Journal or Consulting aad Clinical Psychology1987, №1.55. No. 2,229-235

Copyright 1987 by UK American Psychological Association, Inc.

0022.«>6X/87/$<X>.75

Psychopathology in the Offspring of Anxiety Disorders Patients

Samuel M. Turner, Deborah C. Beidel, and Anthony CostelloDepartment of Psychiatry

Western Psychiatric Institute and ClinicUniversity of Pittsburgh School of Medicine

Children of patients with an anxiety disorders diagnosis were assessed with a battery of self-report

inventories and a semistructured interview schedule. The performance of these children was com-

pared with that of children of patients with a diagnosis of dysthymic disorder, children of normal

parents, and normal school children. Children of anxiety disorders patients were found to be more

anxious and fearful; to report more school difficulties, more worries about family members and

themselves, and more somatic complaints; and to spend more time engaged in solitary activities than

children in either of the two normal groups. In addition, they were found to be more than 7 times

as likely to meet criteria for an anxiety disorder than the two normal groups and to be twice as likely

to have an anxiety disorder than the children of dysthymics. The resultant implications for familial

factors in anxiety disorders are discussed.

There is increasing evidence for the existence of a familial

factor in the anxiety disorders. Support for this factor is derived

from family history data as well as from twin studies. Early fam-

ily history studies with samples of adult anxiety neurotics have

revealed an increased morbidity rate for anxiety states among

the first degree relatives of patients with a diagnosed anxiety

disorder (e.g., Crowe, Pauls, Slyman, & Noyes, 1980; Noyes,

Clancy, Hoenk, & Slyman, 1980; Solyom, Beck, Solyom, & Hu-

gel, 1974). These early findings have been replicated with pa-

tient samples selected on more carefully defined Diagnostic and

Statistical Manual of Mental Disorders (DSM-IIf; American

Psychiatric Association, 1980) criteria (e.g., Crowe, 1985;

Crowe, Noyes, Pauls, & Slyman, 1983; Harris, Noyes, Crowe,

& Chaudry, 1983). For example, Crowe et al. (1983) reported a

panic disorder morbidity risk of 17.3% among relatives of indi-

viduals with diagnosed panic disorder. An additional 7.4% of

relatives had panic attacks that did not meet DSM-III criteria.

This compares with 1.8% and 0.4% morbidity rates among first

degree relatives of control subjects. Similarly, Harris et al.

(1983) reported the morbidity risk for agoraphobia in relatives

of probands with agoraphobia to be 8.6%; for panic disorder, to

be 7.7%; and for all anxiety disorders, to be 31.7%. This com-

pared with a morbidity risk of 4.2% for agoraphobia, 4.2% for

panic disorder, and 14.8% for all anxiety disorders among nor-

mal control subjects.

A recent study of twins with a variety of anxiety disorders

(panic disorder, agoraphobia, obsessive-compulsive disorder,

generalized anxiety disorder) was reported by Torgersen (1983).

This study examined the largest number of twin probands to

date for the anxiety disorders, including both monozygotic

(MZ) and same sex dyzygotic (DZ) pairs. The proband-wise

concordance rate for any diagnostic category of anxiety disor-

This study was supported in part by National Institute of Mental

Health Grant MH30915.

Correspondence concerning this article should be addressed to Sam-

uel M. Turner, 38110'Hara Street, Pittsburgh, Pennsylvania 15213.

der was higher for MZ pairs than for DZ pairs, with the excep-

tion of generalized anxiety disorder. Overall concordance was

34% for MZ twins and 17% for DZ twins. Interestingly, no MZ

co-twin was found to have the same anxiety disorder as the pro-

band, and there was greater concordance among the DZ twins

than among the MZ twins in generalized anxiety disorder. Al-

though Torgersen interpreted his results to support the genetic

transmission of anxiety disorders (except generalized anxiety

disorder), the data in fact seem to more strongly support the

hereditary transmission of a generalized predisposition for de-

veloping some type of anxiety disorder.

These studies provide strong evidence for a familial factor in

the anxiety disorders such that some individuals appear to be at

greater risk for the development of maladaptive anxiety than

others (Carey & Gottesman, 1981). However, whether this fa-

milial factor is biological, environmental, or a combination of

the two has yet to be determined. The concept of anxiety prone-

ness might serve as a valuable heuristic in examining both bio-

logical and psychological influence.

One method for examining the concept of anxiety proneness,

or vulnerability to anxiety, is to study the children of patients

with a diagnosis of an anxiety disorder, as has been done with

the offspring of depressive and schizophrenic patients (e.g.,

Ehrnlenmeyer-Kimling, 1975; Mednick & Schulsinger, 1968).

Although no studies have directly assessed the children of anxi-

ety patients, some data suggest that adult anxiety patients may

have first experienced maladaptive anxiety as children. For ex-

ample, Berg, Marks, McGuire, & Lipsedge (1974) reported ago-

raphobic women suffered from school phobia more often than

a normal control group. Separation anxiety, which in the

DSM-III now includes school phobia, has been shown to be

highly prevalent in the histories of agoraphobic patients. Gittel-

man (1984) reported that a notable proportion of hospitalized

agoraphobic adults reported an early history of severe separa-

tion anxiety. Of course, these data are limited because they rep-

resent retrospective self-report, and a recent study by Thyer,

Nesse, Cameron, and Curtis (1985) did not support this conclu-

229

230 S. TURNER, D. BEIDEL, AND A. COSTELLO

Table 1Subject Demographic Characteristics

Anxiety DysthymicCharacteristic offspring offspring Normal 1 Normal 2

Age(Af)Sex

MaleFemale

RaceBlackWhite

9.5

106

016

10.4

g6

113

9.5

67

49

9.7

124

016

Note. Normal 1 = solicited normal group; Normal 2 = school normalgroup.

The most recent data available are from the family historystudy by Weissman, Leckman, Merikangas, Gammon, and Pru-soff (1984). These investigators compared children of probandswith major depression (with and without anxiety disorders)with a group of matched control subjects. Children of probandswith depression plus panic disorder were found to be mostaffected. The most frequent problem reported in these childrenwas separation anxiety. Although these are important data, in-formation gathered in this fashion is problematic. Family his-tory studies, where the offspring have not been directly inter-viewed, have been shown to underestimate the rate ofpsychopa-thology (Andreasen, Rice, Endicott, Reich, & Coryell, 1986;Kendler, Masterson, Ungaro, & Davis, 1984). Also, Bondy,Sheslow, and Garcia (1985) found that mothers reliably identi-fied their child's main fears but for more secondary fears, reli-ability was quite low. In addition, mothers were more accuratein giving information pertaining to girls than to boys. Thus,data from studies where the child was not actually assessed mustbe viewed with appropriate skepticism.

In summary, there is strong evidence for the existence of afamilial factor in the anxiety disorders, although the specificmechanism of transmission has not been unequivocally identi-fied. Furthermore, anxiety patients report the experience ofvarious anxiety-related problems early in life. Thus, the avail-able data suggest that children of such patients might be at in-creased risk for childhood and adult anxiety disorders. Thepresent study was designed to evaluate the children of anxietydisorders patients by directly assessing them with a semi-struc-tured interview schedule and standardized psychological inven-tories.

Method

Subjects

The subjects were 59 children between the ages of 7 and 12. Sixteen

were the offspring of a parent with an anxiety disorder (agoraphobia orobsessive-compulsive disorder), 14 were the offspring of a parent with

dysthymic disorder, and 13 were the offspring of a parent with no identi-

fied psychiatric disorder who responded to an announcement soliciting

participants for the study. The final 16 children were obtained from an

elementary school and were selected as normal subjects on the basis of

a semistructured interview. The sample consisted of 38 boys and 24

girls. The mean age of the entire sample was 9.8 years. The demographic

characteristics of the sample are presented in Table 1.

Anxiety disorders group. Subjects constituting this group were chil-

dren of patients undergoing treatment in the Anxiety Disorders Clinic

at Western Psychiatric Institute and Clinic. To select subjects in this

group, a list was generated of all patients being treated in the Anxiety

Disorders Clinic with children in the appropriate age range. These pa-

tients were contacted by the senior author and were asked to participatein the study. To ensure that all patients were diagnosed properly, they

were reinterviewed using the Anxiety Disorders Interview Schedule

(ADIS; DiNardo, O'Brien, Barlow, Waddell, & Blanchard, 1983). Addi-

tional selection criteria required that parents had no other DSM-IIl

Axis I diagnosis and no Axis II diagnosis of avoidant, schizotypal, schiz-

oid, or borderline personality disorder. Although the unaffected parent

was not directly interviewed, no child was included if the second parent

had a history of psychiatric treatment as reported by the interviewed

parent.

Dysthymic control group. Children constituting this group were theoffspring of a parent with a DSM-I1I diagnosis of dysthymic disorder.

Patients in this group were recruited from the Affective Disorders Clinic

at Western Psychiatric Institute and Clinic. The ADIS and the General

Behavior Inventory (GBI; Depue, Slater, Wolfstetter-Kausch, Klein,

Goplerud, & Farr, 1981) were used to reach a diagnosis. The same exclu-

sionary criteria used with the anxiety disorders group applied here. In

addition, patients had to be free of any anxiety disorder and had toobtain a score greater than 21 on the GBI Dysthymia scale. Although

the unaffected parent was not directly interviewed, no child was in-

cluded in the sample if the second parent had a history of a psychiatric

disorder. Dysthymic patients were reimbursed $25 for their participa-tion.

Solicited normal volunteer group. Parent-child dyads were solicitedthrough media advertisements recruiting for a study on "feais and anxi-

eties in parents and children." The research was described as a survey

to determine if there was a relation between the fears expressed by par-

ents and those exhibited by their offspring. Inclusion in this group was

based on the absence of any DSM-III diagnosis in the interviewed par-

ent as determined by the ADIS diagnostic interview. The index parent

was also questioned about the history of any psychiatric treatment in

the second parent, and no child was included if there was evidence of

psychiatric disorder or treatment in either parent. In addition, the par-

ent had to score less than 21 on the GBI. Thus, in this group it was the

normality of the parent, and not the child, that determined inclusion.

These subjects were reimbursed $25 for their participation.

Normal child control group. These children were obtained through

an elementary school in the suburban Pittsburgh area and were in-cluded in the study based on the absence of any DSM-II1 diagnosis as

determined by a clinical interview. No information was obtained on the

psychiatric status of the parents of these children.

Assessment

Each child was administered the Fear Survey Schedule for Children-

Revised (FSSC-R; Ollendick, 1983), the State-Trait Anxiety Inventory

for Children (STAIC; Spielberger, 1973), and the Child Assessment

Schedule (CAS; Hodges, McKnew, Cytryn, Stern, & Kline, 1982). The

first two instruments are self-report inventories and were used to deter-

mine the total number of fears expressed by the child (FSSC-R), state

anxiety (STAIC State scale), and anxiety proneness (STAIC Trait scale).The CAS is a semistructured interview schedule that was designed to

measure adjustment in the following content areas: school, friends, ac-tivities, family, fears, worries, self-image, mood, somatic concerns, ex-

pression of anger, thought disorder, and total adjustment. In addition,

the interview is structured so the clinician can gather the pertinent in-

formation for formulation of 16 DSM-I1I diagnoses, including atten-

tion deficit disorder, conduct disorder, overanxious disorder, separation

anxiety disorder, psychotic disorders, and phobias. The CAS served adual purpose in the project: to measure adjustment in each of the con-

tent areas and to aid in documenting (or excluding subjects as in the

OFFSPRING OF ANXIETY PATIENTS 231

Table 2

Scores for Total Sample of Offspring on Interview and Self-Report Measures

Anxiety offspring(n=16)

Measure

CASSchoolFriendsActivitiesFamilyFearsWorriesSelf-imageMoodSomatic complaintsAngerThought disorderTotal score

STA1C

StateTrait

FSSC-R

M

1.75.1.19.1.18.2.814.31.5.13.2.183.25.2.94.2.561.81.

32.00.

30.00.34.06.

138.75

SD

2.351.641.521.944.333.541.833.042.241.413.31

17.19

4.165.60

17.64

Dysthymicoffspring(n = 14)

M

0.57b

1.14.0.14b1.503.93.4.14.2.361.86*1.79*3.291.14*

24.21*

29.28.30.86*

126.29

SD

0.941.230.532.883.344.291.692.712.552.671.75

14.40

2.849.00

32.46

Normal 1(»-13)

M

1.00*1.07.0.23,1.383.31*1.62b

1.770.54*1.84*2.53O.OOi

16.77*

28.31*32.69.

136.31

SD

1.151.930.601.662.721.801.301.662.083.570.009.86

2.907.23

24.87

Normal 2(n=16)

M

0.38b

O.OObO.OOb1.441.38b

0.63b

1.130.00C

0.75b

2.00O-OOt8.8 lc

26.25t27.3 lb

117.19

SD

0.720.000.001.361.200.961.200.001.340.890.003.49

3.593.53

20.04

UnivariateF

2.732.665.951.792.767.831.976.752.950.793.28

10.11

3.513.162.62

P

.05

.05

.01ns

.05

.0005ns

.001

.05ns

.025

.00005

.025

.05

.06

Note. CAS = Child Assessment Schedule; STAIC = State-Trait Anxiety Inventory for Children; FSSC-R = Fear Survey Schedule for Children-Revised. Normal 1 - solicited normal group; Normal 2 = school normal group. Means sharing subscripts are not significantly different at p < .05(Duncan's procedure).

normal child control group) the incidence of any DSM-H! Axis I diag-

nosis.

Procedure

The child independently filled out the self-report inventories. Parentand child were interviewed separately by clinicians experienced in theadministration of the ADIS and the CAS. Parent and child were inter-viewed by different clinicians, and the clinician interviewing the child

was always blind to the parent's psychiatric status. To determine inter-rater reliability, 25% of the parent interviews and 25% of the child inter-

views were randomly selected to be audiotaped. Audiotapes were ratedby a second clinician who was blind to the parent's psychiatric status.

Reliability of the CAS and ADIS Interviews

Reliabilities were calculated separately for each of the 11 content ar-eas of the CAS, using the Pearson product-moment correlation coeffi-cient. Interrater reliability was quite high for 10 of the I I content areas

(ranging from .S8-.99). The exception was the activities category, wherethe coefficient was .61. Interrater reliability for childhood diagnoses was

calculated using the kappa coefficient method, which yielded a kappavalue of. 82. Interrater reliability for adult diagnoses based on the ADISinterviews was also calculated using the kappa coefficient method, re-

sulting in a kappa value of .94.

Results

There were 9 parents (3 in the anxiety disorders group, 3 in

the dysthymic disorder group, and 3 in the normal parent

group) who had 2 children participate in the study. All children

were included in the initial data analysis. In a subsequent analy-

sis, 1 child was randomly selected from each of the multiple

child families to serve as the index case. The data were reana-

lyzed using this reduced set.

Child Assessment Schedule

The 12 individual scales of the Child Assessment Schedule

were analyzed using a one-way multivariate analysis of vari-

ance. The multivariate F statistic, computed by the Wilks's

lambda method, revealed a significant difference in adjustment

scores across the four groups, F(36, 130) = 1.89, p < .005. The

univariate F values indicated significant differences for 9 of the

12 content areas, including school adjustment, friendship, ac-

tivities, fears, worries, mood, somatic complaints, thought dis-

order, and total adjustment (see Table 2). All post hoc compari-

sons were analyzed with Duncan's multiple range test at an al-

pha level of .05. Table 2 lists the means for each of the groups

on each of the variables.

Because the purpose of this research project was to character-

ize the psychological adjustment of children of patients with

an anxiety disorders diagnosis, a comparison of the significant

findings pertaining to the anxiety disorders group is presented

first.

Psychological adjustment of anxiety disorders offspring. Post

hoc examination of the CAS content areas with the Duncan

multiple range test indicated that the anxiety disorders offspring

were significantly different from the normal school children

control group on each of the nine content areas where overall

significant differences occurred. The anxiety disorders offspring

reported more difficulties at school, fewer friendships, more

time spent engaged in solitary activities, more specific fears,

more worries about family members and themselves, more de-

pressed and anxious mood states, more somatic complaints,

and more episodes of confused thinking. In addition, their total

score indicated a significantly higher level of overall maladjust-

ment when compared with the normal school children (all

232 S. TURNER, D. BEIDEL, AND A. COSTELLO

When compared with the offspring of normal parents, the

children of anxiety disorders patients differed significantly in 5

of the 12 content areas. They spent more time engaged in soli-

tary activities, expressed more worries about family members

and themselves, reported more depressed and anxious mood

states, more incidents of confused thinking, and more general

maladjustment (all ps < .05).

Significant differences emerged between the offspring of dys-

thymic and anxiety disorders patients on 2 of the 12 content

areas. The anxiety disorders offspring reported more difficulties

at school and more time engaged in solitary activities than the

dysthymic offspring.

Comparison of dysthymic and normal offspring. Whereas the

anxiety disorders offspring differed significantly from the nor-

mal school children on 9 of 12 variables, the dysthymic off-

spring differed from the normal school children on only 5 of the

12 variables. The dysthymic offspring reported fewer friend-

ships, more fears, more worries about family members and

themselves, higher frequency of depressed and anxious mood

states, and higher levels of general maladjustment (all ps < .05).

Recalling that the anxiety disorder offspring differed from the

children of normal parents on 5 of the 12 scales, it is interesting

to note that there was only one significant difference between

the children of dysthymic parents and the children of normal

parents. Children of dysthymics expressed more worries about

their parents and themselves than did children of normal par-

ents.

Comparison of the two normal groups. There were no sig-

nificant differences between the two normal groups on any of

the 12 variables, although it is interesting to note that the scores

of the children of parents responding to advertisements were in

almost all cases substantially higher (indicating a tendency for

more maladjustment) than scores of the normal school children

recruited from an elementary school.

Analysis of Self-Report Inventories

Scores on the FSSC-R and the State and Trait scales of the

STAIC were analyzed with one-way analyses of variance. Therewere significant differences among the four groups on the State

scale, F(3,5S) = 3.51, p < .025, and the Trait scale, F(3,55) =

3.16, p < .05. Differences on the FSSC-R approached signifi-

cance, f\3, 55) = 2.62, p < .06. Post hoc analyses were con-

ducted with the Duncan multiple range test using a .05 signifi-

cance level.

On the STAIC State scale, both the children of anxiety disor-

ders and dysthymic patients had higher levels of state anxiety

than the normal school children (p < .05). The scores of the

children of the solicited normal parents did not differ signifi-cantly from any of the groups.

On the STAIC Trait scale, the children of anxiety disorders

patients and the children of solicited normal parents reported

significantly higher anxiety proneness than the normal school

children (p < .05). Interestingly, an examination of the means

indicated that the offspring of dysthymics, although not sig-

nificantly different from any of the other three groups, showed

substantially lower anxiety proneness than the children of solic-

ited normal parents and were not significantly higher than those

of the normal school children.

Finally, although scores on the FSSC-R did not quite reach

Table 3Children Meeting DSM-III Criteria (Total Sample)

-ni group

Group

Anxiety disorderDysthmic disorderSolicited normalSchool normal

16141316

7310

4422

80

Note. DSM-III = Diagnostic and Statistical Manual of Mental Disorders(American Psychiatric Association, 1980). Using Fisher's exact test, p =18 for the anxiety disorders group vs. the dysthymic disorders group,p = .0037 for the anxiety disorders group vs. the solicited normal group,and p = .0003 for the anxiety disorders group vs. the school normalgroup.

significance (p < .06), examination of the means in Table 2shows that the children of anxiety patients reported the greatest

number of fears, with the offspring of solicited normal parents

reporting an almost equal number of fears. The dysthymic

group scored 10 points lower than either of these two groups,

whereas the fewest number of fears were reported by the normalschool children.

Analysis of Children Meeting Criteria for a

DSM-III Disorder

A second method used to test the hypothesis of increased risk

in the offspring of anxiety disorders patients was to determine

the number of children in all groups who met DSM-III criteria

for any psychiatric disorder. Table 3 provides a breakdown of

the number of children in each group who met diagnostic cri-

teria for a psychiatric disorder.

As indicated in this table, 7 of the 16 offspring (44%) of anxi-

ety disorders patients met diagnostic criteria for a psychiatric

disorder. Four of the children met criteria for separation anxi-

ety, 2 met criteria for overanxious disorder, and 1 met criteria

for dysthymic disorder. In comparison, 3 of the 14 offspring

(21 %) of dysthymic disorders met diagnostic criteria, including

separation anxiety (1 child), overanxious disorder (1 child), and

social phobia (1 child). Only 1 of the normal parent offspring

(9%) met DSM-III criteria with a diagnosis of overanxious dis-

order. To test whether the anxiety disorders offspring were at

significantly greater risk than the other children, Fisher's exact

test was used. The percentage of anxiety offspring who met

DSM-III diagnostic criteria was statistically greater than both

normal groups (p < .01) but not greater than the offspring of

dysthymics (p > .05). Because statistical significance is partly a

function of the total sample size, an estimate of the degree of

association between parent group and childhood disorder thatwas independent of sample size was computed (cf. Fisher, 1954,

pp. 89-90). The statistic used, the odds ratio, is described in

detail by Fleiss (1981, pp. 61-64). According to this method,

the children of anxiety disorders patients were over 2 times as

likely to have any DSM-III disorder as the children of dys-

thymic patients (o = 2.85) and were twice as likely to have an

anxiety disorder (o = 2.12). Children of anxiety patients were

over 9 times as likely to have any DSM-III disorder as the chil-

OFFSPRING OF ANXIETY PATIENTS 233

Table 4

Scores for Reduced Sample of Offspring on Interview and Self-Report Measures

Anxiety offspring(n-13)

Measure

CASSchoolFriendsActivitiesFamilyFearsWorriesSelf-imageMoodSomatic complaintsAngerThought disorderTotal score

STAIC

StateTrait

FSSC-R

M

1.501.36,1.36.2.86,4.57.5.57.2.293.29.2.93.2.712.07.

33.50.

30.14.33.64,

137.93

SD

2.211.691.552.074.843.481.943.052.401.443.47

17.84

4.445.40

18.77

Dysthymicoffspring(n- 11)

M

0.631.36.0.19,,0.82k4.18,4.09.,,2.271.64.,,1.73*3.641-27*

24.09«>

29.55,31.45*

127.82

SD

1.031.290.600.983.224.161.792.252.802.841.90

14.98

2.709.63

32.19

Normal 1(n - 10)

M

1.331.22.0.22b

0.88b

3.56^1.78k,1.670.77,,2,56,0,3.000.00k

18.44*

28.56.,,32.89.J

138.11

SD

1.222.280.671.052.922.111.221.992.134.240.00

11.26

2.517.13

28.76

Normal 2<n=I6 )

M

0.38O.OOt0.00b1.4%1.38^0.63C

1.130.00t,0.75b

2.00O.OOb8.8U

26.25,,27.3 !„

117.19

SD

0.720.000.001.361.200.961.200.001.340.890.003.49

3.593.53

20.04

UnivariateF

1.943.096.395.073.068.451.766.442.851.063.259.56

3.512.822.29

P

ns.05.001.004.05.0001

ns.001.05

ns.05.0001

.025

.05ns

Note. CAS = Child Assessment Schedule; STAIC = State-Trait Anxiety Inventory for Children; FSSC-R - Fear Survey Schedule for Children-Revised. Normal 1 = solicited normal group; Normal 2 = school normal group. Means sharing subscripts are not significantly different at p < .05(Duncan's procedure).

dren of normal patients (o = 9.33) and were seven times as likely

to have an anxiety disorder (o = 7.2).

Reanalysis of Data Controlling for Families WithMultiple Children

In the previous analysis, each offspring was treated as an in-

dependent observation. Inasmuch as 9 parents each had 2 chil-

dren in the study, the usual assumptions of independent sam-

pling for analysis of variance might have been compromised.

Therefore, we randomly selected 1 child from each of these fam-ilies to serve as the index case and conducted the identical data

analyses using the reduced data set. The results were identical

to those obtained on the larger sample, with the exception of

results on two subscales of the CAS. The School subscale did not

reach significance in the reduced sample, whereas significant

differences did emerge on the Family subscale that were not

present in the larger analysis. Table 4 presents all of the data

from the reduced sample for all groups on each of the interview

and self-report measures.

Children Meeting DSM-m Criteria Using theReduced Sample

Using the reduced sample, re-analysis of the number of chil-

dren meeting DSM-Ifl diagnostic criteria replicated the full

sample results. Table 5 provides the breakdown by group of the

number of children meeting DSM-1I1 criteria for a psychiatric

disorder.Six of the 13 anxiety disorders offspring met criteria for a

DSM-III disorder, including 4 with separation anxiety and 2

with overanxious disorder. Three of the dysthymic offspring

met diagnostic criteria, including 1 with overanxious disorder,

1 with separation anxiety, and 1 with social phobia. There was

1 child in the normal parent group who had a diagnosis of over-

anxious disorder. Using Fisher's exact test, the percentage ofanxiety offspring with a DSM-III diagnosis was statistically

greater than that for the offspring in both normal groups, butnot greater than that for the offspring of dysthymics. Using the

odds ratio, children of anxiety disorders patients were over 2

times as likely to have a DSM-III diagnosis than the childrenof dysthymic patients (o = 2.29). Children of anxiety disorders

patients were over 18 times as likely to have a DSM-III diagno-

sis than children of normal parents (o = 18.2). This large changein the risk ratio comparing anxiety offspring with normal off-

spring was due solely to the removal of 1 child in the normalparent group who had a DSM-III diagnosis.

Discussion

This study examines familial factors in the offspring of anxi-ety disorders patients by directly assessing the children. Results

Table 5

Children Meeting DSM-at Criteria (Reduced Sample)

DSM-iu group

Group

Anxiety disorderDysthymic disorderSolicited normalSchool normal

N

13111016

n

6300

%

462700

Note. DSM-m - Diagnostic and Statistical Manual of Mental Disorders(American Psychiatric Association, 1980). Using Fisher's exact test, p -.30 for the anxiety disorders group vs. the dysthymic disorders group,p = .002 for the anxiety disorders group vs. the solicited normal group,and p = .0003 for the anxiety disorders group vs. the school normalgroup.

234 S. TURNER, D. BEIDEL, AND A. COSTELLO

confirm the findings of family history studies that suggest an

increased prevalence of anxiety disorders among the first degree

relatives of probands with an anxiety disorders diagnosis, in this

case, the children of patients with anxiety disorders. The results

revealed that the children of the anxiety disorders patients were

statistically more likely to meet criteria for a DSM-III child-

hood anxiety disorder than were children of normal volunteers

or normal children recruited from an elementary school. The

offspring of patients with anxiety disorders were more than 7

times as likely to be diagnosed with a DSM-III anxiety disorder

than the offspring of normal parents and twice as likely to reach

criteria for such a diagnosis than the offspring of dysthymic par-

ents. Thus, these data suggest that children of patients with an

anxiety disorder are at a greater risk for having an anxiety disor-

der themselves.

It is important to note that this study does not examine the

nature of this strong familial factor. Thus, the exact role of bio-

logical or psychological factors must await further study. How-

ever, the degree of risk for the anxiety offspring was greatest in

comparison with the normal groups. Although this finding was

not statistically significant, the anxiety offspring were also more

likely to have a DSM-III diagnosis than children of dysthymics.

When compared with the offspring of dysthymics, the anxiety

offspring were still at greater risk, although the difference be-

tween groups was not as great. This might suggest that the pres-

ence of any emotional disorder in parents creates a greater risk

for psychological disturbance in the offspring, as a number of

studies have suggested (e.g., Rutter, 1966).

A major purpose of the present study was to examine the

emotional as well as the overall adjustment of the offspring of

parents with an anxiety disorder. Such an examination consti-

tutes the first step in evaluating the concept of anxiety prone-

ness. It was reasoned that if certain individuals were more prone

to develop maladaptive anxiety, indicators or markers for this

vulnerability would be manifested prior to the onset of the par-

ticular disorder. No specific marker exists for anxiety, with the

possible exception of separation anxiety, which has been impli-

cated as an early indicator of agoraphobia (e.g., Gittelman,

1984). Although specific indicators of children at risk must

await the outcome of longitudinal research, the results pre-

sented here suggest a number of variables that might have heu-

ristic value. The results indicated that children of anxiety pa-

tients were significantly more anxious with respect to state anxi-

ety than children of normal parents or normal grade school

children. Children of dysthymics and those of anxious patients

were not significantly different on this measure. Again, one ex-

planation for this might be that children in any family where

one or more parent has an emotional disturbance are likely to

show some signs of maladjustment, particularly on measures

reflecting current emotional distress. Also, state anxiety can be

reflective of current or transient environmental factors of di-

verse origins.

A different picture emerges with respect to trait anxiety,

which is considered to be an indicator of anxiety proneness or

of a predisposition to respond with anxiety. The offspring of

anxiety patients showed significantly more trait anxiety than

the normal school children. Although this finding was not sta-

tistically significant, they did report somewhat more trait anxi-

ety than children in the other two groups. Whether or not this

indicates that anxiety offspring are more anxiety prone, and

perhaps at a greater risk for developing a specific anxiety disor-

der, must be determined by further study.

In examining the psychological adjustment of these children,

results indicate that the anxiety offspring had significantly

higher scores on factors usually associated with emotional dis-

tress and poor social adjustment than the children in the nor-

mal school group on nine different adjustment areas (see Table

2). Importantly, they showed more specific fears, difficulties at

school, worries about family members and themselves, de-

pressed and anxious mood states, somatic complaints, time

spent in solitary activities, fewer friends, episodes of confused

thinking, and a higher overall maladjustment score. Although

these data are limited to some extent due to their derivation

from self-report, they suggest that the offspring of anxiety disor-

ders patients show at a very early age characteristics similar to

those seen in patients with anxiety disorders. The number of

areas where anxiety offspring had significantly higher scores

was reduced to about half when they were compared with the

children of normal volunteers and to about a fourth when they

were compared with the offspring of dysthymics. In the latter

case, this appears, again, to illustrate the tendency for children

in families with emotional disturbance to show some adjust-

ment difficulty.

With respect to the two normal groups, there were a number

of significant differences when the total sample was used as the

basis for analysis. It is interesting that these differences included

trait anxiety and number of fears. When the sample was re-

duced, these differences did not reach statistical significance.

However, the mean scores for the solicited group actually in-

creased. Thus, the lack of significant differences was most likely

due to a loss of statistical power. Therefore, it appears that the

children of solicited volunteers scored in the direction of greater

maladjustment. The finding regarding the normal groups is an

interesting one. The children recruited from an elementary

school reported fewer problems than the children of normal

parent volunteers. One reason for this difference might be that

the selection criterion for the elementary school children group

called for the absence of any psychiatric diagnosis in the chil-

dren. Therefore, this group might be considered a super normal

group of children. This does not appear to be the case, however.

Recruiting for this sample led to the acceptance of the first 16

children interviewed. No exclusions were made due to psychiat-

ric disorders in the population. Thus, because a large group of

children were not eliminated to obtain the sample, we feel this

group was a representative normal group. A second possible

explanation for why the children of normal volunteers more

closely approximated children from the two patient groups may

be that parents who were concerned about their children were

more likely to volunteer for the project. In a number of in-

stances we felt this was precisely the case. Once again, this raises

the question of the suitability of solicited volunteers for normal

control groups.

The data presented here are limited to some extent by the

primary reliance on self-report, albeit self-report through two

different modalities. Yet, the consistency of these data with di-

agnostic findings is reassuring. Although patients with children

in the appropriate age range were randomly selected to partici-

pate in the study, it might well be that a different pattern of

OFFSPRING OF ANXIETY PATIENTS 235

results would have emerged if individuals not in treatment had

been included as subjects. Because individuals are in treatment,

the disorder may be more severe and may increase the likeli-

hood of problems in the offspring.

There are a number of other limitations to the data reported

here. First, as was noted earlier, the nature of the familial factor

in anxiety disorders cannot be determined from this study.

Thus, one cannot conclude that these data, for example, dem-

onstrate biological factors in the transmission of anxiety disor-

ders. Second, it has been our observation that the children of

anxiety disorders patients, and particularly those who are expe-

riencing panic, exhibit considerable concern about the welfare

of their parent. Therefore, one might expect the child of such a

patient to show more concern and worry regarding the parent

and, perhaps, to show a wider range of fear themselves. This

might not be an indication of a predisposition to anxiety but

merely a reaction to life circumstances. On the other hand, be-

cause observational learning has been shown to be a powerful

mechanism in the transmission of fear (e.g., Mineka, Davidson,

Cook, & Keir, 1985), one condition associated with the aquisi-

tion of fear appears to be present.

Despite these limitations of the data, the percentage of the

anxiety offspring meeting criteria for a DSM-Ifl childhood

anxiety disorder suggests that such children are at risk. These

results may indicate that the family study method is viable for

the anxiety disorders and that the concept of anxiety proneness

might be a valuable heuristic for the study of the genesis of the

anxiety disorders.

In summary, the findings of this study suggest that the off-

spring of anxiety disorders patients are considerably more wor-

ried and fearful than the offspring of normal volunteers and

normal elementary school children. To a lesser extent, offspring

of anxiety patients are also more worried and fearful than the

children of dysthymics. With respect to the potentially impor-

tant variable of anxiety proneness, the anxiety offspring scored

substantially higher than any group and significantly higher

than the normal school children. To the extent that trait anxiety

can be considered an index of the vulnerability to developing

an anxiety disorder, the offspring of anxiety disorders patients

appear to be at greater risk.

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Received May 12,1986

Revision received August 12,1986 •