Family Intervention for Child and Adolescent Anxiety: A Meta-analytic Review of Therapy Targets, Techniques, and Outcomes

Study Preregistration: Targeting Parental Risk Factors for Children's Anxiety: A Factorial Experiment With Three Intervention Components

Anxiety is one of the most common mental health problems in childhood, and causes severe and persistent impairment in children's lives.1 Parents can play a key role in the development of children's anxiety symptoms2; yet, the evidence of parent-focused interventions is relatively thin.3 This may be because little is known about what the optimal content of these interventions should be. Interventions typically either use parents as lay therapists, or target multiple different family risk factors at the same time.4 Traditional randomized trials of these "package deal" interventions provide little insight into what specific parental risk factors should be targeted to most effectively reduce children's anxiety.5 We will examine the effects of targeting distinct parental risk factors to provide more information on the role of these factors in children's anxiety, and to guide the development of intervention programs.

How does family functioning contribute to academic-related outcomes of Chinese adolescents: the mediating role of spirituality

While family functioning is crucial to adolescent developmental outcomes, the mediating role of spirituality in the relationship between family functioning and academic-related outcomes of adolescents has been sparsely explored, particularly in non-Western contexts. To address this gap, based on a short-term longitudinal study, we examined the influence of family functioning on the academic values and academic anxiety of 4,981 Chinese adolescents in Sichuan, China, with spirituality as the mediator. We gathered data from students aged 11 and above at Wave 1 and at six months later (Wave 2). Analysis utilizing structural equation modeling indicated that prior family functioning positively and negatively predicted subsequent academic values and academic anxiety respectively, with spirituality as a significant mediator. Theoretically, this study helps to build up a conceptual model on how family functioning and spirituality of adolescents shape academic values and academic anxiety of adolescents. Practically, the present findings highlight the significance of enhancing family functioning and adolescent spirituality to help adolescents strive for academic success.

Cognitive Behavioral Therapy for Anxiety and Depression in Children and Adolescents

Anxiety and depression are prevalent and impairing psychiatric problems for children and adolescents. In this review, the authors summarize information about their prevalence and impact, the most common assessment methods, the main components of cognitive behavioral therapy (CBT), and research on the effectiveness of CBT for these disorders. Future directions, including improving access to CBT through technology-based approaches and increasing personalization of treatment, are discussed.

The association between anxiety and internet addiction among left-behind secondary school students: the moderating effect of social support and family types

BACKGROUND

The left-behind children (LBC), children and adolescents aged 0-18 whose parents have migrated for economic purposes for extended periods exceeding three months, present a unique social concern. These children remain in their place of household registration, often under the guardianship of relatives, while receiving compulsory education. LBC with growing Internet addiction (IA) have made it urgent to take a close look at the mechanisms and effective interventions for them. Anxiety has been proven to be correlated with IA in adolescents; however, the mechanisms of addiction in this population are less well-fully grasped. Based on the current theories and empirical results, the study examined whether and how social support (SS) and family types moderated the associations between anxiety and IA among left-behind secondary students.

METHODS

Stratified cluster sampling survey. A questionnaire was administered to 5290 secondary school children (2553 classified as left-behind) to explore the relationships between anxiety, IA, left-behind types, family types, and social support. This cross-sectional study employed a stratified cluster sampling survey of students in the ethnic areas of southeast Chongqing. The study sought to appraise the relationships between anxiety and IA in different types of left-behind children and to assess the potential moderating effect of SS on the relationship among the population and its family types differences.

RESULTS

The relationship between anxiety and IA was moderated significantly by social support and family types. Notably, the impact of social support on the moderating effect between IA and anxiety varied among students from both family types. For students from families where both parents had migrated, social support weakened the association between IA and anxiety. Conversely, for students from single-parent families where the parent had migrated, social support seemed to strengthen the relationships between these two issues.

CONCLUSIONS

The moderating effects of SS on the relationship between anxiety and IA differs based on family type among various groups of left-behind secondary students. Gaining insights into the IA mechanisms can guide the development of targeted intervention strategies aimed at minimizing IA among diverse groups of left-behind students.

Testing reciprocal associations between child anxiety and parenting across early interventions for inhibited preschoolers

BACKGROUND

Given the robust evidence base for the efficacy of evidence-based treatments targeting youth anxiety, researchers have advanced beyond efficacy outcome analysis to identify mechanisms of change and treatment directionality. Grounded in developmental transactional models, interventions for young children at risk for anxiety by virtue of behaviorally inhibited temperament often target parenting and child factors implicated in the early emergence and maintenance of anxiety. In particular, overcontrolling parenting moderates risk for anxiety among highly inhibited children, just as child inhibition has been shown to elicit overcontrolling parenting. Although longitudinal research has elucidated the temporal unfolding of factors that interact to place inhibited children at risk for anxiety, reciprocal transactions between these child and parent factors in the context of early interventions remain unknown.

METHOD

This study addresses these gaps by examining mechanisms of change and treatment directionality (i.e., parent-to-child vs. child-to-parent influences) within a randomized controlled trial comparing two interventions for inhibited preschoolers (N = 151): the multicomponent Turtle Program ('Turtle') and the parent-only Cool Little Kids program ('CLK'). Reciprocal relations between parent-reported child anxiety, observed parenting, and parent-reported accommodation of child anxiety were examined across four timepoints: pre-, mid-, and post-treatment, and one-year follow-up (NCT02308826).

RESULTS

Hypotheses were tested via latent curve models with structured residuals (LCM-SR) and latent change score (LCS) models. LCM-SR results were consistent with the child-to-parent influences found in previous research on cognitive behavioral therapy (CBT) for older anxious youth, but only emerged in Turtle. LCS analyses revealed bidirectional effects of changes in parent accommodation and child anxiety during and after intervention, but only in Turtle.

CONCLUSION

Our findings coincide with developmental transactional models, suggesting that the development of child anxiety may result from child-to-parent influences rather than the reverse, and highlight the importance of targeting parent and child factors simultaneously in early interventions for young, inhibited children.

Does Cognitive-Behavioral Therapy for Youth Anxiety Disorders Improve Social Functioning and Peer Relationships?

Child and adolescent anxiety disorders (ADs) contribute to impairment in social functioning and peer relationships, exacerbating anxiety and related difficulties. The extent to which the AD treatment with the strongest evidence-base, cognitive-behavioral therapy (CBT), improves social functioning and peer relationships is unclear. In this article, we report results of the first systematic narrative review of this topic. Randomized clinical trials of CBT for child and/or adolescent ADs were included if they used at least one measure of social functioning or peer relationships as a treatment outcome. Sixteen studies met our inclusion criteria. From each study, we extracted the sample characteristics, treatment arms, social and/or peer outcome measures, and statistical findings. Results show that social functioning and/or peer relationships improved over time in the majority of studies, highlighting an important aspect of treatment efficacy beyond anxiety reduction. There were also several treatment-specific effects, but considerable variability across studies' samples, methods, and findings, makes it difficult to draw firm conclusions about which specific treatments improve specific outcomes. We recommend next steps for research to reconcile these findings, including improved operationalization and standardization of social and peer outcomes, and research on treatment specificity and mechanisms.

The Impact of Family Functioning on Help-Seeking Behavior and Symptom Severity in Obsessive-Compulsive Disorder

ABSTRACT

Poor family functioning is associated with higher symptom severity in pediatric obsessive-compulsive disorder (OCD) and delayed help-seeking behavior in other forms of psychopathology. However, little is known about the impact of family functioning on help-seeking behavior and symptom severity in adults with OCD. The present study investigated the association between family functioning and both treatment delay and symptom severity in adults with obsessive-compulsive symptoms. Participants were 194 adults who self-identified as having OCD and completed an internet survey, including measures assessing family functioning, obsessive-compulsive symptom severity, help-seeking behavior, and depression symptom severity. Poorer family functioning was associated with higher obsessive-compulsive and depression symptom severity, after controlling for significant demographic variables. With respect to domains of family functioning, poorer general functioning, problem solving, communication skills, role functioning, affective involvement, and affective responsiveness were associated with higher obsessive-compulsive and depression symptom severity, after controlling for demographics. Poorer problem solving and communication were not significantly associated with treatment delay after controlling for demographics. Findings highlight the need for family intervention within the treatment framework for adult OCD and suggest targets ( e.g. , communication) to be addressed.

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.

Non-suicidal self-injury in Chinese population: a scoping review of prevalence, method, risk factors and preventive interventions

Non-suicidal self-injury behavior (NSSI) is a serious public health concern that requires immediate attention. Despite the high prevalence of NSSI among the Chinese population, there is a significant gap in research on the comprehensive picture of this field. Therefore, a scoping review was conducted to investigate the prevalence, methods, risk factors, and preventive intervention programs related to NSSI in China. The review found that the estimated lifetime prevalence of NSSI among Chinese youth population is alarmingly high at 24.7% (N = 1,088,433). Common methods of NSSI include scratching, hitting, and biting. Additionally, the review synthesized 249 risk factors based on the biopsychosocial-ecological framework, highlighting the urgent need for intervention. However, only 12 empirical studies focus on NSSI prevention or intervention programs were included. These findings underscore the necessity for more clinical practices and larger studies to identify effective interventions and ultimately alleviate the burden of NSSI on the Chinese population.

Funding

This review was supported by Humanity and Social Science Youth foundation of Ministry of Education (22YJCZH018), Science and Technology Innovation 2030 (STI2030-Major Projects:2021ZD0200702), National Natural Science Foundation of China (81825009), and Shuimu Tsinghua Scholar. No funding agencies were involved in the data collection, data analysis, and writing of this paper.

Family communication and the efficacy of family focused therapy in individuals at clinical high risk for psychosis with comorbid anxiety

AIM

Comorbid anxiety disorder is related to greater illness severity among individuals at clinical high risk (CHR) for psychosis, but its potential role in moderating response to Family Focused Therapy (FFT) for CHR is unexamined. We investigated whether comorbid anxiety disorder in CHR individuals is associated with less constructive communication during family problem-solving interactions, whether their communication skills differentially improve after FFT, and whether FFT is effective in reducing anxiety in this population.

METHODS

Individuals recruited into the second phase of the 8-site North American Prodrome Longitudinal Study (NAPLS2) participated (N = 129). They were randomly assigned to 18-sessions of FFT-CHR or three-sessions of Enhanced Care (EC). Participants completed a diagnostic interview at pre-treatment, a family interaction task at pre-treatment and 6-months, and a self-report anxiety measure at pretreatment, 6 and 12-months.

RESULTS

Individuals at CHR with comorbid anxiety engaged in more negative and fewer positive behaviours during family problem-solving interactions at pre-treatment than did those without comorbid anxiety. There was a significant interaction between anxiety diagnosis and time on interactional behaviour scores, such that individuals at CHR with an anxiety diagnosis showed a greater decrease in negative behaviours and increase in positive behaviours from baseline to 6-months than those without anxiety disorder(s) regardless of treatment condition. However, individuals' self-reported anxiety symptoms decreased more in FFT-CHR than in EC from pre-treatment to 12-month follow-up, regardless of anxiety diagnoses.

CONCLUSIONS

Individuals at CHR with symptoms of anxiety benefit from family interventions in showing reductions in anxiety and improvements in family communication.

Criticism and accommodation are associated with treatment concerns in close others to those with anxiety

OBJECTIVES

Those close to people with mental health difficulties (e.g., family members, romantic partners and close friends) are often involved in their care decisions. Research shows that criticism by close others and accommodation of symptoms are associated with symptom severity and treatment response. Recent research has found that those close to someone with an anxiety disorder report a range of concerns about their loved one starting cognitive-behaviour therapy (e.g., that treatment will cause the person to change in undesirable ways). The purpose of this study was to examine the relationship between close others' criticism and symptom accommodation and their treatment concerns, hypothesizing that these relationships would be significant.

DESIGN

Close others to those with notable anxiety (N = 287) completed self-report measures online. Multiple regression was used to test our hypothesis.

METHODS

Respondents who identified as being close to someone with notable anxiety completed measures of their accommodation of anxiety symptoms, feelings of criticism/hostility towards them, concerns about them starting treatment, perceived impairment due to anxiety, and their own and their loved ones' treatment history.

RESULTS

Greater criticism and accommodation significantly predicted greater treatment concerns, with a medium effect size, controlling for degree of impairment due to anxiety and treatment history.

CONCLUSIONS

Criticism and accommodation may reflect appraisal of the person with anxiety as weak or fragile, which may evoke concerns about treatment success. Implications for clinicians and anxiety treatment are discussed.

Family Matters More Than Friends on Problematic Social Media Use Among Adolescents: Mediating Roles of Resilience and Loneliness

Problematic social media use (PSMU) among adolescents has raised global concern in the current digital age. Despite the important role of perceived social support in adolescents' PSMU has been examined, possible different influences between perceived support from family and friends are still unknown. To address the gap, the present study aimed to examine how perceived support from family and friends is associated differently with PSMU and the mediating roles of resilience and loneliness therein. A sample of 1056 adolescents was recruited to complete standard questionnaires. Mediation analysis showed that resilience and loneliness mediated this association partially between perceived support from family and PSMU but totally between perceived support from friends and PSMU. Further, ANOVA-based analysis showed that influences of perceived support from family and friends on PSMU were mutually independent, and there was no interaction between them. Our results not only highlight different and independent impacts of perceived support from family and friends on PSMU, but also clarify the mediating mechanisms linking perceived social support to adolescent PSMU.

CBT for Youth Anxiety: How Does It Fit Within Community Mental Health?

PURPOSE OF REVIEW

We review (1) the empirical literature for cognitive behavioral therapy (CBT) for youth anxiety delivered in community settings, (2) the use of online delivery methods in this process, and (3) identified barriers and facilitators to implementation of CBT for youth anxiety in community mental health clinics (CMHCs). We provide suggestions for future work.

RECENT FINDINGS

Meta-analytic reviews of effectiveness studies suggest that outcomes comparable to those of efficacy studies can be achieved in community settings, particularly when in-session exposures occur. Several online programs support delivery of these services, with an evidence base that is promising. The notable barrier to the implementation of services is the cost of implementation and sustainability. Organizational factors such as leadership, culture, and climate are consistently identified as barriers and facilitators depending on their valence and appear to be related to implementation outcomes (e.g., on provider attitudes). The current findings need to be integrated into future studies, with a focus on further identifying facilitators (e.g., champions and online programs) of implementation. There is also the need for efforts to address organizational and individual barriers and to compare ways to reduce costs.

Psychometric evaluation of a caregiver-report adaptation of the Overall Anxiety Severity and Impairment Scale (OASIS) for use with youth populations

Background Despite progress in youth anxiety assessment, there is need for a measure that is simultaneously (a) free, (b) brief, (c) focused broadly on anxiety and avoidance severity, frequency, and interference, and (d) concerned with the past week. The adult overall anxiety severity and impairment scale (OASIS) was adapted to yield a caregiver-report of past week youth anxiety and interference (OASIS-Y). Methods In a sample of diverse youth seeking anxiety services (N = 132; 67% racial/ethnic minority) and their caregivers, analyses examined the OASIS-Y factor structure, internal consistency, and convergent and divergent validity. Hierarchical linear modeling in a participant subset examined OASIS-Y sensitivity to treatment-related change. Results OASIS-Y internal consistency was high and confirmatory factor analysis supported a single-factor structure similar to that found in adults. OASIS-Y convergent validity was supported by a medium-sized association with an established, commercially available measure of youth anxiety, and divergent validity was supported by the absence of unique associations with measures of youth attention and externalizing problems. In a sample subset, session-by-session OASIS-Y scores significantly declined across treatment, and declined at a steeper rate among treatment "responders" versus "non-responders," providing evidence of OASIS-Y sensitivity to treatment-related change. Limitations This study focused on a clinical sample and cannot speak to OASIS-Y performance in community settings. Shared method-variance may have also influenced findings. Conclusions This study offers the first psychometric evaluation of the OASIS-Y, and underscores the promising clinical utility of the measure for assessing past week youth anxiety and impairment and for supporting routine outcome monitoring.

Does Training Parents in Reinforcement Skills or Relationship Skills Enhance Individual Youths' Cognitive Behavioral Therapy for Anxiety? Outcome, Specificity, and Mediation

We conducted a dismantling design treatment study comparing individual CBT, CBT targeting parents' reinforcement skills (CBT+Reinf), and CBT targeting parents' relationship skills (CBT+ Relat) in 341 youths with primary anxiety diagnoses. At posttreatment, youths in CBTs with parent involvement had lower anxiety than youths in CBT. At 12-month follow-up, youths in CBT+Relat maintained lower anxiety relative to CBT. At posttreatment, negative reinforcement was significantly lower in CBT+Reinf than CBT+Relat and CBT; negative reinforcement partially mediated youth anxiety reduction. Reducing parental negative reinforcement in CBT+Reinf was associated with lower parental psychological control which also partially mediated youth anxiety reduction. Some of these mediational dynamics continued through follow-up. Targeting concrete behavioral parenting skills, especially negative reinforcement, produced treatment specificity and partial mediation relative to less concrete targeting, and enhanced CBT. Findings highlight complexities in identifying mechanisms through which targeting of parenting skills produces youth anxiety reduction and suggest avenues for future research.

Combined Emotional Socialization Training and Family Accommodation Modification: Impact on Emotional Regulation and Anxiety Symptoms in Anxious Children

Past studies show that emotional socialization and family accommodation are involved in children's anxiety, but research has yet to investigate whether targeting emotional socialization training (EST), family accommodation modification (FAM), or EST and FAM in tandem can reduce anxiety in children. The purpose of this study was to evaluate the efficacy of a combination of EST and FAM on improving emotion regulation (ER) and reducing anxiety symptoms in anxious children. The sample consisted of 80 children with an anxiety disorder (M_age = 6.7, SD = 0.1) and their mothers. Mothers were randomly assigned to an EST (n = 17), FAM (n = 16), Combined (n = 17), or a waitlist control (WLC) (n = 16) groups. Mothers completed The Emotion Regulation Checklist (ERC) and Spence Children's Anxiety Scale (SCAS) at pre-test, post-test, and at 6-month of follow-up. The results showed that the EST, FAM, and Combined groups were more effective than WLC in improving ER and reducing anxiety severity at post-test and follow-up. Among the intervention groups, children in the combined group showed greater reductions in the severity of anxiety symptoms and emotion dysregulation than the other two groups. Assisting parents to use strategies that encourage healthy emotion regulation and decrease family accommodation might help reduce the severity of children's anxiety symptoms.

Relationship between paternal adult attachment and adolescent anxiety: The chain-mediating effect of paternal psychological flexibility and father-adolescent attachment

Grounded in family systems theory and the internal working model of attachment, the present study tested the effects of paternal adult attachment, paternal psychological flexibility and father-adolescent attachment on adolescent anxiety. In total, 906 pairs of fathers and their adolescents completed a set of questionnaires, including the Experiences in Close Relationships Scale, Parental Psychological Flexibility Questionnaire, Inventory of Parent and Peer Attachment, and Trait Anxiety Inventory. The results revealed that paternal adult attachment avoidance had a positive impact on adolescent anxiety. The relationship between paternal adult attachment and adolescent anxiety was chain mediated by paternal psychological flexibility and father-adolescent attachment. The mediation effects contained two paths: the separate mediation effect of paternal psychological flexibility, and the chain mediation effect of paternal psychological flexibility and father-adolescent attachment. The results of the study show that the father's adult attachment can not only directly affect adolescent anxiety, but also indirectly affect adolescent anxiety through the paternal psychological flexibility and the quality of father-adolescent attachment. Fathers have an important effect on adolescent anxiety.

Conceptualizing Emotion Regulation and Coregulation as Family-Level Phenomena

The ability to regulate one’s emotions is foundational for healthy development and functioning in a multitude of domains, whereas difficulties in emotional regulation are recognized as a risk factor for a range of adverse outcomes in childhood, adolescence, and adulthood. Caregivers play a key role in cultivating the development of emotion regulation through coregulation, or the processes by which they provide external support or scaffolding as children navigate their emotional experiences. The vast majority of research to date has examined coregulation in the context of caregiver–child dyads. In this paper, we consider emotion regulation and coregulation as family-level processes that unfold within and across multiple family subsystems and explore how triadic and whole family interactions may contribute to the development of children’s emotion regulation skills. Furthermore, we will examine the implications of a family-centered perspective on emotion regulation for prevention of and intervention for childhood emotional and behavioral disorders. Because emotion regulation skills undergo such dramatic maturation during children’s first several years of life, much of our focus will be on coregulation within and across the family system during early childhood; however, as many prevention and intervention approaches are geared toward school-aged children and adolescents, we will also devote some attention to later developmental periods.

Cognitive Behavioral Therapy for Anxiety Disorders in Youth: Efficacy, Moderators, and New Advances in Predicting Outcomes

PURPOSE OF REVIEW

This review integrates recent systematic reviews and meta-analyses on the efficacy of cognitive behavioral therapy (CBT) for the treatment of anxiety disorders in children and adolescents. To inform personalized approaches to intervention, we also review recent research on moderators and predictors of outcomes.

RECENT FINDINGS

Meta-analyses provide strong support for the efficacy of CBT for youth anxiety disorders, including with preschool-aged children using appropriate modifications. Furthermore, there is evidence that CBT is an effective adjunct treatment to psychopharmacological interventions, and the combination of treatments may be most effective for some youth. There is limited evidence of consistent demographic and clinical moderators of outcomes. Recent work in neuroscience has highlighted novel predictors of treatment outcomes that, with replication, may aid in more personalized approaches to youth anxiety treatment. CBT is efficacious for treating anxiety disorders in youth and lowering recurrence rates. CBT can also be an efficacious adjunct treatment for psychopharmacological interventions. Neuroimaging and psychophysiological measures of threat and motivational processing have shown initial promise in predicting symptom change with CBT, with potential implications for precision medicine.

Prevalence of depression and anxiety among children with type 1 and type 2 diabetes: a systematic review and meta-analysis

BACKGROUND

Evaluation of psychiatric disorders in children is essential in timely treatment. Despite individual studies, there is no information on the exact status of psychiatric disorders in children. The present study was conducted to determine the prevalence of depression among children with type 1 and type 2 diabetes.

METHODS

This meta-analysis is registered with PROSPERO (CRD42021231491). Several databases (Web of Science, Scopus, and PubMed) were searched from January 1, 2000 to December 15, 2020. The key words included: depression, anxiety, children, and diabetes. The steps of search, comprising screening, risk of bias, and extraction of study data, were performed separately by two researchers.

RESULTS

It was found that a total of 109 studies had been conducted involving 52,493 children with type 1 and type 2 diabetes. These studies were included in the present review study. The prevalence of depression, anxiety among children with type 1 diabetes were 22.2% [95% confidence interval (CI) 19.2-25.2], and 17.7% (95% CI 15.2-20.1), respectively. The prevalence of depression was higher among girls (29.7%) than boys (19.7%). The prevalence of depression was higher in lower-middle-income countries at 29.3% (95% CI 18.6-40.0). The prevalence of depression among children with type 2 diabetes was 22.7% (95% CI 17.3-28.0).

CONCLUSION

The results of the present study indicate the importance of paying attention to extensive periodic screening and appropriate activities to reduce pediatric depression.