Are children's own interpretations of ambiguous situations based on how they perceive their mothers have interpreted ambiguous situations for them in the past?

A Pilot Feasibility Open Trial of an Interpretation Bias Intervention for Parents of Anxious Children

Interpretation bias is a transdiagnostic mechanism underlying anxiety. Theoretical models highlight the role of parental interpretation bias in predicting and maintaining child anxiety. However, very few studies have examined parent interpretation bias as a treatment target. The current pilot study tested the feasibility and acceptability of an interpretation bias intervention delivered by a smartphone app, called HabitWorks, in parents of anxious children who self-reported at least mild symptoms of anxiety and negative interpretation bias. Parents of anxious youth (ages 8 to 16) were recruited from the waitlists of three child anxiety clinics. They were asked to complete interpretation modification exercises via the HabitWorks app 3 times per week for 1 month. Participants completed assessments at pre- and post-intervention and 1-month follow-up to assess changes in interpretation bias, anxiety symptoms, and overall perceptions of HabitWorks. Participants (N=14) (Mage=44.36; 14.29% men, 85.71% women) completed an average of 13.29 exercises out of the 12 prescribed. Acceptability ratings were high. Interpretation bias, as measured by an assessment version of the intervention exercise, significantly improved from pre- to posttreatment, and these improvements were maintained at the 1-month follow-up. Anxiety symptoms significantly improved from the "mild" severity range to the "none to minimal" range. In this pilot feasibility study in parents of anxious youth, HabitWorks was a feasible and acceptable low-intensity intervention. These preliminary results support a future controlled trial of HabitWorks for parents. Future studies are also needed to test whether targeting interpretation bias in parents has downstream effects on maladaptive parent behaviors and ultimately, child interpretation bias and anxiety.

Displays of negative facial affect during parent-adolescent conflict and the bidirectional transmission of social anxiety

BACKGROUND

Symptoms of social anxiety rise rapidly during adolescence, particularly for girls. Pervasive displays of parental negative affect may increase adolescents' fear of negative evaluation (FNE), thereby increasing risk for social anxiety symptoms. Adolescent displays of negative affect may also exacerbate parents' social anxiety symptoms (via FNE of their child or their parenting skills), yet little research has tested transactional pathways of transmission in families. By early adolescence, rates of parent-child conflict rise, and offspring become increasingly independent in their own displays of negative affect, increasing opportunities for hypothesized transactional pathways between parent-adolescent displays of negative affect and social anxiety symptoms.

METHODS

This study included 129 parents and daughters (11-13; no baseline social anxiety disorder), two-thirds of whom were at high risk for social anxiety due to a shy/fearful temperament. We used actor-partner interdependence models (APIM) to test whether displays of negative facial affect, assessed individually for each parent and daughter during a conflict discussion, would predict their partner's social anxiety symptoms two years later. Automated facial affect coding assessed the frequency of negative affect during the discussion. Clinician ratings of social anxiety symptoms were completed at baseline and two-year follow-up.

RESULTS

Both parents and daughters who displayed more frequent negative facial affect at baseline had partners with higher follow-up social anxiety symptoms, an effect that was maintained after accounting for actors' and partners' baseline symptoms.

CONCLUSIONS

Findings are consistent with intergenerational models positing that parental negative affective behaviors increase risk for adolescent social anxiety symptoms but also suggest that adolescent negative facial affect may exacerbate parental social anxiety symptoms. These bidirectional effects improve understanding of how social anxiety is maintained within a transactional family structure and highlight that displays of negative affect during parent-adolescent interaction may warrant future examination as a potential treatment target for adolescent social anxiety.

Paternal Feelings and Child's Anxiety: The Mediating Role of Father-Child Insecure Attachment and Child's Emotional Regulation

The study introduces a path model that links between paternal feelings and child’s anxiety symptoms, aiming to test the mediational role of father–child insecure attachment and the child’s difficulties in emotional regulation in the occurrence of anxiety disorders among a sample of 148 fathers and their children (65 boys and 83 girls aged 8–18) attending the child psychiatric center of a public hospital. Participants completed a battery of diagnostical and research questionnaires, including the Parental Feelings Inventory (PFI), the Difficulties in Emotion Regulation Scale (DERS), the Screen for Child Anxiety–Related Emotional Disorders (SCARED), and the Experiences in Close Relationships Scale–Revised Child version (ECR-RC). Using structural equation modeling, we found father’s anger to be associated with father–child anxiety attachment, while the latter simultaneously mediated the link to the child’s anxiety both directly and indirectly (through emotion regulation [ER]). Consistent with previous evidence, we found insecure attachment and emotional regulation to be uniquely associated with the child’s anxiety. The current findings are among the first to demonstrate the interrelations between these variables in the context of father–child relations, suggesting that the child’s exposure to paternal anger might contribute to developing difficulties in ER and elevated anxiety due to a father–child insecure-anxious attachment relationship. The theoretical and practical implications of the findings are discussed in light of parental gender.

Overcoming barriers in cognitive-behavioral therapy for youth anxiety and obsessive-compulsive disorder: Addressing parent behaviors

Exposure-based cognitive-behavioral therapy (CBT) is a well-established treatment for anxiety disorders and obsessive-compulsive disorder (OCD) in youth. Although a majority of youth respond to CBT, a substantial portion remain symptomatic and/or experience a return of symptoms after completing a course of treatment. This highlights the need for further improvements to this evidence-based treatment. Given that parent behaviors can negatively influence treatment, addressing parental behaviors in CBT serves as a novel and promising treatment target to improve youth's therapeutic outcomes. The authors review three common parent behaviors that influence anxiety and treatment outcomes: family accommodation, parent anxious behaviors, and management of disruptive behaviors. The authors then discuss each behavior, its effect on anxiety/OCD and treatment, and how to address the behavior within the context of CBT. In doing so, therapeutic learning can be optimized to improve CBT outcomes for youth with anxiety disorders and/or OCD.

Associations Between Attentional Bias and Interpretation Bias and Change in School Concerns and Anxiety Symptoms During the Transition from Primary to Secondary School

The transition from primary to secondary school is often associated with a period of heightened anxiety and worry. For most children, any feelings of anxiety subside relatively quickly but for a small minority, emotional difficulties can continue into the first year of secondary school and beyond. This study recruited 109 children and measured their anxiety symptoms and school concerns toward the end of primary school and again at the end of their first term of secondary school. We investigated for the first time whether pre-transition measures of attentional and interpretation bias, and the magnitude of change in attentional bias toward and away from threat stimuli were associated with pre- and post-transition measures of anxiety and school concerns, and the change in these measures over time. Over 50% of the current sample exceeded clinical levels of anxiety at pre-transition. However, anxiety symptoms and school concerns had significantly reduced by post-transition. Higher levels of pre-transition anxiety or school concerns, and a greater magnitude of change in attentional bias towards threat stimuli predicted a larger reduction in anxiety symptoms and school concerns across the transition period. A greater interpretation bias toward threat was associated with higher pre-transition anxiety symptoms and school concerns but not post-transition scores, or the change in these scores. While many children experience heightened anxiety prior to school transition, this appears to be largely temporary and self-resolves. Nonetheless, the current findings highlight the importance of monitoring children's anxiety and concerns, and related cognitive processes during this important transition period.

A systematic review of the role of parents in the development of anxious cognitions in children

Anxious cognitions and parental behavior are important in the development of child anxiety. The current review aims to appraise the literature on the relationship between parental factors and chid anxious cognitions. Online database searches of PsycInfo, Scopus, ProQuest Dissertations and Web of Science were systematically searched using key terms related to 'parent', 'child', 'anxiety' and 'cognitions'. Included studies (N = 13) were quality assessed and study findings were appraised in line with cognitive behavioral frameworks of the parental pathways to the development of anxious cognitions in children. Reviewed studies confirmed that parental factors have a role in the development of their children's anxious cognitions by modelling fearful responses, reducing their child's autonomy, and indirectly via their own expectations about their child. Limitations of the literature are considered, including issues of measurement. Future research should consider multi-modal assessment of parental factors and examine parental behavior and child anxious cognitions in the context of real-life threatening events.

Father's and mother's beliefs about children's anxiety

BACKGROUND

Previous research has focused on parenting styles and parental behaviors associated with children's anxiety. Parental beliefs about their child's anxiety have scarcely been studied, in spite of their probable influence in parents seeking help. The present study intended to fil that gap, by exploring what parents think about their children's anxiety and whether these cognitions are related or not to their use of professional help.

METHOD

In-depth semistructured interviews were conducted with 48 parents (50% fathers) of children (9-12 years old) with anxiety problems. Theoretical thematic analysis was performed on the transcripts.

RESULTS

Three dimensions were derived from the analysis, concerning (a) the causes of child's anxiety, (b) the impact of anxiety in the child's functioning, and (c) the evolution of anxiety. Most parents perceived the child's anxiety as a permanent condition, attributing it to external and parental factors and considering that the anxiety problems have a negative impact on the child's well-being. Plus, parents who had previously sought professional help for the child's emotional problems tended to believe that anxiety could improve with child's or parents' efforts and with professional guidance, contrarily to those who had not. Implications for research and clinical practice are discussed.

CONCLUSION

The present study highlighted important parental beliefs about their children's anxiety that might influence their attitudes and decisions (e.g., seek for professional help). Other parental cognitions should be investigated in order to understand parenting in the context of childhood anxiety.

Psychological Intrusion - An Overlooked Aspect of Dental Fear

Dental fear/anxiety is a widely recognised problem affecting a large proportion of the population. It can result in avoidance and/or difficulty accepting dental care. We believe that psychological intrusion may play a role in the aetiology and maintenance of dental fear for at least some individuals. In this narrative review we will take a developmental perspective in order to understand its impact across the lifespan. We will consider the nature of 'self,' parenting styles, the details of intrusive parenting or parental psychological control, and briefly touch upon child temperament and parental anxiety. Finally, we draw together the supporting (largely unrecognised) evidence available in the dental literature. We illustrate the paper with clinical examples and discuss possibly effective ways of addressing the problem. We conclude that psychological intrusion appears to play an important role in dental fear, for at least some individuals, and we call for detailed research into the extent and exact nature of the problem. A simple means of identifying individuals who are vulnerable to psychological intrusion would be useful for dentists.

Influence of maternal negative emotion reactivity and cognitive reappraisal on child anxiety disorder

BACKGROUND

Anxiety disorders are among the most common psychopathologies in childhood. Two underlying contributors to child anxiety disorders (ADs) are negative emotional hyper-reactivity and deficits in reappraisal, a cognitive strategy of emotion regulation. Given that emotion regulation develops in the context of parent-child interaction, the aim of this study was to fill a research gap regarding the association between maternal negative emotional reactivity (NER) and reappraisal and child anxiety by examining (a) whether mothers of children with ADs display abnormalities in emotional reactivity and reappraisal compared to mothers of children without ADs; (b) whether maternal NER and reappraisal are associated with child anxiety; and (c) whether maternal reactivity and reappraisal significantly explain the variance in the level of child anxiety beyond the level of maternal anxiety.

METHOD

Forty-nine mothers and their AD children (aged 10-17) were assessed at admission to an anxiety disorder clinic and were compared to a control group of 42 mothers and their non-anxious (NA) children. Child and maternal anxiety were assessed, as well as maternal NER and reappraisal.

RESULTS

Mothers of AD children showed a higher NER as well as reappraisal deficits compared to the control group. Self-rated child anxiety was associated with maternal deficits in reappraisal. The variance in child anxiety was significantly explained by the level of maternal anxiety as well as maternal reappraisal deficits.

CONCLUSIONS

This study suggests that maternal NER and reappraisal play an important role in child anxiety and should be considered in prevention and intervention of childhood ADs.

Longitudinal Relations between Behavioral Inhibition and Social Information Processing: Moderating Role of Maternal Supportive Reactions to Children's Emotions

Utilizing multiple measures of interpretive biases, the current study examined the roles of toddlers' behavioral inhibition (BI) and maternal supportive reactions to children's negative emotions in relation to children's interpretive biases across middle to late childhood. Toddlers' BI was measured during several laboratory tasks (n = 248) at 2 and 3 years of age. Mothers reported on their reactions to children's negative emotional expressions when children were 7 years old (n = 203), and children's interpretations of social cues were assessed at 7 and 10 years of age (ns = 179 and 161, respectively). Toddlers with high levels of BI expressed less positivity towards social engagement with unfamiliar peers during discussion of ambiguous social situations. Further, children with high BI were less likely to attribute the cause of negative social situations to external factors, particularly when mothers were less accepting of children's negative emotional displays. Findings are discussed in terms of cognition related to the interpretation of ambiguous and threat-related social situations among temperamentally at-risk children.

Social Interpretation Bias in Children and Adolescents with Anxiety Disorders: Psychometric Examination of the Self-report of Ambiguous Social Situations for Youth (SASSY) Scale

BACKGROUND

Anxiety disorders are among the most common mental health problems in youth, and faulty interpretation bias has been positively linked to anxiety severity, even within anxiety-disordered youth. Quick, reliable assessment of interpretation bias may be useful in identifying youth with certain types of anxiety or assessing changes on cognitive bias during intervention.

OBJECTIVE

This study examined the factor structure, reliability, and validity of the Self-report of Ambiguous Social Situations for Youth (SASSY) scale, a self-report measure developed to assess interpretation bias in youth.

METHODS

Participants (N=488, age 7 to 17) met diagnostic criteria for Social Phobia, Generalized Anxiety Disorder, and/or Separation Anxiety Disorder. An exploratory factor analysis was performed on baseline data from youth participating in a large randomized clinical trial.

RESULTS

Exploratory factor analysis yielded two factors (Accusation/Blame, Social Rejection). The SASSY full scale and Social Rejection factor demonstrated adequate internal consistency, convergent validity with social anxiety, and discriminant validity as evidenced by non-significant correlations with measures of non-social anxiety. Further, the SASSY Social Rejection factor accurately distinguished children and adolescents with Social Phobia from those with other anxiety disorders, supporting its criterion validity, and revealed sensitivity to changes with treatment. Given the relevance to youth with social phobia, pre- and post-intervention data were examined for youth social phobia to test sensitivity to treatment effects; results suggested that SASSY scores reduced for treatment responders.

CONCLUSIONS

Findings suggest the potential utility of the SASSY Social Rejection factor as a quick, reliable, and efficient way of assessing interpretation bias in anxious youth, particularly as related to social concerns, in research and clinical settings.

Parental responsibility beliefs: associations with parental anxiety and behaviours in the context of childhood anxiety disorders

BACKGROUND

High levels of parental anxiety are associated with poor treatment outcomes for children with anxiety disorders. Associated parental cognitions and behaviours have been implicated as impediments to successful treatment. We examined the association between parental responsibility beliefs, maternal anxiety and parenting behaviours in the context of childhood anxiety disorders.

METHODS

Anxious and non-anxious mothers of 7-12 year old children with a current anxiety disorder reported their parental responsibility beliefs using a questionnaire measure. Parental behaviours towards their child during a stressor task were measured.

RESULTS

Parents with a current anxiety disorder reported a greater sense of responsibility for their child's actions and wellbeing than parents who scored within the normal range for anxiety. Furthermore, higher parental responsibility was associated with more intrusive and less warm behaviours in parent-child interactions and there was an indirect effect between maternal anxiety and maternal intrusive behaviours via parental responsibility beliefs.

LIMITATIONS

The sample was limited to a treatment-seeking, relatively high socio-economic population and only mothers were included so replication with more diverse groups is needed. The use of a range of stressor tasks may have allowed for a more comprehensive assessment of parental behaviours.

CONCLUSIONS

The findings suggest that parental anxiety disorder is associated with an elevated sense of parental responsibility and may promote parental behaviours likely to inhibit optimum child treatment outcomes. Parental responsibility beliefs may therefore be important to target in child anxiety treatments in the context of parental anxiety disorders.

Parental involvement: contribution to childhood anxiety and its treatment

Anxiety disorders are prevalent in youth. Despite demonstrated efficacy of cognitive behavioral therapy (CBT), approximately 40% of anxiety-disordered youth remain unresponsive to treatment. Because developmental and etiological models suggest that parental factors are relevant to the onset and maintenance of childhood anxiety, researchers have proposed and investigated family-based interventions with increased parent work in treatment, aiming to improve the efficacy of treatment for childhood anxiety. However, contrary to what theoretical models suggest, data to date did not indicate additive benefit of family-based CBT in comparison with child-centered modality. Is parent/family involvement unnecessary when treating childhood anxiety disorders? Or could there be the need for specificity (tailored family-based treatment) that is guided by a revised conceptualization that improves the implementation of a family-based intervention? The current review examines (1) relevant parental factors that have been found to be associated with the development and maintenance of childhood anxiety and (2) interventions that incorporate parental involvement. Relevant findings are integrated to formulate a "targeted" treatment approach for parental involvement in CBT for youth anxiety. Specifically, there is potential in the assessment of parent/family factors prior to treatment (for appropriateness) followed by a target-oriented implementation of parent training.

Predictors of maternal state anxiety on arrival at a Japanese hospital outpatient clinic: a cross-sectional study

AIMS AND OBJECTIVES

To identify the factors that predict maternal state anxiety when mothers and their sick children visit the outpatient unit of a paediatric hospital.

BACKGROUND

While previous studies have focused on predictors of anxiety in mothers with ill children, the existing literature is limited in study design, research timing, respondent characteristics, sample size and data analysis.

DESIGN

A cross-sectional design with self-administered questionnaires.

METHODS

Mothers were recruited from the outpatient unit of a Japanese paediatric hospital (N = 1077). Participants' state anxiety scores were collected using the Japanese version of Spielberger's State-Trait Anxiety Inventory. The independent variables were the mothers' and sick children's background information.

RESULTS

Participants were 1077 mothers; 990 provided valid responses. Mothers' mean state anxiety score was 49·72. Significant predictors of maternal anxiety were mothers' childrearing anxiety, child age, the sick child having a fever, sick child having siblings, having a person providing childrearing support, the mother's first visit to the hospital, out-of-hours visit and severity of the child's illness. The overall model explained 21·6% of the variance (multiple regression analysis).

CONCLUSIONS

As various factors predicted maternal anxiety, identifying methods to address these factors may reduce maternal state anxiety.

RELEVANCE TO CLINICAL PRACTICE

There is potential for improved understanding of the predictors of maternal state anxiety to aid in the development of materials that would best measure anxiety. The present findings may also suggest some means of providing appropriate information and support to anxious mothers. Our findings cannot demonstrate causation, however, and teaching methods and supportive practices were not investigated; therefore, a qualitative study on the concrete content of maternal anxiety and an intervention study to create support services for anxious mothers is required. In addition, prospective or longitudinal studies are also important for investigating causation.

Single-Session Cognitive Bias Modification of Interpretations Training in High-Anxious Adolescents

Anxiety disorders in youths are globally prevalent and carry impairing, long-lasting effects. Interpreting ambiguous cues negatively may be causally related to adolescent anxiety. Extending cognitive bias modification of interpretations (CBM-I) training, which counters anxiety by encouraging positive interpretations, to anxious adolescents could inform the design of new interventions. The study investigates whether single-session CBM-I training (a) altered interpretation biases and negative mood in adolescents selected for high anxiety and (b) whether these training-associated changes were larger than those reported in low-anxious adolescents. Seventy-seven Chinese adolescents received either positive or control training. Positive training encouraged endorsement of positive interpretations of ambiguous scenarios while on control training trials, half of the scenarios were resolved positively and half negatively. A single session of CBM-I altered interpretation biases across all individuals, F(1, 52) = 10.63, p < .01, η2 = .17. However, no training effects on mood measures emerged (all ps > .05). Training effects were not consistently moderated by baseline trait anxiety. Multisession CBM-I may be needed for mood changes to occur.

Reducing negative interpretations in adolescents with anxiety disorders: a preliminary study investigating the effects of a single session of cognitive bias modification training

Anxiety disorders are globally prevalent, debilitating and onset in early life. Cognitive bias modification of interpretations (CBM-I) training has emerged as a targeted intervention for early emerging anxiety problems. While CBM-I can alter interpretational styles in unselected and clinical-analogue samples of adolescents, no studies have assessed its capacity to change biases in clinical samples. Here, we assessed training efficacy in ameliorating interpretation biases and anxious mood in adolescents with anxiety disorders. Twenty-eight Chinese adolescents meeting criteria for a current anxiety disorder were randomly assigned to receive positive or neutral CBM-I training. Training involved completing a word-fragment to resolve the outcomes of sixty ambiguous scenarios. During positive training, scenarios ended with benign/positive resolutions, but during neutral training, half of the scenarios were resolved positively and half negatively. Positively trained patients interpreted new ambiguous scenarios less negatively than the neutral training group although training effects were not observed on a questionnaire measure of interpretation bias. Training effects on mood were also absent. Before the clinical implications of CBM-I can be considered in adolescents, research needs to establish optimal training parameters for symptom-changes to occur.

Parental and Family Factors as Predictors of Threat Bias in Anxious Youth

The present study examined the relative predictive value of parental anxiety, parents' expectation of child threat bias, and family dysfunction on child's threat bias in a clinical sample of anxious youth. Participants (N = 488) were part of the Child/Adolescent Anxiety Multi-modal study (CAMS), ages 7-17 years (M = 10.69; SD = 2.80). Children met diagnostic criteria for generalized anxiety disorder, separation anxiety and/or social phobia. Children and caregivers completed questionnaires assessing child threat bias, child anxiety, parent anxiety and family functioning. Child age, child anxiety, parental anxiety, parents' expectation of child's threat bias and child-reported family dysfunction were significantly associated with child threat bias. Controlling for child's age and anxiety, regression analyses indicated that parents' expectation of child's threat bias and child-reported family dysfunction were significant positive predictors of child's self-reported threat bias. Findings build on previous literature by clarifying parent and family factors that appear to play a role in the development or maintenance of threat bias and may inform etiological models of child anxiety.

Experimental modification of interpretation bias regarding social and animal fear in children

Using an experimental bias modification task, an interpretation bias towards or away from threat was induced about animal or social situations in a sample of 103 children split into a young (7-10 years) and old age group (11-15 years). Children rapidly learned to select outcomes of ambiguous situations which were congruent with their assigned modification condition. Following positive modification, children's threat interpretation biases significantly decreased, while threat biases increased (non-significantly) after negative modification. Bias modification effects also varied as a function of age with children appearing particularly vulnerable to acquiring biases about stimuli that were congruent with the normative fears for their age group. Weak age-related modification-congruent effects on younger but not older children's anxiety vulnerability in response to a behavioral task were also observed. However, no consistent effects of bias modification on avoidance behavior were found.

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

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

Negative Social Cognitions in Socially Anxious Youth: Distorted Reality or a Kernel of Truth?

We review studies that investigate negative social cognitions of socially anxious youth in relation to two specific domains: interpretation of ambiguous social situations and self-evaluation of social performance, including social skills and nervous behaviors. In this review, we address the question whether socially anxious youth's negative perceptions are distortions of reality or reflect a kernel of truth as compared to other sources of information including independent adult observers and age peers. Studies key to this question are those that investigate not only the social perceptions themselves but also the social behavior of socially anxious youth. Hence the selection of studies for the review was based on this criterion. From the relevant literature it is, as yet, unclear whether the negative interpretations of ambiguous social situations shown by socially anxious youth are distorted or a reflection of reality. Socially anxious youth's self-evaluations of social skills appear partly distorted and partly true, depending on the person judging the social skills. In contrast, self-evaluations of nervous behaviors appear distorted. The studies reviewed indicate that research would benefit from including a wider range of perceptions from persons relevant to the socially anxious youth's daily social environment, not only parents and teachers but also their age peers.