The Child Anxiety Prevention Study: intervention model and primary outcomes

Parents' perceptions on offspring risk and prevention of anxiety and depression: a qualitative study

BACKGROUND

Offspring of patients with anxiety or depression are at high risk for developing anxiety or depression. Despite the positive findings regarding effectiveness of prevention programs, recruitment for prevention activities and trials is notoriously difficult. Our randomized controlled prevention trial was terminated due to lack of patient inclusion. Research on mentally-ill parents' perceptions of offspring's risk and need for preventive intervention may shed light on this issue, and may enhance family participation in prevention activities and trials.

METHODS

Qualitative data were collected through semi-structured interviews with 24 parents (patients with anxiety or depression, or their partners). An inductive content analysis of the data was performed. Five research questions were investigated regarding parents' perceptions of anxiety, depression, and offspring risk; anxiety, depression, and parenting; the need for offspring intervention and prevention; and barriers to and experiences with participation in preventive research.

RESULTS

Parental perceptions of the impact of parental anxiety and depression on offspring greatly differed. Parents articulated concerns about children's symptomatology, however, most parents did not perceive a direct link between parent symptoms and offspring quality of life. They experienced an influence of parental symptoms on family quality of life, but chose not to discuss that with their children in order to protect them. Parents were not well aware of the possibilities regarding professional help for offspring and preferred parent-focused rather than offspring-focused interventions such as parent psycho-education. Important barriers to participation in preventive research included parental overburden, shame and stigma, and perceived lack of necessity for intervention.

CONCLUSIONS

This study highlights the importance of educating parents in adult health care. Providing psycho-education regarding offspring risk, communication in the family, and parenting in order to increase parental knowledge and parent-child communication, and decrease guilt and shame are important first steps in motivating parents to participate in preventive treatment.

Developing a model of mental health self-care support for children and young people through an integrated evaluation of available types of provision involving systematic review, meta-analysis and case study

Background

The mental health of children and young people (CYP) is a major UK public health concern. Recent policy reviews have identified that service provision for CYP with mental health needs is not as effective, responsive, accessible or child-centred as it could be. Following on from a previous National Institute for Health Research (NIHR) study into self-care support for CYP with long-term physical health needs, this study explored self-care support’s potential in CYP’s mental health.

Objectives

To identify and evaluate the types of mental health self-care support used by, and available to, CYP and their parents, and to establish how such support interfaces with statutory and non-statutory service provision.

Design

Two inter-related systematic literature reviews (an effectiveness review with meta-analysis and a perceptions review), together with a service mapping exercise and case study.

Setting

Global (systematic reviews); England and Wales (mapping exercise and case study).

Participants (case study)

Fifty-two individuals (17 CYP, 16 family members and 19 staff) were interviewed across six sites.

Main outcome measures (meta-analysis)

A measure of CYP’s mental health symptomatology.

Data sources (literature reviews)

MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, All Evidence-Based Medicine (EBM) Reviews, Applied Social Sciences Index and Abstracts (ASSIA) and Education Resources Information Center (ERIC).

Review methods

Titles and abstracts of papers were screened for relevance then grouped into studies. Two independent reviewers extracted data from studies meeting the inclusion criteria. A descriptive analysis and meta-analysis were conducted for the effectiveness review; descriptive analyses were conducted for the perceptions review. These analyses were integrated to elicit a mixed-methods review.

Results

Sixty-five of 71 included studies were meta-analysable. These 65 studies elicited 71 comparisons which, when meta-analysed, suggested that self-care support interventions were effective at 6-month [standardised mean difference (SMD) = −0.20; 95% confidence interval (CI) −0.28 to −0.11] and 12-month (SMD = −0.12; 95% CI −0.17 to −0.06) follow-ups. However, judged against Cochrane criteria, the studies were mostly low quality. Key elements of self-care support identified in the perceptions review were the acquisition of knowledge and skills, peer support and the relationship with the self-care support agent; CYP also had different perceptions from adults about what is important in self-care support. The mapping exercise identified 27 providers of 33 self-care support services. According to the case study data, effective self-care support services are predicated on flexibility; straightforward access; non-judgemental, welcoming organisations and staff; the provision of time and attention; opportunities to learn and practise skills relevant to self-care; and systems of peer support.

Conclusions

Mental health self-care support interventions for CYP are modestly effective in the short to medium term. Self-care support can be conceptualised as a process which has overlap with ‘recovery’. CYP and their families want choice and flexibility in the provision of such interventions and a continued relationship with services after the nominal therapy period. Those delivering self-care support need to have specific child-centred attributes.

Future work

Future work should focus on under-represented conditions (e.g. psychosis, eating disorders, self-harm); the role of technology, leadership and readiness in self-care support; satisfaction in self-care support; the conceptualisation of self-care support in CYP’s mental health; and efficacy and cost-effectiveness.

Study registration

PROSPERO number (for the effectiveness review) CRD42012001981.

Funding

The NIHR Health Services and Delivery Research programme.

Anxiety-promoting parenting behaviors: a comparison of anxious mothers and fathers

The majority of research identifying anxiety-promoting parenting behaviors has been conducted with mothers, leaving a gap in current knowledge about the role of fathers' parenting behaviors. In an attempt to fill this gap, this study compared anxiety-promoting parenting behaviors of anxious mothers and fathers. Parents completed self-report measures of parenting behavior and independent coders rated parenting behaviors (i.e., overcontrol, granting of autonomy, warmth, hostility, anxious behavior) of mothers (n = 34) and fathers (n = 21) during a challenging parent-child interaction task (children were ages 6-12). Results indicated that anxious fathers were observed to be more controlling than anxious mothers; while anxious mothers reported using more punishment and reinforcement of children's dependence in anxiety provoking situations compared to fathers. Findings extend our knowledge about anxious fathers, and highlight the need for additional research on the impact of fathers' parenting with respect to the development of child anxiety.

Parenting strategies for reducing the risk of adolescent depression and anxiety disorders: a Delphi consensus study

BACKGROUND

The family setting, particularly parents, is a strategic target for preventive interventions for youth depression and anxiety disorders. However, more effective translation of relevant research evidence is required.

METHOD

This study employed the Delphi methodology to establish expert consensus on parenting strategies that are important for preventing adolescent depression or anxiety disorders. A literature search identified 402 recommendations for parents. These were presented to a panel of 27 international experts over three survey rounds, who rated their preventive importance.

RESULTS

One-hundred and ninety parenting strategies were endorsed as important or essential in reducing adolescents' risk of developing depression or anxiety disorders by ≥90% of the panel. These strategies were written into a document suitable for parents, categorised under 11 sub-headings: You can reduce your child's risk of depression and anxiety problems, Establish and maintain a good relationship with your teenager, Be involved and support increasing autonomy, Establish family rules and consequences, Minimise conflict in the home, Encourage supportive relationships, Help your teenager deal with problems, Encourage good health habits, Help your teenager to deal with anxiety, Encourage professional help seeking when needed, and Don׳t blame yourself.

LIMITATIONS

This study utilised an international panel of experts from Western countries, hence the strategies identified may not be relevant for families from other cultural groups.

CONCLUSIONS

This study produced a set of parenting strategies that are supported by research evidence and/or international experts, which can now be promoted in Western English-speaking communities to help parents protect their adolescents from depression and anxiety disorders.

Parental factors associated with depression and anxiety in young people: a systematic review and meta-analysis

BACKGROUND

There is a burgeoning and varied literature examining the associations between parental factors and depression or anxiety disorders in young people. However, there is hitherto no systematic review of this complex literature with a focus on the 12-18 years age range, when the first onset for these disorders peaks. Furthermore, to facilitate the application of the evidence in prevention, a focus on modifiable factors is required.

METHODS

Employing the PRISMA method, we conducted a systematic review of parental factors associated with depression and anxiety disorders in young people which parents can potentially modify.

RESULTS

We identified 181 articles altogether, with 140 examining depression, 17 examining anxiety problems, and 24 examining both outcomes. Stouffer's method of combining p values was used to determine whether associations between variables were reliable, and meta-analyses were conducted to estimate the mean effect sizes of associations between each parental factor and outcome.

LIMITATIONS

Limitations include sacrificing micro-level detail for a macro-level synthesis of the literature, not systematically reviewing moderators and mediators, the lack of generalizability across cultures and to younger or adult children, and the inability to conduct a meta-analysis on all included studies.

CONCLUSIONS

Parental factors with a sound evidence base indicating increased risk for both depression and anxiety include less warmth, more inter-parental conflict, over-involvement, and aversiveness; and for depression additionally, they include less autonomy granting and monitoring.

Effectiveness of depression and anxiety prevention in adolescents with high familial risk: study protocol for a randomized controlled trial

BACKGROUND

Depression and anxiety disorders during adolescence can have detrimental consequences. Both disorders are related to negative outcome in various areas during adolescence and are also predictive of depression and anxiety disorders later in life. Especially parental psychopathology and being female are risk factors that increase the probability of developing one of these disorders during adolescence. Research has shown that prevention programs have promising results, especially for adolescents who have these risk factors. Therefore, in this study, we will focus on the effectiveness of a prevention program 'A jump forward' that has been developed for adolescent girls with a familial risk of depression and/or anxiety.

METHODS/DESIGN

We designed a randomized controlled trial to test the effectiveness of an indicated and selective prevention program aimed at depression and anxiety in adolescent girls. Adolescents aged between 11 and 15 years old with depressive and/or anxiety symptoms and with parents who show indicators of parental psychopathology will be randomly assigned to the experimental (N = 80) or control groups (N = 80). Participants in the experimental group will follow a preventive intervention, consisting of six sessions of 90 minutes each. All participants will complete baseline, intervention phase 1 (after session 2), intervention phase 2 (after session 4), post-intervention, 6 month follow-up, and 12 month follow-up assessments. Furthermore, parents will be asked to complete assessments at baseline, post-intervention, and 12-month follow-up. Primary outcome will be depressive symptoms. Secondary outcomes will be anxiety symptoms, suicidal ideation, response style, negative cognitive errors, parental emotional support and parental control, parental psychopathology, parenting stress and adolescents' depression and anxiety symptoms according to the parents.

DISCUSSION

This paper described the study designed to evaluate a program for preventing depression and/or anxiety in high-risk adolescents over a 12-month follow-up period. If the program showed to be effective in reducing symptoms of depression and anxiety and preventing adolescents from developing clinical levels of these disorders, our results would be relevant to practice. Thus, the intervention could be used on a large scale. Moreover, this study aims to contribute to the evidence-based prevention of depression and anxiety of adolescents.

TRIAL REGISTRATION

Dutch Trial Register NTR3720.

Anxiety-promoting parenting behaviors: a comparison of anxious parents with and without social anxiety disorder

While parenting behaviors among anxious parents have been implicated in the familial transmission of anxiety, little is known about whether these parenting behaviors are unique to specific parental anxiety disorders. The current study examined differences in the use of five specific parenting behaviors (i.e., warmth/positive affect, criticism, doubts of child competency, over-control, and granting of autonomy) in anxious parents with (n = 21) and without (n = 45) social anxiety disorder (SAD) during a 5-minute task with their non-anxious child (aged 7-12 years, M = 9.14). Parents with SAD demonstrated less warmth/positive affect and more criticism and doubts of child competency than did those without SAD. There were no group differences in over-control or granting of autonomy. Findings help clarify inconsistent results in the literature, inform models of familial transmission, and suggest intervention targets for parents with SAD.

Cognitive bias modification versus CBT in reducing adolescent social anxiety: a randomized controlled trial

Social anxiety is a common mental disorder among adolescents and is associated with detrimental long term outcomes. Therefore, this study investigated the efficacy of two possible early interventions for adolescent social anxiety and test anxiety. An internet-based cognitive bias modification (CBM; n = 86) was compared to a school-based cognitive behavioral group training (CBT; n = 84) and a control group (n = 70) in reducing symptoms of social and test anxiety in high socially and/or test anxious adolescents aged 13–15 years. Participants (n = 240) were randomized at school level over the three conditions. CBM consisted of a 20-session at home internet-delivered training; CBT was a 10-session at school group training with homework assignments; the control group received no training. Participants were assessed before and after the intervention and at 6 and 12 month follow-up. At 6 month follow-up CBT resulted in lower social anxiety than the control condition, while for CBM, this effect was only trend-significant. At 12 month follow-up this initial benefit was no longer present. Test anxiety decreased more in the CBT condition relative to the control condition in both short and long term. Interestingly, in the long term, participants in the CBM condition improved more with regard to automatic threat-related associations than both other conditions. The results indicate that the interventions resulted in a faster decline of social anxiety symptoms, whereas the eventual end point of social anxiety was not affected. Test anxiety was influenced in the long term by the CBT intervention, and CBM lead to increased positive automatic threat-related associations.

Trial Registration

TrialRegister.nl NTR965

Temperament and parenting predicting anxiety change in cognitive behavioral therapy: the role of mothers, fathers, and children

OBJECTIVE

A considerable amount of children with anxiety disorders do not benefit sufficiently from cognitive behavioral treatment. The present study examines the predictive role of child temperament, parent temperament and parenting style in the context of treatment outcome.

METHOD

Participants were 145 children and adolescents (ages 8-18) with DSM-IV-TR anxiety disorders who received a 12-session CBT program and were assessed at pretreatment, posttreatment and three months follow-up. Multiple-regression analyses were used to evaluate the following pretreatment and posttreatment variables as potential predictors of treatment response at follow-up: baseline level of anxiety symptoms, child reported maternal and paternal rearing style (emotional warmth, rejection, and overprotection), parent reported child temperament traits (negative affect, effortful control, and extraversion), and mothers' and fathers' self-report temperament traits.

RESULTS

More maternal negative affect and less emotional warmth as perceived by the child before treatment were related to less favorable treatment outcome (accounting for 29% of the variance in anxiety at follow-up). Furthermore, maternal negative affect and children's extraversion measured after treatment also predicted anxiety at follow-up (together accounting for 19% of the variance). Paternal temperament and parenting style were unrelated to treatment outcome, as were children's pretreatment temperament traits.

CONCLUSION

The results suggest that tailoring intervention to include strategies to reduce maternal negative affect and promote an emotional warm rearing style may improve treatment outcome.

Defining treatment response and remission in child anxiety: signal detection analysis using the pediatric anxiety rating scale

OBJECTIVE

To determine optimal Pediatric Anxiety Rating Scale (PARS) percent reduction and raw score cut-offs for predicting treatment response and remission among children and adolescents with anxiety disorders.

METHOD

Data were from a subset of youth (N = 438; 7-17 years of age) who participated in the Child/Adolescent Anxiety Multimodal Study (CAMS), a multi-site, randomized controlled trial that examined the relative efficacy of cognitive-behavioral therapy (CBT; Coping Cat), medication (sertraline [SRT]), their combination, and pill placebo for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. The clinician-rated PARS was administered pre- and posttreatment (delivered over 12 weeks). Quality receiver operating characteristic methods assessed the performance of various PARS percent reductions and absolute cut-off scores in predicting treatment response and remission, as determined by posttreatment ratings on the Clinical Global Impression scales and the Anxiety Disorders Interview Schedule for DSM-IV. Corresponding change in impairment was evaluated using the Child Anxiety Impact Scale.

RESULTS

Reductions of 35% and 50% on the six-item PARS optimally predicted treatment response and remission, respectively. Post-treatment PARS raw scores of 8 to 10 optimally predicted remission. Anxiety improved as a function of PARS-defined treatment response and remission.

CONCLUSIONS

Results serve as guidelines for operationalizing treatment response and remission in future research and in making cross-study comparisons. These guidelines can facilitate translation of research findings into clinical practice.

Exploring Parental Predictors of Child Anxiety: The Mediating Role of Child Interpretation Bias

BACKGROUND

Separate lines of research have shown that higher levels of parental overcontrol and parental anxiety are related to higher levels of child anxiety. The mechanisms of transmission, however, are poorly understood.

OBJECTIVE

It has been theorized, though not empirically tested, that parental overcontrol and anxiety increase children's interpretation bias by signaling to the child that the environment is threatening (e.g. through modeling or restriction of autonomy), thus increasing the child's anxiety level.

METHODS

The present study investigated this theory using 75 parent-child dyads (parents aged 27-52, 82 % female; children aged 7-12, 52 % female, 80 % Caucasian). All parents were diagnosed with a primary anxiety disorder, while no child was diagnosed with an anxiety disorder.

RESULTS

Children's interpretation bias, measured using ambiguous stories, was shown to partially mediate the relation between parental overcontrol and child anxiety and completely mediate the relation between parental anxiety and child anxiety. There was no significant relation between parental overcontrol and parental anxiety.

CONCLUSIONS

Findings partially support theoretical models, which posit that higher levels of overcontrol and parental anxiety signal to children that their environment is threatening, perhaps increasing their threat appraisal of ambiguous situations and increasing their anxiety. Implications and directions for future research are discussed.

Preventive intervention for anxious preschoolers and their parents: strengthening early emotional development

The high prevalence and early onset of anxiety disorders have inspired innovative prevention efforts targeting young at-risk children. With parent-child prevention models showing success for older children and adolescents, the goal of this study was to evaluate a parent-child indicated preventive intervention for preschoolers with mild to moderate anxiety symptoms. Sixteen children (ages 3-5) and at least one of their parents participated in Strengthening Early Emotional Development (SEED), a new 10-week intervention with concurrent groups for parents and children. Outcome measures included clinician-rated and parent-rated assessments of anxiety symptoms, as well as measures of emotion knowledge, parent anxiety, and parental attitudes about children's anxiety. Participation in SEED was associated with reduced child anxiety symptoms and improved emotion understanding skills. Parents reported decreases in their own anxiety, along with attitudes reflecting enhanced confidence in their children's ability to cope with anxiety. Reductions in child and parent anxiety were maintained at 3-month follow-up. Findings suggest that a parent-child cognitive-behavioral preventive intervention may hold promise for young children with mild to moderate anxiety. Improvements in parent anxiety and parental attitudes may support the utility of intervening with parents. Fostering increased willingness to encourage their children to engage in new and anxiety-provoking situations may help promote continued mastery of new skills and successful coping with anxiety.

Targeting parental psychopathology in child anxiety

The increased risk of anxiety in children of parents with psychopathology is a significant public health problem, as early-onset is associated with a variety of difficulties later in life. The aim of this article is to determine if treating parents is associated with improvements in child anxiety through the review of both top-down (parent identified for treatment) and family-focused child anxiety treatment studies. The authors present conclusions based on the state of the current literature, discuss implications for research and clinical practice, and propose utilizing a family-based model for treating parental psychopathology, parental behavior, and child anxiety.

Preventing mood and anxiety disorders in youth: a multi-centre RCT in the high risk offspring of depressed and anxious patients

BACKGROUND

Anxiety and mood disorders are highly prevalent and pose a huge burden on patients. Their offspring is at increased risk of developing these disorders as well, indicating a clear need for prevention of psychopathology in this group. Given high comorbidity and non-specificity of intergenerational transmission of disorders, prevention programs should target both anxiety and depression. Further, while the indication for preventive interventions is often elevated symptoms, offspring with other high risk profiles may also benefit from resilience-based prevention programs.

METHOD/DESIGN

The current STERK-study (Screening and Training: Enhancing Resilience in Kids) is a randomized controlled clinical trial combining selected and indicated prevention: it is targeted at both high risk individuals without symptoms and at those with subsyndromal symptoms. Individuals without symptoms meet two of three criteria of the High Risk Index (HRI; female gender, both parents affected, history of a parental suicide (attempt). This index was developed in an earlier study and corresponds with elevated risk in offspring of depressed patients. Children aged 8-17 years (n = 204) with subthreshold symptoms or meeting the criteria on the HRI are randomised to one of two treatment conditions, namely (a) 10 weekly individual child CBT sessions and 2 parent sessions or (b) minimal information. Assessments are held at pre-test, post-test and at 12 and 24 months follow-up. Primary outcome is the time to onset of a mood or anxiety disorder in the offspring. Secondary outcome measures include number of days with depression or anxiety, child and parent symptom levels, quality of life, and cost-effectiveness. Based on models of aetiology of mood and anxiety disorders as well as mechanisms of change during interventions, we selected potential mediators and moderators of treatment outcome, namely coping, parent-child interaction, self-associations, optimism/pessimism, temperament, and emotion processing.

DISCUSSION

The current intervention trial aims to significantly reduce the risk of intergenerational transmission of mood and anxiety disorders with a short and well targeted intervention that is directed at strengthening the resilience in potentially vulnerable children. We plan to evaluate the effectiveness and cost-effectiveness of such an intervention and to identify mechanisms of change.

TRIAL REGISTRATION

NTR2888.

Treatment and outcomes for anxiety disorders among children and adolescents: a review of coping strategies and parental behaviors

This article reviews the current literature on the treatment of anxiety disorders in children and adolescents and describes the factors that are essential to address in treatment. Coping deficits and parental behaviors are highlighted as factors that contribute to anxiety in youth. Interventions for anxious youth are described, with particular emphasis on cognitive-behavioral therapy for anxiety disorders. Finally, a review of the longitudinal course of anxiety and suggestions for future directions in treatment and research are provided.

Maternal overcontrol and child anxiety: the mediating role of perceived competence

Previous research has shown that maternal overcontrol is related to higher levels of child anxiety. It has been theorized, though not empirically tested, that maternal overcontrol decreases child perceived competence and mastery, which increases child anxiety. The present study investigated this theory using a sample of 89 mother-child dyads (children aged 6-13, 84.3% Caucasian, 6.7% African American, and 51.7% male). After statistically controlling for maternal anxiety level, child perceived competence was shown to partially mediate the relationship between maternal overcontrol and child anxiety. Though current findings are based on cross sectional data, they suggest multiple pathways through which maternal overcontrol impacts child anxiety. One pathway, described in theoretical models, posits that greater levels of parental control reduce children's opportunities to acquire appropriate developmental skills, lowering their perceived competence, and thus increasing their anxiety. Implications of these findings and directions for future research are discussed.

Empirically derived subtypes of lifetime anxiety disorders: developmental and clinical correlates in U.S. adolescents

OBJECTIVE

The current study examined the sex- and age-specific structure and comorbidity of lifetime anxiety disorders among U.S. adolescents.

METHOD

The sample consisted of 2,539 adolescents (1,505 females and 1,034 males) from the National Comorbidity Survey-Adolescent Supplement who met criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSM-IV-TR]) lifetime anxiety disorders (American Psychiatric Association, 2000). Adolescents ranged in age from 13 to 18 years (M = 15.2 years, SE = 0.08 years) and were 39% non-White. Multiple-group latent class analysis was conducted by adolescent sex and age to identify subgroups of adolescents with similar anxiety disorder profiles. Developmental and clinical correlates of empirically derived classes were also examined to assess the nomological validity of identified subgroups.

RESULTS

A 7-class solution provided the best fit to the data, with classes defined primarily by one rather than multiple anxiety disorders. Results also indicated that classes displayed similar diagnostic profiles across age, but varied by sex. Classes characterized by multiple anxiety disorders were consistently associated with a greater degree of persistence, clinical severity, impairment, and comorbidity with other DSM-IV-TR psychiatric disorders.

CONCLUSIONS

The presentation of lifetime anxiety disorders among adolescents and the observation of unique correlates of specific classes provide initial evidence for the utility of individual DSM-IV-TR anxiety disorder categories. Although findings of the present study should be considered preliminary, results emphasize the potential value of early intervention and gender-specific conceptualization and treatment of anxiety disorders.

Family-based interventions for child and adolescent disorders

Emotional and behavioral symptoms and disorders are prevalent in children and adolescents. There has been a burgeoning literature supporting evidence-based treatments for these disorders. Increasingly, family-based interventions have been gaining prominence and demonstrating effectiveness for myriad childhood and adolescent disorders. This article presents the current evidence in support of family-based interventions for mood, anxiety, attention-deficit hyperactivity, disruptive behavior, pervasive developmental particularly autism spectrum, and eating disorders. This review details recent data from randomized controlled trials (RCTs) and promising interventions not yet examined using a randomized controlled methodology. It highlights the evidence base supporting various specific family-based interventions, some of which are disorder dependent. A practitioner perspective is then offered with regard to recommendations for future practice and training. The article closes with a summary and directions for future research.

Effect of preventive interventions in mentally ill parents on the mental health of the offspring: systematic review and meta-analysis

OBJECTIVE

Mental illness in parents affects the mental health of their children. A systematic review and a meta-analysis of the effectiveness of interventions to prevent mental disorders or psychological symptoms in the offspring were performed.

METHOD

The Cochrane, MEDLINE, EMBASE, and PsycINFO databases were searched for randomized controlled trials of interventions in parents with mental disorders. Outcomes in the child included incident mental disorders of the same nature and internalizing (negative emotions, depressive symptoms, anxiety) or externalizing (hyperactivity, aggressiveness, behavioral problems) symptoms. Relative risks and standardized mean differences in symptom scores were combined in random-effects meta-analysis.

RESULTS

Thirteen trials including 1,490 children were analyzed. Interventions included cognitive, behavioral, or psychoeducational components. Seven trials assessed the incidence of mental disorders and seven trials assessed symptoms. In total 161 new diagnoses of mental illness were recorded, with interventions decreasing the risk by 40% (combined relative risk 0.60, 95% CI 0.45-0.79). Symptom scores were lower in the intervention groups: standardized mean differences were -0.22 (95% CI -0.37 to -0.08) for internalizing symptoms (p = .003) and -0.16 (95% confidence interval -0.36 to 0.04) for externalizing symptoms (p = .12).

CONCLUSIONS

Interventions to prevent mental disorders and psychological symptoms in the offspring of parents with mental disorders appear to be effective.

Parenting Practices of Anxious and Non-Anxious Mothers: A Multi-method Multi-informant Approach

Anxious and non-anxious mothers were compared on theoretically derived parenting and family environment variables (i.e., over-control, warmth, criticism, anxious modeling) using multiple informants and methods. Mother-child dyads completed questionnaires about parenting and were observed during an interactional task. Findings revealed that, after controlling for race and child anxiety, maternal anxiety was associated with less warmth and more anxious modeling based on maternal-report. However, maternal anxiety was not related to any parenting domain based on child-report or independent observer (IO) ratings. Findings are discussed in the context of the impact of maternal anxiety on parenting and suggest that child, rather than maternal, anxiety may have a greater influence on parental behavior.

Family support in prevention programs for children at risk for emotional/behavioral problems

We conducted a review of empirically based prevention programs to identify prevalence and types of family support services within these programs. A total of 238 articles published between 1990 and 2011 that included a family support component were identified; 37 met criteria for inclusion. Following the Institute of Medicine's typology, prevention programs were categorized as universal, selective, or indicated; programs containing more than one prevention level were characterized as multi-level. Family support types included those led by a mental health professional, led by a peer, or team-led. Among the 37 prevention programs reviewed, 27% (n=10) were universal, 41% (n=15) were selective, 16% (n=6) were indicated, and 16% (n=6) were multi-level. The predominant model of family support was professionally led (95%, n=35). Two (n=5%) provided team-led services. None were purely peer-led. In terms of content of family support services, all (100%, n=37) provided instruction/skill build. Information and education was provided by 70% (n=26), followed by emotional support (n=11, 30%) and instrumental or concrete assistance (n=11, 30%). Only 14% (n=5) provided assistance with advocacy. The distribution of models and content of services in prevention studies differ from family support within treatment studies. As family support is likely to be an enduring component of the child and family mental health service continuum, comparative effectiveness studies are needed to inform future development.

Prevention of anxiety disorders

Research into the prevention of anxiety has increased dramatically in the past few years. Prevention programs have been directed at broad, nonspecific anxiety and at more specific anxiety types, such as panic disorder and post-traumatic stress disorder. Prevention of anxiety is still a relatively new field, but there has been a recent surge of literature reporting on different prevention programs. Universal prevention trials have shown modest but promising results, and school-based programs offered to all students also help to reduce stigmatization and common barriers to accessing treatment (eg, time, location, and cost). In contrast, targeted programs tend to show somewhat larger effects but rely on identification of relevant populations. Specific programs for the prevention of panic disorder and post-traumatic stress disorder have also demonstrated some preliminary success. This paper reviews the recent studies of prevention of anxiety and discusses several key issues, specifically (1) identification of at-risk participants for prevention programs, (2) motivation for participation, (3) optimal age for intervention, and (4) who should deliver the program.

Maternal anxiety, behaviors, and expectations during a behavioral task: relation to children's self-evaluations

This study examined the associations between maternal anxiety, behaviors, and expectations and children's self-evaluations of distress, coping, and performance during a stressful performance evaluation task. Seventy-five mothers (38 clinically anxious and 37 nonanxious) along with one of their children aged 6-14 (52.0% female; 78.7% Caucasian) were videotaped while preparing the child to deliver a speech about themselves. Child and parent assessments were obtained before and after the speech, and independent coders rated maternal behavior during the speech preparation. Maternal anxiety and behaviors accounted for a greater proportion of variance in children's self-evaluations than did maternal expectations, such that children of mothers who reported higher task anxiety and demonstrated more overcontrol and anxious behavior during the task evaluated themselves more negatively. These findings extend the literature by providing information about the relative associations between maternal factors and children's self-evaluations within the context of an in vivo stressful situation.

The Utility of Clinicians Ratings of Anxiety Using the Pediatric Anxiety Rating Scale (PARS)

Clinician ratings of anxiety hold the promise of clarifying discrepancies often found between child and parent reports of anxiety. The Pediatric Anxiety Rating Scale (PARS) is a clinician-administered instrument that assesses the frequency, severity, and impairment of common pediatric anxiety disorders and has been used as a primary outcome measure in several landmark treatment trials. However, no data on nonanxious youth have been published. The purpose of this study was to address this gap by examining clinician's ratings of anxiety on the PARS in a volunteer sample of youth without anxiety disorders (n = 84; ages 7-12; 51% female, 75% Caucasian). The nonanxious sample was comprised of youth with (At-risk; n = 36) and without (Healthy; n = 48) anxious parents. Data were also used to evaluate the reliability (i.e., internal consistency), convergent, and divergent validity of the clinician-rated PARS. In addition, a receiver operating curve analysis was used to determine optimum cut off scores indicative of clinical levels of anxiety by comparing PARS scores between these nonanxious youth and a clinically anxious sample (n = 77) randomized in the Research Units of Pediatric Psychopharmacology (RUPP) anxiety study (RUPP 2001). Results indicated that anxious and nonanxious youth were significantly different on all PARS severity items. Optimum cutoff scores of 11.5 (5-item total score) and 17.5 (7-item total score) discriminated youth with and without anxiety disorders. Cronbach alphas for the Healthy and At-risk sample were .90 and .91 and .75 and .81 for the 5- and 7-item total PARS scores respectively, supporting the measure's internal consistency among nonanxious youth. PARS total scores were positively correlated with other measures of anxiety (i.e., the Screen for Child Anxiety Related Emotional Disorders) for the At-risk but not Healthy subsample. PARS scores were not significantly correlated with depressive symptoms (i.e., Children's Depression Inventory). Overall, findings support the utility of clinician's assessments of anxiety symptoms for nonanxious youth. Using the PARS can help facilitate determining whether a child's anxiety level is more similar to those with or without an anxiety disorder.

Culturally focused wellness intervention for American Indian women of a small southwest community: associations with alcohol use, abstinence self-efficacy, symptoms of depression, and self-esteem

PURPOSE

This study examined the influence of a culturally focused wellness intervention on alcohol consumption, alcohol abstinence self-efficacy, depression, and self-esteem among women of a small American Indian community in the southwestern United States. Participation in two intervention approaches was compared: a curriculum-based health promotion–only approach and health promotion combined with cognitive-behavioral skills building (CBSB).

DESIGN

The wellness intervention was tested in a prospective, randomized, two-group design with repeated measures. There was no control group.

SETTING

An American Indian community in the Southwest.

SUBJECTS

American Indian women, ages 18 to 50 (N = 268).

INTERVENTION

A 10-session culturally focused curriculum-based health promotion intervention, with a CBSB component, was developed using a community-based participatory research process. Comparisons were made between those who attended the health promotion plus CBSB intervention and those who attended the intervention without the CBSB component.

MEASURES

Information regarding demographics, substance use, alcohol consumption, alcohol abstinence self-efficacy, depressive symptoms, and self-esteem was collected through a structured interview.

ANALYSIS

Regression was used to evaluate the effect of the intervention on alcohol consumption, alcohol abstinence self-efficacy, depressive symptoms, and self-esteem in CBSB and non-CBSB groups.

RESULTS

Although there were no significant differences between the CBSB and non-CBSB groups, the results indicate a significant decrease in alcohol consumption and symptoms of depression, and a significant increase in alcohol abstinence self-efficacy and self-esteem, from baseline to the 6-month follow-up for both groups.

CONCLUSION

Evidence suggests that this culturally focused health promotion intervention has a positive impact on alcohol use, alcohol abstinence self-efficacy, depressive symptoms, and self-esteem among American Indian women.

Parental anxiety and child symptomatology: an examination of additive and interactive effects of parent psychopathology. [corrected]

The current study examined relations between parent anxiety and child anxiety, depression, and externalizing symptoms. In addition, the study tested the additive and interactive effects of parent anxiety with parent depression and externalizing symptoms in relation to child symptoms. Forty-eight parents with anxiety disorders and 49 parents without any psychiatric disorder participated with one of their children (ages 6 to 14 years; 46.4% male; 75.8% Caucasian). Parent anxiety was related to both child anxiety and depression, but not child externalizing symptoms. Hierarchical regression analyses showed that only parent externalizing symptoms had additive effects, beyond parent anxiety symptoms, in relation to child anxiety symptoms. Further, parent anxiety symptoms moderated the relationship between parent and child externalizing symptoms, such that the strength of this relationship was reduced in the presence of high levels of parent anxiety symptoms. Results of this study illuminate the role of parent comorbidity in understanding relations between parent and child symptoms.

Maternal control behavior and locus of control: examining mechanisms in the relation between maternal anxiety disorders and anxiety symptomatology in children

This study tested components of a proposed model of child anxiety and examined the mediational roles of (1) maternal control behavior, (2) maternal external locus of control, and (3) child external locus of control in the association between maternal and child anxiety. Thirty-eight clinically anxious mothers and 37 nonanxious mothers participated along with one of their children aged 6 to 14 (52.0% female; 78.7% Caucasian). Path analysis indicated that the overall model fit the data very well. Analyses also indicated that child external locus of control mediated the associations between (1) maternal and child anxiety and (2) maternal control behavior and child anxiety. Maternal anxiety was not related to maternal control behavior and maternal external locus of control was not associated with child anxiety. Findings are discussed in the context of theoretical models (e.g., Chorpita and Barlow 1998) regarding the transmission of maternal anxiety to their children and the specific roles of maternal behavior and child locus of control.

The effect of parental modeling of anxious behaviors and cognitions in school-aged children: an experimental pilot study

The current study tested: (1) the impact of parental modeling of anxious behaviors and cognitions on child anxiety level, anxious cognitions, desired avoidance, and objective performance using an experimental paradigm; and (2) whether the impact of parental modeling of anxious behaviors and cognitions differed by parent gender. Twenty-five parents (a random selection of 12 male and 13 female parents) participated with one of their children (ages 8-12 years; 56.0% male; 76.0% Caucasian). All children experienced two test conditions: an anxious condition in which their parent was trained to act anxiously before a planned spelling test and a non-anxious condition in which their parent was trained to act in a relaxed and confident manner before a planned spelling test. Results showed that, regardless of parent gender, children endorsed higher anxiety levels, anxious cognitions, and desired avoidance of the spelling test in the anxious relative to the non-anxious condition. Parental modeling of anxiety did not affect child spelling performance. Significant interaction effects indicated that fathers had a stronger impact on child anxiety level and cognitions than did mothers. Results highlight the importance of parental modeling and the potential role of both mothers and fathers in prevention and treatment for child anxiety.

Developments in the treatment and diagnosis of anxiety disorders

Anxiety disorders occur frequently, begin at an early age, significantly impair patients' lives, and are often associated with other comorbid conditions. Despite impressive improvements in the treatment of anxiety disorders in the last decade, the mechanisms leading to comorbidity and the processes responsible for therapeutic change remain unclear. Within this context, clear and precise definitions of the putative active ingredients are needed in order to further improve treatments. This article reviews these critical issues and sets the stage for the other articles in this special issue.