Journal of Affective Disorders 91 (2006) 113 124 www.elsevier.

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Review

An integrative model of control: Implications for understanding emotion regulation and dysregulation in childhood anxiety
Carl F. Weems a,, Wendy K. Silverman b
a

Department of Psychology, University of New Orleans, New Orleans, LA 70148, United States b Florida International University, United States Received 5 July 2005; received in revised form 15 December 2005; accepted 6 January 2006 Available online 17 February 2006

Abstract Theorists and investigators have emphasized an important role for control in emotional problems such as anxiety and anxiety disorders in youth. However, the term control is subject to theoretical ambiguities because of the broad conceptual bases for the term. In this article, we examine the concepts of locus of control, learned helplessness/attributional style, self-efficacy, and perceived control to develop an integrative model of control based on research and theory. The review emphasizes each of the theories distinguishing features in order to show how these distinctive features relate to real versus perceived control and how they may be differentially associated with childhood anxiety. We attempt to clarify the various definitions of control and the implications of these various definitions with respect to childhood anxiety, its disorders and their treatment and present a model of control that is integrative but also addresses the complexities of the different definitions of control (i.e., is multifaceted). The model developed from our review of the literature postulates that individuals differ in the extent to which they actually have control and differ, also on a continuum, in their perceptions of control. The need for this integrative model is highlighted by methodological, developmental, and clinical considerations. In particular, research has operationalized control and related constructs such as emotion regulation in ways that may be confounding actual control and perceived control. The need for an integrative but also multifaceted conceptualization of the role of control in childhood anxiety is also highlighted by clinical and developmental considerations. For instance, different facets of control may have differential relevance to clinical anxiety and at different points in childhood. 2006 Elsevier B.V. All rights reserved.
Keywords: Control; Anxiety; Childhood; Perceived control; Emotion regulation; Self-efficacy

Contents 1. Does control mean the same thing across theories? . . . . . . . 1.1. Internal versus external locus of control . . . . . . . . . . 1.2. Learned helplessness and negative contingency attributions 1.3. Self-efficacy and competence attributions . . . . . . . . . . 1.4. Perceived control and integrative concepts . . . . . . . . . An integrative model of control . . . . . . . . . . . . . . . . . . 2.1. Developmental considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 115 116 117 117 119 121

2.

Corresponding author. E-mail address: cweems@uno.edu (C.F. Weems). 0165-0327/$ - see front matter 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2006.01.009

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2.2. Clinical considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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Control is a pervasively used construct in psychological research and theory and there is a wealth of evidence to suggest that departures from optimal control can play a role in emotional dysregulation (Seligman, 1975; Barlow, 2002). Yet, how control is defined and measured can be ambiguous and inconsistent both within and across literatures (see Costello, 1979; Miller, 1979; Shear, 1991). Such conceptual issues have important implications for understanding the relation of control to emotional disturbances such as anxiety and anxiety disorders. For example, animal studies that experimentally manipulate levels of control have shown that a lack or loss of controllability and or predictability is linked to stress (see Miller, 1979), fear (see Seligman, 1968) and depression (see Seligman, 1975). Yet, models of control derived from this research have been criticized for their lack of conceptual clarity when applied to humans (see e.g., Costello's, 1979 critique of the learned helplessness model of depression or Shear's, 1991 comments on Barlow's, 1991 model of anxiety). Research and theories on control have been derived from a wide variety of sources including social learning theory (e.g., Bandura, 1982; Rotter, 1966, 1975), animal modeling of psychopathology (e.g., Seligman, 1968, 1975), and social psychology (e.g., Burger, 1986; Taylor and Brown, 1988). Defining control is therefore no easy task (see Skinner, 1995). In fact, control can mean very different things depending on the conceptual basis for the term and thus the purpose of this paper is to clarify what control can mean with regard to the regulation and dysregulation of anxiety in youth by presenting an integrative model. Our review of empirical research is drawn primarily from the literature on control and anxiety in youth to facilitate consistency in our conceptual examples and also to keep our review of the literature within the scope of a single paper. However, the broad theoretical and empirical literature on control informed our conceptual analysis and we feel that our model likely has implications beyond childhood anxiety (e.g., adult anxiety, depression) and also for definitional issues in research on emotion regulation more broadly (Bridges et al., 2004). The importance of understanding childhood anxiety has become more salient with the realization that anxiety disorders in childhood can cause significant distress and impairment, are one of the most prevalent

emotional problems and are predictive of adult emotional disorders (See Vasey and Dadds, 2001; Weems and Stickle, 2005). Several investigators and theorists have emphasized a key role for the construct of control in anxiety and its disorders in youth (e.g., Capps et al., 1996; Cortez and Bugental, 1995). In an important review, Chorpita and Barlow (1998) showed how research findings suggest that early childhood experience with diminished control may result in a cognitive style that increases the probability of interpreting events as out of one's control. Based on these findings, Chorpita and Barlow proposed a model in which a lack of control represents a psychological vulnerability for the development of anxiety problems. In this article, we expand upon Chorpita and Barlow (1998) by exploring in detail the conceptual and theoretical underpinnings of the construct of control. This is done by examining the concepts of locus of control; learned helplessness and attributional style; self-efficacy; and perceived control. By so doing, we aim to clarify the various definitions of control and the implications of these various definitions with respect to childhood anxiety, its disorders and their treatment. We then present a model of control and a way of thinking about control that is integrative but also addresses the complexities of the different definitions of control (i.e., is multifaceted) and discuss its methodological, developmental, and clinical implications. 1. Does control mean the same thing across theories? Chorpita and Barlow (1998) in their comprehensive review of the research literature examined child performance tasks and experimental manipulations of control to develop their theory that control is causally linked to the development of anxiety problems. Our focus in this review, however, is mainly on studies that have employed child self-reports. By focusing on child selfratings the nuances involved in the various conceptualizations of control across the theories is most apparent and child self-report measures have been most consistently used across the various definitions of control reviewed. Thus, we start from the premise that control can be causally linked to anxiety problems (Chorpita and Barlow, 1998) and aim to clarify the ways in which

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it may be linked. Table 1 summarizes the concepts to be discussed. 1.1. Internal versus external locus of control Derived from social learning theory (Rotter, 1966, 1975), the concept of internal locus of control involves an individual's perception that control over reinforcement is due to personal skills or characteristics. The concept of external locus of control involves an individual's perception that control over reinforcement is due to external factors such as chance or fate. The potential importance of locus of control in understanding anxiety was suggested early on by Mandler and Watson (1966), who hypothesized that actual or perceived lack of control (i.e., high external control) produces anxiety. That is, a belief that control is external to the self could predispose one to feel anxious about his or her lack of control over reinforcement. The most widely used measure of locus of control for children and adolescents is the Nowicki and Strickland (1973) locus of control (NSLOC) scale, patterned after Rotter's adult scale. The NSLOC consists of 40 questions and is scored using a yes/no format with higher scores indicating greater external locus of control. Empirical research findings suggest a fairly clear and consistent relation between locus of control and self-reported anxiety in children with correlations ranging rather widely from .23 to .68 (Shriberg, 1974; Nunn, 1988; Rawson, 1992). In terms of research employing clinical samples of anxious youth, scores on the NSLOC did not differentiate youth meeting diagnostic criteria for an anxiety disorder
Table 1 Summary of control theories and their potential role in anxiety regulation Theory 1. Locus of control (e.g., Rotter, 1966) Summary distinctive definition of control

(n = 86) from a sample of non-referred youth (n = 31) aged 9 to 17 years (i.e., Weems et al., 2003). Research on locus of control emphasizes responseoutcome beliefs about the power or capacity to regulate reinforcement (see Table 1). If an individual's beliefs are more external (e.g., the individual tends to expect that the capacity to regulate is not a function of self), theoretically, the individual may be less able to regulate his or her anxiety. However, external control beliefs may not be related to elevated anxiety in all children. Specifically, Rotter (1975) cautioned against thinking that internal control is always good and adjusted whereas external control is always bad and maladjusted. For instance, an individual with an external locus of control might not experience more anxiety or negative affect because he or she is also stoically resigned to fate (e.g., It is in God's hands or I can't do anything about it anyway). In other words, additional attributions and beliefs may moderate the role of external control in elevated anxiety. Moreover, an external locus of control may be an accurate assessment of the individual's state of affairs (i.e., the individual may actually not have control over certain things and thus the individual may be accurately responding to the environmental conditions). This accurate assessment may lead to adaptive responses (e.g., stoically accept the situation, seek different environmental conditions). If the external control is inaccurate, that is, the person has control but thinks he or she does not this would seem to lead to less appropriate responses (e.g., accepting lower levels of reinforcement than optimal to the individual, failure to leave the situation) and thus is more likely to result in emotional difficulties. Thus, an external locus of control

Illustrative anxiety de-regulative beliefs I do not control potential anxiety producing events or physiological anxiety reactions. People who don't get scared are just lucky.

Emphasizes that beliefs about the power or capacity to regulate reinforcement revolve around two loci: 1) Internal The capacity to regulate is a function of self. 2) External The capacity to regulate is not a function of self. 2. Learned helplessness/ Emphasizes that if attributions about negative events are attributional style (e.g., ascribed to causes that are perceived as stable, global and Seligman, 1975) internal emotional problems may result. 3. Self-efficacy Emphases that the individual's beliefs about their (e.g., Bandura, 1982) confidence in their competence to successfully execute behaviors to produce and regulate events in their lives are critical to emotional well-being. 4. Perceived control Involves the individual's perception of the capacity to (e.g., Connell, 1985) regulate in each theory as distinguished from actual control. Moreover, can involve the whole set of beliefs about the power to regulate. May or may not be based on actual control.

Because I am in control a bad thing will happen. I cause negative outcomes. I have never been able to control my anxiety. I do not have the skill to control anxiety producing events. People who don't get scared are smarter/more skillful than me. I could control my anxiety if I wasn't so incompetent. Composite: e.g., I have never been able to control my anxiety (learned helplessness) and I will not be able to learn to control (low self-efficacy).

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is not inexorably linked to anxiety in every child as the association may be modified by other attributions as well as the child's actual level of control. This may account, in part, for differences in the strength of the associations found in previous studies as well as the failure of the NSLOC to differentiate youth with anxiety disorders from non-referred youth. 1.2. Learned helplessness and negative contingency attributions The learned helplessness model suggests that organisms subjected to a situation where noxious stimuli are inescapable (e.g., unavoidable shock) fail to avoid noxious stimuli in the future when escape is possible (i.e., they learn helplessness). Abrahamson et al. (1978) suggested that individuals' causal attributions in helpless situations determine the pervasiveness and severity of the feelings of helplessness. According to the learned helplessness theory of Abrahamson et al., once people perceive non-contingency between their actions and an event, their helplessness is attributed to a cause that can be perceived as internal or external, stable or unstable, and global or specific. An important distinction between control in the learned helplessness literature and locus of control is that although both involve contingency beliefs, internal attributions regarding the cause of a negative event are theoretically different from an internal locus of control over reinforcement contingencies (see Miller and Norman, 1979 for an extended discussion). Locus of control in the learned helplessness model represents the assignment of the cause of an event to either internal or external sources. That is, there is an emphasis on past negative and positive events and not just locus of control as an expectancy regarding a response-outcome contingency. Internal control over negative events defined as the cause of those events (e.g., statements such as I cause negative events) should theoretically be positively correlated with anxiety. For example, a child may think, If I am in control of a social situation, I will cause a socially inappropriate thing to happen. This would imply a positive correlation between anxiety and an internal locus of control. Such a conceptualization of control is similar to Beck's (1976) notion of personalizing (i.e., attributing control over the outcome of negative events to internal causes, such as, my team lost the game because of me, they will be mad at me). On the other hand, internal control may be negatively associated with anxiety if the child thinks, I am in control, I can control my anxiety. Kaslow et al. (1978) Children's Attributional Style Questionnaire (CASQ) has been used extensively to

investigate helplessness theory in children, primarily with regard to depression (see Joiner and Wagner, 1995). Studies have suggested a moderate correlation with anxiety levels (Garber et al., 1993; Rodriguez and Routh, 1989). Other measures that assess control as defined by helplessness theory also have been found to be associated with anxiety in youth. The Children's Negative Cognitive Error Questionnaire (CNCEQ; Leitenberg et al., 1986) assesses control via the personalizing subscale (higher scores indicate greater personalizing) and has been linked to anxiety symptoms in several studies (e.g., Epkins, 1996; Leitenberg et al., 1986; Weems et al., 2001). For example, Weems et al. (2001) found that personalizing was significantly related to measures of anxiety symptoms (r's ranging from .33 to .43) and that these associations were still significant even when controlling for levels of depression in a sample of children and adolescents referred for anxiety problems (n = 251, ages 6 to 17 years). Results also indicated that age moderated the relation between personalizing and anxiety. Specifically, statistically significant but smaller correlations were found between personalizing and the anxiety measures in children aged 611 as compared to adolescents aged 1217 years old. These results suggest that younger children may believe they control negative events but that such negative interpretations of a situation may be less strongly related to their anxious or depressed symptoms than older youth. This may occur because it is more developmentally normal to have such egocentric thinking in early school age children (Weisz and Stipek, 1982). Theoretically, the learned helplessness model emphasizes a different conceptualization of control than the locus of control model in social learning theory. Specifically, the learned helplessness model emphasizes control attributions about the failure to regulate events and produce positive outcomes (i.e., helplessness) (see Table 1). When such attributions about the failure to regulate events and produce positive outcomes are ascribed to causes that are perceived as stable, global, and internal, anxiety may result. There is empirical evidence for a significant relation between control as conceptualized in helplessness theory and anxiety in children. Additional research is needed, however, examining the relative importance of the learned helplessness model of control versus the locus of control (e.g., do the different conceptualizations of control provide unique prediction of childhood anxiety?). Finally, with regards to emotional disturbance such as childhood anxiety, helplessness implies that the individual perceives that they are in control of negative events but in actuality they may not. For example, the child who personalizes the loss of a

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basketball game is reasoning (perceiving) that they were in control of the loss when in actuality they were not (i.e., the team is responsible for the loss). Thus, it is important to consider the real level of control the child has in terms of understanding control's relation to emotional disturbances such as anxiety (i.e., personalizing can be considered a discrepancy between real and perceived control). 1.3. Self-efficacy and competence attributions Bandura's (Bandura, 1977,1982; Bandura et al., 1982) concept of self-efficacy refers to an individuals' conviction of their ability to produce and regulate events in their lives (Bandura, 1982, p. 122). Self-efficacy is thought to influence anxiety levels through an enhancement of the cognitive sense of control (Bandura, 1982). Bandura (1982) suggested that a lack of self-efficacy in dealing with frightening situations or events could cause both fear and anxiety in that one's belief in his/her ability to deal with an event could diminish fear arousal. Selfefficacy defined as an individual's belief in his or her ability to accomplish domain specific tasks and an internal locus of control over a specific task are somewhat similar. However, a difference between control in self-efficacy and locus of control involves emphasis on beliefs about competence (as opposed to contingency) or skill and the conviction that the individual can use those skills to accomplish a goal or task [e.g., I personally don't think I have the ability to control or I am confident that I have the ability to control (self-efficacy) versus I don't control (locus of control) and I cause bad things to happen (personalizing)]. Several studies have demonstrated a relation between self-efficacy and anxiety in children including dental anxiety, test anxiety, and clinical anxiety (Liddel and Murray, 1989; Messer and Beidel, 1993; Yue, 1996). For example, Yue (1996) found that self-efficacy was negatively correlated (r = .35) with test anxiety in a sample of 773 junior high-school students (mean age 15 years). The Perceived Competence Scale for Children (PCSC; Harter, 1982) has been commonly used to measure self-efficacy. Items assess children's perceived competence in four domains, cognitive (e.g., good at schoolwork), social (e.g., have lots of friends), physical (e.g., do well in sports), and general selfworth (e.g., sure of myself). The PCSC has 40 items with 10 items for each domain and higher scores indicate greater self-efficacy (Harter, 1982). Messer and Beidel (1993) found that children who met DSM-III-R diagnostic criteria for anxiety disorders had significantly lower scores than children with no anxiety problems

on the PCSC in terms of the physical, cognitive, and general domains. Theoretically, control in self-efficacy emphasizes the individual's conviction/belief about his or her competence to successfully execute behaviors that produce and regulate events in his or her life (see Table 1). If an individual does not feel competent to successfully execute behaviors to avoid threat, perform in social situations, etc., then he or she may experience anxiety. The concept of self-efficacy adds a potentially important dimension in understanding control in anxiety regulation by emphasizing the individual's confidence in his or her competence and skill to control (e.g., I could control if I wasn't so incompetent). This emphasis provides an important theoretical distinction between self-efficacy and an external locus of control. For example, as noted above in the summary for locus of control, a stoic resignation to fate (e.g., it's in God's hands) appears to be a possible moderator of the association between an external locus of control and anxiety. However, such beliefs are unlikely moderators of the association between low self-efficacy and anxiety because self-efficacy emphasizes self-competence and thus thinking of oneself as incompetent would not conceptually appear to be mitigated by resignation to fate. Finally, poor self-efficacy implies that the child perceives that they not are in control but in actuality they may be. For example, the child who has poor self-efficacy with regards to safety may perceive that they do not have control of their safety when dealing with animals, such as a dog, when in actuality the dog may be behind a fence, on a leash, or small enough for the child to control. The child who has poor self-efficacy with regards to peers may perceive that they do not have good social skills and will be disliked when in actuality the child may have social skills. Thus, as with locus of control and helplessness it is important to consider the real level of control the child has in terms of understanding self-efficacy's relation to anxiety (i.e., poor self-efficacy is also really a discrepancy between real and perceived control). However, poor self-efficacy and learned helplessness imply distinct discrepancies between real and perceived control. 1.4. Perceived control and integrative concepts Perceived control can be defined as a belief an individual holds about the nature of control over situational factors and events (see Table 1). Perceived control has often been used as a generic term for the individual's perception of control to subsume each of the specific theories of control reviewed so far (see

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Connell, 1985; Weisz and Stipek, 1982) and as an integrative concept for understanding control and anxiety disorders (Barlow, 1991, 2002). Specific areas of perceived control revolve around two dimensions: (1) where the control is located (e.g., internal, self, external, powerful others, the unknown, fate, God) and (2) what the control is over (e.g., health, anxious feelings, threatening stimuli, interpersonal relations) (see Connell, 1985; Rapee et al., 1996; Rotter, 1975). The cognitive appraisal of where the control is located may be internal-self, external-powerful others, and external unknown. Control also may be directed toward and circumscribed around a variety of other themes (e.g., academic performance, social events, anxiety related events). The term perceived control deserves separate consideration not just as an integrative construct but also because an individual's perceived control may be based on actual control in terms of competence or an accurate perception of the individual's control over contingencies. Yet, perception of control may not correspond to the actual state of an individual's competence or control over contingencies. The actual causal agent in a behavior-consequence sequence may be an internal one, such as not remembering a phone number and being unable to call someone, or external, such as a broken phone line. The perception of control may correspond well with the actual state of affairs or not (i.e., there may be an illusion of control; Burger, 1986; Burger and Cooper, 1979; or as noted above there may be different discrepancies between real and perceived control as implied by self-efficacy and learned helplessness). The work on the illusion of control (e.g., Burger, 1986; Taylor and Brown, 1988) suggests at least two important possibilities in examining the relation of control to anxiety: 1) perceptions of control may be little affected by the extent to which control is actually possible (e.g., true regulation of anxiety may, in some cases, result from the actual capacity to regulate or may be the byproduct of a positive illusion of control) and 2) operationalizations of perceived control may be confounding actual control with an illusion of control, although this may be an important distinction (e.g., actual competence, perceived competence, and perceived contingency may be differentially related to anxiety). In terms of research using integrative measures and assessments of perceived control, Connell (1985) created the widely used Multidimensional Measure of Children's Perceptions of Control (MMCPC) that distinguishes children's attributions for internal, external, and unknown causes of successes and failures. Kim et al. (1997) used the MMCPC with a sample of children whose parents had been divorced (n = 222,

aged 812 years) and found that only the unknown control dimension moderated the relation between psychological symptoms and stress. However, the analyses did not distinguish anxiety symptoms from other psychological symptoms in that anxiety, depression, and conduct problems were combined to produce an index of psychological symptoms. Granger et al. (1994) found that high cortisol reactors (n = 25) compared to low cortisol reactors (n = 25) were more likely to make external attributions of control for others' successes and failures (external control) on the MMCPC. Further, high cortisol reactors were more likely than low cortisol reactors to report higher levels of social anxiety. However, the specific relations among the control measures and anxiety were not reported. Muris et al. (2003) found that contingency beliefs (using the Perceived Contingency Scale; Weisz et al., 1991) and competency/ self-efficacy beliefs (using the PCSC, Harter, 1982) were significantly correlated and that both were concurrently and prospectively (at a four week follow-up) associated with symptoms of anxiety disorders in a community sample of 214 youth aged 10 to 14 years. Although incremental tests were not conducted, competence beliefs were more strongly associated with anxiety symptoms than contingency beliefs (r = .52 and r = .23 respectively after 4 weeks). Weems et al. (2003) investigated the role of control beliefs in childhood anxiety disorders using a developmentally modified version of Anxiety Control Questionnaire (i.e., ACQ-Child version) by Rapee et al. (1996) in a sample of youth who met diagnostic criteria for an anxiety disorder (n = 86) and non-referred youth (n = 31) 9 to 17 years. The measure is based on Barlow's (1991, 2002) theory of control in anxiety disorders and one's perception of control over anxiety related events are assessed in terms of control over internal emotional reactions and over external frightening events. Specifically, the internalexternal distinction refers to the emotional stimuli to be controlled (i.e., internal anxiety reactions such as heart palpitations and feelings or external threat such as a dog or social situations) and integrates contingency and competence type beliefs (e.g., I can take charge and control my feelings, I can handle scary things) beliefs. Findings indicated that perceived control over anxiety related events were significantly negatively correlated with youth selfreported anxiety symptoms and predicted anxiety disorder status even when controlling for self-reported anxiety and locus of control (i.e., NSLOC scores). The results suggest that assessing anxiety control beliefs may add to understanding the clinical picture of anxious children by tapping an aspect of anxiety disorders not

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assessed by the measures of anxiety and locus of control. Ginsburg et al. (2004) found that that general external attributions of control (using the MMCPC) and control in anxiety-specific situations (a measure similar to the ACQ-C) were positively concurrently associated with panic symptoms but only attributions of control in anxiety-specific situations (i.e., not the scales from the MMCPC) were predictive panic symptoms 6 months later in a community sample of African-American adolescents (n = 109; mean age 15.75 years). 2. An integrative model of control Examination of the definitions of control and the research across the theories of locus of control, learned helplessness and attributional style, self-efficacy, and perceived control suggests that each theory may imply different associations with childhood anxiety and its regulation/dysregulation. Because of the conceptual distinctions and potential for differential associations between anxiety and control we suggest that an integrative-multifaceted approach to control may help advance understanding the development and treatment of childhood anxiety. Fig. 1 presents an integrative model of control that also helps to emphasize the need for a multifaceted approach. The model also takes into account real versus perceived control. The model postulates that individuals differ in the extent to which they actually have control and differ,

also on a continuum, in their perceptions of control. The extent to which an individual actually has control and their perceptions of control may change at different points in their life and may differ across different domains, contexts and events. For example, a child with social phobia may have low perceived control in social situations involving peers although they are very bright, capable and could handle the interaction (i.e., they really could control). This same child may have accurate control beliefs in situations involving adults, however, this accurate perception of control might represent a developmental shift in actual control because the child has recently learned various social skills (i.e., earlier in the child's development high perceived control in social situation may have been less accurate). Our review of the literature and the model developed from it suggests that understanding control's association with anxiety requires a multifaceted approach because the various control theories point to different aspects of control that may be related to anxiety. A multifaceted approach is also needed because each notion of control may have variable importance with regards to understanding anxious pathology across developmental periods. Understanding the association between control and anxiety in childhood requires an integrated approach because, together, the various conceptualizations further an understanding of anxiety disorders and their treatment not possible with any one definition of control. The model presented in Fig. 1 suggests an individual's

Real Control High

Poor Self-Efficacy Inaccurate External Locus of Control Denial of Responsibility

Accurate Internal Locus of Control Accurate High Self-Efficacy Accurate Appraisal of Responsibility

Perceived Control Low High

Accurate External Locus of Control Accurate Low Self-Efficacy Accurate Appraisal of Responsibility

Personalizing Inaccurate Internal Locus of Control Over Efficacious

Low

Fig. 1. An integrative model of control.

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control profile be based on perceptions of control as well as real control such as real competencies and actual situational constraints on the individual's capacity to control. Theoretically, youth in the upper left quadrant (high real control, low perceived control) should have anxiety related problems with control in terms of competence beliefs if they perceive they are not competent when in actuality they are. Youth in the upper left quadrant with regards to contingency may actually be denying responsibility (i.e., the opposite of personalizing) or may have an inaccurate sense of control over reinforcement (i.e., an inaccurate perceived external locus of control). Thus, contingency beliefs should be less related to clinical anxiety than competence beliefs in this quadrant. Youth in the lower right should have anxiety related problems associated with control in terms of contingency if they perceive they are responsible for bad things when in actuality they are not. In terms of competence, youth with these beliefs may actually be over confident in their abilities. Thus, competence beliefs are less likely to be associated with anxiety problems than contingency beliefs in this quadrant. Youth in the lower left (low perceived, low real control) should also have anxiety related control problems; however, the type of control (i.e., contingency versus competence) may again be important in terms of regulating anxiety. Specifically, if the youth has poor perceptions of efficacy (i.e., perception of competence is low) and truly poor skills (i.e., actual low competence) high anxiety problems may still result. But in this case the youth may be more likely to seek out skill development (or seek treatment) because of the accuracy of the beliefs. However, if the youth has low perceptions of contingency (i.e., perception of contingency is low) and actual low control, anxiety problems may be mitigated by resignation to the situation as discussed in the above sections and or may also seek actions to remedy the lack of control. Youth in the upper right (high perceived, high real) quadrant should theoretically have the least anxiety problems regardless of the type of control. The importance of considering both real and perceived control is methodologically highlighted by emerging research on the concept of emotion regulation. The concept of emotion regulation concerns the real capacity to modulate emotional expression (Bridges et al., 2004) and thus implies a level of real control over emotional responses, for example the real regulation of fear and anxiety symptoms in scary situations. Research suggests that youth with anxiety disorders actually have a relatively diminished capacity for controlling emotion

(Suveg and Zeman, 2004). It is thus methodologically important that operational definitions of emotion regulation are distinguishing between the child's perception of control and self-efficacy and the actual capacity for emotion regulation. If not, the new research on the role of emotion regulation in childhood anxiety is replicating findings that are already known from the perceived control literature. The model we present suggests that an important way the research on emotion regulation can provide distinct information is by ensuring that real and perceived control is empirically distinguished and by clarifying how real and perceived control are related. The developmental and clinical reasons for utilizing an integrative-multifaceted approach are both discussed below. First, however, in framing the role of control in childhood anxiety, it is important to note that control is just one potential influence within a larger set of potential influences on childhood anxiety. A developmental psychopathology model of anxiety disorders in youth highlights that anxiety disorders are multi-determined (see Vasey and Dadds, 2001; Weems and Stickle, 2005). Such models point to the importance of considering control within the broader context of other additional constructs and variables. For example, that an anxiety disorder may develop from a variety of different initial conditions and through different processes (i.e., equifinality) and that a particular risk factor (e.g., low perceived control) may not necessarily lead to the same outcome in every individual (i.e., multifinality, see Cicchetti and Rogosch, 1996) depending on the complex influence of additional factors. To elaborate upon the above points, constructs such as control may not in all cases be etiological or directly etiological. That is, aspects of an individuals control profile may simply be part of the phenomenology of anxiety disorders or may be an outcome of an anxiety disorder. Moreover, the development of control is itself multi-determined (see Skinner et al., 1995). For example, aspects of control may not always assume a direct etiological role in the development of anxiety disorders, but may nonetheless influence the maintenance, trajectory, or expression of anxiety symptoms. In some of our most recent work in this area we (Weems et al., submitted for publication) have found that anxiety control beliefs were stable over time and that they interacted with initial anxiety levels in a manner consistent with control beliefs serving as a maintainer of stable elevated anxiety levels over a one year period in a community sample of youth (n = 56). An important challenge that therefore lies ahead is to disentangle the thorny relations among control and other risk factors in

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our efforts to improve understanding about the development and prediction of pathological anxiety. 2.1. Developmental considerations Each notion of control may not have equal importance (e.g., equally strong associations with anxiety) in understanding anxious pathology across developmental periods. In other words, one type of control (e.g., contingency based beliefs in particular locus of control) may be less important to anxiety development in older children than to younger children. Where as another conceptualization of control (e.g., self-efficacy) may be relevant throughout childhood because of different developmental trajectories for different types of control. According to Weisz and Stipek (1982), a Piagetian view of cognitive development (e.g., Piaget, 1950, 1983) suggests that children gradually become less likely to attribute outcomes not under their control to their own behavior (e.g., Weisz and Stipek, 1982 cite Piaget's classic example of a child's belief that clouds move because the child moves. In other words contingency beliefs become more external as they become more realistic). However, increasing skill development with age suggests that children's actual competence is increasing. Research has supported the notion that there are different developmental trajectories for these different aspects of control (i.e., contingency versus competence, see Skinner et al., 1995). For example, with regard to locus of control, research and theory suggests high levels of internal locus of control beliefs are normal for younger children (Piaget, 1950, 1983; Skinner et al., 1995; Weisz and Stipek, 1982). So although research supports the notion that an internal locus of control is negatively correlated with anxiety in younger (e.g., preoperational) children, the regulative effect on anxiety may be less strong because the high internal control may be related to cognitive development (i.e., it is less realistic at this point in development) and not yet useful for anxiety regulation. Thus, the strength of the association between anxiety and external locus of control beliefs may increase with age (similar to that shown with personalizing and anxiety, Weems et al., 2001) whereas the association between self-efficacy and anxiety may remain relatively more stable across ages/ development. 2.2. Clinical considerations A model of control that draws equally from the different theories emphasizes that very different aspects

of control may be related to clinical anxiety. To illustrate, children may believe the following with regards to threatening things, events, or situations (1) they do not control them (locus of control), (2) they do not control them because they do not feel they have the ability (self-efficacy), or (3) if they did control the events or situations, the outcome would still be bad, or because they control them the outcome will be bad (learned helplessness/personalizing) (see Table 1 for additional examples). The model depicted in Fig. 1 integrates these possibilities and also posits that these associations may be based on different discrepancies between real and perceived control and thus highlights different causal associations for targets of intervention. Given the various ways in which control may be related to the regulation and dysregulation of anxiety levels as the literature reviewed in the first part of this article suggests there are thus theoretically different implications with regard to fear reduction. For example, a child may be fearful of or worry greatly about a dog because of at least three distinct control instances: 1) the dog is not controllable and might bite me (i.e., external locus of control). In this scenario the reason that control is related to anxiety is because the fear-provoking stimulus is believed to be inherently uncontrollable. The most direct way to reduce anxiety in this case would be to change the belief that the nature of the stimulus is uncontrollable. 2) I personally cannot control what the dog may do to me (i.e., low self-efficacy). In this scenario the reason control is related to anxiety is because the individual believes that s/he does not have the ability to control the stimulus. The most direct way to reduce anxiety in this case would be to change the belief that the individual does not have the ability to control the fearprovoking stimulus (e.g., show the individual how they already have control or how to control). 3) I am in charge of (control) of feeding the dog and if I don't feed him right he might die (i.e., helplessness/personalizing). In this scenario the reason that control is related to anxiety is because the individual believes he/she has too much control. The most direct way to reduce anxiety in this case would be to change the belief that all negative events are under his/her control. Thus, problems with anxiety in a sample of children may be related to control issues but for very different reasons (i.e., from too little control to too much control) and these different reasons may have different implications for fear and anxiety reduction. The model depicted in Fig. 1 also highlights different targets of intervention based on real versus perceived control. For example, the youth who has competencies and thus could control but perceives they do not (upper

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left quadrant of the model) would theoretically benefit most from cognitive modification designed to build confidence and behavioral efforts designed to help the youth actualize their skills. The youth with low real control and low perceived control (lower left quadrant of the model) would theoretically benefit most from being taught behavioral anxiety control strategies and skills. The youth with low real control and high levels of perceived control would theoretically benefit most from cognitive modification of the unrealistic appraisal. In terms of assessment it is thus important to measure the youths' actual abilities. For example, research has used the Comprehensive Test of Basic Skills (CTBS; CTB/ McGraw Hill, 1977) to measure real competence in youth and has found these real competences to mediate gender and ethnic associations with depression (Kistner et al., 2003). In addition, if problematic anxiety is related to control for different reasons conceptually then different anxiety disorders may also be differentially related to control. For example, a child with a specific phobia of dogs who believes that dogs are not controllable and might bite may have external locus of control concerns (i.e., instance 1 above). A child with social phobia who is afraid of failure and ridicule may have self-efficacy related control concerns whereas a child with generalized anxiety disorder who worries about his/her pet dying may have helplessness/personalizing control concerns (i.e., instance 3 above). Such considerations point to the importance of a multifaceted understanding with regards to identifying the specific control beliefs associated with problematic anxiety across individuals. Research indicates that children present with a high degree of anxiety disorder comorbidity (see Weems and Stickle, 2005). So even if specific control beliefs are not equally important to the phenomenology of particular disorders, considering the role of multiple and integrated control beliefs may optimize understanding the comorbidity of anxiety disorders in children more generally. For example, a child may think: I have never been able to control my anxiety (i.e., learned helplessness) and I will not be able to learn the skills to control because I am incompetent (i.e., low self-efficacy). Such a belief system is a combination of instances 2 and 3 above. Such a belief system may help to understand the child with social phobia who is afraid of failure because of a lack of confidence in his/her ability to perform and also has generalized anxiety disorder symptoms because of worries about his or her pet and fears the increased responsibility associated with being in control of feeding the pet. Similarly, an integrative-multifaceted

understanding may be useful because the conflict of multiple control beliefs may be important in understanding childhood anxiety problems. For example, a child with a strong desire to control who experiences initial failures to control certain threatening situations may be more vulnerable than a child with a lower desire to control who experiences initial failures to control. Drawing from the above considerations, an integrative-multifaceted framework may be potentially useful for improving the treatment of anxiety disorders in children. Research has demonstrated the efficacy of cognitive behavioral techniques in treating anxiety and phobic disorders in children (Barrett et al., 1996; Kendall, 1994; Silverman et al., 1999) and researchers have now begun to examine factors that may be related to enhanced treatment outcomes (e.g., Berman et al., 2000). The application of research on control and depression has led to effective brief treatments for depression (see Weisz et al., 1997). In terms of the treatment of anxiety, Silverman and Kurtines (1996) have proposed a transfer-of-control model as a useful framework for helping clients (parent and children) conceptualize treatment for phobic and anxiety disorders. According to this model, the therapist's role is as a consultant or collaborator who shares with (or transfers to) the agents of child change (e.g., the child, parents, peers, teachers) knowledge of evidence based procedures and strategies (i.e., control strategies) that can be used to produce a therapeutic response (e.g., child anxiety reductions). Although speculative at this point, interventions for children's anxiety disorders may improve efficacy through strategies aimed at identifying the various ways control may influence feelings of anxiety and then teaching strategies that focus on this potentially complex control belief system. Specifically, facilitating skill development and mastery as well as confidence in the skills (self-efficacy), providing obtainable contingencies for behaviors (learned helplessness), and teaching children to accurately detect causes and outcomes (locus of control) may each be important strategies in helping to produce a therapeutic response for anxious children. For example, in addition to teaching anxiety regulative skills (e.g., relaxation exercises) it may be important to help the child develop confidence in the skills in anxiety producing contexts and develop confidence in the ability to apply the skill in new contexts to foster self-efficacy beliefs. Providing contingencies that the child can obtain in a variety of contexts (e.g., not just anxiety provoking contexts) may facilitate this process and diffuse helplessness beliefs.

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Acknowledgment The writing of this paper was supported in part by a grant from the National Institute of Mental Health (MH067572) awarded to Carl F. Weems. References
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