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Ginsburg et al.

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This work was supported in part by National Institute of Mental Health
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author.
Address correspondence to Tracy L. Morris, Department of
Psychology, 1124 Life Sciences Building, 53 Campus Drive, West
Virginia University, Morgantown, WV 26506-6040; e-mail: trac)zmorris@
mail.wvu.edu.

Received: October8, 2002


Accepted: April 3, 2003

Anxiety Disorders in Children: Family Matters


G o l d a S. G i n s b u r g , J o h n s H o p k i n s University School o f Medicine
L y n n e S i q u e l a n d , University o f P e n n s y l v a n i a Medical School a n d Children's Center f o r O C D a n d A n x i e t y
C a r r i e M a s i a - W a r n e r , N e w York University School o f Medicine, N Y U Child Study Center
K r i s f i n a A. H e d t k e , Temple University, Child a n d Adolescent A n x i e t y Disorders Clinic

Accumulating evidence indicates that family/parenting behaviors are associated with the etiology of anxiety disorders in children.
This article critically reviews what is known about how family/parenting behaviors have been measured in this literature and presents findings from studies examining the relation between family/parenting constructs and anxiety disorders in children. We review
the role of family involvement in the treatment of anxiety disorders in children and conclude with avenues of future research.

HE ROLE o f p a r e n t i n g a n d the family e n v i r o n m e n t in


the d e v e l o p m e n t a n d m a i n t e n a n c e o f a n x i e t y diso r d e r s is an e m e r g i n g a n d e x c i t i n g field o f i n v e s t i g a t i o n
t h a t h o l d s p r o m i s e for i n f o r m i n g e t i o l o g i c a l m o d e l s a n d
i n t e r v e n t i o n s . T h o u g h t h e field is still in its infancy, evid e n c e is a c c u m u l a t i n g to i n d i c a t e t h a t specific family factors a n d p a r e n t i n g b e h a v i o r s i n f l u e n c e levels o f anxiety

Cognithte

and

Behavioral

Practice

11, 28-43,

2004

1077-7229/04/28-4351.00/0
Copyright 2004 by Association for Advancement of Behavior
Therapy. All fights of reproduction in any form reserved.
[-~

Continuing

EducaUon

Quiz located

on p. 128.

s y m p t o m s in c h i l d r e n . Existing t h e o r e t i c a l m o d e l s for und e r s t a n d i n g t h e d e v e l o p m e n t o f c h i l d h o o d a n x i e t y diso r d e r s stress t h e r e c i p r o c a l r e l a t i o n b e t w e e n p a r e n t a n d


c h i l d factors in t h e c o n t e x t o f e n v i r o n m e n t a l stressors
( C h o r p i t a & Barlow, 1998; C h o r p i t a , Brown, & Barlow,
1998; Manassis & Bradley, 1994; R a p e e , 1997; R u b i n &
Mills, 1991; W a r r e n , H u s t o n , E g e l a n d , & Sroufe, 1997).
O n e such m o d e l ( G i n s b u r g & Schlossberg, 2002), a d a p t e d
f r o m Manassis a n d Bradley (1994) a n d R u b i n a n d Mills
(1991), a n d p r e s e n t e d in Figure 1, depicts these relations.
A l t h o u g h m a n y e l e m e n t s o f this m o d e l r e m a i n to b e empirically evaluated, it serves as a useful s p r i n g b o a r d for
identifying specific child, parent, a n d e n v i r o n m e n t a l factors associated with the d e v e l o p m e n t o f anxiety in children.

Family Matters

CHILD

29

. I PAINT

"

h eotRisto I

i
E

. . . .

tD

Psychologieal/Psychiatrie
Symptoms:

Higher SympatheticArousal
I l.~wer Thre~old of Response to Novel Stimuli

Anxiety [

[ MaladaptiveCoping Style I
W thdrawal I
I Behaviral and Social
~
Peer Relex~t[nnNe~leet

Cognitive Distortions
(e.g. T'm'eat,Uneontro11ability,Insecurity)

Anxiety-Enhancing
Parental Behaviors
e.g.
Model, reinforoe,tolerate child avoidance
Caution/catastrophize
Doubt child's competence

Hostile, reject, criticize


Low warmtldpositivity
Overcontrol,overprotect

Failure to Develop Adaptive Coping Strategies

CHILD
Figure

ANXIETY

i ~

i i ~ i

DISORDER

1. Developmental Model of Childhood Anxiety.

With respect to child risk factors, early t e m p e r a m e n t - namely, behavioral inhibition (presumably due to a genetic predisposition)--is hypothesized to lead to a lower
threshold o f response to the unfamiliar/novel and
higher sympathetic arousal. This response in turn may
lead to behavioral and social withdrawal and an insecure
attachment with a caregiver. These child factors are likely
to influence parenting behaviors.
O n the parent side, temperament and an insecure attachment history are hypothesized to predispose parents
to psychological/psychiatric symptoms, particularly anxiety. High levels of anxiety in parents are t h o u g h t to interfere with the development of their own adaptive coping
skills and lead to specific anxiety-enhancing parenting
behaviors that, in turn, increase their child's vulnerability
to developing an anxiety disorder.
Clearly, parental behavior or family interaction is only
one piece in a complex interaction of factors that influence
the development of anxiety disorders in children. There are
also a n u m b e r of environmental factors that are likely to
influence both parenting and family interactions. For instance, unemployment, death of loved one, lack of social
support and social isolation, and marital discord, in general,
or specifically a r o u n d managing anxious behavior, can influence parenting behavior (e.g., Manassis & Bradley, 1994).

The aim of this article is to critically review what is


known about how family/parenting behaviors are related
to anxiety disorders in children. Toward this end, we first
review and critique how family and parenting variables
have been measured in this literature and provide a summary o f findings from studies examining the relation between family/parenting constructs and anxiety disorders
in children. Most studies have taken a relatively broadstroke approach and have tried to see how general family
functioning concepts apply or do not apply to child anxie~.
Indeed, the majority of studies have n o t e m e r g e d from
theory-specific, conceptual models of anxiety etiology but,
instead, have tried to use existing family measures to document specific family characteristics. In contrast, observational studies are beginning to d o c u m e n t specific patterns
o f interaction in some families with children with anxiety
disorders. Next, we review the role of family involvement in
the treatment of anxiety disorders in children and conclude
by suggesting avenues o f future research. Treatment is beginning to incorporate parents and examine the efficacy of
combined treatments; however, the effect of treatment on
family functioning or parenting behavior is rarely assessed.
The treatment research area requires clarification o f the
targets o f intervention, the mechanisms of change, and
evaluation of whether treatment changes these domains.

30

Ginsburg et al.
F o r all sections o f this review, we have focused on
studies whose participants i n c l u d e d c h i l d r e n d i a g n o s e d
with an anxiety disorder, unless specifically noted. Alt h o u g h we recognize that e x a m i n i n g the relation between
p a r e n t i n g a n d anxiety symptoms may prove fruitful for
i n f o r m i n g etiological models, i n t e r p r e t a t i o n s a n d generalization o f findings from these studies is difficult because the severity a n d i m p a i r m e n t associated with anxiety
symptoms is often unknown. In addition, we have omitted
studies that are based on retrospective reports owing to
the m e t h o d o l o g i c a l limitations i n h e r e n t in this a p p r o a c h
(e.g., recall bias). Finally, a l t h o u g h a t t a c h m e n t theory
has m a d e significant contributions to the area o f developm e n t a l psychopathology, we do n o t include a t t a c h m e n t
studies in this review. T h e c u r r e n t article focuses on easily
observable p a r e n t i n g behaviors that have b e e n directly
l i n k e d to anxiety disorders. A t t a c h m e n t has b e e n indirectly l i n k e d to anxiety, in that rates o f anxiety disorders
are h i g h e r a m o n g c h i l d r e n a n d adolescents classified as
insecurely a t t a c h e d in infancy. T h e link is n o t direct, however, a n d a t t a c h m e n t measures require m o r e training to
a d m i n i s t e r a n d code than is feasible in most n o n r e s e a r c h
settings.

Measurement of Family and Parenting Behaviors


M e a s u r e m e n t of f a m i l y / p a r e n t i n g constructs has b e e n
achieved t h r o u g h two p r i m a r y methods: (a) p a r e n t o r
child self-report data a n d (b) observational paradigms.
T h e most c o m m o n l y used instruments observed in the
child anxiety literature for each of these two a p p r o a c h e s
will be briefly reviewed with an e m p h a s i s o n their advantages a n d limitations as well as relevance to studies
focused on anxiety disorders in children.

Self-Report Measures
Self-report questionnaires have b e e n used to assess
various d i m e n s i o n s o f family f u n c t i o n i n g (e.g., conflict,
cohesion, overprotection) a n d can facilitate u n d e r s t a n d ing the role o f these dimensions in the d e v e l o p m e n t
a n d / o r m a i n t e n a n c e o f a b r o a d range o f child behavior
problems. Relatively few studies, however, have assessed
family f u n c t i o n i n g via self-report in families o f clinically
anxious youth (e.g., Leib et al., 2000; McClure, Brennan,
H a m m e n , & Le Brocque, 2001). Table 1 provides a description o f the seven most c o m m o n l y used self-report
measures o f family functioning, excluding studies using
retrospective reports and studies using self-report measures
o f attachment. T h e table provides details a b o u t each
questionnaire's f o r m a t (e.g., n u m b e r o f items), the dimensions of family f u n c t i o n i n g assessed, a n d psychometric properties.
Because a wide variety of self-report family functioning
instruments exist (see Locke & Prinz, 2002, for a r e c e n t

review), selection o f the following seven measures was


based on their reliability, validity, a n d c u r r e n t utility in
the child a n d a d o l e s c e n t anxiety literature (e.g., B6gels,
van Oosten, Muris, & Smulders, 2001; Gfiiner, Muris, &
Merckelbach, 1999; Hibbs, Hamburger, Kruesi, & Lenane,
1993; Kashani, Lourdes, Jones, & Reid, 1999; Leib et al.,
2000; McClure et al., 2001; Muris, Meesters, Merckelbach,
& Hfilsenbeck, 2000; Siqueland, Kendall, & Steinberg,
1996; Stark, Humphrey, Crook, & Lewis, 1990; Stark, H u m phrey, Laurent, Livingston, & Christopher, 1993). T h e
measures reviewed are i n t e n d e d to be a representative,
b u t n o t exhaustive, sample o f the self-report instruments
currently utilized in the child a n d a d o l e s c e n t literature.
Clinicians are e n c o u r a g e d to carefully review instruments
a n d what they p u r p o r t to measure before selecting o n e to
use, as most o f these measures were n o t d e v e l o p e d to test
hypotheses related to the etiology o f child anxiety a n d
thus may n o t capture the most relevant constructs.

Children's Report of Parent Behavior (CRPBI; Schaefer, 1965).


T h e CRPBI is an inventory based on the assumption that
a child's p e r c e p t i o n o f his or h e r p a r e n t s ' child-rearing
b e h a v i o r may b e m o r e r e l e v a n t to the child's adjustm e n t than the parents' actual behavior ( S c h l u d e r m a n n
& S c h l u d e r m a n n , 1970). T h e original i n s t r u m e n t consisted o f 26 scales, each with 10 items describing p a r e n t a l
behavior. A s h o r t e n e d version o f the CRPBI (Schluderm a n n & S c h l u d e r m a n n , 1970) is now m o r e widely used
in research a n d consists o f 18 scales a n d a total of 108
items. F o r each item, c h i l d r e n are asked to indicate
w h e t h e r the statement is "like," "somewhat like," or "not
like" each o f their parents. T h e factor structure of the
CRPBI allows for classification o f p a r e n t a l behavior along
three dimensions: acceptance vs. rejection, psychological
c o n t r o l vs. psychological autonomy, a n d firm c o n t r o l vs.
lax control. With its 18 scales, o n e o f the advantages o f
using the CRPBI is that it covers a wide range o f parenting behaviors a n d allows for individual assessment of parental behaviors. A 30-item version of the CRPBI has also
b e e n used in at least one study o f anxiety d i s o r d e r e d
youth, c o n d u c t e d by Siqueland a n d colleagues (1996),
which showed that c h i l d r e n with anxiety disorders, comp a r e d to their non-ill peers, r a t e d their m o t h e r s as less
accepting.

Family Adaptability and Cohesion Evaluation Scale (FACES;


Olson, Portneg, & Bell, 1982; Olson, Sprenkle, & Russell, 1979).
FACES is based on the c i r c u m p l e x m o d e l (Olson et al.,
1979) of family f u n c t i o n i n g a n d assesses three central
concepts o f family dynamics: cohesion, adaptability, a n d
c o m m u n i c a t i o n . T h e FACES, now in its fourth version,
measures two of these dimensions: cohesion, the emotional b o n d i n g in the family, a n d adaptability, the ability o f
the family to c h a n g e its power structures, roles, a n d relationship rules. T h e measure consists o f 30 items, scored
on a 5-point Likert scale r a n g i n g from almost never to

Family M a t t e r s

31

Table 1

Commonly Used Self-Report Measures of Family Functioning

Measure

Citation

Dimensions Measured

SRMFF

Bloom(1985)

CRPBI (short
version)

Schludermann &
Schludermann
(1970)
Perris et al. (1993; Emotional Warmth,
EMBU-C) ;
Rejection, Control
Gerlsma et al.
Attempts, Favouring
(1991; EMBU-A)
Subject
Olson et al. (1982); Adaptability Cohesion
Olson et al. (1979)

EMBU-C and
EMBU-A

FACES

FAD

Epstein et al.
(1983)

FAM

Skinner et al.
(1983)

FES

Moos & Moos


(1981)

Cohesion, Expressiveness,
Conflict, IntellectualCultural, Activerecreational, Religious
Emphasis, Family
Sociability, External Locus
of Control, Family
Idealization,
Disengagement,
Democratic Style, LaissezFair Style, Authoritarian
Style, Organization,
Enmeshment
Acceptance, Firm Control,
Psychological Control

Problem Solving,
Communication, Roles,
Affective Responsiveness,
Affective Involvement,
Behavior Control, General
Functioning
Task Accomplishment,
Role Performance,
Communication, Affective
Expression, Involvement,
Control, Values and Norms
Cohesion, Expressiveness,
Conflict, Independence,
Achievement Orientation,
Intellectual-Cultural
Orientation, ActiveRecreational Orientation,
Moral-Religious Emphasis,
Organization, and Control

Number of
Items

Completed
by

Internal
Consistency
(range for
subscales)

75

Parent and
child

.40-.85

108

Child

.49 to .89

41 (EMBU-C)

Child

56 (EMBU-A)

Sample Item
(dimension represented)
"We really get along well
with each other"
(Cohesion)

"My mother is a person who


is very strict with
me" (Firm Control)
.56-.78
"Your parents are scared
(EMBU-C)
that something might
.56-.88
happen to you" (Control
(EMBU-A)
Attempts)
.62 to .77
"It is difficult to get a rule
changed in our
family" (Adaptability)
.57 to .86
"We are reluctant to show
our affection for each
other" (Affective
Responsiveness)

30

Parent and
child

60

Parent and
child

50 (General
Scale),
42 (Dyadic
Scale),
42 (Self-Rating
Scale)
90

Parent and
child

.87-.96

"My family tries to run my


life" (General ScaleInvolvement)

Parent and
child

.61 to .78

"There is very little privacy


in our family"
(Independence)

Note. SRMFF = Self-Report Measure of Family Functioning; CRPBI = Children's Report of Parent Behavior Inventory; EMBU-C = Egna
Minnen BetrSffande Uppfostram-Child Version; EMBU-A = Egna Minnen BetrSffande Uppfostram-Adolescent Version; FACES = Family
Adaptability and Cohesion Evaluation Scale; FAD = Family Assessment Device; FAM = Family Assessment Measure; FES = Family Environment Scale.

almost always, to w h i c h a p a r e n t o r c h i l d r e s p o n d s . Alt h o u g h t h e age r a n g e f o r use o f t h e FACES is n o t specified, t h e m e a s u r e is typically u s e d w i t h family m e m b e r s


age 11 a n d older. E x t r e m e s c o r e s in e i t h e r d i r e c t i o n o n

score on the C o h e s i o n subscale indicates e n m e s h m e n t ,


w h i l e a low s c o r e i n d i c a t e s d i s e n g a g e m e n t . Similarly, a
high score o n the Adaptability subscale indicates chaotic
family f u n c t i o n i n g w h i l e a low s c o r e i n d i c a t e s r i g i d family

each subscale reflect dysfunction. For instance, a high

f u n c t i o n i n g . T h e FACES h a s b e e n u s e d i n s t u d i e s o f

32

Ginsburg et al.
i n p a t i e n t anxious c h i l d r e n (Kashani et al., 1999) a n d
school-phobic adolescents diagnosed with c o m o r b i d anxiety a n d depression (Bernstein, Warren, Massie, & Thomas,
1999). This research has shown that b o t h school-phobic
adolescents a n d their parents r e p o r t low c o h e s i o n a n d
low adaptability, indicating d i s e n g a g e m e n t a n d rigid family f u n c t i o n i n g (Bernstein et al., 1999).

Egna Minnen Betriiffande Uppfostram (EMBU): "My Memories of Upbringing." Similar to the CRPBI, the EMBU focuses on the child's r e p o r t of p a r e n t s ' child-rearing behaviors. T h e EMBU was originally constructed in Sweden
by Perris, Jacobsson, Lindst6m, Von Knorring, a n d Perris
(1980) as a retrospective measure used to assess adults'
recollections o f their p a r e n t s ' child-rearing behaviors
across four dimensions, e m o t i o n a l warmth, rejection,
control attempts, a n d favoring subject (the d e g r e e to
which the subject was "spoiled" or favored over o t h e r siblings). Within the last decade, however, partially d u e to
criticism o f retrospective reports, a d d i t i o n a l versions o f
the EMBU have b e e n constructed that can be used with
c h i l d r e n ages 7 to 12 (EMBU-C; Castro, Toro, van d e r
Ende, & Arrindell, 1993) a n d adolescents ages 10 to 15
(EMBU-A; Gerlsma, Arrindell, van d e r Veen, & Emmelkamp, 1991) for assessing c u r r e n t p e r c e p t i o n s o f parenting behaviors. Both the EMBU-C a n d EMBU-A were dev e l o p e d based on factor analyses of the original 81 items
o f the EMBU, which are scored on a 1-to-4 Likert-type
scale r a n g i n g from no, never to yes, most of the time. T h e
questions for the child a n d a d o l e s c e n t versions were only
c h a n g e d in a way to m a k e the items m o r e simplified, with
verbs in the present instead o f past tense. T h e four factors
(i.e., Emotional Warmth, Rejection, Control Attempts,
a n d Favoring Subject) o f the EMBU-C a n d EMBU-A have
b e e n r e p o r t e d to be c o m p a r a b l e to the adult version of
the EMBU (e.g., Castro et al., 1993; Gerlsma et al., 1991),
a l t h o u g h the n u m b e r o f items c o m p r i s i n g these factors
or d i m e n s i o n s is different t h a n the 81 original items. Specifically, the EMBU-C is a 41-item self-report measure
while the EMBU-A consists o f 56 items assessing p a r e n t a l
behaviors. Both the child a n d adolescent instruments are
a d m i n i s t e r e d separately for each parent, m o t h e r a n d
father, a n d are c o m p l e t e d by the child o r adolescent.
As Muris, Bosma, Meesters, a n d S c h o u t e n (1998)
note, o n e o f the advantages o f the EMBU is that it is a relatively short a n d easy-to-rise instrument. Specific to child
anxiety, some research has shown that certain p a r e n t a l
behaviors as m e a s u r e d by the EMBU are related to child
anxiety symptoms (e.g., G r i i n e r et al., 1999; Muris et al.,
2000), particularly rejection a n d control attempts. However, most studies r e p o r t e d in the child anxiety literature
have typically i n c l u d e d c o m m u n i t y samples o f school
c h i l d r e n a n d only o n e study has i n c l u d e d a sample o f
clinically r e f e r r e d youth (B6gels et al., 2001). In fact,
Muris et al. (1996) f o u n d no differences between "nor-

mal" controls a n d youth with an anxiety d i s o r d e r on


e i t h e r positive (warmth) o r negative (rejection a n d overp r o t e c t i o n ) p a r e n t i n g dimensions; while youth with externalizing disorders r e p o r t e d less positive a n d m o r e negative parental rearing practices. Thus, while certain EMBU
dimensions may be associated with anxiety symptoms, little
is known a b o u t w h e t h e r these dimensions are also associated with the d e v e l o p m e n t a n d / o r m a i n t e n a n c e o f anxiety disorders in youth. A n o t h e r limitation o f the EMBU is
that currently there are different versions for c h i l d r e n
(EMBU-C) a n d adolescents (EMBU-A), p r e s e n t i n g a potential d i l e m m a for researchers who wish to use this measure in samples i n c l u d i n g b o t h age groups.

Family Assessment Measure (FAM; Skinner, Steinhauer, &


Santa-Barbara, 1983, 1995). The FAM was developed based
on the process m o d e l of family f u n c t i o n i n g (Skinner,
Steinhauer, & Sitarenios, 2000). This m o d e l proposes that
seven basic constructs are key to daily family operations:
c o m m u n i c a t i o n , affective expression, role p e r f o r m a n c e ,
task a c c o m p l i s h m e n t , involvement, control, a n d values
a n d norms. T h e process m o d e l stipulates that each o f
these seven constructs or processes is i m p o r t a n t to familial, interpersonal, a n d individual d o m a i n s o f functioning. H e n c e , the FAM was d e v e l o p e d to m e a s u r e all
seven constructs in all three domains. To this end, the
FAM is m a d e u p o f t h r e e scales, which can be c o m p l e t e d
by b o t h parents a n d children. T h e G e n e r a l Scale focuses
on general family f u n c t i o n i n g a n d consists o f 50 items
m a k i n g u p n i n e subscales, seven subscales m e a s u r i n g the
Process Model constructs plus a social desirability a n d defensiveness subscale. T h e Dyadic Relationships Scale is
m a d e up o f 42 items a n d seven subscales (no social desirability o r defensiveness subscale) a n d focuses on relationships between various pairs o r dyads in the family. T h e
Self-Rating Scale, similar to the Dyadic Relationships
Scale, is also 42 items a n d seven subscales, b u t focuses on
the individual's p e r c e p t i o n o f his or h e r f u n c t i o n i n g in
the family. All scales are scored a c c o r d i n g to a 4-point
Likert f o r m a t r a n g i n g from strongly agree to strongly disagree a n d a total score for an individual scale, o b t a i n e d by
s u m m i n g individual items.
O n e o f the advantages o f the FAM is that it can generate an unusually rich picture of c u r r e n t family functioning. In addition, b r i e f versions (14 items) for each o f the
three scales (i.e., General, Self-Rating, a n d Dyadic Relationships) exist, aiding in the efficiency o f a d m i n i s t r a t i o n
(Skinner et al., 1995). Also, data on the FAM exist for num e r o u s clinical groups, i n c l u d i n g c h i l d r e n with social
p h o b i a (SOP; Bernstein & Garfinkel, 1988), school-refusal
c h i l d r e n (Bernstein & B o r c h a r d t , 1996; Bernstein, Svingen, & Garfinkel, 1990), a n d o t h e r anxiety disorders
(Woodside, Swinson, Kuch, & H e i n m a a , 1996). However,
normative data for the full FAM are only available for
youth who are an average age of 15, a n d r e c o m m e n d e d

Family Matters
use of the FAM is with family members who are at least 10
to 12 years old (Skinner, Steinhauer, & Sitarenios, 2000).

The FamilyEnvironment Scale (FES;Moos & Moos, 1981).


Based on family systems theory, the FES measures three
broad conceptual domains of the family social climate:
relationships, personal growth, and system maintenance.
Each domain contains at least two subscales for a total of
10 measured constructs: Cohesion, Expressiveness, Conflict, Independence, Achievement Orientation, IntellectualCultural Orientation, Active-Recreational Orientation,
Moral-Religious Emphasis, Organization, and Control.
The scale consists of 90 true-false items and is available in
three forms: current family functioning, idealized family
functioning, and expected family functioning (taking
into account both current and idealized family functioning), which can be completed by all family members age
12 and older. Scoring the FES is convenient and can be
achieved through the use of a manual (Moos & Moos,
1986) that contains a scoring protocol and scoring template. Additionally, both individual and family scores can
be calculated along with a family incongruence score measuring the extent of familial agreement/disagreement on
family functioning. The FES also has a shorter pictorial
version with normative and psychometric data that can
be used with children as young as 5 years old (Moos &
Moos, 1986). A m o n g the constructs assessed by the FES,
the Cohesion, Expressiveness, Conflict, and Control subscales of the FES may be especially attractive for use with
families of anxious children because they appear to tap
constructs that are c o m m o n l y t h o u g h t to be associated
with the development and maintenance of childhood
anxiety disorders, although there are no data to support
this hypothesis.

FamilyAssessmentDevice(FAD;Epstein, Baldwin, & Bishop,


1983). The FAD is a 60-item, 4-point Likert scale designed to be completed independently by family members over the age o f 12 years. The FAD is rooted in a systems approach to family functioning and is based on
Epstein, Bishop, and Levin's (1978) McMaster Model of
Family Functioning (MMFF). In this model, family functioning varies across six dimensions: Problem Solving,
Communication, Roles, Affective Responsiveness, Affective Involvement, and Behavior Control, plus a General
Functioning subscale. The mean scores for the seven subscales are c o m p a r e d with the cutoff scores for each
subscale suggested by Miller, Epstein, Bishop, and Keitner
(1985) for classifying family f u n c t i o n i n g as either
"healthy" or "unhealthy." A m o n g these subscales, Behavioral Control and Affective Involvement appear to tap
constructs t h o u g h t to be most relevant for families o f
anxious children, although there are currently no data to
support this assumption.
Self-Report Measure of Family Functioning (SRMFF). In
1985, Bloom conducted a factor analysis of four corn-

monly used self-report measures of family functioning:


The FES, the FACES, the FAM, and the Family-Concept Q
Sort (FSQS; van der Veen, 1965). The purpose o f this
analysis was to identify the most reliable set of concepts or
constructs for describing families and combine t h e m to
form an improved self-report measure of family functioning that was both psychometrically sound and short in
length. The final instrument, comprised of 75 items, makes
up fifteen 5-item scales: Cohesion, Expressiveness, Conflict, Intellectual-Cultural Orientation, Active-Recreational
Orientation, Religious Emphasis, Organization, Family
Sociability, External Locus of Control, Family Idealization, Disengagement, Democratic Family Style, LaissezFair Family Style, Authoritarian Family Style, and Enmeshment. Family members respond to statements about
their family using a four-choice format.
Although the SRMFF was created using a sample o f
undergraduates, the scale has been used with all family
members of varying ages. O f particular interest, the
SRMFF has been used with depressed and anxious youth
and has been f o u n d to correctly classify a significant portion of fourth to seventh graders into depressed and anxious groups (Stark et al., 1990).
Observational Methods

The association between family/parenting factors and


clinically anxious children has been examined using observational methods in only a handful of studies. To date,
the majority of observational studies involve parents (usually mothers) and their children engaging in a laboratory
paradigm (e.g., difficult puzzles, discussion of difficult
topics; see H u d s o n & Rapee, 2001, 2002; Siqueland et
al., 1996), which is videotaped and c o d e d by trained observers for certain behaviors (e.g., praise) a n d / o r constructs (e.g., warmth). Typically, observers blind to the
child's diagnostic status are trained to code child a n d / o r
parent behaviors until a m i n i m u m interrater reliability
criterion is achieved. Coding may consist of indicating
the absence or presence of a behavior (e.g., critical statement), the frequency o f a behavior, or Likert ratings of a
construct (e.g., intrusiveness) either in a given time interval (e.g., every 2 minutes) or continuously (e.g., every
statement is coded) t h r o u g h o u t a task. As an indicator o f
the reliability of the observational method, most investigators report percent agreement between coders a n d / o r
kappa or intraclass correlation coefficients o f concordance. These indices may be calculated based on agreem e n t o f all coded observations, or, m o r e often, based on
a certain percentage of videotaped interactions. Table 2
presents a summary o f the tasks, constructs measured,
coded behaviors, and reliability values.
Ambiguous Situations Task. The Ambiguous Situations
Task (AST; see Barrett, Rapee, Dadds, & Ryan, 1996; Chorpita, Albano, & Barlow, 1996; Dadds, Barrett, Rapee, &

33

G i n s b u r g e t al.

34

Table 2
O b s e r v a t i o n a l M e t h o d s of A s s e s s i n g Parent-Child Interactions

Study

Sample

Task

Behaviors Coded

Training
Criterion

Interrater Methods

Reliability Estimates

Barrett,
Rapee,
et al. (1996)

152 anxiety" dx,


27 ODD,
26 n o r m a l

Ambiguous
Situations
Task (AST)

Interpretations:
Threat/nonthreat
Solutions: Prosocial/
aggressive/avoidant

Not specified

Not reported

Report that n o
disagreements occurred

Chorpita
et al.
(1996)

4 anxiety dx,
8 normal

AST Interview

Interview: A n x i o u s /
nonanxious
Interaction: C o n t e n t
(e.g, interpretation,
plan, describe,
question, agree,
disagree)
Valence: A n x i o u s /
nonanxious

80%
agreement

Interview: R a n d o m
sampling of
responses
Interaction: Two
raters c o d e d
simultaneously,
with Observer 1
defining
utterance

Interview: Kappa = .98


Interaction: Kappa for
coded variables r a n g e d
from .85 to .99

Dadds et al.
(1996)

Subset of
Barrett et al.
sample
(66 anxiety dx,
16 ODD a n d CD,
18 normal)

Interview: Same as
Two weeks of
Barrett et al.
training.
Interaction: Content:
Criterion
Describe (threat or
not
nonthreat);
specified
Solution (prosocial,
aggressive, avoidant);
Consequence
(positive or negative)
Process: R e s p o n d
(agree or disagree)
or listen
Affect Ratings: happy,
anxious, sad, angry,
neutral

33% of discussions;
Two observers
scored
simultaneously,
with Observer 1
defining
utterance

Speaker
Listener
Content
Affect =

AST Family
Interaction

AST Interview
AST Family
Interaction

= .99 (.92-1.0)
= .94 (.88-.99)
= .78 (.61-.87)
.72 (.58-.79)

All o t h e r c o n t e n t a n d
affect codes h a d m e a n
kappas above .68

D u m a s et al.
(1995)

Teacher-rated
42 socially
competent
42 aggressive, a n d
42 anxious

Grocery store
task

INTERACT: Actor,
Behavior, Setting,
Adverb, Valence
F o r m e d clusters
(e.g., Positive,
Aversive, Control,
Compliance)

Not specified 45% of observations For clusters, percentage


simultaneously
a g r e e m e n t s = .95-.99
but independently
(M = .97) a n d kappas =
.53-.87 (M = .71)

Hibbs et al.
(1991)

49 OCD,
34 DBD,
45 n o r m a l

Five-minute
speech

Expressed Emotion

Not specified

27 cases

88% agreement,
kappas = .66

Hirshfeld
et al.
(1997a, b)

30 at-risk sample
41 Kagan sample

Five-minute
speech

Criticism
Emotional
overinvolvement
(EOI)

Certified at
UCLA

20 tapes

% agreement/kappa
Criticism: 85%/.69
EOI: 100%/1.0

Hudson &
Rapeeetal.
(2001,
2002)

43 anxiety dx,
20 ODD,
32 n o r m a l

T a n g r a m task
Scrabble task

9-point Likert ratings


Not specified
o n ten behaviors;
R e d u c e d to 2 factors:
Involvement a n d
Negativity

50% o f interactions

Intraclass correlation =
.90 for Involvement a n d
.50 for Negativity

Siqueland
et al. 1996

17 anxiety dx,
27 n o r m a l

Discussions o f 3-point Likert ratings


Kappa - .80
conflictual
on granting
family issues
psychological
a u t o n o m y (GPS) a n d
warmth

50% of tapes

Kappa = .91 GPS a n d .85


for warmth

Family Matters
Ryan, 1996) involves researchers verbally presenting
12 ambiguous situations; half are o f potential physical
threats (e.g., you have a funny feeling in your stomach)
and half social threats (e.g., a g r o u p of kids are laughing
as you walk over). Children and parents are asked three
questions for each situation, two related to their interpretation o f the situation (what is happening) and a third
about a possible solution (what would they do about it).
In addition, the family is asked to discuss two of these situations (one physical and one social) and for the child to
present a final solution following the family discussion.
Barrett, Rapee, et al. (1996) analyzed m e a n n u m b e r s
o f threat interpretations and proactive, aggressive, and
avoidant responses provided by parents and children
(ages 7 to 14), as well as c o m p a r e d solutions provided by
children prior to and after family discussions. Dadds and
colleagues (Dadds et al., 1996) examined the specific
content and process of the family interactions using the
Family Anxiety Coding Schedule (FACS; Dadds, Ryan, &
Barrett, 1993). Interrater reliability on the FACS was
examined by calculating kappas for occurrence or nonoccurrence of each category per utterance across different groups and families (see Table 2 for m e a n kappas and
ranges across families). Chorpita and colleagues (1996)
used a modified coding system based mainly on anxious
versus nonanxious labels.
Expressed emotion. A n o t h e r observational technique is
the assessment of expressed emotion, a measure of an attitude o f criticism a n d / o r emotional overinvolvement that
a parent holds toward a child. Recently, this methodology
has been used in two studies o f children with behavioral
inhibition (ages 4 to 12; Hirshfeld, Biederman, Brody,
Faraone, & Rosenbaum, 1997a, 1997b) and in a sample
of clinically anxious children ranging from ages 8 to 17
years (Hibbs et al., 1991). Parents are asked to give a 5minute speech about their child (e.g., describe your child
and your relationship). Critical statements and instances
o f overinvolved or self-sacrificing behavior expressed by
the parent are coded.
Other parent-child interaction tasks. O t h e r observational
paradigms have included the following:
In a grocery store game, children (ages 2.5 to 6.5
years) had to plan an efficient route t h r o u g h a miniature grocery store. Mothers were instructed to
assist their child as n e e d e d but not to complete the
task for the child (Dumas, LaFreniere, & Serketich,
19951).
In two difficult cognitive t a s k s - - a tangram task in
which children (ages 7 to 15 years) were requested
to place geometric pieces together to form larger

1Children in this study were not diagnosed with an anxiety disorder but rated as highly anxious.

shapes and a scrabble word task in which the child


was asked to generate as many words as possible-mothers were told that they could assist when they
t h o u g h t the child really n e e d e d help (Hudson &
Rapee, 2001, 2002).
In parent-child discussions of difficult family issues
or "hot topics," parents and children (ages 9 to 13
years) were asked to discuss the topic for 6 minutes
(Siqueland et al., 1996).
See Table 2 for more information on the coding and reliability o f these observational tasks.

Critique of Self-Report and Observational Methods


Self-reports. Measuring family functioning through selfreport is clearly a time- and cost-efficient method. Most
questionnaires can be completed in about 20 minutes
and require no or minimal staff time or staff training for
administration. In addition, many of the self-report instruments of family functioning are easily scored and
some instruments have published norms and cutoff scores
for classifying family functioning as adaptive or maladapfive. Despite the advantages of self-reports, they have several limitations. For instance, self-report measures reflect
perceptions (parent or child) rather than actual family
functioning. Furthermore, this perception of family functioning is usually not the same for parents and children,
and self-report ratings are not always consistent with therapist ratings or observational ratings of family functioning. Moreover, agreement between respondents is usually
poor, suggesting biases associated with each perspective
(Rapee, 1997). Children tend to report less healthy patterns of family functioning than their parents (Sawyer et
al., 1988) and view parents as m o r e alike than they actually are, while parents tend to present their child-rearing
behaviors as more favorable than they actually are (Schwarz,
Barton-Henry, & Pruzinsky, 1985). Although combining
informant (e.g., mother, father, child) data may help circumvent difficulties due to lack of informant agreement
by increasing the validity of individual self-report data,
this has n o t been d o n e in most studies (Rapee, 1997).
A n o t h e r general concern with using self-report family
assessments is that subscales typically overlap and are
highly correlated with one another (e.g., Alexander,
J o h n s o n , & Carter, 1984; Miller et al., 1985; Schluderm a n n & Schludermann, 1970), raising questions about
what construct is truly being measured. Related, many of
the measures presented, with the exception of the FES,
do not have n o r m e d or psychometric data available. A
final difficulty is that most of the family questionnaires
presented in this article have b e e n developed based on
family systems theory and may not adequately tap the
constructs believed to be associated with childhood anxiety, such as psychological a u t o n o m y and overcontrol.

35

36

Ginsburg et al.
O b s e r v a t i o n a l methods. In contrast to serf-report methods,
observational/laboratory methods of family functioning/
parenting behaviors assess actual behavior that may capture complex interactions not available via paper-andpencil instruments. They also allow for the assessment of
reciprocal parent-child interactions more adequately
than self-report measures (Burdach & Borduin, 1986).
Moreover, observational methods are considered more
objective than self-report, as we assume less bias in ratings
provided by trained, reliable observers, blind to the diagnostic status of the family members. O n the other hand,
observational m e t h o d s are time-consuming, taking up
to 45 minutes for data collection and multiple hours of
training reliable observers and coding videotapes. Because data analysis can be complicated, the vast amounts
of data generated from these methods are sometimes
difficult to reduce to meaningful dimensions (Epstein et
al., 1983). Further, the m a n n e r in which this is conducted
may influence results. Moreover, little information is available regarding the reliability or validity of these laboratory procedures. Reliability estimates are limited to interobserver agreement indices, and these values are calculated
variably d e p e n d i n g on the given study. No data are available on the test-retest or intertask reliability of these observational paradigms. External validity of observational
assessment methods has not been well established. Specifically, it is not clear if the behavior of families in the
laboratory or during a given task will generalize to other
laboratory situations or to the natural environment. In
addition, the observational paradigm may not elicit the
parenting behavior of interest.
Another limitation of existing observational procedures
is that, most often, family behaviors are only assessed at
one time point and children have already been identified
as anxious, thus leaving the directionality of relationships
in question. That is, did the parent-child interaction cause
anxiety or did anxiety in the child cause this parenting
style? Such designs hinder the identification of etiological variables. With the exception of a few studies (Dadds
et al., 1996; Dumas et al., 1995; Krohne & Hock, 1991),
behaviors have been coded in a unidirectional fashion,
providing litde information about the quality of an interaction or the reciprocal effect of parent and child behaviors. Coding behavior in isolation of behaviors exhibited
by other individuals hinders specification of important
contingencies (Masia & Morris, 1998).
Yet another issue with existing coding systems is that
similar parenting behaviors have been labeled differently
and operational definitions and coding procedures can
significantly affect results (Ginsburg & Schlossberg, 2002;
Masia & Morris, 1998). For example, d e p e n d i n g on the
study, parents who use excessive caution, a high frequency of parental commands, or do not allow child initiative during play may be labeled as overprotective, in-

trusive, or controlling. Even studies on expressed emotion


differed in how this construct was coded. Hibbs et al.
(1991) assigned a high expressed emotion score if the
parent was highly critical or highly overinvolved or both.
In contrast, the Hirshfeld et al. (1997) studies divided expressed emotion into two components: criticism and
emotional overinvolvement (EOI) and rated them separately. Such disparities make it difficult to integrate research
findings and discern key family interactions.

Research Using Self-Report and


Observational Methods
A recent review of studies examining the relation between family/parenting variables and anxiety in children
revealed that approximately 20 studies have been conducted (Ginsburg & Schlossberg, 2002). Family/parenting
variables, assessed using both self-report and observational methods, could be categorized in a variety of ways,
including: overcontrol, overprotection, parental modeling or reinforcing anxious a n d / o r avoidant behavior,
emotional warmth/positive affect, rejection/criticism,
conflict, family environment, and parenting style. A m o n g
these dimensions, overcontrol was examined in seven
studies (Dumas, LaFreniere, & Serketich, 1995; Fristrad
& Crayton, 1991; H u d s o n & Rapee, 2001, 2002; Leib et
al., 2000; McClure et al., 2001; Siqueland et al., 1996).
Five of the seven f o u n d that greater degrees of overcontrol (i.e., intrusive behavior by parent, granting minimal autonomy) were positively related to anxiety (e.g.,
Dumas et al., 1995; H u d s o n & Rapee, 2001, 2002; McClure et al., 2001; Siqueland et al., 1996). For instance,
Siqueland and colleagues (1996) c o m p a r e d 17 clinically
anxious children (ages 9 to 12 years) and their families
with 27 control children (ages 9 to 12 years) and their
families. Each family participated in four 6-minute "revealed differences," which required families to discuss
topics that typically p r o d u c e d conflict or differences between family members. Results demonstrated that parents of children with anxiety disorders granted less autonomy and exerted more control in dialogues with their
children than parents in the control group. Additionally,
children with anxiety disorders, c o m p a r e d to their nonill peers, rated their mothers as less accepting on the
CRPBI.
Overprotection (i.e., excessive caution and restrictive
a n d / o r protective behaviors in the absence o f a cause or
reason) was examined in three studies with children
ranging in age from 7 to 17 (Last & Strauss, 1990; Leib et
al., 2000; Merikangas, Avenevoli, Dierker, & Grillon,
1999). Two of the three studies f o u n d that higher levels
of overprotection were associated with higher levels of
child anxiety (Last & Strauss, 1990; Leib et al., 2000). For
example, Leib et al. used child reports to determine the

Family Matters
association between perceived parental overprotection
and social phobia in adolescents. In this study, 1,047 adolescents (ages 14 to 17) completed the Questionnaire of
Recalled Parental Rearing Behavior (QRPRB), which assesses three dimensions of parenting behaviors, including
parental overprotecfion. Adolescents with social phobia
were more likely to perceive their parents as overprotective compared to adolescents without social phobia.
Studies that have examined parental modeling a n d /
or reinforcement of anxious/avoidant behavior (Barrett,
Rapee, et al., 1996; Chorpita et al., 1996; Dadds et al.,
1996; Muffs et al., 1996) have consistently found that children with anxiety disorders compared to their nonanxious peers are more likely to have parents who model
anxiety a n d / o r reinforce avoidance. For example, Dadds
and colleagues (Dadds et al., 1996) compared interactions between 66 clinically anxious children ages 7 to 14
and their mothers with the interactions of 18 nonanxious
children and their mothers using an ambiguous situation
task described earlier. Findings indicated that parents of
anxious children were more likely to agree with and support anxious interpretations and avoidant strategies suggested by children than parents of nonanxious controls.
Another dimension of parenting that has been consistently associated with anxiety is parental rejection/criticism
(Dumas et al., 1995; Hibbs et al., 1991; Hibbs et al., 1993;
Leib et al., 2000; Muffs et al., 1996). Rejection/criticism
is generally defined as disapproving, judgmental, dismissive, a n d / o r critical (including expressed emotion) behavior on the part of the parent. The majority of studies,
conducted with youth ages 7 to 17, found that higher levels of parental rejection/criticism were associated with
higher levels of child anxiety (Dumas et al., 1995; Hibbs
et al., 1991; Hibbs et al., 1993; Hudson & Rapee, 2001;
Leib et al., 2000). In one such study, Hibbs et al. (1991)
compared levels of expressed emotion (measured using
the 5-minute speech sample) among parents of youth
(mean age 11.7) with OCD (n = 39), disruptive behavioral disorders (n = 34), and normal controls (n = 45).
Findings revealed that, compared to normal controls, expressed emotion was higher in the OCD group. No differences were found between the two clinical groups.
In contrast to the consistent findings for the family dimensions above, evidence supporting a link between parental warmth/positivity (i.e., showing positive affect, expressing affection, showing positive regard) and child
anxiety (Dadds et al., 1996; Dumas et al., 1995; Leib et al.,
2000; McClure et al., 2001; Muris et al., 1996; Siqueland
et al., 1996) has been mixed, with only two of six studies
showing that high degrees of warmth and positivity were
associated with lower levels of anxiety in children (Dadds
et al., 1996; Dumas et al., 1995).
Mixed findings have also been found for family conflict (Kashani et al., 1990; Manassis & Hood, 1998; Stark

et al., 1990; Stark et al., 1993; Siqueland et al., 1996). Specifically, only two of five studies found that high degrees
of family conflict (i.e., disagreements among family members, fighting, arguing, disharmony, and verbal or physical aggression) were associated with high levels of anxiety
among youth ages 7 to 14 (Kashani et al., 1990; Stark et al.,
1990). For example, Stark and colleagues examined the
perceived environments among families with a depressed,
depressed and anxious, anxious only, or normal child
(ages 9 to 14 years). Relevant here, parents completed
the conflict subscale of the SRMFF (Bloom, 1985). Findings indicated that parents of anxious children reported
more conflict than non-ill controls; however, no differences
were found between anxious and depressed children.
A few studies have examined some aspect of the family
environment such as overall family functioning, enmeshment, cohesion, adaptability, religious/moral values, problem soMng, family sociability, locus of control, family
structure, and organization (Fristrad & Crayton, 1991;
Hibbs et al., 1993; Kashani et al. 1990; Kashani et al.,
1999; Leib et al., 2000; Merikangas et al., 1999; Messer &
Biedel, 1994; Stark et al., 1993; Stark et al., 1990; Thomsen, 1994). Again, findings have been mixed: Only half of
the studies detected a significant association between at
least one aspect of the family environment and anxiety in
children ages 7 to 18 (Hibbs et al., 1993; Kashani et al.,
1999; Stark et al., 1990; Stark et al., 1993; Thomsen, 1994).
Finally, two studies have specifically examined parenting styles using Baumrind's (1968) three parenting styles:
authoritarian, authoritative/democratic, and permissive/
laissez-faire (Stark et al., 1990; Stark et al., 1993). In combination with other variables, both studies found that
authoritative/democratic parenting styles were associated
with lower levels of anxiety in youth ages 9 to 14.

Critique of Research Findings


Although a growing number of studies have examined
family/parenting variables in relation to anxiety disorders
in children, several problems plague this literature. These
studies have been extraordinarily diverse with respect to
methodologies, definitions, measures, and sample characteristics, making comparisons across studies difficult.
Many of the problems are due to measurement issues
discussed above (e.g., similar family/parenting behaviors
defined using different terms). Moreover, few studies
have explored whether any f a m i l y / p a r e n t i n g variable
is unique to a specific anxiety disorder (social phobia
versus separation anxiety) or specific to anxiety versus
other psychiatric disorders. Of greater importance, however, is that the majority of measures used in these studies
were based on family systems theory and were not developed specifically to tap constructs proposed in etiological
models of anxiety disorders in children.

37

38

Ginsburg et al.

Family I n v o l v e m e n t a n d T r e a t m e n t
T h e empirical testing o f the role of family involvement
in the t r e a t m e n t o f anxiety disorders in children, t h o u g h
still limited, has shown growth in the last 5 years. Most
family-based interventions have b e e n short-term, r a n g i n g
from 4 to 12 p a r e n t sessions, a n d all were i m p l e m e n t e d in
c o n j u n c t i o n with 10 to 12 sessions o f individual child
CBT. In the first c o n t r o l l e d study, Barrett, Dadds, et al.
(1996) c o m p a r e d a m o d i f i e d version o f the Kendall et
al. (1994) individual CBT t r e a t m e n t to CBT plus a behavioral family intervention (CBT-FAM) in youth ages 7 to 14.
T h e family i n t e r v e n t i o n i n c l u d e d teaching parents to reward c o u r a g e o u s a n d c o p i n g behavior a n d to extinguish
excessive anxious behavior; m a n a g e their own anxiety
with similar CBT techniques; a n d develop new family
c o m m u n i c a t i o n a n d problem-solving skills. At the e n d o f
treatment, 84% o f c h i l d r e n in c o m b i n e d t r e a t m e n t no
l o n g e r m e t DSM-III-R diagnosis c o m p a r e d to 57% of child r e n treated in CBT alone. T h e c o m b i n e d t r e a t m e n t cont i n u e d to show s u p e r i o r o u t c o m e s at 6-month (84% vs
71%) a n d 12-month follow-up (96% vs 70%). These investigators also directly assessed pre-post t r e a t m e n t changes
in the way p a r e n t s i n t e r a c t e d with their children, a n d
f o u n d that the c h i l d r e n in CBT-FAM showed h i g h e r reductions in the n u m b e r of t h r e a t i n t e r p r e t a t i o n s a n d
avoidant plans relative to those in the individual treatment. However, c h i l d r e n in b o t h active t r e a t m e n t conditions showed a r e d u c t i o n in their avoidant plans after
family discussions rather than increasing them. T h e r e were
also significantly b e t t e r scores f o u n d for the CBT-FAM
c o n d i t i o n p o s t t r e a t m e n t on clinician ratings of clinical
global impression, family d i s r u p t i o n by the child's behavior, a n d p a r e n t s ' p e r c e p t i o n o f their ability to deal with
the child's behavior. At 6- a n d 12-month follow-up, CBTFAM was also significantly b e t t e r on clinician ratings of
overall functioning, overall anxiety, avoidant behaviors,
a n d change in child's ability to deal with difficult situations.
Barrett et al. (1996a) is the only study that has specifically tested a c o n j o i n t (parent-child) single f a m i l y - b a s e d
t r e a t m e n t m o d e l , b u t a n u m b e r of o t h e r researchers
have e x a m i n e d the role o f family involvement using a
g r o u p modality. Barrett (1998) c r e a t e d g r o u p t r e a t m e n t
manuals for b o t h the individual CBT a n d family-based
treatments d e s c r i b e d in the Barrett, Dadds, et al. (1996)
study. The two treatments (group CBT o r group CBT plus
family) d i d n o t differ from each o t h e r in p e r c e n t a g e o f
c h i l d r e n (ages 7 to 14) diagnosis-free at p o s t t r e a t m e n t or
follow-up. T h e r e was superiority o f CBT-FAM at follow-up
for clinician ratings o f p a r e n t i n g c o m p e t e n c e a n d family
disruption, clinician ratings o f overall anxiety, overall
functioning, a n d avoidant behavior. In addition, the CBTFAM showed b o t h consistently lower internalizing a n d
externalizing scores o n the Child Behavior Checklist

c o m p a r e d to the CBT alone, suggesting generalization o f


p a r e n t i n g skills to behavioral domains o t h e r than anxie~.
Mendlowitz et al. (1999) c o m p a r e d child only, p a r e n t
only, a n d c h i l d - p a r e n t groups for c h i l d r e n ages 7 to 12
with clinically significant anxiety symptoms. All groups
showed i m p r o v e m e n t on anxiety a n d depressive symptoms with no difference between groups. However, child r e n in the child-parent groups used m o r e active c o p i n g
strategies p o s t t r e a t m e n t than c h i l d r e n in the o t h e r two
t r e a t m e n t groups. In addition, parents in the parentchild t r e a t m e n t r a t e d their c h i l d r e n as significantly m o r e
i m p r o v e d than the c h i l d r e n in the o t h e r two conditions.
Finally, Spence, Donovan, a n d Brechman-Toussaint
(2000) e x a m i n e d the t r e a t m e n t effectiveness for youth
ages 7 to 14 with social phobia. Fifty c h i l d r e n were randomly assigned to a g r o u p child t r e a t m e n t (n = 19), a
g r o u p p a r e n t a n d child (n = 17), a n d a wait-list c o n t r o l
(WLC; n = 14). At posttreatment, b o t h active treatments
faired b e t t e r t h a n the WLC (58%, child only; 88%, pare n t a n d child; 7%, WLC) a n d t h e r e was a t r e n d for youth
in the parent-child t r e a t m e n t to be less likely to m e e t diagnostic criteria (p = .053). At 1-year follow-up, gains
were m a i n t a i n e d in b o t h active treatments (53%, child
only; 81%, p a r e n t a n d child). No statistically significant
differences were r e p o r t e d between the two active treatments, a l t h o u g h power may have b e e n insufficient given
the sample sizes.
A n u m b e r o f o t h e r studies have i n c l u d e d sessions with
parents o r taught p a r e n t i n g skills to m a n a g e anxiety witho u t directly testing the effect o f the family c o m p o n e n t
(e.g., Silverman, Kurtines, Ginsburg, Weems, L u m p k i n ,
et al., 1999). For instance, Silverman et al. c o m p a r e d a
CBT anxiety g r o u p t r e a t m e n t (separate groups for b o t h
c h i l d r e n a n d parents as well as a c o n j o i n t m e e t i n g ) with a
WLC ( N = 56; ages 6 to 16). T h e t r e a t m e n t was based on
the "transfer o f control" m o d e l that stipulates that effective c h a n g e involves a gradual transfer o f the knowledge,
skills, a n d methods, where the sequence is generally f r o m
therapist to p a r e n t to child. Thus, while b o t h parents a n d
y o u t h are t a u g h t a n x i e t y - r e d u c i n g strategies, p a r e n t s
begin to i m p l e m e n t these strategies first via c o n t i n g e n c y
m a n a g e m e n t (see Ginsburg, Silverman, & Kurtines, 1995;
Silverman & Kurtines, 1996, for m o r e d e t a i l e d discussion). Results i n d i c a t e d that at p o s t t r e a t m e n t 64% o f the
c h i l d r e n in the t r e a t m e n t c o m p a r e d to 13% in the WLC
g r o u p n o l o n g e r m e t criteria for their p r i m a r y anxiety
disorders.
Two trials e x a m i n e d the efficacy o f CBT for anxietybased school refusal. O n e study involved a c o m p a r i s o n to
WLC for 34 c h i l d r e n 5 to 15 years o f age (King et al.,
1998) a n d the o t h e r to an e d u c a t i o n a l s u p p o r t c o n d i t i o n
(Last, Hansen, & Franco, 1998) for 56 c h i l d r e n 6 to 17
years o f age. T h e Last study r e q u i r e d that the child or adolescent have a c o n c u r r e n t anxiety d i s o r d e r a n d 85% of

Family Matters
the c h i l d r e n a n d adolescents in the King et al. (1998)
study m e t criteria for an anxiety or p h o b i c disorder. Diff e r e n t CBT manuals were used in the two studies b u t
b o t h i n c o r p o r a t e d similar techniques.
T h e King et al. (1998) t r e a t m e n t focused o n c o p i n g
skills, training, a n d exposure. Both parents a n d teachers
were given specific advice o n how to e n c o u r a g e school attendance. T h e t r e a t m e n t i n c l u d e d 12 sessions over 4
weeks (6 with the child, 5 with parent, a n d 1 with the
teacher). T h e majority o f patients in the CBT condition,
88% (15/17), showed i m p r o v e d school a t t e n d a n c e (def i n e d as 90% a t t e n d a n c e ) c o m p a r e d to 29% (5/17) o f
the wait-list respondents. CBT also l e d to significant imp r o v e m e n t s in self-reports o f fear, anxiety, a n d depression relative to the WLC g r o u p (King et al., 1998)
T h e Last et al. (1998) CBT t r e a t m e n t consisted o f in
vivo exposure, cognitive restructuring, a n d c o p i n g selfs t a t e m e n t training with parents a t t e n d i n g at least p a r t o f
each session. However, it is n o t clear how m u c h the parents were involved in t r e a t m e n t or w h e t h e r p a r e n t i n g behaviors related to school refusal were specifically addressed. Last et al. r e p o r t e d 67% school a t t e n d a n c e in
CBT a n d 60% in the e d u c a t i o n a l support. In addition,
65% o f CBT a n d 50% o f e d u c a t i o n a l s u p p o r t cases n o
l o n g e r m e t intake anxiety diagnosis criteria. T h e r e were
no significant differences between the CBT a n d educational s u p p o r t c o n d i t i o n in the Last et al. study. No assessments of family f u n c t i o n i n g or p a r e n t i n g practices were
e x a m i n e d from pre- to p o s t t r e a t m e n t in e i t h e r o f the two
school-refusal studies.
Finally, several researchers have b e g u n to e x a m i n e the
role o f parents in the t r e a t m e n t o f c h i l d h o o d OCD (e.g.,
Knox, Albano, & Barlow, 1996; Piacentini et al., 2002;
Waters, Barrett, & March, 2001). T h e results o f these
studies suggest that p a r e n t a l involvement is an i m p o r t a n t
a n d potentially necessary c o m p o n e n t o f t r e a t m e n t for
OCD, especially given the effect o f this d i s o r d e r on family
life. However, the e x t e n t a n d n a t u r e o f p a r e n t a l involvem e n t in t r e a t m e n t has yet to be empirically d e t e r m i n e d .
O n e r e c e n t study by Waters et al. (2001) r e p o r t e d the results of a 14-week CBT family t r e a t m e n t for OCD in seven
c h i l d r e n ages 10 to 14 years old. As in Silverman, Kurtines, Ginsburg, Weems, Lumkin, et al. (1999) a n d Silverman, Kurtines, Ginsburg, Weems, Rabian, et al. (1999),
the sessions involved individual child time, individual
p a r e n t skills training, a n d c o n j o i n t time for review a n d
h o m e w o r k planning. T h e focus o f the p a r e n t training
was on p r o v i d i n g psychoeducation, r e d u c i n g p a r e n t a l involvement in child's symptoms, e n c o u r a g i n g a n d supp o r t i n g e x p o s u r e a n d response p r e v e n t i o n at h o m e , a n d
increasing problem-solving skills. Parents were also
t a u g h t p a r e n t a l a n x i e t y - m a n a g e m e n t skills, b u t the work
was focused a r o u n d d e a l i n g with the child's OCD rituals
r a t h e r than p a r e n t a l anxiety in general. Six o u t o f the

seven c h i l d r e n n o l o n g e r m e t OCD criteria posttreatment. Self-reported OCD symptoms a n d family involvement, based o n the Family A c c o m m o d a t i o n Scale for
OCD, were also f o u n d to decrease with treatment. No
c h a n g e was f o u n d over the course of t r e a t m e n t o n parents' score o f the general f u n c t i o n i n g scale o f the FAD.
A n i m p o r t a n t question is w h e t h e r involving p a r e n t s in
t r e a t m e n t improves o u t c o m e s for all families with an anxious child. A l t h o u g h few studies have a d d r e s s e d this
issue, C o b h a m et al. (1998) e x a m i n e d the benefits a n d
limitations o f the family versus child-only t r e a t m e n t s for
families with a n d without p a r e n t a l anxiety. These investigators f o u n d that c h i l d r e n (ages 7 to 14) whose p a r e n t s
d i d n o t have anxiety d i d equally well in the CBT treatm e n t only as in a c o m b i n e d CBT-parent anxiety-managem e n t treatment, while c h i l d r e n whose parents d i d have
anxiety did p o o r l y in the child CBT t r e a t m e n t a n d d i d
well in the c o m b i n e d treatment. C o b h a m et al. only tested
one c o m p o n e n t of the family anxiety-management treatm e n t (i.e., teaching parents how to m a n a g e their own anxiety). T h e addition o f the p a r e n t anxiety-management
c o m p o n e n t led to better outcomes only for children whose
parents h a d elevated levels of anxiety. The outcome differences were primarily f o u n d on child diagnosis posttreatment. Interestingly, anxious m o t h e r s showed decreases
in their own level o f anxiety in b o t h the child only a n d
c o m b i n e d t r e a t m e n t at the e n d o f treatment. N o o t h e r
changes in p a r e n t i n g for family variables were e x a m i n e d .

Predictors of Treatment Outcome in


Family-Based Treatment
Few studies have e x a m i n e d p r e d i c t o r s of response to
family treatments. T h r e e studies suggest that girls may d o
b e t t e r in family-based treatments than boys. Mendlowitz
et al. (1999) r e p o r t e d that girls d i d b e t t e r overall t h a n
boys in all their family treatments. Barrett, Dadds, et al.
(1996) r e p o r t e d that girls d i d b e t t e r in the CBT-FAM, b u t
boys d i d equally well in b o t h CBT a n d CBT-FAM. Similar
results were n o t e d in the C o b h a m et al. (1998) study in
which girls d i d b e t t e r in the c o m b i n e d t r e a t m e n t if they
h a d an anxious parent, b u t this effect was n o t f o u n d for
boys. Barrett, Dadds, et al. (1996) also r e p o r t e d that
y o u n g e r c h i l d r e n (ages 7 to 10) d i d especially well in the
CBT-FAM c o n d i t i o n with little differences between treatments for the older children (11 to 14). N o n e o f the studies
that c o m b i n e d children's anxiety disorder diagnoses (usually separation, generalized, SAD, GAD, overanxious, social
p h o b i a a n d avoidant) have f o u n d differential o u t c o m e by
diagnosis. Howevel, t h e r e were insLffficient n u m b e r s o f
the different diagnoses to adequately test for differences.
Several studies have l o o k e d at long-term p r e d i c t o r s o f
CBT t r e a t m e n t outcomes, i n c l u d i n g f a m i l y / p a r e n t i n g
constructs a n d t r e a t m e n t f o r m a t (Barrett et al., 2001;
B e r m a n et al., 2000). A l t h o u g h these studies e x a m i n e d

39

410

Ginsburg et al.
n u m e r o u s predictors of treatment outcome (e.g., diagnostic status, demographic characteristics, etc.) relevant
here are findings that parental symptoms of psychopathology (e.g., depression, hostility, paranoia) were a m o n g
the best predictors of child outcomes but that CBT alone
and CBT plus family m a n a g e m e n t were equally effective
at long-term follow-up (i.e., 6 years).
Finally, only one study that we are aware of has looked
specifically at family predictors of CBT treatment outcome. In this study by Crawford and Manassis (2001), the
CBT treatment included either individual or group child
CBT treatment with a concurrent group parent training.
Child ratings of overall family dysfunction and frustration
(frequency of parents b e c o m i n g angry, critical, or irritable with their child) predicted lower clinician-rated improvement and lower child-rated improvement. Mother
and father reports of family dysfunction and maternal
parenting stress negatively predicted mother's rating of
child improvement. None o f the predictor variables were
related to changes in father-rated child anxiety. Finally,
father-rated somatization, hut not other parental psychopathology, negatively predicted child-rated improvement.
In addition to objective measures of parental anxiety,
family functioning or conflict, it appears that children
who perceive m o r e family problems or feel their parents'
frustration are less likely to improve in treatment that
does not target these domains specifically (Crawford &
Manassis, 2001). As suggested by Crawford and Manassis,
anger directed at the child may make the child more fearful or uncertain in general. Or it could be that parental
anger or frustration may lead to inconsistent caregiving
and control by parents, which has been f o u n d to be related to child anxiety.

Critique o f Treatment Studies


Despite the encouraging findings for involving parents in CBT treatment for anxiety in children, m u c h
m o r e work is needed. Most obvious are the methodological limitations such as small sample sizes and variations in
measures used to assess family/parenting, family treatm e n t c o m p o n e n t s and format, and sample characteristics (symptoms versus diagnoses). More significandy, few
studies have measured changes in parenting skill from
pre- to posttreatment to assess whether changes actually
occurred in parenting behaviors, and the extent to which
changes in parenting skills are related to changes in child
anxiety. Thus, the rote of parenting skills as a mediator of
treatment outcome is unclear. It is also unclear whether
current family-based CBT interventions, which have focused
on group modalities, are sufficiently potent or adequately
tailored to the needs of the family and child. Moreover,
the family-based treatments do not usually address each
of the parenting and family behaviors f o u n d to be associated with increased levels of anxiety described earlier.

C o n c l u s i o n s a n d Future D i r e c t i o n s
Initial steps in exploring family/parenting behaviors
involved in the etiology and maintenance of anxiety disorders have been promising. However, n u m e r o u s areas
of investigation beckon the interested researcher. With
respect to the measurement of family/parenting constructs, additional work on the psychometric properties
(e.g., reliability and validity) of existing self-report and
observational tasks/behavioral coding systems is sorely
needed. Developing observational tasks that are m o r e realistic, with closer relevance to the psychopathology or
anxiety disorder of interest, is also critical, as is creating
measures that are developmentally appropriate for preschoolers to adolescents.
In addition to more relevant constructs that are linked
to etiological models, additional methods of measuring
parenting behaviors and family factors are needed. O n e
approach is to develop clinician-rated measures of family/
parenting variables. An example of one such measure is
the Family Assessment Clinician-Rated Interview (FACI;
Masia-Warner, Ehrenreich, Mannuzza, & Klein, 2000).
This measure assesses family social activity (e.g., leisure
time, socialization with others), family closeness (e.g., affection, expression of feelings), parental protection (e.g.,
curfew, rules about going out, use of public transportation), child independence (e.g., responsibility for decisionmaking, self-care), and parental expectations (e.g., grades,
achievements). The utility of this measure is being tested
in a longitudinal study examining risk factors for anxiety
in a sample of the children of anxious, depressed, and
normal parents. Regardless of the construct being evaluated or the m e t h o d used, prospective, longitudinal
studies with repeated assessments are n e e d e d to clarify
true etiological factors. Such studies will further identify
how and whether parenting behaviors mediate a n d / o r
moderate anxiety.
As noted earlier, a major limitation of extant studies
has been the reliance on family measures that tap constructs from family systems theory, which may or may not
be relevant for the development of anxiety disorders in
children. Two areas of particular importance are the role
of parental anxiety and that of parental beliefs. Etiological models, such as that presented in Figure 1, suggest
that parents who are anxious themselves may be more
likely to engage in parenting behaviors that increase
their child's anxiety or increase their vulnerability to developing an anxiety disorder. Yet, the effect of parental
anxiety on specific parenting behaviors or family interactions has not been sufficiently examined. One recent
study failed to find differences between anxious and
nonanxious parents during a videotaped parent-child interaction task on levels of overcontrol but did find that
anxious parents (of children ages 6 to 12) were m o r e

Family Matters
d i s e n g a g e d a n d withdrawn c o m p a r e d to n o n a n x i o u s
m o t h e r s (Woodruff-Borden, Morrow, Bourland, & Cambron, 2002).
Clinical e x p e r i e n c e a n d behavioral observation suggests that anxious parents (and some n o n a n x i o u s parents
o f c h i l d r e n with anxiety disorders) have strong beliefs
a b o u t the n a t u r e o f anxiety a n d its expression, the safety
of the world, their child's ability to m a n a g e a n d cope with
anxiety, a n d b o t h their role a n d c o m p e t e n c e in h a n d l i n g
anxiety. Many parents, especially those with anxiety disorders themselves, likely view anxiety as powerful a n d something to be avoided at all costs. As parents, they view their
role as o n e o f p r o t e c t i n g a n d saving t h e i r child a n d themselves from these experiences. These beliefs can l e a d to
specific p a r e n t a l behaviors, i n c l u d i n g p r o m o t i n g anxious
i n t e r p r e t a t i o n o f events, allowing avoidance, taking over
for the child, o r directing the child. Consequently, child r e n may c o m e to view themselves a n d feel their parents
view t h e m as i n c o m p e t e n t to m a n a g e their lives. O n e
measure designed to assess these parental beliefs, Parental
Beliefs Questionnaire on Anxiety in Children (PBQ-AC;
Nauta, B6gels, & Siqueland, 2002, available from the first
a u t h o r ) , has b e e n d e v e l o p e d a n d is currently b e i n g used
in a multisite study o f family a n d CBT t r e a t m e n t to see if
family a n d / o r individual CBT t r e a t m e n t affects these beliefs a n d the effect of c h a n g e in these beliefs on child
outcome.
In terms of treatment, several studies have d e m o n strated that involving family m e m b e r s can a d d to the efficacy o f individual child-focused CBT treatment, especially w h e n parents are anxious. F u t u r e studies must
address i m p r o v i n g the p o t e n c y o f these interventions as
well as identifying which c o m p o n e n t s are most critical.
F o r m a n y families, clinicians can address children's anxious cognitions a n d work with c h i l d r e n to a p p r o a c h situations by s t a n d a r d individual CBT techniques. However,
it would be difficult for some children, especially y o u n g e r
children, to m a i n t a i n this a p p r o a c h in a family environm e n t that w o r k e d against it. Most o f the family app r o a c h e s d e v e l o p e d thus far work with parents to reward
courageous a n d c o p i n g b e h a v i o r a n d limit attention to
anxious behavior; however, they are often n o t specific
a b o u t how this is d o n e in the face o f p a r e n t a l resistance
o r fear. Many CBT therapists have faced the d i l e m m a o f a
p a r e n t who is m o r e afraid of their child's in vivo e x p o s u r e
than their child. Parental fear is usually related to parental beliefs a b o u t the effect o f anxiety, the c o m p e t e n c e o f
their child, or c o n c e r n s that challenging their child may
h u r t the relationship with their child. O n c e these critical
i n g r e d i e n t s o f intervention are identified, family-based
a p p r o a c h e s can b e tailored to m e e t the specific processes
relevant for a particular family (e.g., o n e family may n e e d
h e l p on limiting overprotection, a n o t h e r on decreasing
criticism, a n d a third on o p e n n e g o t i a t i o n o f conflict).

41

A n o t h e r a r e a that is rarely discussed is the work clinicians must d o with parents to arrive at an a g r e e d - u p o n
way o f h a n d l i n g their child's anxious b e h a v i o r w h e n parents disagree a b o u t what is to be done. T h e r e is often a
p a t t e r n where one p a r e n t protects a n d the o t h e r criticizes the child's anxious a n d avoidant behavior. This
leads to a process of u n d o i n g by each p a r e n t a n d lack o f
consistency with the child. Many times the same p r o b l e m atic beliefs o r worries a b o u t the c h i l d ' s c o m p e t e n c e ,
conflict, a n d e m o t i o n a l expression l e a d to this p a r e n t a l
conflict. T h e evaluation o f this type o f family i n t e r a c t i o n
w o r k - - f o c u s i n g on p a r e n t a l beliefs, psychological control, a n d n e g o t i a t i o n o f c o n f l i c t - - i s u n d e r way with anxious adolescents (Siqueland, Rynn, & D i a m o n d , 2003)
a n d in an o n g o i n g multisite study c o m p a r i n g individual
CBT a n d CBT plus family interventions for anxious child r e n a n d adolescents in H o l l a n d (B6gels, p e r s o n a l comm u n i c a t i o n , 2003).
A final critical area o f work n e e d e d is m e a s u r i n g the
e x t e n t to which p a r e n t i n g changes as a result o f treatm e n t a n d the e x t e n t to which these changes are associa t e d with decreases in child anxiety. Changes in parenting c o m p e t e n c e have b e e n f o u n d for family-focused
treatments based on clinician ratings (e.g., Barrett,
Dadds, et al., 1996); however, it would also b e i m p o r t a n t
to assess pre- a n d p o s t t r e a t m e n t changes in p a r e n t s ' perceptions o f their own ability a n d c o n f i d e n c e in p a r e n t i n g
their anxious child. T h e efficacy o f the e d u c a t i o n a l supp o r t conditions (Last et al., 1998; Silverman, Kurtines,
Ginsburg, Weems, Rabian, et al., 1999) suggests the necessity a n d p o w e r of providing t h e r a p e u t i c s u p p o r t a n d
i n f o r m a t i o n alone. It may be i m p o r t a n t in the future to
test the role o f teaching p a r e n t s how to m a n a g e their
child's anxiety a n d evaluating the effect on c h i l d r e n ' s
f u n c t i o n i n g without treating the c h i l d r e n at all. Finally,
the i m p o r t a n c e o f specific p a r e n t i n g likely varies with the
age o f the child. Most o f the CBT studies a n d all o f the
family studies have focused on c h i l d r e n between the ages
o f 7 a n d 13; interventions for o l d e r adolescents a n d
y o u n g e r c h i l d r e n still n e e d to be d e s i g n e d a n d evaluated.

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Address correspondence to Golda S. Ginsburg, Ph.D., Johns Hopkins
University School of Medicine, Department of Psychiatry and
Behavioral Sciences, Division of Child and Adolescent Psychiatry, 600
North Wolfe Street/CMSC 312, Baltimore, MD 21287-3325; e-mail:
gginsbu@jhmi.edu.

Received: September 7, 2002


Accepted: April 3, 2003

43