Health anxiety and associated constructs in school-age children and adolescents with congenital heart disease and their parents: A children’s healthy-heart activity monitoring program in Saskatchewan cohort study

Abstract

Youth with congenital heart disease (CHD) have been found to experience higher levels of health anxiety and associated constructs than typically developing peers. The association between youth and parent health anxiety has been explored in typically developing youth but this association remains unknown in youth with CHD. This association was explored using a prospective, cross-sectional study that included 36 school-age children and adolescents with CHD (median age =10.5 years, IQR = 4) and 35 parents (median age = 44 years, IQR = 10.5). Participants completed a demographic form and measures of health anxiety, anxiety sensitivity, intolerance of uncertainty, and anxiety disorder symptom categories (youth) or general anxiety (parent). Associations were observed between child and adolescent panic/agoraphobia symptoms and parent state anxiety (r = .41), child and adolescent intolerance of uncertainty and parent state and trait anxiety (r = .37; r = .46, respectively), and child and adolescent anxiety sensitivity and parent state anxiety (r = .40). No association was observed between health anxiety in children and adolescents and parents nor between child and adolescent health anxiety and parent associated constructs. For parents, associations between health anxiety and all measures of associated constructs of interest were observed. Study findings will facilitate improved understanding of the psychological needs of school-age children and adolescents with CHD.

Keywords

Congenital heart defects child adolescent anxiety

Introduction

Health anxiety refers to the belief that changes in bodily sensations are indicative of a serious illness (Asmundson et al., 2010; Sunderland et al., 2013). Health anxiety is an important psychological construct to consider in the context of pediatric chronic health conditions, specifically congenital heart disease (CHD). Health anxiety is associated with increased health care expenditures and unnecessary medical interventions (Fink et al., 2010; Rask et al., 2016). As such, being able to identify youth with CHD with elevated health anxiety may be key to preventing them from undergoing additional, unnecessary medical interventions.

Children and adolescents with chronic health conditions (such as CHD) need to monitor changes in their health status, such as changes in heart rate, to determine whether they need to tell their parent/guardian in order to access services or initiate an intervention (Chen et al., 2017; Hafetz and Miller 2010). This in turn leads to a parent/guardian decision as to whether assessment or intervention is required. As such, it is crucial to better understand health anxiety in this population. It is anticipated that improved understanding will aid facilitation of appropriate self-evaluation of symptoms by children and adolescents and it will direct appropriate and prudent use of clinical services.

Knowledge regarding health anxiety in children and adolescents is advancing but remains in its early years (Oliver et al., 2020; Rask et al., 2012, 2016; Wright and Asmundson 2003; Wright et al., 2016, 2017). Researchers have now begun to examine the relationships between health anxiety and associated constructs of interest in specialized heath populations. For example, Oliver and colleagues (2018) examined the associations between health anxiety, anxiety sensitivity, intolerance of uncertainty, and anxiety symptoms amongst typically developing youth and youth with CHD. Results demonstrated youth with CHD self-reported higher levels of health anxiety and associated constructs compared to typically developing youth.

Anxiety sensitivity has been found to be a reliable predictor of health anxiety (Otto et al., 1992; Stewart et al., 1998; Wright and Asmundson, 2003). This construct refers to the fear of anxiety and the related symptoms or sensations deemed to have adverse consequences such as death or insanity (Gerolimatos and Edelstein, 2012; Taylor et al., 2007). An example of anxiety sensitivity could be experiencing fear due to increased heart rate and the evaluation that the change in heart rate could have deleterious effects for one’s health (Gerolimatos and Edelstein, 2012; Taylor et al., 2007). Taylor et al. (2007) suggest that anxiety sensitivity is associated with anxiety disorders as it is an anxiety amplifier. Those who become anxious can become alarmed by the arousal-related sensations, intensifying their anxiety.

Another construct of interest with an established association with health anxiety is intolerance of uncertainty. Intolerance of uncertainty refers to the tendency to react in a negative way in unpredictable situations, and having negative beliefs about the consequences that may follow uncertainty (Carelton et al., 2007; Gerolimatos and Edelstein, 2012). Intolerance of uncertainty is a trait-like characteristic that can predispose one to develop anxiety (Deacon and Abramowitz, 2008; Gerolimatos and Edelstein, 2012). In a typically developing population of 11–17 year olds, there was an association between intolerance of uncertainty and health anxiety (Wright et al., 2016). However, there are mixed findings for this result in adult populations, as some studies have failed to find a relationship between intolerance of uncertainty and health anxiety when controlling for specific factors (e.g., neuroticism, anxiety sensitivity; Boelen and Carleton, 2012; Sexton et al., 2003).

In recent years, researchers have also begun to examine the etiology of health anxiety in childhood (Koteles et al., 2015; Marshall et al., 2007; Thorgaard et al., 2016; Wright et al., 2017). While there has been a progression of our understanding of this phenomenon, the association is not well understood. Existing research suggests there is an association between parent-reported somatic or health beliefs and/or anxiety and those of their child (Koteles et al., 2015; Marshall et al., 2007; Thorgaard et al., 2016; Wright et al., 2017). However, the etiology of health anxiety for children and adolescents with CHD has yet to be examined. Findings yielded from an examination of the contribution of parent health anxiety and associated constructs to health anxiety in their offspring will aid in addressing the gap in our understating of the etiology of health anxiety in children and adolescents in general, and more specifically in school-age children and adolescents with CHD.

Aim

We examined health anxiety and associated constructs between school-age children and adolescents with CHD and their parents as a way to contribute to our understanding of the etiology of health anxiety in this youth population. We hypothesized that there would be (1) a positive association between school-age child and adolescent health anxiety, parent health anxiety, and associated constructs, (2) positive associations between health anxiety and the associated constructs in school-age children and adolescents, and (3) positive associations between health anxiety and the associated constructs of interest in parents.

Methods

Methodological approach

We undertook a prospective, cross-sectional examination of the association between self-reported health anxiety and anxiety sensitivity, intolerance of uncertainty, anxiety disorder symptom categories (for youth), and state and trait anxiety (for parents) in school-age children and adolescents with CHD and that of one of their parents.

Recruitment and procedure

Ethical approval was obtained from the University of Regina Biomedical Research Ethics Board. Eligible school-age children and adolescents (ages 6–16 years) had a diagnosis of CHD. The children and adolescents and their respective parent/guardian were recruited from the Department of Cardiology at the Royal University Hospital (Saskatoon, Saskatchewan). Eligible children and adolescents were pre-screened by pediatric cardiologists for a larger study (i.e., Children’s Healthy Heart Activity Monitoring Program in Saskatchewan; CHAMPS) which had an intervention component. The exclusion criteria for children and adolescents was directed by the larger study. Specifically, the exclusion criteria included (1) cardiac surgery within the last 6 months, (2) cyanotic CHD, and (3) intellectual disability.

Informed consent was obtained from parents/guardians of the children and adolescents, and assent was obtained from the children and adolescents prior to the study. All child and adolescent participants completed a battery of age specific psychological measures, and physiological measures for the larger study. Parents/guardians completed demographic questions about themselves and their child, and a battery of adult specific psychological measures. The participants completed the measures with pen and paper. Research assistants facilitated the administration of measures to the children and adolescents and parents (in separate rooms) prior to the involvement in the larger study. All children and adolescents completed the measures on their own. Research assistants sat beside the child and adolescent participants and answered any questions they had about certain words and concepts, although limited assistance was requested. All participants had the option to not answer questions or to withdraw from the study at any time. A registered clinical psychologist was a study investigator (Dr. Wright) and could be contacted if a participant became distressed. Dr. Wright was not contacted regarding distress of a participant. School-age child and adolescent participants received a $10 gift card as a token of appreciation of their participation.

Measures

Child and adolescent measures

Childhood Illness Attitude Scales (CIAS; Wright and Asmundson 2003)

The CIAS is a 35-item self-report measure used to evaluate fears, beliefs, and attitudes associated with health anxiety in school-aged children (Wright and Asmundson, 2005). Nearly all items are rated on a 3-point Likert scale that ranges from 1 (none of the time) to 3 (a lot of the time). Total scores range from 29 to 87, where higher scores indicate higher levels of health anxiety and illness behavior. There are four subscales incorporated, including fear, help seeking, symptom effects, and treatment experiences (Wright and Asmundson, 2003). The CIAS has demonstrated strong construct validity with associated measures (i.e., r = 0.71; Delparte et al., 2015), high re-test reliability (i.e., r = 0.86; Wright and Asmundson, 2003), and good internal consistency for the total score (i.e., α = .88 to .89; Wright and Asmundson, 2005). The current study demonstrated good internal consistency for the CIAS total score (i.e., α =.86), and for the subscale scores of fear (α = .81), symptom effects (α = .67), help seeking (α = .79), and treatment experiences (α = .69).

Childhood Anxiety Sensitivity Index (CASI; Silverman et al., 1991)

The CASI is an 18-item child self-report measure designed for school-aged children. Each item is rated on a 3-point likert scale that ranges from 1 (none) to 3 (a lot). Total scores range from 18 to 54, where higher scores indicate higher levels of anxiety sensitivity (Silverman et al., 1991). There are three subscales incorporated, including physical concerns, social concerns and psychological concerns. The CASI has demonstrated good internal consistency (i.e., α = .87) and test-retest reliability (Silverman et al., 1991). For the purposes of the present study, only the CASI total score was employed. The current study demonstrated excellent internal consistency for the CASI total score (i.e., α = .91).

Spence Children’s Anxiety Scale (SCAS; Spence, 1998)

The SCAS is a 44-item self-report measure used to assess symptoms regarding anxiety clusters in children designed for school-aged children (Spence, 1998). Each item is rated on a 4-point likert scale that ranges from 0 (never) to 3 (always). There are six subscales are incorporated, including separation anxiety, social phobia, obsessive-compulsive disorder, panic-agoraphobia, generalized anxiety, and fears of physical injury (Spence, 1998). Total scores range from 0 to 114, where higher scores indicate higher levels of anxiety. The SCAS has demonstrated excellent internal consistency with respect to its total score (α = .92; Spence, 1998). The current study demonstrated excellent internal consistency (α = .93) for the SCAS total score.

Intolerance of Uncertainty Scale-Revised (IUS-R; Walker et al., 2010)

The IUS-R is a 12-item self-report measure designed for school-aged children to assess intolerance of uncertainty across the lifespan, allowing comparisons across children, adolescents, and adults. The IUS-R is an adaptation of the 12-item version of the IUS-12 (Carleton et al., 2007). Each item is rated on a 5-point likert scale ranging from 1 (not at all like me) to 5 (entirely like me). Total scores range from 12 to 60, where higher scores indicate a greater degree of intolerance of uncertainty. There are two subscales are incorporated, including the prospective subscale and the inhibitory subscale (Walker et al., 2010). The IUS-R total score has demonstrated good internal consistency (i.e., α = .81 and α = .87; Oliver et al., 2020; Wright et al., 2016, respectively). For the purposes of the present study, only the IUS-R total score was employed. The current study demonstrated good internal consistency for the IUS-R total score (i.e., α = .86).

Parent measures

Short Health Anxiety Index (SHAI; Salkovskis et al., 2002)

The SHAI is an 18-item self-report measure of health anxiety in adults. For each item, respondents can choose from four statements that best represent their experience over the past 6 months. Total scores range from 0 to 48, where higher scores indicate a greater degree of health anxiety. There are two subscales, including a 14-item subscale assessing health anxiety independent of health status, and a four item subscale measuring perceived negative consequences of having an illness. The SHAI has demonstrated good reliability, criterion validity, and sensitivity to treatment (Abramowitz et al., 2007; Salkovskis et al., 2002). For the purposes of the present study, only the SHAI total score was employed. The current study demonstrated good internal consistency for the SHAI total score (α = .84).

Anxiety Sensitivity Index-3 (ASI-3; Taylor et al., 2007)

The ASI-3 is an 18-item self-report measure that is designed to assess the tendency to fear anxiety symptoms due to the belief of their harmful consequences. Each item is rated on a 5-point likert scale that ranges from 0 (agree very little) to 4 (agree very much). Total scores range from 0 to 72, where higher scores indicate higher levels of anxiety sensitivity. There are three subscales, specifically physical concerns, cognitive concerns, and social concerns. The ASI-3 has displayed convergent, discriminant, and criterion validity (Taylor et al., 2007). For the purposes of the present study, only the ASI-3 total score was employed. The current study demonstrated good internal consistency for the ASI-3 total score (α = .88).

State Trait Anxiety Inventory (STAI; Spielberger et al., 1983)

The STAI is a 40-item self-report measure in which respondents rate 20 items measuring their current, in-moment anxiety (STAI-S version) and 20 items measuring their anxiety in general (STAI-T version). Each item is rated on a 4-point likert scale that ranges from 1 (not at all/almost never) to 4 (very much so/almost always). Total scores range from 20 to 80, where higher scores indicate higher levels of state or trait anxiety. The STAI has demonstrated good reliability and construct validity for predicting and measuring anxiety reactions after stressors (Spielberger et al., 1983). The current study demonstrated excellent internal consistency for both state and trait versions of the STAI (i.e., α = .94 and α = .94, respectively).

Intolerance of Uncertainty Scale, Short Form (IUS-12; Carleton et al., 2007)

The IUS-12 is a 12-item measure that is designed to assess responses to uncertainty, ambiguous situations, and the future. The IUS-12 is a short version of the original 27-item IUS (Freeston et al., 1994). Each item is rated on a 5-point likert scale that ranges from 1 (not at all characteristic of me) to 5 (entirely characteristic of me). Total scores range from 12 to 60, where higher scores indicate a greater degree of intolerance of uncertainty. There are two subscales incorporated: prospective anxiety and inhibitory anxiety. The IUS-12 has demonstrated good internal consistency in terms of its total score, and the inhibitory and prospective subscale scores (Carleton et al., 2007). For the purposes of the present study, only the IUS-12 total score was employed. The current study demonstrated excellent internal consistency for the IUS-12 total score (α = .91).

Data analyses

Statistical analyses were performed using the IBM Statistical Package for the Social Sciences (SPSS; version 27). Bivariate correlations and the corresponding confidence intervals were computed. Descriptive statistics were computed for demographic variables and measure total scores, and subscale scores where appropriate. There were seven sets of analyses completed: (1) an independent sample t-test was computed to examine potential gender differences across our child and adolescent participants with respect to age; (2) independent sample t-tests were computed to examine potential gender differences across self-reported child and adolescent measures total scores and subscale scores where appropriate; (3) bivariate correlations were computed between age and child and adolescent health anxiety subscale and total scores, and the associated construct total scores from child and adolescent measures; (4) bivariate correlations were computed between age and total scores from the parent measures; (5) bivariate correlations were computed between child and adolescent health anxiety and total scores from the parent measures; (6) bivariate correlations were computed between child and adolescent measures total and subscale scores where appropriate; and (7) bivariate correlations were computed between the total scores from the parent measures.

Results

Participants

Participants were 36 school-age children and adolescents between the ages of six to16 years old (median age =10.5, IQR = 4), and one parent per child and adolescent participant. There were 35 parents after accounting for one parent participant for a pair of siblings in the study. Child and adolescent participants were comprised of 20 males (median age = 9, IQR = 4.75) and 16 females (median age = 13.00, IQR = 4.75). Of these, 31 (86%) self-reported as Caucasian. In our study group, the two most common heart defects were ventricular septal defect (n = 8; 22%) and hypoplastic left heart syndrome with Fontan circulation (n = 6; 17%). Further, seven (19%) participants were cardiac transplantation recipients. There was one participant who did not complete the entire battery of measures; therefore, this participant was excluded from the primary analyses, leaving us with 36 participants. There were 35 parents (median age = 44, IQR = 10.5) who participated in the study. Of these, 31 (89%) participants were female. There were three (9%) mothers who did not disclose their age. There were 31 (89%) families that resided in an urban area and two (6%) families did not provide location of residence.

Descriptive statistics

Descriptive statistics for child, adolescent, and parent measures were computed (see Table 1). Female child and adolescent participants were older than male participants, t (34) = 2.74, mean difference = 2.39, 95% CI [.616, 4.159]. The median age for females was 13 years compared to 9 years for males. No gender differences were observed across total scores from all child and adolescent measures (see Table 1). No gender-related analyses were completed with parent participants as the majority of parent participants were female.

Table 1.

Descriptive statistics for child/adolescent and parent measures.

	Total Median (IQR)	Females median (IQR)	Males Median (IQR)	t	Mean difference	95% CI For mean difference
Child measures
Childhood illness attitude scales total score	52.0 (13.75)	50.5 (14.25)	52.5 (14.38)	1.02	- 2.94	- 8.77–2.90
Fears subscale	18.00 (8.00)	17.0 (7.83)	20.0 (8.0)	0.76	- 1.17	- 4.28–1.95
Help seeking subscale	19.5 (5.00)	19.0 (5.75)	21.0 (5.50)	1.48	- 1.81	- 4.30–0.67
Treatment experience subscale	7.00 (3.00)	7.5 (2.75)	7.0 (3.0)	0.37	0.19	- 0.84–1.22
Symptom effects subscale	7.00 (3.00)	7.0 (2.50)	6.0 (3.0)	0.23	- 0.15	- 1.46–1.16
Childhood anxiety sensitivity index total score	26.5 (9.88)	27.5 (8.88)	25.5 (11.75)	0.46	- 1.23	- 6.73–4.27
Spence Children’s anxiety scale total score	21.5 (19.97)	22.5 (15.00)	19.0 (22.72)	0.03	- 0.15	- 11.76–11.46
Separation Anxiety subscale	2.5 (4.00)	3.0 (3.28)	2.0 (6.25)	0.66	- 0.86	- 3.74–1.76
Social Phobia subscale	5.00 (5.75)	5.0 (5.75)	4.5 (6.75)	0.68	0.85	- 1.69–3.39
Obsessive-Compulsive subscale	4.00 (4.00)	5.0 (4.50)	3.5 (4.0)	0.26	0.24	- 1.61–2.08
Panic/agoraphobia subscale	2.00 (3.75)	3.0 (2.75)	1.8 (4.75)	0.22	- 0.34	- 3.44–2.77
Physical injury fears subscale	4.00 (3.00)	4.0 (3.75)	3.5 (3.0)	0.03	0.03	- 1.78–1.83
Generalized anxiety subscale	4.50 (4.97)	5.0 (4.75)	3.5 (6.47)	0.06	- 0.07	- 2.44–2.30
Intolerance of uncertainty scale-revised total score	25.00 (14.75)	24.5 (14.50)	28.0 (14.59)	1.35	- 4.17	- 10.43–2.09
Parent measures
Short health anxiety index total score	10.0 (8.75)
Anxiety sensitivity Index-3 total score	12.5 (15.50)
State trait anxiety inventory-state version total score	28.5 (20.25)
State trait anxiety inventory-trait version total score	38.5 (17.00)
Intolerance of uncertainty scale, short form total score	27.5 (16.00)

Note. Descriptive statistics were not computed for each parent gender as the majority of parent participants were female. Higher scores indicate higher levels of the psychological construct examined. Total score ranges: Childhood Illness Attitude Scales, 29 to 87; Childhood Anxiety Sensitivity Index, 18 to 54; Spence Children’s Anxiety Scale, 0 to 114; Intolerance of Uncertainty Scale-Revised, 12 to 60; Short Health Anxiety Index, 0 to 48; Anxiety Sensitivity Index-3, 0 to 72; State Trait Anxiety Inventory, trait version, 20 to 80; State Trait Anxiety Inventory-trait version, 20 to 80; Intolerance of Uncertainty Scale, Short Form, 12 to 60.

In children and adolescents, a negative association was observed between age and the CASI fear subscale [i.e., r (34) = −.43 95% CI -.667, −.123], respectively]. Negative associations were observed between age and the IUS-R total score, r (34) = −.38, 95% CI [-.627, −.055], and SCAS separation anxiety subscale, r (34) = −.44, 95% CI [-.668, −.124]. No other associations between age and the child and adolescent measures were observed. Age was not associated with any parent measure.

Associations between child and adolescent health anxiety, parent health anxiety, and associated constructs

No significant associations were observed between child and adolescent (i.e., CIAS total and subscale scores) and parent health anxiety (i.e., SHAI total score; see Table 2). No associations were observed between measures of child and adolescent health anxiety (i.e., CIAS total and subscale scores) and the total scores from the parent measures of the associated constructs.

Table 2.

Bivarate correlations for child and adolescent health anxiety, parental health anxiety, and associated constructs.

Measures	Short health anxiety index total score			Intolerance of uncertainty scale, short form total score			Anxiety sensitivity Index-3 total score			State trait anxiety inventory-state version total score			State trait anxiety inventory-trait version total score
	r	C.I. limits		r	C.I. limits		r	C.I. limits		R	C.I. limits		r	C.I. limits
	r	Lower	Upper	r	Lower	Upper	r	Lower	Upper	R	Lower	Upper	r	Lower	Upper
Childhood illness attitude scales total score	−.11	−.423	.227	−.02	−.349	.308	.05	−.281	.375	.10	−.320	.337	.05	−.283	.372
Fears subscale	−.12	−.429	.220	.04	−.293	.364	.08	−.255	.398	.05	−.280	.376	.08	−.259	.394
Help seeking subscale	−.07	−.388	.266	−.20	−.496	.137	−.06	−.380	.275	-.14	−.445	.201	−.14	−.451	.194
Treatment experience subscale	−.14	−.449	.197	.22	−.113	.514	−.05	−.375	.280	.11	−.230	.420	.23	−.104	.521
Symptom effects subscale	.03	−.301	.355	.02	−.314	.342	.20	−.133	.499	.10	−.235	.416	.14	−.195	.450
Childhood anxiety sensitivity index total score	.06	−.276	.379	.08	−.256	.397	.14	−.195	.450	.40*	.087	.647	.32	−.005	.590
Spence Children’s anxiety scale total score	−.05	−.370	.286	.02	−.307	.350	.13	−.210	.438	.33	−.003	.591	.20	−.138	.495
Separation Anxiety subscale	−.07	−.386	.268	−.02	−.343	.314	.01	−.324	.333	.22	−.116	.512	.11	−.225	.424
Social Phobia subscale	−.10	−.411	.241	.05	−.283	.373	.09	−.245	.407	.14	−.198	.448	.14	−.197	.448
Obsessive-Compulsive subscale	−.08	−.399	.255	-.05	−.369	.287	.03	−.304	.352	.30	−.035	.570	.13	−.206	.441
Panic/agoraphobia subscale	.05	−.288	.368	.06	−.272	.383	.24	−.096	.527	.41*	.091	.649	.27	−.067	.548
Physical injury fears subscale	.13	−.212	.436	.04	−.293	.363	.16	−.175	.467	.27	−.063	.551	.13	−.204	.442
Generalized anxiety subscale	−.15	−.454	.190	.01	−.322	.335	.06	−.272	.383	.23	−.110	.517	.15	−.192	.453
Intolerance of uncertainty scale-revised total score	.15	−.188	.456	.24	−.093	.529	.28	−.050	.559	.37*	.052	.626	.46**	.157	.686

Note: *p < .05; N = 71; confidence level is set at 0.95.

With respect to associations between child, adolescent, and parent measures of the associated constructs, results demonstrated a positive association between the SCAS panic/agoraphobia subscale score and the STAI-S version total score, r (69) = .41, 95% CI [.091, .649]. Positive associations were also demonstrated between the IUS-R total score and the STAI-S version and STAI-T version total scores [i.e., r (69) = .37, 95% CI [.052, .626]; r (69) = .46, 95% CI [.157, .686], respectively]. Lastly, there was a positive association found between the CASI total score and the STAI-S version total score r (69) = .40, 95% CI [ .087, .647].

Associations between child and adolescent health anxiety and associated constructs

Results demonstrated a positive association between the CIAS total score and the total scores for the CASI total score, r (34) = .34, 95% CI [.011, .600], and the SCAS separation anxiety subscale score r (34) = .47, 95% CI [.163, .690; see Table 3). The CIAS fear subscale score was positively associated with the CASI total score, r (34) = .55, 95% CI [.276, .747], the SCAS total score, r (34) = .55, 95% CI [.276, .747], and most of the SCAS subscale scores (see Table 3). No associations were observed between the CIAS total and subscale scores with the IUS-R total score.

Table 3.

Bivariate correlations for child and adolescent health anxiety and associated constructs.

Youth measures	Childhood illness attitude scales total score			Childhood illness attitude scales Fear subscale			Childhood illness attitude scales help seeking subscale			Childhood illness attitude scales treatment experiences subscale			Childhood illness attitude scales symptom Effects subscale
Youth measures	R	C.I. limits Lower upper		r	C.I. limits		r	C.I. limits		r	C.I. limits		r	C.I. limits
Children’s anxiety sensitivity index total score	.34*	.011	.600	.55**	.276	.747	−.12	−.432	.216	.18	−.157	.480	.30	−.035	.570
Spence Children’s anxiety scale total score	.28	−.053	.558	.55**	.276	.747	−.20	−.495	.139	.03	−.298	.359	.30	−.029	.574
Separation anxiety subscale	.47**	.163	.690	.63**	.373	.791	.01	−.321	.336	.26	−.078	.540	.40*	.078	.641
Social phobia subscale	.07	−.262	.392	.34*	.017	.604	−.29	−.562	.047	−.17	−.470	.170	.20	−.136	.497
Obsessive compulsive subscale	.15	−.184	.459	.37*	.050	.625	−.18	−.476	.163	.01	−.320	.337	.14	−.198	.447
Panic/agoraphobia subscale	.18	−.158	.480	.41*	.096	.652	−.24	−.525	.098	.03	−.300	.357	.27	−.063	.550
Physical injury fears subscale	.13	−.210	.438	.31	−.022	.579	−.14	−.446	.200	−.10	−.413	.238	.19	−.153	.484
Generalized anxiety subscale	.32	−.006	.589	.59**	.318	.767	−.12	−.430	.219	.09	−.248	.405	.22	−.116	.512
Intolerance of uncertainty scale-revised total score	.15	−.190	.454	.33	−.001	.593	−.15	−.453	.191	.07	−.265	.390	.11	−.223	.426

Note: *p < .05. ** p < .01; n = 36; confidence level is set at 0.95.

Association between parent health anxiety and associated constructs

Results demonstrated positive associations between the SHAI total score and the total scores from the ASI-3, r (33) = .66, 95% CI [.417, .810], STAI-S version, r (33) = .56, 95% CI [.289, .753], STAI-T version, r (33) = .58, 95% CI [.312, .764], and IUS-12, r (33) = .58, 95% CI [.314, .765].

Discussion

In the present study, we sought to explore the association between self-reported health anxiety, anxiety, intolerance of uncertainty, and anxiety sensitivity in school-age children and adolescents with CHD and one of their parents. The major novel findings were positive associations between child and adolescent self-reported intolerance of uncertainty and self-reported parent state and trait anxiety. There is some existing research examining the association between intolerance of uncertainty in typically developing children and parental anxiety. Sanchez and colleagues (2016) suggest that maternal and child anxiety are mediated by intolerance of uncertainty. It would be advantageous to explore this association further in children and adolescents with CHD, children and adolescents with other with chronic health conditions, as well general child populations.

Another finding was the positive association observed between child and adolescent anxiety sensitivity, panic/agoraphobia symptoms, and parent state anxiety. With respect to the association between child anxiety sensitivity and parent state anxiety, Drake and Kearney (2008) demonstrated an association between child anxiety sensitivity and parent general anxiety, in that child anxiety sensitivity mediated the relationship between parent general anxiety and child anxiety. These researchers suggested a number of mechanisms by which this association may exist including parents with anxiety may verbally communicate to their children that physical anxiety symptoms may be dangerous or may model anxiety behaviors to their children (e.g., openly discuss situations associated with physical anxiety symptoms, escape or avoidance of situations that incite physical symptoms of anxiety; Drake and Kearney, 2008). However, in children and adolescents with CHD it is advantageous to be aware of physical changes (e.g., changes in heart rate or rhythm) that are important in order to obtain expedient assessment or intervention.

Children and adolescents with chronic health conditions, such as CHD, rely on their parents as key contributors to facilitate the transition to independently managing their own health (Chen et al., 2017). In this transition, children and adolescents require appropriate guidance and education so to be able to decipher physical changes that are clinically meaningful from those that are not, so it is conceivable that an anxious parent’s behaviors could impact the ability of their child to accurately assess their physical health. While the latter appears plausible as it applies to the current population, there is mixed findings regarding the association between child and adolescent anxiety sensitivity and parent anxiety (Francis and Noel, 2010). In future research, it may be important to explore how parents of children and adolescents with CHD experience anxiety as it is related to their child’s illness and how they perceive it impacting their child and their behavior.

No association was observed between child and adolescent health anxiety and parent health anxiety in the current sample, inconsistent with previous research (Koteles et al., 2015; Marshall et al., 2007; Thorgaard et al., 2016; Wright et al., 2017). Interestingly, the direction of the association observed is negative. As child and adolescent health anxiety decreases, parent health anxiety increases. The latter observation requires further examination.

What might explain the divergence in our findings regarding the association between child and adolescent, and parent health anxiety and associated constructs and the existing literature? First, the measurement of health anxiety has not been uniform across existing research. Not all studies have employed the CIAS with children and adolescents and SHAI with parents; this could speak to variation across findings. Second, participant characteristics across the existing studies have varied. For example, some research has included generally healthy parents and typically developing/healthy youth (Rask et al., 2012), and other research has included parents with physical and mental health conditions with typically developing/healthy youth (Marshall et al., 2007; Thorgaard et al., 2016). Our study is the first to explore the association between self-reported school-age child, adolescent, and self-reported parent health anxiety and associated constructs in generally healthy parents and school-age children and adolescents with a specific chronic physical condition. Inherent differences could exist for children and adolescents with CHD and healthy parents when experiencing health anxiety and associated constructs. Further research is required to better understand the association between school-age child, adolescent, and parent health anxiety for this population and to explore the generalizability of our findings to other child and adolescent chronic health populations.

With respect to associations between child and adolescent health anxiety and associated constructs, positive associations were observed between overall health anxiety and anxiety sensitivity, and fear around health and anxiety sensitivity. These findings are consistent with previous research (Oliver et al., 2020) in a CHD youth population as well as in a typically developing/healthy youth sample (Wright et al., 2016). In particular, our findings further validate the relationship between anxiety sensitivity and health anxiety in youth in general (Wright and Asmundson, 2003; Wright, et al., 2016). Anxiety sensitivity is a predictor of health anxiety (Otto et al., 1992; Stewart et al., 1998; Wright and Asmundson, 2003), and that anxiety sensitivity is associated with anxiety disorders because it acts as an anxiety amplifier, such that those who become anxious can become alarmed by the arousal-related sensations which can intensify their anxiety (Taylor et al., 2007). In terms of anxiety disorder symptoms, overall child and adolescent health anxiety was significantly associated with separation anxiety symptoms. Further, results demonstrated positive associations between fear associated with health and overall child and adolescent anxiety symptoms, separation anxiety symptoms, social phobia symptoms, obsessive-compulsive symptoms, panic/agoraphobia symptoms, and generalized anxiety symptoms.

Health anxiety and intolerance of uncertainty were not associated in children and adolescents. This finding is consistent with Oliver and colleagues (2018); however, it is juxtaposed to findings in typically developing/healthy youth (Oliver et al., 2020; Wright et al., 2016) where a positive association was observed. It is possible children and adolescents with CHD may experience uncertainty differently compared to typically developing children and adolescents as they may be exposed to uncertainty more regularly as a function of their health condition. This increased uncertainty may impact the association with health anxiety. The latter speculation requires further investigation.

When looking at the parent measures, positive associations were observed between parent health anxiety and anxiety sensitivity, state anxiety, trait anxiety, and intolerance of uncertainty. Our findings are consistent with previous adult research conducted in non-clinical populations (Wheaton et al., 2012) and in specific medical populations (Jones et al., 2014), where anxiety sensitivity has been identified as a predictor of health anxiety.

Our findings are in line with previous adult research which examined health anxiety and state anxiety. Researchers have found an association between both constructs in adult medical samples (Hadjistavropoulos et al., 2002). Results demonstrated adults with higher levels of health anxiety experienced greater levels of state anxiety compared to those with lower levels of health anxiety (Hadjistavropoulos et al., 2002). Our findings are also consistent with associations found for health anxiety and trait anxiety in adult medical populations (Janzen et al., 2014). In terms of the association between health anxiety and intolerance of uncertainty within adults, previous research has also found that intolerance of uncertainty to be associated with health anxiety (Boelen and Carleton, 2012; Gerolimatos and Edelstein, 2012). Collectively, our findings support the consensus that health anxiety, intolerance of uncertainty, state and trait anxiety, and anxiety sensitivity are all linked in adult populations.

Limitations

Several limitations require attention. First, this study is a part of a larger study in which strict exclusion criteria was applied. For example, children and adolescents could not participate if they had had surgery within the last 6 months. Our sample did include heart transplant recipients and those with heart defects which would be categorized as severe (i.e., hypoplastic left heart syndrome; Franich-Ray et al., 2013) as long as it had been at least 6 months since surgery. However, including children and adolescents with cyanotic CHD and those who had surgery recently may have provided us with a more representative sample and would be an important direction for future studies. Second, related to the first limitation, due to the planned methodology of the larger study few parent demographic characteristics were available. This information would help us fully understand the generalizability of our data. Third, our relatively small sample may preclude widespread generalizability. Future research with a larger sample size will be required to contextualize our current findings. Fourth, our youth sample had a wide age range (i.e., 6 to 16 years). Our sample was not large enough to explore potential meaningful differences as it applies to age in this population.

Clinical relevance

Findings from previous research suggests that youth with CHD experience significantly higher levels of health anxiety, anxiety sensitivity, and anxiety symptoms than typically developing/healthy youth (Oliver et al., 2020). In other patient groups, such as children and adolescents with cystic fibrosis, decreases in mental health functioning is associated with decreased health functioning (Ploessl et al., 2014). It would be advantageous to further our understanding of health anxiety and anxiety-related constructs in school-age children and adolescents with CHD in an effort to prevent the development of clinically elevated psychopathology and decreases in health.

Improved understanding of health anxiety in school-age children and adolescents with CHD could facilitate early identification of clinically significant health anxiety. Doing so could prevent inappropriate and invasive medical investigations or procedures. This in turn would reduce the use of unnecessary health care resources, which are inherent aspects of clinical levels of health anxiety (Rask et al., 2016). Early identification and treatment of health anxiety and associated constructs, particularly anxiety, for this population may also facilitate improved adherence rates for cardiac rehabilitation in adult years. Elevated anxiety, combined with the will to live, has been found to be related to lower adherence rate for cardiac rehabilitation in adulthood (Harris et al., 2019). Longitudinal exploration of the association between health anxiety in childhood and later adherence to cardiac rehabilitation in adulthood represents a novel research direction.

Conclusion

For the first time, we have explored the association between self-reported health anxiety and associated constructs in school-age children and adolescents with CHD and that of one of their parents. We found no association between child and adolescent health anxiety and parent health anxiety, albeit associations were demonstrated with the other parent associated constructs. Future research is required to further explore this finding, and inconsistency with existing literature. Improved understanding of health anxiety and associated anxiety constructs (including the role parents/guardians might play in the etiology of health anxiety), in school-age children and adolescents with CHD are critical to better understand and assess their psychological needs and to provide appropriate, tailored interventions.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this study was provided by the Jim Pattison Children’s Hospital Foundation (JPCHF grant #416803).

ORCID iD

Kristi D Wright

References

Abramowitz

Deacon

Valentiner

(2007) The short health anxiety inventory: psychometric properties and construct validity in a non-clinical sample. Cognitive Therapy and Research 31(6): 871–883.

Asmundson

GJG

Abramowitz

Richter

, et al. (2010) Health anxiety: current perspectives and future directions. Current Psychiatry Reports 12(4): 306–312.

Boelen

Carleton

(2012) Intolerance of uncertainty, hypochondriacal concerns, obsessive-compulsive symptoms, and worry. The Journal of Nervous and Mental Disease 200(3): 208–213.

Carleton

Norton

Asmundson

GJG

(2007) Fearing the unknown: a short version of the intolerance of uncertainty scale. Journal of Anxiety Disorders 21(1): 105–117.

Chen

Chiang

, et al. (2017) Healthcare needs of adolescents with congenital heart disease transitioning into adulthood: a delphi survey of patients, parents, and healthcare providers. European Journal of Cardiovascular Nursing 16(2): 125–135.

Deacon

Abramowitz

(2008) Is hypochondriasis related to obsessive-compulsive disorder, panic disorder, or both? An empirical evaluation. Journal of Cognitive Psychotherapy 22(2): 115–127. DOI: 10.1891/0889-8391.22.2.115

Delparte

Wright

Walker

, et al. (2015) Confirmatory factor analysis of the childhood illness attitude scales. Children's Health Care 44(4): 322–340.

Drake

Kearney

(2008) Child anxiety sensitivity and family environment as mediators of the relationship between parent psychopathology, parent anxiety sensitivity, and child anxiety. Journal of Psychopathology and Behavioral Assessment 30(2): 79–86.

Fink

Ørnbøl

Christensen

(2010) The outcome of health anxiety in primary care. A two-year follow-up study on health care costs and self-rated health. Plos One 5(3): e9873.

10.

Franich-Ray

Bright

Anderson

, et al. (2013) Trauma reactions in mothers and fathers after their infant’s cardiac surgery. Journal of Pediatric Psychology 38(5): 494–505.

11.

Francis

Noel

(2010) Parental contributions to child anxiety sensitivity: a review and recommendations for future directions. Child Psychiatry and Human Development 41(6): 595–613.

12.

Freeston

Rhéaume

Letarte

, et al. (1994) Why do people worry? Personality and Individual Differences 17(6): 791–802.

13.

Gerolimatos

Edelstein

(2012) Predictors of health anxiety among older and young adults. International Psychogeriatrics 24(12): 1998–2008.

14.

Hadjistavropoulos

Asmundson

GJG

La Chapelle

, et al. (2002) The role of health anxiety among patients with chronic pain in determining response to therapy. Pain Research and Management 7(3): 127–133.

15.

Hafetz

Miller

(2010) Child and parent perceptions of monitoring in chronic illness management: A qualitative study. Child: Care, Health and Development 36(5): 655–662.

16.

Harris

Anderson

Landers

, et al. (2019) Higher anxiety and will to live are associated with poorer adherence to cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention 39(6): 381–385.

17.

Janzen

JAC

Hadjistavropoulos

Friesen

(2014) Exploration of health anxiety among individuals with diabetes: prevalence and implications. Journal of Health Psychology 19(2): 312–322.

18.

Jones

Hadjistavropoulos

Gullickson

(2014) Understanding health anxiety following breast cancer diagnosis. Psychology, Health & Medicine 19(5): 525–535.

19.

Koteles

Freyler

Kokonyei

, et al. (2015) Family background of modern health worries, somatosensory amplification, and health anxiety: a questionnaire study. Journal of Health Psychology 20(12): 1549–1557.

20.

Marshall

Jones

Ramchandani

, et al. (2007) Intergenerational transmission of health beliefs in somatoform disorders: exploratory study. The British Journal of Psychiatry 191(5): 449–450.

21.

Oliver

Wright

Kakadekar

, et al. (2020) Health anxiety and associated constructs in children and adolescents with congenital heart disease: a CHAMPS cohort study. Journal of Health Psychology 25(10–11): 1355–1365.

22.

Otto

Pollack

Sachs

, et al. (1992) Hypochondriacal concerns, anxiety sensitivity, and panic disorder. Journal of Anxiety Disorders 6(2): 93–104.

23.

Ploessl

Pettit

Donaldson

(2014) Prevalence of depression and antidepressant therapy use in a pediatric cystic fibrosis population. Annals of Pharmacotherapy 48(4): 488–493.

24.

Rask

Elberling

Skovgaard

, et al. (2012) Parental-reported health anxiety symptoms in 5-to 7-year-old children: The Copenhagen Child Cohort CCC 2000. Psychosomatics 53(1): 58–67.

25.

Rask

Munkholm

Clemmensen

, et al. (2016) Health anxiety in preadolescence - associated health problems, healthcare expenditure, and continuity in childhood. Journal of Abnormal Child Psychology 44(4): 823–832.

26.

Salkovskis

Rimes

Warwick

, et al. (2002) The health anxiety inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychological Medicine 32(05): 843.

27.

Sanchez

Kendall

Comer

(2016) Evaluating the intergenerational link between maternal and child intolerance of uncertainty: A preliminary cross-sectional examination. Cognitive Therapy and Research 40(4): 532–539.

28.

Sexton

Norton

Walker

, et al. (2003) Hierarchical model of generalized and specific vulnerabilities in anxiety. Cognitive Behaviour Therapy 32(2): 82–94.

29.

Silverman

Fleisig

Rabian

, et al. (1991) Childhood anxiety sensitivity index. Journal of Clinical Child and Adolescent Psychology 20(2): 162–168.

30.

Spence

(1998) A measure of anxiety symptoms among children. Behaviour Research and Therapy 36(5): 545–566.

31.

Spielberger

Gorsuch

Luschene

, et al. (1983) Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press.

32.

Stewart

Conrod

Gignac

, et al. (1998) Selective processing biases in anxiety-sensitive men and women. Cognition & Emotion 12(1): 105–134.

33.

Sunderland

Newby

Andrews

(2013) Health anxiety in Australia: prevalence, comorbidity, disability and service use. The British Journal of Psychiatry 202(1): 56–61.

34.

Taylor

Zvolensky

Cox

, et al. (2007) Robust dimensions of anxiety sensitivity: development and initial validation of the Anxiety Sensitivity Index-3. Psychological Assessment 19(2): 176–188.

35.

Thorgaard

Frostholm

Walker

, et al. (2016) Effects of maternal health anxiety on children’s health complaints, emotional symptoms, and quality of life. European Child & Adolescent Psychiatry 26(5): 591–601.

36.

Walker

Birrell

Rogers

, et al. (2010) Intolerance of Uncertainty Scale-Revised(Unpublished Document). Newcastle University.

37.

Wheaton

Deacon

Mcgrath

, et al. (2012) Dimensions of anxiety sensitivity in the anxiety disorders: evaluation of the ASI-3. Journal of Anxiety Disorders 26(3): 401–408.

38.

Wright

Asmundson

GJG

(2003) Health anxiety in children: development and psychometric properties of the childhood illness attitude scales. Cognitive Behaviour Therapy 32(4): 194–202.

39.

Wright

Asmundson

GJG

(2005) Brief report: factor structure of the childhood illness attitude scales (CIAS). Journal of Pediatric Psychology 30(2): 213–218.

40.

Wright

Lebell

Carleton

(2016) Intolerance of uncertainty, anxiety sensitivity, health anxiety, and anxiety disorder symptoms in youth. Journal of Anxiety Disorders 41: 35–42.

41.

Wright

Reiser

Delparte

(2017) The relationship between childhood health anxiety, parent health anxiety, and associated constructs. Journal of Health Psychology 22(5): 617–626.