A parent-focused intervention for anxiety in inhibited children

Anxiety disorders are among the most common forms of childhood psychopathology,
with prevalence estimates in preadolescent children ranging from 2.6% to 41.2%
(Cartwright-Hatton, McNicol, & Doubleday, 2005; Costello, Mustillo, Erkanli,
Keeler, & Angold, 2003; Ford, Goodman, & Meltzer, 2003). Anxiety disorders
significantly impair children*s quality of life and functioning, particularly
their family and emotional functioning (Bastiaansen, Koot, Ferdinand, &
Verhulst, 2004; Ezpeleta, Keeler, Erkanli, Costello, & Angold, 2001). In
addition, childhood anxiety shows developmental continuity both among anxiety
disorders and in relation to other psychiatric disorders (Bittner et al., 2007;
Costello et al., 2003). The high prevalence, adverse outcomes, and continuity
of childhood anxiety disorders emphasize the importance of early, effective
treatment programs.
One construct that seems particularly valuable for the early detection of
anxiety-prone and anxious children is behavioral inhibition. Behavioral
inhibition refers to the consistent tendency of some children to react with
anxiety and withdrawal in the presence of unfamiliar people, objects, or
situations (e.g., Garcia-Coll, Kagan, & Reznick, 1984). Research has shown that
about 10 to 20% of all children display this tendency. When faced with new or
unfamiliar stimuli, they become quiet, stop the activities they were engaged
in, and seek the proximity of their caregivers. These children are described by
their parents as watchful and shy and are called inhibited (Garcia-Coll et al.,
1984; Kagan, Reznick, Clarke, Snidman, & Garcia-Coll, 1984; Kagan, Reznick, &
Gibbons, 1989; Kagan, Reznick, & Snidman, 1988). During the past two decades,
research has consistently shown behavioral inhibition to be related to the
development of anxiety disorders in childhood and adolescence (e.g., Biederman
et al., 1993; Hirshfeld-Becker et al., 2007; Muris, Van Brakel, Arntz, &
Schouten, 2011; Schwartz, Snidman, & Kagan, 1999). Most importantly, research
has indicated that behavioral inhibition can be detected at a fairly young age,
before an anxiety disorder has developed. This underlines that behavioral
inhibition is a highly relevant construct that could be useful for detecting
vulnerable, anxiety-prone children at an early point during their development.
The past few years there has been a progress in cognitive-behavioral therapies
for older children and adolescents (see for a review: Barett et al., 2001),
however, an effective intervention for young children would be highly relevant,
especially from a prevention perspective. This intervention would have to
target the way in which parents handle their anxiety-prone children. Parents of
these children are often anxious themselves, and model their anxious behavior
to their children. Further, parents tend to be overprotective to their
anxiety-prone or anxious children (often augmented by the parents* own
anxiety), by taking over tasks of their child or restrict its exposure to a
broad range of situations. This enhances the child*s behavioral inhibition
across development, ultimately increasing the risk for developing an anxiety
disorder (Rubin, Burgess, Kennedy, & Stewart, 2003).
Rapee, Kennedy, Ingram, Edwards, and Sweeney (2005) developed an early
intervention program for anxiety-prone preschoolers. This brief intervention
program focuses on educating the parents about the nature of anxiety and
reducing anxious modeling by the parents overprotective parenting. The first
studies evaluating this program in Australian preschoolers yielded positive
results (Rapee et al., 2005; 2010). As indicated by the Inventgroep (2005), in
the Netherlands there is a need for an intervention for young children with
anxiety problems, therefore, it would be highly interesting to evaluate this
program also in our country, and to extend previous findings by evaluating the
role of parental factors, namely overprotective parenting and parental anxiety.

To examine whether this promising parent intervention can reduce behavioral
inhibition and anxiety symptoms in Dutch behavioral inhibited children, and
whether parental factors influence the treatment outcomes.

The study uses a randomized controlled trial: parents of anxiety-prone children
will be randomly allocated to either a parent-education intervention condition
or a monitoring-only condition.

The intervention condition consists of a six-session parent-education program,
which is a translation of the program of Rapee et al. (2005; 2010). The
sessions will be conducted in groups of approximately six sets of parents and
teach parents to reduce inhibited and anxious behaviors in their children. More
specifically, the program focuses on psychoeducation about behavioral
inhibition and anxiety (session 1), parent management strategies (session 2),
and cognitive restructuring and exposure techniques (sessions 3 to 6). The
first four sessions are held weekly, with the fifth session two weeks later,
and the final session after one month. Each session lasts approximately 90
minutes.
Participants in the monitoring condition will be asked to complete all
assessments, but will not receive any intervention yet.

The burden for participants consists of the time needed for completing the
questionnaires and attending the intervention (six sessions of approximately 90
minutes). There are no risks associated with participation in the study. The
value of the study is that it can advance theory about risk factors and
prevention of anxiety disorders in young children, and it contributes to the
development and evaluation of a new early intervention program.