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Systematic Review

ChildParent Interventions for Childhood


Anxiety Disorders: A Systematic Review
and Meta-Analysis

Research on Social Work Practice


2014, Vol. 24(3) 287-295
The Author(s) 2013
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DOI: 10.1177/1049731513503713
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Kristen Esposito Brendel1 and Brandy R. Maynard2

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

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).

ChildParent 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 childparent
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
1
2

School of Social Work, Aurora University, IL, USA


School of Social Work, Saint Louis University, MO, USA

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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Research on Social Work Practice 24(3)

to better generalize skills from the clinicians 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 childparent 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 childparent interventions currently in practice. Some of the most common childparent interventions
include family cognitive behavioral therapy (FCBT), parent
child interaction therapy (PCIT), childparent 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 childrens 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.
ParentChild 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 parentchild 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 parentchild relationships by fostering healthy attachments, modifying reinforcement
contingencies, and reducing anxiety-provoking responses (Choate et al., 2005).

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.

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 Winnicotts (1958) notion of being a good
enough mother. Five dimensions present in motherchild
interactions are postulated in this model: structuring, challenging, engagement, nurturing, and play. Jernberg formulated
Theraplay after these dimensions, with the premise that
parentchild 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 childparent interventions. Although childparent
interventions are widely used and supported by practitioners,
little is known about the effectiveness of childparent 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 CartwrightHatton, 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 childparent interventions being developed and
used, this review examines the current state of childparent
intervention research for treating childhood anxiety disorders
and improves upon prior reviews by using systematic review

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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 childparent interventions compared to childfocused interventions for children with anxiety disorders. The
specific research questions guiding this study were as follows:
(1) Are childparent 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 childparent 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 childparent 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 childparent 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 childparent 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.

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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

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.

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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Table 1. Characteristics of Included Studies.


Study
Characteristicsa
Publication year
19901999
20002005
20062009
Publication type
Journal
Dissertation
Country
United States
Australia
Canada
The Netherlands
Sample size
150
51100
101150
151200
Setting
Clinic
Hospital

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)

Note. SAD separation anxiety disorder; GAD generalized anxiety


disorder.
a
N 8 studies.
b
N 670 total child participants.
c
Three studies did not report data.

had a secondary diagnosis, with the vast majority of secondary


diagnoses (83%) being another anxiety disorder.
All childparent 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, SouthamGerow, 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 parentchild 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 masters 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 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).

Discussion and Applications to Social Work


The purpose of the present study was to compare childparent
interventions to other treatment modalities to determine whether
childparent interventions are more effective and to inform
social work practice with children with anxiety. A systematic

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Table 2. Summary of Included Studies.


Author (Year)
Barrett et al. (1996)
Bodden et al. (2008)
Kendall et al. (2008)
Mendlowitz et al. (1999)
Moreno (2007)
Siqueland et al. (2005)
Spence et al. (2000)
Wood et al. (2006)

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.

review methodology was used to search, select, and extract


data from studies examining effects of childparent 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 parentchild 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 Cohens 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

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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 votecounting 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
parentchild interventions. However, despite our best efforts,
we did not locate any studies testing effects of other models
of childparent 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 studys 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 childparent 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 childparent 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 studys limitations. This review is limited to a relatively small number of studies that compared the effects of
childparent 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 parentchild 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 parentchild 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

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Research on Social Work Practice 24(3)

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 childparent 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 childparent interventions
that are in the early stages of development, such as PCIT,
attachment-based family therapy, and childparent psychotherapy. Additionally, follow-up studies to published research are
vital to establishing the long-term effectiveness of parentchild
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.
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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