1

THE PSYCHOLOGY OF
PERFECTIONISM
An Introduction

Joachim Stoeber

Overview
Perfectionism is a multidimensional personality disposition characterized by striving
for flawlessness and setting exceedingly high standards of performance accompanied
by overly critical evaluations of one’s behavior. Perfectionism is a complex
characteristic. It comes in different forms and has various aspects. This chapter has
a dual purpose: It aims to serve as an introduction to The Psychology of Perfectionism
(the edited book you are holding in your hands) and an introduction to the
psychology of perfectionism (what the book is about). To these aims, I first present
a brief history of perfectionism theory and research. Then I introduce the two-
factor theory of perfectionism—differentiating perfectionistic strivings and
perfectionistic concerns—with the intention to provide readers with a conceptual
framework that may serve as a “compass” guiding them through the different
models and measures of perfectionism they will encounter in this book. Going
beyond the two-factor model, I next introduce three aspects of perfectionism that
are important for a comprehensive understanding of perfectionism: other-oriented
perfectionism, perfectionistic self-presentation, and perfectionism cognitions. The
chapter will conclude with a brief overview of the organization of the book and
the contents of the individual chapters.

A Caveat
There is, however, a caveat. This introductory chapter is unlikely to present an
unbiased account of perfectionism research. Perfectionism is a multifaceted
personality characteristic, and—as the chapters of the book will demonstrate—
different researchers have different views of perfectionism. Accordingly, the present
chapter reflects the personal views I have acquired over the near 20 years since I
4 Stoeber

took the first stab at perfectionism research (Stöber, 1998), and they are views that
the authors of the other chapters may share, share in parts, or not share. However,
readers should also be aware that, despite differences in the views of perfectionism,
there is lots of common ground. I personally like to think that—if we as
perfectionism researchers take everything that is published on perfectionism into
account—95% of our views are in agreement. The problem is that we can
passionately disagree about the remaining 5%, making the discrepancies appear
much larger (and perhaps more important) than they actually are. But enough of
the preliminaries. Let’s get started! And what would be a better start than having a
look at the origins of perfectionism theory and how perfectionism research
developed?

A Brief History of Perfectionism Theory and Research

The origins of perfectionism research are based in psychodynamic theory,
particularly in the writings of two prominent psychoanalytic theorists: Alfred
Adler (1870–1937) and Karen Horney (1885–1952). Horney (1950) described
perfectionism as “the tyranny of the should” (p. 64) and regarded it as a highly
neurotic personality disposition void of any positive aspects. In comparison,
Adler had a more differentiated view of perfectionism. In fact, Akay-Sullivan,
Sullivan, and Bratton (2016) recently pointed out that Adler may be regarded as
one of the first to have a multidimensional view of perfectionism recognizing
adaptive and maladaptive aspects in relation to mental health. According to
Adler, “the striving for perfection is innate in the sense that it is a part of life, a
striving, an urge, a something without which life would be unthinkable”
(Ansbacher & Ansbacher, 1956, p. 104), but individuals attempt to achieve the
goal of perfection differently, and their individual attempts can be differentiated
by their functional and dysfunctional behaviors toward this goal (Akay-Sullivan
et al., 2016).
Then came many years that did not see much progress in perfectionism theory
except for a few psychiatric writings on perfectionism (e.g., Hollender, 1965;
Missildine, 1963) leading Hollender (1978) to make the observation that
perfectionism was “a neglected personality trait.” The same year, however, an
influential theoretical article on perfectionism was published. Hamachek (1978)
suggested that two forms of perfectionism should be differentiated: a positive form
he labeled “normal perfectionism” whereby individuals enjoy pursuing their
perfectionistic strivings, and a negative form labeled “neurotic perfectionism”
whereby individuals suffer from their perfectionistic strivings. Furthermore, two
years later, the first self-report measure of perfectionism was published—Burns’
(1980) Perfectionism Scale—followed by another measure three years later—the
perfectionism subscale of the Eating Disorder Inventory (Garner, Olmstead, &
Polivy, 1983)—and empirical research into perfectionism could begin in earnest.
The problem with these measures, however, was that they conceptualized
perfectionism as a one-dimensional construct. Moreover, the measures followed
 Perfectionism: An Introduction  5

Horney’s conception of perfectionism as a highly neurotic disposition. Accordingly,

they exclusively captured neurotic and dysfunctional aspects of perfectionism
reflecting the at the time prominent view that perfectionism was a “kind of
psychopathology” (Pacht, 1984, p. 387). This view, however, must not have been
very inspiring because publications on perfectionism in the 1980s continued to be
few and far between (see Figure 1.1).
But all this changed at the beginning of the 1990s, and dramatically so. The
reason for this was that two research teams (independently of each other) published
multidimensional models of perfectionism and associated multidimensional
measures. Frost, Marten, Lahart, and Rosenblate (1990) published a model
differentiating six dimensions of perfectionism: personal standards, concern over
mistakes, doubts about actions, parental expectations, parental criticism, and
organization. Personal standards reflect perfectionists’ exceedingly high standards
of performance. Concern over mistakes captures perfectionists’ fear about making
mistakes and the negative consequences that mistakes have for their self-evaluation,
whereas doubts about actions capture a tendency toward indecisiveness related to
an uncertainty about doing the right thing. In contrast, parental expectations and
parental criticism refer to perfectionists’ perceptions that their parents expected
them to be perfect and were critical if they failed to meet these expectations.
Finally, organization captures tendencies to be organized and value order and
neatness. At the same time, Hewitt and Flett (1990, 1991) published a model
differentiating three forms of perfectionism: self-oriented, other-oriented, and
socially prescribed. Self-oriented perfectionism comprises internally motivated
beliefs that striving for perfection and being perfect are important. Self-oriented
perfectionists expect to be perfect. In contrast, other-oriented perfectionism
comprises internally motivated beliefs that it is important for others to strive for
perfection and be perfect. Other-oriented perfectionists expect others to be perfect.
Finally, socially prescribed perfectionism comprises externally motivated beliefs
that striving for perfection and being perfect are important to others. Socially
prescribed perfectionists believe that others expect them to be perfect (Hewitt &
Flett, 1991, 2004).

Perfectionistic Strivings and Perfectionistic Concerns

Whereas the two models suggest different dimensions (and the different dimensions
stress different aspects of multidimensional perfectionism), there are common
aspects as Frost, Heimberg, Holt, Mattia, and Neubauer (1993) demonstrated in a
seminal article. Frost and colleagues subjected the nine dimensions of the two
models to a factor analysis (Kline, 1994), and two higher-order dimensions
emerged. One dimension (Dimension 1) combined personal standards, organization,
self-oriented perfectionism, and other-oriented perfectionism. The other dimension
(Dimension 2) combined concern over mistakes, doubts about actions, parental
expectations, parental criticism, and socially prescribed perfectionism. What is
more, when the two dimensions were correlated with measures of positive affect,
 300

250

200

150

Number of publications
100

50

1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016

Year

FIGURE 1.1   umber of publications in the Web of ScienceTM Core Collection database with “perfectionis*” in topic (2016 = estimated).
N
1990/1991 are highlighted as the years when the first multidimensional conceptions of perfectionism were published (Frost et al.,
1990; Hewitt & Flett, 1990, 1991).
 Perfectionism: An Introduction  7

negative affect, and depression, Dimension 1 showed a positive correlation with

positive affect (and nonsignificant correlations with negative affect and depression)
whereas Dimension 2 showed positive correlations with negative affect and
depression (and a nonsignificant correlation with positive affect). Consequently,
Frost and colleagues labeled Dimension 1 “positive striving” and Dimension 2
“maladaptive evaluation concerns,” and so the two-factor model of perfectionism
was born.
The two-factor structure of perfectionism and the two higher-order dimensions
proved to be reliable (e.g., Bieling, Israeli, & Antony, 2004). Further, the structure
replicated across different multidimensional measures of perfectionism (e.g., R. W.
Hill et al., 2004) and also emerged when items taken from various multidimensional
measures were combined (Stairs, Smith, Zapolski, Combs, & Settles, 2012).1
Consequently, the two-factor model can be regarded as a conceptual framework
providing guidance for understanding the different, sometimes opposing,
relationships that various dimensions of perfectionism show with indicators of
psychological adjustment and maladjustment. Following Frost et al.’s (1993)
suggestion that one dimension was “positive” and the other “maladaptive,” a
practice developed whereby researchers gave the two dimensions labels with
evaluative connotations such as adaptive and maladaptive perfectionism, healthy
and unhealthy perfectionism, positive and negative perfectionism, and functional
and dysfunctional perfectionism. Fortunately, this practice is declining and
nowadays the two dimensions are usually referred to as personal standards
perfectionism and evaluative concerns perfectionism (Dunkley, Blankstein, Halsall,
Williams, & Winkworth, 2000) or perfectionistic strivings and perfectionistic
concerns (Stoeber & Otto, 2006). This is preferable because the question of
whether, and to what degree, the two dimensions are adaptive (healthy, positive,
functional) or maladaptive (unhealthy, negative, dysfunctional) should be an
empirical question (see also Gaudreau, 2013). Further, I personally prefer referring
to the two dimensions as perfectionistic strivings and perfectionistic concerns to
indicate that they are two dimensions of the same construct (perfectionism), and
not two different forms of perfectionism.
Table 1.1 shows what aspects of different multidimensional models of
perfectionism—represented by subscales from the associated multidimensional
measures—are regarded as indicators (or “proxies”) of perfectionistic strivings and
perfectionistic concerns across different multidimensional measures of perfectionism.
Consequently, the table may serve as a compass guiding readers through the
different models and measures of perfectionism they will encounter in the various
chapters of this book. However, when inspecting the table, attentive readers may
wonder what happened to other-oriented perfectionism, parental expectations,
parental criticism, and organization all of which were originally included in the
two-factor model (Frost et al,. 1993). The answer (in a nutshell) is that other-
oriented perfectionism is better regarded as a form of perfectionism outside the
two-factor model because it is directed at others, not the self (Stoeber, 2014, 2015).
Parental expectations and criticism are better regarded as developmental antecedents
8 Stoeber

TABLE 1.1  Measures of Perfectionistic Strivings and Perfectionistic Concerns

Subscales representing indicators (“proxies”) of …

Measure Reference Perfectionistic strivings Perfectionistic concerns

FMPS Frost et al. (1990) Personal standards Concern over

mistakes
Pure personal standardsa Concern over
mistakes + doubts
about actionsb
HF-MPS Hewitt and Flett Self-oriented perfectionismc Socially prescribed
(1991, 2004) perfectionism
APS-R Slaney et al. (2001) High standards Discrepancy
PI R. W. Hill et al. (2004) Striving for excellence Concern over
mistakes
MIPS Stoeber et al. (2007) Striving for perfection Negative reactions to
imperfection

Note: Measures are listed in chronological order of their first publication. FMPS = Frost
Multidimensional Perfectionism Scale, HF-MPS = Hewitt–Flett Multidimensional Perfectionism
Scale, APS-R = Almost Perfect Scale–Revised, PI = Perfectionism Inventory, MIPS =
Multidimensional Inventory of Perfectionism in Sport (for examples of adaptations outside sport,
see Stoeber & Rambow (2007) and Stoeber & Rennert (2008)).
a See DiBartolo et al. (2004).
b See Stöber (1998).
c Particularly the subscale capturing perfectionistic striving (see Stoeber & Childs, 2010).

Source: Table adapted from Stoeber and Damian (2016) and Stoeber and Madigan (2016).

of perfectionistic strivings and concerns, rather than defining components (Damian,

Stoeber, Negru, & Băban, 2013; Rice, Lopez, & Vergara, 2005). And organization
was never regarded as a core dimension of perfectionism to begin with (cf. Frost et
al., 1990), and there are factor analyses showing organization and order to form a
third factor separate from perfectionistic strivings and concerns (Kim, Chen,
MacCann, Karlov, & Kleitman, 2015; Suddarth & Slaney, 2001).
The two-factor model of perfectionism—differentiating perfectionistic strivings
and perfectionistic concerns—represents an important framework for understanding
how perfectionism can be adaptive and maladaptive (see Chapters 2–3, 8, and
11–12). Moreover, it represents the foundation of the 2 × 2 model of perfectionism
(Gaudreau & Thompson, 2010) which examines how within-person combinations
of high versus low perfectionistic strivings × high versus low perfectionistic
concerns differ with respect to psychological adjustment and maladjustment (as
detailed in Chapter 3). There are, however, important aspects of perfectionism
going beyond perfectionistic strivings and perfectionistic concerns that need to be
taken into account for a comprehensive understanding of perfectionistic behavior
(cf. Hewitt, Flett, & Mikail, 2017): other-oriented perfectionism, perfectionistic
self-presentation, and perfectionism cognitions.
 Perfectionism: An Introduction  9

Beyond Perfectionistic Strivings and Perfectionistic Concerns

Other-oriented perfectionism was introduced to perfectionism theory and research
over 25 years ago and is an essential part of the tripartite model of perfectionism
(Hewitt & Flett, 1990, 1991). Despite this, other-oriented perfectionism did not
receive the same attention from research on multidimensional perfectionism as
self-oriented and socially prescribed perfectionism, and in fact was often disregarded
(Stoeber, 2014). This, however, has changed in recent years which saw a
reinvigorated interest in other-oriented perfectionism. There are a number of
contributing factors. First, other-oriented perfectionism plays an important role in
the perfectionism social disconnection model (Hewitt, Flett, Sherry, & Caelian,
2006) and its recent extensions (see Chapters 9 and 15). Second, it is a key aspect
of all forms of perfectionism where perfectionistic expectations of others are
important, such as dyadic perfectionism (Stoeber, 2012) and team perfectionism
(A. P. Hill, Stoeber, Brown, & Appleton, 2014). Moreover, the interest in so-called
“dark personality traits” (Marcus & Zeigler-Hill, 2015) has directed attention to
other-oriented perfectionism because of its associations with the dark triad—
narcissism, Machiavellianism, and psychopathy—as a consequence of which,
other-oriented perfectionism is now regarded as a dark form of perfectionism
(Marcus & Zeigler-Hill, 2015; Stoeber, 2014). Finally, other-oriented perfectionism
is a defining component of narcissistic perfectionism which is an emerging construct
in perfectionism research (Nealis, Sherry, Lee-Baggley, Stewart, & Macneil, 2016;
Smith, Saklofske, Stoeber, & Sherry, 2016; see also Chapter 9). Hence, other-
oriented perfectionism is better regarded as a separate form of perfectionism outside
the two-factor model of perfectionism (Stoeber, 2014, 2015).
Perfectionistic self-presentation (Hewitt et al., 2003) is an aspect of perfectionism
that goes beyond perfectionism as a personality disposition (or “trait”) by examining
the motivational principles underlying perfectionism from a self-regulation
perspective (Higgins, 1998).2 According to Hewitt and colleagues (2003),
perfectionistic self-presentation has two central aims: to promote the impression
that one is perfect, and to prevent the impression that one is not. To capture these
aims, Hewitt and colleagues developed a measure differentiating three aspects:
perfectionistic self-promotion, nondisplay of imperfection, and nondisclosure of
imperfection. Perfectionistic self-promotion is promotion-focused and driven by
the need to appear perfect by impressing others, and to be viewed as perfect via
displays of faultlessness and a flawless image. In contrast, nondisplay of imperfection
and nondisclosure of imperfection are prevention-focused. Nondisplay of
imperfection is driven by the need to avoid appearing as imperfect. It includes the
avoidance of situations where one’s behavior is under scrutiny if this is likely to
highlight a personal shortcoming, mistake, or flaw. In comparison, nondisclosure
of imperfection is driven by a need to avoid verbally expressing or admitting to
concerns, mistakes, and perceived imperfections for fear of being negatively
evaluated. Studies have shown that perfectionistic self-presentation explains
variance in psychological maladjustment beyond dispositional perfectionism and,
10 Stoeber

perhaps more importantly, may explain why dispositional perfectionism is associated

with psychological maladjustment (e.g., Hewitt et al., 2003; Hewitt, Habke, Lee-
Baggley, Sherry, & Flett, 2008; Stoeber, Madigan, Damian, Esposito, & Lombardo,
in press). Perfectionistic self-presentation—which represents the interpersonal
expression of perfectionism (Hewitt et al., 2003)—is clearly an important aspect of
perfectionism that needs to be taken into account when regarding perfectionism
and maladjustment and how perfectionism affects interpersonal relations and the
therapeutic process (see Chapter 15).
Finally, there are perfectionism cognitions. Perfectionism cognitions (also called
perfectionistic cognitions) are automatic perfectionistic thoughts reflecting the
need to be perfect and concerns about one’s inability to achieve perfection (Flett,
Hewitt, Blankstein, & Gray, 1998). Like perfectionistic self-presentation,
perfectionism cognitions are an important addition to perfectionism theory and
research and have explained variance in psychological maladjustment beyond
dispositional perfectionism (e.g., Flett et al., 1998; Flett et al., 2012; Flett, Hewitt,
Whelan, & Martin, 2007). Following Cattell and Kline (1977) in differentiating
states and traits in the study of personality, perfectionism cognitions can be
regarded as representing the “states” aspect of perfectionism. Further, there is
evidence suggesting that—like dispositional perfectionism and perfectionistic
self-presentation—perfectionism cognitions should be conceptualized as multi­
dimensional differentiating perfectionistic strivings and concerns (Stoeber, Kobori,
& Brown, 2014a; Stoeber, Kobori, & Tanno, 2010), but this conceptualization is
still debated (Flett & Hewitt, 2014; Stoeber, Kobori, & Brown, 2014b). What
is not debated is that perfectionism cognitions form an essential part of the
“perfectionism puzzle” without which we cannot achieve a comprehensive
understanding of perfectionism, as is detailed in Chapter 5 of this book.

The Psychology of Perfectionism

Turning to the structure of the book and the individual chapters, the book is
organized into four parts. Part I comprises four chapters providing different
perspectives on perfectionism. Chapter 2 (Stoeber, Damian, and Madigan) presents a
motivational perspective on perfectionism examining how perfectionistic strivings
and perfectionistic concerns relate to achievement motivation and self-determination.
Chapter 3 (Gaudreau, Franche, Kljajic, and Martinelli) provides an account of the 2
× 2 model of perfectionism as an analytic framework examining the unique,
combined, and interactive effects of perfectionistic strivings (personal standards
perfectionism) and perfectionistic concerns (evaluative concerns perfectionism).
Chapter 4 (Stoeber, Corr, Smith, and Saklofske) examines multidimensional
perfectionism from the perspective of personality theory regarding how self-oriented,
other-oriented, and socially prescribed perfectionism relate to key dimensions of
personality. Chapter 5 (Flett, Hewitt, Nepon, and Besser) makes the “case for
cognition” by taking a look at perfectionism from a cognitive perspective providing
a detailed examination of, and new perspectives on, perfectionism cognitions.
 Perfectionism: An Introduction  11

Part II presents three chapters reviewing the research literature on perfectionism

in special populations. Chapter 6 (Affrunti and Woodruff-Borden) examines
perfectionism in children and the role that perfectionism and associated factors
play in childhood anxiety disorders. Chapter 7 (Speirs Neumeister) provides a
comprehensive review of research on perfectionism in gifted students examining
the development, incidence, and outcomes of perfectionism in these students.
Chapter 8 (A. P. Hill, Jowett, and Mallinson-Howard) examines perfectionism
in sport, dance, and exercise providing an overview of recent findings in these
areas and the differential effects of perfectionistic strivings and perfectionistic
concerns.
Part III comprises four chapters examining the relationships that multidimensional
perfectionism shows with vulnerability and resilience. Chapter 9 (Sherry,
Mackinnon, and Nealis) provides an account of perfectionism and interpersonal
problems, with a special focus on self-critical perfectionism and narcissistic
perfectionism. Chapter 10 (Molnar, Sirois, Flett, Janssen, and Hewitt) looks at
perfectionism and health, presenting a comprehensive review of how perfectionism
relates to, and affects, health-behaviors and stress-related processes. Continuing
with the topic of stress, Chapter 11 (Dunkley) examines the relationships of
perfectionism, daily stress, coping, and affect from a multilevel perspective including
a case study to illustrate the relationships. Concluding Part III, Chapter 12 (Rice,
Suh, and Davis) focuses on perfectionism and emotion regulation from the
perspective of attachment theory, person-centered theory, and self psychology. In
addition, the chapter presents a research agenda aimed at strengthening
perfectionistic resilience and lowering perfectionistic risk, thus presenting a perfect
transition to the final part of the book.
Part IV, the final part of the book, presents three chapters on the prevention and
treatment of perfectionism. Chapter 13 (Wade) focuses on the prevention of
perfectionism in youth, examining factors that contribute to the development of
perfectionism in children and adolescents and how understanding these factors may
help prevent perfectionism. Chapter 14 (Egan and Shafran) provides a
comprehensive overview of cognitive-behavioral therapy (CBT) for perfectionism
including key CBT techniques for addressing perfectionism and a review of studies
examining the effectiveness of CBT in reducing perfectionism. Chapter 15
(Hewitt, Flett, Mikail, Kealy, and Zhang) employs the perspective of the
perfectionism social disconnection model as a theoretical framework for taking a
look at perfectionism in the therapeutic context and how perfectionism impacts
therapeutic interventions and outcomes.
The book concludes with a chapter (Chapter 16) that—following the same
approach as the present chapter—provides a personal account of what I consider
critical issues in perfectionism research and open questions that perfectionism
research still needs to answer. In addition, the chapter suggests future directions
that I hope perfectionism theory and research will take into consideration.
6
PERFECTIONISM AND ANXIETY
IN CHILDREN
Nicholas W. Affrunti and Janet Woodruff-Borden

Overview
Although perfectionism has long been implicated in anxiety disorders in adults, it
has only recently begun to show similar associations among children. During the
past decade, research has shown that perfectionism is associated with greater anxiety
symptoms, greater severity of disorders, and poor treatment response for childhood
anxiety disorders. This chapter will begin by outlining the research that links
perfectionism with anxiety symptoms, disorders, and treatment response in
children. Then, factors that may influence and explain why perfectionism is
connected with child anxiety will be examined. The chapter will close with a call
for further research in the area. Despite advances in our understanding of the role
of perfectionism in childhood anxiety disorders, there remain many important
areas in need of continued study.

Perfectionism in Childhood Anxiety

Perfectionism has been implicated as a factor that contributes to the development and
maintenance of anxiety disorders (Affrunti & Woodruff-Borden, 2014; Egan, Wade,
& Shafran, 2011; Wheeler, Blankstein, Antony, McCabe, & Bieling, 2011). In adults,
perfectionism predicts social anxiety (Heimberg, Juster, Hope, & Mattia, 1995),
panic disorder (Antony, Purdon, Huta, & Swinson, 1998), generalized anxiety
disorder (Santanello & Gardner, 2007), and obsessive-compulsive disorder (OCD;
Frost & Steketee, 1997; Norman, Davies, Nicholson, Cortese, & Malla, 1998).
Though research on the role of perfectionism and anxiety in children is less prevalent
than research using adults, evidence is beginning to support similar associations.
Theoretically, children who are highly perfectionistic may worry, or feel
anxious about not meeting expectations (Flett, Coulter, Hewitt, & Nepon, 2011;
114  Affrunti & Woodruff-Borden

Flett, Hewitt, Oliver, & Macdonald, 2002). Additionally, these children may fear
the consequences of mistakes as threats with which they cannot cope. Children
who are anxious may use high, rigid standards as a maladaptive strategy to assuage
anxiety in challenging situations. For these children, when standards are met, the
anxiety is reduced and those standards are positively reinforced. This may suggest
to children that rigid standards are needed to provide a sense of certainty in their
pursuit that would otherwise cause anxiety if absent. When standards are not met,
anxiety increases and failing to achieve those standards may be punished (e.g., by
parental criticism or a poor grade). This may lower children’s self-perceived
competence and create greater fear when presented with a subsequent situation
where they may not meet their standards. In this way, high and rigid standards may
predispose children for increased anxiety.
Though these hypotheses remain untested empirically, they suggest that there
are multiple reasons that perfectionistic children are at risk of developing anxiety.
As such, in this chapter we will not only review the literature that links perfectionism
with childhood anxiety but also those factors which may explain the associations
between perfectionism and childhood anxiety. Because this research is in its nascent
stages, it should be interpreted with some caution. In addition, given the preliminary
nature of this research, a future directions section will provide suggestions to
expand the current knowledge base. For the purposes of this chapter, children will
refer to individuals under 18 years of age, adolescents will refer to individuals
between 13 and 18 years of age, and adults will refer to individuals over 18 years
of age.

Associations With Total Anxiety Symptoms

Evidence from numerous studies supports the notion that perfectionism is a risk
and maintenance factor for the development of anxiety symptoms in children. This
section will review research that pertains to total anxiety symptoms, rather than
specific diagnoses, because the majority of studies examining perfectionism and
anxiety in childhood use scales that assess total anxiety symptoms (Hewitt et al.,
2002). Those studies examining symptoms within specific diagnoses (e.g.,
obsessive-compulsive symptoms) are reviewed in a separate section. Individual
studies are summarized in Table 6.1.

TABLE 6.1  Summary of Reviewed Studies Linking Perfectionism With Anxiety Symptoms
and Disorders in Children

Study Symptoms/ Sample Perfectionism Key findings

disorders characteristics dimensions

Affrunti & Worry, N = 61; ages SOP-critical, SOP-critical predicted

Woodruff- anxiety 7–13 years SPP greater worry; SPP
Borden (2016) symptoms predicted greater anxiety
symptoms
 Perfectionism and Child Anxiety  115

Affrunti & Worry N = 66; ages SOP-critical, SOP-critical and SPP

Woodruff- 7–13 years SPP predicted greater worry
Borden (in press)
Essau, Conradt, Anxiety N = 632; ages
Perfectionism Perfectionism decreased
Sasagawa, & symptoms 6–12 years during anxiety
Ollendick (2012) prevention program;
perfectionism predicted
lower treatment gains
Essau, Leung, Anxiety N = 1,022; ages SOP, SPP SOP and SPP associated
Conradt, Cheng, symptoms 12–17 years with greater anxiety
& Wong (2008) symptoms
Flett, Coulter, Worry, N = 81; mean SOP, SPP SOP associated with
Hewitt, & rumination age = 12.8 years worry and rumination;
Nepon (2011) SPP associated with
worry
Hewitt et al. Anxiety N = 114; ages SOP, SPP SOP and SPP associated
(2002) symptoms 10–15 years with greater anxiety
symptoms
Libby, Reynolds, OCD N = 118; 28 PS, CM, PE, PS, CM, and O
Derisley, & Clark diagnosis diagnosed with PC, O associated with an OCD
(2004) OCD; ages diagnosis
11–18 years
McCreary, Anxiety N = 481; SOP-critical, SOP-critical and SPP
Joiner, Schmidt, symptoms African SOP-striving, predicted greater anxiety
& Ialongo, American SPP symptoms over 1 year
(2004) sample; mean
age = 11.8 years
Mitchell, Newall, Anxiety N = 67; SOP, SPP SOP decreased during
Broeren, & symptoms diagnosed with anxiety treatment; pre-
Hudson, (2013) anxiety disorder; treatment SOP predicted
ages 9–12 years lower treatment effect
Nobel, Manassis, Anxiety N = 78; ages SOP, SPP SOP associated with
& Wilansky- symptoms 8-11 years greater anxiety
Traynor (2012) symptoms
O’Connor, Anxiety N = 737; mean SOP-critical, SOP-critical and SPP
Rasmussen, & symptoms age = 15.2 years SOP-striving, predicted greater anxiety
Hawton (2010) SPP symptoms over 6
months
Soreni et al. OCD N = 94; SOP-striving, SOP-critical and CP
(2014) severity diagnosed with SPP, SM, CE, predicted greater OCD
OCD; ages CP, NFA symptom severity
9–17
Ye, Rice, & OC N = 31; SM, CE, CP, SM associated with
Storch (2008) symptoms diagnosed NFA greater OC symptoms
OCD; ages
7–18 years

Note: Symptoms/disorders: OCD = obsessive-compulsive disorder, OC = obsessive-compulsive.

Perfectionism dimensions: SOP = self-oriented perfectionism, SPP = socially prescribed
perfectionism, perfectionism = single dimension of perfectionism used, PS = personal standards,
CM = concern over mistakes, PE = parental expectations, PC = parental criticism, O = organization,
SM = sensitivity to mistakes, CE = contingent self-esteem, CP = compulsiveness, NFA = need for
admiration.
116  Affrunti & Woodruff-Borden

Within this literature, studies vary in their use of sample sizes, sample
characteristics, anxiety rating scales, and methodology. Despite differences in these
specifics, similarities do appear to emerge. First, there are consistent findings that
perfectionism and total anxiety symptoms are positively associated in cross-sectional
studies (Affrunti & Woodruff-Borden, 2016; Essau, Leung, Conradt, Cheng, &
Wong, 2008; Hewitt et al., 2002; Nobel, Manassis, & Wilansky-Traynor, 2012).
For example, in the largest of these studies, Essau and colleagues (2008) examined
self-oriented perfectionism and socially prescribed perfectionism (Hewitt & Flett,
1991) in 594 children aged 12 to 17 years and found that both forms of perfectionism
were positively associated with total anxiety symptoms. Similar findings were
reported in children aged 8 to 11 years (Nobel et al., 2012). Second, the dimensions
of perfectionism that predict increased total anxiety symptoms may differ depending
on the study. For example, Hewitt et al. (2002) found that both self-oriented
perfectionism and socially prescribed perfectionism predicted total anxiety
symptoms, whereas Affrunti and Woodruff-Borden (2016) found that socially
prescribed perfectionism predicted total anxiety symptoms when controlling for
depressive and worry symptoms. Such differences make direct comparisons
difficult; however, it appears likely that different dimensions of perfectionism are
related to anxiety symptoms in different circumstances. Third, perfectionism
predicts increased total anxiety symptoms longitudinally, as demonstrated in two
studies (McCreary, Joiner, Schmidt, & Ialongo, 2004; O’Connor, Rasmussen, &
Hawton, 2010). These studies found that the same dimensions of perfectionism
predicted anxiety symptoms at six-month and one-year follow-ups in large samples
of children with mean ages of 11 and 15 years respectively. These studies provide
the strongest evidence yet that increased perfectionism leads to increased anxiety,
rather than the two simply co-occurring. In sum, though studies are sparse, current
research has consistently linked perfectionism with total anxiety symptoms in
youths. As such, perfectionism appears not only to commonly occur alongside
anxiety, but is predictive of anxiety over time.
Although these studies did not differentiate anxiety symptoms, they provide
important information on the nature of perfectionism and anxiety in children. For
example, studies linking perfectionism and total anxiety symptoms suggest that
children who are perfectionistic may be more fearful and vigilant for threat in their
environments, regardless of situation. Indeed, such biases have been shown related
to perfectionism in adults (Lundh & Öst, 2001). Further, studies linking
perfectionism with total anxiety symptoms suggest perfectionism and anxiety
symptoms arise from similar processes. For example, anxious rearing—a parental
style characterized by a focus on the negative consequences of mistakes and the use
of controlling behaviors to minimize those consequences—is linked with both
perfectionism and child anxiety (Affrunti & Woodruff-Borden, 2015; Mitchell,
Broeren, Newall, & Hudson, 2013). Importantly, these hypotheses remain to be
tested. Yet, knowledge of the links between perfectionism and total anxiety
symptoms allows further analysis into prospective mutual causes and effects and
specific anxiety symptom dimensions.
 Perfectionism and Child Anxiety  117

Associations With Worry

In addition to studies examining perfectionism and total anxiety symptoms, studies
have found perfectionism to be positively associated with childhood worry. Worry
may have a particular link with perfectionism as children who are perfectionistic
may worry in an attempt to control their emotions (Affrunti & Woodruff-Borden,
2016). Additionally, children who are perfectionistic may see worry as beneficial
and necessary to achieve their standards. Such cognitions are often seen in high
worriers (Gosselin et al., 2007). However, few studies have examined the role of
perfectionism in childhood worry as a separate anxiety symptom. Yet, within those
few studies, common findings appear.
The three studies that currently have linked perfectionism and worry in children
have used relatively small community samples (all under 100 children) and cross-
sectional data, which greatly limit the conclusions that can be made. However, two
of these studies have found that both self-oriented perfectionism and socially
prescribed perfectionism were implicated in childhood worry, such that higher
perfectionism scores predicted greater worry (Affrunti & Woodruff-Borden, in
press; Flett et al., 2011). One study found that only self-oriented perfectionism
predicted greater worry, when controlling for other symptoms of anxiety and
depressive disorders (Affrunti & Woodruff-Borden, in press). Despite the noted
limitations in this research, there are consistent findings suggesting that perfectionism
predicts greater worry in children. Further research will be needed to determine if
such relationships hold over time and extend to clinical samples.

Associations With Anxiety Disorders

Distinct from the above reviewed studies, previous work has examined the role of
perfectionism in specific anxiety disorders. Additionally, this section will include
studies examining anxiety at the symptom level provided they do so within a
specific disorder (e.g., OCD). Importantly, this body of research is relatively sparse
compared with those examining total anxiety symptoms. Yet, it is important to
differentiate between the two areas of research because research focusing on a
discrete anxiety disorder may yield more specific information as to how associations
differ across anxiety disorders (Affrunti & Woodruff-Borden, 2014).
The only anxiety disorder that has been investigated with specificity is OCD.
Libby, Reynolds, Derisley, and Clark (2004) examined perfectionism using the
Frost Multidimensional Perfectionism scale which differentiates six perfectionism
dimensions: personal standards, concern over mistakes, doubts about actions,
parental expectations, parental criticism, and organization (Frost, Marten, Lahart,
& Rosenblate, 1990). They found personal standards, concern over mistakes, and
organization were positively associated with a diagnosis of OCD. Parental
expectations and parental criticism were not associated with a diagnosis of OCD,
and the dimension of doubts about actions was not evaluated. Although the
investigation into a specific anxiety disorder is a strength of this study, the use of a
118  Affrunti & Woodruff-Borden

small sample and cross-sectional data limit the study’s conclusions. Soreni et al.
(2014) reported that perfectionism was positively associated with the severity of
OCD symptoms in a sample of children and adolescents, aged 9 to 17 years,
diagnosed with OCD. Similar findings were reported by Ye, Rice, and Storch
(2008) in a separate sample of children and adolescents, aged 7 to 18 years,
diagnosed with OCD. Taken together, these studies suggest that perfectionism is
associated with greater and more severe symptoms in OCD, which parallels
findings from research on adults (Frost & Steketee, 1997; Rhéaume, Freeston,
Dugas, Letarte, & Ladouceur, 1995). However, the directionality of the relationship
is not clear. At this point, no longitudinal studies have been conducted examining
perfectionism and OCD in children. Future work must remedy this. Additionally,
the lack of research examining perfectionism in other childhood anxiety disorders
(e.g., social phobia, separation anxiety disorder, generalized anxiety disorder) is a
glaring gap in the literature. Far more work is needed in this area to understand the
role of perfectionism across childhood anxiety disorders.

The Effect of Perfectionism on Anxiety Treatment

Further evidence for the role of perfectionism in childhood anxiety disorders
comes from research examining the effects of perfectionism in the treatment and
prevention of anxiety disorders. Perfectionism has been hypothesized to interfere
and undermine effective treatment and prevention by creating unrealistic standards
for coping in the patient (Hewitt & Flett, 1991). Because these standards cannot be
reached during treatment, patients perceive treatment to have failed and return to
previous patterns of thinking and behaving. For example, children may expect the
elimination of all distress from treatment. When this does not occur, they can
become emotionally reactive; not only distressed by the stressor in the environment,
but also by their failure to meet the treatment goal. Additionally, some children
may also struggle with the process of working toward their goals in therapy, either
hiding their difficulty completing tasks to appear perfect or refusing to engage in
tasks due a perception that they will fail at meeting their goals. Though there is
some evidence for these assumptions in the treatment of childhood depression
(Jacobs et al., 2009; Nobel et al., 2012), findings are less clear in the treatment of
childhood anxiety disorders.
In the only examination of the role of perfectionism in the treatment for
children diagnosed with an anxiety disorder, Mitchell, Newall, Broeren, and
Hudson (2013) found that pre-treatment self-oriented perfectionism (but not
socially prescribed perfectionism) predicted poorer treatment outcome for a group
of children receiving cognitive-behavioral treatment (CBT). These findings were
the same at post-treatment and six-month follow-up. Furthermore, two studies
investigated perfectionism in the prevention of anxiety disorders and symptoms in
at-risk children (Essau, Conradt, Sasagawa, & Ollendick, 2012; Nobel et al. 2012).
Similar to the findings of Mitchell, Newall et al. (2013), Essau et al. (2012) found
that perfectionism impeded treatment gains of a CBT prevention program at a
 Perfectionism and Child Anxiety  119

12-month follow-up. That is, children with lower levels of perfectionism had
greater decreases in symptoms 12 months after the completion of the prevention
program. The authors speculated that those children with greater levels of
perfectionism saw lower decreases in symptoms because they may have struggled
to generate problem-solving strategies and may have made more perseverative
errors, which reduced the efficacy of the treatment. Discrepant from these findings,
Nobel et al. (2012) found that perfectionism did not impact treatment outcomes
for a school-based CBT program for at-risk children. Data were only collected at
post-treatment, but long-term follow-up data were not reported. It is possible that
the discrepant findings from Nobel et al. are the result of different follow-up times.
For example, it is possible that perfectionistic children at-risk of anxiety disorders
show immediate treatment gains from such a prevention program. However, these
gains may not last. Indeed, consistent with Hewitt and Flett’s (1991) theory,
children with high levels of perfectionism may revert to old patterns of behavior
over time because their standards for coping are not met. At-risk children may be
more likely to show immediate treatment gains, when compared to diagnosed
children, because experiences with strong negative emotions arise less frequently
for at-risk children than diagnosed children. As such, in the short term, at-risk
children may function better until reverting to old patterns of behavior because of
unmet standards for coping. Future studies focusing on the trajectory of treatment
for perfectionistic children, both within and after treatment is completed, are
needed to contextualize these findings. Additionally, differences in how
perfectionism affects treatments aimed at at-risk children versus treatments aimed
at diagnosed children need to be further understood.
The growing body of literature linking perfectionism with childhood anxiety
disorders lends initial support to the theory that perfectionism is a significant factor
for the development and maintenance of these disorders. Perfectionism predicts
total anxiety symptoms, suggesting perfectionistic children are more fearful overall
and biased toward threat across environments. Additionally, the link between
perfectionism and worry in children may arise because perfectionistic children are
more fearful. That is, perfectionistic children may worry as an attempt to control
emotions such as fear. By engaging in worry, perfectionistic children perpetuate
their fear and emotion dysregulation. Separately, perfectionism may have similar
associations with OCD. Perfectionistic children may engage in compulsive
behaviors as a maladaptive attempt to cope with obsessive thoughts. Despite the
above hypotheses on why perfectionism associates with anxiety disorders in
children, the unique contribution of perfectionism to the development and
maintenance of anxiety disorders over developmental factors such as temperament,
executive function, and parenting is not well known.
To help explain how and why the above associations between perfectionism
and child anxiety exist, mediating factors must be examined (cf. Baron & Kenny,
1986). Such factors may explain why perfectionism is associated with multiple
anxiety disorders. It is likely that various factors occurring throughout development
act as mechanisms through which perfectionism exerts its effect on childhood
120  Affrunti & Woodruff-Borden

anxiety disorders. Although such research is in its infancy, a growing body of

evidence suggests that perfectionism may associate with anxiety disorders through
a number of separate mechanisms.

Mediators of Perfectionism and Anxiety Disorders

Theory and research have implicated multiple mechanisms linking perfectionism
and anxiety (Hill, Hall, & Appleton, 2010; Libby et al., 2004; Moretz & McKay,
2009). Intolerance of uncertainty, lowered perceived competence, “not just right
experiences,” and effortful control have all shown associations with perfectionism
and anxiety disorders. Indeed, these factors have been theorized as possible
mechanisms through which perfectionism relates to the development of anxiety
disorders (Affrunti & Woodruff-Borden, 2014). They may also represent possible
paths that are part of multiple causal routes within the development of these
disorders. Importantly, much of this research remains preliminary, limiting our
understanding of the exact nature of the associations observed across development.
Additionally, research using children is sparse. Consequently, in the following
section, we will also review research using adult samples where research using
children is absent from the literature.

Intolerance of Uncertainty
Intolerance of uncertainty reflects the concept that ambiguity in situations is
inherently threatening or negative and should be avoided (Dugas, Buhr, &
Ladouceur, 2004), and it has been implicated in disorders such as generalized
anxiety disorder, OCD and depression (Buhr & Dugas, 2006; Dugas, Schwartz, &
Francis, 2004; Gallagher, South, & Oltmanns, 2003; Gentes & Ruscio, 2011;
Tolin, Abramowitz, Brigidi, & Foa, 2003). Intolerance of uncertainty may link
perfectionism with anxiety disorders because the high and rigid standards and
perceived negative consequences that occur in perfectionism make uncertainty a
fearful prospect. In uncertain situations, perfectionistic children may be unsure if
standards have been met, creating fear and worry about that situation. This
increased distress may in turn increase their risk of developing an anxiety disorder.
This may be especially true for generalized anxiety disorder and OCD. For
example, perfectionistic children who are also intolerant of uncertainty may engage
in worry or compulsive behaviors in an attempt to reduce distress around uncertain
situations.
Research examining the relationship of intolerance of uncertainty and
perfectionism has only been correlational. Buhr and Dugas (2006) reported
significant positive correlations between intolerance of uncertainty and
perfectionism in 197 undergraduates. Similar significant correlations were found in
a sample of 191 adolescents, 14 to 18 years of age (Boelen, Vrinssen, & van Tulder,
2010). No conclusions can be drawn about temporal or causal directionality or
specific dimensions. Yet, these findings are consistent with the proposition that
 Perfectionism and Child Anxiety  121

intolerance of uncertainty mediates the association between perfectionism and

child anxiety.
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 (Clark, 2004; Frost & Steketee, 2002; Libby et
al., 2004). Indeed, in factor analytic studies, perfectionism and intolerance of
uncertainty in adults have collapsed into a single factor (Taylor, Afifi, Stein,
Asmundson, & Jang, 2010). This suggests that those who are highly perfectionistic
are also likely to develop intolerance of uncertainty in the context of OCD.
Longitudinal studies are needed to determine directionality and strengths of these
relationships across development. Preliminary evidence for intolerance of
uncertainty as a mediator between perfectionism and OCD comes from a sample
of 475 undergraduates (Reuther et al., 2013). Researchers found that intolerance
of uncertainty mediated the relationship between perfectionism and obsessive-
compulsive symptoms. Although the data were not longitudinal, the findings are
consistent with the theory that perfectionism leads to distress in uncertain,
unexpected situations, which may lead to increased risk for anxiety disorders.
The need for further investigation of perfectionism and intolerance of
uncertainty across development is clear. As no studies have investigated
perfectionism and intolerance of uncertainty in children, hypothetical explanations
for their association are presented. It is plausible that intolerance of uncertainty and
perfectionism influence each other throughout development, putting children at
increased risk for anxiety. Additionally, perfectionism and intolerance of uncertainty
together may prime children to worry, or engage in compulsive behaviors,
increasing their risk of generalized anxiety disorder and OCD. Longitudinal studies
are required to understand the temporal directionality and causality of these
relationships.

Perceived Competence
Perceived competence has been defined as the belief in one’s own mastery over
things in the environment. This has been conceptualized as including separate but
related domains of competence: cognitive, social, and physical (Harter, 1982). Yet,
these competence-based domains relate to a global factor of competence (Granleese
& Joseph, 1994). Both the competence-based domains and the global factor have
shown links with perfectionism and anxiety disorders (Grills & Ollendick, 2002;
McVey, Pepler, Davis, Flett, & Abdolell, 2002; Rice, Choi, Zhang, Morero, &
Anderson, 2012). Theoretically, continued perceived failure at achieving high and
rigid standards would lead to the development of low competence. This low
competence would then lead to anxiety disorders by raising anxiety and lowering
coping. For example, children who perceive themselves as failures in the social
domain may become more anxious in social situations, which puts them at risk of
developing social phobia. Whereas no study has examined these assumptions across
development, separate lines of research do provide some support.
122  Affrunti & Woodruff-Borden

Perfectionism has been linked with low perceived competence. In a sample of

286 undergraduates, interpersonal competence was negatively associated with
perfectionism (Jackson, Towson, & Narduzzi, 1997). Similar results were reported
in a sample of 363 females with a mean age of 13 years (McVey et al., 2002). In a
sample of 187 females with a mean age of 14 years, perfectionism was found to be
negatively associated with domain-specific competencies (McArdle, 2010). That is,
perfectionism about cognitive tasks was associated with low perceived competence
about cognitive tasks, but not with low perceived competence about physical tasks.
Conversely, perfectionism about physical tasks was associated with low perceived
competence about physical tasks, but not with low perceived competence about
cognitive tasks. This suggests that perfectionism leads to domain-specific
competence deficits. Yet, some research has shown that perfectionism predicts
greater global deficits of competence (DiBartolo, Frost, Chang, LaSota, & Grills,
2004; Rice, Ashby, & Slaney, 1998).
Separately, there is a large body of research that has linked poor competence
with anxiety disorders (Masten, Burt, & Coatsworth, 2006; Messer & Beidel, 1994;
Rutter, Kim-Cohen, & Maughan, 2006). For example, in a longitudinal study
following 87 children from Grade 2 to Grade 5, perceptions of social incompetence
were predictive for subsequent internalizing problems, including anxiety (Hymel,
Rubin, Rowden, & LeMare, 1990). Further, more specifically, lower self-
competence predicted child anxiety symptoms (Affrunti & Ginsburg, 2012; Messer
& Beidel, 1994). A longitudinal study examining predictors of social anxiety and
fear of negative evaluation in children of 13 to 18 years, found that a lack of
perceived social competence predicted social anxiety (Teachman & Allen, 2007).
In a separate longitudinal study following 205 children from the age of 8 years to
28 years, social incompetence predicted subsequent internalizing problems at all
follow-ups: 7, 10, and 20 years after the initial assessment (Burt, Obradović, Long,
& Masten, 2008). Furthermore, children diagnosed with an anxiety disorder tend
to perceive themselves as less competent when compared to their non-diagnosed
peers (Ekornås, Lundervold, Tjus, & Heimann, 2010).
No study so far has combined these two lines of research. Taken together,
however, the extant research suggests that individuals high in perfectionism may
develop low competence when faced with frequent perceived failure. This may
occur when a perfectionistic individual fails to achieve to the standard set by them
or by others, perceiving themselves to have failed. This may influence domain-
specific areas of competence. For example, specific areas of perfectionistic concern
(e.g., social relationships) may lead to reduced competence for this specific area
when a standard is not met. This reduced competence may then increase the risk
of developing anxiety disorders in children.
Importantly, research has not yet investigated the temporal or causal directionality
of the relationship between perfectionism and lowered self-competence.
Competence, like perfectionism, is likely influenced by multiple developmental
factors. For example, parental control and authoritarian parenting have shown to
be predictive of competence deficits by restricting a child’s ability to develop
 Perfectionism and Child Anxiety  123

competence in challenging situations (de Minzi, 2006; Grolnick & Ryan, 1989).
These parental factors have also shown to be predictive of perfectionism in children
(e.g., Affrunti & Woodruff-Borden, 2015) and adolescents (Soenens et al., 2008).
Future research must better clarify the role of perfectionism in the development of
competence and the multiple pathways they may create in the development of
anxiety disorders in children.

“Not Just Right Experiences”

The phenomenon of a “not just right experience” (NJRE) reflects experiences
when individuals report uncomfortable sensations that compel them to perform
certain behaviors until the uncomfortable sensation is resolved as being “just right”
(Coles, Frost, Heimberg, & Rhéaume, 2003). These behaviors are conceptualized
as a striving for perfection, certainty, or control that needs to be achieved in order
to reduce distress. That distress likely arises out of a mismatch between input and
expectations (Coles, Frost, Heimberg, & Steketee, 2003). NJREs are often
observed in OCD, though they have also been observed in individuals with tic
disorders (Ghisi, Chiri, Marchetti, Sanavio, & Sica, 2010; Miguel et al., 2000; Neal
& Cavanna, 2013). There is also some research indicating that NJREs are positively
related to generalized anxiety disorder symptoms and worry (Fergus, 2014).
Perfectionism likely leads to the sensation that certain experiences are imperfect, or
“not just right,” which leads to distress. Behaviors such as compulsions or worry
may function as a way to decrease this distress, leading to anxiety disorders such as
OCD and generalized anxiety disorder.
Few studies have investigated the association between perfectionism and
NJREs. However, in these few studies, perfectionism has been found to be strongly
positively associated with NJREs. Coles, Frost, Heimberg, and Rhéaume (2003)
found that NJREs positively associated with all perfectionism dimensions of two
perfectionism questionnaires in a sample of 119 undergraduates. Similar results
were reported in another undergraduate sample of 188 students (Moretz & McKay,
2009). Whereas these studies provide preliminary evidence for the link between
NJREs and perfectionism, they are limited by their use of undergraduates and
cross-sectional data. More research is needed to confirm that perfectionism
precedes the development of NJREs in the development of OCD or worry.
Furthermore, more research is needed exploring these developmental links in
children.
Though NJREs are understudied in children, sensory intolerance may represent
analogous experiences in children. Sensory intolerance reflects the phenomenon of
marked intolerance or intrusive re-experiencing of sensory stimuli that drive
compulsive behaviors (Hazen et al., 2008). As such, sensory intolerance may
include NJREs as one possible subtype (Miguel et al., 2000) and is common in
children diagnosed with OCD or tic disorders (Ferrão et al., 2012; Hazen et al.,
2008). Yet, the role of perfectionism within sensory intolerance experiences is not
well understood. Though clinical case studies report co-occurrences between
124  Affrunti & Woodruff-Borden

sensory intolerance and perfectionism (Hazen et al., 2008), no studies have

empirically investigated this connection. It is possible that NJREs and sensory
intolerance are indicators of perfectionism in children, which may put them at risk
of anxiety disorders. However, far more research is needed in exploring the
associations between NJREs, sensory intolerance, perfectionism, and anxiety
among children.

Effortful and Emotional Control

Effortful control is the ability to suppress a dominant response in order to perform
a subdominant response. It is often conceptualized as a temperament factor and
refers to the focusing and shifting of attention and inhibiting behavior when
appropriate (Rothbart, Ellis, & Posner, 2004). In particular, it is the combination
of attentional and inhibitory control that acts to regulate experience and overlaps
with executive function, temperament, and self-regulation (Kochanska, Murray, &
Harlan, 2000). Additionally, effortful control can assist in the modulation of
emotional responses using executive function (Gioia, Isquith, Guy, & Kenworthy,
2000). Separate lines of research have linked effortful control with perfectionism
(Mandel, Dunkley, & Moroz, 2015; Tangney, Baumeister, & Boone, 2004) and
anxiety (Lonigan & Vasey, 2009; Muris, van der Pennen, Sigmond, & Mayer,
2008; Muris, de Jong, & Engelen, 2004) in children. These studies suggest that
perfectionism may predispose children to effortful control deficits, which may
predict increased anxiety symptoms and disorders in youths. Hypothetically,
perfectionism may predict lower effortful control by preventing children from
regulating their actions when perceived failure occurs. Perfectionistic children may
experience distress when perceived failure occurs, be unable to regulate that
distress, and feel anxious or worry about that situation in the future. Although
research has yet to test this hypothesis directly, previous research has provided
indirect support for it (e.g., Muris et al., 2004; Tangney et al., 2004)
Similarly, emotional control, or the ability to modulate emotional responses
using executive control, has been theorized to associate with both increased
perfectionism and anxiety symptoms (Affrunti & Woodruff-Borden, 2014).
Perfectionism may predict decreased emotional control, as children who are
perfectionistic may be unable to modulate their emotional responses when
perceived failure occurs. This may show when a child becomes overwhelmed and
has difficulty coping with strong emotions in the face of perceived failure. There
are studies suggesting that emotional control and perfectionism are linked, yet they
have been primarily conducted with adult samples (Rudolph, Flett, & Hewitt,
2007; Wirtz et al., 2007). Additionally, this decreased ability to control their
emotions may cause children to become anxious or worried about future situations.
Indeed, children with emotional control deficits have shown to be at risk for
increased anxiety (Suveg & Zeman, 2004) and worry (Gramszlo & Woodruff-
Borden, 2015). A single study has linked these two areas of research. In this study
of 66 children, aged 7 to 13 years, emotional control deficits were found to mediate
 Perfectionism and Child Anxiety  125

the association between perfectionism and worry (Affrunti & Woodruff-Borden,

in press). Although this was not a clinical sample and only measures of worry, not
anxiety, were used, the findings provide preliminary support for the above
propositions.
Although the factors discussed above all have some studies providing empirical
evidence to suggest they mediate the relationship between perfectionism and
childhood anxiety, there are few conclusive studies. Directionality and causality
remain poorly understood and require further studies. Additionally, few studies
have used child samples. Unique associations may be observed in children. Further,
the mediators mentioned may be implicated in specific anxiety disorders. As noted
earlier, perfectionism may put children at risk of developing social phobia by
decreasing their perceived self-competence in social situations. Similarly,
perfectionism may put children at risk of generalized anxiety disorder by increasing
worry and distress in uncertain situations. In these ways, perfectionism may act as
a risk factor for multiple anxiety disorders.

Conclusions
Research has provided some support for the link between perfectionism and
childhood anxiety disorders. Although this area of study is burgeoning and much
remains to be known, it appears that perfectionism predicts greater total anxiety
symptoms, worry, and the diagnosis of an anxiety disorder. Moreover, it disrupts
the treatment of anxiety disorders in children. As noted throughout, this research
is not without its limitations. Many studies examining the role of perfectionism in
childhood anxiety have used small samples, correlational analyses, cross-sectional
data, and have differed in their measurement of anxiety and perfectionism. Such
inconsistencies do restrict the conclusions that can be drawn from these studies.
However, research to date also provides an important foundation to build upon.
This is because research has begun to identify the link between perfectionism and
childhood anxiety, allowing further research to test more specific hypotheses using
more advanced methodologies. Furthermore, recent studies (e.g., Mitchell,
Newall, et al., 2013; Soreni et al., 2014) have looked beyond simple associations
between perfectionism and childhood anxiety into how perfectionism may affect
symptom severity and treatment outcomes. Not only this, but preliminary findings
have allowed researchers to attempt to understand why and how associations
between perfectionism and childhood anxiety disorders occur.
Although research is sparse, there is evidence that further variables may act as
factors through which perfectionism impacts childhood anxiety. The four factors
reviewed here (intolerance of uncertainty, perceived competence, “not just right
experiences,” and effortful and emotional control), however, have so far the best
empirical support. These factors likely help explain why perfectionism links with
many different anxiety disorders and other psychopathologies (see Figure 6.1).
There is research from both child and adult studies that supports these links (e.g.,
Buhr & Dugas, 2006; Flett, Hewitt, & Cheng, 2008). However, further research
126  Affrunti & Woodruff-Borden

Intolerance of
uncertainty

Perceived
competence
Anxiety
Perfectionism Worry
OCD
NJREs

Effortful/
emotional control

FIGURE 6.1   he effect of perfectionism through mediators on child anxiety, worry, and
T
obsessive-compulsive disorder (OCD). NJREs = not just right experiences.

will be needed to determine whether the observed relationships are causal. It is

possible that perfectionism and the four factors influence each other over time and
are best characterized by bidirectional relationships that increase the risk of
developing anxiety disorders in children. Furthermore, the four factors may be
important in the treatment of anxious children. Indeed, research has begun to
identify intolerance of uncertainty, competence, and effortful control as factors that
influence treatment outcomes for childhood anxiety disorders (Kendall, 1994;
Krain et al., 2008; Rapee, Schniering, & Hudson, 2009). As such, they may explain
not only why perfectionism positively relates to child anxiety, but also why it
negatively impacts treatment outcomes. Interventions addressing perfectionism
may profit from also addressing the factors reviewed here to increase the efficacy of
childhood anxiety disorder prevention and treatment (cf. Chapter 13).

Future Directions
Given the preliminary nature of the research on perfectionism and childhood
anxiety, many suggestions for future research have been presented throughout the
chapter. However, there remain specific directions that may serve to accelerate
understanding in this area. First, similar factors may explain the development of
both childhood anxiety and perfectionism. For example, Flett and colleagues
(2002) detail a model suggesting the role of anxious parenting practices in
contributing to the development of perfectionism. Indeed, such parenting practices
have shown links with both childhood anxiety (Affrunti & Woodruff-Borden,
2014) and childhood perfectionism (Mitchell, Broeren, et al., 2013). Yet, the
 Perfectionism and Child Anxiety  127

trajectory of these links remains poorly understood. Do these parenting practices

increase perfectionism and subsequently anxiety, or do they increase anxiety and
subsequently perfectionism? More research is needed to understand the relationship
of similar developmental constructs in the etiology of both childhood anxiety and
perfectionism.
As noted earlier, few studies have examined perfectionism within specific
childhood anxiety disorders. Beyond understanding the role that perfectionism
plays in these different disorders, future research should explore why and how
perfectionism creates risk for these distinct disorders. Perfectionism may place
children at risk for, and interact with, other cognitive deficits that may lead to
specific anxiety disorders. For example, perfectionistic children may be more likely
to experience NJREs due to their high and rigid standards, and thus be at risk for
developing OCD. More research is needed exploring possible mechanisms for the
development of specific anxiety disorders. Furthermore, findings from such
research may serve to help devise treatments to address perfectionism within a
specific disorder. Although the contribution of perfectionism may be similar across
disorders (i.e., incorporating high and rigid standards, and valuing only the
attainment of these standards), it may depend on the domain in which the child is
perfectionistic as perfectionism is typically focused on selected domains (Stoeber &
Stoeber, 2009). As such, children who are perfectionistic in social domains may not
be perfectionistic in academic domains. This may show as the former children
being socially reticent, whereas the latter may engage in high levels of checking,
for example, when working on home assignments.
Treatments would be required to address the salient domain and the subsequent
relevant mediators. Novel treatment methods have been devised to address
perfectionism (e.g., Egan et al., 2014; Sullivan, Keller, Paternostro, & Friedberg,
2015; see also Chapters 13–15), but their applicability to children with specific
anxiety disorders is not well known. Given the various links between perfectionism
and anxiety in children, effective prevention and treatment of perfectionism may
not only reduce the dysfunctional effects of perfectionism in children, but may also
help treat childhood anxiety disorders.

References
Affrunti, N. W., & Ginsburg, G. S. (2012). Maternal overcontrol and child anxiety: The
mediating role of perceived competence.  Child Psychiatry & Human Development,  43,
102–112.
Affrunti, N. W., & Woodruff-Borden, J. (2014). Perfectionism in pediatric anxiety and
depressive disorders. Clinical Child and Family Psychology Review, 17, 299–317.
Affrunti, N. W., & Woodruff-Borden, J. (2015). Parental perfectionism and overcontrol:
Examining mechanisms in the development of child anxiety. Journal of Abnormal Child
Psychology, 43, 517–529.
Affrunti, N. W., & Woodruff-Borden, J. (2016). Negative affect and child internalizing
symptoms: The mediating role of perfectionism. Child Psychiatry & Human Development,
47, 358–368.