Parent emotion management

It is well established that parents of children and young people with anxiety have higher rates of anxiety and depressive disorders than parents of young people who are not anxious (e.g., Cooper, Fearn, Willetts, Seabrook, and Parkinson 2006; Last, Hersen, Kazdin, Orvaschel, and Perrin 1991), and that lifetime prevalence rates of depression in parents of children and young people with depression are considerably higher than in parents of young people who do not have depression (e.g., Asarnow, Goldstein, Tompson, and Guthrie 1993). Furthermore, parental anxiety and depression have been found to be associated with poorer treatment outcomes for children and young people with anxiety (e.g., Cobham, Dadds, and Spence 1998; Cooper, Gallop, Willetts, and Creswell 2008; Southam-Gerow, Kendall, and Weersing 2001), while remission in depression in mothers has been found to have a positive impact on their child’s psychiatric symptoms (including depression) and functioning (e.g., Birmaher 2011; Weissman et al. 2006; Wickramaratne et al. 2011).

There are a number of reasons that may account for poorer treatment outcomes for children and young people in the context of parental emotional difficulties, including shared stressful life events (e.g., Hammen et al. 1987) and genetic factors (e.g., Eley et al. 2011); but here we have focused on those cognitive and behavioral factors that are amenable to therapeutic change. As suggested in Figure 19.1 and illustrated in Case 19.1a, anxiety and depression in parents are hypothesized to make them behave in a way that may maintain their child’s problem. Examples of such behavior are taking over, enabling the child to avoid a situation, disengaging from the young person and from the family, and modeling maladaptive responses. These responses may be accounted for by parents’ negative expectations about the child (e.g., “she’ll freak out,” “he’s not going to be able to cope,” or “she’s going to fail”) or by parents’ ability to alter or cope with the situation (“unless I get involved, they won’t be able to cope,” “there is nothing I can do,” or “I can’t bear it”).

If the anxiety or depression experienced by the parent is clinically significant, that parent may be keen to seek individual therapy to address his/her own concerns. However, many individuals with significant mental health difficulties wait a considerable amount of time before seeking help through clinical services (e.g., Hollander 1997; Stobie, Taylor, Quigley, Ewing, and Salkovskis 2007); this is likely to relate to a range of factors, including fear of or shame about revealing one’s experiences to others. Therefore the child’s or young person’s clinician may have an important role in enabling the parent to make sense of his/her symptoms and to understand their impact on the child, in challenging any associated beliefs that may be unhelpful in relation to the child’s treatment progress, in addressing issues around stigma and blame, in providing information about services and the process of therapy, and in supporting the parent in the referral process.

In cases where symptoms are not at a clinically significant level, parent emotion management (Sburlati et al. 2011) can be used throughout treatment (e.g., Rapee et al. 2006), to enable parents to learn the same CBT strategies that are taught to the young person. By using the example of Joshua and his mother Georgia, Case 19.1b illustrates strategies that a therapist could use to address parental emotions.

Parental expectations management

The expectations that parents place on their children can impact on parental behavioral responses and ultimately on the young person’s self-perception. Parents of children and young people with depression are more likely to have unrealistically high expectations of their children (Cole and Rehm 1986) and are less likely to provide positive reinforcement, or they reserve positive reinforcement for high achievements (Cole and Rehm 1986; Pineda, Cole, and Bruce 2007). High parental criticism and hostility, emotional over-involvement, and a lack of warmth have been observed in families of children and young people with depression (e.g., Asarnow et al. 1993; Goodman and Gotlib 1999), and young people with depression consistently report less support, warmth, and closeness from parents (Greenberger, Chen, Tally, and Dong 2000). In the context of depression in children and young people, these parental expectations and behaviors are likely to compound the young person’s difficulties. For children and young people with anxiety, it is hypothesized that low parental expectations, for example, about the child’s ability to cope may lead parents to reinforce their child’s avoidant and over-dependent behaviors, maintaining the young person’s anxiety (e.g., Creswell et al. 2011; Hudson and Rapee 2004).

The main features of parental expectations management strategies include therapists’ identification of areas where parental expectations are unrealistic (e.g., either too high or too low/anxious), and working with parents to find a more balanced and empathic approach. For children and young people with both anxiety and depression, this may first involve psycho-education with the family about the influence of symptoms of anxiety and depression on the young person, in order to help parents develop realistic expectations. This may be followed by discussion and formulation designed to develop a shared understanding of the potential cycles in which parental expectations and responses may maintain the young person’s anxious and/or depressed cognitions and behaviors, and vice versa. Parents are thus helped by therapists to identify and try out different responses to their child, in order to test alternative expectations and appraisals of their child’s behaviors. Case 19.2a illustrates several strategies that therapists may use to help parents manage their expectations of their child.

Family communication and conflict resolution

Communication and conflict difficulties arise in most families from time to time, but they are particularly important in the context of anxiety and depression in children and young people. Interpersonal conflicts within the home environment are often stressful and, as such, they present risk and function as maintaining factors, for depression in particular (Grant, Compas, Thurm, McMahon, and Gipson 2004; Joiner, Coine, and Blalock 1999). Families where there is a young person with depression have been found to experience more communication problems and greater levels of interpersonal conflict (e.g., Kaslow, Deering, and Racusin 1994; Rapee 1997), and young people with depression report more frequent perceptions of family conflict (Stein et al. 2000). In addition, conflict with parents is associated with suicidal behavior in young people (Kerfoot, Dyer, Harrington, Woodham, and Harrington 1996).

The interpersonal difficulties experienced by children and young people with depression (Gotlib and Hammen 1992; Sheeber, Davis, Lever, Hops, and Tildesley 2007) may be influenced by negative cognitive biases associated with depressed mood (Beck 1976). For example, young people with depression are more likely to make negative attributions about their parents’ behaviors and to underreport parental happy and neutral affect, by comparison with young people who do not have depression (Ehrmantrout, Allen, Leve, Davis, and Sheeber 2011), so the former may be inclined to respond in a more hostile manner to their parents. These interactions may be exacerbated in the presence of parental psychopathology, in particular depressed mood (e.g., Goodman and Gotlib 1999), which is likely to influence both cognitive and behavioral parental responses. Taken together or in combination, these factors may create an environment that is vulnerable to a vicious cycle characterized by frequent family discord and depression in both young people and their parents.

Several empirically tested treatments for children and young people with depression include strategies aimed at family communication and conflict resolution (e.g., Brent and Poling 1997; Clarke, Lewinsohn, and Hops 1990; Curry et al. 2005). The main aim of the strategies is to help family members to communicate more effectively with each other in order to improve the relationship between parents and their children and to reduce the likelihood of interpersonal conflict. One of the most common conflict resolution strategies employed with families in treatment programs is family problem-solving skills training. In conflict resolution or family problem-solving skills training, those family members involved in the conflict are taught by the therapist to (i) identify the problem; (ii) generate potential solutions together; (iii) evaluate the predicted outcome for each of these solutions; (iv) choose the most appropriate course of action; and (v) evaluate the outcome (e.g., Curry et al. 2005; Rapee et al. 2006). Case 19.2b illustrates how therapists may use family problem-solving skills training (in combination with other CBT strategies and techniques) to address family communication and conflict resolution.

Parental intrusiveness and overprotection management

It is well established that there is a link between anxiety in children and young people and parental control (e.g., Wood, McLeod, Sigman, Hwang, and Chu 2003), in particular a lack of autonomy granting (McLeod, Wood, and Weisz 2007). In addition, experimental research has supported the hypothesis that a lack of autonomy granting leads to an increase in anxiety symptoms in children and young people (e.g., de Wilde and Rapee 2008; Thirlwall and Creswell 2010). With regard to low mood, psychological control – such as manifest in the induction of guilt and/or shame – has been linked to childhood depression (e.g., Barber 1996). Similarly, depressed children describe their parents as more controlling than do those without depression (e.g., Stark, Humphrey, Crook and Lewis 1990).

Reducing parental overprotectiveness and intrusiveness is thus seen as an important part of the treatment for children and young people with anxiety disorders, where these parental behaviors are evident in the family environment. Such reduction can be achieved by using a number of strategies, which ultimately aim to promote independence in the young person. Initially it is helpful for the therapist to identify the type of situations in which the parent is being intrusive or overprotective; and these situations may well be linked to areas in which the parent experiences anxiety (Creswell et al. 2012). For example, Figure 19.2 demonstrates the maintenance cycle that was developed for Case 19.1a, which then informed treatment interventions.

Consideration of what is appropriate for the young person’s developmental level is also important. Supporting the parent in allowing the child to be more independent might involve providing the parent with alternative ways to support the young person, such as promoting the young person’s use of particular CBT strategies, for instance problem solving or Socratic questioning. It may also involve contingency management, whereby the parent actively rewards the young person for independent activity. The reduction of parental provisions of reassurance is often a key part of promoting autonomy; instead, the therapist should enable parents to encourage their child to challenge their anxious thoughts and should give the young person clear positive messages about his/her ability to cope on his/her own. Some parents may find reducing their overprotectiveness extremely challenging. In our experience, empowering parents to feel confident about using alternative responses is often effective. However, at times parental emotions and expectations will need to be managed in the first instance, in order to allow them to change their behavioral responses to their child. Case 19.1c illustrates a therapist making use of parental intrusiveness and overprotection management in combination with other specific CBT techniques.