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The University of Hong KongDepartment of Psychologycenter16482500Student Name: Chan Sin Kan University Number: 3035392933Degree: Master of Social Sciences in the field of Educational PsychologyTitle of Thesis: The Interaction between Parental Demandingness and Executive Functioning in Predicting Anxiety among Hong Kong StudentsSupervisor: Dr. Lo, Barbara Chuen YeeYear of Submission: 2018The Interaction between Parental Demandingness and Executive Functioning in Predicting Anxiety among Hong Kong StudentsSin K. ChanThe University of Hong KongAuthor NoteSin K. Chan, Department of Psychology, The University of Hong Kong.This research was conducted in partial fulfilment of the requirements for the degree of Master of Social Sciences in the field of Educational Psychology, as part of a research project coordinated by the author’s supervisor, Dr. Lo, Barbara Chuen Yee. The author declares that there are no known potentially competing interests, both financially and non-financially, that could appear to have influenced the submitted work.Correspondence concerning this article should be addressed to Sin K.

Chan, Department of Psychology, The University of Hong Kong, Pokfulam, Hong Kong. E-mail: [email protected] Acknowledgement The author would like to take this opportunity to express her heartfelt gratitude to her supervisor, Dr.

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Lo, for her insightful guidance, kindness and support throughout. She has provided invaluable advice and feedback at each stage of the research process. This thesis would not have been made possible without her supervision.

Sincere gratitude also goes to the student helpers, as recruited by Dr. Lo’s lab, who have contributed to the data collection process. The author is also deeply grateful to all the schools, parents and students for their time and participation in this research. Last but not least, the author would like to thank her family and friends, especially her classmates of the MSocSc (Educational Psychology) programme and Ms.

Charlene Cheng, for their unwavering support and encouragement along the journey.AbstractAnxiety has become one of the major mental health concerns among the school-aged population in Hong Kong. Both personal and environmental factors are suggested to contribute to the development of anxiety, including executive functioning (EF) and parenting, but little is known about the development of anxiety in the Eastern culture.

The present study therefore aimed to investigate how EF and parental demandingness would contribute to the development of anxiety among Hong Kong students. Ninety students (Mage = 12.16 years, SD = 1.32 years) who were ethnically Chinese and free from mental health disorders first completed a series of EF tasks and a measure of anxiety.

Parental demandingness was rated based on an observation of parent-child interactions. At one-year follow-up, the children completed the anxiety measure again. Results showed that EF only predicted anxiety level when parental demandingness was high. The study findings could have potential implications for providing anxiety intervention to the school-aged population in Hong Kong.Table of ContentsCHAPTER 1: INTRODUCTION………………………………………………..

5Childhood Anxiety………………………………………………………. 5Executive Functioning…………………………………………………… 6The Role of Parenting…………………………………………………..

. 11The Role of Parenting in the Eastern Culture…………………………..

. 15The Present Study………………………………………………………. 18CHAPTER 2: METHOD……………………………………………………….. 19Participants……………………………………….…………………….

. 19Measures…………………………………………………………………

19Procedures……………………………………………………………… 23CHAPTER 3: RESULTS……………………………………………………….. 24CHAPTER 4: DISCUSSION……………………………………………………

42Implications…………………………………………………………….. 45Limitations and Future Directions………………………………………. 47Conclusion……………………………………………………………… 49References…………………………………………………………………….

… 50Appendix………………………………………………………………………… 69The Interaction between Parental Demandingness and Executive Functioning in Predicting Anxiety among Hong Kong Students Childhood Anxiety Anxiety is characterised by apprehension or worrisome thinking when anticipating a future threat or negative outcomes. It is suggested to be contributed by three interconnecting components: cognition (e.g.

, worry), affect (e.g., nervousness), and behaviour (e.g., avoidance; Handelzalts & Keinan, 2010).

Anxiety may be considered an inevitable part of life and may actually help the individual to prepare for potential future dangers. However, anxiety might become dysfunctional when it is prolonged or becomes more intense than what would be normally expected. Anxiety is one of the most prevalent mental health concerns in children. According to a recent survey, approximately 20.7% of primary students and 30% of secondary students in Hong Kong experienced some kind of anxiety symptoms (HKSAR Social Welfare Department, 2015). The most common themes of worry as reported by children were found to be school, health and personal harm (Silverman, Greca, & Wasserstein, 1995).

In particular, they were often worried about relationships with the family and peers. It has been suggested that the presentation of anxiety may differ between children and adults, due to differences in daily environments and developmental needs (March, Parker, Sullivan, Stallings, & Conners, 1997). For instance, school phobia and separation anxiety (anxiety experienced upon separation from emotionally attached figures) are more common in children than adults (Last, Strauss & Francis, 1987). Childhood anxiety can have significant academic and psychosocial implications, including school withdrawal, perceived self-competence, and peer relations (Van Ameringen, Mancini, & Farvolden, 2003; Messer & Beidel, 1994). It may also be a predictor of adult depression, substance abuse and other emotional behavioural problems (Bittner et al., 2007).

Therefore, it would be important to examine the vulnerabilities that contribute to anxiety symptoms so as to identify possible sources of intervention. As Bronfenbrenner (1979) noted, human development is influenced by the interactions between the individual and different environmental systems. As a result, anxiety may be contributed by the interaction between the child’s personal characteristics and his/her surrounding systems. Two of the major factors are cognitive control/executive functioning and parenting.Executive Functioning The level of executive functioning (EF) has been posited to be related to anxiety. EF is often considered as an umbrella term for higher-order cognitive processes that help coordinate goal-directed behaviour (Banich, 2009). Miyake et al., (2000) proposed the “unity/diversity executive functioning” model as they found that three of the commonly postulated EF abilities were interrelated yet clearly separable.

The three EF abilities were mental set-shifting (flexibly switching attention or between goals), updating working memory (monitoring and revising the content of working memory), and inhibition of prepotent responses. EF is believed to be important for self-regulation of behaviour as they help individuals adaptively modify their behaviour in response to changes in environmental demands. Therefore, deficits in EF may increase the exposure to stress and hence increased vulnerability to anxiety. Individuals with anxiety symptoms have often been found to experience EF difficulties. Studies have found that the inhibition and cognitive shifting abilities among individuals with a high level of anxiety were weaker than those with a low level of anxiety, as indicated by various experimental paradigms, such as the classic Stroop task, Wisconsin Card Sorting Test and Cognitive Assessment System (Toren et al., 2000; Visu-Petra, Miclea, ; Visu-Petra, 2013).

Furthermore, among children and adolescents, anxiety has been found to be related to dysregulated brain activity in the prefrontal cortex which is commonly shown to be associated with EF control (Fitzgerald et al., 2013; Sylvester et al., 2013).

Recently there has been a growing number of studies suggesting that EF might actually play an important role in the development and maintenance of anxiety. As anxiety is characterised by worrisome thinking which is considered as repetitive negative thoughts or images that are usually intrusive and difficult to control (Silverman et al., 1995), reduced inhibitory control may provide a gateway for unwanted negative thoughts, according to the gateway mechanism proposed by De Raedt and Koster (2010). Deficits in shifting and cognitive flexibility may result in the experience of “getting stuck” on the thoughts, thus leading to the maintenance of negative repetitive thinking (Sharp, Miller, ; Heller, 2015). Low attentional control might also undermine emotion regulation processes and perceived controllability, and this has been shown to increase anxiety (Opitz, Gross, ; Urry, 2012; Mineka ; Kelly, 1989). Birk, Opitz and Urry (2017) found that subjective anxiety and autonomic arousal were strongly associated with the participants’ attentional control capacities. Hendrawan, Yamakawa, Kimura, Murakami and Ohira (2012) even found that the participants’ performance on EF tests predicted their physiological stress reactivity as measured by cortisol level, heart rate and skin conductance during an acute psychological stress exposure. Apart from cross-sectional studies, evidence in support of the relationship between EF and anxiety is provided by longitudinal research.

For example, Kertz, Belden, Tillman and Luby (2016) found that deficits in inhibition and shifting among five-year-olds were associated with increased anxiety level after 3.5 to 7.5 years, with the influence of other factors being controlled for, such as IQ, gender and the anxiety level prior to the study. However, these prospective studies among the school population have been mostly done in western cultures and it remains unknown whether the relationship between EF and childhood anxiety also holds in other cultures such as in East Asians. Many tasks have been identified to assess EF, such as the Wisconsin Card Sorting Test (WCST; Heaton, Chelune, Talley, Kay, ; Curtiss, 1993), Tower of London (ToL; Culbertson ; Zillmer, 2005), the Letter Memory Task (Morris ; Jones, 1990), and the Stop-signal Task (Logan, 1994). Among the EF measures, the WCST and ToL have been found to be the most frequently used in research and clinical practice in the field of neuropsychology (Etnier ; Chang, 2009). The WCST is a classical neuropsychological task that was originally developed to assess cognitive strategies in the normal population. It has then gained popularity in clinical settings to study cognitive dysfunction in patients (Rabin, Barr, ; Burton, 2005).

In the WCST, participants are required to sort cards based on one of the three characteristics of the card, in which the sorting rule changes regularly and has to be inferred from the examiner’s feedback. It has been primarily conceptualised as a set-shifting task because participants are required to flexibly switch between sorting strategies (Berg, 1948; Puente, 1985). Although some researchers have hypothesised that it also assesses other EF skills such as inhibition and updating (Ozonoff & Strayer, 1997), path analyses showed that set-shifting was the single most significant ability tested by the WCST (Miyake et al., 2000). In particular, the number of perseverative errors made on the WCST has been suggested to directly indicate an individual’s shifting ability or cognitive flexibility (Miyake et al., 2000; Robinson, Heaton, Lehman, ; Stilson, 1980), and therefore, it has been purported to be the best metric of EF from the WCST (Rhodes, 2004).

The ToL is another classical EF task that has been used extensively in both normal and clinical populations (Kim, woo Yi, Jung, ; Nam, 2017; Chang et al., 2011). It requires the participants to move the beads one-by-one from one peg to another so as to achieve their target positions on the “tower” as quickly as possible using the least number of moves. The ToL has often been described to measure executive planning and problem-solving abilities (Chang et al., 2011) because the participants have to anticipate the consequences of action and the transformation required from the initial to goal state beforehand.

However, it has been suggested that the participants may tend to rely on the perceptual strategy spontaneously when making the next move, which involves considering whether the current state is perceptually closer to the target, instead of the more demanding strategy with careful planning and extensive goal management (Goel ; Grafman, 1995; Miyake et al., 2000; Murji ; DeLuca, 1998). Therefore, the ToL may place greater emphasis on inhibition than planning, as one may need to inhibit his tendency of making salient and perceptually congruent yet incorrect moves.The Role of ParentingAccording to Bronfenbrenner (1979), the child’s family is part of the microsystem which is the most immediate environmental system that affects the child’s development.

Parenting style plays an important role in family dynamics, and it may be understood as the expression of particular behaviour and the constellation of attitudes communicated to children, through which an “emotional climate” is created (Darling ; Steinberg, 1993). Therefore, children’s emotional development may be socialised through family processes including parenting style and modelling in the family (Bandura, 1999; Morris, Silk, Steinberg, Myers, & Robinson, 2007).The conceptions of parenting styles have been traditionally based on Baumrind’s typology (Baumrind, 1967; Baumrind, 1991). Along the two dimensions of parental responsiveness (the degree of responsiveness to the child’s needs) and demandingness (the extent of control over the child), Baumrind classified parenting styles into three categories: authoritarian, permissive, and authoritative. The authoritarian parenting style is characterised by being unresponsive and highly demanding, setting high expectations for children with little warmth or support; whereas the permissive parenting style is characterised by being overly responsive to children’s demands without setting rules or high expectations.

The authoritative parenting style was considered to be optimal by Baumrind (1991), as it involved a combination of high responsiveness and high demandingness, being attentive to children’s needs while imposing clear and appropriate demands. Maccoby and Martin (1983) further expanded upon Baumrind’s typology and added the “neglectful parenting style” as the fourth category, which is characterised by being unresponsive and undemanding towards children. Research has traditionally focused on parenting as the discrete styles described i.

e., authoritarian, permissive, authoritative, neglectful (Dornbusch, Ritter, Leiderman, Roberts, ; Fraleigh, 1987; Wolfradt, Hempel, ; Miles, 2003). However, a more dimensional approach of studying parenting has begun to gain its popularity recently (Pinquart, 2017). Instead of defining parenting by the presence or absence of the dimensions (i.e., responsiveness, demandingness) as proposed by Baumrind (1967) as well as Maccoby and Martin (1983), some have suggested that parenting styles actually lie on a continuum (Soysa ; Weiss, 2014).

Studying parenting along its individual dimensions (such as parental warmth/responsiveness and demandingness) may also allow for more flexible comparisons (Pinquart, 2017). In particular, research has indicated that the level of parental demandingness or control was related to anxiety and other mental health outcomes in children (Pinquart, 2017; Soysa ; Weiss, 2014; Niditch ; Varela, 2012; McLeod, Wood, ; Weisz, 2007). Parental demandingness has been suggested to take different forms, including behavioural control (efforts to monitor children’s behaviour), psychological control (attempts to control children’s psychological experiences), and the lack of autonomy granting (encouragement of children’s own decision making; Pinquart, 2017). A positive correlation was found between high demandingness from parents and children’s anxiety in novel situations (Cooper-Vince, Pincus, ; Comer, 2014). Parents who are highly controlling might often accomplish tasks for their children that could be completed independently otherwise, and therefore lowering their children’s self-confidence and problem-solving abilities (Cooper-Vince et al., 2014; Jongerden & Bogels, 2015). It was also found that parental pressure in academic achievement was positively correlated with worry and test anxiety (Putwain, Woods, & Symes, 2010), as children might have internalised parental demands as their own cognitive expectancies (Bandura, 1999; Soysa & Weiss, 2014).

Anxiety or other mental health conditions are often considered to be contributed by the interaction between personal and environmental factors, such that certain personal risk factors may not necessarily lead to mental health problems, given the existence of appropriate and sufficient protective factors in the environment (Hettema, Prescott, Myers, Neale, & Kendler, 2005). Previous literature suggested that parental demandingness might moderate the relationship between EF and anxiety (Bernier, Carlson, & Whipple, 2010; Hughes, Roman, Hart, & Ensor, 2013). It was found that negative emotional climate in the family was associated with poorer EF of the children (Hughes et al., 2013), and that negative correlations were found between parental control and both set-shifting and inhibition abilities in children (Bernier et al., 2010). The exposure to stress may have negative influences on children’s EF capacities (Pechtel, ; Pizzagalli, 2011).

Furthermore, as anxiety is suggested to be related to worrying about one’s own competence in overcoming a future threat, it often involves self-evaluation and comparison against the assumed external standards (Rapee & Heimberg, 1997). Stress from both the self and the environment may play important roles in contributing to anxiety. When parental demandingness is high, parental demands may be internalised by children as their own cognitive expectancies (Bandura, 1999; Soysa & Weiss, 2014). Children with poorer EF may find it more difficult to meet the expectations or shift their attention from the controlling statements of their parents, compared to those with better EF, resulting in stress and self-criticisms which are related to increased anxiety (Gilbert et al., 2008). However, when parents are relatively less demanding, the effect of EF on anxiety may be reduced, as children may be able to meet the lowered standards irrespective of their EF abilities.

They may also be less likely to internalise parental pressure and set high expectations for themselves across different aspects in life, creating lower demands for EF and attenuating the relationship between EF and anxiety (Bandura, 1999; Soysa & Weiss, 2014).The Role of Parenting in the Eastern CultureThe Eastern culture has been suggested to be higher on the collectivistic values than Western cultures (Oyserman, Coon, & Kemmelmeier, 2002), suggesting that conformity and compliance are more valued in the East. In particular, parents who adhered strongly to Chinese cultural values were found to place greater emphasis on filial piety and academic achievement (Ho, 1994) than the psychosocial development of children (Stevenson et al., 1990). These socio-cultural norms and beliefs may influence parenting practices (Chao, 1996). Traditional Chinese values were found to be correlated with authoritarian and authoritative parenting styles (Xu, Farver, Zhang, Zeng, Yu, & Cai, 2005), showing higher levels of directiveness and coercion (Lansford et al., 2005).

There seem to be inconsistent findings regarding the relationship between parenting and emotional wellbeing among children from the Eastern culture. On the one hand, some studies have shown that Chinse parenting styles were related to psychological outcomes in children in a pattern similarly found in Western contexts, and in particular, it was primarily the demandingness dimension that was related to anxiety and maladaptive social functioning (Zhou, Eisenberg, Wang, & Reiser, 2004; Porter et al., 2005). On the other hand, some have shown that highly controlling parental behaviours in collectivistic cultures were less associated with low parental warmth and negative views of the children, compared to those from individualistic backgrounds, implying that higher parental demandingness might not necessarily lead to poorer psychological outcomes in children from collectivistic cultures (Rudy & Grusec, 2006). Besides, few studies have investigated the relationship between parenting and EF in the Chinese culture, although Zhou and colleagues (2004) found that authoritarian parenting was associated with poorer cognitive control.

Therefore, there is a need for further research into the relationships among parental demandingness, EF and anxiety in the Eastern culture.Various methods have been used to measure parenting or parental demandingness in particular, such as child- or parent-report (Robinson, Mandleco, Olsen, & Hart, 2001), and observer ratings (Zaslow et al., 2006). Studies have generally found that observational measures showed the most consistent associations between parenting and anxiety (Zaslow et al., 2006; McLeod et al., 2007), and that self-report might be subject to bias such that results were inconsistent across different informants (Pinquart, 2017).

One of the most commonly used standardised observational measures is the Dyadic Parent-Child Interaction Coding System (DPICS), which evaluates parent-child interactions using real-life situations (Eyberg & Robinson, 1981; Shanley & Niec, 2011). Parent verbalisations or behaviours are coded based on various behaviour categories such as Direct Command, Indirect Command, and Critical Statement. The DPICS has shown its sensitivity in evaluating parenting practices, treatment outcomes, and child behavioural problems (Borrego, Timmer, Urquiza, & Follette, 2004; Bagner & Eyberg, 2007; Shanley & Niec, 2011).

It is suggested to be a more objective and realistic assessment tool than self-report or questionnaires (Thornberry, & Brestan-Knight, 2011).The Present StudyDespite the wealth of research examining the separate relationships between EF or parenting and anxiety in Western contexts (e.g., Lungarini, 2015; Visu-Petra et al.

, 2013), few studies have examined the interaction between EF and parenting in predicting anxiety, and whether such relationships hold in the Eastern culture. Therefore, the present study aimed to investigate the prospective relationship between EF and anxiety, and whether the relationship varies as a function of parental demandingness, among school children in the Hong Kong context. In particular, the EF abilities “shifting” and “inhibition” would be focused on, as they were shown to play important roles in anxiety (Silverman et al., 1995; Kertz et al., 2016). The following hypotheses were tested: H1: Better EF (i.e. shifting, inhibition) at Time 1 (T1: initial time of measurement) would be associated with a lower level of anxiety at Time 2 (T2; one-year follow-up).

H2: The prospective relationship between EF and anxiety would be enhanced when the level of parental demandingness at T1 was high.H3: The prospective relationship between EF and anxiety would be weakened when the level of parental demandingness at T1 was low.MethodParticipants Ninety children (42 girls, Mage = 12.16 years, SD = 1.32 years, age range: 9–14 years) and their parents participated in the study.

They were recruited through 13 mainstream schools in Hong Kong: eight of them were secondary schools and five were primary schools. Informed consent was obtained from both the children and their parents (please see the Appendix for the sample of an informed consent form). All of the participants were ethnically Chinese and none was found to have neuropsychological disorders based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children – Present and Lifetime version (K-SADS-PL; Kaufman et al., 1997). MeasuresMultidimensional Anxiety Scale for Children (MASC).

The MASC (March et al., 1997) is a self-report measure of the severity of anxiety symptoms in the past two weeks. It consists of 39 statements which are rated on a 4-point Likert scale, ranging from 1 (never true about me) to 4 (often true about me). A total score was derived from the sum of four subscale scores: Physical Symptoms, Social Anxiety, Separation Anxiety/Panic, and Harm Avoidance.

A higher MASC total score indicated a higher anxiety level. Cronbach’s alphas were reported to range from .74 to .85, indicating moderate to good reliability (March et al., 1997). A Chinese version of the MASC was used in the present study.Wisconsin Card Sorting Test (WCST). The WCST (Heaton et al.

, 1993) is a widely used measure of EF. It assesses the shifting ability which is to shift cognitive strategies in response to changing rules. The participants were asked to match 64 response cards with four stimulus cards one-by-one. Both the response cards and stimulus cards depict figures of different colours, forms and numbers of objects, and the participants had to sort the cards based on these three categories.

However, they only received feedback regarding the correctness of each of their sorting responses and were not explicitly informed of the sorting rule which also changed regularly. Therefore, the participants had to adjust their sorting methods by inferring from the examiner’s feedback. The number of perseverative errors was used to indicate the level of cognitive flexibility or EF. Perseverative errors were made when the participants persisted in sorting the cards based on a rule that was no longer correct as inferred from the examiner’s feedback. The raw scores of perseverative errors were transformed to T scores, and a lower T score indicated the commitment of more perseverative errors or weaker EF. The generalisability coefficient for Perseverative Errors was reported to be .52 (Heaton et al.

, 1993), which indicated moderate to good reliability.Tower of London-Drexel University 2nd Edition (ToLDX 2nd Ed). The ToLDX 2nd Ed (Culbertson ; Zillmer, 2005) was used as another measure of EF, especially in the inhibition ability. It was intended for children between the ages of 7 and 15. In the ToL task, the examiner and participant each had a wooden board with a set of three beads (red, blue, and green).

On each wooden board, there were three vertical pegs of different heights: the tallest peg could hold at most three beads, the medium peg could hold two beads and the shortest one could hold one bead only. The participant had to move beads from the starting configuration to the goal configuration as fast as possible, also with the fewest number of moves possible. Only one bead could be moved at one time. After the demonstration of the moves and rules using the examiner’s wooden board, two practice problems were presented. Then the test began and 10 test problems requiring a minimum number of three to seven moves were shown one at a time. Performance on the ToL was indicated by several measures: Total Move (deduction of minimum number of moves from total number of moves made by the participant), Total Correct (number of test problems solved in a minimum number of moves), Initiation Time (the time from being presented the test problem to removing the first bead from a peg), Execution Time (the time from moving the first bead to problem completion), Total Time (the sum of Initiation Time and Execution Time), Time Violation (the number of times when the participant could not complete the test problem within 60 s), and Rule Violation (number of times when a rule is violated). Dyadic Parent-Child Interaction Coding System-IV (DPICS-IV).

A 15-minute recording of the interaction between each child and his/her parent was obtained. During the recording, the parent-child dyad was asked to plan an activity that both of them would be willing to participate together, such as going on a trip or to the cinema. The DPICS-IV (Eyberg, Nelson, Ginn, Bhuiyan, & Boggs, 2013) was used to code the parent’s verbalisations, and determine the number of Direct Commands (DC; declarative statements containing an order) and Indirect Commands (IC; suggestion in the form of a question/wish, or does not indicate the necessity of compliance) directed to the child. Parental demandingness was represented by a Demand score which was the sum of DC and IC. A higher Demand score was considered to indicate a higher level of parental demandingness. The inter-coder reliability coefficients of DC and IC were reported to be .82 and .

66 respectively (Eyberg et al., 2013).Procedures The participants completed two sessions in total (T1 and T2), approximately one year apart. Both sessions took place at the University of Hong Kong.

At T1, the children completed the MASC, WCST and ToLDX 2nd Ed individually. Both the children and their parents also participated in the DPICS-IV observation task, and only one parent-child dyad was observed each time. The order of administration of the four tasks was randomised across the participants. At the T2 follow-up, the children’s anxiety level was re-evaluated by completing the MASC again, in order to investigate the effects of EF measured at T1 on the anxiety level at T2 as well as whether the relationship would be moderated by parental demandingness at T1, while controlling for T1 anxiety level.

The entire experiment lasted approximately two hours and all the participants received $300 cash as compensation.ResultsThe descriptive statistics of all the variables tested are shown in Table 1 by gender. It was found that female students tended to have higher MASC T1 scores than male students, t(88) = -2.04, p = .045. No significant differences were found among other variables between males and females.Table 1Comparing Male with Female Students on All the Variables TestedVariable Overall Male Female M SD M SD M SD t(88) pChild’s age 12.16 1.

32 12.06 1.28 12.26 1.38 -0.71 .48MASC T1 36.46 14.

87 33.52 13.59 39.81 15.70 -2.04 .045MASC T2 29.

19 14.42 27.77 13.89 30.81 15.01 -1.00 .

32WCSTPerseverative Errors 58.87 10.51 58.25 10.06 59.57 11.

09 -0.59 .56ToL Total Move 94.62 14.58 92.

88 14.60 96.62 14.48 -1.22 .23ToL Total Correct 95.24 11.04 94.

38 11.33 96.24 10.74 -0.80 .43ToL Initiation Time 92.13 7.15 91.

21 5.89 93.19 8.31 -1.32 .19ToL Execution Time 98.04 15.

97 98.08 14.67 98.00 17.51 0.03 .

98ToL Total Time 100.42 15.45 99.71 14.22 101.24 16.89 -0.

47 .64ToL Time Violation 98.13 15.

08 96.25 15.97 100.29 13.

87 -1.27 .21ToL Rule Violation 92.

36 17.84 94.75 16.

83 89.62 18.76 1.37 .18Demand 8.20 5.

48 8.58 5.11 7.76 5.90 0.

71 .48Note. MASC = Multidimensional Anxiety Scale for Children; WCST = Wisconsin Card Sorting Test; ToL = Tower of London-Drexel University 2nd Edition; T1 = Time 1 (initial time of measurement); T2 = Time 2 (one-year follow-up). WCST perseverative errors are presented in T scores. ToL Total Move, ToL Total Correct, ToL Initiation Time, ToL Execution Time, ToL Total Time, ToL Time Violation, and ToL Rule Violation are presented in standardised scores.Table 2 shows the correlations among all the variables tested. The child’s age was found to be significantly correlated with WCST Perseverative Errors T scores, such that older children committed fewer perseverative errors, r(88) = .23, p = .

029. MASC T1 was positively correlated with MASC T2, r(88) = .32, p = .002. Higher MASC T1 (r88 = .20, p = .057) and MASC T2 (r88 = .30, p = .

004) scores were correlated with more WCST perseverative errors. MASC T2 was also negatively correlated with ToL Execution Time and ToL Total Time standard scores, such that higher anxiety level was correlated with weaker performance on execution time (r88 = -.21, p = .

052) and total time (r88 = -.21, p = .043) on the ToL task. Furthermore, higher ToL Initiation Time was correlated with lower ToL Execution Time (r88 = -.22, p = .

041), Total Time (r88 = -.38, p < .001) and Time Violation (r88 = -.26, p = .014).Table 2Correlations among All the Variables TestedVariable 1. 2.

3. 4. 5.

6. 7. 8. 9. 10.

11. 12.1.Child’s age 1 2.MASC T1 .

10 1 3.MASC T2 .03 .32 ** 1 4.WCSTPerseverative Errors .

23* .20 .30** 1 5.ToL Total Move .10 .08 -.

09 .14 1 6.ToL Total Correct .12 -.

09 -.14 .12 .

43 ** 1 7.ToL Initiation Time .03 -.07 .18 .

15 .08 .13 1 8.ToL Execution Time .11 .07 -.

21 -.07 .41 ** .15 -.22* 1 9.ToL Total Time .

11 .15 -.21* .02 .

47 ** .15 -.38** .

84** 1 10.ToL Time Violation .13 .13 -.15 .12 .26* .02 -.

26* .62** .76** 1 11.ToL Rule Violation .08 .

03 .12 .34** .24* .19 .07 .13 .

08 .08 1 12.Demand .17 .

07 .21* .09 -.07 -.001 .12 .07 .05 .

04 .03 1Note. MASC = Multidimensional Anxiety Scale for Children; WCST = Wisconsin Card Sorting Test; ToL = Tower of London-Drexel University 2nd Edition; T1 = Time 1 (initial time of measurement); T2 = Time 2 (one-year follow-up). WCST perseverative errors are presented in T scores. ToL Total Move, ToL Total Correct, ToL Initiation Time, ToL Execution Time, ToL Total Time, ToL Time Violation, and ToL Rule Violation are presented in standardised scores. * p ; .05. ** p ; .

01.Moderation analyses were conducted to investigate the effects of parental demandingness (Demand) on the relationship between EF (WCST and ToL scores) and anxiety level (MASC T2). Model 1 in PROCESS (Hayes, 2013) was specified to estimate a moderation model with a single moderator. The MASC T2 variable was entered as the Outcome Variable, the EF variables were entered one-by-one in separate analyses as the Independent Variable, and the Demand score was entered as the M (moderator) variable. The control variables were the child’s age and gender, as well as MASC score at T1. Wisconsin Card Sorting TestThe results of the moderation analysis investigating the effect of parental demandingness on the prospective relationship between WCST Perseveration Errors and anxiety are shown in Table 3. It was found that the interaction effect WCST Perseverative Errors x Demand was significant (b = 0.

07, t = 2.36, p = .02), controlling for the child’s age and gender, as well as MASC score at T1. Table 3Moderation Analysis of Parental Demandingness in the Prospective Relationship between WCST Perseveration Errors and Anxiety at One-Year Follow-Up Variable b SE ? t pChild’s age -1.35 1.41 -0.

10 -0.96 .34Child’s gender 1.87 2.81 0.07 0.66 .51MASC T1 0.

23 0.10 0.24 2.

39 .02WCST Perseverative Errors -0.18 0.26 -0.13 -0.

68 .50Demand -3.54 1.73 -1.34 -2.05 .04WCST Perseverative Errors x Demand 0.07 0.

03 1.63 2.36 .02Note. MASC = Multidimensional Anxiety Scale for Children; WCST = Wisconsin Card Sorting Test; T1 = Time 1 (initial time of measurement).

To further explore the moderation effects of parental demandingness, simple slopes analyses and the Johnson-Neyman method were used. Simple slopes analyses were conditioned on the mean, one SD above and one SD below the mean of the moderator. The analyses showed that when the value of the Demand score was low (2.

72), the relationship between WCST Perseverative Errors T scores and MASC T2 was non-significant (b = 0.0038, t = 0.02, p = .99). At the mean value of the Demand score (8.20), there was a significant positive relationship between WCST Perseverative Errors T scores and MASC T2 (b = 0.

37, t = 2.71, p = .008). When the value of the Demand score was high (13.

68), there was also a significant positive relationship between WCST Perseverative Errors T scores and MASC T2 (b = 0.74, t = 3.46, p ; .

001). The simple slopes graph is shown in Figure 1. Using the Johnson-Neyman method, it was found that the relationship between WCST Perseverative Errors T scores and MASC T2 was only significant when the value of the Demand score was at or greater than 6.81 (b = 0.28, t = 1.

99, p = .05), and the strength of relationship became increasingly positive when the Demand score increased (the b values increased from 0.28 to 1.50). left40926200Figure 1. Simple slopes equations of the regression of WCST Perseverative Errors T scores on MASC T2 at three levels of Demand score. MASC = Multidimensional Anxiety Scale for Children; WCST = Wisconsin Card Sorting Test; T2 = Time 2 (one-year follow-up).Tower of LondonTable 4 shows the results of the moderation analyses investigating the effects of parental demandingness on the prospective relationship between various ToL variables and anxiety. The interaction effects ToL Total Time x Demand (b = -0.05, t = -2.71, p = .008), and ToL Time Violation x Demand (b = -0.05, t = -2.64, p = .01) were found to be significant. All the other interaction effects between ToL (Total Correct, Total Move, Initiation Time, Execution Time, and Rule Violation) and the Demand score were non-significant, all p ; .05. Table 4Moderation Analyses of Parental Demandingness in the Prospective Relationship between Various ToL Variables and Anxiety at One-Year Follow-UpModel Variable b SE ? t pToL Total Time Child’s age -0.31 1.36 -0.02 -0.23 .82Child’s gender 0.35 2.81 0.01 0.13 .90MASC T1 0.33 0.09 0.35 3.59 .001ToL Total Time 0.10 0.16 0.10 0.61 .55Demand 4.96 1.65 1.88 3.01 .003ToL Total Time x Demand -0.05 0.02 -1.76 -2.71 .008ToL Time Violation Child’s age -0.48 1.39 -0.03 -0.34 .73Child’s gender 1.55 2.86 0.05 0.54 .59MASC T1 0.31 0.10 0.32 3.23 .002ToL Time Violation 0.19 0.17 0.20 1.10 .28Demand 5.71 1.97 2.17 2.90 .005ToL Time Violation x Demand -0.05 0.02 -2.03 -2.64 .01ToL Total Correct Child’s age -0.27 1.45 -0.02 -0.19 .85Child’s gender 1.13 3.00 0.04 0.38 .71MASC T1 0.29 0.10 0.29 2.85 .006ToL Total Correct 0.22 0.26 0.17 0.85 .40Demand 4.74 2.46 1.80 1.92 .06ToL Total Correct x Demand -0.4 0.03 -1.64 -1.72 .09ToL Total Move Child’s age -0.61 1.46 -0.04 -0.42 .68Child’s gender 1.69 2.99 0.06 0.56 .57MASC T1 0.30 0.10 0.31 3.01 .003ToL Total Move 0.11 0.20 0.11 0.57 .57Demand 3.00 1.91 1.14 1.57 .12ToL Total Move x Demand -0.03 0.02 -.97 -1.32 .19ToL Initiation Time Child’s age -0.54 1.44 -0.04 -0.38 .71Child’s gender 0.41 3.05 0.01 0.14 .89MASC T1 0.31 0.10 0.32 3.05 .003ToL Initiation Time 0.03 0.47 0.02 0.07 .95Demand -2.87 4.23 -1.09 -0.68 .50ToL Initiation Time x Demand 0.04 0.05 1.30 0.79 .43ToL Execution Time Child’s age -0.35 1.40 -0.03 -0.25 .80Child’s gender 0.41 2.92 0.01 0.14 .89MASC T1 0.30 0.10 0.31 3.12 .002ToL Execution Time 0.009 0.15 0.009 0.06 .95Demand 3.31 1.44 1.26 2.29 .02ToL Execution Time x Demand -0.03 0.02 -1.11 -1.93 .06ToL Rule Violation Child’s age -0.80 1.46 -0,06 -0.55 .58Child’s gender 2.08 3.01 0.07 0.69 .49MASC T1 0.28 0.10 0.29 2.81 .006ToL Rule Violation 0.23 0.14 0.28 1.58 .12Demand 1.91 1.31 0.73 1.46 .15ToL Rule Violation x Demand -0.02 0.01 -0.56 -1.08 .29Note. MASC = Multidimensional Anxiety Scale for Children; ToL = Tower of London-Drexel University 2nd Edition; T1 = Time 1 (initial time of measurement).Simple slopes tests of the ToL Total Time x Demand interaction term are depicted in Figure 2. When the value of the Demand score was low (2.72), there was a non-significant relationship between ToL Total Time and MASC T2 (b = -0.03, t = -0.23, p = .82). At the mean value of the Demand score (8.20), there was a significant negative relationship between ToL Total Time and MASC T2 (b = -0.27, t = -3.09, p = .003). When the value of the Demand score was high (13.68), there was also a significant negative relationship between ToL Total Time and MASC T2 (b = -0.52, t = -3.96, p ; .001). The Johnson-Neyman technique showed that the relationship between ToL Total Time and MASC T2 was significant only when the value of the Demand score was at or greater than 6.19 (b = -0.18, t = -1.99, p = .05), and the relationship became increasingly negative as the Demand score increased (the b values changed from -0.18 to -1.03). left53181700Figure 2. Simple slopes equations of the regression of ToL Total Time on MASC T2 at three levels of Demand score. MASC = Multidimensional Anxiety Scale for Children; ToL = Tower of London-Drexel University 2nd Edition; T2 = Time 2 (one-year follow-up).Figure 3 shows the simple slopes analyses of the ToL Time Violation x Demand interaction term. When the value of the Demand score was low (2.72), the relationship between ToL Time Violation and MASC T2 was non-significant (b = 0.05, t = 0.35, p = .73). When the Demand score was at the mean value (8.20), there was a significant negative relationship between ToL Time Violation and MASC T2 (b = -0.24, t = -2.54, p = .013). A significant negative relationship between ToL Time Violation and MASC T2 was also found when the value of the Demand score was high (13.68), b = -0.53, t = -3.37, p = .001. From the Johnson-Neyman method, it was shown that ToL Time Violation only significantly predicted MASC T2 when the value of the Demand score was at or greater than 7.15 (b = -0.19, t = -1.99, p = .05). The relationship became increasingly negative as the Demand score increased (the b values changed from -0.19 to -1.12). left58610500Figure 3. Simple slopes equations of the regression of ToL Time Violation on MASC T2 at three levels of Demand score. MASC = Multidimensional Anxiety Scale for Children; ToL = Tower of London-Drexel University 2nd Edition; T2 = Time 2 (one-year follow-up).DiscussionThe present study investigated the relationship between EF, specifically shifting and inhibition, and anxiety level at one-year follow-up, and whether such relationship was moderated by parental demandingness among school-aged children in Hong Kong. Consistent with the hypotheses, the results showed that parental demandingness moderated the prospective relationships between certain EF variables (WCST Perseverative Errors, ToL Total Time, and ToL Time Violation) and anxiety. Specifically, when the level of parental demandingness was low, EF did not significantly predict anxiety level; when the parental demandingness increased and exceeded a certain level, weaker EF significantly predicted a higher level of anxiety, and this relationship continued to become stronger as the level of parental demandingness further increased, having controlled for the effects of the child’s gender, age, and the initial anxiety level. Previous research done in Western cultures reveals a negative relationship between EF and anxiety (Toren et al., 2000; Visu-Petra et al., 2013; Fitzgerald et al., 2013; Sylvester et al., 2013), and that high parental control is associated with poor socio-emotional well-being in children (Pinquart, 2017; Soysa & Weiss, 2014; Niditch & Varela, 2012; McLeod et al., 2007). The present study further finds support that, among students in Hong Kong, EF actually predicts anxiety level at one-year follow-up, but such prospective relationship only holds when the level of parental demandingness is high. Anxiety is usually characterised by beliefs that are related to uncontrollability, insecurity and inability (Rapee & Heimberg, 1997; Gilbert et al., 2008). For children with weaker EF, high parental demandingness may induce pressure that further reduces their sense of control and mastery, leading to internalising symptoms (Garber & Flynn, 2001); children with weaker inhibitory control and cognitive flexibility may also have difficulty disengaging from their parents’ controlling statements, resulting in the maintenance of rumination on negative thoughts. This could potentially be a vicious cycle. Toren et al. (2000) found that those with anxiety symptoms performed worse after receiving negative feedback, and this may further create stress and worry that impedes their performance. However, when the amount of parental control is lower, even though the children have weaker EF, they may be less likely to internalise high external standards as their own cognitive expectancies (Bandura, 1999; Soysa ; Weiss, 2014), reducing the amount of stress and self-criticisms. Among the ToL variables tested, only ToL Total Time (total time used to solve the problem) and ToL Time Violation (the frequency of failing to complete the problem within the time limit) were found to interact significantly with parental demandingness in the prediction of anxiety; whereas previous research has mostly found that patients with EF deficits performed poorly on ToL Total Correct (number of problems correctly solved) and ToL Rule Violation (the frequency of violating a rule; Unterrainer et al., 2016; MacAllister et al., 2018; Levin et al., 1994). However, previous studies involving the ToL have mostly been done with children with neuropsychological problems other than anxiety, including Autism Spectrum Disorders, Attention Deficit/Hyperactivity Disorder, epilepsy, and closed head injury (Unterrainer et al., 2016; MacAllister et al., 2018; Levin et al., 1994). It has been suggested that anxiety is primarily related to costs in processing efficiency, such as response time, rather than accuracy, as individuals with anxiety symptoms may tend to be pre-occupied with worrisome thinking which reduces their working memory capacity and increases their mental effort to perform the task (Visu-Petra et al., 2013; Eysenck ; Calvo, 1992). Processing efficiency may be represented by ToL Total Time and ToL Time Violation; apart from being affected by anxiety, processing efficiency may actually interact with parental demandingness in predicting anxiety as shown by the present study. Low processing efficiency may be related to poor inhibitory control which provides a gateway for negative repetitive thinking as suggested by the gateway mechanism (De Raedt ; Koster, 2010), increasing the propensity of developing anxiety symptoms.Besides, the findings that older children tended to commit fewer perseverative errors on the WCST but no significant relationship was found between age and ToL performance are in line with previous research. Cognitive flexibility has been shown to develop continuously from 7 to 12 years of age (Anderson, 2002; Davidson, Amso, Anderson, ; Diamond, 2006). However, little development has been observed for inhibitory control from the age of 7 to 12 (Johnstone et al., 2007). Implications The present findings underscore the importance of the interaction between personal and environmental factors, in particular, EF and parental demandingness, in the development of anxiety symptoms. Therefore, these may serve as promising targets for preventive intervention for anxiety. In Hong Kong, most of the current preventive intervention programmes for anxiety have focused on building personal resilience and the cognitive-behavioural approach, such as “The Adventures of DoReMiFa” programme (The Hong Kong Jockey Club Centre for Suicide Research and Prevention, 2013), and the FRIENDS programme (Barrett, Turner, ; Lowry-Webster, 2000). The effectiveness of anxiety preventive interventions may be further enhanced by incorporating EF training, especially on cognitive flexibility and inhibitory control. Strategies that have been shown to help improve EF include practising mindfulness (Flook et al., 2010), and auditory attention training which was actually found to reduce the frequency of thought intrusion and the biased attention on negative stimuli (Callinan, Johnson, ; Wells, 2015). Apart from EF training, parenting interventions would also be important, as the current study reveals that parental demandingness is a moderating factor in the prediction of anxiety level: children with weaker EF did not necessarily have greater anxiety level, unless the parental demandingness was high. As the child can hardly be isolated from his surrounding systems and there are constant exchanges between them that help shape the child’s development, the surrounding systems should be involved as far as possible in the interventions. Working with the child only may not thoroughly tackle the factors that help maintain the problems. Parents should be aware that their daily feedback and verbalisations are impactful, in terms of the child’s emotional well-being. Their expectations on the child should also be managed, and that being highly demanding may help induce anxious mood in the child. It is worthwhile to note that the average number of demanding statements from the parents in the present sample was 8.20, but the moderating effect of parental demandingness was already significant at values (6.19 – 7.15 in different analyses as presented above) below the average, implying that the current interaction patterns may already be putting at least some of the children at risk for anxiety. Limitations and Future DirectionsAlthough the present study provides support for the interacting effect of EF and parental demandingness in predicting anxiety level, several limitations are acknowledged which also highlight directions for future research. First, parental demandingness was objectively observed based on the number of commands produced by the parents, but the subjective experiences of the children were not measured. According to the cognitive information processing theory, the children may have different interpretations of their parents’ commands and respond to them differently, such that a high frequency of demands may not necessarily equate with high demandingness as perceived by the children. As the subjective experiences of parenting were found to influence one’s coping and affect (Wolfradt, et al., 2003), it may be important for the children to also rate their perceived parental demandingness. Second, parental responsiveness was not measured in this study. It is possible that the negative emotional outcomes were actually due to the influences of both parental demandingness and responsiveness, as has been previously found in the distinction between authoritative and authoritarian parenting styles (Baumrind, 1991; Jabeen, Anis-ul-Haque, ; Riaz, 2013). It may therefore be worthwhile to further explore whether parental responsiveness also plays a role in the interaction effect and compare the relative importance of the two dimensions in predicting anxiety level. Other recommendations for future research include separately analysing the different forms of demand: behavioural control, psychological control, and the lack of autonomy granting (Pinquart, 2017). It is possible that they have differential effects on anxiety. EF skills other than cognitive flexibility and inhibition may also be investigated, such as working memory, to explore whether the interaction effect would apply to specific EF skills only or general EF abilities instead. This may help provide a more comprehensive picture of how anxiety symptoms are developed. Furthermore, the interaction effect between EF and parental demandingness may also be investigated in other types of mental health problems. This may have potential implications in the search of common elements that contribute to the development of mental health disorders in general as well as the “universal ingredients” to be included in interventions. Finally, future work will also be needed to compare the interaction effects of EF and parental demandingness across different age groups or developmental stages. Different EF skills have been suggested to develop and mature at different ages (Zelazo, ; Carlson, 2012), and the relative importance of parenting might vary across developmental periods (Masten, Juvonen, ; Spatzier, 2009). ConclusionAnxiety among the school-aged population has been receiving more attention from the educationalists. Although there is growing research suggesting that EF and parenting are related to anxiety outcomes, few have explored the interaction between the two factors and the relationship in the Eastern culture. 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