ARTICLES
Preventing Onset of Anxiety Disorders in Offspring of
Anxious Parents: A Randomized Controlled Trial of
a Family-Based Intervention
Golda S. Ginsburg, Ph.D., Kelly L. Drake, Ph.D., Jenn-Yun Tein, Ph.D., Rebekah Teetsel, M.A., Mark A. Riddle, M.D.
Objective: The authors examined the efficacy of a family-
based intervention to prevent the onset of anxiety disorders in
offspring of anxious parents.
Method: Participants were 136 families with a parent
meeting DSM-IV criteria for an anxiety disorder and one
child 6–13 years of age without an anxiety disorder. Families
were randomly assigned to the family-based intervention
(N=70) or to an information-monitoring control condition
(N=66). All families were expected to complete assess-
ments, administered by blind interviewers, at baseline, at the
end of the intervention (or 8 weeks after randomization) and
at 6- and 12-month follow-ups. Onset of any anxiety
disorder and anxiety symptom severity (assessed using
the Anxiety Disorders Interview Schedule for Children) at
12 months were the primary and secondary outcome
measures, respectively.
On average, 10% of children and adolescents in the United
States meet criteria for an anxiety disorder, which impairs
their social, familial, and academic functioning (1, 2). Etio-
logical models of anxiety disorders implicate several family-
based risk factors (3). Family aggregation studies indicate that
children of anxious parents have an elevated risk of having an
anxiety disorder (4), and specific parenting practices, such as
modeling of anxiety and overcontrol/overprotection, con-
tribute to elevated anxiety (5). Family-based treatments for
pediatric anxiety disorders that target these parenting
practices, along with other cognitive-behavioral strategies,
have been found to reduce child anxiety (6–8).
In light of the high prevalence, associated impairment, and
familial nature of pediatric anxiety disorders, family-based
prevention targeting high-risk offspring holds promise for
reducing the incidence and burden of these illnesses. To date,
anxiety prevention programs have been only modestly suc-
cessful, and most have been conducted in schools (i.e., a
universal prevention approach) (9, 10). Meta-analyses of
anxiety prevention programs have reported modest effect
sizes (an average Cohen’s d of 0.18 and Hedges’ g of 0.22) at
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Results: The incidence of child anxiety disorders was 31% in
the control group and 5% in the intervention group (odds
ratio=8.54, 95% CI=2.27, 32.06). At the 1-year follow-up,
youths in the control group also had higher anxiety symp-
toms ratings than those in the intervention group. Effect sizes
were medium to large (0.81 at 6 months and 0.57 at 12 months
for anxiety symptoms), and the number needed to treat was
3.9 at 12 months. Significant moderators included baseline
levels of child anxiety; significant mediators were parental
distress and modeling of anxiety. Child maladaptive cogni-
tions and parental anxiety did not mediate outcomes.
Conclusions: A brief psychosocial prevention program holds
promise for reducing the 1-year incidence of anxiety dis-
orders among offspring of anxious parents.
AJP in Advance (doi: 10.1176/appi.ajp.2015.14091178)
postintervention assessment, and no program in the United
States has targeted high-risk offspring of anxious parents for
prevention (9, 10).
We sought to address this gap by evaluating the efficacy of
a family-based intervention (the Coping and Promoting
Strength program) for high-risk offspring. The intervention
was grounded in cognitive-behavioral strategies for pediatric
anxious youths (11) and Beardsley’s prevention program for
offspring of depressed parents (12). In a pilot test using a small
sample (N=40), the intervention showed positive effects over
a 1-year period (13). The present study is a replication with
a sufficiently large sample to test the efficacy of the Coping
and Promoting Strength intervention. The primary study aim
was to assess the efficacy of the intervention relative to an
information-monitoring control group in reducing the in-
cidence of anxiety disorders and the severity of anxiety
symptoms in offspring of anxious parents over 1 year. The
effects of selected theory-driven parent and child mediators
(global parental psychopathology, parental anxiety severity,
parental modeling of anxiety, and child maladaptive cogni-
tions) and moderators (child age, child gender, parent gender,
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PREVENTING ONSET OF ANXIETY DISORDERS IN OFFSPRING OF ANXIOUS PARENTS
parent comorbidity, parent-child gender match, and baseline
child and parent anxiety level) were also examined.
METHOD
Design
A randomized controlled trial was conducted with families in
which at least one parent met criteria for a current anxiety
disorder according to DSM-IV-TR criteria and at least one
child did not have an anxiety disorder. In each family, only
one parent and one child were enrolled in the study, although
all family members were invited to participate in the in-
tervention. The study was funded by the National Institute of
Mental Health and was conducted in an outpatient research
clinic at the Johns Hopkins University School of Medicine.
The trial was approved by the Johns Hopkins University
institutional review board; parents provided written in-
formed consent and children provided assent after receiving
a complete description of the study.
Participants
Participants were 136 volunteer families. Children were
between 6 and 13 years old, did not meet criteria for an anxiety
disorder, were not currently receiving treatment for anxiety,
and did not have any medical or psychiatric conditions
contraindicating the study interventions (e.g., suicidality),
based on clinical interview. At least one biological parent in
each family met criteria for a current primary diagnosis of
an anxiety disorder (Table 1), and none had any medical
or comorbid psychiatric conditions contraindicating study
participation (e.g., substance use disorder), based on clini-
cal interview. There were no restrictions regarding family
composition. Comorbid psychiatric disorders were allowed
but had to have lower severity or impairment levels than the
anxiety disorder. The presence of psychiatric disorders and
associated severity or impairment were determined by the
parent and child versions of the Anxiety Disorders Interview
Schedule for DSM-IV (14, 15).
Measures
Parental and child psychiatric disorders were assessed by
trained independent evaluators. Onset of a child anxiety dis-
order was the primary outcome measure. The Anxiety Dis-
orders Interview Schedule is the gold-standard assessment
tool for determining anxiety disorders and is well validated
(16, 17). The instrument yields both a diagnosis (present/
absent) and a clinical severity rating that ranges from 0 to 8;
scores of 4 or higher are indicative of a clinical disorder.
Clinical severity ratings represent the degree of severity and
impairment or interference in functioning. The independent
evaluators were supervised by a senior child psychiatrist
(M.A.R.) who reviewed all diagnoses and clinical severity
ratings and remained blind to intervention condition
throughout the study. The sum of the child Anxiety Disorders
Interview Schedule clinical severity ratings across all anxiety
disorders, as determined by the evaluator after interviewing
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the parent and child separately, was used as a measure of
anxiety symptom severity/impairment. Interrater agreement
on a randomly selected 25% of Anxiety Disorders Interview
Schedule administrations was 97% for parents and 97% for
children. Diagnostic agreement was defined as matching on
the presence/absence of a disorder and a clinical severity
rating within 1 point.
Demographic information, obtained from the participat-
ing anxious parent, included parent age, gender, race/
ethnicity, education, income, and marital status, as well as
child age and gender. Parental anxiety, examined as a mod-
erator, was assessed using the trait version of the State-Trait
Anxiety Inventory (baseline internal consistency, 0.92) (18).
The overall severity levels of the parents’ psychopathology
and anxious modeling (examined as potential mediators)
were assessed with the global severity index of the Brief
Symptom Inventory (baseline internal consistency, 0.95) (19)
and the anxious modeling subscale of the Learning History
Questionnaire–Revised (baseline internal consistency, 0.83)
(20), respectively. Child maladaptive cognitions, examined as
a mediator, were assessed using the social subscale of the
Children’s Negative Cognitive Error Questionnaire (baseline
internal consistency, 0.80) (21). Finally, mental health service
utilization for anxiety (dichotomized as yes/no) was obtained
from the anxious parent by monthly telephone check-ins
and/or in-person interviews after randomization over the
course of the study.
Intervention Condition
The Coping and Promoting Strength intervention consisted of
eight weekly 60-minute sessions and three optional monthly
booster sessions. (The Coping and Promoting Strength pro-
gram manual and the information-monitoring condition hand-
out are available from the first author on request.) Each family
met individually with a trained therapist. The intervention (13)
targets theory-driven modifiable child and parent risk fac-
tors. Child factors included elevated anxiety symptoms, social
avoidance/withdrawal, maladaptive cognitions, and deficits in
coping and problem-solving skills; parent factors included
anxiety-enhancing parenting behaviors (e.g., modeling of anxi-
ety, overcontrol/overprotection). Families were taught how to
identify the signs of anxiety and how to reduce anxiety (psy-
choeducation), cognitive restructuring, in vivo desensitization,
problem solving, and parenting strategies (e.g., contingency
management and increasing child independence and auton-
omy). The first two sessions were with parents alone; the
remaining sessions included all interested family members.
Information-Monitoring Condition
Participants in the information-monitoring condition were
given a 36-page pamphlet containing information about
anxiety disorders and associated treatments (22). The pam-
phlet did not include detailed information about the anxiety-
reduction strategies included in the Coping and Promoting
Strength program. The information-monitoring condition
was selected as a control to mimic usual care; high-risk
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 GINSBURG ET AL.

TABLE 1. Baseline Demographic and Clinical Characteristics for the Coping and Promoting Strength intervention condition (using
Program and Information-Monitoring Groupsa random numbers derived
Coping and from randomization.com). An
Promoting Strength Information-Monitoring independent evaluator con-
Program Group Control Group
Baseline Characteristics (N=70 Families) (N=66 Families) tacted families monthly by
telephone to assess anxiety
Mean SD Mean SD
symptoms and mental health
Child age (years) 8.53 1.76 8.86 1.85 service utilization.
Parent age (years)b 39.89 4.80 41.75 5.07
Anxiety Disorders Interview Schedule, clinical 7.99 4.54 7.80 4.31
severity rating for anxietyc Statistical Analysis
Initial analyses examined
N % N %
baseline equivalence of the in-
Child tervention and control groups,
Male 26 37.1 34 51.5
using chi-square tests for cat-
Caucasian 58 82.9 57 86.4
Non-anxiety disorders egorical variables and t tests
Attention deficit hyperactivity disorder 1 1.4 3 4.5 for continuous variables. At-
Enuresis 1 1.4 3 4.5 trition analyses (23) were con-
Subclinical anxiety (Anxiety Disorders Interview 36 50.7 34 48.6 ducted to examine whether
Schedule, clinical severity rating=3)
attrition rates differed across
Anxious parent conditions. Outlier analyses
Male 16 22.9 13 19.7
Married 64 91.4 57 87.7
were conducted to deter-
Education, college or higher 61 87.1 56 86.1 mine whether outliers sub-
Family income, over $80K 52 74.3 55 84.6 stantially biased the results
Primary anxiety disorder (24). Intention-to-treat an-
Generalized anxiety disorder 46 65.7 48 72.7 alyses were performed in
Social phobia 7 10.0 9 13.6
Panic disorderd 13 18.6 4 6.1
Mplus, version 7.11 (25), using
Obsessive-compulsive disorder 2 2.9 5 7.6 full-information maximum-
Specific phobia 2 2.9 0 0.0 likelihood estimation to han-
Receiving treatment 47 67.1 41 63.1 dle missing data. Intervention
Comorbid diagnosis 44 62.9 43 65.2 effects were examined using
a
Parent data refer to the participating anxious parent. No significant differences between groups except as otherwise noted. three analytical approaches.
b
Significant difference between groups, p,0.05.
c Baseline child anxiety symp-
Sum of the child Anxiety Disorders Interview Schedule clinical severity ratings across all anxiety disorders.
d
Significant difference between groups, p,0.05, although one cell size was ,5. tom scores were included as
a covariate in these analyses.
We first compared the in-
offspring of anxious parents are unlikely to receive any pre- tervention and control groups at the postintervention as-
ventive intervention as part of usual care other than general sessment and each of the follow-up assessments, using
prevention approaches such as an educational pamphlet. analysis of covariance (ANCOVA) for continuous outcomes
and logistic regression for binary outcomes. The second
Procedures approach used survival analysis to examine the intervention
Participant families were recruited through advertisements effect on the incidence of anxiety disorders over 1 year. The
in local newspapers, mailings to local physicians and psy- third approach compared the trajectory of anxiety symptoms
chiatrists, community flyers, and radio advertisements. In- over time for the two groups, using multigroup piecewise
terested families called study staff and completed a telephone growth curve modeling to examine whether the program
screening in which key inclusion criteria such as psychiatric effect after the intervention persisted, faded, or increased
disorder and age were assessed. Families who met initial over time. Alpha was set to 0.05 (two-tailed). Several mod-
inclusion criteria were invited for an in-person baseline as- erators of intervention effects were examined, including
sessment. All participating families were expected to com- child age, gender, and baseline anxiety symptoms; parent
plete assessments, administered by interviewers blind to gender; parent-child gender match; parent baseline anxiety
intervention condition and reviewed by a senior child psy- severity; and psychiatric comorbidities. One moderator was
chiatrist, at end of the intervention (or 8 weeks after ran- examined at a time by adding group-by-moderator in-
domization) and at follow-ups 6 and 12 months after the teraction into the model. If none of the moderation effects
8 weeks. (The flow of participant families through the study were significant, we reassessed the model without the in-
is presented in a CONSORT diagram in the data supple- teraction. Theory-driven parent and child mediators of
ment that accompanies the online edition of this article.) intervention effects on anxiety symptoms and diagnosis at
Eligible families were randomly assigned in a 1:1 ratio to an 12-month follow-up were also examined, including reduction

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PREVENTING ONSET OF ANXIETY DISORDERS IN OFFSPRING OF ANXIOUS PARENTS

TABLE 2. Children in the Coping and Promoting Strength Program and Information-Monitoring Groups Meeting Diagnostic Criteria for an
Anxiety Disorder at Each Follow-Up Assessment, and Cumulatively
Coping and
Promoting
Strength Information-
Program Monitoring Program
Group Control Group Effect Number Absolute
Odds Needed Relative Risk
Assessment N % N % B 95% CI Ratio 95% CI t p to Treat Risk Reduction
a
Postintervention 0 0 5 8.33 10.77 9.80, 11.58 — — 21.87 ,0.001 12.00 0.00 0.08
6 months 2 3.92 7 13.72 1.42 –0.22, 3.06 4.14 0.80, 21.29 1.70 0.09 10.20 0.28 0.10
12 months 1 1.81 7 14.00 2.20 0.02, 4.03 9.04 1.02, 80.00 1.98 ,0.05 8.21 0.13 0.12
Cumulative cases 3 5.26 19 30.65 2.14 0.82, 3.47 8.54 2.27, 32.06 4.30 ,0.001 3.94 0.17 0.25
a
Odds ratio approached infinity with 0 cases in the Coping and Promoting Strength Program group.

FIGURE 1. Cumulative Proportion of Onset of Anxiety Disorders in because of the small attrition rate (N=4) in the information-
Children in the Coping and Promoting Strength Program and monitoring group. One outlier, in the information-monitoring
Information-Monitoring Groups Over the 12-Month Follow-Up
Period
group, was identified on the clinical severity rating of the
Anxiety Disorders Interview Schedule at the 6-month follow-
0.30
up (outlier score, 35, compared with scores #18 for all
Information-monitoring control group
0.25
others). For analyses involved with this variable, the results
Coping and Promoting Strength group
were consistent between the models with and without the
0.20
outlier. We present the more conservative results without
Hazard Ratio

the outlier in the model.

0.15
0.10
0.05
0 attended was 9.01 out of 11 (SD=2.63, range, 0–11). The
0 1 2 3 4 5 6 7
Month
of parental anxiety and global psychopathology (measured by
the Brief Symptom Inventory), parental anxious modeling,
and child cognitive errors at the postintervention and 6-
month follow-up assessments (26).
RESULTS
Baseline Characteristics and Group Comparisons
Table 1 summarizes participants’ baseline clinical and de-
mographic characteristics. The two groups did not differ
significantly on child demographic variables or on levels of
child or parent anxiety. Mean parental age was higher in the
information-monitoring group. There were also group dif-
ferences in the attrition rate, with significantly more children
in the intervention condition failing to complete the 1-year
assessment within the allotted window (p=0.03; see the
CONSORT diagram in the online data supplement). Attrition
analysis comparing families that remained in the study and
families that dropped out indicated that parents who dropped
out were significantly younger on average (mean age, 41.3
years compared with 37.2 years; p=0.002). Attrition analyses
for group-by-attrition interaction were not performed
Intervention Attendance and Adherence
Among the families in the Coping and Promoting Strength
intervention group, the average number of sessions attended
was 6.63 out of eight (range, 0–8) and 1.2 out of three booster
sessions (range, 0–3); the total mean number of sessions
8 9 10 11 12 13 14 participating anxious parent attended all sessions and was
accompanied by the other parent in a mean of 4.07 of the eight
sessions (range, 0–8). Intervention adherence was assessed
on 25% of each family’s recorded sessions by independent
evaluators. Each evaluator rated adherence to specific session
objectives (e.g., explaining the intervention model of anxiety
reduction, teaching relaxation or cognitive restructuring
techniques). The average adherence ratings per family
ranged from 86.36% to 100%, and the mean adherence rat-
ing across all sessions was 97.58% (SD= 3.51), reflecting
high levels of clinician adherence. Total number of sessions
attended was unrelated to child outcomes.
Test of Independent Evaluator Blindness
At the postintervention and follow-up assessments, the in-
dependent evaluators were asked to guess group assignment.
Kappa values for agreement between actual assignment
and guessed assignment were 0.32, 20.08, and 0.03 at the
three assessments, respectively. The independent evaluators
seemed to be more aware of the group condition at the
postintervention assessment than at the 6-month and 12-
month follow-up assessments.
Onset of Child Anxiety Disorder
Table 2 lists the numbers of children in each group who
developed an anxiety disorder over the course of the 1-year

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TABLE 3. Adjusted Mean Scores and Analysis of Covariance Results for Anxiety Symptom Severity on the Anxiety Disorders Interview
Schedule for DSM-IV, Child Versiona
Adjusted Estimated Means
Coping and
Promoting
Program
Strength Information-
Main Effect
Program Monitoring
Assessment Group Group B 95% CI
Postintervention 5.40 6.74 1.35 0.53, 2.15 3.27 ,0.000
6 months 4.09 7.03 2.94 1.49, 4.39 4.13 0.000
12 months 3.65 5.35 1.70 0.62, 2.78 3.08 0.002
a
Ratings represent the clinical severity ratings for anxiety only. B=unstandardized regression coefficient.
b
Cohen’s d of the main effect, representing the effect size at the mean for baseline symptom scores.
c
Cohen’s d for the effect size at +1 SD of the baseline symptom scores.
study. Cumulatively, three children in the intervention group
(5.26%) and 19 children in the control group (30.65%) de-
veloped an anxiety disorder (odds ratio=8.54, 95% CI=2.27,
32.06; number needed to treat=3.9). The results of the sur-
vival analysis indicated that the rate of onset of anxiety
disorders for children in the control group was 6.6 times
higher than that for children in intervention group during
the 1-year period (hazard ratio=6.60, 95% CI=2.00, 21.82;
p=0.002). Figure 1 illustrates the hazard functions for the
two groups.
Changes in Anxiety Symptom Severity
Table 3 shows the results of ANCOVAs for comparisons
between the intervention and control groups on severity of
anxiety symptoms at each of the postrandomization assess-
ments. On average, youths who received the Coping and
Promoting Strength intervention had significantly lower
symptom scores at the postintervention assessment, as well as
the 6- and 12-month follow-up assessments, compared with
the control group.
Figure 2 illustrates the piecewise growth models for the
intervention and control groups. Results of the multigroup
comparisons of the growth factors on anxiety symptoms
(i.e., the intercept, changes at the postintervention assessment,
and linear growth after the postintervention assessment)
showed that although both groups improved from baseline to
end of intervention, the scores were reduced significantly
more in the intervention group (B=25.23, SE=0.82, p,0.01)
compared with the control group (B=22.21, SE=0.63, p,0.01)
(difference=23.02, 95% CI=25.04, 21.00]). From the post-
intervention assessment to the 12-month follow-up, additional
significant reductions occurred for the intervention group
(B=20.43, SE=0.13, p,0.01) but not for the control group.
Moderators and Mediators
The intervention effects were moderated by baseline child
anxiety symptoms but not by any of the other moderators
examined (child age and gender; parent gender, anxiety,
comorbidity; parent-child gender match). Probing of the
intervention effect at one standard deviation above and below
the mean of baseline child anxiety symptoms (27) indicated
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GINSBURG ET AL.
Group-by-Baseline
Cohen’s d
Interaction
at the Cohen’s d
t p Meanb B 95% CI t p at +1 SDc
0.59 0.26 0.07, 0.44 2.65 0.008 0.74
0.81 0.40 0.07, 0.73 2.07 0.04 0.83
0.57 0.22 –0.03, 0.48 1.70 0.09 0.62
that the benefit of the intervention was stronger for children
with higher baseline anxiety symptoms than for those with
lower baseline anxiety symptoms (see Table 3).
Mediation analyses revealed that significant reductions
in both parental modeling of anxiety and parental global
distress (but not anxiety alone) at the postintervention and
6-month follow-up assessments significantly mediated the
intervention effects on outcomes for severity of child anx-
iety symptoms at the 1-year follow-up (mediation effect—
where ab refers to the product of the unstandardized
betas, a=regression path for intervention → mediator, and
b=regression path for mediator → anxiety—through post-
intervention assessment anxiety modeling: ab=0.392, 95%
CI=0.113, 0.642; through 6-month assessment anxiety modeling:
ab=0.423, 95% CI=0.106, 0.725; through postintervention as-
sessment parental distress modeling: ab=0.233, 95% CI=0.014,
0.488; through 6-month assessment parental distress modeling:
ab=0.337, 90% CI=0.018, 0.713). Changes in child maladaptive
cognitions did not mediate the intervention effects on
outcomes.
Service Utilization
Parent reports of the use of mental health services for anxiety
(yes/no) indicated that 21.5% of the control families, com-
pared with 13.2% of the intervention families, reported
receiving mental health services for their child’s anxiety
over the course of the study (not a statistically significant
difference).
DISCUSSION
The study demonstrated that the Coping and Promoting Strength
program, a brief family-based cognitive-behavioral intervention,
reduced the incidence of anxiety disorders and the severity of
anxiety symptoms over a 1-year period in offspring of anxious
parents, a population at high risk for developing anxiety disorders.
The onset of anxiety disorders over 12 months among high-risk
children in the information-monitoring control group was
nearly seven times higher than among those who received the
intervention. The number needed to treat was 3.9. In ad-
dition to a lower rate of onset of anxiety disorders, the
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PREVENTING ONSET OF ANXIETY DISORDERS IN OFFSPRING OF ANXIOUS PARENTS

FIGURE 2. Growth Trajectories of Anxiety Symptoms Over Time in the Coping and average effect sizes of 0.18–0.22 (9, 10). The
Promoting Strength Program and Information-Monitoring Groups, Using Multigroup present findings also parallel outcomes of
Piecewise Growth Curve Modeling
interventions aimed at preventing the onset of
Coping and Promoting Strength Group depression in the offspring of adults with
Post- 6-month 12-month depression. Compas et al. (28) reported a
Baseline intervention follow-up follow-up
20 1-year incidence rate of 20.8% for depression
in an information-monitoring condition and
8.9% in a family intervention group.
It is notable that 31% of the control
15 group developed an anxiety disorder within
Severity of Anxiety Symptoms

12 months. This finding also replicates our

pilot study data (13), underscores the vul-
nerability of offspring of anxious parents, and
10 is of considerable concern from a public
health perspective. Given the adverse aca-
demic, social, and economic impact of anxiety
disorders and the fact that many anxious
5 youths never receive treatment (29), addi-
tional resources are needed to identify and
implement preventive or early intervention
programs for at-risk youths in settings in the
0 health care system that are practical and
0 2 4 6 8 10 12 14
Month accessible for youths and families (e.g.,
primary care).
Information-Monitoring Control Group With respect to the moderators examined,
Post- 6-month 12-month the intervention had a similar effect for girls
Baseline intervention follow-up follow-up
20 and boys as well as for younger compared with
older youths, although the majority of youths
fell into a narrow age range (7–12 years old). In
contrast, among youths who received the in-
15 tervention, those with high baseline anxiety
Severity of Anxiety Symptoms

symptom severity levels showed greater

10
5 “room for improvement” that these youths
0 less anxious counterparts and thus benefited
0 2 4 6
Month
intervention group also exhibited lower severity of anxiety
symptoms than the control group at each postbaseline as-
sessment point, with medium to large effect sizes. Of par-
ticular note, while the largest reduction in anxiety symptoms
was observed immediately after the intervention, reductions
in anxiety symptoms were sustained for youths who received
the intervention.
These findings are consistent with our pilot study results
(13), and this selective intervention fared better than uni-
versal anxiety prevention programs, which have shown
reductions in severity than those with low
baseline levels, which suggests that the in-
tervention is particularly helpful for youths
with elevated anxiety symptoms. This is
consistent with data from other prevention
trials for anxiety (30) and likely reflects the
exhibit. It may also be that youths with higher
levels of baseline anxiety utilized the skills
learned in the intervention more than their
8 10 12 14
more from the intervention. Consistent with
anxiety treatment trials (31), parental trait
anxiety level was not found to moderate out-
comes, perhaps because trait anxiety does not adequately
capture distress or impairment associated with parental
anxiety or because the parents’ anxiety was effectively
treated (63%267% of anxious parents were in treatment).
Additional parental moderators deserve examination in fu-
ture studies.
An examination of several theory-driven intervention
mediators revealed that the program reduced parental
modeling of anxiety, which was directly targeted in the in-
tervention, and that reductions in both modeling of anxiety

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and global parental distress (which included but was not
limited to anxiety symptoms) led to lower levels of child
anxiety symptoms. This finding clarifies potential mecha-
nisms of the intervention’s impact and suggests that targeting
specific parenting behaviors (such as reducing anxious
modeling) and lowering parents’ overall distress levels (not
anxiety specifically) were critical in reducing child anxiety
symptoms. This is consistent with data from family-based
treatment studies of anxious youths, which suggest that in-
cluding parents in treatment leads to positive outcomes (32).
In contrast, child maladaptive cognitions, which have been
found to be elevated in youths with anxiety disorders and to
be a mediator of treatment response in clinically anxious
youths (33), were not affected by the intervention, and
reductions in these cognitions did not explain the inter-
ventions’ effects at the 1-year follow-up. It is possible that
maladaptive cognitions among youths without an anxiety
disorder are not as salient as they are for clinically anxious
youths or that other child risk factors, such as attention bias
or behavioral avoidance, may be more important. Future
analyses will examine additional mediators and whether the
intervention had a greater impact on specific domains of
anxiety.
A critical question for prevention programs is whether
they have a net positive balance of economic costs and
benefits. While our study was not designed to directly assess
this question, we observed a higher rate of mental health
service utilization among participants in the control condi-
tion, although it was not statistically different from the rate in
the intervention group. The absence of a stronger divergence
in mental health service use between groups is consistent
with data showing that the majority of anxious youths do not
seek or receive treatment (29). Alternatively, the intervention
may not have had an impact on treatment-seeking behavior
or mental health service utilization. A longer follow-up of
youths as they enter into the peak age of psychiatric illness
onset would shed light on this issue.
Limitations
The study had several limitations. Our sample was made up of
volunteers from predominantly Caucasian, two-parent families
with relatively high incomes, and the findings may not gen-
eralize to nonvolunteers or to a more racially or economically
diverse population. It is also possible that the parents in this
sample were less severely ill than many parents with anxiety
disorders, as they had few comorbid diagnoses and had greater
resources to support their engagement in prevention. A ma-
jority of the parents had a primary diagnosis of generalized
anxiety disorder, which may reflect the excessive worry about
their child’s well-being that is characteristic of this disorder (in
contrast to social anxiety and avoidance, which may have re-
duced the likelihood of these parents enrolling). The children
in this study may also not be representative of the population
of high-risk offspring both because youths were excluded if
they already had an anxiety disorder or any other psychiatric
condition that required immediate treatment.
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GINSBURG ET AL.
Another limitation is that the information-monitoring
condition did not control for therapist time and attention.
Thus, whether this intervention is superior to another active
prevention program is unknown. Moreover, we did not
conduct an evaluation of whether specific intervention com-
ponents (e.g., relaxation, problem solving) were uniquely
responsible for the beneficial outcomes. The completion rate
for study evaluations was higher in the control group than in
the intervention group, a finding that may be attributed to the
offer of receiving the intervention after the 1-year assessment.
We did not examine an exhaustive list of potential moderators
and mediators, the sample size for specific moderation effects
was small, and analyses were likely to be underpowered to
detect these effects. Finally, the length of the follow-up was
limited to 12 months; a longer follow-up is needed to further
assess mental health outcomes and the balance of costs and
benefits.
AUTHOR AND ARTICLE INFORMATION
From the Department of Psychiatry, School of Medicine, University of
Connecticut Health Center, West Hartford; the Department of Psychiatry
and Behavioral Sciences and the Division of Child and Adolescent Psy-
chiatry, Johns Hopkins University School of Medicine, Baltimore; and the
Department of Psychology, Arizona State University, Tempe.
Address correspondence to Dr. Ginsburg (gginsburg@uchc.edu).
Supported by NIMH grant R01 MH077312 to Dr. Ginsburg.
Clinicaltrials.gov identifier: NCT00847561.
The authors report no financial relationships with commercial interests.
Received September 22, 2014; revisions received March 9 and April 23,
2015; accepted May 1, 2015.
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