One-year follow-up of family versus child CBT for anxiety disorders: Exploring the roles of child age and parental intrusiveness

A Randomized Controlled Trial of Two Parenting Interventions on Enhancing Parental Resilience Resources and Reducing Children's Problem Behaviors in Chinese Cross-Boundary Families: Positive Benefits and Moderation Effects

Daily cross-boundary schooling between Shenzhen and Hong Kong constitutes a constant challenge for Chinese cross-boundary families in terms of parenting burden. To address their most urgent parenting needs, we adapted and evaluated two intervention approaches-improving emotional regulation and providing knowledge about Hong Kong. A cluster randomized controlled trial with repeated assessments (pre-, post-intervention, and one-month follow-up) was adopted to evaluate the intervention effects on the increases of parental resilience resources and reduction of children's problem behaviors. We further conducted moderation analyses to investigate whether parents with more increases in parental resilience resources would report a greater reduction in children's problem behaviors. A total of 214 mothers of cross-boundary families were randomly assigned to the emotional regulation arm (ER, n = 120) or the information provision arm (IP, n = 94). Both intervention arms showed positive effects on emotional regulation strategies, and the IP arm outperformed the ER arm in knowledge acquisition. Both arms showed significant and comparable improvements in parental self-efficacy and children's problem behaviors. Moreover, participants in the IP arm who reported more improvements in parental resilience resources showed a greater reduction in children's problem behaviors. By adapting two interventions to a new population of cross-boundary families, this trial extended the benefits from parents to children and demonstrated that the improvement of parental resilience resources makes a difference in reducing children's problem behaviors in the IP arm. Future studies are suggested to focus on parental resilience resources and maximize the benefits on children's outcomes.

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.

Family based treatment of anxiety disorders: A review of the literature (2010-2019)

Anxiety disorders are the most common and impairing mental health problems across the lifespan. Familial factors are strongly implicated in the onset and maintenance of anxiety, but available evidence-based treatments are usually individual-focused. The aim of this review was to evaluate the current evidence base (2010-2019) of family based interventions addressing youth and adult anxiety and highlight findings comparing family based and individual-focused treatments. A systematic literature search was conducted. Articles were considered if they targeted primarily anxiety-related issues and utilized a randomized controlled trial design, resulting in 22 included youth studies. No adult studies met criteria for inclusion. Overall, family based treatments performed better than no-treatment controls and as well as individual-based interventions, with some evidence that family based interventions might outperform individual-based ones in certain populations (i.e., autism). Family based interventions may represent a good alternative for anxiety treatment in youth. Additional research on family based treatment for anxiety is adults is needed.

The Pediatric Autism Spectrum Therapy Observation System: Development, Psychometric Properties, and Sensitivity to Treatment

An observational coding system was developed to track clinical change in children with autism spectrum disorder (ASD) during psychotherapy. The Pediatric Autism Spectrum Therapy Observation System (PASTOS) consists of 23 items divided into 5 subscales and is used to rate child behaviors in individual psychotherapy sessions. Manual-based cognitive behavioral therapy session transcripts of 22 children diagnosed with ASD (IQ > 70) and a concurrent anxiety disorder (M = 9.41 years, SD = 1.56 years) enrolled in a randomized, controlled trial were coded. Results suggested that the PASTOS exhibited promising interrater reliability, internal consistency, convergent validity at post-treatment, and treatment sensitivity. The PASTOS may be a useful tool for studying process and outcome in psychotherapy research on children with ASD.

Supporting the parents of children and young people with anxiety and depressive disorders is an opportunity not to be missed: a scoping review

Guidance is scarce on whether and how to involve parents in treatment for anxiety and depressive disorders in children and young people. We did a scoping review of randomised controlled trials of psychological interventions for anxiety and depressive disorders in children and young people, in which parents were involved in treatment, to identify how parents and carers have been involved in such treatments, how this relates to both child and broader outcomes, and where research should focus. We identified 73 trials: 62 focused on anxiety and 11 on depressive disorders. How parents were involved in treatments varied greatly, with at least 13 different combinations of ways of involving parents in the anxiety trials and seven different combinations in the depression trials. Including parents in treatment did not impair children's and young people's outcomes, but the wide variability in how they were involved prevents clarity about why some trials favoured parent involvement and others did not. Studies must consider the long-term and wider benefits beyond children's and young people's mental health, such as enhanced engagement, family wellbeing, and economic gains.

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

Parent- and family-level correlates of youth anxiety are well-documented, and they highlight potential targets for family-focused intervention. Although family-based approaches for treating youth anxiety generally are considered efficacious for achieving symptom reduction, they vary in format and approach and it remains unclear whether they offer an advantage over individual child treatment. To better understand the current state of the evidence, we used meta-analytic methods to examine the therapeutic approaches described in existing family interventions for child and adolescent anxiety, whether they mapped to the major mechanisms proposed in the literature, and the timeline along which relevant parent/family variables were measured. We examined how these mechanism-focused family interventions performed in RCTs relative to individual child CBT and whether they shifted symptoms and relevant parenting behaviors. A total of 11 randomized controlled trials (RCTs) compared individual cognitive behavior therapy (CBT) to CBT+ a family component (CBT + FAM) and included a youth anxiety measure at pre- and post-treatment; only half of these (n=6) also included a parent/family functioning measure at both pre- and post-treatment (across both primary and secondary outcome papers). Only a single study included anxiety measures at a mid-treatment time point, and none included parent measures at a mid-treatment time point. Findings are discussed in terms of design considerations and advancing the field of family intervention for youth anxiety.

Cognitive behaviour therapy-based early intervention and prevention programme for anxiety in South African children with visual impairments

Background

Anxiety is the most common psychological difficulty reported by youth worldwide and may also be a significant problem for children with visual impairments. Cognitive behaviour therapy (CBT) interventions have proven to be successful in treating childhood anxiety; however, mostly these are not suitable for children with visual impairments, as the materials used are not sufficiently accessible to this population.

Objectives

The present study was motivated by the dearth of research on this topic and aimed to examine the effects of a specifically tailored, group-based, universally delivered, CBT intervention for anxiety in children with visual impairments and to examine the influence of three predictor variables (i.e. age, gender and level of visual impairment) on prevention effects.

Method

A randomised wait-list control group design with pre-, post- and follow-up intervention measures was employed. The final sample of 52 children (aged 9–14) with varying degrees of visual impairment received the anxiety intervention. Participants were followed over a course of 10 months during which their anxiety symptoms were assessed quantitatively at four time points (T1–T4).

Results

The results indicated that the anxiety intervention did not significantly decrease symptoms of anxiety within the intervention groups. However, the intervention appeared beneficial for girls, younger children and legally blind participants.

Conclusion

This study demonstrated how CBT interventions can be adapted for use in children with visual impairments. Results obtained provide a foundation upon which future updated anxiety intervention programmes can be built, meeting the need for further research in this area.

Potential for children with intellectual disability to engage in cognitive behaviour therapy: the parent perspective

BACKGROUND

This study aimed to obtain the opinions of parents and carers of children with intellectual disability (ID) as to whether cognitive behaviour therapy (CBT) could be useful for their children.

METHODS

A mixed qualitative and quantitative method was employed. Twenty-one carers of children aged 10 to 17 having borderline to moderate intellectual functioning responded to an online questionnaire. Participants were provided with information about CBT and asked to respond to open-ended questions. Quantitative data pertained to questions about their child's ability to identify and describe thoughts, feelings and behaviours. Thematic analysis of responses was conducted using an inductive method of identifying themes from the qualitative data collected.

RESULTS

Five themes emerged from the qualitative analysis: Emotional Attunement (i.e. parent's understanding and recognition of their child's emotions), Role of the Therapist (i.e. ways therapists could facilitate the intervention), Role of the Parent (i.e. ways parents could engage in the therapy process), Anticipated Obstacles (i.e. what may get in the way of the therapy) and Suggested Adaptations for Therapy (i.e. how CBT can be adapted to suit the needs of children with ID). Seventy-six per cent agreed that their child would be able to engage in CBT with assistance.

CONCLUSIONS

The majority of parents believed that CBT is an intervention that children with ID could engage in, provided the therapy is adapted, and the therapist accommodates their needs.

Attention to Peer Feedback Through the Eyes of Adolescents with a History of Anxiety and Healthy Adolescents

During adolescence, youth may experience heightened attention bias to socially relevant stimuli; however, it is unclear if attention bias toward social threat may be exacerbated for adolescents with a history of anxiety. This study evaluated attentional bias during the Chatroom-Interact task with 25 adolescents with a history of anxiety (18F, Mage = 13.6) and 22 healthy adolescents (13F, Mage = 13.8). In this task, participants received feedback from fictional, virtual peers who either chose them (acceptance) or rejected them (rejection). Overall, participants were faster to orient toward and spent longer time dwelling on their own picture after both rejection and acceptance compared to non-feedback cues. Social feedback was associated with greater pupillary reactivity, an index of cognitive and emotional neural processing, compared to non-feedback cues. During acceptance feedback (but not during rejection feedback), anxious youth displayed greater pupil response compared to healthy youth, suggesting that positive feedback from peers may differentially influence youth with a history of an anxiety disorder.

An experimental test of the impact of adolescent anxiety on parental sick role reinforcement behavior

A large body of work links parental sick role reinforcement behavior to adolescent panic vulnerability. To date, however, little work has examined the role of the adolescent in this process. The current study addressed this gap in the literature, using a novel method to experimentally test the impact of adolescent anxiety during a straw-breathing task on parental propensity to engage in sick role reinforcement behavior. An unselected sample of 51 early adolescents (26 female, 10-14 years) and their parents participated in the study. Adolescents were trained to mimic a straw-breathing task, and adolescent reactions to the task were scripted. Parents were randomly assigned to watch their adolescent react either a) anxiously or b) non-anxiously to the straw-breathing task. Parents who viewed their adolescent react anxiously ended the task earlier, reported that they would reinforce more sick role behavior, and reported more negatively valenced reactions during the task than parents who viewed their adolescent react non-anxiously to the task. No group differences emerged in terms of parental self-reported or physiological arousal during the task. Results suggest that adolescent anxiety increases parental sick role reinforcement behavior. Findings are discussed in terms of future directions for reducing parenting behaviors thought to increase vulnerability for panic among adolescents.

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.

Effects of a parent training programme for the treatment of young children with separation anxiety disorder

Cognitive behavioural therapy (CBT) has been shown to be an effective treatment for anxiety disorders in children. However, the majority of studies conducted to date have included heterogeneous samples of children combining social anxiety disorder, generalized anxiety disorder and separation anxiety disorder (SAD) together. Few studies have examined the efficacy of CBT to specifically treat SAD. Moreover, research on the impact of CBT for SAD in children younger than 7 years old has been very limited. To address these issues, we examined the effects of a CBT parent training programme with six children with SAD aged between 4 and 7 years using a non-concurrent multiple baseline design. Parents completed semi-structured interviews, questionnaires and daily diaries to assess their child's anxiety symptoms, parental practices and parental stress. Results indicated that five of six children no longer met the criteria for SAD diagnosis after treatment and at 3-month follow-up. Moreover, the daily diaries showed that four of six children presented a systematic favourable change of the total weekly frequency of SAD symptoms. Finally, four mothers reported a decrease in overprotection, but we observed no changes in parental stress.

Assessment and Treatment of Anxiety Among Children and Adolescents

Among children and adolescents, anxiety disorders are common psychiatric disorders that confer risk of comorbid psychiatric disorders and social and academic impairment. This review focuses on the assessment and treatment of anxiety disorders among children and adolescents, with attention to separation anxiety disorder, social phobia disorder (social anxiety disorder), panic disorder, and generalized anxiety disorder. Comprehensive assessment of child and adolescent anxiety disorders benefits from a multimethod approach to evaluation and diagnosis, including semistructured interviews; child and informant questionnaires; collateral information from parents, teachers, pediatricians, and school psychologists; and behavioral observations. Because anxiety symptoms can include avoidance behaviors, somatic complaints, social difficulties, and sleep disturbances, consideration of a differential diagnosis is important. Among the available psychosocial interventions, cognitive-behavioral therapy (CBT) and exposure-based therapies have emerged as the most well-established treatment approaches for addressing anxiety disorders among children and adolescents. Pharmacologically, selective serotonin reuptake inhibitors (SSRIs) have been established to be safe and efficacious for the treatment of pediatric anxiety and are considered the medications of choice for this population. Research indicates that CBT plus SSRI medication is the most effective treatment of anxiety for youths ages seven to 17, compared with either CBT or medication alone. Medication monotherapy and CBT monotherapy have also been demonstrated to be effective treatments.

Parenting Stress Among Caregivers of Children With Bipolar Spectrum Disorders

Caregivers of psychiatrically impaired children experience considerable parenting stress. However, no research has evaluated parenting stress within the context of pediatric bipolar spectrum disorders (BPSD). Thus, the aim of this investigation was to identify predictors and moderators of stress among caregivers in the Longitudinal Assessment of Manic Symptoms study. Participants included 640 children and their caregivers in the Longitudinal Assessment of Manic Symptoms cohort. Children had a mean age of 9.4 ± 1.9 years (68% male, 23% BPSD); parents had a mean age of 36.5 ± 8.3 years (84% mothers). Children with BPSD had more service utilization, psychiatric diagnoses, mood and anxiety symptoms, and functional impairment but fewer disruptive behavior disorders. Caregivers of children with BPSD were more likely than caregivers of children without BPSD to have a partner, elevated depressive symptoms, antisocial tendencies, and parenting stress (Cohen's d = .49). For the whole sample, higher child IQ, mania, anxiety, disruptive behavior, and caregiver depression predicted increased parenting stress; maternal conduct disorder predicted lower stress. Child anxiety and disruptive behavior were associated with elevated caregiver stress only for non-BPSD children. Caregivers of children with BPSD experience significant burden and thus require specialized, family-focused interventions. As stress was also elevated, to a lesser degree, among depressed caregivers of children with higher IQ, mania, anxiety, and disruptive behavior, these families may need additional supports as well. Although parents with conduct/antisocial problems evidenced lower stress, these difficulties should be monitored. Thus, parenting stress should be evaluated and addressed in the treatment of childhood mental health problems, especially BPSD.

Applying new evidence standards to youth cognitive behavioral therapies - A review

This review included 136 published randomized controlled trials (RCTs) of youth cognitive behavioral therapy (CBT) treatments. We aimed to test the premise that evidence-based youth treatments can be better differentiated from each other by applying more nuanced standards of evidence. Accordingly, we applied three standards to this article sample to determine how many treatments produced significant results: (a) on multiple target symptom measures, (b) at follow-up, and/or (c) against an active comparison group. We identified how many trials met standards individually and in combination. Although 87 of the 136 articles produced at least one significant treatment result at post-assessment, the subsets of "passing" articles were smaller and varied for any one of our three standards, with only 11 articles (8%) meeting all three standards simultaneously. Implications are discussed regarding the definition of "evidence-based," the need for multi-parameter filtering in treatment selection and clinical decision making, and future directions for research. We ultimately argue the value in assessing youth treatments for different types of evidence, which is better achieved through dynamic sets of standards, rather than a single approach to assessing general strength of evidence.

Threat interpretation and parental influences for children with asthma and anxiety

Anxiety disorders are highly prevalent in children with asthma yet very little is known about the cognitive and parent factors that may underpin this relationship. The present study investigated interpretation biases in children with asthma and anxiety and their parents, and whether parent-child discussions influenced children's interpretations. Eighty-nine parent-child dyads were included across four groups: children with asthma and anxiety, children with anxiety only, children with asthma only and healthy children (aged between 8 and 13 years old). Interpretation bias was assessed using ambiguous scenarios. Children with anxiety showed an interpretation bias in the general threat scenarios, whereas children with asthma showed an interpretation bias in the asthma threat scenarios. Parental predictions of their child's responses showed similar results. Parent-child discussions increased avoidance for children with anxiety and no asthma across all scenarios, but only for children with asthma and anxiety in the asthma threat scenarios. The results provide partial support for a cognitive theory of asthma and anxiety in children and suggest that parents play a role in influencing children's thinking styles. Treatment programs could thus aim to target and modify interpretation biases in children with anxiety, and include parents as part of treatment.

Parental Involvement in Cognitive-Behavioral Intervention for Anxious Children: Parents' In-Session and Out-Session Activities and Their Relationship with Treatment Outcome

The present study explored the role of parents' in-session and out-session involvement in CBT for anxious children. Fifty 8- to 12-year-old children with a principal DSM-IV anxiety disorder participated in a group CBT program. Parental involvement in the therapy was assessed by the clinician and the children and parents completed a standardized anxiety scale as the main therapy outcome measure, at pre- and post-intervention. In addition, the parents completed questionnaires to evaluate a number of possible correlates of parental involvement, namely, child's anxiety symptoms intensity and interference, parental beliefs about anxiety, expectancies regarding the efficacy of the intervention, and parental anxiety. The results indicated that the parents were moderately involved in the therapy and that socio-economic status and parental beliefs about anxiety were significant correlates of parental involvement. Finally, partial support was found for the idea that parents' involvement in the therapy might have a positive impact on therapy outcome.

Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety

Anxiety disorders are the most common mental health disorder among children and adolescents. We examined 111 treatment outcome studies testing 204 treatment conditions for child and adolescent anxiety published between 1967 and mid-2013. Studies were selected for inclusion in this review using the PracticeWise Evidence-Based Services database. Using guidelines identified by this journal (Southam-Gerow & Prinstein, 2014), studies were included if they were conducted with children and/or adolescents (ages 1-19) with anxiety and/or avoidance problems. In addition to reviewing the strength of the evidence, the review also examined indicators of effectiveness, common practices across treatment families, and mediators and moderators of treatment outcome. Six treatments reached well-established status for child and adolescent anxiety, 8 were identified as probably efficacious, 2 were identified as possibly efficacious, 6 treatments were deemed experimental, and 8 treatments of questionable efficacy emerged. Findings from this review suggest substantial support for cognitive-behavioral therapy (CBT) as an effective and appropriate first-line treatment for youth with anxiety disorders. Several other treatment approaches emerged as probably efficacious that are not primarily CBT based, suggesting that there are alternative evidence-based treatments that practitioners can turn to for children and adolescents who do not respond well to CBT. The review concludes with a discussion of treatments that improve functioning in addition to reducing symptoms, common practices derived from evidence-based treatments, mediators and moderators of treatment outcomes, recommendations for best practice, and suggestions for future research.

Parental involvement in youth anxiety treatment: conceptual bases, controversies, and recommendations for intervention

Parents are often perceived as a contributing or maintaining source of youth anxiety disorders, making them natural targets for either intervention or involvement in treatment protocols. Efforts to increase the efficacy and durability of standard treatments by incorporating parents have been successful, yet they often do not outperform child-focused treatment. Breinholst et al. (2012) review and discuss several overlooked parental research variables (anxiety, overcontrol, beliefs and assumptions, global family dysfunction) found to promote and maintain child anxiety. However, it remains unclear how these proposed variables interfere with active therapeutic ingredients (e.g., exposure) or how the identified problems might be addressed. We propose that insufficient attention to exposure-based treatment and family behavioral responses explain the comparatively low added value for parental involvement in child anxiety treatment and outline directions for research to address them. With meaningful attention being given to exposure and its accompanying variables in the treatment of childhood anxiety, we believe that treatment outcomes and intervention acceptability can be improved.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

A previous Cochrane review (James 2005) showed that cognitive behavioural therapy (CBT) was effective in treating childhood anxiety disorders; however, questions remain regarding (1) the relative efficacy of CBT versus non-CBT active treatments; (2) the relative efficacy of CBT versus medication and the combination of CBT and medication versus placebo; and (3) the long-term effects of CBT. 

OBJECTIVES

To examine (1) whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison with (a) wait-list controls; (b) active non-CBT treatments (i.e. psychological placebo, bibliotherapy and treatment as usual (TAU)); and (c) medication and the combination of medication and CBT versus placebo; and (2) the long-term effects of CBT.

SEARCH METHODS

Searches for this review included the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Depression, Anxiety and Neurosis Group Register, which consists of relevant randomised controlled trials from the bibliographic databases－The Cochrane Library (1970 to July 2012), EMBASE, (1970 to July 2012) MEDLINE (1970 to July 2012) and PsycINFO (1970 to July 2012).

SELECTION CRITERIA

All randomised controlled trials (RCTs) of CBT versus waiting list, active control conditions, TAU or medication were reviewed. All participants must have met the criteria of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD) for an anxiety diagnosis, excluding simple phobia, obsessive-compulsive disorder, post-traumatic stress disorder and elective mutism.

DATA COLLECTION AND ANALYSIS

The methodological quality of included trials was assessed by three reviewers independently. For the dichotomous outcome of remission of anxiety diagnosis, the odds ratio (OR) with 95% confidence interval (CI) based on the random-effects model, with pooling of data via the inverse variance method of weighting, was used. Significance was set at P < 0.05. Continuous data on each child's anxiety symptoms were pooled using the standardised mean difference (SMD).

MAIN RESULTS

Forty-one studies consisting of 1806 participants were included in the analyses. The studies involved children and adolescents with anxiety of mild to moderate severity in university and community clinics and school settings. For the primary outcome of remission of any anxiety diagnosis for CBT versus waiting list controls, intention-to-treat (ITT) analyses with 26 studies and 1350 participants showed an OR of 7.85 (95% CI 5.31 to 11.60, Z = 10.26, P < 0.0001), but with evidence of moderate heterogeneity (P = 0.04, I² = 33%). The number needed to treat (NNT) was 6.0 (95% CI 7.5 to 4.6). No difference in outcome was noted between individual, group and family/parental formats. ITT analyses revealed that CBT was no more effective than non-CBT active control treatments (six studies, 426 participants) or TAU in reducing anxiety diagnoses (two studies, 88 participants). The few controlled follow-up studies (n = 4) indicate that treatment gains in the remission of anxiety diagnosis are not statistically significant.

AUTHORS' CONCLUSIONS

Cognitive behavioural therapy is an effective treatment for childhood and adolescent anxiety disorders; however, the evidence suggesting that CBT is more effective than active controls or TAU or medication at follow-up, is limited and inconclusive.

Parental changes after involvement in their anxious child's cognitive behavior therapy

OBJECTIVE

Specific parental behaviors and cognitions are associated with child anxiety. Studies informing us of the directionality of the associations are lacking. We investigated the effect of parental involvement in children's anxiety treatment on parental behaviors and cognitions.

METHOD

Children (N=54, 7-12 years) and parents were randomly allocated to different treatment groups (involved, not involved). Observed behavior, self-reported behavior and cognitions were assessed separately for mothers and fathers at pre-, posttreatment and follow-up.

RESULTS

There were no differences over time for self-reported parental efficacy and observed negativity, but self-reported autonomy granting increased for both groups over time. Differential effects were found between groups for observed paternal over-involvement (fathers involved in treatment showed a more rapid decrease) and self-reported maternal autonomy-granting (non-involved mothers showed a greater increase).

CONCLUSION

Our findings suggest that child anxiety significantly influences parental behaviors and cognitions. Child therapy may successfully change the family system.

The effect of parent involvement in the treatment of anxiety disorders in children: a meta-analysis

Among clinicians, it is common practice to include parents in treatment, and it has been taken for granted that parents' involvement in their children's treatment is beneficial for therapy outcome, although research on this issue is far from clear. A meta-analysis was carried out in order to investigate whether parent involvement potentiates the outcome for children with anxiety disorders when treated with cognitive-behavior therapy. Sixteen studies, which directly compared parent-involved treatments with child-only treatments, were included in the meta-analysis. The results showed a small, nonsignificant effect size of - 0.10 in favor of the child-only treatments. There was no indication of publication bias in the analysis. Implications of the results are discussed.

Measuring anxiety as a treatment endpoint in youth with autism spectrum disorder

Despite the high rate of anxiety in individuals with autism spectrum disorder (ASD), measuring anxiety in ASD is fraught with uncertainty. This is due, in part, to incomplete consensus on the manifestations of anxiety in this population. Autism Speaks assembled a panel of experts to conduct a systematic review of available measures for anxiety in youth with ASD. To complete the review, the panel held monthly conference calls and two face-to-face meetings over a fourteen-month period. Thirty eight published studies were reviewed and ten assessment measures were examined: four were deemed appropriate for use in clinical trials, although with conditions; three were judged to be potentially appropriate, while three were considered not useful for clinical trials assessing anxiety. Despite recent advances, additional relevant, reliable and valid outcome measures are needed to evaluate treatments for anxiety in ASD.

Child anxiety and parenting in England and Italy: the moderating role of maternal warmth

BACKGROUND

Parenting factors have been implicated in the aetiology and maintenance of child anxiety. Most research has been correlational with little experimental or longitudinal work. Cross-cultural comparison could be illuminating. A comparison of Italian and British children and their mothers was conducted.

METHODS

A sample of 8- to 10-year old children, 60 Italian and 49 English, completed the Spence Child Anxiety Scale. Mothers also completed two questionnaires of parenting: the Skills of Daily Living Checklist (assessing maternal autonomy granting) and the Parent-Child Interaction Questionnaire (assessing maternal intrusiveness). Parenting was assessed in two video-recorded blindly rated mother-child interaction tasks, the 'belt-buckling tasks and the 'etch-a-sketch', providing objective indices of overcontrol, warmth, lack of autonomy granting, and overprotection.

RESULTS

There were no differences between the children in overall anxiety and specific forms of anxiety. Parenting, however, was markedly different for the two countries. Compared to English mothers, on the two questionnaires, Italian mothers were significantly less autonomy granting and more intrusive; and in terms of the observed indices, a significantly greater proportion of the Italian mothers displayed a high level of both overprotection and overcontrol, and a low level of autonomy granting. Notably, Italian mothers evidenced significantly more warmth than English mothers; and maternal warmth was found to moderate the impact of self-reported maternal intrusiveness on the level of both overall child anxiety and the level of child separation anxiety; and it also moderated the relationship between both observed maternal intrusiveness and overall child anxiety and observed maternal overprotectiveness and child separation anxiety.

CONCLUSIONS

Although, compared to the British mothers, the Italian mothers were more likely to evidence high levels of parenting behaviours previously found to be anxiogenic, the high levels of warmth displayed by these mothers to their children appears to have neutralised the adverse impact of these behaviours.

The effectiveness of booster sessions in CBT treatment for child and adolescent mood and anxiety disorders

BACKGROUND

To investigate the effects of booster sessions in cognitive behavioral therapy (CBT) for children and adolescents with mood or anxiety disorders, whereas controlling for youth demographics (e.g., gender, age), primary diagnosis, and intervention characteristics (e.g., treatment modality, number of sessions).

METHODS

Electronic databases were searched for CBT interventions for youth with mood and anxiety disorders. Fifty-three (k = 53) studies investigating 1,937 youth met criteria for inclusion. Booster sessions were examined using two case-controlled effect sizes: pre-post and pre-follow-up (6 months) effect sizes and employing weighted least squares (WLSs) regressions.

RESULTS

Meta-analyses found pre-post studies with booster sessions had a larger effect size r = .58 (k = 15; 95% CI = 0.52-0.65; P < .01) than those without booster sessions r = .45 (k = 38; 95% CI = 0.41-0.49; P < .001). In the WLS regression analyses, controlling for demographic factors, primary diagnosis, and intervention characteristics, studies with booster sessions showed larger pre-post effect sizes than those without booster sessions (B = 0.13, P < .10). Similarly, pre-follow-up studies with booster sessions showed a larger effect size r = .64 (k = 10; 95% CI = 0.57-0.70; P < .10) than those without booster sessions r = .48 (k = 20; 95% CI = 0.42-0.53; P < .01). Also, in the WLS regression analyses, pre-follow-up studies showed larger effect sizes than those without booster sessions (B = 0.08, P < .01) after accounting for all control variables.

CONCLUSIONS

Result suggests that CBT interventions with booster sessions are more effective and the effect is more sustainable for youth managing mood or anxiety disorders than CBT interventions without booster sessions.

Exploring the Effect of Case Formulation Driven CBT for Children with Anxiety Disorders: A Feasibility Study

Background: Little is known about the effect of case-formulation based cognitive behaviour therapy (CBT) for anxious children. Aim: The present study explores the feasibility of case-formulation driven CBT for anxious children. Parents were involved in treatment as either co-facilitators (involved only as the child's assistants, treatment being primarily directed at the child), or as co-clients (parents received therapy targeting theoretically established maintaining mechanisms; children received half of the sessions, parents the other half). Method: Feasibility of the case-formulation driven CBT was established by comparing the completion rate and the percentage of children free of anxiety after treatment, with manualized treatments reported in existing meta-analyses. Children aged 7–12 years and their parents participated (n = 54). Families were assessed at pre- and posttreatment and at 6-month follow-up. Results: All families completed treatment and the percentage of recovery in the case-formulation driven approach was comparable to results obtained in manualized treatments. Conclusion: The findings from this stage I study supports the notion that a case-formulation driven approach to CBT may be a feasible option when selecting treatment for anxious children; however, further studies must be conducted before firm conclusions can be drawn.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

A previous Cochrane review (James 2005) showed that cognitive behavioural therapy (CBT) was effective in treating childhood anxiety disorders; however, questions remain regarding (1) the relative efficacy of CBT versus non-CBT active treatments; (2) the relative efficacy of CBT versus medication and the combination of CBT and medication versus placebo; and (3) the long-term effects of CBT. 

OBJECTIVES

To examine (1) whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison with (a) wait-list controls; (b) active non-CBT treatments (i.e. psychological placebo, bibliotherapy and treatment as usual (TAU)); and (c) medication and the combination of medication and CBT versus placebo; and (2) the long-term effects of CBT.

SEARCH METHODS

Searches for this review included the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Depression, Anxiety and Neurosis Group Register, which consists of relevant randomised controlled trials from the bibliographic databases－The Cochrane Library (1970 to July 2012), EMBASE, (1970 to July 2012) MEDLINE (1970 to July 2012) and PsycINFO (1970 to July 2012).

SELECTION CRITERIA

All randomised controlled trials (RCTs) of CBT versus waiting list, active control conditions, TAU or medication were reviewed. All participants must have met the criteria of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD) for an anxiety diagnosis, excluding simple phobia, obsessive-compulsive disorder, post-traumatic stress disorder and elective mutism.

DATA COLLECTION AND ANALYSIS

The methodological quality of included trials was assessed by three reviewers independently. For the dichotomous outcome of remission of anxiety diagnosis, the odds ratio (OR) with 95% confidence interval (CI) based on the random-effects model, with pooling of data via the inverse variance method of weighting, was used. Significance was set at P < 0.05. Continuous data on each child's anxiety symptoms were pooled using the standardised mean difference (SMD).

MAIN RESULTS

Forty-one studies consisting of 1806 participants were included in the analyses. The studies involved children and adolescents with anxiety of mild to moderate severity in university and community clinics and school settings. For the primary outcome of remission of any anxiety diagnosis for CBT versus waiting list controls, intention-to-treat (ITT) analyses with 26 studies and 1350 participants showed an OR of 0.13 (95% CI 0.09 to 0.19, Z = 10.26, P < 0.0001), but with evidence of moderate heterogeneity (P = 0.04, I² = 33%). The number needed to treat (NNT) was 6.0 (95% CI 7.5 to 4.6). No difference in outcome was noted between individual, group and family/parental formats. ITT analyses revealed that CBT was no more effective than non-CBT active control treatments (six studies, 426 participants) or TAU in reducing anxiety diagnoses (two studies, 88 participants). The few controlled follow-up studies (n = 4) indicate that treatment gains in the remission of anxiety diagnosis are not statistically significant.

AUTHORS' CONCLUSIONS

Cognitive behavioural therapy is an effective treatment for childhood and adolescent anxiety disorders; however, the evidence suggesting that CBT is more effective than active controls or TAU or medication at follow-up, is limited and inconclusive.

"You can do it!": The role of parental encouragement of bravery in child anxiety treatment

Individual cognitive-behavioral therapy (CBT) provides anxious youth with skills and experiences to increase "brave" behavior in the face of feared situations. This study addresses whether parental encouragement of bravery during an anxiety provoking and potentially avoidable naturalistic speech task (a) differs between parents of youth (ages 9-13) with anxiety disorders (N=47) and parents of healthy non-anxious controls (N=20); (b) influences response to treatment; and (c) changes during treatment for anxious youth randomized to receive CBT (N=30) or Child-Centered Therapy (CCT; a non-directive active comparison treatment; N=17). Parent-child dyads were videotaped during a discussion of whether or not the child should complete an optional speech task. Parents of anxious youth showed less encouragement of bravery than parents of controls. Encouragement of bravery increased from pre- to post-treatment for youth who received CBT but not CCT, and pre-treatment encouragement of bravery predicted a better response to treatment, particularly for youth receiving CBT.

Outcome domains in child mental health research since 1996: have they changed and why does it matter?

OBJECTIVE

Child mental health treatment and services research yields more immediate public health benefit when they focus on outcomes of relevance to a broader group of stakeholders. We reviewed all experimental studies of child and adolescent treatment and service effectiveness published in the last 15 years (1996-2011) and compared the distribution and types of outcome domains to a prior review that focused on studies from the prior 15 years (1980-1995).

METHOD

Studies were included if they focused on children from birth to 18 years of age with specific or general psychiatric conditions, employed randomized designs, and examined intervention effects with a six-month or longer post-treatment assessment in treatment studies or a 6-month or longer post-baseline assessment for services studies. Two hundred (n=200) studies met criteria. Reported outcome measures were coded into conceptual categories drawn from the 1980-1995 review.

RESULTS

There was a five-fold increase in the total number of studies (38 versus 200) across the two 15-year time periods, with the largest increase in the number of studies that focused on consumer-oriented outcomes (from eight to 47 studies, an almost sixfold increase); two new domains, parent symptoms and health-related outcomes, were identified. The majority of studies (more than 95%) continued to focus on symptoms and diagnoses as an outcome. Impact ratings were higher among studies examining four or more outcomes versus one to two outcomes in all categories with the exception of Posttraumatic Stress Disorder.

CONCLUSIONS

Given major shifts in health care policy affecting mental health services, the emergence of health and parent-related outcomes as well as greater attention to consumer perspectives parallels emerging priorities in health care and can enhance the relevance of child outcome studies for implementation in the real world.

Targeting parental psychopathology in child anxiety

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

Changes in parenting behaviors, attachment, depressive symptoms, and suicidal ideation in attachment-based family therapy for depressive and suicidal adolescents

This study examined whether Attachment-Based Family Therapy (ABFT) was associated with decreases in maternal psychological control and increases in maternal psychological autonomy granting, and whether such changes were associated with changes in adolescents' attachment schema and psychological symptoms. Eighteen suicidal adolescents and their mothers received 12 weeks of ABFT. Maternal psychological control and autonomy granting behaviors were observationally coded at sessions 1 and 4. Adolescents' reports of perceived maternal care and control, attachment-related anxiety and avoidance, and depressive symptoms and suicidal ideation were collected at baseline, 6, 12 weeks (posttreatment), and 36 weeks. Results indicated that from session 1 to session 4, maternal psychological control decreased and maternal psychological autonomy granting increased. Increases in maternal autonomy granting were associated with increases in adolescents' perceived parental care from pre to mid-treatment and decreases in attachment-related anxiety and avoidance from pre to 3 months posttreatment. Finally, decreases in adolescents' perceived parental control during the treatment were associated with reductions in adolescents' depressive symptoms from pretreatment to 12 weeks posttreatment. This is the first study examining the putative change mechanisms in ABFT.

One year follow-up to modular cognitive behavioral therapy for the treatment of pediatric anxiety disorders in an elementary school setting

The current study sought to evaluate the relative long-term efficacy of a modularized cognitive behavioral therapy (CBT) program for children with anxiety disorders. Twenty four children (5-12 years old) randomly assigned to modular CBT or a 3-month waitlist participated in a 1-year follow-up assessment. Independent evaluators blind to treatment condition conducted structured diagnostic interviews, and caregivers and children completed symptom checklists at pre- and post-, and 1 year follow-up assessments. Analyses revealed that 71.4% of children who received CBT demonstrated a positive treatment response 1 year following treatment, and 83.3% were free of any anxiety diagnosis at 1 year follow-up. Analyses further revealed robust effects of intervention on diagnostic outcomes, caregiver- and child-report measures of anxiety at 1 year follow-up. Results provide evidence of an ongoing advantage on anxiety-specific outcomes for this modularized school-based CBT program 1 year post-treatment.

Integrating etiological models of social anxiety and depression in youth: evidence for a cumulative interpersonal risk model

Models of social anxiety and depression in youth have been developed separately, and they contain similar etiological influences. Given the high comorbidity of social anxiety and depression, we examine whether the posited etiological constructs are a correlate of, or a risk factor for, social anxiety and/or depression at the symptom level and the diagnostic level. We find core risk factors of temperament, genetics, and parent psychopathology (i.e., depression and anxiety) are neither necessary nor sufficient for the development of social anxiety and/or depression. Instead, aspects of children's relationships with parents and/or peers either mediates (i.e., explains) or moderates (i.e., interacts with) these core risks being related to social anxiety and/or depression. We then examine various parent- and peer-related constructs contained in the separate models of social anxiety and depression (i.e., parent-child attachment, parenting, social skill deficits, peer acceptance and rejection, peer victimization, friendships, and loneliness). Throughout our review, we report evidence for a Cumulative Interpersonal Risk model that incorporates both core risk factors and specific interpersonal risk factors. Most studies fail to consider comorbidity, thus little is known about the specificity of these various constructs to depression and/or social anxiety. However, we identify shared, differential, and cumulative risks, correlates, consequences, and protective factors. We then put forth demonstrated pathways for the development of depression, social anxiety, and their comorbidity. Implications for understanding comorbidity are highlighted throughout, as are theoretical and research directions for developing and refining models of social anxiety, depression, and their comorbidity. Prevention and treatment implications are also noted.

The maintenance effect of cognitive-behavioural treatment groups for the Chinese parents of children with intellectual disabilities in Melbourne, Australia: a 6-month follow-up study

BACKGROUND

Caring for a child with intellectual disability can be stressful. No data on the longer-term effects of cognitive-behavioural treatment (CBT) on parents from a Chinese-speaking background who have children with intellectual disabilities are available in the literature. This study attempted to fill this research gap by examining the maintenance effect of CBT among the Chinese parents of such children in Melbourne, Australia.

METHOD

Thirty-nine participants took part in our CBT groups and attended follow-up meetings. A questionnaire comprising four instruments, the Parenting Stress Index (PS) - Parent Domain, General Health Questionnaire-12 (GHQ-12), Abbreviated Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-18) and Dysfunctional Attitude Scale (DAS), was administered to the participants at the pre- and post-test stage and at the 6-month follow-up.

RESULTS

One-way repeated-measures analyses of variance revealed significant time and group effects in the PS (F(2,27) = 16.93, P < 0.001), Q-LES-Q-18 (F(2,27) = 15.98, P < 0.001), GHQ-12 (F(2,27) = 81.93, P < 0.001) and DAS (F(2,27) = 15.50, P < 0.001) scores at the three measurement times. The participants continued to maintain significant improvements in mental health and quality of life and declines in the severity of parenting stress and dysfunctional attitudes at the 6-month follow-up. Effect size analyses revealed mostly large differences in the foregoing measurements (Cohen's d = 0.76-2.18) between the pre-test and 6-month follow-up. Employing a cut-off score of 3/4 in the GHQ-12 to identify at-risk and not-at-risk cases, approximately 90.5% of the participants could be classified as not-at-risk at the follow-up. Lastly, regression analyses showed that changes in DAS scores significantly predicted changes in the GHQ-12 and Q-LES-Q-18 scores at the follow-up.

CONCLUSIONS

This study provides preliminary evidence of the 6-month maintenance effect of CBT groups for the Melbourne-resident Chinese parents of children with intellectual disabilities.

The direction of effects between perceived parental behavioral control and psychological control and adolescents' self-reported GAD and SAD symptoms

This study examined the direction of effects and age and sex differences between adolescents' perceptions of parental behavioral and psychological control and adolescents' self-reports of generalized anxiety disorder (GAD) and separation anxiety disorder (SAD) symptoms. The study focused on 1,313 Dutch adolescents (early-to-middle cohort n = 923, 70.3%; middle-to-late cohort n = 390, 29.7%) from the general population. A multi-group, structural equation model was employed to analyze the direction of the effects between behavioral control, psychological control and GAD and SAD symptoms for the adolescent cohorts. The current study demonstrated that a unidirectional child effect model of the adolescents' GAD and SAD symptoms predicting parental control best described the data. Additionally, adolescent GAD and SAD symptoms were stronger and more systematically related to psychological control than to behavioral control. With regard to age-sex differences, anxiety symptoms almost systematically predicted parental control over time for the early adolescent boys, whereas no significant differences were found between the late adolescent boys and girls.

Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism

This study aimed to determine if a joint attention intervention would result in greater joint engagement between caregivers and toddlers with autism. The intervention consisted of 24 caregiver-mediated sessions with follow-up 1 year later. Compared to caregivers and toddlers randomized to the waitlist control group the immediate treatment (IT) group made significant improvements in targeted areas of joint engagement. The IT group demonstrated significant improvements with medium to large effect sizes in their responsiveness to joint attention and their diversity of functional play acts after the intervention with maintenance of these skills 1 year post-intervention. These are among the first randomized controlled data to suggest that short-term parent-mediated interventions can have important effects on core impairments in toddlers with autism. Clinical Trials #: NCT00065910.

Parental anxiety in the treatment of childhood anxiety: a different story three years later

This study reports on the results of a long-term follow-up of 60 (29 girls and 31 boys, all of Caucasian ethnicity) children and adolescents diagnosed with an anxiety disorder and treated 3 years earlier with child-focused cognitive behavior therapy (CBT) or child-focused CBT plus parental anxiety management (PAM). Sixty-seven children aged 7 to --14 years were assigned to either the "child anxiety only" or the "child + parental anxiety" condition based on parents' trait anxiety scores. Within conditions, participants were randomly assigned to one of the two treatment conditions. Results indicated that at follow-up, parental anxiety did not represent a risk factor for children's treatment outcome. In addition at follow-up, children who received the combined CBT + PAM intervention (regardless of parental anxiety status) were significantly more likely to be anxiety diagnosis free compared with children who received the child-focused CBT intervention only.