Anxiety disorders in children of anxious parents : risk and prevention

<p dir="ltr">Background: Children of parents with anxiety disorders constitute a risk group for developing anxiety disorders themselves, and the parenting behaviors of anxious parents have been suggested to contribute to this elevated risk.</p><p dir="ltr">Aim: This thesis aimed to advance the understanding of the risk for anxiety disorders in children of anxious parents and to examine whether they can be prevented through a novel parenting intervention. Study I investigated the relative risk of anxiety disorders in children of parents diagnosed with an anxiety disorder, compared to children of parents with no anxiety diagnosis. Study II assessed if the Confident Parents Brave Children (CPBC) program, an online group-intervention for anxious parents, was effective in reducing the risk for child anxiety disorders and symptoms within 12 months, compared to a self-help control condition. Study III aimed to develop a self-assessment tool measuring parental anxious modeling. Lastly, Study IV assessed the psychometric properties of the Parental Overprotection Measure, and developed a short version of the scale.</p><p dir="ltr">Methods: Study I was a population-based cohort study. Children (N=516,134) living in Stockholm, Sweden, were followed in registers until they were diagnosed with anxiety, moved, or turned 18. The primary and secondary exposures were parental diagnoses of specified and unspecified anxiety disorder, respectively. The outcome was the first occurrence of a specified anxiety diagnosis in the child. In Study II, 215 parents and their children (n=271) were randomly assigned to the CPBC program or a self-help control condition. The primary endpoint was the 12-month follow-up, with the primary outcome being Clinical Severity Rating (CSR) assessed using the Anxiety Disorders Interview Schedule. Secondary outcomes included parent-rated child anxiety symptoms. Study III and IV were based on survey data from 1,092 parents of children aged 4-12 years. The survey included the PROMIS Anxiety short forms (adult and parent proxy report scale) and the Parental Overprotective Measure (POM). Further, it included 51 novel items, generated to describe parental modeling of anxious and non- anxious behaviors. Based on this item pool, Study III developed and validated the Modeling of Parental Anxiety Questionnaire (MPAQ). Study IV examined the psychometric properties of the Parental Overprotection Scale (POM). In Study III and IV, exploratory factor analysis was utilized to determine the factor structure, Rasch model for item reduction, and validity was evaluated by analyzing association between the new scale and related constructs.</p><p dir="ltr">Results: Study I found that having a parent diagnosed with a specified anxiety disorder was associated with a modest risk increase for anxiety disorders in the child (HR: 1.44, 95% CI: 1.38-1.51). The risk was attenuated after adjustment for other parental psychiatric disorders (HR: 1.27, 95% CI: 1.21-1.34). The risk was higher for parental anxiety recorded in specialized psychiatric care compared to primary care (HR: 1.69, 95% CI: 1.60,1.79, vs. HR: 1.24, 95% CI: 1.17,1.32). No increased risk for anxiety disorders was observed in children of parents diagnosed with unspecified anxiety (HR: 1.02, 95% CI: 0.98-1.07). In Study II, the 12-month assessment was completed by 204 parents (95%). The results demonstrated no statistically significant decrease in risk for CPBC children compared to control children in terms of movement to a higher CSR category (OR=0.67, 95% CI: 0.30-1.48) or the development of anxiety disorders (OR=0.57, 95% CI: 0.24-1.31). In a separate analysis based on child age, 5-6-year-olds in the CPBC condition exhibited a lower risk of increased CSR (OR=0.24, 95% CI: 0.08, 0.77) and anxiety disorders (OR=0.23, 95% CI: 0.05, 0.84) compared to the control group. Regarding secondary outcomes, parent ratings indicated that CPBC children's anxiety symptoms decreased more compared to control children from pre- to the 12-month assessment, Cohen's d = - 0.35 (95% CI: - 0.55, -0.15). In Study III, factor analysis revealed four separate factors, used to form four independent MPAQ subscales: (1) being curious and content, (2) being on guard, (3) displaying anxiety and avoidance, and (4) displaying stress. The internal consistency of the subscales ranged from moderate to good. The anxiety and avoidance subscale showed the strongest positive correlation with child anxiety symptoms. In Study IV, eight out of the original 19 items from the Parental Overprotection Measure (POM) were removed based on poor psychometric performance or expert evaluations indicating misalignment with the construct of parental overprotection. The eleven retained items form the POM-11, a shorter scale with adequate psychometric properties.</p><p dir="ltr">Conclusion: This thesis provides evidence for a modest risk increase for anxiety disorders in children of parents diagnosed with a specified anxiety disorder. The overall risk was found to be lower than previously reported, however, the risk varied depending on parent care level and type of anxiety diagnosis. The Confident Parents, Brave Children (CPBC) program did not demonstrate overall effectiveness in preventing anxiety disorders in children. However, for children aged 5 to 6, CPBC effectively prevented the onset of anxiety disorders. Additionally, across all age groups, children whose parents participated in CPBC experienced a significant reduction in anxiety symptoms compared to those in the self-help control group. Although further research is warranted, the results give partial support for the potential for parent-only interventions to prevent pediatric anxiety disorders, at least in young children. Further, POM-11 and the MPAQ are measurements with acceptable psychometric properties suitable to use in research and clinical practice.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Elfström, S.</b>, Wicks, S., Dalman, C., & Åhlén, J. (2024). A detailed investigation of anxiety disorders in children of clinically anxious parents: A population-based study [Manuscript]</p><p dir="ltr">II. <b>Elfström, S.</b>, Rosengren, A., Andersson, R., Engelbrektsson, J., Isaksson, A., Meregalli, M., van Leuven, L., Lalouni, M., Öst, L., Ghaderi, A., & Åhlén, J. (2025). Evaluating a program to prevent anxiety in children of anxious parents: a randomized controlled trial. Journal of Child Psychology and Psychiatry. <a href="https://doi.org/10.1111/jcpp.14151">https://doi.org/10.1111/jcpp.14151</a><br></p><p dir="ltr"><br></p><p dir="ltr">III. <b>Elfström, S.</b>, & Åhlén, J. (2022). Development and validation of the Modeling of Parental Anxiety Questionnaire. Journal of Anxiety Disorders, 85, 102515. <a href="https://doi.org/10.1016/j.janxdis.2021.102515">https://doi.org/10.1016/j.janxdis.2021.102515</a><br></p><p dir="ltr"><br></p><p dir="ltr">IV. <b>Elfström, S.</b>, & Ahlen, J. (2025). Psychometric Evaluation of the Parental Overprotective Measure: Toward a Reliable and Practical Assessment Tool. Journal of Child and Family Studies, 34(1), 164- 173. <br><a href="https://doi.org/10.1007/s10826-024-02967-z">https://doi.org/10.1007/s10826-024-02967-z</a><br></p>