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Child-Parent Interventions for Childhood Anxiety Disorders: A Systematic

Review and Meta-Analysis

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DOI: 10.1177/1049731513503713

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Research Article

Child–Parent Interventions for Childhood Anxiety Disorders: A Systematic Review and Meta-Analysis

Kristen Esposito Brendel 1

and Brandy R. Maynard 2

Abstract Objective: This study compared the effects of direct child–parent interventions to the effects of child-focused interventions on anxiety outcomes for children with anxiety disorders. Method: Systematic review methods and meta-analytic techniques were employed. Eight randomized controlled trials examining effects of family cognitive behavior therapy compared to individual or group child-only therapy met criteria. Results: The overall mean effect of parent–child interventions was 0.26, 95% confidence interval [0.05, 0.47], p < .05, a small but positive and significant effect, favoring child–parent interventions. Results of the heterogeneity analysis were not significant (Q ¼ 8.08, df ¼ 7, p > .05, I2 ¼ 13.41). Discussion: Parent–child interventions appear to be more effective than child-focused individual and group cognitive behavioral therapy in treating childhood anxiety disorders. Implications for practice and research are discussed.

Keywords anxiety disorder, systematic review, meta-analysis, family cognitive behavioral therapy

Childhood anxiety disorders are the most prevalent of all

childhood psychiatric disorders, with lifetime prevalence esti-

mates ranging from 2.6% to 32% (American Psychological Association, 2000; Cartwright,-Hatton, McNicol, & Doubleday,

2006; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003;

Merikangas, He, Burstein, Swanson, Avenevoli, Cui, et al.,

2010). Childhood anxiety disorders have been linked to signifi-

cant negative implications for children across social, academic

and family domains and serious mental disorders, such as

depression, substance use disorders, and other anxiety disorders

in later adolescence and adulthood (Albano, Chorpita, & Bar-

low, 2003; Bittner et al., 2007; Langley, Bergman, McCracken,

& Piacentini, 2004). In light of the high prevalence and rates of

comorbidity with other behavioral and emotional problems,

longitudinal and population-based research examining corre-

lates, causes, and the developmental course of childhood anxiety

disorders has increased, including a focus on family and parental

factors that contribute to childhood anxiety disorders.

During the past two decades, a growing body of research

examining parental factors in relation to childhood anxiety dis-

orders suggests that parental anxiety and modeling behaviors

contribute to the development and maintenance of childhood

anxiety disorders (Choate, Pincus, Eyberg, & Barlow, 2005;

Ginsburg & Schlossberg, 2002; Rapee, 1997; Siqueland, Ken-

dall, & Steinberg, 1996). Research suggests an intergenerational

transmission of anxiety, with both genetic and environmental

factors implicated. Children are estimated to be 3 or 5 times

more likely to develop an anxiety disorder if one parent has an

anxiety disorder and 6 times more likely if both parents have

an anxiety disorder (Beidel & Turner, 1997; Last, Hersen,

Kazdin, Francis, & Grubb, 1991; Merikangas, Avenevoli, Dier-

ker, & Grillon, 1999). Additional parent-related risk factors have

been implicated in the cause and maintenance of childhood

anxiety disorders including high parental control, insecure attach-

ment, and parental modeling of poor coping strategies (Ginsburg

& Schlossberg, 2002; Maid, Smokowski, & Bacallao, 2008;

Silverman & Dick-Niederhauser, 2004; Wood, McLeod, Sigman,

Hwang, & Chu, 2003).

Child–Parent Interventions for Childhood Anxiety Disorders

In light of the growing research suggesting an influence of

parental factors in the development and maintenance of child-

hood anxiety disorders, a growing number of child–parent

interventions have been developed and purported as efficacious

in the treatment of childhood anxiety disorders. Research also

supports the integration of parents in child therapy as a means

1 School of Social Work, Aurora University, IL, USA

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

Corresponding Author:

Kristen Esposito Brendel, School of Social Work, Aurora University, 347

Gladstone, Aurora, IL 60506, USA.

Email: [email protected]

Research on Social Work Practice 00(0) 1-9 ª The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049731513503713 rsw.sagepub.com

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to better generalize skills from the clinician’s office to the

home environment and for both the children and the parents

to learn and practice better methods to cope with issues of

anxiety that may be pervasive within the household (Bodden

et al., 2008; Bogels & Siqueland, 2006; Mendlowitz et al.,

1999; Wood, Piacentini, Southam-Gerow, Chu, & Sigman,

2006). Although all child–parent interventions have a common

factor, that the child and parent participate in the intervention

together, there are variations in the theories and methods used

across the array of child–parent interventions currently in prac-

tice. Some of the most common child–parent interventions

include family cognitive behavioral therapy (FCBT), parent-

child interaction therapy (PCIT), child–parent psychotherapy

(CPP), and Theraplay.

Family Cognitive Behavioral Therapy. FCBT integrates cognitive behavioral therapy in a family setting that includes parents and

children; the family is seen as the most favorable setting for

effecting change in children’s irrational thoughts. FCBT typi-

cally involves a treatment manual that guides the therapeutic

process and helps family members recognize essential thoughts

that are irrational and reframe them as more rational and pro-

ductive types of beliefs (Bogels & Siqueland, 2006; Kendall,

Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008). FCBT

directly focuses on the most common parental factors that

have been associated with the development and maintenance

of childhood anxiety disorders, including parental control,

acceptance, and modeling, as well as other issues identified

during the assessment process and throughout treatment. More-

over, FCBT encourages parents to facilitate new opportunities

with their children to test distorted beliefs when at home and

while jointly engaging in community activities (Barrett &

Shortt, 2003). Parents also can model their own functional

cognition and behaviors to their children during the treatment

process and at home.

Parent-Child Interaction Therapy. PCIT integrates play therapy with developmental, social learning, and behavioral theories.

Although originally developed for preschool-age children

experiencing externalizing behavioral problems (Brinkmeyer

& Eyberg, 2003; Herschell & McNeil, 2005), researchers have

begun to investigate PCIT for other issues, including victims

of physical abuse, children in foster care, children with develop-

mental delays (Chaffin, Taylor, Wilson, & Igelman, 2007;

Herschell & McNeil, 2005), and children with separation anxiety

disorder (SAD; Choate et al., 2005; Herschell & McNeil, 2005).

Similar to FCBT, the premise of PCIT for children with anxiety

disorders is to effect change within the parent–child system.

PCIT is typically conducted in two phases, a child-directed

phase and then a parent-directed phase. During each phase, par-

ents learn how to modify their own actions, hence modifying the

reactions of their children. PCIT enhances parent–child relation-

ships by fostering healthy attachments, modifying reinforcement

contingencies, and reducing anxiety-provoking responses (Cho-

ate et al., 2005).

Child-Parent Psychotherapy. CPP is a model of family play therapy that involves treatment of the parent–child unit, using play as the

primary medium of intervention (Lieberman & Van Horn,

2005). Lieberman and colleagues posit that by using play in con-

joined sessions with child and parent, parental understanding of

the child’s inner experience increases, as well as trust, recipro-

city, and pleasure within the parent–child relationship (Lieber-

man & Inman, 2009). CPP involves the parent actively

playing with the child in the therapeutic milieu. It is a

relationship-based intervention that helps to change mutual

reinforcement of negative behaviors and instead enhances

emotional attunement (Lieberman & Van Horn, 2005).

Because CPP is designed to facilitate positive and healthy

associations between parent and child, it is conjectured that

it can also be helpful for children with anxiety disorders.

Research needs to be conducted on the efficacy of CPP as

an intervention specifically for children with anxiety disorders.

Theraplay. Theraplay is a systematic procedure invented by Ann M. Jernberg in the 1960s to increase positive interactions

between parent and child (Jernberg, 1979). Jernberg modeled

Theraplay after Winnicott’s (1958) notion of being a ‘‘good

enough mother.’’ Five dimensions present in mother–child

interactions are postulated in this model: structuring, challen-

ging, engagement, nurturing, and play. Jernberg formulated

Theraplay after these dimensions, with the premise that

parent–child interactions can be therapeutic for a number of

childhood disorders by fostering bonding, attunement, and play-

fulness (Jernberg, 1999; Wettig, Franke, & Fjordbark, 2006).

As research during the past decade has begun to elucidate

the relationship of parental influences and behavior and the

causes and maintenance of anxiety disorders in children, prac-

titioners have begun to treat childhood anxiety disorder in the

context of child–parent interventions. Although child–parent

interventions are widely used and supported by practitioners,

little is known about the effectiveness of child–parent interven-

tions compared to child-focused interventions in the treatment

of childhood anxiety disorders. Although prior reviews have

examined the effects of interventions for childhood anxiety dis-

orders, these reviews primarily focused on individual and/or

cognitive behavioral interventions, did not use a systematic

methodology or meta-analytic techniques, included diagnostic

classifications beyond anxiety disorders, or were conducted

before recent advancements in the field (see Cartwright-

Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004;

Creswell & Cartwright-Hatton, 2007; In-Albon & Schneider,

2007; Ishikawa, Okajima, Matsuoka, & Sakano, 2007; James,

Soler, & Weatherall, 2009; King et al.,1998; Reynolds, Wilson,

Austin, & Hooper, 2012; Silverman, Pina, & Viswesvaran,

2008). In light of the advancements made in understanding and

treating childhood anxiety disorder in the past decade and the

plethora of child–parent interventions being developed and

used, this review examines the current state of child–parent

intervention research for treating childhood anxiety disorders

and improves upon prior reviews by using systematic review

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methods and meta-analytic techniques to provide a comprehen-

sive picture of effects.

Purpose of the Present Study

The purpose of this systematic review and meta-analysis is to

specifically examine the differential effect on anxiety out-

comes of child–parent interventions compared to child-

focused interventions for children with anxiety disorders. The

specific research questions guiding this study were as follows:

(1) Are child–parent interventions more effective than inter-

ventions involving solely the child in decreasing anxiety for

children with anxiety disorders? and (2) Are there differences

in magnitude of effects by type of child–parent intervention?

Method

Systematic review procedures, following the Campbell Colla-

boration guidelines (see www.campbellcollaboration.org), were

used for all aspects of the search, retrieval, selection, and coding

of published and unpublished studies meeting study inclusion

criteria. Meta-analytic techniques were employed to quantita-

tively synthesize the results from included studies. The protocol

and screening and coding instruments guiding the conduct of this

study are available from the first author upon request.

Study Eligibility Criteria

Studies were eligible for inclusion if they examined the effects

of a child–parent intervention (i.e., an intervention in which a

parent or guardian and child were directly involved in the treat-

ment) against the effects of interventions targeting only the

child (an individual or group intervention in which the parent

did not directly participate) for children under the age of 18

with at least one anxiety disorder. Interventions were consid-

ered a child–parent intervention if they included at least one

intergenerational family unit, that is, parent and child or pri-

mary caretaker and child. Studies must have employed a rando-

mized or quasi-experimental design, measured at least one

anxiety outcome, and reported sufficient information to calcu-

late an effect size. Published and unpublished studies were eli-

gible and no geographical restrictions were imposed; however,

this review was limited to English language reports of studies

conducted between 1980 and 2013.

Search Strategy

A comprehensive and systematic search strategy was conducted in

an attempt to identify and retrieve all relevant published and

unpublished studies meeting inclusion criteria. The search, com-

pleted in April 2013, involved several sources and used the follow-

ing key words: ‘‘anxiety disorders,’’ ‘‘family therapy,’’ ‘‘childhood

anxiety,’’ ‘‘family treatment,’’ ‘‘randomized,’’ ‘‘experimental,’’

‘‘quasi-experimental,’’ ‘‘clinical,’’ and ‘‘intervention.’’ Informa-

tion sources included seven electronic databases (PsychINFO, Pro-

Quest, Dissertations and Abstracts, Academic Search Premier,

Social Work Abstracts, PubMed, and Medline); personal contacts

with the first authors of all relevant studies, relevant researchers,

research institutes, and professional associations; hand searches

of journals relevant to the topic of the review (i.e., Journal of Mar-

riage and Family Therapy, Journal of the American Association of

Child and Adolescent Psychiatry, The American Journal of

Orthopsychiatry, and Psychiatric Services); online searches

through Google, Google Scholar, Yahoo!, and relevant websites of professional organizations; and reference lists of prior reviews

and included studies.

Study Selection and Coding Procedures

The first author screened titles and abstracts for relevance.

Those that were obviously ineligible (i.e., did not involve the

target population, did not involve a child–parent intervention,

or were theoretical in nature) were screened out. The full text

of all studies that were not obviously ineligible or were ques-

tionable at this stage was obtained and screened for eligibility,

using a screening instrument developed by the first author.

The first author and a trained graduate student then coded stud-

ies deemed eligible by using a coding instrument developed by

the authors to guide systematic examination and extraction of

data. The coding instrument included categories concerning all

relevant bibliographic information, study context, intervention

and sample descriptors, research methods and quality descrip-

tors, and effect size data (Lipsey & Wilson, 2001).

To ensure reliability of coding procedures, the first author

and a trained graduated student independently coded 100% of the studies. Interrater reliability was obtained by dividing the

number of agreements by the number of possible agreements

for each study. There was 98% agreement between the two coders. All discrepancies were discussed and resolved.

Statistical Methods

Statistical analysis was designed to produce descriptive

information on the characteristics of the included studies, the

effect size of each intervention on anxiety outcomes, the grand

mean effect size, and the heterogeneity of effect sizes around

the mean. The standard mean difference effect size statistic,

corrected for small sample size bias (Hedges’ g), was

calculated for each study using a statistical software package,

Comprehensive Meta-Analysis, Version 2.0 (Borenstein,

Hedges, Higgins, & Rothstein, 2005) by inputting the means,

standard deviations, and sample sizes for the treatment and

control groups reported by the primary study authors. To main-

tain statistical independence of data, only one effect size was

computed for each subject sample. Four of the eight studies

used multiple measures to assess anxiety. In cases where mul-

tiple measures were used, the most valid measure was selected.

In two cases, the measure used in the meta-analysis included

both a parent and child report, which were reported by the pri-

mary study authors together as one score. In cases where more

than one comparison group was used (i.e., a waitlist control and

an alternative treatment), the group that received the alternative

child-focused treatment was used in the analysis.

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The effects of included studies were quantitatively synthe-

sized in Comprehensive Meta-Analysis. Effect sizes were

inverse variance weighted and random effects statistical mod-

els were assumed. Cochrane’s Q was used to assess heteroge-

neity in the effect sizes. A significant Q rejects the null

hypotheses, indicating that the variability in effect sizes

between studies is greater than what would be expected from

sampling error alone (Hedges & Olkin, 1985). Moderator anal-

ysis was not indicated, as the statistical test assessing heteroge-

neity was not significant (Lipsey & Wilson, 2001). We had

planned to assess and report publication bias by constructing

a scatter plot of study effect size by sample size; however, due

to the small number of studies, and thus low power, the use of

funnel plots or other techniques such as regression to assess

publication bias was not indicated (Card, 2012).

Results

The search procedures yielded close to 300 titles. After review of

titles and abstracts, 33 potential studies were retrieved in full text

for screening. Of those, 15 reports were excluded due to not

meeting basic eligibility criteria and the remaining 18 reports

were fully coded. Of those 18 studies, 10 were deemed ineligi-

ble. These studies were excluded due to using a single-group

pretest–posttest design (n ¼ 6), reporting secondary results of

included studies (n ¼ 2), or not providing sufficient statistics to compute an effect size (n ¼ 2). The final sample for this review includes eight randomized controlled trials. See Figure

1 for a flowchart detailing the search and selection process.

Descriptive Analysis

The characteristics of the eight included studies are summar-

ized in Table 1. Of the eight studies, one was an unpublished

dissertation and seven were peer-reviewed journal articles. The

studies were conducted in four countries: the United States

(n ¼ 4), Australia (n ¼ 2), Canada (n ¼ 1), and the Netherlands (n ¼ 1). The majority of the studies were conducted in a clinic setting (n ¼ 7), and one was conducted in a hospital setting.

Across the eight studies, participants included a total of 710

children and at least one parent. The age range of child partici-

pants was wide across studies (n ¼ 1, 6–13 years; n ¼ 1, 6–16 years; n ¼ 1, 7–12 years; n ¼ 3, 7–14; n ¼ 1, 12–17 years; n ¼ 1, 8–17 years). No studies included a subgroup analysis by age

range. Studies included a balanced proportion of male and

female child participants. Most of the participants across the

eight studies were Caucasian (68%), and 91% of the partici- pants had a primary diagnosis of social phobia, SAD, or gener-

alized anxiety disorder. Approximately 98% of the participants

Figure 1. Study search and selection process flow chart. RCT ¼ randomized controlled trial.

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had a secondary diagnosis, with the vast majority of secondary

diagnoses (83%) being another anxiety disorder. All child–parent interventions in this review used a treat-

ment manual and were based on FCBT; the comparison group

interventions were either individual CBT with the child (n ¼ 7) or group CBT with children only (n ¼ 1). All interventions were delivered in 12 to 16 sessions of 60 to 90 minutes each.

Four included studies tested Coping Cat (Kendall & Hedtke,

2006) or adaptations of Coping Cat, including a modified Coping

Cat for adolescents (Siqueland, Rynn, & Diamond, 2005), Coping

Koala (Barrett, Dadds, & Rapee, 1991), and Coping Bear (Men-

dlowitz & Scapillato, 1996). Coping Cat is a manualized cogni-

tive behavioral treatment program that assists school-age

children in recognizing and coping with anxious feelings and

physical reactions to anxiety. Wood, Piacentini, Southam-

Gerow, Chu, and Sigman (2006) examined the Building Confi-

dence Program, developed specifically for their study. This inter-

vention involved combining child-focused cognitive behavioral

therapies with in vivo exposure and parent involvement. Spence,

Donovan, and Brechman-Toussaint (2000) used the Social Skills

Training: Enhancing Social Competence in Children and Adoles-

cents program. The program integrated CBT, social skills train-

ing, relaxation techniques, problem-solving, and exposure

interventions. The parent–child interventions in the remaining

three studies were not named, but all used manualized cognitive

behavioral interventions developed for their studies.

At least one doctoral level therapist or psychiatrist delivered

all interventions. Other treatment personnel included doctoral

students in five studies, one social worker, eight research

assistants (in a single study), one family therapist, one youth

care worker, and other unspecified master’s and doctoral level

clinicians. Six studies used a combination of trained clinicians.

Meta-Analytic Results

The grand mean effect size for anxiety outcomes from the eight

independent samples reported in the included studies, assuming

a random effects model, was 0.26 (95% confidence interval [0.05, 0.47], p < .05), demonstrating a small but positive and

statistically significant effect, favoring child–parent interven-

tions on anxiety outcomes. Table 2 provides a summary of the

characteristics and mean effect sizes for each of the included

studies. The mean effect size and confidence intervals for each

study are also shown in the forest plot in Figure 2. As seen in

the table and forest plot, the effect sizes range from a very small

and negative 0.01 to .88. Moreover, the confidence intervals

around the mean effect size in seven of the eight studies cross

zero, indicating that the child–parent intervention group did not

differ significantly on anxiety outcomes from the child-focused

intervention group. However, when the studies are pooled, the

mean effect is positive, small, and statistically significant.

Analysis of Homogeneity. To examine whether between-study var- iance is greater than what would be expected from sampling

error alone, an analysis of heterogeneity was conducted using the

Q-test. The result of the test of homogeneity was not significant

(Q ¼ 8.08, df ¼ 7, p ¼ .325, I2 ¼ 13.41), indicating that any var- iance in effect sizes across included studies can be attributed to

sampling error alone, rather than systematic or random differ-

ences between studies (Lipsey & Wilson, 2001). Although the

Q-test was not significant, we assumed a random effects model

because the Q-test does not have much statistical power with

small sample sizes and may fail to reject homogeneity when

there is significant variability of effect sizes across studies (Lip-

sey & Wilson, 2001). Moreover, the random effects model was

selected a priori because it was anticipated that the included

studies would vary in terms of study, participant, and interven-

tion characteristics. Because we found no significant variability

beyond sampling error, and due to the small number of included

studies, moderation analysis was not indicated.

Analysis of Publication Bias. To mitigate publication bias, special efforts were made to search for and retrieve unpublished

reports; however, only one unpublished report was included

in this review. Conducting a formal assessment of publication

bias, such as constructing and visually inspecting a funnel plot

or using the trim and fill method, was not indicated due to the

study’s small sample size and low power (Littell, 2008).

Discussion and Applications to Social Work

The purpose of the present study was to compare child–parent

interventions to other treatment modalities to determine whether

child–parent interventions are more effective and to inform

social work practice with children with anxiety. A systematic

Table 1. Characteristics of Included Studies.

Study Characteristics

a N (%)

Participant Characteristics

b N (%)

Publication year Sex 1990–1999 2 (25) Male 347 (52) 2000–2005 2 (25) Female 323 (48) 2006–2009 4 (50)

Publication type Participating parentc

Journal 7 (88) Mother 460 (91) Dissertation 1 (13) Father 249 (38)

Country Anxiety disorder United States 4 (50) Social phobia 229 (34) Australia 2 (25) SAD 199 (30) Canada 1 (13) GAD 182 (27) The Netherlands 1 (13) Other 60 (9)

Sample size Racec

1–50 3 (38) Caucasian 323 (68) 51–100 2 (25) Hispanic 114 (24) 101–150 2 (25) African American 21 (4) 151–200 1 (13) Other 20 (4)

Setting Clinic 7 (88) Hospital 1 (13)

Note. SAD ¼ separation anxiety disorder; GAD ¼ generalized anxiety disorder. a N ¼ 8 studies.

b N ¼ 670 total child participants.

c Three studies did not report data.

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review methodology was used to search, select, and extract

data from studies examining effects of child–parent inter-

ventions against child-focused interventions. Eight studies

met inclusion criteria for this review. Meta-analytic results

revealed a small but overall positive and significant effect

of parent–child interventions compared to child-focused

individual or group interventions. On average, FCBT outper-

formed child-focused CBT individual and group interventions

on anxiety outcomes. While an effect size of .26 is considered

small using Cohen’s rules of thumb (Cohen, 1988), given that

this review directly compares FCBT to already established

interventions, a statistically significant effect size of .26 is

impressive and reveals a non-negligible advantage of FCBT over

already established child-focused CBT interventions. Although

there was some variation in the delivery of the FCBT interven-

tions, there was no statistically significant difference in the mag-

nitude of effects of the FCBT interventions across studies,

indicating that any variations in the FCBT models used did not

affect the magnitude of effect of the intervention.

It is interesting to note that the effect sizes in seven of the

eight studies, when examined individually, were not signifi-

cantly different from zero, meaning that there was no evidence

Figure 2. Forest plot of mean effects (Hedges’ g) of included studies. CI ¼ confidence interval.

Table 2. Summary of Included Studies.

Author (Year) Type of Intervention N Age Range Comparison Intervention Anxiety Measure ES 95% CI

Barrett et al. (1996) FCBT 79 7–14 ICBT RCMAS 0.41 [�0.13, 0.95] Bodden et al. (2008) FCBT 128 8–17 ICBT ADIS C/P 0.53 [�0.05, 1.12] Kendall et al. (2008) FCBT 161 7–14 ICBT MASC �0.01 [�0.38, 0.36] Mendlowitz et al. (1999) FCBT 68 7–12 ICBT RCMAS 0.16 [�0.54, 0.86] Moreno (2007) FCBT 143 6–16 GCBT RCMAS 0.05 [�0.33, 0.43] Siqueland et al. (2005) FCBT 11 12–17 ICBT HAM-A 0.48 [�0.62, 1.59] Spence et al. (2000) FCBT 50 7–14 ICBT ADIS-P 0.34 [�0.35, 1.04] Wood et al. (2006) FCBT 40 6–13 ICBT ADIS-C/P 0.88* [0.22, 1.53]

Note. CI ¼ confidence interval; FCBT ¼ family cognitive behavioral therapy; ICBT ¼ individual cognitive behavioral therapy; RCMAS ¼ Revised Children’s Manifest Anxiety Scale; ADIS ¼ Anxiety Disorder Interview Schedule (C ¼ Child Version, P ¼ Parent Version); MASC ¼ Multidimensional Anxiety Scale for Children; GCBT ¼ group cognitive behavioral therapy; HAM-A ¼ Hamilton Anxiety Rating Scale. *p < .05.

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that FCBT was more effective than child-focused CBT found in

the majority of the individual studies. When combined, how-

ever, the pooled effect size was significantly different from

zero, indicating that FCBT was more effective than child-focused

CBT on average. Given the small sample sizes in several of the

included studies, it is possible that the primary studies failed to

demonstrate a significant effect because they were underpowered.

One of the strengths of meta-analysis over narrative or vote-

counting methods is the capability to find effects that are not readily

apparent or are obscured when using less sophisticated approaches

(Lipsey & Wilson, 2001). By pooling effect size estimates across

studies, meta-analysis can combine the results of underpowered

studies, producing a synthesized effect estimate with considerably

more statistical power to discover meaningful effects that can be

missed in low-powered individual studies (Card, 2012).

Given the advances in the development of non-CBT parent–

child interventions for anxiety disorders, we had anticipated

finding at least some studies examining effects of non-CBT

parent–child interventions. However, despite our best efforts,

we did not locate any studies testing effects of other models

of child–parent interventions against child-focused interven-

tions that met inclusion criteria. Moreover, all of the compari-

son groups received a variant of individual or group CBT

interventions. On the one hand, the lack of diversity in the

interventions examined in this review and the homogeneity

of effects across studies provide greater confidence in the pres-

ent study’s findings. On the other hand, finding only FCBT

studies that met inclusion criteria was disappointing, as we did

not intend for this review to focus on CBT interventions.

The failure to find child–parent intervention studies that met

inclusion criteria and that were not based on FCBT could be

attributed to a number of potential reasons. It is possible that

non-CBT interventions do not receive sufficient empirical

attention (or funding), that research with other types of inter-

ventions is not as well developed or rigorous, that rigorous

research exists but is not compared to child-focused interventions,

or that research is not published or otherwise made available (pos-

sibly due to issues related to reporting bias). Nevertheless, the lack

of rigorous research on non-CBT child–parent interventions for

treating childhood anxiety disorder is concerning and perplexing.

Although the meta-analytic findings indicate support for

FCBT interventions over child-focused CBT interventions,

gaps remain in the evidence base in terms of identifying for

whom and under what circumstances FCBT is more effective.

Primary studies in this review included children across a wide

range of ages and developmental periods. Despite hypotheses

that family interventions may be more effective and develop-

mentally appropriate for younger children, the included studies

did not examine differential effectiveness between ages or

developmental stages of the study participants. Thus, despite

prior recommendations by several researchers to examine dif-

ferential effects of FCBT across age groups (Creswell &

Cartwright-Hatton, 2007; Reynolds et al., 2012), we still know

little about the relative effectiveness of FCBT for children in

different age groups. Similarly, some included studies were

missing relevant information regarding the demographics of

the participants, and some studies did not report effects by

race/ethnicity or other relevant demographic characteristics.

Child-focused CBT may be more appropriate and more effec-

tive than FCBT for some groups of children or parents, based

on race/ethnicity, socioeconomic status, or other demographic

variables. Future research could begin to parse out differential

effectiveness, based on participant characteristics.

Based on the results of the present study, one cannot draw con-

clusions about the relative efficacy of FCBT for different types of

anxiety disorders. While there is some extant evidence of differen-

tial effects of interventions for different anxiety or comorbid disor-

ders (Kendall et al., 2008; Rapee et al., 2013), we were unable to

examine effects by type of disorder in the present study. The

included studies tested FCBT interventions with a range of anxiety

disorders; however, no studies differentiated effects by type, sever-

ity, or duration of anxiety disorders, and no study limited the sam-

ple to a specific disorder. Most studies also included participants

with comorbid conditions; thus, it is unclear whether there are dif-

ferential effects between diagnostic categories. Future research can

begin to elucidate whether and which anxiety disorders are more or

less responsive to FCBT compared to child-focused CBT and other

modalities, either by focusing specifically on one disorder or pro-

viding subsets of outcome data by diagnostic category.

While this study expands and improves upon prior reviews

and contributes to the growing evidence base of intervention

effectiveness for childhood anxiety disorders, the present study

is not without limitations and the findings must be interpreted

in light of the study’s limitations. This review is limited to a rel-

atively small number of studies that compared the effects of

child–parent interventions to those of alternative interventions

for children with anxiety disorders and that met the other inclu-

sion criteria specified for this review. Also, we may not have

captured every eligible intervention study, despite our compre-

hensive and systematic search process. Despite our intent to

include a variety of parent–child interventions outside of CBT,

all of the studies included in this review compared a variant of

FCBT to individual or group CBT. Findings from this review

may not generalize to studies examining effects of different

types of parent–child interventions or studies that were

excluded from this review due to not meeting inclusion criteria

or not being identified in the search. Also, despite our attempts

to include unpublished studies through our gray literature

search, we discovered only one unpublished study and thus

publication bias is a potential threat to the validity of this

review. Moreover, because we calculated effects by using the

most reliable and valid anxiety measure reported in each of the

included studies, the outcome measures used in this analysis

may not represent the outcome measures that the primary study

authors or another reviewer would have selected and in some

cases may overestimate or underestimate the treatment effect

compared to other measures reported in the primary studies.

Conclusion

Due to the significant immediate and long-term implications of

childhood anxiety disorders, it is important that children and

Brendel and Maynard 7

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adolescents who experience anxiety receive effective treatment.

Social workers and other treatment professionals are mandated,

through their respective professional code of ethics, to engage

in evidence-informed practice. The present study contributes to

the evidence base of interventions for childhood anxiety disorders

by synthesizing the effects of child–parent interventions to assist

practitioners in making evidence-informed decisions with their

clients. While the study results provide evidence of effectiveness

of FCBT compared to individual or group child-focused CBT

interventions in reducing anxiety, gaps and areas ripe for further

study were also identified. Future directions for research include

replicating current primary studies, particularly with larger sam-

ple sizes, and assessing effects of other child–parent interventions

that are in the early stages of development, such as PCIT,

attachment-based family therapy, and child–parent psychother-

apy. Additionally, follow-up studies to published research are

vital to establishing the long-term effectiveness of parent–child

interventions. Future research also needs to systematically exam-

ine potential moderating and mediating variables, such age, sex,

race, socioeconomic status, severity and type of anxiety disorder,

parental anxiety, and other comorbid conditions that may have a

differential impact on the effects of interventions. In addition to

research on effects of interventions, future research could assess

and report on implementation issues, intervention fidelity, and the

cost and benefit of interventions to help clinicians, organizations,

and clients make well-informed decisions about treatment.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the

research, authorship, and/or publication of this article: This research

was supported in part by the Meadows Center for Preventing

Educational Risk and the Institute of Education Sciences (grant #

R324B080008).

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