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Question: Does a cognitive-behavioural based group parenting intervention relieve anxiety in children with anxiety disorders?
Patients: Families of 74 children below 9 years of age (range 2.7–9 years, average 6.6 years) who had levels of anxiety at or above clinical cut-off of Parent Reported Child Behavior Checklist and appeared likely to have an anxiety disorder on preliminary interview with a clinical psychologist. Parents or children with moderate to severe learning difficulties were excluded, as were children with moderate to severe autistic spectrum disorder (assessed by clinical psychologist).
Setting: The Wellcome Trust Clinical Research Facility, Manchester, UK; recruitment 2006–2008.
Intervention: ‘Timid to Tiger’ parenting intervention or waiting list control for 10 weeks. The parenting intervention was a manualised, group, 10-session course for parents. It was delivered by two clinical psychologists and attended by three to seven families per course. The course targeted providing children with a warm, calm and predictable home environment and helping parents to manage children's anxiety symptoms using cognitive-behavioural skills.
Outcomes: Child's anxiety diagnosis assessed by a blinded diagnostic interview (Anxiety Disorders Interview Schedule for Children and Parents–IV, ADIS).
Patient follow-up: 85% completed treatment period (without protocol deviation); 78% completed follow-up; 99% included in analyses.
Design: Randomised controlled trial.
Blinding: Single blind (assessors blinded).
Follow-up period: 12 months (includes 10-week treatment period).
The children were assessed preintervention and postintervention using diagnostic interview to determine their primary anxiety diagnosis. At postassessment, the parenting intervention increased the likelihood of children being free from their primary ADIS diagnosis compared with the waiting list control (21/37 (56.8%) with intervention vs 5/33 (15%) with control; OR 7.35, 95% CI 2.85 to 35.61, p<0.001). The parenting intervention also reduced the likelihood of any ADIS anxiety diagnosis postintervention (12/37 (32%) with intervention vs 2/33 (6%) with control; OR 7.44, 95% CI 1.72 to 24.98, p<0.05). At 12-month follow-up, the parenting group were still more likely to be free from their primary anxiety diagnosis than were the control group (20/37 (54%) with the intervention vs 8/33 (24%) with control group; OR 3.68, 95% CI 1.24 to 17.33, p<0.05). The parenting group were also more likely to be free from their any anxiety diagnosis at this 12-month follow-up (17/37 (46%) with the intervention vs 3/33 (9%) with control; OR 8.50, 95% CI 2.55 to 33.29, p<0.01). In the follow-up period, 38% of control children had received additional interventions for their anxiety compared with only 7% in the intervention group.
The 10-week ‘Timid to Tiger’ group parent training course for parents of anxious children reduces anxiety diagnoses among children aged 3–9-year postintervention. The treatment effects were maintained at 12 months.
All analyses were by intention to treat using a last observation carried forward approach for missing data. However, when no suitable value was available, the subsequent observation was carried back.
This study describes a parenting intervention for anxiety in very young children, of whom the overwhelming majority had responded to media advertisements and a minority were referred from clinical services. Anxiety disorders are one of the more common disorders in children and are often see in medical settings as well as in the general population.
The authors rightly identify that the younger children, who are the focus of this trial, are relatively neglected in terms of trials of interventions. This intervention is novel in that it focuses on young children and uses parents as the primary therapists, providing parents with strategies to manage the anxiety in their children. The authors have focused on harsh discipline as a possible mediator for anxiety and proposed that reducing it will reduce the children's anxiety. There is less focus on anxiety in the parents, which is a pity, given the clear association between anxiety in parents and their children. Managing childhood anxiety by teaching parents skills to intervene is unique, as the authors have pointed out. However, there have also been positive effects on internalising disorders including anxiety from other parenting programmes that have disruptive behaviours as a primary target, such as Incredible Years. The trial was of high quality and was conducted in a way that minimised bias. The results are impressive. There was a substantial improvement compared with the wait-list control group in all measures of depression apart from the Multidimensional Anxiety Scale for Children (MASC), which was only administered to children aged 6 years or above and was a self-rated scale. There is concern that self-ratings in this age group may not be reliable. The main limitation to this study is the population participating in the research, which was mostly not a clinical population. However, the entry criteria were clear and appropriate, and included children in the clinical range.
This may indeed be an effective therapy and is one that would be reasonably easy to implement with little chance of harm. Ideally, it should be replicated, if possible, in a clinical setting.
Sources of funding The first author received support from the Medical Research Council.
Competing interests None.
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