variables was low in studies examining parental anxiety disorders in general and parental
panic disorder specifically, as well as parental anxiety and phobic anxiety; young children
and adolescents; a diverse group of clinic-referred children, those non-referred children
whose parents were referred and/or diagnosed, and non-referred healthy parent–child
dyads; and child AS as assessed by the CASI and the ASI. Of the two studies reporting the
sex of the parent assessed, mothers comprised the majority in both (100% in Ollendick and
Horsch [33]; 79.7% in Tsao et al. [23]). Additionally, each of these studies employed
sizable samples (ranging from 121 to 340 participants) and provided sufficient information
Child Psychiatry Hum Dev (2010) 41:595–613 603
123
to estimate an effect size; yet across all studies the effect size of this relationship was small
(ranging from .001 to .05).
However, none of the studies reporting a non-significant relationship between parental
anxiety and child AS examined AS as comprised of physical, cognitive, and social
dimensions. Similarly, none of these studies examined the relationship between parental
anxiety and child AS within child sex or age groups, with the exception of Tsao et al. [23]
in which the correlation reported between parental anxiety and child AS did control for
child age and sex, and the relationship between parental anxiety and child AS when
controlling for parental AS was reported for each sex. Collectively, although this evidence
appears to suggest that parental anxiety does not confer an increased risk upon the child of
displaying elevated levels of AS, further investigation of this relationship using specific
dimensions of AS and comparing child sex and age groups might be warranted.
Parental AS as a Predictor of Child AS
Five published studies [23–25, 32, 34] to date have examined the relationship between
parental AS and child AS. Tsao et al. [23] reported a significant correlation between
parental and child AS. Additionally, a significant correlation was observed between the
ASI social dimension items and the CASI, but the ASI physical and mental dimensions
were not significantly correlated with child report on the CASI. The relationship between
parental and child AS, when examined by child age, was significant for children aged 12
and over, but not for children aged 11 and under. Interestingly, these results parallel those
reported by Chorpita et al. [13] in which AS significantly predicted anxiety amongst youth
aged 12 and above, but not for younger children. Tsao et al. [23] also examined group
differences between male and female children. Results suggested that parental AS (and in
particular parental AS specific to social concerns) is a significant predictor of child AS only
for girls, and that the association between these variables is strongest for girls aged 12 and
older.
In the second study reporting conditional associations for parental and child AS, East
et al. [34] reported a significant association between parental and offspring AS for fathers,
but not for mothers. Although this study provides some support for a relationship between
parental and child AS, it was conducted with offspring who were no longer residing with
their family of origin and yielded a relatively low effect size, with paternal AS accounting
for less than 7% of variance in child AS.
In the third study reporting a conditional association for parent and child AS, Drake and
Kearney [32] reported 16 correlations between four dimensions of the ASI (somatic
concerns, losing control, phrenophobia, and gastrointestinal concerns) and four dimensions
of the CASI (disease concerns, unsteady concerns, mental incapacitation concerns, and
social concerns). Of the 16 reported correlations 6 were significant, suggesting that specific
components of parental AS accounted for between 4 and 7% of the variance in specific
components of child AS.
Of the two studies that did not find significant associations between parental and child
AS, Silverman and Weems [24] reported that ‘‘a clear relation between ASI scores and
CASI scores was not found’’ (p. 262). However, actual correlations are not reported.
Finally, van Beek et al. [25] reported a small and non-significant relationship between
parental and child AS in both a high-risk (panic-disordered parents) and healthy group of
children and adolescents.
604 Child Psychiatry Hum Dev (2010) 41:595–613
123
Summary
Initially, this group of studies appears to suggest contradictory evidence with respect to
whether parental AS is a significant contributor to child AS. However, upon closer
examination, these findings instead appear to suggest that whether or not parental AS is a
significant contributor to child AS is conditional upon several factors. Specifically, the
three studies to report a significant association between parental and child AS found only
conditional associations, such that Tsao et al. [23] reported a significant relationship for
older girls only, East et al. [34] reported a significant association for fathers only, and
Drake and Kearney [32] reported significant relationships between only certain facets of
parental and child AS. Although Tsao et al. [23] assessed both mothers and fathers, a
comparison between these two groups of respondents was not conducted; similarly,
although East et al. [34] assessed both male and female offspring, between-sex compari-
sons were not made, thus making comparisons across these two studies impossible. With
respect to Drake and Kearney [32], it must be noted that although 16 correlations were
calculated, only 6 were significant and no correction for the number of tests conducted was
applied.
Of those two studies that failed to find a significant association between parental and
child AS, one did not provide actual correlations [24], making it impossible to ascertain the
magnitude of the relationship found. Interestingly, the other study [25] reported a non-
significant correlation between parental and child AS (r = .15) that was identical to the significant correlation reported by Tsao et al. [23]. This discrepancy with respect to sta-
tistical significance suggests that sample size might have been an issue in detecting a
relationship between these variables, given that Tsao et al. [23] employed a larger sample
(n = 244) than did van Beek et al. [25] (n = 68 per parent group). Similarly, Silverman and Weems [24] also employed a relatively smaller sample (n = 144) than did Tsao et al. [23]. As such, when examining the relationship between parental and child AS, employing
a large enough sample to compare male and female children, comparing mother and father
reporters, and analyzing specific facets of both parental and child AS might contribute to
the ability to better understand this potentially complex relationship.
Finally, it should also be noted here that only two studies in this section [23, 32]
examined the individual dimensions of the ASI and CASI, yielding interesting findings.
Specifically, Tsao et al. [23] reported that the social factor of the ASI was the only
component of parental AS to significantly account for child AS; similarly, only the social
factor of the CASI significantly accounted for variance in parental AS. Conversely, Drake
and Kearney [32] found that three of four ASI facets (somatic concerns, losing control, and
phrenophobia, but not gastrointestinal concerns) accounted for a significant proportion of
variance in only two facets of child AS, namely social and unsteady concerns. Together
these studies suggest the importance of examining individual facets of AS for both parents
and children in an attempt to yield additional information to better understand the rela-
tionship between these two variables.
Parental Cognitions and Behaviors as Predictors of Child AS
One study has examined the relationship between parental cognitions and child AS [35],
reporting a significant association between parents’ beliefs that somatic symptoms of
anxiety are potentially dangerous and child AS. Specifically, parental cognitions accounted
for almost 8% of the variability in child AS. However, this study relied solely on child
Child Psychiatry Hum Dev (2010) 41:595–613 605
123
report and did not employ a parental measure of cognitions related to anxiety or behaviors
that might be associated with the transmission of anxiety.
One study has examined the relationship between parental behaviors and child AS [36],
reporting that childhood exposure to parental behaviors classified as threatening, hostile,
and rejecting was significantly predictive of later AS. Specifically, Scher and Stein [36]
reported that parental rejection/aggression/hostility scores accounted for 6.7% of variance
in offspring AS. Of the three parental behaviors examined, parental threatening behavior
best predicted child AS, accounting for 6.6% of its variance and remaining a significant
predictor of child AS when parental hostility and rejection were controlled for. Similarly,
when examining individual ASI factors, parental threatening behavior was also the best
predictor of publicly observable symptom fears (social), such that it accounted for 7.3% of
the variance in this factor score. None of the parenting behaviors assessed significantly
accounted for bodily sensation fears (physical). Parental hostility and rejection best
accounted for fear of losing control over one’s thoughts (cognitive), explaining 6.4% of the
variance in this ASI factor.
These findings suggest that rather than a specific parental disorder (e.g., anxiety) con-
ferring risk of child AS, specific parenting behaviors might instead be associated with
increased child AS. However, this study employed an undergraduate sample of students
(necessitating use of the ASI rather than the CASI) and administered measures of parenting
behavior that were retrospective in nature and relied solely on the ‘‘child’s’’ report.
Employing this type of methodology thus yields findings that might suggest a relationship
between the child’s current cognitive state and their current recollections of their parents’
behavior, rather than perhaps actual or parent-reported parenting behaviors.
Summary
Two studies have been conducted to date that, rather than looking at parental anxiety or
AS, have instead examined the effect of specific parental cognitions and behaviors on child
AS. Although each study provides support for notions that (a) parental beliefs about their
child’s anxious symptomatology is significantly associated with child AS, and (b) parental
threatening behaviors are significantly associated with child AS, neither study assessed
parental cognitions or behaviors directly, relying instead on child report of both AS and
parental cognitions and behaviors. Moreover, one of these studies [36] relied on retro-
spective child report, rather than assessing child AS and parental behaviors concurrently.
Although these studies suggest that specific parental cognitions and behaviors might be
meaningfully related to child AS, explaining between 6 and 8% of the variance in child AS,
further examination of these questions is required.
Moderational and Mediational Analyses of Parental Attributes and Child AS
Three studies have been conducted in which moderational or mediational models involving
child AS and a parental attribute have been examined. Pollock et al. [27] studied the
association between child AS and child anxiety by testing parental anxiety as a moderator
of this relationship. They reported that child age, child sex, parental substance abuse, and
whether the parent had an anxiety or mood disorder collectively did not account for a
significant proportion of variance in child anxiety. However, their findings did suggest that
a parental diagnosis of an anxiety disorder significantly moderated the relationship
between child AS and anxiety diagnosis such that although parental anxiety did not
606 Child Psychiatry Hum Dev (2010) 41:595–613
123
uniquely account for variance in child AS, it did strengthen the association between child
AS and child anxiety diagnosis.
Drake and Kearney [32] used structural equation modeling to test two mediational
models, one involving child AS and the other involving parent AS. Specifically, their
results suggested that child AS mediated the relationship between parental psychopa-
thology and child anxiety. Interestingly, support was not observed for parental AS as a
mediator of this relationship. To explain these results, Drake and Kearney [32] speculate
that parents who themselves are experiencing elevated levels of psychopathology might
also convey to their child that physical anxiety symptoms are harmful (either by displaying
hypervigilance for their own symptoms or communicating to the child catastrophic out-
comes related to anxious symptomatology). Such information might then lead the child to
be fearful of his or her own symptoms, thus leading to an exacerbation of anxiety in the
child.
Finally, Scher and Stein [36] reported support for a mediational model in which parental
AS significantly mediated the relationship between parental threatening behaviors and
current child anxiety symptoms, but not lifetime or a past history of child anxiety. When
examining specific facets of child AS, these authors found that child social AS (fears of
publicly observable symptoms of anxiety) also significantly mediated the relationship
between parental threatening behaviors and current child anxiety (but not past anxiety).
Moreover, child cognitive AS (fears of losing control over one’s thoughts) significantly
mediated the relationship between parental hostile and rejecting behaviors and current and
past child depression. The authors conclude that these results yield support for child AS as
one mechanism through which exposure to parenting behaviors can affect a child’s later
emotional distress.
Summary
One study reviewed in this section examined parental anxiety as a moderator of the
relationship between child AS and child anxiety, whereas two other studies examined AS
as a mediator of the relationship between parental behaviors or psychopathology and child
anxiety. Specifically, Pollock et al. [27] demonstrated that parental anxiety affects the
strength of the relationship between child AS and child anxiety, such that children with
parents diagnosed with anxiety have a stronger association between AS and anxiety than
children whose parents are not experiencing clinically significant symptoms of anxiety.
The effect of parental anxiety on the relationship between child AS and anxiety was
observed among a sample of clinically referred parents and their adolescent children (aged
12–17). Moreover, these authors included estimates of effect size in their study, indicating
that for children of anxiety-disordered parents, child AS accounted for 18% unique vari-
ance in child anxiety diagnostic status after taking into account child anxious symptom-
atology. Such findings suggest the potential importance of parental diagnostic status with
respect to better understanding the relationship between child AS and anxiety.
The second two studies reviewed in this section examined AS as a mediator of the
relationship between parental behaviors or psychopathology and child anxiety. Although
Drake and Kearney [32] did not find support for parental AS as a significant mediator of
parental psychopathology and child anxiety in a non-clinical child sample, Scher and Stein
[36] found that parental AS significantly mediated the relationship between parental
threatening behaviors and child anxiety amongst a sample of non-clinical adults. Several
reasons might be posited for these discordant findings: Drake and Kearney [32] were
measuring parental anxious symptomatology using the SCL-90-R, whereas Scher and Stein
Child Psychiatry Hum Dev (2010) 41:595–613 607
123
[36] assessed specific parental threatening behaviors; Drake and Kearney [32] employed a
somewhat smaller sample size of 157 compared to the 249 studied in the Scher and Stein
study [36]; and Scher and Stein [36] conducted their study with an undergraduate sample,
thus relying on retrospective accounts of parenting behaviors as reported by the ‘‘child’’,
whereas Drake and Kearney [32] assessed children between the ages of 7 and 18 and their
parents simultaneously. To better understand the impact that parental AS has on the
relationship between parenting behaviors and child anxiety, Scher and Stein’s study [36]
should be replicated using a child sample and obtaining reports of parenting behaviors
either from parents or from observational methods. Interestingly, Drake and Kearney [32]
did find that child AS mediated the relationship between parental psychopathology and child anxiety, suggesting that the child’s beliefs about their anxious symptomatology might
be more salient in linking parental psychopathology to child anxiety than the parents’
cognitions about their own anxious symptoms.
Discussion
This paper attempted to review those studies to date that have examined parental contri-
butions to child AS. The research questions examined in these studies were separated into
four types of design: (1) those examining the relationship between parental anxiety and
child AS, (2) those examining the relationship between parental AS and child AS, (3) those
examining the relationship between parental cognitions and behaviors and child AS, and
(4) those testing moderational or mediational models involving child AS and some mea-
sure of parental psychopathology or behavior.
Of the 10 studies reviewed for this paper, the majority included research questions
examining the relationship between (a) parental anxiety and child AS or (b) parental AS
and child AS, suggesting that the focus in this area of research is examining specific
parental anxiety-related contributions to child AS. Specifically, the majority of research in
this area is concerned with the general question of whether or not parental anxiety and AS
are related to child AS. With respect to the first group of studies, the evidence appears to
suggest relative consensus with respect to the lack of a significant relationship between
parental anxiety and child AS. Moreover, the absence of this relationship was reported
across studies employing a diverse range of methodologies, including different child ages,
samples (clinical and non-clinical), and means of assessing parental anxiety (self-report
measures and diagnostic interviews). It is perhaps noteworthy to mention that the only
study reporting a significant relationship between parental anxiety and child AS observed
this association only for certain facets of AS, suggesting one key area for future investi-
gations is to examine specific dimensions of both child and parental AS, rather than simply
assessing and reporting on AS as a unitary construct.
Amongst those studies examining the relationship between parental and child AS, the
consistently emerging theme appeared to be that the association between these two vari-
ables is conditional upon the child reporter, the parent reporter, and the specific dimensions
of AS being tested. Collectively these studies suggest further research on this specific
question is needed with samples of sufficient size to compare male and female children,
mother and father reporters, the various combinations of parent–child reporters, younger
and older child reporters, and specific dimensions of both parental and child measures of
AS. Although this group of studies initially appears to suggest a lack of consensus amongst
findings, no two studies to date have tested the relationship between child and parental AS
employing a similar methodology (e.g., employing child participants of the same age,
608 Child Psychiatry Hum Dev (2010) 41:595–613
123
examining similar facets of AS), thus rendering direct comparison across these studies
challenging. As such, the best answer to the question of whether parental AS is signifi-
cantly associated with child AS appears to remain that this association is conditional upon
a number of methodological factors.
The two other categories in which studies were reviewed were each comprised of a
small number of investigations, suggesting that although research in the area of parental
contributions to child AS is new, the work being done in these particular areas is quite
preliminary. Overall, these studies suggested (a) initial evidence that specific parental
cognitions and behaviors might be related to child AS and (b) preliminary evidence sug-
gesting some specific mechanisms underlying the relationship between child AS and
parental anxiety and AS. As was the case with those studies examining the relationship
between parental AS and child AS, no two studies in these latter categories employed
similar methodology to allow for direct comparison across studies. As such, each of the
findings reviewed here requires replication and further study to comprehensively under-
stand these relationships.
Recommendations for Future Directions
On the basis of the studies reviewed above, several recommendations for future research
are offered. The most readily apparent recommendation for future work in this area is that
more research is needed. This recommendation is evidenced by the paucity of published
studies addressing the contribution of parental factors to child AS (10 studies to date).
Moreover, the effect sizes observed across these studies were quite modest and in the small
to medium range (R2 = \ .01 to .15; see Table 3). Despite the small effect sizes that were observed across the studies reviewed here, however, closer examination of these studies
indicated the virtual absence of methodological consistency across studies. This absence is
important for two reasons: (1) it reveals that the findings reported here have not been
replicated, thus shedding doubt on their robustness, and (2) without the direct comparison
allowed by employing similar methodologies, key questions cannot be addressed (for
example, child age and gender differences). As such, even though the parental contribu-
tions to child AS might appear, at this stage, to be small, corroboration of these findings
with refined methodologies (elaborated upon below) is required before drawing firm
conclusions in this area.
In several instances throughout this review, the utility of examining specific AS facets
was noted. Of the 10 studies reviewed here, only two [23, 32] examined specific dimen-
sions of AS for both parent and child, whereas only one [36] reported on specific AS
dimensions for offspring participants. In those instances where investigators examined
interrelationships between parental and child variables utilizing specific AS dimensions,
different and often more fine-grained relationships were noted than when examining AS as
a unity construct. However, consistency will be key in this area. Although in adult research
there has been relatively wide-spread support for the existence of three intercorrelated yet
distinct AS factors (physical concerns, cognitive concerns, social concerns [e.g., 37–39]), a
consistent approach to defining specific factors of the CASI has yet to emerge. Specifically,
in the two studies reviewed here that examined distinct factors of the CASI, although both
Drake and Kearney [32] and Tsao et al. [23] examined a four-factor solution (disease
concerns, unsteady concerns, mental concerns, social concerns), Tsao et al. [23] also
reported on a three-factor solution (physical concerns, mental concerns, social concerns). It
is thus suggested that one particularly salient area of future research might be to reach
consensus on the appropriate factor structure of the CASI and to then demonstrate how this
Child Psychiatry Hum Dev (2010) 41:595–613 609
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factor structure corresponds to that established for the ASI. Such work will allow future
researchers in this area to examine the relationship between parental and child AS per
specific dimension, rather than for AS more globally.
Of the studies reviewed here, all but two [24, 33] employed either a non-identified child
sample or a sample in which the parent was identified but the child was not. Consistent
with Ollendick and Horsch’s [33] recommendation, future investigations should employ a
sample of anxiety-disordered youth in order to examine the contribution of parental
variables to child AS. Such bottom-up studies would facilitate differentiating the parental
characteristics of children with and children without elevated AS while simultaneously
providing another perspective on parental contributions to child AS. Similarly, studying a
sample of anxiety-disordered youth would allow for further investigation of the specific
anxiety disorders which might be associated with a stronger link between parental vari-
ables and child AS. A recent meta-analytic review of AS in adults indicated that AS
significantly differentiates panic disorder from other anxiety disorders [40], and similar
findings have been noted with youth [e.g., 41]. As an extension of such findings, examining
differences in parental contributions across various child anxiety disordered groups would
appear to be a fruitful area of future research.
Additionally, it is recommended that future studies in this area employ sufficiently large
samples to allow for comparisons between male and female children, mother and father
reporters, and all permutations of parent–child reporter dyads. This recommendation is
consistent with previous findings indicating that for women AS has been found to have a
high heritability component, but the same has not been reported for men, such that for men,
AS dimensions appear to be more heavily influenced by environmental factors [21]. Such
findings might explain some of the sex differences observed in child studies to date (e.g.,
significant associations between parental anxiety and AS and child AS for only girls as
observed in Tsao et al. [23]); however, these sex differences cannot be examined in more
detail until larger samples allowing for such comparison are studied.
Similarly, future studies in this area should also allow for comparisons across child age
groups. Specifically, previous studies have found support for AS as a construct unique from
anxiety in older children (aged 12 and above), but not in younger children [13]. Similar
findings were noted in this review with respect to the Tsao et al. study [23] in which a
significant relationship between parental and child AS was observed only for children aged
12 and over. These results suggest that studying parental contributions to child AS might
yield more informative results when examined across child age groups.
Although this was not an issue for the studies reviewed here, it is recommended that
future studies in this area continue to use consistent measurement strategies to assess AS
for both parent and child respondents. For example, consistently employing the CASI to
assess child AS and the ASI or ASI-R to assess adult AS reduces the likelihood that AS
measurement issues are responsible for discrepancies between studies, instead facilitating
comparisons across investigations.
Conversely, however, it is also suggested that other modes of assessment be employed
to measure AS. More specifically, it is of concern that this entire body of research has been
conducted on the basis of one measure, namely the CASI. Despite the promising psy-
chometric properties that have been observed, the CASI remains an 18-item self-report
questionnaire that assesses AS strictly from the child’s perspective. To better understand
the construct of child AS, particularly in relation to parental contributions, future research
in this area should obtain reports of AS from other informants (e.g., parents) as well as via
other means (e.g., behavioral observation and physiological challenge tasks). Expanding
upon measurement strategies for child AS would serve to not only strengthen the validity
610 Child Psychiatry Hum Dev (2010) 41:595–613
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of this construct among youth, but also to more comprehensively assess the relationship
between parental factors and child AS.
General Summary
Anxiety sensitivity (AS) has been the focus of numerous empirical investigations amongst
child samples. More recently, this variable has been examined in relation to parental AS
and parental anxiety in order to elucidate parental contributions to child AS. Because this
literature spans a relatively brief time period (1999–2008) and the number of studies in this
area is somewhat limited (10), the findings yielded from this body of research have been
challenging to integrate given the apparent lack of consensus across these investigations.
Specifically, the question ‘‘What are the significant parental contributions to child anxiety
sensitivity?’’ has not been easy to answer. However, when the specific research questions
posed by these studies are examined in aggregate, with the specific methodology of the
study taken into consideration, some consistency to these findings emerges. As such, this
paper attempted to provide a comprehensive review of the studies conducted to date that
have examined specific parental contributions to child AS. One specific goal of this review
was to examine recently reported findings in this area by research question, thus facilitating
a comparison of studies and attempting to account for discrepancies between findings by
more closely examining factors related to the studies’ methodology. Across the studies
reviewed here, parental anxiety was not found to be a significant predictor of child AS, and
the relationship between parental and child AS depended upon several methodological
factors, including the child reporter, the parent reporter, and the specific dimension of AS
being assessed. On the basis of the findings reviewed here, one general recommendation is
that more research in this area is needed, employing larger samples and studying these
constructs not only in normal samples, but in child clinical samples as well. Moreover,
asking more fine-grained research questions by examining specific facets of both parental
and child AS will also contribute to a better understanding of this area. Finally, as with any
area of research, replication of the findings reviewed here will be essential, particularly
with studies employing similar methodologies.
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