Parental involvement: contribution to childhood anxiety and its treatment

Mental Health Problems Among Children and Adolescents From a Sports Sociology Perspective

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The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043-1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303-311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138-144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616-629, 2013; Kendall et al. Cogn Behav Pract 12:136-148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34-43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

Optimizing indicated cognitive behavioral therapy to prevent child anxiety and depression: A cluster-randomized factorial trial

Identifying effective components can lead to interventions that are less resource-intensive and better suited for real-world needs. In this 2×2×2 cluster-randomized factorial trial (clinicaltrials.gov NCT04263558), we investigated the effects of three components of an indicated, transdiagnostic CBT intervention for children: 1) Intervention Delivery Format (child group format versus a blended format with group sessions and automated web-based sessions), 2) Parental Involvement in the intervention (group-based versus psychoeducational brochure), and 3) a Measurement Feedback System (MFS; on versus off). The intervention was delivered at schools in a group-based format. The participants (N = 701 children) were school children (age 8-12 years) with elevated symptoms of anxiety or depression, and their parents. The main outcomes were self-reported (N = 633) and parent-reported (N = 725) symptoms of child anxiety and depression post-intervention. The secondary outcome was children's user satisfaction with the intervention. We did not find significant main or interaction effects of Delivery Format, Parental Involvement, or MFS on children's symptom levels. There were no significant effects on children's user satisfaction. Results were compatible with retaining the least resource intensive combination (i.e., blended format, parental brochure, no MFS) in an optimized intervention.

Better together? A randomized controlled microtrial comparing different levels of therapist and parental involvement in exposure-based treatment of childhood specific phobia

INTRODUCTION

Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE).

METHODS

Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up.

RESULTS

TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up.

CONCLUSIONS

These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.

Modifiable Parent Factors Associated with Child and Adolescent School Refusal: A Systematic Review

School refusal is a complex problem that refers to difficulty attending/remaining at school due to emotional distress about attendance. Despite its occurrence being associated with negative outcomes, many are unresponsive to the current treatment options. While parent factors have a key role to play in school refusal, they are not adequately addressed in existing treatments. Further research is needed to consolidate understanding and implement new treatments. Employing the PRISMA method, this review aims to identify modifiable parent factors associated with child and/or adolescent school refusal. Eight studies met inclusion criteria from which nine factors were identified. Factors found to be associated with school refusal included: parent psychopathology, family functioning and maternal overprotection (communication subdomain). Other factors such as maternal overprotection (affection, assistance and travel subdomains) and parental self-efficacy had weak or inconsistent results warranting further investigation. Overall, findings call for action in this field that has sparse and dated literature.

'Playing a guessing game': Recognising and responding to anxiety in children with intellectual disability

BACKGROUND

Children with intellectual disability are at greater risk of developing anxiety than the general population. Limited research has examined the challenges associated with recognising and responding to anxiety in children with intellectual disability, and its perceived impact.

AIM

This study aimed to explore anxiety in children with intellectual disability, from the child and parent perspective to better understand how parents and children recognise and respond to anxiety.

METHOD AND PROCEDURES

Six children with an intellectual disability (age range: 12-17, four boys) and their mothers participated in a semi-structured interview online. Interviews were transcribed verbatim and interpreted using thematic analysis.

OUTCOME AND RESULTS

Mothers elaborated on the difficulties with recognising signs of anxiety due to the impact of the child's primary diagnosis and the overlap of symptoms with co-occurring conditions. Mothers and children discussed the 'contagious' effect of anxiety within the household and how this influenced mothers' approaches to managing their child's anxiety. They reported that anxiety limited the meaningful activities in which children and families could engage.

CONCLUSIONS AND IMPLICATIONS

These findings highlight the importance of supporting mothers to recognise their children's anxiety and to assist them with strategies on how best to respond and cope. These findings have implications for future research, and practitioners working in this field.

Anxiety disorders in children and adolescents: A summary and overview of the literature

Considerable work has advanced understanding of the nature, causes, management, and prevention of anxiety disorders in children and adolescents over the past 30 years. Prior to this time the primary focus was on school refusal and specific phobias. It is now recognised that children and adolescents experience the full gamut of anxiety disorders in very similar ways to adults and that anxiety disorders in the paediatric years can predict a lifelong mental-health struggle. Given the vast array of specific studies in this field, the current review summarises current knowledge about these high prevalence disorders, points to overarching limitations, and suggests potentially important future directions. Following a brief historical overview, the review summarises knowledge about demographic and epidemiological characteristics, distal and proximal risk factors, current treatment directions, and prevention. There is still a great deal to learn about the causes and treatments of child and adolescent anxiety disorders. By amalgamating our current knowledge, this review provides a window to the research directions that are likely to lead to future advances.

Do Parents Enhance Cognitive Behavior Therapy for Youth Anxiety? An Overview of Systematic Reviews Over Time

The last 20 years has seen debate regarding the merits of involving parents in cognitive behavior therapy (CBT) for youth anxiety played out across systematic reviews which have high impact. These reviews examined varying treatment formats in relation to parent involvement, including youth only CBT (Y-CBT), parent only CBT (P-CBT) and family CBT (youth and parent; F-CBT). This is a novel overview of systematic reviews examining evidence for parental involvement in CBT for youth anxiety over the period this was studied. Two independent coders systematically searched for studies in medical and psychological databases using the categories "Review", "Youth", "Anxiety", "Cognitive Behavior Therapy" and "Parent/Family". Of the 2,189 unique articles identified, there were 25 systematic reviews since 2005 which compared the effects of CBT for youth anxiety with varying parent involvement. Despite systematically studying the same phenomenon, the reviews were heterogeneous in outcome, design, inclusion criteria and often had methodological limitations. Of the 25 reviews, 21 found no difference between formats and 22 reviews were considered inconclusive. Yet while there were typically no statistical differences, consistent patterns in the direction of effects were detected over time. P-CBT was less effective than other formats, suggesting the importance of directly treating anxious youths. Early reviews favored F-CBT over Y-CBT, however, later reviews did not show this trend. We consider the effects of moderators including exposure therapy, long-term outcomes and the child's age. We consider how to manage heterogeneity in primary studies and reviews to better detect treatment differences where they exist.Trial registration This protocol is registered with the Open Science Framework: osf.io/2u58t.

What caregivers like the most (and least) about cognitive behavioral therapy for youth anxiety: A mixed methods approach

Cognitive behavioral therapy (CBT) is an efficacious therapy for youth anxiety disorders. Caregivers are key stakeholders in youth therapy, and their feedback on treatment can help to inform intervention personalization. This mixed-methods study applied a systematic inductive thematic analysis to identify themes among most- and least-liked CBT features reported by caregivers using open-ended responses on the Client Satisfaction Questionnaire (CSQ-8). The sample included 139 caregivers of youth ages 7-17 (M = 12.21, SD = 3.05; 59% female; 79.1% Caucasian, 5.8% Black, 2.9% Asian, 2.2% Hispanic, 7.9% Multiracial, 2.2% Other) with principal anxiety diagnoses who completed 16-sessions of CBT. CSQ-8 quantitative satisfaction scores (M = 29.18, SD = 3.30; range: 16-32) and survey-based treatment response rates (responders n = 93, 67%) were high. Most-liked treatment features included: coping skills (i.e., exposure, understanding/identifying anxiety, rewards, homework), therapist factors (interpersonal style/skill, relationship, accessibility), caregiver involvement, one-on-one time with a therapist, structure, consistency, and personally tailored treatment. Least-liked treatment features included: questionnaires, logistical barriers, telehealth, need for more sessions, non-anxiety concerns not addressed, insufficient caregiver involvement, and aspects of exposure tasks. Proportional frequencies of most- and least-liked themes differed by treatment responder status (e.g., responders cited exposure and homework as most-liked more frequently).

Parent Versus Individual Cognitive Behavioral Therapy for Youth Anxiety: Protocol for an Overview of Systematic Reviews Over Time

BACKGROUND

Cognitive behavioral therapy (CBT) has shown to be highly effective for treating youth anxiety; yet, there is ongoing debate as to whether involving parents improves outcomes. For example, parents who attend may learn CBT skills to help their child in an ongoing way; yet, they could also distract their child from treatment depending on how they interact. As evidence has accumulated, reviews and meta-analyses have attempted to examine the most effective treatment format. These reviews often have high impact in the field; however, they use varied methodologies and draw on different primary studies. Different formats of CBT for youth anxiety have been developed in relation to parental involvement, including youth-only CBT (Y-CBT; where the youth alone attends treatment), youth and parent or family CBT (F-CBT; where youths and their parents attend together), and, most recently, parent-only CBT (P-CBT; where the parent alone attends).

OBJECTIVE

This protocol describes an overview of systematic reviews comparing the relative efficacy of different formats of CBT for youth anxiety (Y-CBT, F-CBT, and P-CBT) over the study period. The protocol will also examine the moderating effects of variables on the efficacy of different formats; for example, youths' age and long-term outcomes.

METHODS

We will analyze the results of systematic reviews that compare different levels and types of parental involvement in CBT for youth anxiety over the study period. A systematic review of medical and psychological databases (PsycINFO, PubMed, SCOPUS, Web of Science, Cochrane Library, and Embase) will identify reviews comparing the efficacy of different formats of parent involvement in CBT for youth anxiety. Data extraction will include (1) author names (and year of publication), (2) review design, (3) age range, (4) analysis type, (5) conclusions, and (6) moderators. This overview will present the relative efficacy of formats chronologically in a table and then describe the main results longitudinally in a narrative summary. A Measurement Tool to Assess Systematic Reviews, 2nd Edition (AMSTAR 2), quality rating will be given to each review, and the amount of primary study overlap across reviews will be quantified.

RESULTS

The last search was conducted on July 1, 2022. The reviews were published between 2005 and 2022. We found a total of 3529 articles, of which we identified 25 for the final analysis.

CONCLUSIONS

This overview will compare and report the relative efficacy of Y-CBT, P-CBT, and F-CBT for youth anxiety over the study period, describe the heterogeneity across reviews and primary studies, and consider the moderating effect of relevant variables. It will describe the limitations of an overview, including the potential for nuance in the data to be lost, and provide conclusions and recommendations for conducting systematic reviews regarding parental involvement for CBT for youth anxiety.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/48077.

Youth Anxiety: The Moderating Effects of Accommodation and Emotional Warmth

Parental accommodation (i.e., modifying behavior to reduce child distress) is among the most empirically supported anxiety enhancing parenting practices; while emotional warmth (i.e., support and affection) has demonstrated a less clear link to anxiety. The current study aims to explore the interactive nature of emotional warmth within the context of accommodation. We hypothesized that accommodation would moderate the relationship between emotional warmth and anxiety. The sample included parents of youth (N = 526) ages 7-17. A simple moderation analysis was conducted. Accommodation significantly moderated the relationship [B = 0.03, C.I. (0.01, 0.05), p = 0.01]. Additional variance was accounted for by adding the interaction term to the model (R² = 0.47, p < 0.001). At high levels of accommodation, emotional warmth significantly predicted child anxiety symptoms. This study affirms that emotional warmth is significantly related to anxiety in the context of high accommodation. Future work ought to build upon these findings to explore these relationships. Limitations of the study include sampling and parent-report data.

Elucidating the Roles of Maternal Overcontrol and Warmth in the Development of Childhood Anxiety and Depression: A Moderated Mediation Framework

Studies have linked childhood anxiety and depression with parenting characterized by high control and low warmth. However, few studies have examined how control and warmth may work together to influence internalizing symptoms in children. Therefore, the goal of this study was to examine the moderating effect of warmth on the relationship between overcontrol and anxiety and depressive symptoms, as well as whether negative thoughts serve as a mediator of these pathways. A total of 182 fourth and fifth grade children completed measures of maternal parenting behavior, negative thoughts, and anxiety and depressive symptoms. Results showed an interaction between overcontrol and warmth for depressive but not anxiety symptoms. Furthermore, low warmth increased the strength of the mediating relationship between overcontrol and depression via thoughts of personal failure. Findings may signal a need for early interventions to address parenting behaviors, such as controlling behaviors, in parents of children at risk for internalizing difficulties.

School-based cognitive-behavioural therapy for children and adolescents with social anxiety disorder and social anxiety symptoms: A systematic review

BACKGROUND

Social anxiety disorder (SAD) is prevalent among children and adolescents. Cognitive-behavioural therapy (CBT) has been used as the first-line treatment. However, evaluation of CBT conducted in a school setting has been scarce.

OBJECTIVES

This study aims to review the CBT and its effectiveness in the school setting for children and adolescents with SAD or social anxiety symptoms. Quality assessment on individual studies was conducted.

METHODS

Studies were identified through the search in PsycINFO, ERIC, PubMed and Medline targeting CBT conducted in a school setting with an aim to treat children and adolescents with SAD or social anxiety symptoms. Randomised controlled trials and quasi-experimental studies were selected.

RESULTS

A total of 7 studies met the inclusion criteria. Five studies were randomised controlled trials, and two were quasi-experimental studies with 2558 participants aged 6-16 years from 138 primary schools and 20 secondary schools. There were minor effects to reduce social anxiety symptoms for children and adolescents at post-intervention in 86% of the selected studies. Friend for Life (FRIENDS), Super Skills for Life (SSL) and Skills for Academic and Social Success (SASS) conducted in school were more effective than the control conditions.

CONCLUSIONS

There is a lack of quality of the evidence for FRIENDS, SSL and SASS, due to inconsistencies on the outcome assessments, statistical analyses, and the fidelity measures adopted in individual studies. Insufficient school funding and workforce with relevant health background, and the low level of parental involvement in the intervention would be the major challenges in school-based CBT for children and adolescents with SAD or social anxiety symptoms.

Reducing Anxiety and Stress among Youth in a CBT-Based Equine-Assisted Adaptive Riding Program

Simple Summary

Reining in Anxiety (RiA) is a therapeutic program for youth with mild-to-moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA is based on five foundational components of Cognitive Behavioral Therapy (CBT): in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. The intervention sought to support youth between the ages of 6–17 with self-identified anxiety. Due to global pandemic trauma, in the second iteration of the protocol, researchers also included two evidence-based trauma components: maintenance and personal safety skills. All instructors were trained in the RiA curriculum and delivered the same lessons. In addition to assessing the youth’s perception and changes over time, the researchers also assessed changes in the horses, both through saliva sampling. The authors learned that RiA may be a promising approach for reducing anxiety and stress among youth and that the intervention can be delivered by adaptive/therapeutic horseback riding instructors in a non-clinic setting.

Abstract

Reining in Anxiety (RiA) is a therapeutic program for youth with mild to moderate anxiety delivered in a therapeutic riding setting by Certified Therapeutic Riding Instructors. RiA was developed after a review of the evidence base for youth anxiety, is manualized, and includes five core CBT components: in vivo exposure, cognitive restructuring, youth psychoeducation, relaxation, and caregiver psychoeducation about anxiety. This study extended findings from a prior RCT that examined (1) the feasibility of collecting saliva samples from horses and children to measure stress (cortisol) and relaxation (oxytocin); (2) whether changes in stress and relaxation occurred both during each lesson and over the course of the 10-week intervention for horses and youth; (3) whether changes in anxiety symptoms, emotional regulation, and self-efficacy found in the first trial were comparable; and (4) if fidelity to the program was reliable. Youth participants (n = 39) ages 6–17 with caregiver-identified mild-to-moderate anxiety participated in a ten-week therapeutic intervention (RiA), which combined adaptive riding and components of CBT. Physiological data and self-report measures were taken at weeks one, four, seven, and ten for the youth and horses. Saliva assays assessed cortisol as a physiological marker of stress and anxiety, and oxytocin as a measure of relaxation. Fidelity data were recorded per session. Anxiety, as measured by caregiver self-reporting, significantly decreased from pre- to post-test, while emotional regulation scores increased. No significant changes in self-efficacy from pre- to post-test were observed. Saliva samples obtained from participants before and after riding sessions showed a consistent decrease in cortisol and a significant increase in oxytocin at two of the four timepoints (Week 1 and Week 7), but no overall pre- to post-test changes. Horse saliva data were collected using a modified bit; there were no significant changes in oxytocin or cortisol, suggesting that the horses did not have an increase in stress from the intervention. RiA may be a promising approach for reducing anxiety and stress among youth, as measured both by self-reported and by physiological measures. Collection of salivary assays for both youth and horses is feasible, and the intervention does not increase stress in the horses. Importantly, RiA can be delivered by adaptive/therapeutic horseback riding instructors in naturalistic (e.g., non-clinic-based) settings. As youth anxiety is a growing public health problem, novel interventions, such as RiA, that can be delivered naturalistically may have the potential to reach more youth and thus improve their quality of life. Further research is needed to examine the comparative value of RiA with other animal-assisted interventions and to assess its cost-effectiveness.

Co-developmental trajectories of parental involvement: Relations to academic achievement and externalizing and internalizing problems among Chinese elementary schoolchildren

BACKGROUND

Parental involvement is an important multi-faceted factor in children's academic performance and school behaviour. However, most prior studies have involved cross-sectional designs, with few studies exploring the co-developmental nature of various parental involvement characteristics over time and their associations with children's academic achievement, externalizing, and internalizing problems.

AIMS

This study explored (a) co-developmental trajectories of seven parental involvement characteristics in elementary schoolchildren, and (b) relations to children's academic achievement, externalizing, and internalizing problems.

SAMPLE AND METHODS

A total of 3553 Chinese elementary schoolchildren (M_age  = 9.90, SD = .72; 53.9% boys) completed relevant measures on 4 occasions at 6-month intervals. Parallel process latent class growth modelling was used for examining study hypotheses.

RESULTS

Four co-developmental trajectories of parental involvement were identified: 'High motivation and involvement', 'Low motivation and involvement', 'Incongruent motivation and involvement', and 'Incongruent motivation and high involvement'. The highest academic achievement and fewest externalizing and internalizing problems were observed for schoolchildren in the 'High motivation and involvement' class, followed by those who were in the 'Incongruent motivation and high involvement' and 'Incongruent motivation and involvement' classes, and finally, schoolchildren were the 'Low motivation and involvement' class.

CONCLUSIONS

The identification of heterogeneous trajectories with differential outcomes highlights the importance of individual differences considerations in understanding the co-developmental patterns of parental involvement, suggesting that specific interventions need to be formulated for differing groups.

Girls' Stuff? Maternal Gender Stereotypes and Their Daughters' Fear

One of the most robust findings in psychopathology is the fact that specific phobias are more prevalent in women than in men. Although there are several theoretical accounts for biological and social contributions to this gender difference, empirical data are surprisingly limited. Interestingly, there is evidence that individuals with stereotypical feminine characteristics are more fearful than those with stereotypical masculine characteristics; this is beyond biological sex. Because gender role stereotypes are reinforced by parental behavior, we aimed to examine the relationship of maternal gender stereotypes and children’s fear. Dyads of 38 mothers and their daughters (between ages 6 and 10) were included. We assessed maternal implicit and explicit gender stereotypes as well as their daughters’ self-reported general fearfulness, specific fear of snakes, and approach behavior toward a living snake. First, mothers’ fear of snakes significantly correlated with their daughters’ fear of snakes. Second, mothers’ gender stereotypes significantly correlated with their daughters’ self-reported fear. Specifically, maternal implicit gender stereotypes were associated with daughters’ fear of snakes and fear ratings in response to the snake. Moreover, in children, self-reported fear correlated with avoidance of the fear-relevant animal. Together, these results provide first evidence for a potential role of parental gender stereotypes in the development and maintenance of fear in their offspring.

Effectiveness, User Engagement and Experience, and Safety of a Mobile App (Lumi Nova) Delivering Exposure-Based Cognitive Behavioral Therapy Strategies to Manage Anxiety in Children via Immersive Gaming Technology: Preliminary Evaluation Study

BACKGROUND

Childhood anxiety disorders are a prevalent mental health problem that can be treated effectively with cognitive behavioral therapy, in which exposure is a key component; however, access to treatment is poor. Mobile-based apps on smartphones or tablets may facilitate the delivery of evidence-based therapy for child anxiety, thereby overcoming the access and engagement barriers of traditional treatment. Apps that deliver therapeutic content via immersive gaming technology could offer an effective, highly engaging, and flexible treatment proposition.

OBJECTIVE

In this paper, we aim to describe a preliminary multi-method evaluation of Lumi Nova, a mobile app intervention targeting mild to moderate anxiety problems in children aged 7-12 years using exposure therapy delivered via an immersive game. The primary objective is to evaluate the effectiveness, user engagement and experience, and safety of the beta version of Lumi Nova.

METHODS

Lumi Nova was co-designed with children, parents, teachers, clinicians, game industry experts, and academic partnerships. In total, 120 community-based children with mild to moderate anxiety and their guardians were enrolled to participate in an 8-week pilot study. The outcome measures captured the app's effectiveness (anxiety symptoms, child-identified goal-based outcomes, and functional impairment), user engagement (game play data and ease-of-use ratings), and safety (mood ratings and adverse events). The outcome measures before and after the intervention were available for 30 children (age: mean 9.8, SD 1.7 years; girls: 18/30, 60%; White: 24/30, 80%). Additional game play data were automatically generated for 67 children (age: mean 9.6, SD 1.53 years; girls: 35/67, 52%; White: 42/67, 63%). Postintervention open-response data from 53% (16/30) of guardians relating to the primary objectives were also examined.

RESULTS

Playing Lumi Nova was effective in reducing anxiety symptom severity over the 8-week period of game play (t₂₉=2.79; P=.009; Cohen d=0.35) and making progress toward treatment goals (z=2.43; P=.02), but there were no improvements in relation to functional impairment. Children found it easy to play the game and engaged safely with therapeutic content. However, the positive effects were small, and there were limitations to the game play data.

CONCLUSIONS

This preliminary study provides initial evidence that an immersive mobile game app may safely benefit children experiencing mild to moderate anxiety. It also demonstrates the value of the rigorous evaluation of digital interventions during the development process to rapidly improve readiness for full market launch.

Evaluation of a parent-led cognitive behaviour therapy programme in routine clinical practice: A controlled trial

Parent-led cognitive behavioural therapy for child anxiety disorders have garnered a growing evidence base. However, it is unclear how such approaches translate into routine clinical practice. The current study aims to evaluate the effectiveness of an 8-session treatment (From Timid to Tiger) in reducing child anxiety and behavioural difficulties, as well as family accommodation. The parents of 71 children (aged 4-11) were assigned to the treatment or a waitlist control. Parent report measures were completed pre-treatment, at treatment-end, and at 3-month follow-up. Parents assigned to the waitlist were assessed 8 weeks after the initial assessment. Findings indicated that parents who attended the group reported significant reductions in child anxiety and behavioural difficulties. In addition, the parents in the treatment group reported a reduction in family accommodation compared to those in the waitlist. The current control trial provides tentative evidence of the use and effectiveness of such parent-led approaches in addressing child anxiety difficulties commonly seen in routine clinical practice. PRACTITIONER POINTS: Parent-led approaches are effective treatments in managing child anxiety difficulties. Very little research to date has assessed the effectiveness of such approaches in routine clinical practice. The From Timid to Tiger program is a brief parent-led CBT intervention. The programme was effective in reducing child anxiety and behavioural difficulties. Parents also reported a reduction in behaviours related to family accommodation. Such programmes show promise and can be used in routine clinical practice.

Feasibility and acceptability of an enhanced cognitive behavioural therapy programme for parent-child dyads with anxiety disorders: a mixed-methods pilot trial protocol

BACKGROUND

Cognitive behavioural therapy (CBT) is the most widely recognised and efficacious psychological therapy for the treatment of anxiety disorders in children and adults. However, suboptimal remission rates indicate room for improvement in treatments, particularly when both children and their parents have anxiety disorders. Bidirectional transmission and maintenance of anxiety within parent-child dyads could be better targeted by CBT, to improve treatment outcomes for children and parents with anxiety disorders. This study aimed to develop and evaluate the feasibility and acceptability of a concurrent parent-child enhanced CBT intervention that targets the individual's anxiety disorder(s), as well as the bidirectional factors that influence and maintain anxiety in the dyad.

METHODS

Feasibility and acceptability of the proposed CBT protocol will be evaluated in an open-label pilot trial of the intervention utilising qualitative and quantitative data collection. Ten parent-child dyad participants (n = 20) with anxiety disorders will be recruited for the proposed intervention. The intervention is based on an empirically supported 10-week CBT programme for anxiety disorders in adults, adapted to be delivered to parent-child dyads concurrently, and to target anxious modelling and overprotective behaviours through joint observational exposures. Intervention feasibility will be explored by pre-post symptom change on a range of clinician- and self-report measures to determine preliminary indications of participants' intervention response and effect size calculations to estimate sample size for a future definitive randomised controlled trial (RCT). Additional feasibility measures will include recruitment rates, completion rates, and adherence to programme requirements. To explore participant acceptability of the intervention, qualitative interviews will be conducted with five parent-child dyads who complete the intervention (n = 10), along with five parent-child dyads with anxiety symptoms who express interest in the intervention (n = 10). Acceptability measures will include prospective and retrospective quantitative self-report and qualitative interview data.

DISCUSSION

This pilot trial will utilise a mixed-methods design to determine the feasibility and acceptability of delivering an enhanced CBT intervention for the concurrent treatment of parent-child dyads with anxiety disorders. The results of this trial will inform the development and implementation of a future definitive randomised clinical trial to evaluate intervention efficacy.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ANZCTR1261900033410 . Prospectively registered: pre-results. Registered 04 March 2019.

Impact of treatment improvement on long-term anxiety: Results from CAMS and CAMELS

OBJECTIVE

This article examined associations between change in youth and family characteristics during youth anxiety treatment and long-term anxiety severity and overall functioning.

METHOD

Participants (N = 488; age 7-17 years; 45% male; 82% white) were randomized to 12 weeks of cognitive behavioral therapy (Coping Cat), medication (sertraline), their combination, or pill placebo in the Child/Adolescent Anxiety Multimodal Study (CAMS). A subset participated in the naturalistic follow-up Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS; n = 319; 3.70-11.83 years post-treatment). The current secondary analyses examined how change in anxiety severity (Child Global Impression-Severity), overall functioning (Children's Global Assessment Scale), caregiver psychopathology (Brief Symptom Inventory), caregiver strain (Family Burden Assessment Scale), and family dysfunction (Brief Family Assessment Measure) during CAMS was associated with anxiety severity and overall functioning years later (M = 7.72 years). CAMS procedures were registered on clinialtrials.gov.

RESULTS

Improvements in factors related to functioning (i.e., overall functioning, family dysfunction, caregiver strain) were associated with improvements in anxiety severity in CAMELS (|βys| ≥ .04, ps ≤ .04). Improvements in factors related to psychopathology (i.e., anxiety severity, caregiver psychopathology) were associated with improvements in overall functioning in CAMELS (|βys| ≥ .23, ps ≤ .04). It was changes in each of the variables examined (rather than baseline values) that predicted anxiety severity and overall functioning.

CONCLUSIONS

Both youth and family factors play a significant role in long-term treatment outcomes. Therapists would be wise to monitor how these factors change throughout treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Anxiety in autistic individuals who speak few or no words: A qualitative study of parental experience and anxiety management

Anxiety is a common co-occurring condition in autism and impacts quality of life of autistic individuals and their families; autistic individuals who speak few or no words represent an under-researched group. This qualitative study aimed to understand more about parental recognition and management of anxiety in autistic individuals who speak few or no words. Semi-structured interviews were conducted with parents/carers of 17 autistic individuals (m_age = 14.29) recruited from an existing participant database and social media adverts. Using thematic analysis, 15 themes were placed under three a-priori grand themes: parental recognition of anxiety; parental management of anxiety; and anxiety impact on the autistic individual and their family. Due to reduced verbal language use and overlap with other behaviours, parents described difficulties recognising anxiety in their child. However, they also described use of a number of management strategies, including some which overlap with components of evidence-based interventions for emotional and behavioural problems in autistic individuals (e.g. exposure/sensory calming). Despite this, parents reported that anxiety continues to have significant impact on quality of life. The findings of this study can help to inform the development of targeted intervention and assessment measures for anxiety in autistic individuals who speak few or no words.

The Impact of Comorbidity on Cognitive-Behavioral Therapy Response in Youth with Anxiety and Autism Spectrum Disorder

The impact of externalizing comorbidity on treatment outcome was examined in 104 youth ages 7-16 (M = 11.09 years) with autism spectrum disorder and primary anxiety/obsessive compulsive disorder who completed modular cognitive behavioral therapy (CBT) for anxiety/OCD. Three comorbidity profiles were utilized for group comparisons: participants with oppositional defiant or conduct disorder with attention-deficit hyperactivity disorder (ODD; CD; ADHD; group EXT, n = 25); those without ODD/CD and only ADHD (group ADHD, n = 46); and those without externalizing comorbidity (NO-EXT, n = 33). Post-treatment outcomes were measured continuously (Pediatric Anxiety Rating Scale, Clinical Global Impression-Severity) and categorically (treatment response, remission). The ADHD group was four times more likely of being a treatment responder compared to NO-EXT (OR 4.05). Comorbidity group did not impact remission. After controlling for pre-treatment scores, there was a significantly greater reduction of the CGI-S for ADHD versus NO-EXT and EXT versus NO-EXT, but results did not significantly differ for the PARS. Results suggest that a modular CBT approach yields positive impact for treatment outcomes in youth with comorbid externalizing problems, particularly among those with comorbid ADHD.

Use of the C.A.T. Project for a Socially Anxious Teenager: Lessons Learned From Manual Modification

Social anxiety disorder (SAD) is a prevalent mental disorder among adolescents, often causing significant impairments in social and academic functioning with a broad pattern of fear and avoidance. Cognitive-behavioral therapy (CBT) has been shown to be an effective treatment for SAD with more than 20 randomized controlled trials. Specifically, the present case study utilized the C.A.T. Project (adolescent version of Coping Cat), which is a widely studied and commonly used treatment for youth anxiety disorders. Treatment consisted of 22 sessions over 11 months with a 14-year-old Caucasian female with outcome data demonstrating some significant reductions in anxiety. However, the client terminated prior to finishing the C.A.T. Project manual. As such, this case study emphasizes complicating factors, potential benefits and drawbacks of manual modifications, and resulting treatment implications for clinician consideration.

Comorbidity, Parental Psychopathology, and Accommodation in the Treatment of Pediatric Obsessive-Compulsive Disorder: A Case Study

This article discusses the treatment of a young person with obsessive-compulsive disorder (OCD) characterized primarily by symptoms of physical and mental contamination, as well as religious obsessions. The treatment was complicated by several factors that will be reviewed and addressed. First, this client had a comorbid diagnosis of attention-deficit/hyperactivity disorder. Second, the young client's mother was also diagnosed with OCD and had a significantly anxious presentation. This impacted treatment in two primary ways. One important way treatment was complicated was that the client frequently attempted to manage her mother's emotions by underreporting her own distress at times. The other implication of the mother's diagnosis was that it became difficult to involve her in the treatment of her daughter and reduce her accommodation of her daughter's symptoms. The manner in which these complicating factors were addressed in the successful treatment of this client by adapting evidence-based practice will be presented as a guide for clinicians facing similar challenges.

Prenatal Maternal Distress: A Risk Factor for Child Anxiety?

The deleterious association between various types of prenatal maternal psychological distress (PNMS, anxiety, depression, psychological distress, stress) and childhood anxiety symptomatology (internalizing behaviors, anxiety symptoms) has been established using both retrospective and prospective longitudinal studies across varied demographic cohorts and throughout development. Yet, the existing literature cannot claim maternal distress during pregnancy to be a specific risk factor for anxiety symptomatology, as studies utilizing such observational designs are unable to adequately account for confounding of potential genetic factors and the postnatal environment. In this review, we examine studies that attempt to minimize such confounding and thus disentangle the unique intrauterine exposure effect of varying types of PNMS on childhood anxiety symptomatology. Such methodologies include paternal versus maternal comparison studies, sibling comparisons, prenatal cross-fostering designs and timing of exposure studies (including disaster studies). Of the identified studies, findings indicate that prenatal maternal distress is likely to constitute a risk factor for anxiety symptomatology, although more studies are needed to replicate current findings in order to determine whether there are clear differences in effects across specific types of PNMS and for specific subpopulations. We review the methodological limitations and strengths of the literature prior to exploring avenues of future research and implications for theory and clinical practice.

The role of prenatal maternal stress in the development of childhood anxiety symptomatology: The QF2011 Queensland Flood Study

It is possible that findings suggesting a link between prenatal maternal stress (PNMS) and anxiety symptoms in offspring are confounded by postnatal and/or shared mother-child heritability effects. Following exposure to a natural disaster, the Queensland Flood Study investigated the unique and additive effects of various types of disaster-related PNMS (objective hardship, cognitive appraisal, and subjective distress) on childhood anxiety symptomatology (internalizing and/or anxiety symptom measures). Timing of flood exposure during pregnancy and child sex were examined as potential moderators. After controlling for maternal psychosocial factors, greater objective hardship as a result of the floods was significantly associated with greater anxiety symptoms (N = 114) and marginally associated with greater internalizing behaviors (N = 115). Earlier timing of the flood in pregnancy was associated with greater anxiety symptoms. No such associations were found between any PNMS measure and teacher-rated child internalizing behaviors (N = 90). Sex and timing did not moderate associations. Our findings suggest that, in isolation, increased maternal hardship due to exposure to an independent stressor, during pregnancy, may have a programming effect on childhood anxiety symptoms.

The mediating role of parenting behaviors in the relationship between early and late adolescent levels of anxiety: Specificity and informant effects

INTRODUCTION

The role of parenting behavior is often highlighted in the development of anxiety in youth. However, previous reports are limited in terms of the specificity of relationships between different types of anxiety and parenting behaviors, informant effects on these relationships, and direction of effects.

METHODS

This study investigates these questions using longitudinal data from 1350 Swedish adolescents and their parents. Adolescents' self-reports of six dimensions of anxiety and adolescents' and parents' reports of six dimensions of parenting behaviors were used in the analyses. Parallel multiple mediation models were employed to analyze specificity and informant effects within a reciprocal effects model.

RESULTS

Overall, and irrespective of informant, this study found little support for a mediating role of parenting behaviors in the relationship between early and late adolescent levels of anxiety. Evidence for specificity within the parenting-anxiety relationship was scarce with specific mediating effects observed only for panic/agoraphobia and total anxiety through the parenting dimension of rejection.

CONCLUSIONS

The findings of this study concern the un-conditional mediating role of parenting. Parenting behaviors may be more influential among some adolescents, depending on individual differences in other factors related to the development and course of adolescent anxiety. Thus, further research on moderating factors of the influence of parenting on adolescent anxiety is warranted.

Anxiety-related disorders: An overview

Anxiety-related disorders are common in the child and adolescent population. They cause significant distress, which can affect social, emotional, family and academic functioning. They frequently present in general paediatric and primary care settings. Comprehensive assessment should include the child as well as parent and family functioning because anxiety-related disorders in other family members are common and, if untreated, can affect outcomes for the child. There are good evidence-based psychological interventions available, which should be the first line of treatment offered; accessing appropriate therapies for an adequate duration of treatment can, however, be challenging. Medication, particularly selective serotonin reuptake inhibitors, may have a role to play but should be used in the context of psychologically based therapies. Prevention of anxiety-related disorders in childhood is a major public health issue. Prevention programmes are available and should commence in the antenatal period through infancy, early childhood and adolescence, promoting positive attachments and resilience.

Maternal Acceptance Moderates Fear Ratings and Avoidance Behavior in Children

Avoidance is a hallmark feature of anxiety disorders, and avoidance-related impairment is often key to meeting diagnostic criteria. In children and adolescents with anxiety disorders, levels of avoidance vary considerably. Using a novel motion-tracking measure of avoidance behavior, we examined whether maternal acceptance, characterized by warm and accepting responses to child feelings and behaviors, moderates the association between fear of spiders and behavioral avoidance of spider stimuli in 103 clinically anxious children. As hypothesized, maternal acceptance significantly moderated children's avoidance behavior. Child's fear of spiders was significantly associated with behavioral avoidance when mothers were low in acceptance, as rated by either mothers or children. When mothers were high in acceptance, as rated by either mothers or children, child self-rated fear of spiders was not significantly associated with child avoidance. These are the first results to empirically demonstrate the moderating role of maternal acceptance in anxious children's avoidance behavior.

A Multi-Informant Examination of Maternal Symptoms and Autonomy Granting in Youth Anxiety

Evidence suggests the important role of (a) parenting behaviors and (b) parental psychopathology in the development and maintenance of youth anxiety. Using a multi-informant approach, the current study examined the association of maternal autonomy granting and maternal symptoms (i.e., anxiety and depression) with youth anxiety among mothers and 88 youth (ages of 6-17) diagnosed with a principal anxiety disorder. Results from the generalized estimating equations (GEE) analyses indicated that mothers reported higher youth anxiety symptoms compared to youth self-reports. Youth-perceived maternal autonomy granting was inversely associated with youth anxiety, and maternal self-reported anxiety and depressive symptoms significantly moderated this relationship: As mothers reported higher anxiety and depressive symptoms, the inverse association between parental autonomy granting and youth anxiety weakened. The interaction between parenting behavior and parental psychopathology significantly influenced youth anxiety symptoms, which presents important clinical implications to integrate into parenting work in the treatment of youth anxiety disorders.

Delivery of a Therapist-Facilitated Telecare Anxiety Program to Children in Rural Communities: A Pilot Study

Objective: This pilot study explored the feasibility and preliminary efficacy of a therapist-facilitated telecare cognitive behavioural anxiety program delivered through schools to children within rural communities. Method: Sixteen children aged 9–12 years (82.5% male), with a principal diagnosis of an anxiety disorder, and their mothers participated in the pilot study. The treatment program was an adaption of the Cool Kids Child and Adolescent Anxiety Management Program. Treatment was delivered by clinical psychologists and involved 10 weekly sessions with children via an interactive, real-time videoconferencing online platform at their school. Parents also received 4 phone calls during the treatment program. Outcome measures included clinician-rated diagnostic status and child- and parent-reported symptoms and interference. Results: According to combined parent and child reports, 62.5% of children no longer met diagnostic criteria for their primary anxiety disorder, and 31.25% did not meet diagnostic criteria for any anxiety disorder post-treatment. Results indicated that the severity of anxiety symptoms, functional impact of anxiety symptoms, externalising difficulties, and depressive symptoms in children decreased significantly post-treatment, as reported by both parents and children. Conclusions: A telecare model of therapy could be a feasible and effective way of delivering evidence-based intervention to children in rural communities.

Maternal emotion regulation during child distress, child anxiety accommodation, and links between maternal and child anxiety

Environmental contributions are thought to play a primary role in the familial aggregation of anxiety, but parenting influences remain poorly understood. We examined dynamic relations between maternal anxiety, maternal emotion regulation (ER) during child distress, maternal accommodation of child distress, and child anxiety. Mothers (N=45) of youth ages 3-8 years (M=4.8) participated in an experimental task during which they listened to a standardized audio recording of a child in anxious distress pleading for parental intervention. Measures of maternal and child anxiety, mothers' affective states, mothers' ER strategies during the child distress, and maternal accommodation of child anxiety were collected. Mothers' resting respiratory sinus arrhythmia (RSA) reactivity during the recording was also acquired. Higher maternal negative affect and greater maternal ER switching (i.e., using multiple ER strategies in a short time without positive regulatory results) during child distress were associated with child anxiety. Sequential mediation modeling showed that maternal anxiety predicted ineffective maternal ER during child distress exposure, which in turn predicted greater maternal accommodation, which in turn predicted higher child anxiety. Findings support the mediating roles of maternal ER and accommodation in linking maternal and child anxiety, and suggest that ineffective maternal ER and subsequent attempts to accommodate child distress may act as mechanisms underlying the familial aggregation of anxiety.

One Session Treatment for Specific Phobias: An Adaptation for Paediatric Blood-Injection-Injury Phobia in Youth

Blood-injection-injury (BII) phobia is a chronic and debilitating disorder, which has largely been neglected in the child literature. The present paper briefly reviews the aetiology of specific phobias with particular attention to BII and provides an integrated developmental model of this disorder in youth. Evidence-based treatments for child-specific phobias are discussed, and the development of a modified one session treatment (OST) approach to enhance treatment outcomes for BII phobia in children and adolescents is described. This approach is illustrated in two children with a primary diagnosis of BII phobia. The cases illustrate the unique challenges associated with treating BII in youth and the need for a modified intervention. Modifications included addressing the role of pain (e.g., psychoeducation, more graduated exposure steps) and disgust (e.g., disgust eliciting exposure tasks) in the expression of the phobia and fainting in the maintenance of this phobia. Moreover, it is recommended that parents be more actively involved throughout treatment (e.g., education session prior to OST, contingency management training, guidance regarding planning exposure tasks following treatment) and for families to participate in a structured e-therapy maintenance programme post-treatment.

ACCOMMODATION AND TREATMENT OF ANXIOUS YOUTH

BACKGROUND

Parental accommodation refers to the ways in which a parent modifies their behavior to avoid or reduce the distress their child experiences. Parents of youth with anxiety disorders have been found to accommodate their child's anxiety in a variety of ways that contribute to the maintenance of the disorder. The current study evaluated the relationship between parental accommodation and the outcome of treatment for youth with anxiety.

METHODS

Sixty-two youth (age 6-17) and their parents were evaluated for youth anxiety and parental accommodation before and after treatment. All youth received individual cognitive behavioral therapy (CBT).

RESULTS

Parental accommodation was significantly reduced from before to after treatment. Reduction in parent-rated accommodation was significantly associated with the severity of youth's posttreatment anxiety, even when controlling for pretreatment youth anxiety. Level of pretreatment accommodation was significantly associated with treatment response.

CONCLUSIONS

Findings indicate that parental accommodation is significantly reduced after individual youth CBT, and suggest that accommodation may be an important treatment focus. Clinical implications and future directions are discussed.

Parents' difficulties as co-therapists in CBT among non-responding youths with anxiety disorders: Parent and therapist experiences

No increased effect has been associated with parent involvement in cognitive behavioral therapy (CBT) for youths with anxiety disorders. The purpose of this study was to explore parent and therapist experiences of CBT among non-responding youths with anxiety disorders, with a primary focus on parent involvement in therapy. Interpretative phenomenological analysis was applied to 24 sets of semi-structured interviews with families and therapists of anxiety-disordered youths who had not profited from CBT with parental inclusion. From the superordinate theme parents' difficulties acting as co-therapists, which emerged from the analyses, two master themes represented the perspectives of parents (difficulty working together with the youth and feeling unqualified, with limited resources), and two represented the perspectives of therapists (family dynamics stood in the way of progress and difficulty transferring control to parents). Parent and therapist experiences complemented each other, offering two different perspectives on parent difficulties as co-therapists. However, the two groups' views on their respective roles in therapy were in conflict. Parents wished to remain being "just the parents" and for the experts to take over, while therapists wished to act as facilitators transferring the control to parents. Clinical implications are drawn for parental involvement and enhancement of treatment outcomes for likely non-responders.

Parental Attitudes, Beliefs, and Understanding of Anxiety (PABUA): Development and psychometric properties of a measure

The Parental Attitudes, Beliefs, and Understanding of Anxiety (PABUA) was developed to assess parental beliefs about their child's anxiety, parents' perceived ability to cope with their child's anxiety and to help their child manage anxious symptoms, and to evaluate parents' understanding of various parenting strategies in response to their child's anxiety. The study evaluated the PABUA in mother-child dyads (N=192) seeking treatment for youth anxiety. Exploratory factor analysis yielded a three-factor solution and identified PABUA scales of Overprotection, Distress, and Approach (with Cronbach's alpha ranging from .67 to .83). Convergent and divergent validity of PABUA scales was supported by the pattern of associations with measures of experiential avoidance, beliefs related to children's anxiety, empathy, trait anxiety, and depressive symptoms; parent-reported family functioning; parent- and youth-reported anxiety severity; and parent-reported functional impairment (n=83). Results provide preliminary support for the PABUA as a measure of parental attitudes and beliefs about anxiety, and future studies that investigate this measure with large and diverse samples are encouraged.

Stressful Life Events and Child Anxiety: Examining Parent and Child Mediators

While a number of factors have been linked with excessive anxiety (e.g., parenting, child temperament), the impact of stressful life events remains under-studied. Moreover, much of this literature has examined bivariate associations rather than testing more complex theoretical models. The current study extends the literature on life events and child anxiety by testing a theory-driven meditational model. Specifically, one child factor (child cognitions/locus of control), two parent factors (parent psychopathology and parenting stress), and two parent-child relationship factors (parent-child dysfunctional interaction and parenting style) were examined as mediators in the relationship between stressful life events and severity of child anxiety. One hundred and thirty anxious parents and their nonanxious, high-risk children (ages ranged from 7 to 13 years) participated in this study. Results indicated that levels of parenting stress, parental anxious rearing, and dysfunctional parent-child interaction mediated the association between stressful life events and severity of anxiety symptoms. Child cognition and parent psychopathology factors failed to emerge as mediators. Findings provide support for more complex theoretical models linking life events and child anxiety and suggest potential targets of intervention.

The Effect of Child Distress on Accommodation of Anxiety: Relations With Maternal Beliefs, Empathy, and Anxiety

Little is known about the influence of child behaviors on accommodation of anxiety and how accommodation relates to other parent factors. The present study examined the comparative effect of high and low levels of child distress on mother-reported accommodation, mother factors in relation to accommodation, and moderators of the relation between accommodation and child distress. Maternal perceptions of accommodation were measured by vignettes depicting youth exhibiting high or low levels of distress in anxiety-provoking situations that elicited social anxiety, generalized anxiety, or separation anxiety in a sample of 7- to 17-year-old youth with anxiety disorders (N = 70, M = 11.66, 47.1% male). Findings indicated an effect of child distress on mother-reported accommodation of youth anxiety, such that mothers reported more overall accommodation under conditions of high child distress; situation-level analyses revealed this effect for social and generalized anxiety situations. Furthermore, an association was found between greater mother-reported accommodation and more negative beliefs about their child's experience of anxiety, which held across situations. Maternal empathy moderated the relation between overall accommodation and child distress. Maternal anxiety also moderated the relation between accommodation and child distress, with results varying based on situation type. Findings, consistent with theory, indicate a relation between child distress and mother-reported accommodation and suggest that maternal beliefs about anxiety are an important treatment target. High maternal empathy may be related to a greater degree of adaptability in response to child behaviors, whereas maternal anxiety may be linked with less adaptive responses to child behaviors.