تغییرات والدین پس از دخالت در رفتاردرمانی شناختی کودک مضطرب شان

Abstract Objective Specific parental behaviors and cognitions are associated with child anxiety. Studies informing us of the directionality of the associations are lacking. We investigated the effect of parental involvement in children's anxiety treatment on parental behaviors and cognitions. Method Children (N = 54, 7–12 years) and parents were randomly allocated to different treatment groups (involved, not involved). Observed behavior, self-reported behavior and cognitions were assessed separately for mothers and fathers at pre-, posttreatment and follow-up.

Several theoretical models of the development of childhood anxiety disorders have over the years been posed and also empirically tested. Most etiological models (e.g., Ginsburg et al., 2004 and Murray et al., 2009) incorporate the role of the parents as a potential risk and/or maintaining factor for the development of anxiety in the child. Although conceptual and terminological differences between the models exist, they generally incorporate parental psychopathology, parental rearing behaviors, and cognitions as factors contributing to both the general development and psychopathological development of the child. Regarding direction, it has been suggested that parental factors may be linked with childhood anxiety by directly causing or eliciting anxiety in the child, and/or that the child's anxiety elicits the specific parenting behaviors (Wood, McLeod, Sigman, Hwang, & Chu, 2003). The most consistent finding is within the area of parental control. Over-involvement or over-intrusive behavior, where parents provide unsolicited help and do not encourage autonomy in the child, seems to be one of the most influential rearing behaviors associated with anxiety disorders (McLeod et al., 2011 and Rapee et al., 2009). Thus, at present, the interaction between parental factors and child anxiety is considered to be bidirectional. Parental avoidance and over-protection may elicit child anxiety, but child sensitivity and poor adjustment may also elicit these parental behaviors (see Edwards et al., 2010 and Silverman et al., 2009). Thus, research applying, for instance, intervention designs is still required to inform us on the directionality of change (Silverman et al., 2009). Intervention designs targeting these mechanisms, e.g. over-involvement, may thus provide information on their relation with anxiety as it changes following therapy. Parental behaviors are relatively well described in the literature, although mostly through studies applying cross sectional ( Bögels and Brechman-Toussaint, 2006) and/or laboratory-based observation designs ( Rapee et al., 2009). Cognitive aspects of parenting have only recently become a target of research. Studies of parental cognitions about their children have shown that parents of anxious children have lower expectations regarding their child's ability to cope in new or stressful situations ( Creswell et al., 2011, Creswell et al., 2006 and Kortlander et al., 1997). Another line of research on parental cognitions concerns cognitions regarding parenting efficacy. High parental self-efficacy beliefs refer to high expectations of being able to cope with rearing, including successfully influencing the behavior and development of the child in difficult situations (Coleman and Karraker, 2000). Parental efficacy and satisfaction are closely associated, and at times combined, in an overall concept of parental competence (Jones and Prinz, 2005). Only two studies have assessed the impact of parental beliefs regarding their efficacy, satisfaction and competence as parents on anxiety in children (Esbjørn et al., 2014 and Waters et al., 2009). The former study found that reduced parental beliefs about their efficacy and competence as parents were associated with anxiety in children who were referred for treatment (Esbjørn et al., 2014). The latter assessed the effect of treatment on competency beliefs, and reported a decrease in satisfaction from pre- to posttreatment (Waters et al., 2009). The lack of research within the field of parental competence in parents of anxious children is surprising, as parental efficacy beliefs have been studied extensively in relation to the development of externalizing child behaviors. Research in this area has shown parental competency beliefs to be associated with child adjustment and to contribute significantly to the parent–child interaction when difficult child behavior is present (Coleman and Karraker, 2000 and Jones and Prinz, 2005). The patterns of change in intervention studies can inform us on the relation between child anxiety and parental behaviors and cognitions. If parental behaviors, e.g., over-involvement, were to play a causal or maintaining role, then treatment involving parents where this behavior was directly targeted, should result in a greater positive change of these behaviors and their associated cognitions as well as result in higher levels of improvement of the child's anxiety levels than would be obtained through treatment of the child alone (Wood et al., 2003). However, the effect of involving parents in treatment has primarily been assessed for diagnostic status or anxiety symptoms of the child (for a review see: James, James, Cowdrey, Soler, & Choke, 2013). Whether the involvement of parents in therapy contributes to reductions in measures of the parental factors thought to maintain the child's anxiety has only been assessed in very few studies described below (e.g., Silverman et al., 2009 and Wood et al., 2009). 1.1. Child evaluation of parental factors in an intervention design Different approaches to choice of informants have been applied when evaluating parental factors; some applying child evaluations. In a clinical trial involving 119 youth aged 7–16 years, significant improvements in the young person's appraisal of maternal behavior and conflict in the parent–child relation were found from pretreatment to 12-months follow-up. To assess mechanisms of change, treatment had been provided in either of two conditions; child focused CBT (CCBT) and family focused CBT (FCBT). The positive gains were associated with the child's level of anxiety at posttreatment, independent of treatment condition, suggesting that when children's anxiety decreases, their evaluation of parental behaviors improve (Silverman et al., 2009). Other studies have applied an experimental task before and after a randomized controlled trial of CCBT and FCBT (Barrett et al., 1996a and Barrett et al., 1996b). Parenting behaviors were measured indirectly through an assessment of the children's interpretations and responses to their parent's behavior in a specific situation. The child was asked to interpret and respond to two ambiguous situations, first alone and then with the parents. At posttreatment, the children's avoidant responses decreased after family discussions in both treatment groups. Positive effects were obtained whether or not parents were involved in treatment (Barrett et al., 1996a and Barrett et al., 1996b). This finding also indicates that the change in children's anxiety levels may be sufficient to affect parental behaviors in a positive direction. In a phase I and II study of the development of a CBT + attachment based family therapy (CBT-ABFT), 11 anxious adolescents rated their perceptions of parenting behavior before and after treatment (Siqueland, Rynn, & Diamond, 2005). The adolescents were assigned to either the CBT-ABFT condition or CBT. In both treatment conditions, the adolescents reported an increase in parental acceptance after treatment, but they did not report a decrease in parental control from pre- to posttreatment. Another study including reports from 13 families and assessed changes in dysfunctional parental beliefs, parental rearing, and family functioning from pre- to posttreatment in FCBT. The children in this study did not report any positive changes in perceived rearing behaviors (Bögels and Siqueland, 2006), despite experiencing symptom alleviation. The results regarding child evaluation of parent factors in intervention design studies generally indicate that as the children improve and become less anxious, their evaluation of the parental behaviors and the parent–child interaction tend to improve. This may in part be explained by true changes in child behavior that elicit a different and more positive behavior in the parent. However, it is well established that anxiety disorders are associated with cognitive and attention biases (Hadwin and Field, 2010). The changes in perceived parental behaviors may therefore also be a result of a reduction of biases in the child. Knowledge on directionality of change should therefore also include direct observation of parental behaviors and/or parents’ report of their own behaviors. 1.2. Observation and parental evaluations of parental factors One study applied both direct observation and parental self-report (Wood et al., 2009). A composite score of parental intrusiveness was created using direct observation in a belt-buckling task together with three questionnaire measures (one of which was child rated). In the observation task, the parents were told that the children could probably do the task by themselves, and that they could help the child if needed. A total of 35 families, who had been assigned to either FCBT or CCBT, participated in the 1-year follow-up. In the FCBT condition there was a significantly greater change toward less parental intrusiveness compared to the CCBT condition. Mediational analyses indicated that reduced intrusiveness among parents in the FBCT group only mediated lower anxiety levels among adolescents, but not among children. The previously mentioned study by Siqueland and colleagues (2005), assessing CBT and CBT-ABFT, also examined parental perceptions of their own acceptance, psychological control and firm control after treatment. The parents themselves did not report any significant changes of parental acceptance or controlling behavior from pre- to posttreatment (Siqueland et al., 2005). A similar trend was found in the study by Bögels and Siqueland (2006). Parents reported positive changes in questionnaire-based perceived rearing behaviors from pre- to posttreatment; however, none of these results remained significant after statistical correction of the significance levels. A different effect of involving parents was found in a study by Waters et al. (2009), who provided CBT in a parent only condition and a child + parent condition for anxious children aged 4–8 years. In both treatment conditions, parental satisfaction, and to some degree parents’ sense of competence, decreased from pre- to posttreatment. Moreover, there were no significant changes in parenting style. These findings may reflect that when children become more independent and competent as an effect of treatment and thus begin to show less reliance on their parents, parents may experience a temporary decrease in parental satisfaction and competence while adjusting to their child's newly acquired skills (Waters et al., 2009). Overall, the findings regarding changes in parental cognitions and behaviors as a result of treatment are ambiguous and still in their infancy. Only few studies have attempted to evaluate directionality between parental factors and child anxiety by examining changes in these parenting variables in an intervention design. Motivated by this, the scope of the present study was to evaluate if directly targeting parental behaviors and cognitions in therapy would result in a greater change in parental behaviors and cognitions compared to the change obtained in parents where the child was the primary recipient of therapy. Greater change in the parent treatment groups would support that parental factors play a causal effect on child anxiety, whereas similar changes in both groups would support that changing the level of anxiety in the child influences parental behavior and cognitions. We provided individualized case-formulation based treatment (Esbjørn et al., 2013). Our treatment conditions either involved parents as co-clients, where half of the treatment was provided to the child and half to parents. In the parent sessions parental factors known to maintain child anxiety (e.g., intrusive/over-involved behavior) were directly targeted; or included parents as co-facilitators, where the actual therapy was provided to the child. Based on the scarce literature within the field, it was hypothesized that there would be a significant improvement in parental cognitions and behaviors following treatment, but that there would be no significant differences between the treatment conditions in parental self-efficacy beliefs or self-reported rearing behavior. These hypotheses, if confirmed, support the assumption that child anxiety levels may elicit negative parental behaviors and efficacy beliefs. However, we expected parents in the co-client group to be factually less overinvolved than parents in the co-facilitator condition after treatment, which would suggest that parental behaviors may also elicit child anxiety.

. Results 4.1. Preliminary analyses Preliminary analyses, as reported in Table 1 suggested a significant decline in anxiety over the three assessment points (η2 = .57; p < .001), but no significant differences between the two treatment groups (η2 = .04; p = .39). As can be seen in Table 2, we found no differences between treatment groups on the relevant parental measures at pretreatment, based on a Bonferroni corrected alpha level of .012. Table 1. Differences in self-rated anxiety levels between the two treatment conditions. Co-client Co-facilitator P Pretreatment SCARED-Rchild 47.0 (24.7) 37.2 (19.1) 0.12 SCARED-Rparent 43.9 (13.6) 40.2 (11.9) 0.30 Posttreatment SCARED-Rchild 34.2 (23.4) 24.7 (17.7) 0.11 SCARED-Rparent 40.0 (17.6) 30.6 (12.7) 0.03 Follow-up SCARED-Rchild 30.9 (22.2) 23.2 (21.1) 0.22 SCARED-Rparent 34.2 (19.1) 29.1 (15.6) 0.30 Note: SCARED-R reported as mean and standard deviation. None of the differences were significant after Bonferroni corrections (p-value set to 0.012). Table options Table 2. Pretreatment differences between the treatment conditions on parental variables. Co-client Co-facilitator P Mothers Self-report Self-efficacy 30.9 (4.2) 32.7 (4.4) 0.16 Autonomy granting 40.2 (4.4) 43.3 (4.1) 0.01 Observed Over-involvement 24.2 (7.2) 23.7 (6.3) 0.82 Negative tone 13.7 (3.9) 13.3 (4.1) 0.72 Fathers Self-report Self-efficacy 29.5 (4.6) 29.6 (5.2) 0.94 Autonomy granting 41.8 (4.2) 41.9 (4.3) 0.96 Observed Over-involvement 27.4 (7.2) 25.9 (6.7) 0.52 Negative tone 13.4 (4.7) 13.5 (3.3) 0.96 Note: Included outcome variables at pretreatment reported as mean and standard deviations. None of the differences were significant after Bonferroni corrections (p-value set to 0.012). Table options 4.2. Changes in parental cognitions 4.2.1. Effect of time and treatment condition on parental sense of efficacy The Pillai's trace within-subjects interaction effect from Time by Treatment-group for parents’ sense of efficacy was not significant (η2 = .05; p = .87). A rerun of the analyses revealed no main effect from neither time (η2 = .28; p = .06) nor treatment group. Univariate F tests for main effects from Treatment-condition as well as the Time * Treatment-condition interaction also indicated no significant effects (all: p > .05). These findings suggest that the parental sense of efficacy did not change significantly from before to after treatment and that there were no differences between the treatment groups. Analyses of the changes for mothers and fathers separately indicated that the mothers’ sense of efficacy increased significantly from pre- to posttreatment (η2 = .17; p = .02); however, the effect vanished at follow-up (η2 = .003; p = .79). Visual inspection of the estimated marginal means profiles suggested that mothers in the co-client treatment condition experience a drop almost back to baseline at 6 months follow-up. However, there were no significant differences between treatment groups for mothers (η2 = .12; p = .06) or fathers (η2 = .002; p = .83). 4.2.2. Effect of time and treatment condition on perceived autonomy granting The Pillai's trace within-subjects interaction between Time and Treatment-group for parents’ self-reported granting of autonomy produced a non-significant effect (η2 = .14; p = .37). However, the rerun, without the interaction term, rendered a significant effect from time (η2 = .49; p = .001) and treatment group (η2 = .22; p = .028). The former suggests that self-reported autonomy granting increased over time. For both mothers and fathers, the overall significant change of autonomy granting occurred between posttreatment and follow-up; but not from pre- to posttreatment. The effect of treatment group was a result of diverging slopes for mothers, as there was a greater increase in the co-facilitator group between posttreatment and follow-up than in the co-client group. The mothers in the co-facilitator group had a slope close to zero between pre- and posttreatment, followed by the significant increase, whereas mothers in the co-client group seem to have experienced an ongoing increase across all three time-points. Separating mothers’ and fathers’ respective contribution indicated that a significant group difference was only found for mothers (η2 = .18; p = .015). In fact, a visual examination of fathers’ estimated marginal means suggests that self-reported autonomy granting behaviors decreased in the co-client treatment group from pre- to posttreatment. 4.3. Changes in observed parental behavior 4.3.1. Effect of time and treatment condition on over-involved behavior The Pillai's trace within-subjects interaction between Time and Treatment-group for parents’ over-involved behavior produced a non-significant effect (η2 = .29; p = .36). The rerun without the interaction term rendered a significant effect from time (η2 = .64; p = .01), but not from treatment group (η2 = .07; p = .61) suggesting that there was a decrease in observed over-involved behavior from pre- to posttreatment, but that there were no significant differences between the treatment groups. Further analyses of the mothers’ and fathers’ separately suggested that the drop in maternal over-involved behavior was mainly accounted for by a posttreatment to follow-up decrease (η2 = .29; p = .03). There were no significant differences across treatment conditions for mothers, suggesting that mothers experienced the same pattern of change across time in both treatment conditions. For fathers, conversely, the contrast analysis suggested the largest overall drop in over-involved behavior to be between pre- and posttreatment (η2 = .24; p = .04). However, visual inspection of the estimated marginal means moderates this picture. The co-facilitator group had an apparent close to zero slope between pre-and posttreatment and thereafter a noticeable drop, whereas the slope for fathers in the co-client group flattened after post-test. The contrasts also indicated a significant interaction between treatment group and time for fathers, in particular between pre- and posttreatment (η2 = .25; p = .04). 4.3.2. Effect of time and treatment condition on negative behavior The Pillai's trace interaction between Time and Treatment-group for parents’ negative behaviors produced a non-significant effect (η2 = .14; p = .73). This was also found for the reruns, where no significant within-subject main effects (p > .05) or between subjects effect of Treatment group (p > .05) appeared. The within-subjects contrasts also revealed no significant changes across or between assessment points.