Psychiatric illness in the mothers of anxious children

Assessing parental cognitions about child anxiety: Are parents' thoughts about child anxiety associated with child anxiety and anxiety sensitivity?

Anxiety sensitivity (AS) or the fear of anxious symptomatology, has garnered support in both adult and child samples for its predictive validity of anxiety disorders. Recent efforts to identify familial factors that predict anxiety amongst youth have identified a construct similar to AS amongst parents, but instead focused on the child rather than on the self. The overarching goal of the present study was to examine the extent to which two measures of this construct [the Parent Sensitivity to Child Anxiety Index (PSCAI) and the Parental Beliefs about Anxiety Questionnaire (PBA-Q)] correlated with child and parent AS and anxiety and how these measures explained the relationships between parent- and child-reported AS and anxiety. A secondary aim of the present study was to psychometrically compare the PSCAI and the PBA-Q with respect to not only their convergence with parent and child AS and anxiety, but also the extent to which each mediated the parent-child relationships between these variables. The PSCAI and PBA-Q significantly mediated the relationship between parent and child AS, each yielding small significant indirect effects. Support was also observed for a double mediation model in which parental anxiety predicted parental AS, which predicted parental beliefs about and parental sensitivity to child anxiety, which in turn predicted child anxiety. Findings suggest that both parental beliefs about and sensitivity to child anxiety are both correlated with and partially explain the relationship between parent and child AS and anxiety, providing potential points of intervention in treatment and prevention efforts for child anxiety.

What are the odds of anxiety disorders running in families? A family study of anxiety disorders in mothers, fathers, and siblings of children with anxiety disorders

This family study investigated (1) the prevalence of anxiety disorders (ADs) in parents and siblings of children (n = 144) aged 8-18 years with ADs compared to control children (n = 49), and (2) the specificity of relationships between child-mother, child-father, and child-sibling ADs. Clinical interviews were used to assess current DSM-IV-TR ADs in children and siblings, and lifetime and current ADs in parents. Results showed that children with ADs were two to three times more likely to have at least one parent with current and lifetime ADs than the control children (odds ratio (OR) = 2.04 and 3.14). Children with ADs were more likely to have mothers with current ADs (OR = 2.51), fathers with lifetime ADs (OR = 2.84), but not siblings with ADs (OR = 0.75). Specific relationships between mother-child ADs were found for Social Anxiety Disorder (SAD, OR = 3.69) and Generalized Anxiety Disorder (OR = 3.47). Interestingly, all fathers and siblings with SAD came from families of children with SAD. Fathers of children with SAD were more likely to have lifetime ADs themselves (OR = 2.86). Findings indicate that children with ADs more often have parents with ADs, and specifically SAD is more prevalent in families of children with SAD. Influence of parent's (social) ADs should be considered when treating children with ADs.

Risk factors for parental psychopathology: a study in families with children or adolescents with psychopathology

The parents of children with psychopathology are at increased risk for psychiatric symptoms. To investigate which parents are mostly at risk, we assessed in a clinical sample of families with children with psychopathology, whether parental symptom scores can be predicted by offspring psychiatric diagnoses and other child, parent and family characteristics. Parental depressive, anxiety, avoidant personality, attention-deficit/hyperactivity (ADHD), and antisocial personality symptoms were measured with the Adult Self Report in 1805 mothers and 1361 fathers of 1866 children with a psychiatric diagnosis as assessed in a child and adolescent psychiatric outpatient clinic. In a multivariate model, including all parental symptom scores as outcome variables, all offspring psychiatric diagnoses, offspring comorbidity and age, parental age, parental educational attainment, employment, and relationship status were simultaneously tested as predictors. Both 35.7% of mothers and 32.8% of fathers scored (sub)clinical for at least one symptom domain, mainly depressive symptoms, ADHD symptoms or, only in fathers, avoidant personality symptoms. Parental psychiatric symptoms were predicted by unemployment. Parental depressive and ADHD symptoms were further predicted by offspring depression and offspring ADHD, respectively, as well as by not living together with the other parent. Finally, parental avoidant personality symptoms were also predicted by offspring autism spectrum disorders. In families with children referred to child and adolescent psychiatric outpatient clinics, parental symptom scores are associated with adverse circumstances and with similar psychopathology in their offspring. This signifies, without implying causality, that some families are particularly vulnerable, with multiple family members affected and living in adverse circumstances.

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

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

Parental Meta-Emotion Philosophy and Emotion Coaching in Families of Children and Adolescents with an Anxiety Disorder

Using a multi-method approach, this study examined differences in parental meta-emotional philosophy (including, parental emotional awareness and emotion coaching) for families with anxiety disordered (AD; n = 74) and non-AD (n = 35) children (aged 7 to 15). Further, it was investigated whether children's emotion regulation (ER) varied across the AD and non-AD groups. Parent(s) were interviewed about their awareness of emotions and emotion coaching; completed a battery of questionnaires that included a measure assessing children's emotion regulation; and engaged in a parent-child discussion task. Results indicated that compared to parents of non-AD youth, parents of AD youth were less aware of their own emotions and their children's emotions, and these results varied by emotion type. Parents of AD youth engaged in significantly less emotion coaching than parents of non-AD youth. AD youth were identified as having significantly greater difficulty regulating their emotions when compared to non-AD youth. Implications for the role of parental meta-emotional philosophy and AD youth's emotion regulation are discussed.

Cross-generational influences on childhood anxiety disorders: pathways and mechanisms

Anxiety disorders are common across the lifespan, cause severe distress and impairment, and usually have their onset in childhood. Substantial clinical and epidemiological research has demonstrated the existence of links between anxiety and its disorders in children and parents. Research on the pathways and mechanisms underlying these links has pointed to both behavioral and biological systems. This review synthesizes and summarizes several major aspects of this research. Behavioral systems include vicarious learning, social referencing, and modeling of parental anxiety; overly protective or critical parenting styles; and aspects of parental responses to child anxiety including family accommodation of the child's symptoms. Biological systems include aspects of the prenatal environment affected by maternal anxiety, development and functioning of the oxytocinergic system, and genetic and epigenetic transmission. Implications for the prevention and treatment of child anxiety disorders are discussed, including the potential to enhance child anxiety treatment outcomes through biologically informed parent-based interventions.

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

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

Spousal resemblance in psychopathology: A comparison of parents of children with and without psychopathology

BACKGROUND

Spouses resemble each other for psychopathology, but data regarding spousal resemblance in externalizing psychopathology, and data regarding spousal resemblance across different syndromes (e.g. anxiety in wives and attention deficit/hyperactivity disorder [ADHD] in husbands) are limited. Moreover, knowledge is lacking regarding spousal resemblance in parents of children with psychiatric disorders. We investigated and compared spousal resemblance within and across internalizing and externalizing symptom domains in parents of children with and without psychopathology.

METHODS

Symptoms of depression, anxiety, avoidant personality, ADHD, and antisocial personality were assessed with the Adult Self Report in 728 mothers and 544 fathers of 778 children seen in child and adolescent psychiatric outpatient clinics and in 2075 mothers and 1623 fathers of 2784 children from a population-based sample. Differences in symptom scores and spousal correlations between the samples were tested.

RESULTS

Parents in the clinical sample had higher symptom scores than in the population-based sample. In both samples, correlations within and across internalizing and externalizing domains of psychopathology were significant. Importantly, correlations were significantly higher in the clinical sample (P=0.03). Correlations, within and across symptoms, ranged from 0.14 to 0.30 in the clinical sample and from 0.05 to 0.23 in the population-based sample.

CONCLUSIONS

This large study shows that spousal resemblance is not only present within but also across symptom domains. Especially in the clinical sample, ADHD symptoms in fathers and antisocial personality symptoms in mothers were correlated with a range of psychiatric symptoms in their spouses. Clinicians need to be alert of these multiple affected families.

Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis

BACKGROUND

Cognitive-behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder.

OBJECTIVES

This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated.

DESIGN

Participants were randomised to receive (i) child cognitive-behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT + maternal cognitive-behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother-child interactions (MCIs) (CCBT + MCI).

SETTING

A NHS university clinic in Berkshire, UK.

PARTICIPANTS

Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder.

INTERVENTIONS

All families received eight sessions of individual CCBT. Mothers in the CCBT + MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact.

MAIN OUTCOME MEASURES

Primary clinical outcomes were the child's primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost-utility analysis framework with associated uncertainty.

RESULTS

MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBT + MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBT + MCBT nor CCBT + MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, p = 0.29; adjusted RR CCBT + MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, p = 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, p = 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, p = 0.13). CCBT + MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBT + MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%.

CONCLUSIONS

Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19762288.

FUNDING

This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership (09/800/17) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

Family accommodation mediates the association between anxiety symptoms in mothers and children

OBJECTIVE

The link between child anxiety and maternal anxiety has been well established but the factors underlying this association are not well understood. One potential factor is family accommodation, which describes ways in which parents change their behaviour to help a child avoid or alleviate anxiety. Family accommodation has been associated with greater symptom severity, more impairment and poorer treatment outcomes in the child. The aim of this study was to investigate whether maternal accommodation mediates the relation between parent and child anxiety.

METHOD

Mothers of children (N = 85) aged 7-17 years (M = 11.79) completed measures of their own anxiety (State-Trait Anxiety Inventory (STAI)), their child's anxiety (Screen for Child Anxiety Related Disorders (SCARED)), and family accommodation (Family Accommodation Scale Anxiety (FASA)). Structural equation modelling (SEM) was used to test the mediational role of accommodation linking parent and child anxiety.

RESULTS

Family accommodation was found to significantly mediate the link between maternal anxiety and child anxiety.

CONCLUSION

These results inform theory and imply that the development of interventions designed to target family accommodation may improve the prognosis of those diagnosed with paediatric anxiety disorders and youth with subclinical anxiety symptoms by reducing both parent and child anxiety.

Parents of children with psychopathology: psychiatric problems and the association with their child's problems

Knowledge is lacking regarding current psychopathology in parents whose children are evaluated in a psychiatric outpatient clinic. This especially accounts for fathers. We provide insight into the prevalence rates of parental psychopathology and the association with their offspring psychopathology by analyzing data on psychiatric problems collected in 701 mothers and 530 fathers of 757 referred children. Prevalence rates of parental psychopathology were based on (sub)clinical scores on the adult self report. Parent-offspring associations were investigated in multivariate analyses taking into account co-morbidity. Around 20 % of the parents had a (sub)clinical score on internalizing problems and around 10 % on attention deficit hyperactivity (ADH) problems. Prevalence rates did not differ between mothers and fathers. Parent-offspring associations did not differ between girls and boys. Maternal anxiety was associated with all offspring problem scores. In addition, maternal ADH problems were associated with offspring ADH problems. Paternal anxiety and ADH problems scores were specifically associated with offspring internalizing and externalizing problem scores, respectively. Associations with offspring psychopathology were of similar magnitude for mothers and fathers and were not influenced by spousal resemblance. Our study shows that both fathers and mothers are at increased risk for psychiatric problems at the time of a child's evaluation and that their problems are equally associated with their offspring problems. The results emphasize the need to screen mothers as well as fathers for psychiatric problems. Specific treatment programs should be developed for these families in especially high need.

Psychodynamic Treatment for Separation Anxiety in a Treatment Nonresponder

Separation anxiety, long an area of interest for psychoanalysts, has been included in DSM-5 among general "anxiety disorders" that span across age groups. The syndrome of separation anxiety has been shown to correlate with nonresponse to treatments for anxiety and mood disorders (Milrod et al. 2014). It is therefore of public health importance to develop targeted treatments for this syndrome. Some psychoanalysts have suggested that brief psychoanalytic interventions may be of particular value in addressing separation anxiety. Our clinical work with patients with anxiety disorders with high levels of separation anxiety indicates that they have such intense anger and ambivalence in fraught intimate relationships that they feel stuck and helpless, almost eliminating more positive feelings. This ambivalence and associated unconscious conflicts inevitably emerge in the therapeutic relationship and can threaten to disrupt treatment efforts. We propose a set of focused psychodynamic psychotherapeutic interventions to address separation anxiety, developed as part of Panic-Focused Psychodynamic Psychotherapy-eXtended Range (PFPP-XR; Busch et al. 2012). We present a case from our research study of treatment nonresponders with anxiety disorders and separation anxiety. The patient was successfully treated with PFPP-XR in a 21-session treatment.

Avoidance moderates the association between mothers' and children's fears: findings from a novel motion-tracking behavioral assessment

BACKGROUND

Fear and anxiety in children are associated with similar symptoms in parents. Parental modeling of fearful or avoidant behavior is believed to contribute to this association. We employed a novel motion-tracking experimentation platform to test the hypothesis that mothers' behavioral avoidance of spiders moderates the association between fear of spiders in mothers and children.

METHOD

Participants were 86 children (aged 7-17) presenting with an anxiety disorder, and their mothers. Children and mothers completed the Spider Phobia Questionnaire. Mothers completed a motion-tracking assessment of behavioral avoidance of spiders.

RESULTS

Fear of spiders in mothers was associated with fear of spiders in children (r85  = 0.48, 95%CI 0.30 - 0.63, P < 0.001). Two metrics of behavioral avoidance in mothers were associated with mothers' self-reported fear of spiders (r = -0.49, 95% CI 0.31-0.64, P < 0.001; and r = 0.42, 95%CI 0.23 - 0.58 P < 0.001). Mothers' behavioral avoidance moderated the association between fear of spiders in mothers and in children. When mothers' avoidance was intermediate or high the association was significant, and as mothers' behavioral avoidance increased the strength of the association increased. Fear of spiders in mothers with low behavioral avoidance was not associated with fear of spiders in their children.

CONCLUSIONS

The study demonstrates that behavioral avoidance can be measured using the motion-tracking platform and can be useful in understanding the links between symptoms of anxiety in mothers and children. Reducing parents' overt expressions of avoidance may lower the risk of fears being transmitted to children.

Parental anxiety as a predictor of medication and CBT response for anxious youth

The aim of this investigation was to evaluate how parental anxiety predicted change in pediatric anxiety symptoms across four different interventions: cognitive-behavioral therapy, medication (sertraline; SRT), their combination (COMB), and pill placebo. Participants were 488 youths (ages 7-17) with separation anxiety disorder, generalized anxiety disorder, and/or social phobia and their primary caregivers. Latent growth curve modeling assessed how pre-treatment parental trait anxiety symptoms predicted trajectories of youth anxiety symptom change across 12 weeks of treatment at four time points. Interactions between parental anxiety and treatment condition were tested. Parental anxiety was not associated with youth's pre-treatment anxiety symptom severity. Controlling for parental trait anxiety, youth depressive symptoms, and youth age, youths who received COMB benefitted most. Counter to expectations, parental anxiety influenced youth anxiety symptom trajectory only within the SRT condition, whereas parental anxiety was not significantly associated with youth anxiety trajectories in the other treatment conditions. Specifically, within the SRT condition, higher levels of parental anxiety predicted a faster and greater reduction in youth anxiety over the acute treatment period compared to youths in the SRT condition whose parents had lower anxiety levels. While all active treatments produced favorable outcomes, results provide insight regarding the treatment-specific influence of parental anxiety on the time course of symptom change.

Preventing Childhood Anxiety Disorders

Although much has been written about the need for prevention of anxiety disorders in children, there has been a marked absence of empirical research to evaluate the effectiveness of such programs. This paper suggests that there is now sufficient evidence to identify risk and protective factors for the development of childhood anxiety disorders. Early childhood temperament, negative life events, and children's coping styles are suggested to play a significant role. Acting in association with these variables are parental behaviours that serve to model, prompt, and reinforce anxious behaviour and emphasise the threatening nature of events. Our knowledge of these causal variables enables us to identify children at risk for the development of anxiety problems and highlights variables that should be targets of change in prevention programs. Indicated prevention is designed to disrupt the trajectory towards the development of clinical levels of psychological disorder. This paper describes an “indicated” preventive program for children identified as being at risk for the development of anxiety disorders given evidence of mild anxious symptomatology.

Difference in anxiety symptoms between children and their parents facing a first seizure or epilepsy

Many studies have shown that anxiety disorders are common in children with epilepsy. We explored symptoms of anxiety simultaneously in children and their parents. We conducted a cross-sectional study using the Revised Children's Manifest Anxiety Scale in children and the State-Trait Anxiety Inventory for Adult in parents. We included 118 parents and 67 children, who were divided into three groups: (1) first seizure, (2) epilepsy, and (3) nonepileptic paroxysmal event. We found that the level of anxiety in parents and children differed. We observed a significant increase in the anxiety level of parents whose children have had a first seizure, while we found a significant increase in the anxiety level of children and adolescents followed for epilepsy. These findings suggest that there is no direct relationship in the anxiety of the parents and their child. Further studies are needed to understand this variation over time.

Transdiagnostic and disorder-specific models of intergenerational transmission of internalizing pathology

BACKGROUND

Numerous studies have supported an association between maternal depression and child psychiatric outcomes, but few have controlled for the confounding effects of both maternal and offspring co-morbidity. Thus, it remains unclear whether the correspondence between maternal and offspring depressive and anxiety disorders is better explained by associations between shared features of maternal and offspring internalizing disorders or by specific effects exerted by unique aspects of individual disorders.

METHOD

Pairs of mothers and offspring overselected for maternal depression (n = 815) were assessed at offspring age 15 years for anxiety and depressive disorders; 705 completed a follow-up at offspring age 20 years. For both mothers and offspring, structural equation modeling was used to distinguish transdiagnostic internalizing pathology--representing the overlap among all depressive and anxiety disorders--from diagnosis-specific forms of pathology. To discriminate between general versus specific pathways of intergenerational transmission of psychopathology, we examined (a) the general association between the maternal and offspring internalizing factors and (b) the correlations between maternal and offspring diagnosis-specific pathology for each disorder.

RESULTS

For mothers and offspring, a unidimensional latent variable model provided the best fit to the correlations among depressive and anxiety disorders. The maternal transdiagnostic internalizing factor strongly predicted the corresponding factor among offspring. In addition, the unique component of post-traumatic stress disorder among offspring was significantly related to the analogous unique component among mothers, but specific components of other maternal disorders, including depression, did not predict corresponding offspring pathology.

CONCLUSIONS

Results suggest that intergenerational transmission of internalizing disorders is largely non-specific.

The impact of brief parental anxiety management on child anxiety treatment outcomes: a controlled trial

Parental anxiety is a risk to optimal treatment outcomes for childhood anxiety disorders. The current trial examined whether the addition of a brief parental anxiety management (BPAM) program to family cognitive behavioral therapy (CBT) was more efficacious than family CBT-only in treating childhood anxiety disorders. Two hundred nine children (aged 6-13 years, 104 female, 90% Caucasian) with a principal anxiety disorder were randomly allocated to family CBT with a five-session program of BPAM (n = 109) or family CBT-only (n = 100). Family CBT comprised the Cool Kids program, a structured 12-week program that included both mothers and fathers. Overall, results revealed that the addition of BPAM did not significantly improve outcomes for the child or the parent compared to the CBT-only group at posttreatment or 6-month follow-up. Overall, however, children with nonanxious parents were more likely to be diagnosis free for any anxiety disorder compared to children with anxious parents at posttreatment and 6-month follow-up. BPAM did not produce greater reductions in parental anxiety. The results support previous findings that parent anxiety confers poorer treatment outcomes for childhood anxiety disorders. Nevertheless the addition of BPAM anxiety management for parents in its current format did not lead to additional improvements when used as an adjunct to family CBT in the treatment of the child's anxiety disorder. Future benefits may come from more powerful methods of reducing parents' anxiety.

"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.

The association between parental history of diagnosed mood/anxiety disorders and psychiatric symptoms and disorders in young adult offspring

BACKGROUND

Parental history of mood or anxiety disorders is one of the strongest and most consistent risk factors for the development of these disorders in offspring. Gaps remain however in our knowledge of whether maternal or paternal disorders are more strongly associated with offspring disorders, and whether the association exists in non-clinical samples. This study uses a large population-based sample to test if maternal or paternal history of mood and/or anxiety disorders increases the risk of mood and/or anxiety disorders, or symptoms of specific anxiety disorders, in offspring.

METHODS

Data were drawn from the Nicotine Dependence in Teens Study, a prospective cohort investigation of 1293 grade 7 students. Data on mental health outcomes were collected in mailed self-report questionnaires when participants were aged 20.4 (0.7) years on average. Parental data were collected in mailed self-report questionnaires. This current analysis pertains to 564 participants with maternal and/or paternal data. The association between maternal and paternal history and each of diagnosed anxiety disorder, diagnosed mood disorder, and symptoms of specific anxiety disorders in offspring was studied in multivariate logistic regression.

RESULTS

A higher proportion of mothers than fathers had a diagnosed mood/anxiety disorder (23% versus 12%). Similarly, 14% of female offspring had a diagnosed mood/anxiety disorder, compared to 6% of male offspring. The adjusted odds ratio (95% confidence interval) for maternal history was 2.2 (1.1, 4.5) for diagnosed mood disorders, 4.0 (2.1, 7.8) for diagnosed anxiety disorders, and 2.2 (1.2, 4.0) for social phobia symptoms. Paternal history was not associated with any of the mental health outcomes in offspring.

CONCLUSION

Maternal, but not paternal mood/anxiety disorders were associated with diagnosed psychiatric disorders, as well as symptoms of specific anxiety disorders, in offspring. Efforts to detect mood and anxiety disorders in offspring with a maternal history should be encouraged.

The relationships of child and parent factors with children's anxiety symptoms: parental anxious rearing as a mediator

A considerable body of research has identified various child and parent factors that contribute to and maintain anxiety symptoms in children. Yet relatively few studies have examined child factors (including threat-based cognitive bias, neuroticism, gender, puberty and age) as well as parent factors (including maternal anxiety and child-rearing style) in association with child anxiety symptoms, and the extent to which these factors serve as unique predictors of child anxiety. Moreover, research is lacking on whether parent factors such as child-rearing style, which is often targeted in early intervention and treatment programs, might mediate the association between child factors such as neuroticism, and child anxiety symptoms. In a sample of 85 children between 7 and 12 years of age with varying levels of anxiety, including those with diagnosed anxiety disorders, results showed that children were more anxious when they were reported to be more advanced in pubertal status by their parents, when they had a tendency to interpret more threat in ambiguous situations, and when they self-reported more neuroticism. Regarding parent factors, maternal self-reported trait anxiety and children's perceptions of their mother as having an anxious child-rearing style were associated with higher levels of child anxiety. Moreover, when these correlates of child anxiety were examined in a multivariate model to identify those that had direct as well as indirect associations via maternal anxious child-rearing style, child neuroticism remained as a significant and unique predictor of child anxiety that was also mediated by maternal anxious-rearing. Child neuroticism also mediated the relationship between child pubertal stage and anxiety symptoms. Results are discussed in terms of relevant theory and empirical evidence regarding the roles of both child and parent factors in the development of child anxiety.

Early stuttering, temperament and anxiety: two hypotheses

PURPOSE

The topic of temperament and early stuttering and the extent to which it involves anxiety is theoretically and clinically relevant. The topic can contribute to theory development and clinical practices with early stuttering.

METHOD

We present a review of the empirical literature for this area with a view to determining which of two hypotheses might be true. The first is that, for the population of those who stutter, unusual temperament is a causal factor for the development of the disorder and its later association with anxiety. The second hypothesis is that for the population of those who stutter the developmental manifestation of anxiety is an effect of stuttering. Both hypotheses attempt to account for the well-known association of anxiety with chronic stuttering.

RESULTS

A firm conclusion about the matter would be premature at present because the literature involved is limited and contains some inconsistencies. We suggest some quantitative and qualitative directions for future research. We argue also that the only way to resolve the matter is with longitudinal studies of cohorts ascertained prior to stuttering onset.

CONCLUSION

Conclusive findings about the matter can only emerge when research extends beyond its modest scope of 10 interpretable publications.

EDUCATIONAL OBJECTIVES

The reader will be able to: (a) describe temperament and the role it plays during anxiety development, (b) explain two alternative hypotheses which implicate temperament in early childhood stuttering; (c) describe current knowledge regarding temperament similarities and differences between stuttering and control children, and (d) discuss the theoretical and clinical implications of understand the relationship between temperament, anxiety and early stuttering.

Examining potential risk factors for anxiety in early childhood

Anxiety disorders are amongst the most prevalent psychiatric disorders in children and adolescents, with occurrence emerging early in the developmental trajectory. This study was one of the first to investigate potential risk factors for anxiety (i.e., behavioural inhibition, parental negative affect, parenting stress) in early childhood. Examination of risk factors was achieved through structural equation modelling and based on mothers' and fathers' report of 236 preschool aged children (4-6 years) in Brisbane, Australia. The structural model was found to fit the data well. All direct predictors of early childhood anxiety were significant and behavioural inhibition partially mediated parents' negative affectivity and mother's parenting stress. Results highlight the unique contribution of both parents in the aetiology of early childhood anxiety and assist in informing the development of intervention and prevention programs for young children.

Efficacy of Cognitive—Behavioural Therapy for Children and Adolescents With Anxiety Disorders

Support for the efficacy of cognitive—behavioural therapy (CBT) for anxious youth has accumulated. Significant treatment effects are observed and maintained over the long term for the majority of children receiving individual, family or group-based treatments. Nevertheless, all children do not improve. In fact, there is evidence to suggest that a significant percentage of children continue to experience anxiety following treatment and will seek additional treatment for their anxiety. This article will review the substantial evidence for CBT, the current information available on predictors of outcome and mechanisms of change. The article will also discuss the need for adequately powered randomised clinical trials that continue to refine and evaluate treatments for anxious children in an effort to improve outcomes for those children whose needs are not being met by our current treatments.

The Association Between Maternal Anxiety and Treatment Outcome for Childhood Anxiety Disorders

This study examined the influence of maternal anxiety on the treatment outcome of anxious children. Forty-eight clinically anxious children (aged 6–14 years) were classified into two groups based on the presence of an anxiety disorder diagnosis in their mother. Diagnostic data at posttreatment showed that children with anxious mothers responded significantly less favourably to cognitive behavioural therapy (CBT) than did children with nonanxious mothers (28% vs. 58% improved, respectively). At 12-month follow-up, 68% of children with anxious mothers improved, compared to 79% of children with nonanxious mothers. This difference was not significant. Findings were not consistent across outcome measures. This study also investigated the changes in maternal anxiety across child treatment. Prior to treatment, diagnostic data showed that 60% of mothers met criteria for an anxiety disorder. At posttreatment, 21% of these mothers were free of their primary diagnosis. There was also a significant reduction in self-reported maternal anxiety across treatment that was maintained at follow-up. Theoretical and clinical implications of the findings are discussed.

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.

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

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

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

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

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

The intergenerational transmission of anxious cognitions and behaviors may be a possible mechanism underlying concordance between maternal and child anxieties. By disambiguating ambiguous situations for their child in a threatening manner, anxious mothers may 'train' their children towards a general tendency to also interpret ambiguity in a threatening way. Ninety-two children and their mothers completed trait anxiety measures. Children completed two ambiguous scenario questionnaires, to measure their own interpretations of ambiguous situations (ASQ-C) and to measure their expectations of their mother's interpretation and behavior in response to ambiguous situations involving them (ASQ-EM). Maternal and child anxiety were significantly correlated. Children who made threat interpretations also anticipated that their mother would disambiguate situations for them in a threatening way. The relationship between maternal anxiety and child threat cognitions was mediated by children's expectations of how their mother would disambiguate situations for them when taken together with children's trait anxiety. The present findings provide preliminary support for the suggestion that children of anxious mothers may learn to interpret and respond to ambiguous situations based on how their mothers have interpreted ambiguous situations for them in the past.

The development of anxiety disorders in childhood: an integrative review

We present an integrative review of the development of child anxiety, drawing on a number of strands of research. Family aggregation and genetic studies indicate raised vulnerability to anxiety in offspring of adults with the disorder (e.g. the temperamental style of behavioural inhibition, or information processing biases). Environmental factors are also important; these include adverse life events and exposure to negative information or modelling. Parents are likely to be key, although not unique, sources of such influences, particularly if they are anxious themselves. Some parenting behaviours associated with child anxiety, such as overprotection, may be elicited by child characteristics, especially in the context of parental anxiety, and these may serve to maintain child disorder. Emerging evidence emphasizes the importance of taking the nature of child and parental anxiety into account, of constructing assessments and interventions that are both disorder specific, and of considering bidirectional influences.

Childrearing style in families of anxiety-disordered children: between-family and within-family differences

This study examined whether (1) parents of anxiety-disordered (AD) children differed from those of non-clinical controls in their childrearing style, and whether (2) the child-rearing style of parents towards AD children is different from that towards their siblings. A clinical sample of 25 AD children, age range 8-13 years, was compared with 25 siblings and a non-clinical control group (n = 25). Childrearing was assessed by means of parental self-report, child report and through an expressed emotion interview measure. AD children perceived more parental rejection than non-clinical control children or the AD children's siblings. High-expressed emotion was scored significantly more often towards AD children than non-clinical control children, or their siblings. On [Symbol: see text]care' and [Symbol: see text]control' parental self-report showed some differences regarding AD children on the one hand and non-clinical control children or siblings of AD children on the other. These results suggest that the rearing of AD children differs significantly both from the rearing of their siblings and that of non-clinical control children.

Cognitive-behavioral intervention with young anxious children

Despite evidence that preschool and early elementary school-age children can present with anxiety disorders that may put them at risk for later psychopathology and dysfunction, the cognitive-behavioral protocols available for treating anxiety in children have been tested almost exclusively in older children. However, there could be benefits to treating children earlier, before anxiety disorders begin to impair their social and academic development. This report discusses the adaptations necessary in providing cognitive-behavioral therapy to young anxious children and describes a manualized, cognitive-behavioral intervention, with child and parent components, that was piloted openly in nine families with children aged 4 to 7 years - each of whom had multiple risk factors for developing anxiety disorders, and most of whom had already presented with anxiety disorders. Eight of the nine children were judged "much" or "very much improved" at postintervention on number of anxiety diagnoses, number of DSM-IV anxiety symptoms, and ability to cope with feared situations. Cases are presented to illustrate the way that cognitive-behavioral therapy can be conducted with youngsters in this age range. Whereas randomized, controlled trials are needed to confirm the efficacy of this manualized treatment, our experience suggests that cognitive-behavioral protocols for anxiety can be adapted and successfully implemented with young children.

Fathers' role in the etiology, prevention and treatment of child anxiety: A review and new model

Fathers have been neglected in investigations of the development, prevention, and treatment of anxiety and anxiety disorders in children and adolescents. This review provides a historical background of what is known about fathers' roles in the etiology of anxiety problems and provides evidence from bottom-up, top-down, and cross-sectional correlation studies of the connections between fathers' and their children's anxiety. Treatment and prevention programs are discussed in terms of the limited findings regarding fathers' involvement in treatment for children's and adolescents' anxiety problems. Finally, a model is presented to show the unique ways in which mothers and fathers are involved in the development of anxiety disorders in their children. Future directions for research in this area are highlighted.

Parental responses to positive and negative emotions in anxious and nonanxious children

This study examined the role of multiple children's emotions and parental anxiety during parent-child interactions of anxiety disordered (AD) and nonanxious (NA) children ages 7 to 13 years. Families (mother, father, child) each discussed three recent and real separate situations in which the child experienced anxiety, anger, and happiness. Results revealed significant differences in behavior between parents of AD and NA children. Maternal behavior, but not paternal behavior, was related to the emotion the child was experiencing. Mothers of AD children displayed greater intrusive involvement than mothers of NA children in those situations in which the child was experiencing negative affect. A significant interaction was evident between maternal anxiety disorder and emotion, whereby anxious mothers were more intrusive in situations involving anxiety and anger (compared to positive emotion situations), whereas nonanxious mothers were more intrusive only during situations involving anger.

Theoretical models of affectionate versus affectionless control in anxious families: a critical examination based on observations of parent-child interactions

Psychosocial theories focused on the intrafamilial transmission of anxiety often concentrate on specific parenting behaviors that increase risk of anxiety disorders in children. Two such theories--affectionate versus affectionless control--both implicate parenting, although differently, in the pathogenesis of childhood anxiety. The present article reviews observational studies that focus on interactions between parents and children in anxious families in order to examine critically each of these two models. We divide these observational studies into two groups: those that seek to characterize the behavior of anxious parents (top-down studies) versus parents of anxious children (bottom-up studies). This approach reveals that there is a consistent relationship between controlling parental behavior in families with anxiety-disordered children as well as a consistent relationship between parental behavior low in warmth and families with anxiety-disordered parents. The present article discusses the implications of the pattern that unfolds from the observational studies of the last decade and provides suggestions for future research in the area.

Treatment Response in Child Anxiety is Differentially Related to the Form of Maternal Anxiety Disorder

An examination was made of the extent to which maternal anxiety predicted response to treatment of children presenting with an anxiety disorder. In a sample of 55 children referred to a local NHS CAMH service for treatment of an anxiety disorder, systematic mental state interview assessment was made of both mothers and children, and both completed self-report questionnaires to assess aspects of anxiety, both immediately before the children received treatment and following treatment. Children of mothers with anxiety disorder overall responded less well to treatment than children of mothers with no anxiety disorder. There was some diagnostic specificity in this in that children of mothers with GAD did as well in treatment as children whose mothers had no anxiety, whereas children of mothers with social phobia did poorly. The outcome for children with anxiety appears to be related to the presence and nature of maternal anxiety. It would seem prudent that treatment of children with anxiety involves assessment of maternal anxiety. It is important to establish in systematic investigation whether treatment of maternal anxiety improves the outcome for child anxiety.

Parental Modeling, Reinforcement, and Information Transfer: Risk Factors in the Development of Child Anxiety?

The purpose of this article is to provide a comprehensive review and a conceptual integration of research examining the potential role of learning from parents in the development of child anxiety. Specifically, research in this area is discussed within the framework of three specific mechanisms: parental modeling, information transfer, and parental reinforcement of anxious/avoidant behavior. Implications of the research in this area are discussed, as well as limitations and directions for future research.

Family Treatment of Child Anxiety: Outcomes, Limitations and Future Directions

Anxiety of childhood is a common and serious condition. The past decade has seen an increase in treatment-focussed research, with recent trials tending to give greater attention to parents in the treatment process. This review examines the efficacy of family-based cognitive behaviour therapy and attempts to delineate some of the factors that might have an impact on its efficacy. The choice and timing of outcome measure, age and gender of the child, level of parental anxiety, severity and type of child anxiety and treatment format and content are scrutinised. The main conclusions are necessarily tentative, but it seems likely that Family Cognitive Behaviour Therapy (FCBT) is superior to no treatment, and, for some outcome measures, also superior to Child Cognitive Behaviour Therapy (CCBT). Where FCBT is successful, the results are consistently maintained at follow-up. It appears that where a parent is anxious, and this is not addressed, outcomes are less good. However, for children of anxious parents, FCBT is probably more effective than CCBT. What is most clear is that large, well-designed studies, examining these factors alone and in combination, are now needed.

Prevention of Childhood Emotional Disorders: Reducing the Burden of Suffering Associated with Anxiety and Depression

Anxiety and depression are the most common mental health problems affecting young people today. This review presents a description of the prevalence and impact of these emotional disorders in children and youth. While treatment offers one approach to intervening, research indicates that most sufferers will not actually receive clinical intervention, and of the minority who do, many will terminate prematurely, fail to respond, or experience recurrent difficulties despite treatment. Prevention approaches offer an alternative and adjunct to treatment, and have become a priority for governments, offering a cost effective and efficient means of providing services to children and youth prior to the onset of psychopathology. This review describes current practises in prevention research and provides an overview of an Australian developed cognitive-behavioural programme that has acquired a solid evidence-base as well as popularity in schools as one approach to building emotional resilience in children and youth, whilst effectively reducing the burden associated with emotional disturbances of anxiety and depression. Future directions for prevention practice and research are highlighted.