Systematic review and meta-analysis: anxiety and depressive disorders in offspring of parents with anxiety disorders

Objective: We conducted meta-analyses to assess risk of anxiety disorders among offspring of parents with anxiety disorders and to establish whether there is evidence of specificity of risk for anxiety disorders as opposed to depression in offspring, and whether particular parent anxiety disorders confer risks for particular child anxiety disorders. We also examined whether risk was moderated by offspring age, gender, temperament and the presence of depressive disorders in parents. Method: We searched PsycINFO, PubMed and Web of Science in June, 2016 and July, 2017 (PROSPERO CRD42016048814). Study inclusion criteria: published in peer-reviewed journals; contained at least one group of parents with anxiety disorders and at least one comparison group of parents who did not have anxiety disorders; reported rates of anxiety disorders in offspring, and used validated diagnostic tools to ascertain diagnoses. We used random and mixed-effects models and evaluated study quality. Results: We included 25 studies (7285 offspring). Where parents had an anxiety disorder, offspring were significantly more likely to have anxiety (RR: 1.76, 95% CI = 1.58-1.96) and depressive disorders (RR: 1.31, 95% CI = 1.13-1.52) than offspring of parents without anxiety disorders. Parent Panic Disorder and Generalized Anxiety Disorder appeared to confer particular risk. Risk was greater for offspring anxiety than depressive disorders (RR: 2.50, 95% CI = 1.50-4.16), and specifically for offspring Generalized Anxiety Disorder, Separation Anxiety Disorder and Specific Phobia, but there was no evidence that children of parents with particular anxiety disorders were at increased risk for the same particular anxiety disorders. Moderation analyses were possible only for offspring age, gender and parental depressive disorder; none were significant. Conclusions: Parent anxiety disorders pose specific risks of anxiety disorders to offspring. However, there is limited support for transmission of the same particular anxiety disorder. These results support the potential for targeted prevention of anxiety disorders

Barriers to and facilitators of the identification, management and referral of childhood anxiety disorders in primary care: A survey of general practitioners in England

Objectives: Although anxiety disorders are the most common emotional disorders in childhood and are associated with a broad range of negative outcomes, only a minority of affected children receive professional support. In the UK, General Practitioners(GPs) are seen as "gate-keepers" to mental health services. The aim of this study was to examine the extent to which GPs experience barriers and facilitators to identifying, managing and accessing specialist services for these disorders, as well as factors associated with GPs’ confidence. Design & setting: Cross-sectional, self-report questionnaire in primary care, addressing identification, management and access to specialist services for children(under 12 years) with anxiety disorders. Participants: 971 GPs in England. Primary outcomes: The primary outcomes for this research was the extent to which GPs felt confident a)identifying and b)managing anxiety disorders in children. Results: Only 51% and 13% of GPs felt confident identifying and managing child anxiety disorders respectively. A minority believed that their training in identification(21%) and management(10%) was adequate. Time restrictions inhibited identification and management, and long waiting times was a barrier to accessing specialist services. Being female(Ex(B)=1.4,95%CI 1.1-1.9) and being in a less deprived practice(Ex(B)=1.1,95%CI 1-1.1) was associated with higher confidence identifying childhood anxiety disorders. Being a parent of a child over the age of 5(Ex(B)=2,95%CI 1.1-3.5) and being in a less deprived practice(Ex(B)=1.1,95%CI 1-1.2) was associated with higher confidence in management. Receipt of psychiatric or paediatric training was not significantly associated with GP confidence. Conclusions: GPs believe they have a role in identifying and managing childhood anxiety disorders, however their confidence appears to be related to their personal experience and the context in which they work, rather than their training, highlighting the need to strengthen GP training and facilitate access to resources and services to enable them to support children with these common but debilitating conditions. Funding: This work was supported by grant a National Institute for Health Research ‘Research Professorship’ to CC (NIHR-RP-2014-04-018). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

Guided parent delivered cognitive behavioural therapy for childhood anxiety: predictors of treatment response

Background: Guided Parent-delivered Cognitive Behaviour Therapy (GPD-CBT) is a brief, effective treatment for childhood anxiety disorders, however not all children respond favourably. Aims: To examine predictors of response to GPD-CBT. Methods: Parents of 125 children (7 – 12 years) with an anxiety disorder received GPD-CBT over 2.6 or 5.3 hours). Recovery was measured post treatment and six months later. Results: Younger children and those with primary Generalised Anxiety Disorder (GAD) improved more post treatment, but older children and those without primary GAD had better outcomes at six month follow up. Fewer children allocated to 2.6 hours had recovered post treatment compared to those allocated to the 5.2 hour intervention, but did not differ significantly six months later. Conclusions: The identification of predictors of short and longer-term treatment outcomes can guide treatment decisions following this low-intensity approach. Declaration of interest: CC receives royalties for the book provided to parents

Are children with social anxiety disorder more likely than children with other anxiety disorders to anticipate poor social performance and reflect negatively on their performance?

Background: The cognitive theory of social anxiety disorder (SAD) suggests that adults with SAD have a tendency to anticipate poor social performance and reflect negatively on their performance following a social event. While a number of studies with socially anxious adults have supported the role of poor performance anticipation and post-event rumination in SAD, to date, only a few studies have addressed whether this also applies to children with SAD. Methods: Children (7-12 years) diagnosed with SAD (n=40), other anxious children (n=40) and non-anxious children (n=34) were exposed to a social stressor speech task and their pre- and post-performance appraisals assessed, taking into account objective performance ratings. Results: Although observers rated some aspects of performance as significantly worse among children with SAD than children with other anxiety disorders, children with SAD were not more likely than their anxious or non-anxious peers to show a general bias in pre- or post-performance appraisals. Furthermore, children with SAD were just as likely as their anxious and non-anxious peers to recognize good performance but were more critical of themselves when their performance was poor. Limitations: The speech task did not involve a same-age peer. Participants were relatively affluent group of predominantly non-minority status. Specificity for SAD in relation to other anxiety disorders remains unclear. Conclusions: Focusing on counteracting pre- and post-event social performance appraisals may potentially be inappropriate for childhood SAD. Children with SAD might benefit from interventions that focus on helping them to become less critical of themselves after social interactions have not gone well

A randomized controlled trial of internet-delivered cognitive behaviour therapy for adolescent anxiety disorders in a routine clinical care setting with and without parent sessions

Background: Computerized treatments have been shown to be effective in young people with anxiety disorders within research settings. The aims of this study were to evaluate a self-completed, therapist-supported online treatment for adolescent anxiety disorders in a routine clinical care setting, and examine whether additional sessions for parents improved treatment outcome. Method: 60 adolescents (13-18 years) referred by primary and secondary care services for treatment of an anxiety disorder and their parent(s) were randomly allocated to begin treatment immediately or after a 16-week waitlist. Half the parents (receiving treatment immediately or after a waitlist) were allocated to receive sessions themselves. Assessments were conducted pre- and post-treatment and at 6-month follow-up. Results: There was no significant difference post-treatment between the immediate treatment and waitlist groups in remission of primary anxiety disorder (Odds Ratio (OR) = 2.19, 95% CI 0.72-6.70). Parent sessions did not significantly improve adolescent outcomes immediately or at 6-month follow-up (OR = 0.75, 95% CI 0.26-2.15; OR = 1.14, 95% CI 0.42-3.15). Conclusions: Within a routine clinical care setting, a therapist-supported online treatment failed to deliver significantly better outcomes for adolescents with anxiety disorders than a waitlist. Further research is needed to develop more effective treatments for this population

Parent-led cognitive behaviour therapy for child anxiety problems: overcoming challenges to increase access to effective treatment

Background: Anxiety problems have a particularly early age of onset and are common among children. As we celebrate the anniversary of the BABCP, it is important to recognise the huge contribution that cognitive behavioural therapy (CBT) has made to the treatment of anxiety problems in children. CBT remains the only psychological intervention for child anxiety problems with a robust evidence base, but despite this, very few children with anxiety problems access CBT. Creative solutions are urgently needed to ensure that effective treatments can be delivered at scale. Here we focus on parent-led CBT as this offers a potential solution that is brief and can be delivered by clinicians without highly specialised training. Over the last decade there has been a substantial increase in randomised controlled trials evaluating this approach with consistent evidence of effectiveness. Nonetheless clinicians, and parents, often have concerns about trying the approach and can face challenges in its delivery. Method: We draw on empirical evidence and our clinical experience to address some of these common concerns and challenges, with particular emphasis on the key principles of empowering parents and working with them to provide opportunities for new learning for their children. Conclusions: We conclude by highlighting some important directions for future research and practice, including further evaluation of who does and does not currently benefit from the approach, determining how it should be adapted to optimise outcomes among groups that may not currently get maximum benefits and across cultures, and capitalising on recent technological developments to increase engagement and widen access

Intolerance of uncertainty, anxiety and worry in children and adolescents: a meta-analysis

Background Intolerance of uncertainty (IU) has been implicated in the development and maintenance of worry and anxiety in adults and there is an increasing interest in the role that IU may play in anxiety and worry in children and adolescents. Method We conducted a systematic review and meta-analysis to summarize existing research on IU with regard to anxiety and worry in young people, and to provide a context for considering future directions in this area of research. The systematic review yielded 31 studies that investigated the association of IU with either anxiety or worry in children and adolescents. Results The meta-analysis showed that IU accounted for 36% of the variance in anxiety and 39.69% in worry. Due to the low number of studies and methodological factors, examination of potential moderators was limited; and of those we were able to examine, none were significant moderators of either association. Most studies relied on questionnaire measures of IU, anxiety, and worry; all studies except one were cross-sectional and the majority of the studies were with community samples. Limitations The inclusion of eligible studies was limited to studies published in English that focus on typically developing children. Conclusions There is a strong association between IU and both anxiety and worry in young people therefore IU may be a relevant construct to target in treatment. To extend the existing literature, future research should incorporate longitudinal and experimental designs, and include samples of young people who have a range of anxiety disorder

Social communication deficits: specific associations with Social Anxiety Disorder

Background Social communication deficits are prevalent amongst children with anxiety disorders; however whether they are over-represented specifically among children with Social Anxiety Disorder has not been examined. This study set out to examine social communication deficits among children with Social Anxiety Disorder in comparison to children with other forms of anxiety disorder. Methods Parents of 404 children with a diagnosed anxiety disorder completed the Social Communication Questionnaire (SCQ; Rutter, M., Bailey, A., Lord, C., 2003. The Social Communication Questionnaire – Manual. Western Psychological Services, Los Angeles, CA). Children with a diagnosis of Social Anxiety Disorder (n=262) and anxious children without Social Anxiety Disorder (n=142) were compared on SCQ total and subscale scores and the frequency of participants scoring above clinical cut-offs. Results Children with Social Anxiety Disorder scored significantly higher than anxious children without Social Anxiety Disorder on the SCQ total (t(352)=4.85, p<.001, d=.55, r=.27), Reciprocal Social Interaction (t(351)=4.73, p<.001, d=.55, r=.27), communication (t(344)=3.62, p<.001, d=.43, r=.21) and repetitive, restrictive and stereotyped behaviors subscales (t(353)=3.15, p=.002, d=.37, r=.18). Furthermore, children with Social Anxiety Disorder were three times more likely to score above clinical cut-offs. Limitations The participants were a relatively affluent group of predominantly non-minority status. The social communication difficulties measure relied on parental report which could be influenced by extraneous factors. Conclusions Treatments for Social Anxiety Disorder may benefit from a specific focus on developing social communication skills. Future research using objective assessments of underlying social communication skills is required

Complete recovery from anxiety disorders following Cognitive Behavioural Therapy in children and adolescents: a meta analysis

Cognitive Behavior Therapy (CBT) is a well-established treatment for childhood anxiety disorders. Meta-analyses have concluded that approximately 60% of children recover following treatment, however these include studies using a broad range of diagnostic indices to assess outcomes including whether children are free of the one anxiety disorder that causes most interference (i.e. the primary anxiety disorder) or whether children are free of all anxiety disorders. We conducted a meta-analysis to establish the efficacy of CBT in terms of absence of all anxiety disorders. Where available we compared this rate to outcomes based on absence of primary disorder. Of 56 published randomized controlled trials, 19 provided data on recovery from all anxiety disorders (n = 635 CBT, n = 450 control participants). There was significant heterogeneity across those studies with available data and full recovery rates varied from 47.6 to 66.4% among children without autistic spectrum conditions (ASC) and 12.2 to 36.7% for children with ASC following treatment, compared to up to 20.6% and 21.3% recovery in waitlist and active treatment comparisons. The lack of consistency in diagnostic outcomes highlights the urgent need for consensus on reporting in future RCTs of childhood anxiety disorders for the meaningful synthesis of data going forwards