Child–Parent Interventions for Childhood Anxiety Disorders

Abstract

Objective:

This study compared the effects of direct child–parent interventions to the effects of child-focused interventions on anxiety outcomes for children with anxiety disorders.

Method:

Systematic review methods and meta-analytic techniques were employed. Eight randomized controlled trials examining effects of family cognitive behavior therapy compared to individual or group child-only therapy met criteria.

Results:

The overall mean effect of parent–child interventions was 0.26, 95% confidence interval [0.05, 0.47], p < .05, a small but positive and significant effect, favoring child–parent interventions. Results of the heterogeneity analysis were not significant (Q = 8.08, df = 7, p > .05, I ² = 13.41).

Discussion:

Parent–child interventions appear to be more effective than child-focused individual and group cognitive behavioral therapy in treating childhood anxiety disorders. Implications for practice and research are discussed.

Keywords

anxiety disorder systematic review meta-analysis family cognitive behavioral therapy

Childhood anxiety disorders are the most prevalent of all childhood psychiatric disorders, with lifetime prevalence estimates ranging from 2.6% to 32% (American Psychological Association, 2000; Cartwright,-Hatton, McNicol, & Doubleday, 2006; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Merikangas, He, Burstein, Swanson, Avenevoli, Cui, et al., 2010). Childhood anxiety disorders have been linked to significant negative implications for children across social, academic and family domains and serious mental disorders, such as depression, substance use disorders, and other anxiety disorders in later adolescence and adulthood (Albano, Chorpita, & Barlow, 2003; Bittner et al., 2007; Langley, Bergman, McCracken, & Piacentini, 2004). In light of the high prevalence and rates of comorbidity with other behavioral and emotional problems, longitudinal and population-based research examining correlates, causes, and the developmental course of childhood anxiety disorders has increased, including a focus on family and parental factors that contribute to childhood anxiety disorders.

During the past two decades, a growing body of research examining parental factors in relation to childhood anxiety disorders suggests that parental anxiety and modeling behaviors contribute to the development and maintenance of childhood anxiety disorders (Choate, Pincus, Eyberg, & Barlow, 2005; Ginsburg & Schlossberg, 2002; Rapee, 1997; Siqueland, Kendall, & Steinberg, 1996). Research suggests an intergenerational transmission of anxiety, with both genetic and environmental factors implicated. Children are estimated to be 3 or 5 times more likely to develop an anxiety disorder if one parent has an anxiety disorder and 6 times more likely if both parents have an anxiety disorder (Beidel & Turner, 1997; Last, Hersen, Kazdin, Francis, & Grubb, 1991; Merikangas, Avenevoli, Dierker, & Grillon, 1999). Additional parent-related risk factors have been implicated in the cause and maintenance of childhood anxiety disorders including high parental control, insecure attachment, and parental modeling of poor coping strategies (Ginsburg & Schlossberg, 2002; Maid, Smokowski, & Bacallao, 2008; Silverman & Dick-Niederhauser, 2004; Wood, McLeod, Sigman, Hwang, & Chu, 2003).

Child–Parent Interventions for Childhood Anxiety Disorders

In light of the growing research suggesting an influence of parental factors in the development and maintenance of childhood anxiety disorders, a growing number of child–parent interventions have been developed and purported as efficacious in the treatment of childhood anxiety disorders. Research also supports the integration of parents in child therapy as a means to better generalize skills from the clinician’s office to the home environment and for both the children and the parents to learn and practice better methods to cope with issues of anxiety that may be pervasive within the household (Bodden et al., 2008; Bogels & Siqueland, 2006; Mendlowitz et al., 1999; Wood, Piacentini, Southam-Gerow, Chu, & Sigman, 2006). Although all child–parent interventions have a common factor, that the child and parent participate in the intervention together, there are variations in the theories and methods used across the array of child–parent interventions currently in practice. Some of the most common child–parent interventions include family cognitive behavioral therapy (FCBT), parent–child interaction therapy (PCIT), child–parent psychotherapy (CPP), and Theraplay.

Family Cognitive Behavioral Therapy

FCBT integrates cognitive behavioral therapy in a family setting that includes parents and children; the family is seen as the most favorable setting for effecting change in children’s irrational thoughts. FCBT typically involves a treatment manual that guides the therapeutic process and helps family members recognize essential thoughts that are irrational and reframe them as more rational and productive types of beliefs (Bogels & Siqueland, 2006; Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008). FCBT directly focuses on the most common parental factors that have been associated with the development and maintenance of childhood anxiety disorders, including parental control, acceptance, and modeling, as well as other issues identified during the assessment process and throughout treatment. Moreover, FCBT encourages parents to facilitate new opportunities with their children to test distorted beliefs when at home and while jointly engaging in community activities (Barrett & Shortt, 2003). Parents also can model their own functional cognition and behaviors to their children during the treatment process and at home.

Parent–Child Interaction Therapy

PCIT integrates play therapy with developmental, social learning, and behavioral theories. Although originally developed for preschool-age children experiencing externalizing behavioral problems (Brinkmeyer & Eyberg, 2003; Herschell & McNeil, 2005), researchers have begun to investigate PCIT for other issues, including victims of physical abuse, children in foster care, children with developmental delays (Chaffin, Taylor, Wilson, & Igelman, 2007; Herschell & McNeil, 2005), and children with separation anxiety disorder (SAD; Choate et al., 2005; Herschell & McNeil, 2005). Similar to FCBT, the premise of PCIT for children with anxiety disorders is to effect change within the parent–child system. PCIT is typically conducted in two phases, a child-directed phase and then a parent-directed phase. During each phase, parents learn how to modify their own actions, hence modifying the reactions of their children. PCIT enhances parent–child relationships by fostering healthy attachments, modifying reinforcement contingencies, and reducing anxiety-provoking responses (Choate et al., 2005).

Child–Parent Psychotherapy

CPP is a model of family play therapy that involves treatment of the parent–child unit, using play as the primary medium of intervention (Lieberman & Van Horn, 2005). Lieberman and colleagues posit that by using play in conjoined sessions with child and parent, parental understanding of the child’s inner experience increases, as well as trust, reciprocity, and pleasure within the parent–child relationship (Lieberman & Inman, 2009). CPP involves the parent actively playing with the child in the therapeutic milieu. It is a relationship-based intervention that helps to change mutual reinforcement of negative behaviors and instead enhances emotional attunement (Lieberman & Van Horn, 2005). Because CPP is designed to facilitate positive and healthy associations between parent and child, it is conjectured that it can also be helpful for children with anxiety disorders. Research needs to be conducted on the efficacy of CPP as an intervention specifically for children with anxiety disorders.

Theraplay

Theraplay is a systematic procedure invented by Ann M. Jernberg in the 1960s to increase positive interactions between parent and child (Jernberg, 1979). Jernberg modeled Theraplay after Winnicott’s (1958) notion of being a “good enough mother.” Five dimensions present in mother–child interactions are postulated in this model: structuring, challenging, engagement, nurturing, and play. Jernberg formulated Theraplay after these dimensions, with the premise that parent–child interactions can be therapeutic for a number of childhood disorders by fostering bonding, attunement, and playfulness (Jernberg, 1999; Wettig, Franke, & Fjordbark, 2006).

As research during the past decade has begun to elucidate the relationship of parental influences and behavior and the causes and maintenance of anxiety disorders in children, practitioners have begun to treat childhood anxiety disorder in the context of child–parent interventions. Although child–parent interventions are widely used and supported by practitioners, little is known about the effectiveness of child–parent interventions compared to child-focused interventions in the treatment of childhood anxiety disorders. Although prior reviews have examined the effects of interventions for childhood anxiety disorders, these reviews primarily focused on individual and/or cognitive behavioral interventions, did not use a systematic methodology or meta-analytic techniques, included diagnostic classifications beyond anxiety disorders, or were conducted before recent advancements in the field (see Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004; Creswell & Cartwright-Hatton, 2007; In-Albon & Schneider, 2007; Ishikawa, Okajima, Matsuoka, & Sakano, 2007; James, Soler, & Weatherall, 2009; King et al.,1998; Reynolds, Wilson, Austin, & Hooper, 2012; Silverman, Pina, & Viswesvaran, 2008). In light of the advancements made in understanding and treating childhood anxiety disorder in the past decade and the plethora of child–parent interventions being developed and used, this review examines the current state of child–parent intervention research for treating childhood anxiety disorders and improves upon prior reviews by using systematic review methods and meta-analytic techniques to provide a comprehensive picture of effects.

Purpose of the Present Study

The purpose of this systematic review and meta-analysis is to specifically examine the differential effect on anxiety outcomes of child–parent interventions compared to child-focused interventions for children with anxiety disorders. The specific research questions guiding this study were as follows: (1) Are child–parent interventions more effective than interventions involving solely the child in decreasing anxiety for children with anxiety disorders? and (2) Are there differences in magnitude of effects by type of child–parent intervention?

Method

Systematic review procedures, following the Campbell Collaboration guidelines (see www.campbellcollaboration.org), were used for all aspects of the search, retrieval, selection, and coding of published and unpublished studies meeting study inclusion criteria. Meta-analytic techniques were employed to quantitatively synthesize the results from included studies. The protocol and screening and coding instruments guiding the conduct of this study are available from the first author upon request.

Study Eligibility Criteria

Studies were eligible for inclusion if they examined the effects of a child–parent intervention (i.e., an intervention in which a parent or guardian and child were directly involved in the treatment) against the effects of interventions targeting only the child (an individual or group intervention in which the parent did not directly participate) for children under the age of 18 with at least one anxiety disorder. Interventions were considered a child–parent intervention if they included at least one intergenerational family unit, that is, parent and child or primary caretaker and child. Studies must have employed a randomized or quasi-experimental design, measured at least one anxiety outcome, and reported sufficient information to calculate an effect size. Published and unpublished studies were eligible and no geographical restrictions were imposed; however, this review was limited to English language reports of studies conducted between 1980 and 2013.

Search Strategy

A comprehensive and systematic search strategy was conducted in an attempt to identify and retrieve all relevant published and unpublished studies meeting inclusion criteria. The search, completed in April 2013, involved several sources and used the following key words: “anxiety disorders,” “family therapy,” “childhood anxiety,” “family treatment,” “randomized,” “experimental,” “quasi-experimental,” “clinical,” and “intervention.” Information sources included seven electronic databases (PsychINFO, ProQuest, Dissertations and Abstracts, Academic Search Premier, Social Work Abstracts, PubMed, and Medline); personal contacts with the first authors of all relevant studies, relevant researchers, research institutes, and professional associations; hand searches of journals relevant to the topic of the review (i.e., Journal of Marriage and Family Therapy, Journal of the American Association of Child and Adolescent Psychiatry, The American Journal of Orthopsychiatry, and Psychiatric Services); online searches through Google, Google Scholar, Yahoo!, and relevant websites of professional organizations; and reference lists of prior reviews and included studies.

Study Selection and Coding Procedures

The first author screened titles and abstracts for relevance. Those that were obviously ineligible (i.e., did not involve the target population, did not involve a child–parent intervention, or were theoretical in nature) were screened out. The full text of all studies that were not obviously ineligible or were questionable at this stage was obtained and screened for eligibility, using a screening instrument developed by the first author. The first author and a trained graduate student then coded studies deemed eligible by using a coding instrument developed by the authors to guide systematic examination and extraction of data. The coding instrument included categories concerning all relevant bibliographic information, study context, intervention and sample descriptors, research methods and quality descriptors, and effect size data (Lipsey & Wilson, 2001).

To ensure reliability of coding procedures, the first author and a trained graduated student independently coded 100% of the studies. Interrater reliability was obtained by dividing the number of agreements by the number of possible agreements for each study. There was 98% agreement between the two coders. All discrepancies were discussed and resolved.

Statistical Methods

Statistical analysis was designed to produce descriptive information on the characteristics of the included studies, the effect size of each intervention on anxiety outcomes, the grand mean effect size, and the heterogeneity of effect sizes around the mean. The standard mean difference effect size statistic, corrected for small sample size bias (Hedges’ g), was calculated for each study using a statistical software package, Comprehensive Meta-Analysis, Version 2.0 (Borenstein, Hedges, Higgins, & Rothstein, 2005) by inputting the means, standard deviations, and sample sizes for the treatment and control groups reported by the primary study authors. To maintain statistical independence of data, only one effect size was computed for each subject sample. Four of the eight studies used multiple measures to assess anxiety. In cases where multiple measures were used, the most valid measure was selected. In two cases, the measure used in the meta-analysis included both a parent and child report, which were reported by the primary study authors together as one score. In cases where more than one comparison group was used (i.e., a waitlist control and an alternative treatment), the group that received the alternative child-focused treatment was used in the analysis.

The effects of included studies were quantitatively synthesized in Comprehensive Meta-Analysis. Effect sizes were inverse variance weighted and random effects statistical models were assumed. Cochrane’s Q was used to assess heterogeneity in the effect sizes. A significant Q rejects the null hypotheses, indicating that the variability in effect sizes between studies is greater than what would be expected from sampling error alone (Hedges & Olkin, 1985). Moderator analysis was not indicated, as the statistical test assessing heterogeneity was not significant (Lipsey & Wilson, 2001). We had planned to assess and report publication bias by constructing a scatter plot of study effect size by sample size; however, due to the small number of studies, and thus low power, the use of funnel plots or other techniques such as regression to assess publication bias was not indicated (Card, 2012).

Results

The search procedures yielded close to 300 titles. After review of titles and abstracts, 33 potential studies were retrieved in full text for screening. Of those, 15 reports were excluded due to not meeting basic eligibility criteria and the remaining 18 reports were fully coded. Of those 18 studies, 10 were deemed ineligible. These studies were excluded due to using a single-group pretest–posttest design (n = 6), reporting secondary results of included studies (n = 2), or not providing sufficient statistics to compute an effect size (n = 2). The final sample for this review includes eight randomized controlled trials. See Figure 1 for a flowchart detailing the search and selection process.

Figure 1.

Study search and selection process flow chart. RCT = randomized controlled trial.

Descriptive Analysis

The characteristics of the eight included studies are summarized in Table 1. Of the eight studies, one was an unpublished dissertation and seven were peer-reviewed journal articles. The studies were conducted in four countries: the United States (n = 4), Australia (n = 2), Canada (n = 1), and the Netherlands (n = 1). The majority of the studies were conducted in a clinic setting (n = 7), and one was conducted in a hospital setting.

Table 1.

Characteristics of Included Studies.

Study Characteristics^a	N (%)	Participant Characteristics^b	N (%)
Publication year		Sex
1990–1999	2 (25)	Male	347 (52)
2000–2005	2 (25)	Female	323 (48)
2006–2009	4 (50)
Publication type		Participating parent^c
Journal	7 (88)	Mother	460 (91)
Dissertation	1 (13)	Father	249 (38)
Country		Anxiety disorder
United States	4 (50)	Social phobia	229 (34)
Australia	2 (25)	SAD	199 (30)
Canada	1 (13)	GAD	182 (27)
The Netherlands	1 (13)	Other	60 (9)
Sample size		Race^c
1–50	3 (38)	Caucasian	323 (68)
51–100	2 (25)	Hispanic	114 (24)
101–150	2 (25)	African American	21 (4)
151–200	1 (13)	Other	20 (4)
Setting
Clinic	7 (88)
Hospital	1 (13)

Note. SAD = separation anxiety disorder; GAD = generalized anxiety disorder.

^a N = 8 studies. ^b N = 670 total child participants. ^cThree studies did not report data.

Across the eight studies, participants included a total of 710 children and at least one parent. The age range of child participants was wide across studies (n = 1, 6–13 years; n = 1, 6–16 years; n = 1, 7–12 years; n = 3, 7–14; n = 1, 12–17 years; n = 1, 8–17 years). No studies included a subgroup analysis by age range. Studies included a balanced proportion of male and female child participants. Most of the participants across the eight studies were Caucasian (68%), and 91% of the participants had a primary diagnosis of social phobia, SAD, or generalized anxiety disorder. Approximately 98% of the participants had a secondary diagnosis, with the vast majority of secondary diagnoses (83%) being another anxiety disorder.

All child–parent interventions in this review used a treatment manual and were based on FCBT; the comparison group interventions were either individual CBT with the child (n = 7) or group CBT with children only (n = 1). All interventions were delivered in 12 to 16 sessions of 60 to 90 minutes each.

Four included studies tested Coping Cat (Kendall & Hedtke, 2006) or adaptations of Coping Cat, including a modified Coping Cat for adolescents (Siqueland, Rynn, & Diamond, 2005), Coping Koala (Barrett, Dadds, & Rapee, 1991), and Coping Bear (Mendlowitz & Scapillato, 1996). Coping Cat is a manualized cognitive behavioral treatment program that assists school-age children in recognizing and coping with anxious feelings and physical reactions to anxiety. Wood, Piacentini, Southam-Gerow, Chu, and Sigman (2006) examined the Building Confidence Program, developed specifically for their study. This intervention involved combining child-focused cognitive behavioral therapies with in vivo exposure and parent involvement. Spence, Donovan, and Brechman-Toussaint (2000) used the Social Skills Training: Enhancing Social Competence in Children and Adolescents program. The program integrated CBT, social skills training, relaxation techniques, problem-solving, and exposure interventions. The parent–child interventions in the remaining three studies were not named, but all used manualized cognitive behavioral interventions developed for their studies.

At least one doctoral level therapist or psychiatrist delivered all interventions. Other treatment personnel included doctoral students in five studies, one social worker, eight research assistants (in a single study), one family therapist, one youth care worker, and other unspecified master’s and doctoral level clinicians. Six studies used a combination of trained clinicians.

Meta-Analytic Results

The grand mean effect size for anxiety outcomes from the eight independent samples reported in the included studies, assuming a random effects model, was 0.26 (95% confidence interval [0.05, 0.47], p < .05), demonstrating a small but positive and statistically significant effect, favoring child–parent interventions on anxiety outcomes. Table 2 provides a summary of the characteristics and mean effect sizes for each of the included studies. The mean effect size and confidence intervals for each study are also shown in the forest plot in Figure 2. As seen in the table and forest plot, the effect sizes range from a very small and negative 0.01 to .88. Moreover, the confidence intervals around the mean effect size in seven of the eight studies cross zero, indicating that the child–parent intervention group did not differ significantly on anxiety outcomes from the child-focused intervention group. However, when the studies are pooled, the mean effect is positive, small, and statistically significant.

Figure 2.

Forest plot of mean effects (Hedges’ g) of included studies. CI = confidence interval.

Table 2.

Summary of Included Studies.

Author (Year)	Type of Intervention	N	Age Range	Comparison Intervention	Anxiety Measure	ES	95% CI
Barrett et al. (1996)	FCBT	79	7–14	ICBT	RCMAS	0.41	[−0.13, 0.95]
Bodden et al. (2008)	FCBT	128	8–17	ICBT	ADIS C/P	0.53	[−0.05, 1.12]
Kendall et al. (2008)	FCBT	161	7–14	ICBT	MASC	−0.01	[−0.38, 0.36]
Mendlowitz et al. (1999)	FCBT	68	7–12	ICBT	RCMAS	0.16	[−0.54, 0.86]
Moreno (2007)	FCBT	143	6–16	GCBT	RCMAS	0.05	[−0.33, 0.43]
Siqueland et al. (2005)	FCBT	11	12–17	ICBT	HAM-A	0.48	[−0.62, 1.59]
Spence et al. (2000)	FCBT	50	7–14	ICBT	ADIS-P	0.34	[−0.35, 1.04]
Wood et al. (2006)	FCBT	40	6–13	ICBT	ADIS-C/P	0.88*	[0.22, 1.53]

Note. CI = confidence interval; FCBT = family cognitive behavioral therapy; ICBT = individual cognitive behavioral therapy; RCMAS = Revised Children’s Manifest Anxiety Scale; ADIS = Anxiety Disorder Interview Schedule (C = Child Version, P = Parent Version); MASC = Multidimensional Anxiety Scale for Children; GCBT = group cognitive behavioral therapy; HAM-A = Hamilton Anxiety Rating Scale.

*p < .05.

Analysis of Homogeneity

To examine whether between-study variance is greater than what would be expected from sampling error alone, an analysis of heterogeneity was conducted using the Q-test. The result of the test of homogeneity was not significant (Q = 8.08, df = 7, p = .325, I ² = 13.41), indicating that any variance in effect sizes across included studies can be attributed to sampling error alone, rather than systematic or random differences between studies (Lipsey & Wilson, 2001). Although the Q-test was not significant, we assumed a random effects model because the Q-test does not have much statistical power with small sample sizes and may fail to reject homogeneity when there is significant variability of effect sizes across studies (Lipsey & Wilson, 2001). Moreover, the random effects model was selected a priori because it was anticipated that the included studies would vary in terms of study, participant, and intervention characteristics. Because we found no significant variability beyond sampling error, and due to the small number of included studies, moderation analysis was not indicated.

Analysis of Publication Bias

To mitigate publication bias, special efforts were made to search for and retrieve unpublished reports; however, only one unpublished report was included in this review. Conducting a formal assessment of publication bias, such as constructing and visually inspecting a funnel plot or using the trim and fill method, was not indicated due to the study’s small sample size and low power (Littell, 2008).

Discussion and Applications to Social Work

The purpose of the present study was to compare child–parent interventions to other treatment modalities to determine whether child–parent interventions are more effective and to inform social work practice with children with anxiety. A systematic review methodology was used to search, select, and extract data from studies examining effects of child–parent interventions against child-focused interventions. Eight studies met inclusion criteria for this review. Meta-analytic results revealed a small but overall positive and significant effect of parent–child interventions compared to child-focused individual or group interventions. On average, FCBT outperformed child-focused CBT individual and group interventions on anxiety outcomes. While an effect size of .26 is considered small using Cohen’s rules of thumb (Cohen, 1988), given that this review directly compares FCBT to already established interventions, a statistically significant effect size of .26 is impressive and reveals a non-negligible advantage of FCBT over already established child-focused CBT interventions. Although there was some variation in the delivery of the FCBT interventions, there was no statistically significant difference in the magnitude of effects of the FCBT interventions across studies, indicating that any variations in the FCBT models used did not affect the magnitude of effect of the intervention.

It is interesting to note that the effect sizes in seven of the eight studies, when examined individually, were not significantly different from zero, meaning that there was no evidence that FCBT was more effective than child-focused CBT found in the majority of the individual studies. When combined, however, the pooled effect size was significantly different from zero, indicating that FCBT was more effective than child-focused CBT on average. Given the small sample sizes in several of the included studies, it is possible that the primary studies failed to demonstrate a significant effect because they were underpowered. One of the strengths of meta-analysis over narrative or vote-counting methods is the capability to find effects that are not readily apparent or are obscured when using less sophisticated approaches (Lipsey & Wilson, 2001). By pooling effect size estimates across studies, meta-analysis can combine the results of underpowered studies, producing a synthesized effect estimate with considerably more statistical power to discover meaningful effects that can be missed in low-powered individual studies (Card, 2012).

Given the advances in the development of non-CBT parent–child interventions for anxiety disorders, we had anticipated finding at least some studies examining effects of non-CBT parent–child interventions. However, despite our best efforts, we did not locate any studies testing effects of other models of child–parent interventions against child-focused interventions that met inclusion criteria. Moreover, all of the comparison groups received a variant of individual or group CBT interventions. On the one hand, the lack of diversity in the interventions examined in this review and the homogeneity of effects across studies provide greater confidence in the present study’s findings. On the other hand, finding only FCBT studies that met inclusion criteria was disappointing, as we did not intend for this review to focus on CBT interventions.

The failure to find child–parent intervention studies that met inclusion criteria and that were not based on FCBT could be attributed to a number of potential reasons. It is possible that non-CBT interventions do not receive sufficient empirical attention (or funding), that research with other types of interventions is not as well developed or rigorous, that rigorous research exists but is not compared to child-focused interventions, or that research is not published or otherwise made available (possibly due to issues related to reporting bias). Nevertheless, the lack of rigorous research on non-CBT child–parent interventions for treating childhood anxiety disorder is concerning and perplexing.

Although the meta-analytic findings indicate support for FCBT interventions over child-focused CBT interventions, gaps remain in the evidence base in terms of identifying for whom and under what circumstances FCBT is more effective. Primary studies in this review included children across a wide range of ages and developmental periods. Despite hypotheses that family interventions may be more effective and developmentally appropriate for younger children, the included studies did not examine differential effectiveness between ages or developmental stages of the study participants. Thus, despite prior recommendations by several researchers to examine differential effects of FCBT across age groups (Creswell & Cartwright-Hatton, 2007; Reynolds et al., 2012), we still know little about the relative effectiveness of FCBT for children in different age groups. Similarly, some included studies were missing relevant information regarding the demographics of the participants, and some studies did not report effects by race/ethnicity or other relevant demographic characteristics. Child-focused CBT may be more appropriate and more effective than FCBT for some groups of children or parents, based on race/ethnicity, socioeconomic status, or other demographic variables. Future research could begin to parse out differential effectiveness, based on participant characteristics.

Based on the results of the present study, one cannot draw conclusions about the relative efficacy of FCBT for different types of anxiety disorders. While there is some extant evidence of differential effects of interventions for different anxiety or comorbid disorders (Kendall et al., 2008; Rapee et al., 2013), we were unable to examine effects by type of disorder in the present study. The included studies tested FCBT interventions with a range of anxiety disorders; however, no studies differentiated effects by type, severity, or duration of anxiety disorders, and no study limited the sample to a specific disorder. Most studies also included participants with comorbid conditions; thus, it is unclear whether there are differential effects between diagnostic categories. Future research can begin to elucidate whether and which anxiety disorders are more or less responsive to FCBT compared to child-focused CBT and other modalities, either by focusing specifically on one disorder or providing subsets of outcome data by diagnostic category.

While this study expands and improves upon prior reviews and contributes to the growing evidence base of intervention effectiveness for childhood anxiety disorders, the present study is not without limitations and the findings must be interpreted in light of the study’s limitations. This review is limited to a relatively small number of studies that compared the effects of child–parent interventions to those of alternative interventions for children with anxiety disorders and that met the other inclusion criteria specified for this review. Also, we may not have captured every eligible intervention study, despite our comprehensive and systematic search process. Despite our intent to include a variety of parent–child interventions outside of CBT, all of the studies included in this review compared a variant of FCBT to individual or group CBT. Findings from this review may not generalize to studies examining effects of different types of parent–child interventions or studies that were excluded from this review due to not meeting inclusion criteria or not being identified in the search. Also, despite our attempts to include unpublished studies through our gray literature search, we discovered only one unpublished study and thus publication bias is a potential threat to the validity of this review. Moreover, because we calculated effects by using the most reliable and valid anxiety measure reported in each of the included studies, the outcome measures used in this analysis may not represent the outcome measures that the primary study authors or another reviewer would have selected and in some cases may overestimate or underestimate the treatment effect compared to other measures reported in the primary studies.

Conclusion

Due to the significant immediate and long-term implications of childhood anxiety disorders, it is important that children and adolescents who experience anxiety receive effective treatment. Social workers and other treatment professionals are mandated, through their respective professional code of ethics, to engage in evidence-informed practice. The present study contributes to the evidence base of interventions for childhood anxiety disorders by synthesizing the effects of child–parent interventions to assist practitioners in making evidence-informed decisions with their clients. While the study results provide evidence of effectiveness of FCBT compared to individual or group child-focused CBT interventions in reducing anxiety, gaps and areas ripe for further study were also identified. Future directions for research include replicating current primary studies, particularly with larger sample sizes, and assessing effects of other child–parent interventions that are in the early stages of development, such as PCIT, attachment-based family therapy, and child–parent psychotherapy. Additionally, follow-up studies to published research are vital to establishing the long-term effectiveness of parent–child interventions. Future research also needs to systematically examine potential moderating and mediating variables, such age, sex, race, socioeconomic status, severity and type of anxiety disorder, parental anxiety, and other comorbid conditions that may have a differential impact on the effects of interventions. In addition to research on effects of interventions, future research could assess and report on implementation issues, intervention fidelity, and the cost and benefit of interventions to help clinicians, organizations, and clients make well-informed decisions about treatment.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by the Meadows Center for Preventing Educational Risk and the Institute of Education Sciences (grant # R324B080008).

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