Abstract
Objective: This study compared the effects of direct childparent 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 parentchild interventions was 0.26, 95% confidence interval [0.05, 0.47], p < .05, a small but positive and significant effect, favoring childparent interventions. Results of the
heterogeneity analysis were not significant (Q 8.08, df 7, p > .05, I2 13.41). Discussion: Parentchild 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
Corresponding Author:
Kristen Esposito Brendel, School of Social Work, Aurora University, 347
Gladstone, Aurora, IL 60506, USA.
Email: kbrendel@aurora.edu
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ChildParent Psychotherapy. CPP is a model of family play therapy that involves treatment of the parentchild 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 childs inner experience increases, as well as trust, reciprocity, and pleasure within the parentchild 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.
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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.
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
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.
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Figure 1. Study search and selection process flow chart. RCT randomized controlled trial.
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. Cochranes 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
pretestposttest design (n 6), reporting secondary results of
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.
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, 613 years; n 1, 616
years; n 1, 712 years; n 3, 714; n 1, 1217 years; n 1,
817 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
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N (%)
2 (25)
2 (25)
4 (50)
7 (88)
1 (13)
4
2
1
1
(50)
(25)
(13)
(13)
3
2
2
1
(38)
(25)
(25)
(13)
Participant
Characteristicsb
Sex
Male
Female
Participating parentc
Mother
Father
Anxiety disorder
Social phobia
SAD
GAD
Other
Racec
Caucasian
Hispanic
African American
Other
N (%)
347 (52)
323 (48)
460 (91)
249 (38)
229 (34)
199 (30)
182 (27)
60 (9)
323 (68)
114 (24)
21 (4)
20 (4)
7 (88)
1 (13)
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 childparent 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 childparent 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.
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, I2 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
studys small sample size and low power (Littell, 2008).
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Type of Intervention
Age Range
Comparison Intervention
Anxiety Measure
ES
95% CI
FCBT
FCBT
FCBT
FCBT
FCBT
FCBT
FCBT
FCBT
79
128
161
68
143
11
50
40
714
817
714
712
616
1217
714
613
ICBT
ICBT
ICBT
ICBT
GCBT
ICBT
ICBT
ICBT
RCMAS
ADIS C/P
MASC
RCMAS
RCMAS
HAM-A
ADIS-P
ADIS-C/P
0.41
0.53
0.01
0.16
0.05
0.48
0.34
0.88*
[0.13, 0.95]
[0.05, 1.12]
[0.38, 0.36]
[0.54, 0.86]
[0.33, 0.43]
[0.62, 1.59]
[0.35, 1.04]
[0.22, 1.53]
Note. CI confidence interval; FCBT family cognitive behavioral therapy; ICBT individual cognitive behavioral therapy; RCMAS Revised Childrens 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.
Figure 2. Forest plot of mean effects (Hedges g) of included studies. CI confidence interval.
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Conclusion
Due to the significant immediate and long-term implications of
childhood anxiety disorders, it is important that children and
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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).
References
References marked with an asterisk indicate studies included in the
meta-analysis.
Albano, A. M., Chorpita, B. F., & Barlow, D. H. (2003). Childhood anxiety disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (2nd ed., pp. 279319). New York, NY: Guilford Press.
American Psychological Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1991). Coping Koala
workbook (Unpublished manuscript). School of Applied Psychology, Griffith University, Nathan, Australia.
*Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment
of childhood anxiety: A controlled trial. Journal of Consulting and
Clinical Psychology, 64, 333342.
Barrett, P. M., & Shortt, A. L. (2003). Parental involvement in the
treatment of anxious children. In A. E. Kazdin & J. R. Weisz
(Eds.), Evidence-based psychotherapies for children and adolescents (pp. 101119). New York, NY: Guilford Press.
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