Increasing access to low‐intensity interventions for childhood anxiety: A pilot study of a guided self‐help program for Scandinavian parents

Cognitive Behavior Therapy (CBT) is an effective treatment for child anxiety. However, access to treatment is limited. It has been suggested that low‐intensity formats of parent‐delivered CBT may improve access to treatment. Our aim was to develop and pilot‐test the acceptability and effect of a low‐intensity therapist‐guided parent‐delivered group program for anxious children (age 7–12 years) adjusted to the Scandinavian culture. The program required 1.5 hours of therapist‐time per family. Mothers, fathers and children reported on revised child anxiety and depression scale (RCADS) at referral, pre‐ and post‐treatment. Mothers and fathers also gave a qualitative account of their experiences. Thirty‐one families were enrolled and only one family dropped out. Mean age of the children was 9 years. Intent‐to‐treat analyses revealed significant reductions in anxiety and depressive symptoms from pre‐ to post‐treatment for all informants. Large effect sizes were found for child anxiety symptoms as reported by mothers and fathers, and for child depressive symptoms as reported by mothers. Medium to large effect sizes was found for the self‐reported anxiety symptoms by the children, and for depressive symptoms reported by both children and fathers. More than 93% of the parents would recommend the program. Results suggest that our program may provide a new approach to improve access to treatment for anxious children in Scandinavia; however, further research must be conducted before firm conclusions can be drawn.     

Do Parents Benefit From Help When Completing a Self-Guided Parenting Program Online? A Randomized Controlled Trial Comparing Triple P Online With and Without Telephone Support

In response to recent increases in the dissemination of Web-based parenting supports, an important consideration is whether the core benefits of self-directed participation in online parenting interventions are counterbalanced by issues such as high dropout and noncompletion rates commonly reported within the Internet intervention literature. This study outlines a randomized controlled trial of Triple P Online, a Web-based variant of the Triple P—Positive Parenting Program, delivered with varied levels of support scaffolding. Participants were 183 parents of children between 1 and 8 years of age with concerns about their child’s behavior and at least one area of disadvantage or family difficulty. Participants were randomized to self-directed Triple P Online, telephone-supported Triple P Online, or a wait-list control. Primary outcomes measured at baseline, postintervention, and 5-month follow-up were negative parenting styles and child behavior problems. Secondary outcomes included parent confidence, anger, and adjustment; relationship quality; program engagement; and parent satisfaction. Self-directed participants showed short-term treatment effects, including reductions in overall negative parenting and frequency of child behavior problems, while practitioner support led to greater improvements in negative parenting and intensity of difficult child behaviors. Participants in the supported condition were also more likely to complete modules and reported greater program satisfaction. At follow-up, 50% of outcomes for the self-directed condition were significantly better than the control, while 94% of outcomes were significantly better than the control in the practitioner-supported condition. Although self-directed online approaches to parenting intervention are promising, this research highlights how minimal support can improve effective engagement and enhance outcomes for families.     

Examining the Relation Between the Therapeutic Alliance, Treatment Adherence, and Outcome of Cognitive Behavioral Therapy for Children With Anxiety Disorders

Little is known about the contribution of technical and relational factors to child outcomes in cognitive behavioral therapy (CBT) for children with anxiety disorders. This study investigated the association between treatment adherence, the child-therapist alliance, and child clinical outcomes in manual-guided individual- and group-based CBT for youths diagnosed with anxiety disorders. Trained observers rated tapes of therapy sessions for treatment adherence and child-therapist alliance in a sample of 52 children (aged 8 to 12) with anxiety disorders. Self-reported child anxiety was assessed at pre-, mid-, and posttreatment; parent-reported child internalizing symptoms was assessed at pre- and posttreatment. The results showed high levels of treatment adherence and child-therapist alliance in both CBT programs. Neither treatment adherence nor child-therapist alliance predicted traditional measurements of child outcomes in the present study, but a relation between alliance and outcome was found using a more precise estimation of the true pre-post differences. Implications of these findings for expanding our understanding of how treatment processes relate to child outcome in CBT for children with anxiety disorders are discussed.     

Pilot Evaluation of the ACT Raising Safe Kids Program on Children’s Bullying Behavior

Research documents that parents play a critical role in the development and maintenance of behavior problems in children. Few bullying prevention programs, however, target children in early childhood or include a parenting component in spite of experts recommending that parent training in behavior management be addressed. Based upon these recommendations, the present study examines the relationship among parent characteristics (hostility, depression, and overall parenting skills) and child bullying and the effects of the American Psychological Association’s ACT Raising Safe Kids program on reducing early childhood bullying. The ACT-RSK program is a primary family violence and child physical abuse prevention program for parents of young children. Fifty-two parents/caregivers, representing children ages 4–10, completed the Brief Symptom Inventory, the ACT Parents Raising Safe Kids Scale, and Early Childhood Bullying Questionnaire (derived from the Child Behavior Checklist and Strengths and Difficulties Questionnaire). Twenty-five of these parents/caregivers were trained in effective parenting including nonviolent discipline, child development, anger management, social problem-solving skills, effects of violent media on children, and methods to protect children from exposure to violence through the ACT-RSK program. The remaining 27 parents/caregivers received treatment as usual. Results indicate decreased bullying in children whose parents completed the ACT-RSK program. Furthermore, of the parent characteristics assessed, parental hostility is the only significant parent predictor for child bullying. These findings suggest the efficacy of this brief intervention for preventing bullying.     

Effectiveness of an Individualized Case Formulation-Based CBT for Non-responding Youths with Anxiety Disorders

The study examined the effectiveness of an individualized case formulation-based cognitive behavior therapy (CBT) for youths (9–17 years) with anxiety disorders and their parents after unsuccessful treatment with a manualized group CBT program (the Cool Kids). Out of 106 participant youths assessed at a 3-month follow-up after manualized CBT, 24 were classified as non-responders on the Clinical Global Impression-Improvement scale (CGI-I), and 14 of 16 non-responders with anxiety as their primary complaint accepted an offer for additional individual family CBT. The treatment was short-term (M sessions = 11.14) and based on a revised case formulation that was presented to and agreed upon by the families. At post-treatment, nine youths (64.3 %) were classified as responders on the CGI-I and six (42.9 %) were free of all anxiety diagnoses, while at the 3-month follow-up 11 (78.6 %) had responded to treatment and nine (64.3 %) had remitted from all anxiety diagnoses. Large effect sizes from pre- to post-individualized treatment were found on youths’ anxiety symptoms, self-reported (d = 1.05) as well as mother-reported (d = .81). There was further progress at the 3-month follow-up, while treatment gains remained stable from post-treatment to the 1-year follow-up. Results indicate that non-responders to manualized group CBT for youth anxiety disorders can be helped by additional CBT targeting each family’s specific needs.     

Group Cognitive Behavioral Treatment for Parents and Children At-Risk for Physical Abuse: An Initial Study

To compare the relative efficacy of two types of group cognitive-behavioral therapy for treating the traumatized child and at-risk or offending parent in cases of child physical abuse (CPA), 24 parents and their children were treated with Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT) and 20 parents were treated with Parent-Only CBT. Outcome measures assessing children's emotional and behavioral functioning and parents' parenting skills were administered to both parent and child participants before treatment, after 15 sessions of treatment, and 3 months after the completion of treatment. A series of correlated t tests and analyses of covariance were used to compare the scores on the outcome measures. The children and parents in the CPC-CBT group demonstrated greater improvements in total posttraumatic symptoms and positive parenting skills, respectively, compared to those who participated in the Parent-Only CBT group. The parents in the Parent-Only CBT group reported using less corporal punishment to manage their children's behavior at posttest than the parents in the CPC-CBT group. The differential benefits of including the child in treatment are discussed.     

Parent Training for Childhood Anxiety Disorders: The SPACE Program

Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in children’s therapy, training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment manual are included with the hope of “bringing the treatment to life” and conveying a rich sense of the therapeutic process. Parents participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the child’s motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may be effective in improving childhood anxiety.     

Homework Compliance and Quality in Cognitive Behavioral Therapies for Anxiety Disorders and Obsessive-Compulsive Disorder

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.     

Telehealth parent training for a young child at risk for autism spectrum disorder

The global pandemic has highlighted the importance of telehealth to access behavioral interventions. Face-to-face parent training improves the development and behaviors of young children at risk for autism spectrum disorder (ASD). We evaluated a telehealth parent training intervention for a child at risk for ASD. Two parents identified possible early ASD symptoms in their 30-month-old son (lack of imitation, pointing, and vocal manding). Both parents simultaneously received telehealth behavioral skills training on the Parent Intervention for Children at Risk for Autism program for 1 hour per week over 29 weeks. Multiple baseline designs across parent and child behaviors showed that both parents improved their parent teaching fidelity above 80% and the child improved on all trained behaviors. This study expands the utility of telehealth behavioral parent training to young children at risk for ASD to mitigate early symptoms of ASD.     

Erratum to: Parental Anxiety and Child Symptomatology: An Examination of Additive and Interactive Effects of Parent Psychopathology

The current study examined relations between parent anxiety and child anxiety, depression, and externalizing symptoms. In addition, the study tested the additive and interactive effects of parent anxiety with parent depression and externalizing symptoms in relation to child symptoms. Forty-eight parents with anxiety disorders and 49 parents without any psychiatric disorder participated with one of their children (ages 6 to 14 years; 46.4% male; 75.8% Caucasian). Parent anxiety was related to both child anxiety and depression, but not child externalizing symptoms. Hierarchical regression analyses showed that only parent externalizing symptoms had additive effects, beyond parent anxiety symptoms, in relation to child anxiety symptoms. Further, parent anxiety symptoms moderated the relationship between parent and child externalizing symptoms, such that the strength of this relationship was reduced in the presence of high levels of parent anxiety symptoms. Results of this study illuminate the role of parent comorbidity in understanding relations between parent and child symptoms.     

Parent-directed cognitive behavioral therapy for young anxious children: a pilot study

Anxiety in children age 8 years and above has been successfully treated with cognitive behavioral therapy (CBT). However, the efficacy of CBT for anxious children ages 4-7 years has not, to date, been fully investigated. This paper piloted a CBT intervention targeting child anxiety that was delivered exclusively to parents of 26 children with anxiety symptoms ages 4-7 years. The intervention consisted of four 2-hour group sessions of four to six parents (couples). These group sessions were followed by four individual telephone sessions, once per week across a 4-week period. The pre- and postintervention assessment involved measures of multiple constructs of child anxiety (anxiety symptoms, children's fears, behavioral inhibition, and internalizing symptoms) from multiple informants (parents, children, and teachers). Parents also reported parenting strategies they were likely to use to manage their children's anxiety pre- and postintervention. Results indicated a significant decrease in child anxiety and behavioral inhibition as reported by parents and teachers. Furthermore, mothers reported significant increases in their use of positive reinforcement, and modeling and reassurance, and a significant decrease in their use of reinforcement of dependency directly after treatment. Taken together, parent-directed CBT appears to be an effective approach for treating children ages 4-7 years with anxiety symptoms. Limitations of the current research are discussed.     

Parental Anxiety and Child Symptomatology: An Examinzation of Additive and Interactive Effects of Parent Psychopathology

The current study examined relations between parent anxiety and child anxiety, depression, and externalizing symptoms. In addition, the study tested the additive and interactive effects of parent anxiety with parent depression and externalizing symptoms in relation to child symptoms. Forty-eight parents with anxiety disorders and 49 parents without any psychiatric disorder participated with one of their children (ages 6 to 14 years; 46.4% male; 75.8% Caucasian). Parent anxiety was related to both child anxiety and depression, but not child externalizing symptoms. Hierarchical regression analyses showed that only parent externalizing symptoms had additive effects, beyond parent anxiety symptoms, in relation to child anxiety symptoms. Further, parent anxiety symptoms moderated the relationship between parent and child externalizing symptoms, such that the strength of this relationship was reduced in the presence of high levels of parent anxiety symptoms. Results of this study illuminate the role of parent comorbidity in understanding relations between parent and child symptoms.     

Predictors of outcome in Internet-based cognitive behavior therapy for severe health anxiety

Internet-based cognitive behavior therapy (CBT) for severe health anxiety can be effective, but not all patients achieve full remission. Under these circumstances, knowledge about predictors is essential for the clinician in order to make reliable treatment recommendations. The primary aim of this study was to investigate clinical, demographic, and therapy process-related predictors of Internet-based CBT for severe health anxiety. We performed three types of analyses on data from a sample comprising participants (N = 81) who had received Internet-based CBT in a randomized controlled trial. Outcomes were a) end state health anxiety, b) improvement in health anxiety (continuous change scores), and c) clinically significant improvement. Outcomes were assessed at six-month follow-up. The results showed that the most stable predictors of both end state health anxiety and improvement were baseline health anxiety and depressive symptoms. Treatment adherence, i.e. the number of completed treatment modules, also significantly predicted outcome. Notably, health anxiety at baseline was positively associated with symptom improvement while depressive symptoms was negatively related to improvement. Demographic factors were largely without significant impact on end state symptoms or improvement. We conclude that baseline symptom burden and adherence to treatment have strong predictive effects in Internet-based CBT for severe health anxiety.     

Correlates of adolescent parenting

A self-selected sample of 177 teenage parents participated in a study of the correlates of teenage parenting. An ecological model of the predictors of parenting behavior was used to define factors which potentially influence teenage parents' parenting skills as measured by the Home Observation for Measurement of the Environment (HOME). The factors tested include level of punitiveness toward child rearing, knowledge of developmental milestones, level of depression, perceived social support, parental age, and parental race. The results of a stepwise hierarchical regression analysis found that parental race, punitive attitudes toward child rearing, and parental age were statistically significant predictors of total HOME scores. The older, white adolescent mother with less punitive attitudes toward child rearing and child discipline scored the highest on parenting skills. The relevance of these findings to program planners and service providers involved in teenage parent support and education programs is discussed.     

A Comparison of Interactions Among Children,Parents, and Therapists in Cognitive Behavior Therapy for Anxiety Disorders in Australia and Japan

Despite growing attention to the efficacy of culturally adapted cognitive-behavioral treatment (CBT) programs for children and adolescents, there is still little empirical and practical information available to therapists who adapt original treatment protocols to suit clients of a specific culture. The current study aimed to compare therapeutic interactions across CBT treatment delivered with two different cultural groups. We developed an observational coding system to examine behaviors exhibited by child, parent, and therapist during CBT sessions conducted in Australia and Japan for children with anxiety disorders. Our results demonstrated significant differences between the two countries with respect to the treatment readiness of children, the proportion of talking during the sessions by parents and children, therapists’ laughter, length of silence during the first session, and parent indices of accommodation. In terms of transitions over time (i.e., first to last CBT session), parents in both countries tended to talk more during the last CBT session, whereas only Australian therapists talked less over time. The proportion of silence decreased over time during the Japanese sessions, and the amount of interruptions by parents increased over time for Australian sessions. Finally, our exploratory analyses demonstrated that a number of behavioral observations were correlated with anxiety treatment outcome at posttreatment. This study suggests that interactions between a child, parent, and therapist during CBT sessions may be affected by the culture in which the CBT session occurs, which could have implications for culturally adapted CBT programs.     

Predicting Treatment Outcomes From Internet-Based Cognitive Behavior Therapy for Obsessive–Compulsive Disorder

Internet-based cognitive-behavioral therapy (ICBT) with therapist support shows promise as a treatment for obsessive-compulsive disorder (OCD). Yet, not all patients respond to ICBT. It is therefore important to identify predictors of ICBT outcomes to determine who is likely to benefit. Relative to the large literature on predictors of outcomes for in-person CBT for OCD, very few studies have investigated ICBT predictors. Therefore, we analyzed predictors of outcome in an open trial (n = 30) of ICBT for OCD using the OCD-NET platform, which consists of 10 online modules delivered with therapist support. The Yale-Brown Obsessive-Compulsive Scale (YBOCS) was administered by independent raters as the primary outcome measure at baseline and posttreatment. In this sample, greater baseline OCD severity and OCD-related avoidance behaviors were associated with higher end-state OCD symptoms (i.e., poorer outcome). Patients with a past history of face-to-face CBT for OCD also had worse outcomes. Although these results require replication, these factors may identify individuals at risk for poor ICBT outcomes.     

A Measurement Model of Media Parenting: Differences Across Parent and Child Reports and Youth Age and Sex

For youth raised in the Digital Age, online risks such as cyberbullying and sexting have become increasingly problematic. Since digital media is primarily consumed at home, parents play an important role in mitigating these risks; parents can teach children about online dangers, regulate the amount of time spent online, and, to some extent, curate the online content children see. The present study evaluated the psychometric properties of a four-factor media parenting measurement model introduced by Livingstone et al. (2011) across self-reports of a U.S. sample of parents (M_age?=?38.5) and children (ages 10–14; M_age?=?11.8). To identify meaningful group differences, latent mean comparisons were evaluated across youth age and gender. Confirmatory Factor Analysis results provided good fit to the data for the four-factor media parenting model based on both parent [χ2(201, n?=?306)?=?384.407; RMSEA_{(.046—.063)}?=?.055; CFI?=?.958; TLI/NNFI?=?.951; SRMR?=?.050] and child report [χ2(203, n?=?306)?=?378.033; RMSEA_(.045-.061)?=?.053; CFI?=?.942; TLI/NNFI?=?.934; SRMR?=?.060]. The final latent parenting factors included: Active Mediation, Monitoring, Technology Control, and Restrictive Mediation. Latent mean comparisons revealed that parents of girls reported higher levels of Monitoring than parents of boys, whereas girls reported higher levels of parental Restriction than boys. Similarly, older children and their parents reported lower Restriction than younger children and their parents. Overall, latent mean differences identified between media parenting domains may be important for youth outcomes and provide support for their inclusion as distinct factors in predictive models.

     

Evaluating the Effectiveness of a Group CBT for Parents of ADHD Children

Improvements in parenting skills do not necessarily lead to improvements in child and parent outcomes for children with attention deficit and hyperactivity disorder (ADHD). Cognitive factors such as parental cognitions and parenting self-efficacy may influence such outcomes. Clinical research on the effects of cognitive-behaviour therapy (CBT) on parental cognitions, parenting self-efficacy and mental health in Chinese parents of children with ADHD is lacking. This quasi-experimental study intended to assess the effects of a culturally attuned group CBT treatment on the mental health and quality of life of Chinese parents aged 26–58 years, with children with ADHD in Hong Kong. Participants in the experimental group received group CBT and standard treatment and their counterparts in the control group received standard treatment. Primary outcome variables of mental health and quality of life and process variables including parenting stress, parenting efficacy and dysfunctional attitudes were measured at baseline, post-treatment and 3-month follow-up. Data were analysed using 2?×?3 ANCOVAs, Cohen’s d statistics and multiple mediation analyses. Group by time interactions were found for most outcome variables. Effect size statistics indicated that group CBT had small to moderate effects on most outcome variables at post-treatment and follow-up assessments. The effect of CBT on mental health was mediated by the reduction in parenting stress and the effect of CBT on quality of life was mediated by the reductions in parenting stress and dysfunctional attitudes. Given its potential benefit, it is worth considering incorporating this group CBT programme into interventions for Chinese parents with ADHD children.     

Targeted Prevention of Childhood Anxiety: Engaging Parents in an Underserved Community

Selective prevention programs hold the promise of alleviating child anxiety symptoms, decreasing the risk for emotional problems across the lifespan. Such programs have particular public health import for young children of poor, underserved communities. Identifying factors related to parent engagement, and methods to improve engagement, are paramount in the effort to develop anxiety‐focused, community prevention programs. This feasibility study investigated the effect of an enhanced recruitment strategy to maximize parent engagement, as well as factors related to attendance in a single session focused on anxiety prevention. Participants were poor, ethnic minority parents of children aged 11–71 months (n = 256) who completed a survey that assessed anxiety risk according to trauma exposure, child anxiety, or parent anxiety, as well as preferences for preventive services (phase 1). Those meeting risk criteria (n = 101) were invited to a preventive group session (phase 2). Half of parents received enhanced recruitment (ER), which included personalized outreach, matching parent preferences, and community endorsement. Other parents were invited by mail. Chi square analyses indicated that ER was associated with planning to attend (49 vs. 6 % of control). Parents receiving ER were 3.5 times more likely to attend. Higher sociodemographic risk was correlated with higher child anxiety symptoms but not attendance. Results highlight the need for improved strategies for engaging parents in preventive, community‐based interventions.     

Predictors of changes in child behaviour following parent management training: Child,context, and therapy factors

This non‐randomised study examined a set of predictive factors of changes in child behaviour following parent management training (PMTO). Families of 331 Norwegian girls (26%) and boys with clinic‐level conduct problems participated. The children ranged in age from 3 to 12 years (M_age = 8.69). Retention rate was 72.2% at post‐assessment. Child‐, parent‐ and therapy‐level variables were entered as predictors of multi‐informant reported change in externalising behaviour and social skills. Behavioural improvements following PMTO amounted to 1 standard deviation on parent rated and ½ standard deviation on teacher rated externalising behaviour, while social skills improvements were more modest. Results suggested that children with higher symptom scores and lower social skills score at pre‐treatment were more likely to show improvements in these areas. According to both parent‐ and teacher‐ratings, girls tended to show greater improvements in externalising behaviour and social skills following treatment and, according to parents, ADHD symptomology appeared to inhibit improvements in social skills. Finally, observed increases in parental skill encouragement, therapists' satisfaction with treatment and the number of hours spent in therapy by children were also positive and significant predictors of child outcomes.