Baker, 1986). Generally, children's and adolescents' use of problem-focused coping strategies has been found to be more associated with positive psychological adjustment than their use of emotion-focused coping strategies. Interestingly, adolescent use of avoidant coping has been found to be associated with high levels of depression in adolescence (Ebata & Moos, 1991). There has been little systematic research on the association between specific types of coping strategies and the development and maintenance of anxiety disorders in adolescence. There also has been little systematic research on which specific coping skills should be taught to adolescents across diverse anxiety-provoking situations. Research in this area is clearly of importance given that coping-skills training represents a major feature of cognitive-behavioral treatments (see Chapter 10). Another characteristic of the individual that relates to cognitions is individuals' perceived control. Specifically, Barlow (2001) has suggested that children who experience uncontrollable events early in life may develop a propensity to perceive or process events as not being under their control, which for some youngsters may serve as a risk for the development of anxiety and its disorders. Chorpita, Brown, and Barlow (1998) have presented some interesting data showing that perceived control may serve as a mediator of family environment among youths with anxiety disorders. Clearly, further research on the role of perceived control as a protective and risk factor in anxiety disorders is needed, particularly on its specificity (or lack thereof) to anxiety.

As discussed in greater detail in Chapter 9, genetic factors clearly influence the risk for anxiety disorders and, taken together, the epidemiological and genetic data imply distinct biological profiles for the varied anxiety disorders, many of which implicate neurochemical processes. A recent meta-analysis found only a modest genetic contribution to four anxiety categories, and no evidence for a significant effect of shared environment (Hettema, Neale, & Kendler, 2001). When the individual studies themselves are re viewed, however, inconsistencies emerge with respect to the degree to which genetics were implicated in transmission of anxiety disorders; rates appear to vary as a function of the site of the laboratory, as well as the informant supplying the relevant information. There is evidence for genetic contributions to personality traits such as neuroticism, introversion (Eaves, Eysenck, & Martin, 1989), shyness (Daniels & Plomin, 1985), and behavioral inhibition (DiLalla, Kagan, & Reznick, 1994; Kagan, 1994), each of which may increase risk for the subsequent development of anxiety disorder. In general, many studies of the genetics of anxiety disorders involving children and adolescents have substantive methodological limitations, thus there remains a great deal to discover in this area. Also, it is important to note that the presence of a genetic influence for anxiety disorders does not imply that the course of illness is immutable. From the perspective of prevention, it may be that studying other risk factors in youth at genetic risk for anxiety disorders may prove especially fruitful, and may suggest roads to interventions that reduce the genetic risk.

All four of the attachment styles in children according to the classification by Ainsworth, Blehar, Waters, and Wall (1978) and by Main and Solomon (1990)—secure, insecure-avoidant, insecure-ambivalent, and insecure-disorganized —have been found to be represented in children with anxiety disorders. The highest risks for developing an anxiety disorder are associated with disorganized attachment, which is associated with unresolved trauma or loss, and ambivalent attachment (Cassidy, 1995; Manassis, Bradley, Goldberg, Hood, & Swinson, 1994; Warren, Huston, Egeland, & Sroufe, 1997). The specificity of an association between disorganized attachment in terms of its link with a specific type of anxiety disorder, such as separation anxiety disorder, has not been established.

The research conducted on parenting has focused primarily on parental rearing styles, with the latter conceptualized along two orthogonal dimensions: warmth versus hostility, and control versus autonomy (Boer, 1998; Cassidy, 1995; Dadds, Barrett, Rapee, & Ryan, 1996; Lutz & Hock, 1995; Manassis et al., 1994; Rapee 1997; Siqueland, Kendall, & Steinberg, 1996; Warren et al., 1997).

The ecology of adolescent development and culture includes an expanded network of peer, school, and community affiliations. The transition to middle and high school constitutes a period of high developmental risk, in which there is an increased incidence of school truancy, failure and dropout, engagement in high-risk sexual and self-injurious behaviors, smoking and drug use, initiation into gangs, and contact with the juvenile justice system. It is also a period of increased exposure to interpersonal violence. For example, in 1999, almost 10% of 9th to 12th graders reported being hit or physically hurt by a boyfriend or girlfriend. In the sections below, particular high-risk activities engaged in by adolescents and their associated risk with anxiety are discussed.

Initiation into cigarette smoking in adolescents is recognized as a major public health problem. As summarized by Upadhyaya, Deas, Brady, and Kruesi (2002) from a number of national surveys, approximately 3,000 adolescents start smoking each day, resulting in about 21% of high school seniors smoking daily, and a total of 4 million adolescent smokers. Smoking prevention and early treatment are important components of universal and selective public health prevention strategies, especially given that the American Health Association estimates that addiction to tobacco during adolescence accounts for 80% of adult smokers. As Upadhyaya et al. (2002) discuss, there is continuing interest in the interaction between onset of adolescent psychiatric conditions and smoking behavior, including experimental smoking and cessation difficulty. Among the disorders studied, Johnson et al. (2000) report that heavy cigarette smoking (defined as over 20 cigarettes per day) is associated with higher rates of agoraphobia, anxiety, and panic disorders in adolescents. Other studies have reported an even stronger association of adolescent smoking with attention-deficit hyperactivity disorder (Johnson et. al., 2000) and major depressive disorder (Dierker et al., 2001). Most of these studies note the importance of the relationship between peer smoking influences and individual psychiatric vulnerabilities. The general conclusion is two-pronged: first, smoking prevention and cessation programs need to incorporate screening for adolescent psychiatric disorders, including anxiety disorders and, second, attention to adolescent anxiety and comorbid disorders need to include strategies to address risks of tobacco addiction.

Adolescence is a developmental period in which experimentation with alcohol and drugs is com

mon. It also is a time of development risk for early onset of alcohol and substance abuse and dependence. Nelson and Wittchen (1998) found that among youth and young adults, the peak incidence of alcohol disorders occurred at 16–17 years of age. Alcohol and drug use problems in adolescents are a strong predictive factor of adult alcohol and drug dependence (Swadi, 1999). Studies of substance abuse and alcohol motivation in adolescents suggest a multifactorial explanatory framework. Among the many factors, Comeau, Stuart, and Loba (2001) found that high anxiety sensitivity predicts conformity motives for alcohol and marijuana use, whereas anxiety traits are associated with coping motives for alcohol and cigarette use. Zucker, Craske, Barrios, and Holguin (2002) reported that among young adults with panic disorder, up to one in five cases had an onset related to an adolescent experience with a psychoactive drug. In a review of studies of adolescent use of the recreational drug “ecstasy,” Montoya, Sorrentino, Lukas, and Price (2002) found a strong association between repeated drug use and anxiety disturbances, with potential neurobiological consequences that are of concern within this critical developmental stage.

Initiation and use of alcohol and drugs among adolescents are also related to life stresses, including traumatic events (Wills, Vaccaro, & McNammar, 1992). In one study, substance-abusing adolescents were found to be five times more likely to have a history of trauma and concurrent posttraumatic stress disorder (PTSD) compared to a community sample (Deykin & Buka, 1997). In a large study of adolescents enrolled in four drug treatment programs, a high positive correlation was found between severity of posttraumatic stress symptoms and higher levels of substance use and HIV risk behavior (Stevens, Murphy, & McNight, 2003).

As with cigarette addiction, prevention strategies for adolescent substance abuse need to include early intervention for anxiety vulnerable and traumatized youth and at the same time recognize that prevention or early intervention for adolescent substance abuse may also constitute an anxiety disorder prevention strategy.

Gang affiliation is a serious cultural problem in adolescence. There are an estimated 24,000 gangs, with over 772,000 members active across the United States (U.S. Department of Justice, 2002). There is a complexity to youth involvement in gangs. Many studies have examined the confluence of risk factors that predict gang membership, including neighborhood, family, school, peer group, and individual variables (Hill, Levermore, Twaite, & Jones, 1996). There is an emerging literature about the extent of trauma and loss exposure associated with gang membership and delinquent behavior more generally (Wood, Foy, Layne, Pynoos, & James, 2002). Despite high rates of trauma exposure prior to gang membership, commonly youth report that their worst traumatic experiences are gang related and the source of current PTSD symptoms (Wood et al., 2002). Ages 11–13 are primary years for solicitation and inculcation into gang affiliation and activities, contributing to years of increased trauma and loss exposure during adolescence. Consequently, intervention programs to prevent youth from becoming involved in gangs should be considered an adjunct prevention strategy for adolescent PTSD.

Adolescence is also the time when involvement in the justice system accelerates. Approximately 1.8 million youth go through the juvenile justice system each year, with over 360,000 detained and 176,000 incarcerated (U.S. Department of Justice, 2002). Recently, attention has turned to the high prevalence of adolescent psychiatric disorder present among juvenile justice detainees. Of importance, the rate of anxiety disorders is as high as one in three and equal to or exceeds those of mood disorder. Of the anxiety disorders, studies vary in the prevalence of specific anxiety disorders. Studies that have assessed PTSD have found it to be among the highest (Wasserman, McReynolds, Lucal, Fisher, & Santos, 2002). Interestingly, separation anxiety disorder among adolescents (an age-range where it is less expected) is surprisingly high among African-American and Hispanic and Latino detained youth (Teplin, Abram, McClelland,