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Anxiety

Are Parents the Key to Treating Children's Anxiety?

Research suggests that improving parents' interpretive style could help kids.

Key points

  • A parent's tendency to interpret ambiguous situations as threatening may be passed on to their child, which can reinforce anxiety in the child.
  • Teaching parents to interpret situations as positive or neutral using an app can improve interpretation bias and reduce parents' anxiety.
  • Parent-focused treatments may help meet an urgent, unmet need for innovative and more accessible child anxiety treatments.

Research has repeatedly shown that parental anxiety predicts and maintains child anxiety. There are many potential mechanisms that may explain how parental anxiety leads to child anxiety. Genetics is one obvious potential explanation. However, there are also psychological factors that parents may pass on to their children through various anxiety-promoting behaviors.

Theoretical models have identified interpretation bias — the tendency to jump to negative conclusions when faced with ambiguous or uncertain situations — as one way that parents transmit anxiety to their children. A model by Ollendick and Benoit (2012) posits that a negative interpretation bias may cause parents to perceive ambiguous situations in their own life and their child’s environment as threatening. This threatening interpretation may result in anxiety-promoting parenting behaviors that transmit a threat interpretation bias to their children and reinforce anxious behaviors.

For example, let’s look at a day-to-day interaction between Taylor and their parent Robin, who has been diagnosed with anxiety and frequently interprets situations in a negative manner. Suppose Taylor is invited to their classmate’s birthday party at a popular laser tag center. Upon hearing about this party, Robin immediately perceived it as a dangerous situation — there will be a bunch of kids which will make it hard to keep track of Taylor, and laser tag involves lots of running around and climbing which could result in injury.

Robin may express their concerns to Taylor, not let Taylor attend, or encourage Taylor to not actively participate due to their interpretation of this event as dangerous. Over time, when faced with similar situations and parental reactions, Taylor may learn to associate such events with danger and fear, and may in turn avoid situations in which they could get lost or hurt. This parent has effectively passed on their threat interpretation bias and anxiety to their child.

Can we treat parents’ interpretation bias to ultimately help child anxiety?

Although 15 to 32 percent of children in the United States experience an anxiety disorder in their childhood (Merikangas et al., 2010), only 18 percent of anxious children receive any form of treatment (Merikangas et al., 2011). Consequently, there is currently an urgent, unmet need for innovative and more accessible treatments for child anxiety. As there aren’t enough child anxiety providers, one potential solution is to treat the parents.

In our lab, we asked parents of anxious youth to use a smartphone app designed to improve interpretation bias. The app, called HabitWorks, was originally developed for a severe psychiatric population (Beard et al., 2020) and had never been tested in parents of anxious youth. HabitWorks utilizes a simple task involving ambiguous situations with corrective feedback with the goal of training users to think more flexibly by identifying positive or neutral interpretations of ambiguous situations. By training users to stop jumping to negative automatic conclusions, the app aims to promote healthy mental habits, and in parents, stop the transmission of interpretation bias and anxiety.

In our first pilot study, we recruited from child anxiety clinics in the Boston area. A total of 14 parents of anxious children (Mean age=44.36 years, 85.71 percent women, 64.29 percent White, 85.71 percent heterosexual) were asked to use the HabitWorks app for one month. During this month, parents were asked to complete brief, five-minute interpretation bias exercises three times per week, along with a once-weekly check-in that included mood surveys, a diary entry, and email check-in with research staff.

Results from our study showed that (Beckham et al., 2020):

  • Parents’ anxiety symptoms significantly improved from the “mild” severity range to the “none to minimal” range.
  • Parental interpretation bias improved significantly from pre- to post-treatment, and this improvement was maintained at the one-month follow-up.
  • On measures of app usability and acceptability, parents reported that they found HabitWorks to be helpful, user-friendly, satisfying, and above average in usability.
  • Parents demonstrated strong adherence to the study protocol, completing an average of 13.29 out of 12 prescribed exercises over the treatment month.

Stopping parents from passing anxiety onto children

These promising results point to the potential utility of slowing the intergenerational transmission of anxiety via a smartphone app. Such interventions are easily disseminated as they are self-administered by parents and may be integrated into even the most hectic daily schedule.

To see how such smartphone apps may benefit parent and child anxiety, let’s look at what might have happened with Taylor and Robin should Robin have used the HabitWorks app and successfully improved their interpretive style:

When Taylor is invited to their classmate’s birthday party at a popular laser tag center, Robin immediately shared how much fun they think the day will be — there will be a bunch of new kids to meet, and Taylor will love running and climbing in the arena. Robin encourages Taylor to attend the party. Robin instills confidence in Taylor that they are capable of asking for help from an employee should they get lost, and calmly relays a meeting spot should they get separated. Over time, when faced with similar situations and parental reactions, Taylor may learn to embrace new or uncertain situations as exciting, rather than avoiding any experience with a potential scary outcome.

Take-home message

The bad news: Parents may unintentionally pass on their biases and anxiety to their children. The good news: Interpretation bias is malleable, and we have interventions that can improve parents’ interpretive style. Next steps to realize this potential parent intervention for child anxiety are to conduct a much larger study, compare the treatment group to a strong control condition, and assess child outcomes.

Erin Beckham, BA, a research assistant in the Cognition and Affect Research and Education (CARE) Lab at McLean Hospital, contributed to this post.

References

Beard, C., Ramadurai, R., McHugh, R. K., Pollak, J. P., & Björgvinsson, T. (2021). HabitWorks: Development of a CBM-I smartphone app to augment and extend acute treatment. Behavior Therapy, 52(2), 365-378.

Beckham, E., Solomon, A., Watson, K., Ramadurai, R., Fenley, A., Pincus, D., & Beard, C. (2020, October). Cognitive bias modification for parents of anxious children: a pilot study. Poster Presented virtually at the Technology in Psychiatry Online Summit, Boston, MA.

Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., Georgiades, K., & Swendsen, J. (2010). Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989. https://doi.org/10.1016/j.jaac.2010.05.017

Merikangas, K. R., He, J., Burstein, M. E., Swendsen, J., Avenevoli, S., Case, B., … Olfson, M. (2011). Service utilization for lifetime mental disorders in U.S. adolescents: Results of the National Comorbidity Survey Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 50(1), 32–45. https://doi.org/10.1016/j.jaac.2010.10.006

Ollendick, T. H., & Benoit, K. E. (2012). A parent–child interactional model of social anxiety disorder in youth. Clinical Child and Family Psychology Review, 15(1), 81-91.

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