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Research Article                                                                                                                                        Open Access

## Exploring the Contribution of Parental Perceptions to Childhood Anxiety

Barbara H. Esbjørn*, Ida D. Caspersen, Mikael J. Sømhovd, Sonja Breinholst, Marie Louise Reinholdt-Dunne

Department of Psychology, University of Copenhagen, 1353 Copenhagen K, Denmark

*Corresponding author: barbara.hoff@psy.ku.dk

## Abstract

Parental rearing practices such as over-involvement are associated with childhood anxiety; however, little is known about the contribution of parental perceptions to child anxiety. This study explores the relationship between maternal and paternal perceptions of parenting and childhood anxiety. The perceived rearing behaviors and parental sense of competence (i.e., satisfaction and efficacy) of the parents of anxious children (n = 59) were compared with those of a non-clinical control sample (n = 44). In line with the findings from the literature that addresses externalizing disorders, parental sense of competence was significantly associated with childhood outcomes. Logistical regression suggested that paternal efficacy beliefs, acceptance, and maternal satisfaction were associated with an absence of clinical anxiety and lower levels of anxiety symptoms in children. Parental perceptions may thus provide an important area for understanding childhood anxiety.

Keywords: Child anxiety disorder, parental cognitions, rearing practice, sense of competence

## Introduction

An increased understanding of early risk factors and mechanisms involved in the development and maintenance of anxiety disorders during childhood precedes the detection, prevention, and treatment of the condition. Parental anxiety, which may lead to a genetic vulnerability in the child (1),  has  been shown to contribute to child anxiety. The remaining risk is the result of individual or shared environmental factors, such as parental rearing behaviors. Bögels and Brechman-Toussaint (2) suggested that cognitions and beliefs held by parents  may  be important predictors of actual parental behavior, but they admitted that the study of  this  topic  had  been  highly  neglected.  Further studies of parental perceptions and how they relate to childhood anxiety should therefore be conducted to address this shortcoming of the literature.

## Parental perceptions and cognitions

At a general level, Bugental and Johnston (3) conceptualize  parental  perceptions  and  cognitions as deriving from two interacting levels: the schematic level and the event-dependent level. The schematic level involves stable knowledge structures that  operate  implicitly  and  automatically,  without conscious  awareness,  whereas  the  event-dependent level  operates  with  high  awareness  and  reflection. Both  are  driven  by  specific  events  and  situations. Within these levels, four different types of parental cognitions  may  be  identified:  1) descriptive  cognitions describe  the way  interactions  in the family are perceived to be based on experiences in the family context; 2) analytical cognitions relate to the understanding of causal relations for family-related events;  3) evaluative-prescriptive cognitions describe  the idealistic perceptions (i.e., values and goals) of how the  family  should  function;  and  d) efficacy  cognitions involve  the  correspondence  between  the  perceived reality (descriptive cognitions) and the desired ideals (evaluative-prescriptive cognitions). Thus, a sense of parental efficacy arises when parents expect themselves to be able to cope with the demands of child rearing and to successfully influence the behavior  and  development  of  a  child,  including coping with difficulties in the parenting context (4).

A derivative of parental efficacy is parental satisfaction. Parental efficacy may be thought of as referring  to  the  instrumental  aspects  of  parenting, whereas parental satisfaction describes the affective dimension. Parental satisfaction consists of the emotional derivatives of the parents' perceived ability to cope with the tasks of parenting in light of their  idealized  perceptions  of  how  it  should  be. Parental  efficacy  and  satisfaction  have  been  joined in the overall concept of parental sense of competence; the two dimensions seem to be highly associated, although  the  direction of the effect remains unclear (5). It has been suggested that high parental satisfaction boosts parental efficacy (6) and that  high  parental  efficacy  predicts  high  parental satisfaction (4).

Parental cognitions and sense of competence have been studied extensively with regard to externalizing child  behavior.  Parental  self-efficacy  beliefs  have been  associated  with  child  adjustment,  and  they contribute significantly to the parent-child interaction  when  difficult  child  behavior  is  present (4,5).  Furthermore,  increased  parental  competence is associated with reduced levels of problem behavior in children (7). Some treatment programs designed  to  alleviate  problem  behavior  in  children build  on the notion that enhancing the skills, confidence,  and  self-sufficiency  of  the  parents  will promote child competencies within the behavioral, social, intellectual, and emotional fields (8). Findings from the field of externalizing disorders suggest that further research regarding the importance of parental  perceptions  on  childhood  anxiety  should also be conducted.

## Parental perceptions and child anxiety

To  fully understand how  the perceived family dynamics  may  be  involved  in  creating  negative parental  perceptions,  one  should  consider  the  key dimensions  of  rearing  behavior  involved  in  child anxiety.  Anxious  modeling,  over-involvement,  and excessive control as well as high levels of negativity have been reported to be associated with increased levels  of  child  anxiety  (9).  However,  evidence  for the  unique  contribution  to  childhood  anxiety  of each  of  these  parenting  variables  is  inconsistent (10).  The  most  stable  evidence  has  been  collected for the effect of parental over-involvement. It suggests that reduced autonomy granting and excessive  involvement  are  related  to  an  increased risk of child anxiety (11,12). Current theories suggest a bidirectional association in which parental factors may increase the risk of anxiety in the child and in which child anxiety may increase the risk of negative behaviors in the parent (9). Although some of this evidence is collected via observational measures of  actual  parental  behavior,  most  studies have  included  self-  or  child-report  measures  (13). Studies  that  include  child-report  measures  suggest that clinically anxious children perceive their parents as less accepting as compared with control children (14).  Moreover,  a  positive  correlation  between  the child's level of worry and his or her perceptions of parental  rejection  and  anxious  rearing  has  been reported in non-clinical (15) and clinical child samples  (16).  Children  with  high  levels  of  social anxiety have reported that perceived anxious behavior in their fathers-but not in their mothers-increased their level of anxiety in a hypothetical social situation (17).

Studies  of  parental  cognitions  (other  than  the ones  mentioned  previously)  that  have  discussed perceived rearing behavior have predominantly addressed  parental cognitions at the descriptive level.  These  have  mainly  addressed  the  potential influence  of  maternal  expectations  regarding  the anxious behavior of the child on child adjustment. Maternal  expectations  of  poor  coping  behavior  in the  child  (18),  parental  beliefs  about  child  anxiety (19), and elevated threat perceptions (20) have been suggested to be characteristic of maternal cognitions in mothers of clinically anxious children (21). Because most studies solely focus on the descriptive level  of  parental  cognitions,  important  information about the family dynamics, including the impact of parental perceptions on other levels (e.g., the efficacy level), should be assessed in populations in which childhood anxiety disorders are present. The assessment of parental efficacy beliefs supplements the descriptive level by adding a subjective evaluation of the agreement between perceived and desired reality.

## Parental gender

Most  studies  of  parental  behavior  involve  only mothers.  However,  studies  involving  fathers  have shown that fathers of anxious children exhibit more controlling  and  less  autonomy-granting  behavior than fathers of non-anxious children (22,23). It has been suggested that fathers play a different role than mothers  by  encouraging  children  to  explore  the external  world  to  a  larger  extent  than  mothers  do (24).  To  date,  little  is  known  about  how  parental perceptions and parent-child interactions are moderated by parent gender (10).

A  recent  study  of  586  mothers  and  615  fathers found  fathers  to  score  higher  on  the  satisfaction subscale  than  mothers,  whereas  mothers  scored higher on the efficacy subscale (25). However, only one parent per family participated,  thereby making it  difficult to disentangle the contribution of family dynamics.  Nevertheless,  the  finding  that  fathers associate the parenting role with higher satisfaction has also been demonstrated by Rogers and Matthews (26), who assessed co-parenting mothers and fathers from a sample of individuals participating in a parenting program. Despite these findings, the intergenerational transmission mechanisms  that link parental factors to child anxiety are still not clearly understood (21). Attempts  should  be  made  to  understand  which factors  other  than  genetic  predisposition,  parental anxiety, and parenting behaviors are associated with childhood anxiety.

## Aim of the study

The  goal  of  the  present  study  was  to  explore whether parent-reported beliefs about parental behavior,  efficacy,  and  satisfaction  contribute  to children's reported levels of anxiety. We  also assessed the  unique influence of mothers' and fathers' perceptions of parenting behavior and competence on childhood anxiety. As a result of the lack of studies addressing this topic within the field of childhood anxiety disorders, this study is exploratory in nature, and we therefore caution the reader when  interpreting the results. However, drawing on findings from the literature that addresses  externalizing  behavior,  we  expected  to find similar significant associations between reported  levels  of  anxiety  and  parental  efficacy, satisfaction, and behavior. We also expected parents of anxious children to report lower levels of competence  and  satisfaction  than  parents  of  nonanxious control children. Although conclusions from the literature about the unique contribution of maternal and paternal perceptions are still preliminary  in  nature,  we  did  expect  to  find  some gender-specific differences with regard to contribution.

## Materials and methods

## Participants

The study enrolled two groups of participants. The clinical  sample  (n  =  59)  included  children  between the ages of seven and 12 years who were referred by their  parents  for  treatment  at  a  specialized  anxiety clinic. The control sample consisted of non-anxious children (n = 44). We recruited control children in two  waves.  During  the  first  wave,  we  matched control  children  with  the  sample  children  for  age, gender,  and  area  of  residence.  During  the  second wave,  we  recruited  control  children  via  a  local school with similar intake criteria. As a result, both waves  of  control  children  are  effectively  matched with  the  sample  children  in  terms  of  gender,  age, and  area  of  residence.  For  both  waves,  we  sent information letters to the parents, and we encouraged them to contact the clinic if they wished to  participate.  Because  the  parents  of  the  sample children self-referred their children, we only enrolled self-referred controls, which led to different sample sizes.

## Procedures

Children and parents participated in a screening for the fulfillment of inclusion criteria. The assessment procedure  lasted  approximately  three  hours  and comprised a self-reported battery of tests as well as interviews. Tests and questionnaires were administered in a predetermined order. As a result of a change in the testing procedure, some parents were  not asked to complete  all questionnaires. However,  analyses  of  dropouts  did  not  reveal  any relevant  differences  between  those  who  completed the full-range assessment and those who did not.

The inclusion criteria for the clinical sample were as  follows:  1)  the  child  had  a  primary  diagnosis  of separation anxiety disorder, generalized anxiety disorder,  social  phobia,  or  a  specific  phobia  as diagnosed  with  the  use  of  the Anxiety  Disorders Interview Schedule for DSM-IV, Child and Parent Versions (ADIS-IV-C/P) (27); 2) the child had an IQ of  70  or  more;  and  3)  at  least  one  parent  was  a native  Danish  speaker.  Inclusion  criteria  for  the control sample were as follows: 1) the child did not meet the criteria for any anxiety disorder based on the parent version of the ADIS-IV-C/P; and 2) at least  one  parent  was  a  native  Danish  speaker.  The sample was thoroughly described in a recently published  paper  about  treatment  effect  (28).  The results  demonstrated  that  46%  of  the  sample  had separation  anxiety  disorder,  26%  had  a  specific phobia,  22%  had  generalized  anxiety  disorder,  and 6% had social phobia as their primary disorder (28). The  mean  clinical  severity  rating  for  the  primary disorder of the total sample was 7.4.

## Measures

The  Screen  for  Child  Anxiety  Related  Emotional Disorders  (SCARED-R)  measures Diagnostic and Statistical  Manual  of  Mental  Disorders,  Fourth  Edition (DSM-IV)-related  types  of anxiety disorders in children (29). It consists of 69 items scored on a 3point scale (0 = almost never; 1 = sometimes; and 2 = often). In the current study, we applied the childreported  total  scale.  The  SCARED-R  has  been reported  to  have  satisfactory  test-retest  reliability and good internal consistency (29). It discriminates well  between  anxiety  disorders  and  other  types  of psychopathology,  and  it  is  sensitive  to  effects  of treatment (30). In the present study, the child-report data  from  the  SCARED-R were applied. Our data yielded excellent scale reliability, with a Cronbach's alpha of .95 for the total scale.

A  standardized  Danish  version  of  the  Symptom Checklist (SCL) was used (31). The SCL is a widely used questionnaire that assesses psychological symptoms  and  distress  in  adults.  We  used  a  sum score composites of the anxiety subscale (ten items) and the phobia subscale (seven items) in the present study.  It  was  calculated  as  the  total  sum  of  the included  items  divided  by  the  number  of  items. Each item consists of a statement that is rated on a scale  that  ranges  from  0  to  4  (0  =  not  at  all,  2  = somewhat,  4  =  very  much);  low  scores  indicate lower levels of psychopathology. The psychometric properties of the anxiety and phobia subscales were satisfactory  (Cronbach's alphas of .86 and .80, respectively) (32).

The Parenting Sense of Competence Scale (PSOC)  is  a  self-reported  scale  that  measures  the parental sense of competence in the two dimensions of  satisfaction  and  efficacy  (33).  It  consists  of  16 items rated on a 6-point Likert scale (6 = strongly disagree,  1  =  strongly  agree).  Internal  consistency (25),  convergent  and  discriminant  validity  (34,  35), and  reliability  have  been  shown  to  be  satisfactory (33).  High  scores  indicate  higher  satisfaction  and higher  efficacy,  respectively.  In  the  present  study, PSOC  reliability  was  found  to  be  good,  with  a Cronbach's alpha of more than .7 for both mothers' and fathers' efficacy and satisfaction scales.

The Rearing Behavior Questionnaire (RBQ) measures  perceptions  of  parental  behavior,  with each  parent  rating  his  or  her  own  style  (36).  The RBQ consists of 33 items rated on a 4-point scale. In  the  present  study,  we  applied  the  two  RBQ dimensions: overprotection versus autonomy granting  and  rejection  versus  acceptance.  Higher scores indicate more positive parental behavior. The internal  consistency,  construct  validity,  and  testretest  reliability  of  this  tool  have  been  reported  to be  good  (36).  In  our  data,  overall  internal  scale reliability coefficients for RBQ were excellent, with Cronbach's  alphas  of  .86  for  mothers  and  .85  for fathers.  RBQ  subscales  for  autonomy  also  had acceptable  reliability,  with  Cronbach's  alphas  of more  than  .7  for  both  mothers  and  fathers.  The RBQ subscale that measured acceptance had lower yet acceptable reliability, with Cronbach's alphas of .65 for both mothers and fathers.

## Ethical statement

The study was approved by the Institutional Review Board  at  the  University  of  Copenhagen,  and  it complies  with  Danish  ethical  standards  regarding the assessment and treatment of children enrolled in psychological  research  studies.  Written  informed consent to participate was obtained from all parents of participating children.

## Data analyses

We  conducted  preliminary  Kruskal-Wallis  tests  to examine whether parents in the clinical and control groups  differed  with  regard  to  education  level  and household income. Parents' anxiety symptom levels were also compared with a grouped t -test on a sum score composite of the anxiety and phobia subscales of the SCL.

For  the main  analysis, we  conducted  logistic regressions  to  assess  whether  parental  perceptions of parental efficacy and satisfaction (PSOC) as well as  of  autonomy  and  parental  acceptance  (RBQ) were  associated  with  the  presence  of  an  anxiety diagnosis in the child. We then conducted ordinary least  squares  (OLS)  regression  analyses  to  assess whether  the  same  input  was  associated  with  the continuous total anxiety symptoms level (SCAREDTotal Scale) as reported by the child. To explore the specific influence of parental gender, we ran separate analyses for mothers  and  fathers.  We provided two full models for each parent in addition  to  a  common  model  that  included  data from both parents, with diagnosis as output.

During the initial analysis, all four subscales (two from PSOC and two from RBQ) were included as input  variables  in  both  models  for  both  parents. This  study  is  exploratory  in  nature,  so,  to  achieve the  most  parsimonious  models,  we  ran  backward regression procedures for both the logistic regressions  and  the  OLS  regressions.  Both  logistic and  OLS  regressions  were  conducted  with  the default  .05  variable  inclusion  criteria  and  the  .1 exclusion criteria. The logistic regressions backward procedure  was  set  up  within  a  Wald  chi-square algorithm for the inclusions and exclusions and with a maximum of 20 iterations used to reach convergence.

## Results

The clinical  sample  (n  =  59)  consisted  of  30  boys (mean age: nine years and five months) and 29 girls (mean  age: nine years and nine months).  The control sample comprised 22 boys (mean age: nine years and five months) and 22 girls (mean age: nine years and eight months). The comparison of ranked means by the Kruskal-Wallis test revealed no noticeable differences between parents in the clinical group as compared with those in the control group  or  in  the  categorized  educational  levels  for either the mothers (χ 2  = 1.53; p = .22) or the fathers (χ 2  = 1.49; p = .24). The anxiety symptom levels of the  parents  did  not  differ  significantly  between sample parents and control parents ( t = -1.905 and p =  .05  for  mothers; t =  -1.26  and p =  .21  for fathers).  However,  families  in  the  clinical  group versus the control group differed significantly with regard  to  household  income  (χ 2   =  4.41; p =  .04), with  the  members  of  the  clinical  group  having higher incomes. Means and standard deviations for parental perceptions are shown in Table 1. Equivalent analyses comparing the first and second waves of controls revealed no differences between the control groups.

TABLE  1. Means  and  standard  deviations  of  variables  in  the  clinical  and control groups

|                             | Clinical   | Clinical   | Control    | Control    |
|-----------------------------|------------|------------|------------|------------|
|                             | Mothers    | Fathers    | Mothers    | Fathers    |
| Parental efficacy           | 31.9 (4.3) | 29.6 (4.7) | 34.2 (7.5) | 32.7 (7.0) |
| Parental satisfaction       | 41.8 (6.7) | 43.4 (5.1) | 45.0 (9.4) | 44.7 (9.4) |
| Percieved autonomy granting | 41.9 (4.5) | 41.9 (4.1) | 42.0 (8.0) | 41.6 (8.7) |
| Percieved acceptance        | 35.6 (2.4) | 34.8 (3.0) | 35.8 (6.1) | 34.8 (6.8) |

Note: There are no significant differences between the groups

Pearson's correlations between mother and father reports in both groups are given in Table 2. Overall, there were no significant correlations between maternal  and  paternal  perceptions  in  the  clinical group,  whereas  highly  significant  correlations  were present for most variables in the control group.

TABLE 2. Pearson's correlations  between maternal and paternal variables in the two groups

|          |                           | Fathers    | Fathers   | Fathers   | Fathers   | Fathers   |
|----------|---------------------------|------------|-----------|-----------|-----------|-----------|
|          | Mothers                   | 1          | 2         | 3         | 4         | 5         |
| Clinical | 1 Efficacy                | -.02       | -.02      |           |           |           |
|          | 2 Satisfaction            | -.09       | .11       |           |           |           |
|          | 3 Psychological control   |            |           | -.01      | -.02      | -.21      |
|          | 4 Autonomy granting       |            |           | -.26      | .15       | .16       |
|          | 5 Acceptance              |            |           | -.16      | -.09      | .24       |
| Control  | 1 Efficacy 2 Satisfaction | .28 .82 ** | .39 * **  |           |           |           |
|          |                           |            | .87       |           |           |           |
|          | 3 Psychological control   |            |           | .74 **    | .63 **    | .70 **    |
|          | 4 Autonomy granting       |            |           | .62 **    | .88 **    | .89 **    |
|          | 5 Acceptance              |            |           | .77 **    | .85 **    | .93 **    |

* p < .05; ** p < .01

## Anxiety diagnoses as the outcome variable

A  total  of  80  mothers  completed  both  the  PSOC and  the RBQ.  As  a  result of changes  in the administration  of  the  questionnaire  packages,  an additional 23 mothers did not complete the RBQ or the PSOC. Apart from that, the data included three cases  with  less  than  10%  randomly  missing  user data  for  any  subscale;  these  data  were  replaced  by case means and included in the analysis.

The logistic model for mothers of anxious children (n = 50) versus control children (n = 30) is presented  in  Table  3.  This  model  converged  after three  steps.  In  step  two,  RBQ  acceptance  was excluded  on  the  basis  of  the  .1  criterion  (β  =  0.074; χ 2  = .83; P = .36). In step three, PSOC sense of efficacy was excluded (β = -0.054; χ 2  = .77; p = .38). The final model for mothers suggests that high maternal satisfaction with parenting as measured by the  PSOC  scale  was  associated  with  an  increased likelihood  of  having  a  child  without  an  anxiety diagnosis. The granting of autonomy was still kept as  a  covariate  in  the  model  on  the  basis  of  the  .1 exclusion criterion, but it was not significant under the Cronbach's alpha .5 criterion (Table 3).

TABLE 3. Logistic regression for mother's parental sense of competence and rearing behavior

|        |                       |   β value |   SE* |   P value |
|--------|-----------------------|-----------|-------|-----------|
| Step 2 | Parental efficacy     |     0.054 |  .062 |      .380 |
|        | Parental satisfaction |     0.108 |  .058 |      .063 |
|        | Granting of autonomy  |    -0.121 |  .065 |      .064 |
| Step 3 | Parental satisfaction |     0.130 |  .054 |      .016 |
|        | Granting of autonomy  |    -0.113 |  .063 |      .075 |

*SE = Standard Error

A similar model that applied data from 77 fathers (46  who  had  diagnosed  anxious  children  and  31 who had non-anxious control children) is displayed in  Table  4.  As  with  the  mothers,  a  change  in administration  procedure  led  to  25  cases  that  did not  include  RBQ  or  PSOC  data.  Apart  from  that, the data included an ignorable single case with less than  10%  randomly  missing  user  data  for  any subscale of the  RBQ;  those values were thus replaced by case means.

The fathers' logistic model converged after three steps  with  a  model  that  included  PSOC  sense  of efficacy (β = 0.18; χ 2  = 7.98; p = .005) and reduced levels  of  acceptance  (β  =  -0.145;  χ 2   =  3.91; p = .048). Parental satisfaction for fathers was excluded in  step  two  (β  =  0.012;  χ 2   =  .41; p =  .84).  and granting of autonomy was excluded in step three (β = -0.061; χ 2  = .82; p = .37)

TABLE 4. Logistic  regression  for  father's  parental  sense  of  competence  and rearing behavior

|        |                      |   β value |   SE* |   p value |
|--------|----------------------|-----------|-------|-----------|
| Step 2 | Parental efficacy    |     0.190 |  .065 |      .003 |
|        | Granting of autonomy |    -0.061 |  .068 |      .365 |
|        | Acceptance           |    -0.090 |  .093 |      .332 |
| Step 3 | Parental efficacy    |     0.179 |  .062 |      .005 |
|        | Acceptance           |    -0.145 |  .052 |      .048 |

*SE = Standard Error

## Anxiety symptom level as the outcome variable

We  ultimately  conducted  an  exploratory  backward OLS regression with the same input variables. This model converged after three steps. The final model suggested that, for mothers, PSOC satisfaction was associated  with the child reported  total anxiety symptoms level score as measured by SCARED-R (β  =  -0.374; t =  -2.21; p =  .03).  In  other  words, high maternal satisfaction was associated with lower anxiety  levels.  As  in  the  logistic  diagnosis-based model,  the  OLS  model  also  withheld  mothers' granting of autonomy; however, this was not significant with a Cronbach's alpha value of .5 (β = 0.305; t = 1.81; p = .08).

For  fathers  (n  =  77),  higher  PSOC  efficacy  was associated  with  lower  total  anxiety  levels  (β  =  0.451; t = -3.24; p = .002). As in the logistic model, for the fathers, the model also withheld the acceptance covariate in the final model (β = 0.232; t = 1.67; p = .09). However, this was not significant with a Cronbach's alpha value of .05.

## Discussion

We set out to explore whether parental perceptions about their roles as parents should receive attention as part of the theoretical understanding of childhood anxiety disorders. Results of the present, highly  explorative  study  point  to  the  possibility  of differential  associations  between  child  anxiety  and maternal  and  paternal  perceptions.  For  mothers, higher levels of parental satisfaction  and  lower granting of autonomy  during child rearing are related to a decrease in the occurrence of childhood anxiety.  Alternatively,  for  fathers,  lower  levels  of child anxiety are related to a higher paternal sense of efficacy and acceptance.

Previous  theoretical  models  of  the  development of  anxiety  during  childhood  have  incorporated  the role of parental behaviors (37), with most empirical evidence supporting autonomy granting, overinvolvement,  and  anxious  modeling  as  important contributors (13) in a bidirectional interplay between  parents  and  children  (9).  Some  models even incorporate parental expectations of their children's  ability  to  cope  with  anxiety-provoking situations (21). Despite the existence of these models,  mechanisms  that  link  parental  factors  to child anxiety are still not clearly understood, although  the  effects  of  these  mechanisms  have consistently  been  reported  to  be  bidirectional  in nature; in other words,  parents influence child outcome  variables  while  children  influence  parent outcome variables (9,38).

Our results demonstrated that autonomy granting and parental competence together formed the best models for explaining the variance in the presence of childhood  anxiety for mothers  but  not for fathers, for whom acceptance together with parental competence provided the best-fitting model. Decreased parental competence was the sole predictor that was significantly associated with high levels of child anxiety for both parents.

The  findings  that  parental  efficacy  beliefs  and satisfaction with the parenting role are of importance when examining child anxiety is in line with  previous  studies  that  linked  these  constructs with  externalizing  behavior during  childhood  (5,8). Although firm conclusions should not yet be drawn with  regard  to  their  role  in  relation  to  childhood anxiety, our results suggest that parental perceptions of parental competence are also of importance for the adjustment of children with internalizing difficulties.

Our  results  indicated  that,  although  perceptions regarding  specific  rearing  practices  (i.e.,  autonomy granting and acceptance) were included in the statistical  models  of  the  variance  of  anxiety  in children,  these  correlations  were  small  and  in  the opposite direction of what would be expected (13). A  decrease  in  the  maternal  granting  of  autonomy was associated with the lack of an anxiety diagnosis. However,  a  very  recent  study  that  examined  the impact  of  child  age  on  this  relationship  found  a similar  pattern  of  correlations  as  that  seen  in  our study (39). In a community sample of children less than  10  years  old,  both  maternally  and  paternally increased levels of autonomy granting were associated  with  increased  levels  of  anxiety.  The authors  suggested  that  the  granting  of  non-ageappropriate  autonomy  may  increase  the  likelihood of  anxiety  in  the  children  (39).  Because  clinically anxious  children  generally  strive  to  obtain  control over  their  environment  and  thereby  often  take  on adult  responsibilities,  it  is  highly  likely  that  similar mechanisms are at play in our study, which included a high number of children with clinically diagnosed anxiety with a mean age of less than 10 years.

## Impact of parental gender

It  has  been  suggested  that  fathers  play  a  different role as compared with mothers in that they encourage  their  children  to  explore  the  external world  to  a  larger  extent  than  mothers  do  (24).  To date, little is known about how parental perceptions and parent-child interactions are  moderated by parent gender (10).

Our findings highlight the possibility that mothers and  fathers  may  contribute differently to child anxiety.  Maternal  satisfaction  and  paternal  efficacy beliefs were consistently associated with child outcome at a diagnostic level as well as with anxiety symptoms.  Our  finding  of  a  negative  correlation between  maternal  satisfaction  and  anxiety  in  the child  is  in  accordance  with  previous  findings  that maternal perceptions of child emotionality influence maternal satisfaction, regardless of maternal efficacy beliefs (4). However, it is partly in contrast with the result  of  two  other  studies  (25,26).  These  studies found  significant gender  differences but in the opposite  direction,  with  satisfaction  found  to  be high  in  fathers  and  efficacy  found  to  be  high  in mothers. The previous studies assessed parenting in a normal sample as well as in a sample in which the parents attended a parenting program; in our sample, we included a large number of children with yet-to-be-treated  clinical  anxiety.  We  found  lower levels of paternal efficacy and maternal satisfaction to be associated with anxiety in the child. Thus, the present sample may  represent more vulnerable family dynamics than have been examined previously. As previous studies have suggested, the interactions  between  parents  and  children  may  be bidirectional (9).  It  is  thus  likely  that  children  who experience difficulties within the clinical range affect parental perceptions  differently  than  when  only elevated  levels  of  symptoms  of  difficulties  are  in play. For example, children who suffer from separation  anxiety  disorders  will  often  rely  heavily on  maternal  reassurance,  avoid  parting  from  their mother, and resist attempts that their mother makes to  part  from  them.  This  behavior  may  influence maternal  satisfaction  as  the  mother  becomes  a victim of the child's anxiety. However, the father is often  less  affected  by  this  situation,  because  the child  may  present  with  less  anxious  reactions  in relation to him. A father's sense of parental competence  may  therefore be less affected by fathering a child with clinical levels of anxiety.

An  unexpected  finding  in  our  study  was  the different patterns of association between the mother and father reports in the two groups. In the control group, most associations between maternal and paternal reports were highly significantly correlated,  whereas  the  opposite  was  true  for  the clinical group. As a clinician, one often experiences marked differences in maternal and paternal understanding  of  the  child's  problems  and  their own  behaviors when  the child is referred for treatment. In addition, the anxious child will often react very differently toward each parent.  Our findings  may  indicate  that  the  parents  of  clinically anxious  children  have  very  different  experiences with-and thus perceptions of-the rearing process. It may therefore be helpful if these issues are  addressed  and  the  parents  are  again  able  to establish a more unified understanding of their child as well as of their own and their partner's perceptions  and  behaviors.  This  assumption  is  in part corroborated by a qualitative study that investigated  the  parental  understanding  of  having fathers  involved  in  treatment  (40).  One  of  the findings reported in this study was that mothers and fathers obtained a more  unified view of their children after participating in therapy together.

Finally, parents in the control group of the present study had a higher overall household income  than  the  parents  in  the  clinical  group; however,  there  were  no  significant  differences  in relation to educational level or anxiety levels. Although  both  top-down  and  bottom-up  studies have  shown  an  increased  risk  of  anxiety  among family  members,  the  lack  of  an  increased  level  of anxiety among the parents in this study is corroborated by reports that other specialized clinics have not found increased levels of anxiety or depression  among  parents  seeking  help  for  their anxious children (41).

## Limitations

Although  our  explorative  study  provides  new  data for  this  area  of  study,  it  is  not  without  limitations. One such limitation concerns the specificity of the parental effects; this point was previously made by Murray  and  colleagues  (1).  Basically, it  remains unclear whether the identified patterns of maternal and  paternal  perceptions  are  specifically  related  to the development of childhood anxiety or if they are more accurately  interpreted  in  the  broader  context of  childhood  psychopathology.  In  addition,  our small sample sizes and the ethnicity of our subjects may compromise the generalizability of the findings. Our  study  consisted  of  ethnic  Danes  and  did  not include  children  with  other  backgrounds; however, Denmark is a small country with a very homogenous  ethnic  background,  thereby  allowing for  generalizations  to  other  Caucasian  populations. The  scarcity of prior studies against which  to discuss our results also cautions against the drawing of  firm  conclusions  at  present.  Nonetheless,  our results point to an important and previously neglected area that is of theoretical importance. It is also relevant to the treatment of childhood anxiety disorders,  so  it  should  therefore  be  examined  in further detail.

We  also  acknowledge  that  questionnaire-based methods  have  potential  limitations,  but  they  also have advantages. Thorough observational assessments of parenting often result in more solid associations between variables of child anxiety and parenting than can be obtained with parent or child self-reports (21). Alternatively, observational measures  of  parent-child  interactions  in  a  research setting  may not reflect the behaviors that maintain child  anxiety  during  everyday  life  (42). Results that are  based solely on self-ratings should generally be interpreted  with  care,  because  they  are  at  risk  of being influenced by subjective evaluations. As pointed  out  by  McClure  and  colleagues  (43),  selfratings  may  not  mirror  actual  rearing  behavior. Instead, they may be affected by biased cognitions toward a perceived threat, which is frequently reported  among  clinically  anxious  individuals  and children  with  high  levels  of  trait  anxiety  (44,45). However, the present study focused on perceptions. We  did  not  aim  to  evaluate  the  actual  rearing behavior, but rather sought to examine how parental perceptions (in this case, perceptions about the  parent-child  interaction  and  parental  sense  of competence) can potentially affect child adjustment.

## Conclusions and applied implications

In line with studies found in the literature regarding externalizing behaviors during childhood, we explored the possible contribution of parental perceptions  of  parental  satisfaction  and  efficacy  in explaining childhood anxiety. We supplemented the body of existing  literature  by  trying  to  unravel  the possible  gender-specific  contributions  of  paternal and maternal perceptions for explaining variances in symptom  levels  as  well  as  the  presence  of  anxiety diagnoses in children. Our results demonstrated that the  level  of  parental  sense  of  competence  and  the presence  of  child  anxiety  were  indeed  associated. Although this association is most likely bidirectional, the present study outlines the potential importance of parental perceptions in the development of anxious children. However, further studies are required before firm conclusions can be drawn.  Parental  differences  were  also  found,  with maternal  satisfaction  and  paternal  efficacy  beliefs providing  differential  and  significant  contributions in  the  statistical  models.  Further  knowledge  of  the impact of parental competence on the development and maintenance of anxiety disorders may be of use to researchers trying to unravel the risk mechanisms of the disorder as well as to clinicians working with families with anxious children. Because parents with lower levels of parental competence may be reluctant to engage in therapy or to disengage from therapy,  it  may  be  necessary  to  address  this  issue early  during  the  therapy  process  to  ensure  a  solid working  relationship  with  the  parents  as  well  as their compliance with treatment.

## Conflict of interest

The authors declare that they have no conflicts of interest.

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## Acknowledgements

This work was supported by the Egmont Foundation under grant number  831-2205; the Helse  Foundation  under  grant  numbers  2008A438 and  2009A617;  and  the  Simon  Spies  Foundation under grant number 004610. We wish to thank all participating  children  and  parents  for  contributing to  this  study  as  well  as  all  staff  and  students  who have assisted with this process.