Behavior Problems in Children of Parents with Anxiety Disorders
WENDY K. SILVERMAN, PH.D., JEROME A. CERNY, PH.D., WENDY B. NELLES, M.A.,
A ND ANNETTA E. BURKE, PH.D.
Abstract. T he Ch ild Behavior Checklist was obtained on 42 children whose parent s were given DSM -Ill
diagnoses of agoraphobia with panic attacks, panic disorder, generalized an xiety disorder. and a group of mixed
phob ics. Although prelim inary, results suggest that avoida nce in agoraphobia ma y be a key variable associated
with child maladjustment. Some possible mechanisms of familial transmission are discussed , with emphasis placed
on modeling. the family structure. and the severity of disorder. J. Am. Acad. Child Adolcsc. Psychiatry, 1988, 27.
6: 779-784. Key Words : risk, behavior problems. offspring, parents with anxiety disorders.
Evidence indicates that increased risk for child behavior
problems is associated with parental psychopathology. Chil-
dren of parents with anxiety disorders may constitute one
such sample at risk. Weissman et al. (1984) reported that
children ofdepressed patients with agoraphobia (AG) or panic
disorder (PD) were more likely to display separation anxiety
than ch ildren of depressed probands without anxiety disor-
ders. Similarl y, while the morbidity risk for all anxiety disor-
ders is 15% among the first degree relatives of controls, the
morbidity risk is 32% among the first degree relatives of AG
patients and 33% among the first degree relatives of indi vid-
uals with PD (e.g., Harris et al., 1983). There is also a
suggestion that genetic factors may be important in the de-
velopment of anxiety disorders (e.g., Inouye . 1965; Rose et
al., 1981; Torgersen, 1979, 1983; Young et al., 1971).
Recentl y, data have appeared that focus directly on assess-
ing the offspring of patients with anxiety disorders. Turner et
al. (1987) evaluated 16 children (ages 7 to 12) of anxiet y
disorders patients using a semistructured interview schedule ,
the Child Assessment Schedule (CAS) (Hodges et al., 1982),
and two self-report instruments, the Fear Survey Schedule
Accepted June 6. 1988.
Dr. Silverman is Director of the Child and Adolescent Fear and
Anxiety Treatment Program at The Center for Stress and Anxiety
Disorders. Psychology Department , The University at Albany-SUNY.
Ms . Nelles is a doctoral candidate in the clinical psychology training
program at The University at Albany-SUNY. Dr. Cerny is Professor
of Psychology at Indiana Stat e University. Terre Hallie. IN. Dr. Burke
recently received her Ph.D. in clinical psychology from the University
at Albany. She is currently Clinical Coordinator f or the Astor House
for Children. Rhinebeck. N Y.
The authors thank Andre w Eisen. Wayne Fleisig, and Chris Kearny
for assisting in the interviewing of subjects, and Bruce Dudek fo r
consulting with us on the data analytic procedures. Special thanks are
due to Dr. David H. Barlow f or his comme nts on an earlier draft of
this manuscript and for providing us with the patient population
necessary f or successf ul completion ofthis study.
This study was supported by a Faculty Development Grant awarded
to Dr. Silverman from the Research Foundation of the State University
of New York. Dr. Cerny was on sabbatical leave at the University at
Alban y. with partial support from a Faculty Development Grall!from
the Indiana Stat e University Research Foundation.
An elaboration of some of the issues raised in this article appears
in Advances in Clinical Child Psychology, Vol. II. B. B. Lah ey & A.
E. Kazdin, Plenum Press: New York. in press.
Reprint requests to Dr. Silverman , Department of Psychology.
University at Albany, State University of New York. Albany . NY
/2222.
0890-8567/88/2706-0779$02.00/0 © 1988 by the American Acad-
emy of Child and Adolescent Psychiatry .
779
Revised (FSSC-R) (Ollendick, 1983) and the State-Trait Anx-
iety Inventory for Children (STAIC) (Spielberger, 1973). The
comparison control group consisted of children of normal
parents (N = 13) who had responded to an announcement
soliciting part icipants for the study , and a sample of normal
school children (N = 16). Results indicated that the offspring
of patients with anxiet y disorders met the criteria for a DSM-
lIJ childhood anxiety disorder more frequently than the other
children. In particular, children of anxiety disorder parents
were more than seven times as likely to be diagnosed as
having an anxiety disorder compared to the children of nor-
mal controls and twice as likely to reach criteria for such a
diagnosis than the offspring of dysthymic parents. On the
CAS, the anxiety offspring had significantl y higher scores on
factors usually associated with emotional distress and social
adjustment than the children in the normal school children
group. In terms of the questionnaire measures , although the
FSSC-R showed no significant differences across groups, chil-
dren of anxiety disorder parents reported the most fears. These
children also scored highest on the STAIC state and trait
scales compared to any other group.
Sylvester et al. (1987) conducted a controlled study on
children (aged 7 to 17) of parents with anxiety disorders (PD
(N = 50), depression (N = 27), and normals (N = 48». The
results revealed that children from families with PD or depres-
sion had poorer adjustment ratings than the children of
normals. The child self-report measures of fearfulness and
anxiety state and trait revealed that only relatively increased
levels of severe fearfulness and anxiety trait differentiated
children of pathological parents from those of normal con-
trols. The depression measures differentiated children of PD
parents from those of depressed parents but failed to differ-
entiate children of PD probands from normal controls.
Rosenbaum et al. (1988) investigated the role of"behavioral
inhibition to the unfamiliar" as a predisposing characteristic
in children of parents with PO and AG by blindly evaluating
56 children (aged 2 to 7) for behavioral inhibition. Behavioral
indicators of "inhibition" include long latencies to interaction
with unfamiliar adults, retreat from unfamiliar objects or
people. cessation of play and vocalization, clinging to the
mother, and crying. According to the authors, this tempera-
mental quality of behavioral inhibition to the unfamiliar
might be a predisposing characteristic in children at risk for
PO and/or AG in later years.
The results revealed that the rates of behavioral inhibition,
as manifested by high latency to speak and a small number
780 SILVERMAN ET AL.
of spontaneous comments, in children of probands with PD
and AG, with or without comorbid major depressive disorder,
were significantly higher than for the comparison group (i.e.,
children who had parents without PD and AG but had a
family member in treatment at the same outpatient setting).
The data further suggested a progression of increasing rates
of inhibition from the comparison group without major de-
pressive disorder, to major depressive disorder, to comorbid
PD and AG and major depressive disorder, and to PD and
AG. Interestingly, no significant differences emerged in the
frequency of behavioral inhibition in the children of pro bands
with primary major depressive disorder or major depressive
disorder alone.
Although longitudinal research is necessary to determine
what might be specific indicators of risk for the anxiety
disorders, the studies reviewed above suggest several variables
that might have heuristic value . Nevertheless, in light of the
suggestion that parental diagnosis may be less predictive of
child maladjustment than other variables that interact or
correlate with parental psychopathology (e.g., Campbell,
1984; Fisher et al., 1980), it is important that some of these
other variables be explored in order to ascertain what it is
about anxiety disorders that may place youngsters who live
with an anxiety disorder parent at risk for psychological
problems. This was the purpose of the study described below.
Method
Subjects
The sample consisted of 28 families that included a parent
who had received a primary DSM-l/I diagnosis of agorapho-
bia with panic attacks (AG) (N = 14), generalized anxiety
disorder (GAD) (N = 5), panic disorder (PD) (N = 5), and a
group of mixed phobias (simple phobia, social phobia, and/
or obsessive-compulsive; N = 4). Information on the average
severity of the diagnosis, average duration of the disorder,
average number of panic attacks, and average severity rating
of avoidance was also available for each patient.
The families provided a total of 42 children who partici-
pated in the study: 22 children between the ages of 6 and II
and 20 children between the ages of 12 and 16. Of these 42
children, there were 24 boys with a mean age of 10 years, 10
months and 18 girls with a mean age of 13 years, 1 month.
There were nine sets of siblings included in this group of 42
children.
Measures and Procedures
Patients completed the Child Behavior Checklist (CBCL)
(Achenbach and Edelbrock, 1983), which assesses for a wide
range of childhood behavior problems and has age and gender
norms for clinic and non-clinic referred children. The children
completed several self-report measures. including the FSSC-
R, the Revised Children's Manifest Anxiety Scale (RCMAS)
(Reynolds and Richmond, 1978), and the Children's Depres-
sion Inventory (CDI).
Child behavior problems were also assessed by a semistruc-
tured interview designed by the first author, the Anxiety
Disorders Interview Schedule for Children, children and par-
ent versions (the ADlS-C and ADIS-P) (Silverman & Nelles,
1988), to yield one overall diagnosis. In contrast to other
existing child interviews (e.g., the DICA, KIDDIE-SADS), the
ADlS-C and ADIS-P are more specific for diagnosing child-
hood and adult anxiety disorders in children. The interviews
also permit the clinician to rule out alternative diagnoses such
as affective disorders and to provide quantifiable data con-
cerning anxiety symptomatology, etiology, course, and a func-
tional analysis of the disorder. The ADlS-C and ADIS-P have
been found to be reliable tools for diagnosing behavior prob-
lems in children with a special focus on anxiety disorders
(Silverman and Nelles, 1988). (A copy of the interview sched-
ule is available from the first author upon request.) Specifi-
cally, agreement between two independent raters on both the
child and the parent interviews for a primary diagnosis has
been calculated using the kappa statistic (Heiss, 1971). The
overall kappa coefficient has been found to be 0.84 for the
ADIS-C, 0.83 for the ADIS-P, the 0.78 for the composite
diagnosis (based upon combining the ADlS-C and ADlS-P
data). These kappas indicate a high level of agreement for
specific diagnostic categories.
Results
Accuracy a/Child Behavior Problems as Reported by
Patients
Methods of identifying child behavior problems were ex-
amined first to determine their accuracy. Child behavior
problems were identified from the CBCL if any of the indi-
vidual CBCL scales or the total CBCL raw score was greater
than the upper limit of the normal range reported by Achen-
bach and Edelbrock (1983) . The correlation between prob-
lems reported on the CBCL and problems identified during
the clinical interview with the child was 0.67. An agreement
of 74% was found between behavior problems reported by
the parent in the parent interview and the behavior problems
reported by the child in the child interview. A parent reported
a current behavior problem that was not confirmed by a
clinician when interviewing the child in just three cases, the
sons of two AG parents and the daughter of one GAD parent.
Thus, these data support the accuracy of the methods used in
this study and suggest that anxiety disorder patients do not
tend to overestimate problem behaviors in their offspring.
Parental Descriptive Data
Table I presents descriptive data for the parents diagnosed
with AG, PD, and GAD, as well as the group of mixed
phobics. The identified patient/parent was the mother in all
cases except three; the AG group, the GAD group, and the
PD group each had one father who was the identified patient.
In the AG group, none of the individuals had a concurrent
primary diagnosis; two AGs had secondary diagnoses of sim-
ple phobia of heights and hypochondria. In the GAD group,
one individual had a past episode of panic disorder; one also
had two secondary diagnoses, social phobia and dysthymia.
Of the five in the PD group, one had a concurrent primary
diagnosis of dysthymia, one had a concurrent diagnosis of
social phobia, and three had secondary diagnoses of simple
phobia. The mixed phobic group consisted offour individuals,
one with obsessive-compulsive disorder, one with social pho-
bia and two with both obsessive-compulsive disorder and
simple phobia. In addition, three of the four mixed phobics
had secondary diagnoses of social phobia.
 CHILDREN OF PARENTS WITH ANXIETY DISORDERS 781
TABLE 1. Descriptive Datafor Parent Diagnostic Categories TABLE 2. CBCL Total Mean Raw Scores for Offspring of Patients
Variable AG PD GAD Mixed with Anxiety Disorders Compared with the CBCL Nonclinical
Samples
No. of families 14 S S 4
M:F ratio 1:13 1:4 1:4 0:4 Nonclinical
Group Offspring T
Average age 36.92 40.2 36.0 38.2S Sample"
(S.38) (4.02) (2.3S) (2.22) Girls 6-11
Average no. of Mean 39.S0 19.90 3.10·
children 2.4 2.0 1.8 2.0 SD IS.60 14.20
Duration (yrs) 9.64 12.4 28.3 23.S· N=9
(6.4S) (16.60) (13.9) ( 11.7) Girls 12-16
Severity ( 1.17) S.23 S.OO 4.40 Mean 24.10 16.60 2.80·
(0.00) (O.SS) (1.29) S.SO SD IO.S0 14.10
Panic symp- 9.00 9.86 4.00 6.S0· N=9
toms ( 1.9S) (2.41) (S.OS) (2.38) Boys 6-11
Panic frequency 4.09 4.00 0.40 3.S0 Mean 29.90 21.70 1.74
per week (7.38) (2.00) (O.SS) (4.04) N= 13 IS.70 is.oo
Avoidance 12.71 8.60 0.80 9.00' Boys 12-16
(S.S4) (3.21) ( 1.79) (4.97)'
Note: AG = agoraphobics with panic attacks. PD = panic disorder, Mean 29.80 17.S0 1.98
GAD = generalized anxiety disorder, Mixed = mixed phobic group. SD 18.60 IS.60
Standard deviations are in parentheses. N= II
·p<O.OI. Q: Data for the nonclinical samples are taken from Achenbach and
Edelbrock, 1983.
• P < O.OS.
One-way analysis of variance indicated that both the GAD
and the mixed phobic groups tended to have longer duration sistently higher total behavior problem scores than the non-
of disorder than the AG and PD groups (F[3, 24] = 6.36, p clinical samples.
< 0.01). None of the groups was found to differ significantly, The number of children whose total CBCL raw scores
using a Games-Howell modification of the Tukey procedure, would place them in the clinical range was examined next. Of
which is a stringent correction for heterogeneity of variance. the 42 children in our sample, five of 24 boys (two from the
The AG group had higher avoidance ratings than the mixed same family) and eight of 18 girls (two from the same family)
phobic, PD and GAD groups (F[3, 27] = 8.01, p < 0.01). A had total CBCL raw scores that were in the clinical range.
Games-Howell modification found the GAD group to be These data are displayed in Tables 3 and 4. Four boys and
significantly lower than the other three groups. Both the AG six girls were assigned diagnoses by the clinical interviewers
and the PD groups reported more panic symptoms than either but were not rated by their parents on the CBCL as having
the mixed phobic or the GAD groups (F[3, 27] = 5.11, p < an identifiable behavior problem. Three of these four boys
0.0 I). None of the groups was found to differ significantly, and three of these six girls had parents who were diagnosed
using the Games-Howell modification. Although the AG and as AG. The parents of the remaining four children were part
PD groups had almost identical mean scores on frequency of of the mixed phobic group. These data again demonstrate
panic attacks, the range for panic episodes was three times that anxiety disorder patients, especially those with AG or
greater for the AG group. Similar to previous reports (Barlow other phobias, do not overestimate behavior problems in their
et aI., 1986), panic attacks were reported across all four children.
diagnostic categories. Overall, these data confirm that the AG Tables 3 and 4 reveal that 12 boys (50%) and 13 girls (72%)
group has the highest rate of avoidance behavior and that the were identified as having a behavior problem based upon
rate of panic attacks does not distinguish AG from PD. either or both parental reports on the CBCL or upon inter-
viewing the child. With the exception of one boy who was
Behavior Problems Displayed by the Children diagnosed with oppositional disorder plus simple phobia, and
Whether the children of the anxiety disorder patients had one girl and one boy who were both diagnosed with attention
more behavior problems on average than the children who deficit disorder, the clinical diagnoses derived from the
comprised the CBCL normative sample was examined next. ADIS-C were all anxiety related.
T-tests were conducted to compare the total CBCL raw scores To further examine the relationship between parent diag-
of all the children in our sample with the appropriate age and nosis and child maladjustments, the children were reclassified
gender norms from Achenbach and Edelbrock's (1983) non- according to the diagnosis of the parent/patient. Seventeen of
clinical sample. When siblings fell into the same age-gender the 21 (81%) children with an AG parent, two of the seven
group, only the oldest child's scores were included. On the (29%) children with a GAD parent, none of the six children
average, the CBCL total raw scores for our sample were higher with a PD parent, and six of the eight (75%) children with a
than the normative sample for all four age-gender groups. mixed phobic parent received a clinical diagnosis and/or had
The 6- to II-year-old girls and the 12- to 16-year-old girls one or more CBCL scale scores in the clinical range. The chi-
both had significantly higher mean total behavior problem square analysis of these data was significant (x~ = 16.40, p <
scores than did the respective nonclinical samples (see Table O.OS) suggesting that the presence of phobic or avoidance
2). Though not significant, the boys in our sample had con- behavior is highly associated with child behavior problems.
782 SILVERMAN ET AL.

TABLE 3. CBCL Scores and Interview Diagnoses for Boys of Parents TABLE 4. CBCL Scores and Interview Diagnoses for Girls of Parents
with Anxiety Disorders with Anxiety Disorders
Total CBCL Scales Total CBCL Scales
Parent Parent
Subject" Age CBCL in Clinical Subject" Age CBCL in Clinical Child Ox "
Ox " Ox "
Score' Ranged Score ' Range d
I, 9 A+P 17 None I, 10 A+P 52 int , ext SP
2, 8 A+P 36 d. int Sop.SP 2, II A+P 66 a. b. c. d. SP
3, 7 A+P 4 None into
4 II A+P 45 f, Sum None ext ,
5 II A+P 59 c, e, int, ext None Sum
6, 6 A+P None 3 10 A+P 46 int, Sum OA
7 13 A+P 60 k, g. h, ext OPP. SP 4 15 A+P 27 OA
8, 12 A+P 27 g SP,OA 5 15 A+P 44 e, f, int, SoP,SP
9 16 A+P 19 Av, SP Sum
10 15 A+P 10 SA,OA 6 18 A+P 17 SP,SoP
II 15 A+P 19 Av, SP 7 13 A+P 60 SP,OA
12 17 A+P 20 SP 8 10 A+P 60 SP. OA, SoP
13, 15 PO 18 None 9 15 A+P 14 Past episode PO
14, 14 PO None 10 9 PO 23 None
15. 16 PO None II 15 PO 28 None
16 6 GAO 31 None 12 14 PO 26 None
17 II GAO 15 None 13 15 GAO 51 g, h. None
18 6 GAO 24 None 14, 9 GAO 14 None
19. 7 GAO 18 None 15, 10 SoP 27 Attdef
20~ 12 GAO 45 h. j. int, ext Attdef 16, 13 SoP 14 Av
21~ 8 SP 53 a, b. c, f, i. int OA 17, 7 OC 30 OC
226 II SP SP 18, 10 OC 36 c, int OC
236 9 OC 25 None " Subjects having the same subscript are siblings.
24 12 OC 18 None " A+P = agoraphobia with panic, PO = panic disorder, GAO =
" Subjects having the same subscript are siblings. generalized anxiety disorder, OC = obsessive-compulsive disorder,
"A+P = agoraphobia with panic. PO = panic disorder. GAO = SoP = social phobia. SP = simple phobia, OA = overanxious disorder.
generalized anxiety disorder. SP = simple phobia. OC = obsessive- Attdef = attention deficit disorder, Conduct = conduct disorder, Av
compulsive disorder. SoP = social phobia. OA = overanxious disor- = avoidant anxiety disorder.
der, Opp = oppositional disorder. Attdef = attention deficit disorder, ' Scores in italics are above the upper limit of the nonclinical
SA = separation anxiety disorder, Av = avoidance anxiety disorder. samples.
' Scores in italics are above the upper limit of the nonclinical d a = depressed. b = social withdrawal. c = sex problems, d =
samples. aggressive, e = anxious/obsessive. f = somatic complaints. g = de-
,J a = schizoid/anxious, b = depressed. c = uncommunicative, d = pressed/withdrawn, h = delinquent. int = internalizing. ext = exter-
obsess/comp, e = somatic complaint, f = social withdrawal. g = nalizing.
hyperactive, h = aggressive, i = delinquent.j = immature, k = hostile
withdrawal, int = internalizing, ext = externalizing.
(N = 3) families had more than one child identified as having
a behavior problem .
Internalizing, externalizing. and total CBCL raw scores for
each of the four diagnostic categories were also compared. Parental Avoidance as a Risk Factor
Although not significant, the AG group tended to score higher
than the other three groups for total behavior problems, and In addition to parental diagnosis, the above data suggest
higher than the GAD and PD groups and equal to the mixed that parent diagnoses associated with higher levels of avoid-
phobic group on both internalizing and externalizing scales. ance behavior (i.e., AG and mixed phobics) may present the
Only one significant difference emerged on the children 's greatest risk to the offspring. To examine this hypothesis, the
questionnaire data. Children with an AG parent scored sig- children were classified according to the avoidance scores of
nificantly higher on the FSSC-R than the children with a their parents. regardless of parental diagnosis. Avoidance
GAD parent (F[3 , 37] = 3.20, p < 0.05). The phobic and PD scores were obtained from the ADIS. the diagnostic interview
groups had scores that fell between these two groups. administered to the patients (DiNardo et al., 1983). On the
The number of families that had at least one child whose ADIS. the clinician rates each patient's avoidance in 23
score had an identified behavior problem was also examined , commonly encountered situat ions on a 0 to 4 point scale
since some of the children in this sample were siblings. Eleven ranging from no avoidance (enters without difficulty) to very
of the 14 AG families. none of five PD families, one of five severe avoidance (never enters a situation even with a safe
GAD families, and three of four mixed phobic families had person). The low avoidance group had avoidance scores be-
one or more children who were identified as having a behavior tween 0 and 9 whereas the high avoidance groups had scores
problem that was significantly different (x~[3] = 6.59, p < between 10 and 20. The children of these patients were
0.05). In addition, only the AG (N = 4) and the mixed phobic classified into either a low or high avoidance group according
 CHILDREN OF PARENTS WITH ANXIETY DISORDERS
to a median split of their parents' avoidance scores. There
were 19 children in the low avoidance group and 23 children
in the high avoidance group.
Nine of 19 (47%) children in the low avoidance group were
assigned a clinical diagnosis and/or had one or more CBCL
score in the clinical range; 15 of23 (65%) children in the high
avoidance group received a clinical diagnosis and/or had one
or more CBCL scale scores in the clinical range. Although the
children in the high avoidance group tended to have higher
internalizing, externalizing, and total CBCL raw scores than
the children in the low avoidance group, these differences
were not significant. On the children's questionnaire data, the
high avoidance group had significantly higher trait anxiety
scores than the low avoidance group (1[38] = -2.02, p <
0.050). No other fear or anxiety measure was significantly
different between the two groups.
Since the occurrence of panic attacks has also been identi-
fied as a key factor in the development of psychopathology in
first degree relatives (Weissman et al., 1984), it seemed im-
portant to clarify the roles of panic attacks and avoidance
behaviors in the increased risk associated with anxiety disor-
ders. Thus, subjects were reclassified as offspring of AG pa-
tients with low panic frequency; offspring of AG patients with
high panic frequency; offspring of PD patients (i.e., patients
with panic attacks but no or very low rates of avoidance
behaviors); and offspring of the mixed phobic group. The
group of youngsters ofan AG parent with low panic frequency
contained 12 children, the AG group with high panic fre-
quency contained nine children, the PD group contained six
children, and the mixed phobic group contained 25 children.
The AG groups with low and high panic frequency had,
respectively, 10of 12 (83%) and seven of nine (78%) children
who had one or more behavior problem identified on the
parental CBCL and/or the child interview. Eight of 15 chil-
dren (53%) in the mixed phobic group were identified as
having a behavior problem. None of the six children in the
PD group, however, had an identified behavioral problem.
Similar findings appeared when the data for families rather
than for children were examined. Six of the seven low panic
AG families and five of seven of the high panic AG families
had children with identifiable behavior problems. Five of nine
(65%) mixed phobic families had a child with an identifiable
behavior problem, and none of the PD families had any
children with identifiable behavior problems.
Discussion
Despite the relatively small sample sizes of this study,
consistent findings emerged. Irrespective of panic attack fre-
quency, the AG groups consistently had the most children
with identifiable behavior problems, followed by the mixed
phobic group and the PD group. Since both the low and high
panic frequency AG groups had high rates of avoidance
behavior but differed in their panic frequencies, it is likely
that it is the occurrence of avoidance behavior rather than the
rate of panic attacks that is primary in the development of
child maladjustment. The relatively high rate of problem
behaviors among the children of the mixed phobic group
whose parents have, on average, rates of avoidance behavior
783
higher than PD patients but rates lower than AG patients,
provides further support for this notion.
Since the course of the childhood problems identified in
this study is unclear, the children's developmental progress is
being monitored. One year follow-up data from approxi-
mately one quarter of the sample reveals that the identified
behavioral problems have persisted. If this trend continues, it
will suggest that the identifiable problems may be early mark-
ers of greater susceptibility of anxiety related problems.
It is premature to state definitively what it is about agora-
phobic/avoidance behavior that may put children at risk, but
a few speculations can be offered. As Rosenbaum et aI. (1988)
noted, exposure to an AG parent may predispose a child to
develop a more anxious stance by offering a model of caution
and fearfulness. There have also been reports that the families
of AG patients were overprotective of them as children (Roth,
1959; Terhune, 1949). Solyom and his colleagues ( 1974, 1976)
have reported that mothers of AG patients score significantly
higher than controls on measures of maternal control and
concern than the overprotective mothers on whom the scale
norms were based. This would suggest, therefore, that an AG
parent may instill anxious attachment in the child.
Clinical experience has also indicated that AG parents who
avoid a large number ofdifferent situations frequently develop
a rule system, either implicit or explicit, focusing on phobic
symptomatology. These rules tend to be rigid and ritualistic,
sustaining the parent's avoidance behavior. Many AG patients
also deny their phobic problems to family members for fear
of loss of self esteem and prestige within the family. Clinical
observation has also shown that some patients insist that
children remain home from school, so the patient has access
to "a safe person." In light of the above, it is readily under-
standable how such a rigidly structured and seemingly irra-
tional environment could contribute to behavior problems in
the child.
It has also been suggested that AG may represent the most
extreme form of pathology among the anxiety disorders (e.g.,
Breier et al., 1986; Noyes et al., 1986). If this is true, it is
possible that child maladjustment is associated with any pa-
rental mental disorder that is severe. In other words, the
severity of the disorder, not the specific problem, is what is
associated with child psychopathology (e.g., Campbell, 1984;
Rutter, 1966). To more fully pursue this issue, the authors
plan to include comparison groups of parents with different
psychiatric disorders in future work.
The above argument suggests that PD and AG are different
points along the same continuum and that it is avoidance
behavior that is the critical feature associated with the severity
of the disorder. This then raises the question about the role
of panic attacks as the critical variable associated with risk. In
the authors' view, several important points weaken the sug-
gestion that it is panic attacks as opposed to overt avoidance
behavior that is the key element. One point is that panic
attacks frequently occur in all the anxiety disorders (e.g.,
Barlow et al., 1986; Cerny et al., 1984). Indeed, in this sample,
the number of panic attacks across the four diagnostic cate-
gories was not significantly different. Second, irrespective of
panic attack frequency, the AG groups consistently had the
most children with identifiable behavior problems. Certainly
784 SILVERMAN ET AL.
the relative contribution of parental panic attacks and avoid-
ance behavior in predicting child maladjustment requires
further research. The results from other risk studies (cf. Camp-
bell, 1984), also underscore the importance of investigating
the combined input of multiple risk factors, rather than
examining these factors individually.
This study is not without methodological limitations that
should be noted , including the relatively small sample sizes
studied and the absence of comparison groups (i.e., a normal
comparison group and an other psychiatric disordered parent
group). The absence of a normal comparison group is not a
major problem, since the CBCL has normative data for both
clinical and nonclinical samples that allowed the authors' to
make comparisons. Statistical deviance may not necessarily
imply pathology (Rutter et al., 1976); however, beyond using
the normative data of the CBCL, it would have been useful if
the study had used comparison groups from the local popu-
lation. Also lacking in this study were ratings from additional
"unbiased" sources, such as teachers or the other "normal"
spouse. The use of multiple informants would have helped to
generate a more complete, unb iased picture of the children's
behavior across multiple settings . These data are being ob-
tained in the authors' current work. In addition, these children
need to be followed longitudinally to learn whether the iden-
tified problems are in fact early markers of anxiety. Finall y,
one cannot determine from these data the nature of the
familial factor (e.g., biological, psychological, etc.). Despite
these limitations, the present study is a reasonable step in
determining the nature of the familial influence in the anxiety
disorders.
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