Research Spotlight: Temperament Predicts Persistent Anxiety in Early Childhood

By Sara Bufferd, Ph.D., California State University San Marcos

In short, what is the study about?

Emerging research has identified that preschool-aged children (ages 3 to 5) experience symptoms of anxiety as well as meet criteria for anxiety disorders. In a previous study (Bufferd et al., 2012), we identified that parents of up to 20% of 3-year-old children reported that their children demonstrated behavior consistent with an anxiety disorder (i.e., multiple symptoms of anxiety, such as worry, fears, and avoidance along with feelings of distress and/or impaired functioning in their ability to play, complete activities of daily living, and develop and maintain relationships). We followed these children from age 3 to age 6 and assessed anxiety disorders again. In this follow-up study, we found that children who met criteria for an anxiety disorder at age 3 were four times more likely to meet criteria for an anxiety disorder again at age 6 compared to children who did not meet criteria for an anxiety disorder at age 3. When we examined the data another way, we found that of the group of children who met criteria for an anxiety disorder at age 3, only 33.7% of them continued to meet criteria for an anxiety disorder at age 6. Therefore, we wanted to know whether we could predict which children would be more likely to continue to meet criteria for an anxiety disorder. In other words, we were curious why anxiety persisted for some children and not others during this period of time in early childhood and whether temperament predicts persistent anxiety in early childhood.

Of children who show symptoms of anxiety at age 3, only one-third continue to exhibit anxiety at age 6, and research showed that temperament predicted this persistence of anxiety in early childhood

To address this question, we considered whether children’s temperament could predict the likelihood of continued anxiety. Temperament is biologically-based and reflects children’s enduring tendencies in how they respond to different situations and regulate their emotions. We predicted that children with more inhibited, more negative, and less positive temperament would be more likely to demonstrate persistent anxiety compared to children with less inhibited, less negative, and more positive temperament. We measured children’s temperament (inhibition, negative emotionality, and positive emotionality) at age 3 by observing their behavior in various situations in our laboratory and having parents complete questionnaires, and we measured children’s anxiety at age 3 and age 6 by administering diagnostic interviews to parents.

What would be the most important take-home messages from the study?

We found that anxiety disorders were more likely to persist from age 3 to age 6 among children who demonstrated more inhibited and less positive temperament based on their behavior observed in the lab and according to parent reports of their children’s temperament. Conversely, children who met criteria for an anxiety disorder at age 3 and demonstrated less inhibited and more positive temperament were less likely to continue to meet criteria for an anxiety disorder at age 6. When we examine all temperament variables together, inhibition was the strongest predictor of persistent anxiety. Negative temperament (e.g., anger, sadness) was not associated with persistence of anxiety.

These findings help us understand which children may be at greater risk of persistent anxiety in early childhood. Children who are inhibited tend to avoid or withdraw from new experiences; when they do endure them, they may experience distress. These experiences include situations typical for young children to encounter, such as play dates, playground time, birthday parties, and socializing with parents’ friends. When inhibited children avoid these situations, they tend to feel better in the short-term. However, in the long-term, they may not learn how to manage these situations that are challenging for them, and therefore may not learn they actually can enjoy these situations. When children with low levels of positive emotionality have experiences such as learning a new skill or undergoing an effective social interaction that most children enjoy, they may not derive much satisfaction or pleasure. Taken together, inhibition and low positive emotionality can increase avoidance and withdrawal associated with anxiety disorders; in other words, behaviors that reflect high levels of inhibition and limited positive emotionality may increase risk for persistent anxiety in young children.

How are these findings important in practice?

It is important to identify whether young children’s behavior and emotional experiences are normative, mild, and/or transient, or whether their behavior and emotional experiences may reflect a potentially problematic, enduring issue. However, it is difficult to make this distinction as anxiety is developmentally typical in young children (e.g., it is common for young children to have fears, to be worried about separating from a caregiver, and to be nervous about interacting with new people or new situations). Therefore, the present findings can contribute to an emerging literature that seeks to use data to identify ways to better understand overlap and differences between typical and potentially problematic emotional and behavioral development (e.g., Bufferd et al., in press b; Wakschlag et al., 2012; 2014). Ideally, child practitioners (e.g., pediatricians, psychologists) can eventually use data from these types of studies to improve assessment, decision making, and prevention of and intervention for early-emerging psychological difficulties (Bufferd et al. 2016).

With regard to the present study, practitioners should know that children who demonstrate temperamental inhibition (e.g., distress, withdrawal, and/or avoidance in situations with new people, new objects, and/or in new places) and low positive emotionality (e.g., limited pleasure, joy, contentment) along with symptoms of anxiety and associated distress and/or impairment, should be identified and provided early intervention to improve their symptoms and reduce the likelihood that their anxiety will persist and impact their future development. The preschool period is an ideal time for prevention and intervention: first, there is greater neural plasticity in early childhood compared to other developmental periods when children are older, which suggests intervention can be particularly impactful at this time; second, intervention in early childhood can reduce difficulties that can worsen as children begin formal schooling and as opportunities for socialization increase; finally, inhibition and other factors in childhood can increase risk for the development of anxiety disorders over time (e.g., Clauss & Blackford, 2012; Hudson & Dodd, 2012; Wichstrøm et al., 2013), highlighting the importance of early intervention. As many studies have established effective treatments for preventing and reducing anxiety in young children (e.g., Chronis-Tuscano et al., 2015; Hirshfeld-Becker et al., 2010; Pincus et al., 2008; Rapee et al., 2010), such efforts are not only important but also achievable.

What other studies can be recommended to further an understanding/application of the findings?

I recommend reading the studies mentioned above:

Bufferd, S. J., Dougherty, L. R., Carlson, G. A., Rose, S. R., & Klein, D. N. (2012). Preschool psychopathology: Continuity from age 3 to 6. American Journal of Psychiatry, 169, 1157-1164.

Bufferd, S. J., Dougherty, L. R., & Olino, T. M. (In press b). Mapping the frequency and severity of depressive behaviors in preschool-aged children. Child Psychiatry & Human Development.

Bufferd, S. J., Dyson, M. W., Hernandez, I. G., & Wakschlag, L. S. (2016). Explicating the “developmental” in preschool psychopathology. In D. Cicchetti (Ed.), Developmental Psychopathology, Third Edition (pp. 152-186). Hoboken, NJ: John Wiley & Sons.

Chronis-Tuscano, A., Rubin, K. H., O’Brien, K. A., Coplan, R. J., Thomas, S. R., Dougherty, L. R., . . . Huggins, S. L. (2015). Preliminary evaluation of a multimodal early intervention program for behaviorally inhibited preschoolers. Journal of Consulting and Clinical Psychology, 83, 534-540.

Clauss, J. A., & Blackford, J. U. (2012). Behavioral inhibition and risk for developing social anxiety disorder: a meta-analytic study. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 1066-1075.

Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely, L. R., Pollock-Wurman, R. A., McQuade, J., . . . Biederman, J. (2010). Cognitive behavioral therapy for 4- to 7-year-old children with anxiety disorders: a randomized clinical trial. Journal of Consulting and Clinical Psychology, 78, 498-510.

Hudson, J. L., & Dodd, H. F. (2012). Informing early intervention: Preschool predictors of anxiety disorders in middle childhood. PLoS ONE, 7, e42359.

Pincus, D. B., Santucci, L. C., Ehrenreich, J. T., & Eyberg, S. M. (2008). The implementation of modified parent-child interaction therapy for youth with separation anxiety disorder. Cognitive and Behavioral Practice, 15, 118-125.

Rapee, R. M., Kennedy, S. J., Ingram, M., Edwards, S. L., & Sweeney, L. (2010). Altering the trajectory of anxiety in at-risk young children. American Journal of Psychiatry, 167, 1518-1525.
Wakschlag, L. S., Choi, S. W., Carter, A. S., Hullsiek, H., Burns, J., McCarthy, K., Leibenluft, E., Briggs-Gowan, M. J. (2012). Defining the developmental parameters of temper loss in early childhood: Implications for developmental psychopathology. Journal of Child Psychology and Psychiatry, 53, 1099-1108.

Wakschlag, L. S, Briggs-Gowan, M. J., Choi, S. W., Nichols, S. R., Kestler, J., Burns, J. L., Carter, A. S., & Henry, D. (2014). Advancing a multidimensional, developmental spectrum approach to preschool disruptive behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 53, 82-96.e83.

Wichstrom, L., Belsky, J., & Berg-Nielsen, T. S. (2013). Preschool predictors of childhood anxiety disorders: A prospective community study. Journal of Child Psychology and Psychiatry, 54, 1327-1336.

Link to the primary paper

Bufferd, S. J., Dougherty, L. R., Olino, T. M., Dyson, M. W., Carlson, G. A., & Klein, D. N. (In press a). Temperament distinguishes persistent/recurrent from remitting anxiety disorders across early childhood. Journal of Clinical Child and Adolescent Psychology. Advance online publication.


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