Clin Child Fam Psychol Rev DOI 10.1007/s10567-014-0164-4

Perfectionism in Pediatric Anxiety and Depressive Disorders Nicholas W. Affrunti • Janet Woodruff-Borden

Ó Springer Science+Business Media New York 2014

Abstract Although perfectionism has been identified as a factor in many psychiatric disorders across the life span, it is relatively understudied in pediatric anxiety and depressive disorders. Furthermore, there exists little cohesion among previous research, restricting the conclusions that can be made across studies. In this review, research associating perfectionism with pediatric anxiety and depression is examined and a framework is presented synthesizing research to date. We focus on detailing the current understanding of how perfectionism develops and interacts with other developmental features characteristic of anxiety and depression in children and potential pathways that result in anxiety and depressive disorders. This includes: how perfectionism is measured in children, comparisons with relevant adult literature, the development of perfectionism in children and adolescents, mediators and moderators of the link between perfectionism and anxiety and depression, and the role of perfectionism in treatment and prevention of these disorders. We also present research detailing perfectionism across cultures. Findings from these studies are beginning to implicate perfectionism as an underlying process that may contribute broadly to the development of anxiety and depression in a pediatric population. Throughout the review, difficulties, limitations, and gaps in the current understanding are presented while offering suggestions for future research. Keywords Children
Anxiety
Depression
Perfectionism
Development

N. W. Affrunti (&)
J. Woodruff-Borden The University of Louisville, Louisville, KY, USA e-mail: [email protected]

Perfectionism has been implicated as a factor in many psychiatric disorders (Egan et al. 2011). In children and adolescents, there have long been theories that perfectionism is associated with psychological distress (Shaffer 1974), but this literature has undergone a recent growth. One specific area that has shown an increase in research is the link between perfectionism and childhood anxiety and depressive disorders (Hewitt et al. 1997, 2002). Current research is becoming increasingly concerned with examining the associations and effects that perfectionism has in these disorders. Despite increased study, there remains much information regarding the correlates, developmental trajectory, and consequences of perfectionism in anxiety and depressive disorders that has been unexplored (Flett et al. 2011). This paper will primarily focus on perfectionism in children and adolescents as it relates to childhood anxiety and depressive disorders, though adult research will be integrated where pediatric research is nonexistent. First, we present a brief definition of perfectionism and an overview of common measures used in this literature. Next, we review the development of perfectionism, including transmission from parent to child. Additionally, we examine the links of pediatric perfectionism with depression, suicidality, and anxiety symptoms and disorders. Then, the effect of perfectionism in the treatment for these disorders is explored. Following this, we review mediators and moderators of its development. Lastly, we briefly consider cultural aspects of perfectionism and present unexplored or underrepresented areas of research. Based on the research reviewed and proposed hypothetical relations among constructs, we have included a model of perfectionism in pediatric anxiety and depressive disorders. The model aims to synthesize current knowledge as it pertains to the role of perfectionism in these disorders, as well as including

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theorized constructs for future research. Further, the model presents a possible longitudinal process that perfectionism affects, resulting in pediatric anxiety and depression.

Perfectionism Defined Understanding the definition of perfectionism is vital in identifying how it affects pediatric anxiety and depression. Perfectionism is defined as setting an almost unattainable high standard, valuing only successes and the attainment of all goals set (Flett et al. 2011). However, numerous studies have used statistical procedures such as factor or cluster analysis to reveal that perfectionism can be conceptualized as two types: adaptive and maladaptive perfectionism (Frost et al. 1993; Rice et al. 1998; Rice and Slaney 2002). This split is also consistent with early hypotheses on the nature of perfectionism (Hamachek 1978). Adaptive perfectionism has little clinical relevance (Burns 1980). However, for those with maladaptive perfectionism, failure, no matter how small, becomes unacceptable and the desire to avoid failure threatens the ability to succeed. In fact, there are few links between perfectionism and actual achievement (Stornelli et al. 2009). It is this maladaptive perfectionism that has been linked with psychopathology (Bieling et al. 2004; Hewitt and Flett 2002). That is, perfectionism may lie on a continuum from adaptive to maladaptive; yet, in pediatric anxiety and depressive disorders, perfectionism reflects a maladaptive process, which leads to distress in individuals. It is important to note that many studies avoid using a categorical split (i.e., adaptive and maladaptive) and instead use levels of perfectionism. However, for studies that do use a split, even when using the same measures (see Soenens et al. 2005; Turner and Turner 2011), different criteria have been used to determine what adaptive and maladaptive perfectionism is. Bieling et al. (2004) used factor analysis to determine which subscales of measures loaded on a positive striving or maladaptive concern construct. This represents a more empirical method of splitting the constructs; yet, it only applies to the two measures used. Despite the importance of this separation in theories of perfectionism, there is no universally accepted method of operationalizing this split. As such, many studies have resorted to a more continuous approach. In addition to the conceptualization of perfectionism into adaptive and maladaptive types, the literature further defines perfectionism as either a unidimensional or multidimensional trait. Both multidimensional and unidimensional definitions of perfectionism capture the distinctions between adaptive and maladaptive perfectionism (Bieling et al. 2004). One multidimensional view defines perfectionism by both the intra-individual and inter-individual

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components: self-oriented perfectionism (SOP), requirements imposed by the individual on his/herself for him/her to be perfect; socially prescribed perfectionism (SPP), requirements perceived by the individual that others require him/her to be perfect; and other-prescribed perfectionism (OPP), requirements imposed by the individual on others to be perfect (Hewitt and Flett 1991a). Another multidimensional view of perfectionism further distinguishes these into specific content areas (Frost et al. 1990). That is, SOP can consist of content about personal standards or doubts about one’s actions, whereas SPP can consist of parental expectations or criticisms. Much of the previous literature has defined perfectionism as multidimensional (Hewitt and Flett 1991a; Tozzi et al. 2004). Yet, unidimensional conceptualizations exist (Shafran et al. 2002). The unidimensional view purported by Shafran et al. (2002) is defined by an overdependence on the pursuit of personally demanding standards despite adverse consequences. This relates strongly to maladaptive perfectionism and likely reflects the aspects of dimensions from multidimensional views (e.g., SOP) but considers other dimensions (e.g., OPP) as related, not integral, facets of perfectionism. However, both unidimensional and multidimensional views suggest that when high standards are not achieved, self-criticism follows. If the standard is achieved, it is evaluated as not sufficiently demanding (Frost et al. 1990; Shafran et al. 2002). These processes are often seen in depression and anxiety disorders (e.g., Blatt et al. 1982; Cox et al. 2000). Ultimately, both unidimensional and multidimensional conceptualizations of perfectionism measure similar constructs and relate comparably to anxiety and depressive disorders, although the distinction between them is notable. Different dimensions of perfectionism often show different associations with disorders and symptoms (see Donaldson et al. 2000; Hewitt et al. 2002). A multidimensional approach better characterizes the complex ways it can affect an individual. However, due to the similarities between them, research employing either a unidimensional or multidimensional definition of perfectionism will be included in this review.

Measurement of Perfectionism The definition of perfectionism has been closely linked with its method of measurement (Shafran et al. 2002). Different approaches in measurement can impact results and conclusions pertaining to pediatric anxiety and depression. Indeed, understanding the measurement of perfectionism allows accurate interpretations as to why it has shown relations to these disorders. It also serves to contextualize the strengths and weaknesses of much of this

Clin Child Fam Psychol Rev Table 1 Common measures of perfectionism in children and adolescents Scale name

References

Age range

Dimensions

Subscales

Reliability

Dysfunctional Attitudes Scale (DAS)

Weissman and Beck (1978)

12 years and older

Unidimensional

n/a

a = .84–.92, r = .80–.84 (test–retest)

Multidimensional Perfectionism ScaleFrost (MPS-F)

Frost et al. (1990)

10 years and older

Multidimensional

Personal standards, concern of mistakes, doubts about actions, parental expectations, parental criticism, organization

a = .77–.88

Multidimensional Perfectionism ScaleHewitt (MPS-H)

Hewitt et al. (1991)

14 years and older

Multidimensional

Self-oriented perfectionism, socially prescribed perfectionism, otheroriented perfectionism

a = .79–.89, r = .75–.88 (test–retest)

Child and Adolescent Perfectionism Scale (CAPS)

Flett and Hewitt (1990)

7–18 years

Multidimensional

Self-oriented perfectionism, socially prescribed perfectionism

a = .85, a = .86

Adaptive–Maladaptive Perfectionism Scale (AMPS)

Rice and Preusser (2002)

9–18 years

Multidimensional

Sensitivity to mistakes, contingent self-esteem, compulsiveness, need for admiration

a = .73–.91

Figure Copy Task

Mitchell et al. (2013a)

7–12 years

Unidimensional

Self-oriented perfectionism

a = .80, ICC = .66

Only subscales related to perfectionism are presented here. Measures may include subscales related to other constructs not reviewed by this table ICC intra-class correlation

research. That is, strengths and flaws in measurement translate into strengths and flaws in the research. As such, we review commonly used perfectionism measures. Of those measures, three were originally developed for adult populations but have been downwardly applied to children and adolescents (Dysfunctional Attitude Scale, Multidimensional Perfectionism Scale-Frost, and Multidimensional Perfectionism Scale-Hewitt) and three were developed specifically for pediatric populations (Child and Adolescent Perfectionism Scale, Adaptive/Maladaptive Perfectionism Scale, and Figure Copy Task). Table 1 presents a summarized overview of these measures. Dysfunctional Attitude Scale The Dysfunctional Attitude Scale (DAS; Weissman and Beck 1978) measures perfectionism unidimensionally. This scale, subsequently adapted by Burns (1980), assesses a range of dysfunctional thoughts, based on a cognitive– behavioral conceptualization of depression, of which perfectionism is one of a series of thoughts assessed. The measure is self-report, which individuals respond to questions on a 7-point scale denoting how strongly they agree to the statement. The DAS has been widely used in adult depressed patients and psychiatric control populations (Oliver and Baumgart 1985). The perfectionism subscale has been shown to be both valid and reliable (Dunkley et al. 2004). It has also been used in adolescent samples

with individuals as young as 12 years old (The TADS Team 2003). Multidimensional Perfectionism Scale-Frost The Multidimensional Perfectionism Scale (MPS-F; Frost et al. 1990) is a multidimensional measure. The MPS-F is a 35-item self-report questionnaire that asks participants to respond on a 5-point scale denoting how much they agree with the statement. The MPS-F utilizes a six-factor structure consisting of personal standards, concern of mistakes, doubts about actions, parental expectations, parental criticism, and organization (not included in the total score; Frost et al. 1990). It has shown to be a valid, with high convergent validity, and reliable measure (Frost et al. 1993), and has been used in clinical and nonclinical samples (Frost and Steketee 1997). Although the MPS-F was designed for use with adults, it has been used with samples of children and adolescents as young as 10 years old (Stumpf and Parker 2000). Multidimensional Perfectionism Scale-Hewitt The Multidimensional Perfectionism Scale (MPS-H; Hewitt et al. 1991) is a 45-item self-report measure designed to assess three major dimensions of perfectionism: SOP, OPP, and SPP (Hewitt et al. 2002). Individuals respond to statements on a 7-point scale denoting how

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much they agree with the statement. It has been widely used in adult research with a variety of clinical, inpatient, outpatient, and normal populations (e.g., Antony et al. 1998; Hewitt and Flett 1991b) and has shown high convergent and divergent validity (see Hewitt et al. 1991). The three-factor solution has been shown valid in both clinical and nonclinical populations (Hewitt and Flett 1991a). Although the MPS-H was designed for use in adults, it has been used in research with samples of children as young as 14 years old (Hankin et al. 1997). Child and Adolescent Perfectionism Scale The most widely used multidimensional measure for pediatric research is the Child and Adolescent Perfectionism Scale (CAPS; Flett and Hewitt 1990). The CAPS is a 22-item self-report questionnaire that is answered on a 5-point scale describing how true a statement is for the child. The CAPS utilizes two subscales: SOP and SPP. However, some research has shown the CAPS to have a three-factor structure with SPP, SOP: striving (adaptive perfectionism), and SOP: critical (maladaptive perfectionism; McCreary et al. 2004; O’Connor et al. 2009). Despite the different factor structures reported, SPP and SOP represent the two particular domains to have more robust associations with different cognitive biases and maladjustment (Hewitt et al. 2002). Specifically, this includes the SOP: critical factor (McCreary et al. 2004). The CAPS is a reliable measure (Flett and Hewitt 1990) but no specific validity studies have been conducted on it. The CAPS has been used with children and adolescents from ages 7–18 years and many different populations (e.g., adolescent psychiatric inpatients and outpatients; Hewitt et al. 1997). Adaptive/Maladaptive Perfectionism Scale Another scale to investigate a multidimensional construct of perfectionism in children is the Adaptive/Maladaptive Perfectionism Scale (AMPS; Rice and Preusser 2002). The AMPS is a 27-item self-report measure that factors into four dimensions: sensitivity to mistakes, contingent selfesteem, compulsiveness, and the need for admiration. Items are responded to on a 4-point scale denoting how like the child a specific symptom is. The AMPS has shown to be a reliable measure (Rice and Preusser 2002), and the subscales were appropriately correlated with self-concept scales (Rice et al. 2004). It has been used in both clinical and nonclinical samples (Ye et al. 2008).The AMPS was developed on a sample of 9- to 11-year-old children and has been used in samples with children up to 18 years old (Rice and Preusser 2002).

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Figure Copy Task A notable exception to the use of self-report questionnaire measures is a recent activity aimed at assessing the behavioral manifestations of perfectionism. Mitchell et al. (2013a) developed a task, the Figure Copy Task, where the child attempts to copy sets of figures as accurately as possible over three separate 1-min trials. Children are informed their scores are based on the similarity between their drawings and the original, and that the test is timed. The tasks are recorded and subsequently coded for perfectionistic behavior (e.g., checking behaviors, slowed task completion, and displeasure with their performance). Because the task has only recently been published, few studies have published results using it. Further, Mitchell et al. (2013a) do not report its associations with other measures of perfectionism. It will be important to validate the task as an accurate measure of behavioral manifestations of perfectionism. The above measures provide some options for assessing perfectionism in children and adolescents. These measures are also presented in Table 1. Beyond summarizing the instruments, the table provides age ranges for appropriate use, the dimensionality of the scale, reliabilities, and the subscales included. Although other measures exist, these represent the most commonly seen in the literature base. Instrument recommendations depend largely on the goal of the assessment. Since multidimensional scales (e.g., CAPS, MPS-F, and MPS-H) are more widely used in the previous research, they have more robust psychometrics and allow stronger comparisons across studies. If interested in behavioral expressions of perfectionism, the Figure Copy Task is a novel instrument to assess for this, though it has yet to be validated. Importantly, a multiinformant approach may best capture perfectionism and perfectionistic behaviors in children. The use of parent-, teacher-, and selfreport measures allows observable perfectionistic behaviors in different domains to be rated and perhaps a more substantiated assessment of perfectionism.

Development of Perfectionism in Pediatric Anxiety Disorders and Depression While the development of anxiety disorders and depression has received considerable empirical attention (Rapee 1997; Zahn-Waxler et al. 2000), research on the development of perfectionism, and its link with these disorders, has only recently begun to emerge. Consistent with the literature on anxiety disorders and depression, research has provided support that perfectionism does run in families. For example, Vieth and Trull (1999) found that the levels of SOP in college students (ages 17–38 years) were related to

Clin Child Fam Psychol Rev Fig. 1 Proposed model of pediatric perfectionism in anxiety and depressive disorders

Parent Psychopathology

Parent Perfectionism

Parent Behaviors

Genetic Factors

Temperament

Hopelessness

Self-competence

Social Disconnection

Suicidality

SOP levels in same-sex parents (e.g., mother–daughter) but not related to opposite-sex parents. Similar findings have been reported by others in adult samples (e.g., Frost et al. 1991). Yet, these samples have included disproportionate numbers of females (e.g., Frost et al. 1991 used a sample exclusively of women), and findings have not been replicated in pediatric samples. Genetics There is preliminary evidence that genetic factors may influence the link between parent and child perfectionism (Bachner-Melman et al. 2007; Tozzi et al. 2004). As such, genetic factors represent the first link from parent to child within our figure (see Fig. 1). In a study of 1,022 twins (no ages were provided) from the Mid-Atlantic Twin Registry, Tozzi et al. (2004) found that shared genetic factors did significantly relate to domains of perfectionism (i.e., personal standards, doubts about actions, and concern over mistakes). The authors state that perfectionism may be

Perfectionism

Effortful Control

Intolerance of Uncertainty

Peer Relations

Anxiety Worry Depression

moderately heritable with different domains of perfectionism showing varying amounts of heritability. For example, personal standards, as compared to doubts about actions and concern of mistakes, showed the highest heritability factor. A study by Bachner-Melman et al. (2007) looked at genes that confer risk for anorexia nervosa and their relation to perfectionism across 202 anorexia nervosa and 408 control families, 14 through 36 years of age. They found that genes previously identified as related to disordered eating were also related to perfectionism scores. No such studies have been conducted in anxious or depressed samples. Despite the preliminary evidence of a genetic influence of perfectionism, these studies are limited in their conclusions. First, Bachner-Melman et al. (2007) found genes associated with eating disorders to also be associated with perfectionism but cannot conclude to what extent the genes represent the disordered eating, the perfectionistic thoughts, or both. It is possible that environmental factors are underlying apparent genetic relations. Indeed, Tozzi et al. (2004) found

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that nonshared and shared environmental factors were stronger predictors of different domains of perfectionism than genetic factors. Furthermore, epigenetic phenomena (see Feil 2006 for a review) are not accounted for in either of these studies. As such, it seems likely, and consistent with this research, that the genetic influence may represent the transmission of broad risk factors, rather than the specific transmission of perfectionism. Since most of the variance in this link is explained by environmental factors, research has predominantly focused on understanding the environmental mechanisms involved in the transmission of perfectionism from parent to child. These mechanisms often mirror those seen in anxiety and depression. Parenting Original theories postulated that child perfectionism grew out of a need to gain approval from critical, rigid, or controlling parents. Specifically, the use of parental control has been the focus of theory (Flett et al. 2002). According to the Social Expectations Model proposed by Flett et al. (2002), parents who are perfectionistic set perfectionistic standards for their children and become over-involved and controlling in the progress toward those standards. When parents engage in these behaviors, they may convey to the child that he/she must be perfect to receive the parents’ love and that failure is intolerable, resulting in the child’s distress. As such, parental factors represent another antecedent to perfectionism in our hypothetical model (Fig. 1). There is preliminary support for this theory. Soenens et al. (2005) found, in a sample of undergraduates 18–24 years old, that parent maladaptive, but not adaptive, perfectionism was significantly related to the use of psychological control. Further, psychological control completely mediated the relationship between parent and child maladaptive perfectionism. Similar results were reported in a separate study of undergraduates, 16–20 years of age (Turner and Turner 2011). In this study, parental control predicted higher levels of perfectionism for individuals regardless of their behavioral inhibition level. KenneyBenson and Pomerantz (2005) investigated parental control with children, ages 7–10 years, in the context of depressive symptoms. Mother’s increased use of control was associated with child perfectionism, and that child perfectionism was associated with depressive symptoms. This was true for both SPP and SOP. Further, child perfectionism was shown to mediate the relationship between maternal control and child depressive symptoms. Convincing evidence for the role of parenting comes from an experimental manipulation of perfectionistic parenting behaviors (Mitchell et al. 2013a). Children, aged 7–12 years, received either high or nonperfectionistic rearing behaviors from their parents during a task. The authors defined

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perfectionistic rearing behaviors as focusing on mistakes, the negative consequences of mistakes, and overprotection from mistakes through verbal and nonverbal behaviors. The nonperfectionistic rearing behaviors were defined as not focusing on mistakes, displaying a relaxed and calm demeanor, and to verbally encourage the child. Both anxious and nonanxious children saw an increase in observed SOP for the perfectionistic rearing condition. However, consistent with the previous studies (e.g., Stornelli et al. 2009), the nonperfectionistic condition showed significantly greater task accuracy (Mitchell et al. 2013a). Thus, perfectionistic rearing behaviors increase SOP while negatively affecting task performance. Further, perfectionistic rearing behaviors affected anxious and nonanxious children in the same way, which suggests they are problematic regardless of child psychopathology. Yet, the effect of parent perfectionism on these findings was unexplored. Cook and Kearney (2009) examined perfectionism within families. The authors, using 97 youths (11–17 years of age) and their parents, found that maternal SOP was related to sons’ SOP and this relation was mediated by maternal obsessive–compulsive symptoms. Further, maternal SPP was linked with child internalizing symptoms. The authors state that the reason maternal perfectionism was related to child perfectionism, and subsequent internalizing symptoms, may be due to reasons analogous to anxiety research; that parents may model perfectionism for their children by avoiding situations that they are likely to make a mistake in, taking extra precautions, punishing mistakes, and praising perfection (see Chorpita and Barlow 1998; Ginsburg et al. 2005). Although conclusions are preliminary, research has implicated genetic and environmental factors in the development of pediatric perfectionism. However, the specific heritability of perfectionism, compared to a general inherited risk, is not known. Parenting behaviors are often implicated as well. The most common of these is parental control (Kenney-Benson and Pomerantz 2005; Mitchell et al. 2013a; Turner and Turner 2011), though there is evidence, from undergraduate research, that parental criticism and communication style may be other mechanisms relevant in the development of perfectionism (Biran and Reese 2007; Miller-Day and Marks 2006). These mechanisms have sparsely been investigated in children (see Clark and Coker 2009). Additionally, there is evidence that the development of perfectionism is associated with the development of anxiety and depressive disorders.

Pediatric Perfectionism in Depression Early research found positive associations between depressive symptoms and diagnoses and perfectionism

Clin Child Fam Psychol Rev

(Leon et al. 1980; Robins and Hinkley 1989; Steiger et al. 1992). While these early results provided an important foundation for this research, there are flaws in the way perfectionism was assessed. Early investigators had no generally accepted method of assessing childhood perfectionism (Rice et al. 2007). As more detailed measures became available, research was able to identify specific aspects of perfectionism related to depression. Associations with Depressive Symptoms Basic associations between perfectionism and depressive symptoms have been found in pediatric populations. In an investigation of perfectionism, achievement, and depression, 223 children, who were in either regular (n = 162), gifted (n = 86), or fine arts (n = 33) programs, in grade 4 or grade 7 (9–14 years of age) completed measures of perfectionism, specifically SOP and SPP; achievement, as measured by the Canadian Achievement Test; and sadness, as measured by a nine-item abbreviated version of the Positive Affect Negative Affect Scale (Watson and Clark 1992). While there was no association between group (regular, gifted, or arts) and perfectionism, and no association between perfectionism and achievement, SOP and SPP were positively associated with sadness (Stornelli et al. 2009). Similar findings were reported in a sample of 481 urban, African American children in the sixth grade with a mean age of 11.8 years (McCreary et al. 2004). That is, SPP and SOP were correlated with depressive symptoms. Beyond that, SPP was found to be a robust predictor of internalizing symptoms at 1-year follow-up and especially related to depression in boys. However, the same finding did not hold true for girls. The authors state that this may be due to highly stable depression scores for girls across the year, so there was less variance after controlling for baseline depression. It is important to note that as part of this study, SOP was split, using factor analysis, into SOP-striving and SOP-critical, where the SOP-striving represented a more adaptive form of perfectionism and SOP-critical was more related to poor psychological well-being. Associations with Depression Diagnosis Similar to the link between perfectionism and depressive symptoms, studies have found perfectionism to be associated with a diagnosis of depression. Rogers et al. (2009) studied 422 adolescents, 12–17 years of age, with a current diagnosis of major depression disorder. They found that a unidimensional conceptualization of perfectionism was significantly correlated with the severity of depression symptoms as measured by self-report scales, the Reynolds Adolescent Depression Scale (Reynolds 1987), and the

Children’s Depression Rating Scale-Revised (Poznanski and Mokros 1996). However, correlations were smaller and nonsignificant when interviewing parents. Further, since for 86 % of this sample the depressive episode was their first (The TADS Team 2003), the authors argue that perfectionism may play a role early in the course of depression, though further research is necessary to confirm this (Rogers et al. 2009). In another large sample, 768 Australian children, 10–11 years of age, were assessed for a diagnosis of depression and completed measures of SPP and SOP. In total, 50 children met criteria for a depressive disorder. SPP was the only reported predictor of diagnostic status (Huggins et al. 2008). The authors purport that SPP may be a more robust predictor of depressive symptoms in children because children may be more influenced by parent–child dynamics than adults. However, they also note that SOP may still be a predictor of depression diagnosis, but may interact with relevant stressors over time, and therefore its impact could not be effectively analyzed in a cross-sectional study. Dimensions of Perfectionism and Depression The majority of research has implicated both SPP and SOP as the primary dimensions involved in depression. Yet, some inconsistencies remain in the literature regarding the link between SPP and SOP and depression. While both SPP and SOP have been associated with depression, neither has been consistently linked. For example, in a 2002 study, Hewitt and colleagues found that both SPP and SOP related to depressive symptoms in a sample of 114 children, ages 10–15 years. Here, the authors make the case that the relation of SOP to depression may be due to the perfectionist overgeneralizing his/her failures and having an overly punitive style of self-evaluation and self-blame (Hewitt and Flett 2002). This is somewhat contrary to the case made by Huggins et al. (2008) that SOP interacts over time, as Hewitt and Flett’s (2002) explanation was revealed cross-sectionally. This discrepancy is interesting to note for a few reasons. First, Huggins et al. (2008) controlled for gender in their study. It is possible that gender plays a significant role in the effect of SOP on depression. Second, it may also indicate that there are different pathways on which perfectionism can exert influence in pediatric depression (i.e., both SPP and SOP may interact with other variables in pediatric depression). Third, there may be different effects of SPP and SOP on depression at different age groups. Although there is only a slight difference in age in the above studies, adolescents may have internalized more SPP from parents, or other sources, influencing the relationship between SOP and depression, whereas younger children may not yet have internalized SPP and would thus

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be affected more strongly by SPP. While there may be some support for Hewitt et al.’s (2002) reasoning in cognitive models of childhood depression (e.g., Cole 1991), it is important to note that these proposed mechanisms have not yet been empirically tested. The lack of conclusive evidence for the relationship between SPP, SOP, or both, and depression makes these important hypotheses to further examine. The above studies typically operationalized depression as a singular construct. However, there may be symptoms of depression that have specific relations with perfectionism. One such symptom that has received considerable research, not specifically identified above, is suicidality. We have presented a separate section on perfectionism and suicide because the literature has investigated suicidality separately from depression. While many factors may overlap between the two, enough of a separation exists for the literature to be explored separately.

Pediatric Perfectionism and Suicidality Theoretically, there has long been the hypothesis that maintaining an unrealistic and high standard for oneself and critically evaluating one’s performance (i.e., perfectionism) is predictive of suicide attempts (Blatt 1995). In further support of this, Stephens (1987) described highly suicidal adolescent girls as having both backgrounds where perfectionism was expected from them by loved ones, and also where they believed they needed to always attain that perfect standard. Other studies have echoed these sentiments (Goldsmith et al. 1990; Maltsberger 1986; Ranieri et al. 1987; Woods and Muller 1988). Dimensions of Perfectionism and Suicidality Similar to the research on depressive symptoms, both SPP and SOP have been related to suicidality. Hewitt et al. (1997) examined a group of 66 adolescent inpatients (grades 6–12) and found that SOP and SPP were both associated with hopelessness, as measured by the Hopelessness Scale for Children (Kazdin et al. 1986). However, only SPP was associated with suicidal ideation, as measured by the Suicide Ideation Questionnaire (Reynolds 1988). Subsequently, in the study of 68 adolescent suicide attempters, ages 11–17 years, Donaldson et al. (2000) found similar results. That is, hopelessness, and a known factor in suicidality (Mazza and Reynolds 1998) was strongly associated with SPP. Furthermore, Boergers et al. (1998) found that high levels of depression and SPP were significantly related to death, as opposed to seeking help, being the primary reason for suicide attempts in 120 adolescent suicide attempters.

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Similar findings were reported by Enns et al. (2003) for a group of 78 adolescents, with a mean age of 15.4 years, admitted to a psychiatric inpatient hospital, when reports were examined cross-sectionally at the beginning of inpatient admission for suicidal behavior. However, following these adolescents until the end of their inpatient stay, only self-criticism and not SOP or SPP was found to predict depression and hopelessness. The authors theorize that this may be due in part to treatment received while a patient and that SOP is partially adaptive (i.e., having high goals and being flexible in one’s ability to attain such a goal is adaptive; Cox et al. 2002; Enns et al. 2001). That is, when SOP is inflexible and paired with self-criticism, where a child is unable to cope with performance that does not meet his/her high standard, then suicidal ideation and hopelessness is more likely. Perfectionism Social Disconnection Model Based on the evidence implicating SPP in suicidal ideation and hopelessness (Flamenbaum and Holden 2007; O’Connor 2007), Hewitt et al. (2006) proposed the Perfectionism Social Disconnection Model (PSDM). The PSDM included socially relevant aspects of perfectionism, not only SPP but also perfectionistic self-presentation. Perfectionistic self-presentation includes cognitive and behavioral facets of interpersonal perfectionism: perfectionistic self-promotion (promoting oneself as perfect), concealing imperfection (avoid behaviors displaying imperfection), and nondisclosure of imperfection (avoiding verbal disclosures of imperfection; Roxborough et al. 2012). The PSDM suggests that interpersonal aspects of perfectionism, including SPP and perfectionistic self-presentation, are related to social disconnection, which is both a perceived and objective detachment from others, suicidal ideation, and hopelessness. That is, the relationship between interpersonal aspects of perfectionism and suicidal ideation and hopelessness is mediated by a perceived and actual isolation from others. To test this model, Roxborough et al. (2012) studied 158 children and adolescents from a psychiatric outpatient clinic. Participants completed the measures of SPP and SOP, perfectionistic self-presentation, measured by the PSP Scale-Junior Form (Hewitt et al. 2011), suicidal risk, measured by the Child–Adolescent Suicidal Potential Index (Pfeffer et al. 2000), self-ratings of suicidal intent, and ratings of social disconnection, measured by questions regarding bullying and relationship problems answered on a 3-point Likert’s scale. Individually, SPP, perfectionistic self-presentation, and social detachment were related to suicidal intent and risk. Further, social detachment was found to mediate the relationship between interpersonal dimensions of perfectionism and suicidal risk and intent

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(Roxborough et al. 2012), providing support for the PSDM. Although there have been limited studies testing the model, it presents a promising direction for further suicidality and perfectionism research. Previous research has moved from demonstrating the links between pediatric perfectionism and suicidality, consistent with the adult literature, to a narrowed focus on the socially relevant aspects of perfectionism. Despite the preliminary research supporting the PSDM, less is known about how the model links with constructs such as hopelessness, self-competence, and self-worth, demonstrated in prior research. Further, these constructs are possible factors that influence the effect perfectionism has in suicidality, and are represented as such in our hypothesized model (Fig. 1).

Pediatric Perfectionism in Anxiety, Worry, and Stress Theoretically, perfectionism is thought to relate to anxiety and worry through increased concerns regarding the consequences of mistakes. That is, the threat of mistakes will cause a perfectionistic child to worry or feel anxious about not meeting expectations (Flett et al. 2011). Although the link between anxiety and perfectionism has been repeatedly demonstrated in adults, evidence for such a link in children is less conclusive. Dimensions of Perfectionism and Anxiety Both SOP and SPP have been implicated in pediatric anxiety research, though in different ways. Hewitt et al. (2002) investigated anxiety, social stress, SPP, and SOP in 114 children and adolescents ages 10–15. Both SOP and SPP were significantly related with anxiety. Further, SOP interacted with social stress to predict anxiety. The authors suggest that SOP may act as a vulnerability factor that is activated by stress to influence anxiety. This may indicate that the influence of SOP on childhood anxiety is different from that of SPP. SPP may affect childhood anxiety more directly, while SOP is moderated by stress. Essau et al. (2008) extended these findings to different cultures. The authors used samples of 594 adolescents from Germany and 428 from Hong Kong between 12 and 17 years of age. Taken separately, both adolescents from Hong Kong and Germany showed significant associations of SOP and SPP with total anxiety symptoms. However, the authors did not test for associations between SOP, SPP, and specific diagnostic symptoms (e.g., generalized anxiety symptoms). Also, no information is provided comparing perfectionism levels in Hong Kong adolescents versus German adolescents. Despite these limitations, the correlations between perfectionism and anxiety in two distinct

cultural samples provide important evidence for the link between the two constructs cross-culturally. A more detailed review of cultural research is provided later. Perfectionism and Worry Though studies are sparse, preliminary research has connected SPP and SOP with worry (Flett et al. 2011). Theoretically, perfectionistic children may see worry as a beneficial process, a cognition often related to worry (see Gosselin et al. 2007), helping them to avoid future negative mistakes. It could be further hypothesized that perfectionistic children show a poor problem orientation, or the ability to perceive and appraise problems and control the problem-solving process. A poor problem orientation is often linked with excessive worry in patients with GAD (Davey 1994; Ladouceur et al. 1998). However, that represents only one potential explanation of the data. It is possible that perfectionism significantly overlaps with the construct of worry. For example, worry about one’s performance in school could also be conceptualized as perfectionism. In this example, the child exhibits both worry and perfectionistic thinking, with the two constructs difficult to disentangle. Yet, there may exist unique aspects of each. For example, a perfectionistic thought may prime an individual to worry in order to use avoidance, or as an act of problem-solving, to reduce distress associated with that thought. Thus, in this example, perfectionistic thinking acts as a specific pathway that results in worry. Determining how child perfectionism relates with contemporary worry models (e.g., positive worry beliefs, avoidance, and poor problem orientation) may suggest how these constructs relate and differ. Perfectionism in Pediatric OCD Perfectionism has been linked with obsessive–compulsive disorder (OCD) in adults (Frost and Steketee 1997; Sassaroli et al. 2008). Results have been similar in child samples. For example, one study investigating the link between OCD and different cognitive appraisals, including perfectionism, split adolescents 11–18 years of age into groups based on diagnostic status (OCD, other anxiety disorders, and nondisordered controls; Libby et al. 2004). Adolescents with OCD had significantly higher scores on the concern over mistakes scale, a subscale of the MPS-F than both nondisordered and other anxiety-disordered controls. This is analogous to findings in adult samples. However, the authors note that the other anxiety-disordered adolescents fell between the OCD and nondisordered controls on the concern for mistakes scale, though they were not significantly different from either. It is important

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to note that the other anxiety-disordered group was treated as a homogenous group, despite different diagnoses, which may limit conclusions made about the other anxiety disorders. Ye et al. (2008) investigated the link between perfectionism, obsessive–compulsive (OC) symptoms, and peer relations among 31 children 7–18 years of age, diagnosed with OCD. The authors found that sensitivity to mistakes, as measured by the Adaptive–Maladaptive Perfectionism Scale (Rice and Preusser 2002), was significantly correlated with OC symptoms. They also note that perfectionism contributes uniquely to the interpersonal domain for these children. That is, perfectionism accounted for a significant portion of the variance in loneliness, poor peer relations, and approached significance for peer victimization over and above OC symptoms. However, this study was not able to conclude whether perfectionistic beliefs precede and then cause OC symptoms or that OC symptoms occur and perfectionism maintains those symptoms. Preliminary research on pediatric perfectionism and anxiety disorders has often been consistent with adult research. However, because the research is relatively sparse, associations are often not replicated or robust and data are usually cross-sectional and correlational, so conclusions regarding causality or developmental importance must be conservative. It also lacks the depth of adult research. Related constructs (e.g., intolerance of uncertainty, cognitive shift, and temperament) are absent from the literature. Further, based on the findings from Ye et al. (2008), the association between perfectionism and interpersonal distress should be replicated and extended to all anxiety disorders, not just OCD. Similar to the research on depression, the research assessing anxiety usually treats it as a singular construct. This can be problematic as studies have shown that perfectionism may differ among different anxiety disorders (Libby et al. 2004).

Pediatric Perfectionism: Treatment Implications for Anxiety Disorders and Depression Given the demonstrated links between perfectionism and anxiety and depression in children and adolescents, researchers are beginning to investigate what role it may play in the treatment for these disorders. Theoretically, individuals who are highly perfectionistic may hold unrealistic coping standards that can undermine effective treatment and relapse prevention (Hewitt and Flett 1991a). Further, perfectionism may serve to decrease social support and increase interpersonal difficulties (Shahar et al. 2003, 2007). Thus, effective treatments for anxiety and depression (e.g., cognitive–behavioral therapy (CBT) based on Beck’s cognitive model) attempt to directly address

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cognitive factors such as perfectionism during treatment (Clark and Beck 1999). However, these theories have been primarily based on adult research. As such, their applicability to children is an important aim for research. Previous research has examined the mediating role of automatic thoughts on CBT for depression in adolescents (Kaufman et al. 2005) but these did not investigate perfectionism. In fact, only a few studies have directly examined the treatment implications of perfectionism in pediatric anxiety and depression. Depression There is preliminary evidence that perfectionism affects treatment for pediatric depression. Using a unidimensional construct of perfectionism, as measured by the Dysfunctional Attitude Scale (DAS; Weissman and Beck 1978), Jacobs et al. (2009) investigated the effect of perfectionism on the treatment for adolescent depression. In the Treatment for Adolescent Depression Study (TADS), a randomized controlled trial comparing CBT, fluoxetine, and their combination with pill placebo, 439 clinically depressed adolescents, 12–17 years of age, those who had higher perfectionism was more likely to have severe depression. Further, adolescents with higher perfectionism experienced less improvement during the treatment period, regardless of treatment type. Lastly, perfectionism served as a mediator of treatment response, reducing the treatment effect for depressed adolescents. These results are consistent with the adult literature, suggesting that perfectionism impedes treatment progress (Blatt et al. 1995, 1998). The authors do caution that replication with multidimensional measures of perfectionism is necessary to understand the results in the larger context of perfectionism. Anxiety Evidence for the effect of perfectionism in the treatment for anxiety is less consistent. Mitchell et al. (2013b) examined 67 children, aged 6–13 years, who were diagnosed with an anxiety disorder and were enrolled in a group cognitive–behavioral therapy program. Pre-treatment SOP, but not SPP, was found to predict poorer child self-reported treatment outcome both immediately following treatment and at a 6-month follow-up. Further, despite not reaching statistical significance, the authors note a trend of higher SOP predicting poorer clinician severity ratings of child anxiety symptoms at 6-month follow-up. Both SOP and SPP decreased from pre- to post-treatment. Similar results were reported by Essau et al. (2012) using a 12-month follow-up. In a sample of children, 9–12 years of age, randomized to the FRIENDS program, a CBT prevention program for anxiety symptoms (see

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Barrett and Turner 2001) or control group, perfectionism mediated the treatment gains for both anxiety and depression symptoms. That is, lower levels of perfectionism resulted in greater treatment gains. Yet, the authors make no distinction between SOP and SPP, instead using a total score of perfectionism. Essau et al. (2012) state that less concern for one’s performance was necessary for effective implementation of the FRIENDS program. Furthermore, perfectionistic children may be less adept at generating novel problem-solving strategies in the therapeutic context due to cognitive shift deficits, and subsequently make more perseverative errors, thereby making treatment less successful. Total perfectionism scores, SOP, and SPP decreased at 12-month follow-up for the FRIENDS group, while those in the control group remained stable. Different results were reported from a randomized controlled trial investigating the efficacy of a school-based CBT program for the symptoms of anxiety and depression in at-risk children aged 8–11 years. Nobel et al. (2012) found that pre-treatment SOP levels influenced post-treatment depression scores but not anxiety scores. Pre-treatment SPP was not found to influence post-treatment scores for either depression or anxiety. Furthermore, perfectionism was not affected by treatment condition. That is, SOP was reduced in both the CBT and activity control groups, while SPP showed no effect by participation in either group. Post-treatment data were collected approximately 2 weeks after the conclusion of treatment and the authors note that results may differ at long-term follow-up. Although the results from Essau et al. (2012) and Mitchell et al. (2013b) are somewhat contradictory to the Nobel et al. (2012) findings, there are clear differences in methodology that may account for these differences. Sample characteristics, treatment methodologies, and follow-up times are plausible reasons for the discrepant findings. Further research is needed to understand the effect of perfectionism on treatment; yet, the hypothesis that perfectionism impacts anxiety and depression treatment efficacy remains plausible.

above, Jacobs et al. (2009) found that perfectionism was related to the severity of depression and, subsequently, poorer treatment outcomes. Nobel et al. (2012) noted that perfectionistic individuals procrastinate often, which can interfere with CBT homework completion. In depressed adults, perfectionistic patients had lower increases in therapeutic alliance over the course of treatment (Zuroff et al. 2000). Further, poorer treatment outcomes experienced by perfectionistic patients were mediated by a failure to develop stronger therapeutic alliances. That is, perfectionism interfered with the development of the therapeutic alliance, which in turn contributed to poorer gains in therapy. This finding has yet to be replicated in children. From preliminary studies investigating perfectionism in anxiety and depression treatment, the results suggest perfectionism may impede treatment outcomes. Consistent ¨ st with adult studies (e.g., Chik et al. 2008; Lundh and O 2001), Essau et al. (2012), Jacobs et al. (2009), and Mitchell et al. (2013b) have shown that anxiety and depression treatments are affected by perfectionism levels in pediatric samples. Yet, additional studies are needed to investigate these links. Further, research examining the effect of targeted perfectionism treatments, like those proposed by Flett et al. (2011), is absent from the literature.

Mediators and Moderators of Perfectionism and Pediatric Anxiety and Depression Based on the associations seen in the adult literature, and separately in pediatric anxiety and depression literature, different mediators and moderators have been hypothesized as relating to perfectionism (O’Connor and Forgan 2007; Randles et al. 2010; Tchanturia et al. 2004). The factors that seem to emerge from the literature are temperament traits, intolerance of uncertainty, and executive function and effortful control deficits. Much of this research is preliminary and based on cross-sectional data, limiting tests of whether constructs are mediators, moderators, or predictors.

Perfectionism and Effective Treatment Temperament While perfectionism may directly impact treatment response, it may also have an effect on constructs known to influence treatment response. Existing research has identified specific mechanisms of change, mediators, and moderators to treatment efficacy in pediatric anxiety disorders and depression. Factors such as comorbidity, severity of symptoms, parental psychopathology, and therapeutic alliance have been identified as mediating or moderating effective treatment (see Rapee et al. 2009; Weisz et al. 2006 for more detailed reviews). Perfectionism has been shown to affect these constructs. Indeed, as noted

Typically, the temperamental trait most often associated with depression and anxiety has been behavioral inhibition (Mian et al. 2011), or a constant tendency to display fear, withdrawal, or show uncertainty when faced with novel situations (Kagan et al. 1987). However, the relationship between behavioral inhibition and perfectionism has only been shown in undergraduates and adults (Turner and Turner 2011). Kobori et al. (2005) found that low novelty seeking and high harm avoidance were related to both SOP and SPP in Japanese undergraduates. Behavioral inhibition

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has also been found to influence the link between perfectionism and rumination (Randles et al. 2010) and worry (Chang et al. 2007) in undergraduates. In addition to behavioral inhibition, temperamental factors such as conscientiousness have also played a role in perfectionism (Dunkley and Kyparissis 2008). In adolescents, 14–19 years old, conscientiousness predicted for increases in SOP, but not SPP, over time. Further, SOP did not predict for increases in conscientiousness over time (Stoeber et al. 2009). This may suggest that temperamental factors can cause increases in perfectionism. However, the role conscientiousness plays in pediatric anxiety and depression is not clear (Compas et al. 2004). A recent study by Muris et al. (2009) found no relationship between conscientiousness and self- or parent-reported child anxiety or behavioral inhibition symptoms, in children aged 9–12 years. While these studies do suggest that temperament and perfectionism may be interrelated in pediatric anxiety and depression, there have been no studies to empirically demonstrate this effect. The nature of these associations, whether moderating or mediating, has not been tested. The effect that parenting can have on both temperament and perfectionism further obfuscates our understanding of these associations. As mentioned above, parenting is often implicated as a reason for the development of perfectionism, but it also affects temperament (Biederman et al. 1995; Rubin et al. 2003). This is summed in Fig. 1 by having both temperament and perfectionism as affecting and being affected by parental factors. It may be likely that child temperament directly influences perfectionism while also influencing how parental factors relate to the development of perfectionism. Such hypotheses remain in need of inquiry.

Preliminary evidence does suggest that perfectionism may play a role in cognitive shift deficits and possibly those deficits seen in pediatric anxiety and depression. One study, using retrospective reports of childhood perfectionism, found that it was strongly correlated with poor performance on set-shifting tasks (Tchanturia et al. 2004). That is, current deficits in the cognitive shift domain were significantly related to childhood levels of perfectionism. While this study focused primarily on anorexia nervosa patients, this finding was present across all groups of the study: those with a current anorexia nervosa diagnosis (prior to treatment), those with a past diagnosis (after treatment), and healthy controls. This suggests that deficits are related to the levels of perfectionism, not diagnosis. The results are consistent with the hypothesis that perfectionism leads to executive function deficits implicated in pediatric anxiety and depression. Despite preliminary evidence for this association, research remains absent testing and replicating this finding in children. Based on the previous literature that found effortful control and executive function to have a mediational effect (e.g., Affrunti and Woodruff-Borden 2013), it is plausible that these constructs would have a similar effect on perfectionism. Further, we would hypothesize that the cognitive shift deficits and an inability to inhibit seen across disorders may be due, in part, to perfectionism. These deficits may be seen in children who make perseverative mistakes, compulsively check answers, or have difficulty changing tasks and who cannot regulate their emotions in these situations. However, as of yet, this has not been empirically investigated. Intolerance of Uncertainty

Effortful Control and Executive Function Another factor, implicated in both childhood and adult anxiety and depressive disorders, is effortful control and the executive function domain of cognitive shifting (Fontenelle et al. 2001; Snyder 2013; Veale et al. 1996). Effortful control is the ability to inhibit a dominant response in order to perform a subdominant response, allowing an individual to regulate his/her behavior in certain circumstances (Rothbart et al. 2004). Relatedly, cognitive shift is the ability to flexibly switch attention and cognitive sets or strategies. Both of these have been related to anxiety and depression in children (see Klimkeit et al. 2011; Muris et al. 2008; Toren et al. 2000). They have also been shown to relate to temperamental and personality processes in children (Affrunti and Woodruff-Borden 2013; Kochanska and Knaack 2003). Yet, there is little research examining these constructs as they relate to perfectionism in children, and none combining the constructs.

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A third factor hypothesized to affect perfectionism is intolerance of uncertainty. Intolerance of uncertainty is the concept that ambiguity in situations is inherently threatening or negative and should be avoided (Dugas et al. 2004), and it has been implicated in disorders such as generalized anxiety disorder, OCD, obsessive–compulsive personality disorder and depression (Buhr and Dugas 2006; Dugas et al. 2004; Gallagher et al. 2003; Gentes and Ruscio 2011; Tolin et al. 2003). Similar to research on temperament and perfectionism, the relationship of intolerance of uncertainty and perfectionism has only been investigated in adults. Buhr and Dugas (2006) reported significant correlations between the intolerance of uncertainty and perfectionism. In some contemporary cognitive models of OCD, intolerance of uncertainty and perfectionism are conceptualized as specific dysfunctional beliefs that give rise to obsessive–compulsive symptoms (Libby et al. 2004; Frost and Steketee 2002). These have been derived to be a single

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factor in factor analytic studies (Taylor et al. 2010); yet, this was only in the context of OCD. The need for further investigation of perfectionism and intolerance of uncertainty in children is clear. Even basic correlations need replication in pediatric samples. While adult research has suggested that perfectionism and intolerance of uncertainty may be linked, specifically in OCD (Clark 2004), this finding has not been investigated in pediatric samples or in other disorders. Further, neither adult nor pediatric research has investigated any causal relationship between intolerance of uncertainty and perfectionism. Either construct may also influence the way a child interacts with the environment, increasing the risk for the development of the other. Because of this, it may be important to understand the separate risks associated with each perfectionism and intolerance of uncertainty, and the larger role each plays in anxiety and depressive disorders. Since both constructs relate highly to anxiety and depression, grasping both the unique and shared aspects of these constructs is of vital clinical importance. Despite preliminary research, there remains an abundance of unanswered questions and untested hypotheses, including the nature of these associations, in need of further study. Additionally, temperament, intolerance of uncertainty, and cognitive switching are factors applied from adult research. There likely exists other such constructs more strongly associated with perfectionism in children rather than adults. These too will need to be investigated.

Similarly, Striegel-Moore et al. (2000) found that African American children, ages 11–14 years, reported higher levels of perfectionism compared to Caucasian peers. This is consistent with the research from adult samples (Nilsson et al. 1999). Wassenaar et al. (2000) found that South African Black students, with a mean age of 22 years, had higher levels of perfectionism compared separately to Caucasian and Asian students. It has been theorized that African American parents may feel they have a tenuous grasp on their status, possibly due to racism and oppressive forces, which may cause them to be concerned for the future of their child and demand high achievement (Hines and Boyd-Franklin 1996). Although existing studies may suggest cultural factors influence levels of perfectionism, they must be interpreted cautiously. First, these studies have typically used nonclinical adult samples. It is possible that in clinical samples, these differences will be more or less pronounced. Further, these processes should be evident in parent–child relations, though few studies have investigated this. Preliminarily, parents who possess an achievement goal orientation, rather than a learning goal orientation, tend to have children with higher levels of perfectionism (Ablard and Parker 1997). Yet, this sample was comprised of academically talented children. Investigating culturally diverse parent–child dyads may help provide support for extant theories. Lastly, there is a paucity of research examining the outcomes of such cultural differences in perfectionism. That is, does perfectionism, or different levels of perfectionism, lead to depression, anxiety, or worry differently for separate cultural groups?

Pediatric Perfectionism Across Cultures and Ethnicities Much of the research on perfectionism in pediatric populations has ignored the influences of cultural and ethnic factors. With some notable exceptions (e.g., Essau et al. 2008; McCreary et al. 2004), research has used primarily Caucasian samples. This may be problematic as adult studies have found that different cultural groups may display increased perfectionistic behaviors (Nilsson et al. 1999; Peng and Wright 1994; Yee 1992). In Asian American populations, it has been theorized that perfectionistic behaviors may develop from parents who have high expectations and children who have a deep concern about meeting those expectations. For example, Asian American children may feel obligated to meet high parental expectations for success, experience criticism when they do not meet those standards, and thus develop distress at not meeting perfectionistic standards (Castro and Rice 2003; Chang 1998). This is substantiated by findings that Asian American college students were more vulnerable to depression when exhibiting perfectionistic behaviors (Yoon and Lau 2008).

Summary and Model The construct of pediatric perfectionism appears to be a complex and multidimensional one (Hewitt and Flett 1991a). In an attempt to summarize the known and hypothesized factors and pathways, a model has been constructed (see Fig. 1). The model is presented as a crosssectional representation of the pathways involved in pediatric perfectionism. However, we hypothesize that the model may represent a developmental trajectory as well, beginning with parental factors and terminating at pediatric psychopathology. Still, longitudinal studies are needed for this to be confirmed. For the purposes of the model, perfectionism is represented as a singular construct including multiple dimensions of perfectionism. To understand how perfectionism develops in children and adolescents, it is imperative to examine parental factors. Indeed, research has identified parental psychopathology, perfectionism, and behaviors such as overcontrol as specific factors involved in the passage of perfectionism

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from parent to child (Cook and Kearney 2009; Flett et al. 2002; Kenney-Benson and Pomerantz 2005; Soenens et al. 2008). There likely exists other parental factors, such as those identified in depression and anxiety research (e.g., parental criticism; see Chorpita and Barlow 1998; Cicchetti and Toth 1998; Kertz and Woodruff-Borden 2011; McCarty and McMahon 2003), which may also communicate perfectionistic thoughts to children. As indicated in the model, multiple interacting parental factors likely account for this predisposition. It is likely that an amalgam of parental factors creates and affects genetic risk factors transmitted to the child. As pediatric perfectionism develops out of these factors, our model also indicates that there exists many variables that act as mechanisms in the trajectory of perfectionism in anxiety and depressive disorders. Constructs such as intolerance of uncertainty, hopelessness, effortful control, self-competence, and temperament may mediate and moderate the relation perfectionism has with pediatric anxiety and depression. There is preliminary evidence from child and adult studies to support this (Buhr and Dugas 2006; Donaldson et al. 2000; Enns et al. 2001; Flett et al. 2008; Hewitt et al. 1997; Kobori et al. 2005; Tchanturia et al. 2004). For example, addressing perfectionism in cognitive–behavioral interventions may not only reduce perfectionism but may help to reduce other associated maladjusted cognitions. However, we present these associations as bidirectional because they likely influence the development and expression of perfectionism as well as being affected by it. It is likely that these constructs are related, and influence each other over time, increasing the risk for developing internalizing disorders and suicidality. However, research is currently quite limited in this area, leaving many of these hypothesized paths in need of confirmation. Perfectionism has been linked with pediatric depression, suicidality, and anxiety (Enns et al. 2003; Flett et al. 2011; Hankin et al. 1997; Hewitt et al. 2002; Huggins et al. 2008). Addressing it in the treatment for these disorders may be instrumental in relieving distress. Indeed, perfectionism is an important target in cognitive–behavioral treatment for anxiety and depressive disorders (Clark and Beck 1999; Essau et al. 2012; Nobel et al. 2012) and may have an important mediating role in treatment outcomes (Jacobs et al. 2009). However, it is unclear whether changes in perfectionism precede changes in anxiety and depression, or follow as a result of changes in anxiety and depression. Also, how perfectionism relates to specific diagnoses is an area needing further investigation. Understanding the unique effects that perfectionism may have on specific diagnoses will allow for more targeted treatments. Many of the prospective paths based on the pediatric research are similar to findings in the adult literature (e.g.,

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Buhr and Dugas 2006; Egan et al. 2011; Fontenelle et al. 2001), which may indicate that perfectionism plays a significant role in these associations across the life span. These relations may not represent the totality of factors implicated in these disorders, though they do portray the multitude of ways perfectionism can influence them. Notably, we have included anxiety, worry, and depression, three separate but related constructs, as one terminus in this model. Although each of these constructs has separately shown relations with perfectionism, research is inconsistent with the differential effects of perfectionism on these different psychopathologies. The interactions of perfectionism with other factors, and when developmentally they occur, may contribute to different behavioral presentations that can distinguish between pediatric anxiety and depressive disorders.

Future Directions There remain important future directions in order to illuminate the nature of perfectionism. For example, though much of the research uses a multidimensional concept of perfectionism, the dimensionality of perfectionism has not been cemented. Even within the multidimensional literature, there are differences in what those dimensions are (McCreary et al. 2004). Better understanding the dimensionality of perfectionism will undoubtedly lead to more informative results from its study. Further, it will allow better measurement of the construct. This should include research on parent and teacher adaptations of measures in order to encourage a multiinformant approach to the assessment of perfectionism. Additionally, in many current studies, certain sample characteristics may influence results. For example, wide age ranges and genders have often been combined when there is evidence that the measured constructs may change for individuals within these groups (Hankin 2005; Frost et al. 1991). Using longitudinal methods, with specific age ranges, and cross-cultural samples may hold promising information for differential effects. Behavioral methodology may allow for specific deficits and strengths of perfectionistic children to be revealed. Factoring out those behaviors more unique to perfectionistic children, as well as those shared with other risk factors, and their relation to internalizing disorders, will be highly useful clinical research. While most research has focused on specific associations between perfectionism and anxiety, worry, and depression, few studies have distinguished between the effects of perfectionism in each disorder. One distinction may lie in the way perfectionism interacts with other cognitive deficits present. A child who has high SOP and

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low self-competence may show depression, hopelessness, or suicidality. Conversely, a child who has high SOP and high intolerance of uncertainty may show high levels of worry. Further, the predictive power of perfectionism within each disorder, or above certain symptoms of a disorder, is currently unknown. Finally, identifying the links between perfectionism and other maladjusted cognitions related to anxiety and depression in children and adolescents is vital. It is likely too simplistic to state that one construct causes or completely explains the other (e.g., perfectionism causes intolerance of uncertainty) but it may be likely that perfectionism and other cognitions interact and influence the development of anxiety and depressive disorders over time. Understanding the course and nature of perfectionism and its influence on related constructs will provide critical information to inform prevention and treatments of pediatric anxiety disorders and depression.

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