1

British Journal of Clinical Psychology (2018)

© 2018 The British Psychological Society
www.wileyonlinelibrary.com

Preventing family transmission of anxiety:

Feasibility RCT of a brief intervention for parents
Sam Cartwright-Hatton1* , Donna Ewing1, Suzanne Dash1,
Zoe Hughes1, Ellen J. Thompson1, Cassie M. Hazell1, Andy P. Field1
and Helen Startup2
1
School of Psychology, University of Sussex, Brighton, UK
2
Research and Development, Sussex Education Centre, Mill View Hospital, Hove, UK

Objectives. Children of anxious parents are at high risk of anxiety disorders

themselves. The evidence suggests that this is due to environmental rather than genetic
factors. However, we currently do little to reduce this risk of transmission. There is
evidence that supporting parenting in those with mental health difficulties can ameliorate
this risk. Therefore, the objective of this study was to test the feasibility of a new one-
session, group-based, preventive parenting intervention for parents with anxiety
disorders.
Design. Feasibility Randomized Controlled Trial.
Methods. A total of 100 parents with anxiety disorders, recruited from adult mental
health services in England (and child aged 3–9 years), were randomized to receive the
new intervention (a 1-day, group workshop), or to treatment as usual. Children’s anxiety
disorder and anxiety symptoms were assessed to 12 months by outcome assessors who
were blind to group allocation. Exploratory analyses were conducted on an intention to
treat basis, as far as possible.
Results. A total of 51 participants were randomized to the intervention condition and
49 to the control condition (82% and 80% followed to 12 months, respectively). The
attendance rate was 59%, and the intervention was highly acceptable to parents who
received it. The RCT was feasible, and 12-month follow-up attrition rates were low.
Children whose parents were in the control condition were 16.5% more likely to have an
anxiety disorder at follow-up than those in the intervention group. No adverse events
were reported.
Conclusions. An inexpensive, light-touch, psycho-educational intervention may be
useful in breaking the intergenerational cycle of transmission of anxiety disorders. A
substantive trial is warranted.

Practitioner points
 Anxiety disorders run in families, but we currently do little to help anxious parents to raise confident
children. A brief group workshop was highly acceptable to such parents and was very inexpensive to
run.

*Correspondence should be addressed to Sam Cartwright-Hatton, School of Psychology, University of Sussex, Pevensey 1, Brighton
BN1 9QH, UK (email: S.cartwright-hatton@sussex.ac.uk).

DOI:10.1111/bjc.12177
2 Sam Cartwright-Hatton et al.

 Children of parents who took part in the brief intervention were 16.5% less likely to have an anxiety
disorder, 1 year later, than children whose parents were in the control group.
 This was a feasibility study, and while it showed that both the intervention and the research were
feasible, the study needs replicating with a much larger sample.
 Many parents faced barriers to attending the workshop, and future efforts should focus on widening
accessibility.
 We were unable to obtain sufficient self-report data from children, so the outcomes are based on
parent report only.

We know that mental health problems run in families, but we do almost nothing to
prevent this from happening. In this study, we describe a brief inexpensive intervention,
targeted at anxious parents, to help them to raise less anxious children.
Anxiety disorders are prevalent and may be the most common psychological disorder
of childhood (Cartwright-Hatton, McNicol, & Doubleday, 2006; Somers, Goldner,
Waraocj, & Hsu, 2006). With onset typically before adolescence (Kessler, Berglund,
Demler, Jin, & Walters, 2005), many of those living with anxiety will be young adults with
children of their own. Anxiety disorders also run in families: In one study, offspring of
clinically anxious parents were seven times more likely to meet diagnostic criteria than
controls (Turner, Beidel, & Costello, 1987). In another, over one-third of children with a
clinically anxious parent had an anxiety disorder. This rose to two-thirds where both
parents were clinically anxious, compared to around one-fifth where no parent was
anxious (Merikangas, Avenevoli, Dierker, & Grillon, 1999).
Moreover, much of this intergenerational transmission of anxiety disorders is
attributable to environmental rather than genetic processes. In a recent ‘Children of
Twins’ study, exploring genetic and environmental factors in the intergenerational
transmission of adolescent anxiety, Eley and colleagues concluded that: ‘For both
anxiety and neuroticism, the models provide support for significant direct
environmental transmission from parents to their adolescent offspring. In contrast,
there was no evidence of significant genetic transmission’ (Eley et al., 2015). The
degree to which environmental processes seem to be responsible for intergenera-
tional transmission of anxiety presents us with an opportunity for prevention work
with anxious parents.
Anxiety disorders in childhood present a number of risks: a large proportion of sufferers
have anxiety difficulties into adulthood (Last, Hansen, & Franco, 1997) and experience
problems with education (Wood, 2006), relationships (Pine, 1997), and reduced quality of
life (Mendlowicz & Stein, 2000). Children with anxiety disorders are at risk of developing
other diagnoses, particularly mood disorders (Kashani, Orvaschel, Rosenberg, & Reid, 1989),
and substance misuse (Kushner, Sher, & Beitman, 1990). Societally, childhood anxiety
disorders are costly: A Dutch Study found societal costs for anxious children that were 21
times higher than for typical children (Bodden, Dirksen, & B€ogels, 2008). Moreover, there is
evidence that childhood anxiety disorders are increasing (Twenge, 2000).
Recent British policy documents (e.g., ‘Think Family’ and ‘Future in Mind’;
Department-for-Children-Schools-and-Families, 2008; Department of Health, 2015) urge
adult services to give attention to the needs of clients’ families. But despite the personal
and societal costs that are associated with the intergenerational transmission of anxiety,
we currently do very little. There are a number of reasons for this inaction, including
commissioning arrangements that silo adult and child mental health services, leading to
neither being in the position to offer intergenerational support. However, a key factor is
that the evidence base for suitable interventions is very small: There are currently no
 Preventing family transmission of anxiety 3

interventions that are likely to be suitable for widespread use in the British health care
context.
This study set about developing such an intervention for anxious parents. A
number of approaches were considered: Adult services might prioritize treatment
of anxiety for adults who have children: However, treatment is not always available
or wanted, and there is no guarantee of success; we also have no evidence that
this would improve outcomes for children. Another might be to target the ‘at-risk’
children themselves: However, given the pragmatic and ethical difficulties in
delivering clinical interventions to non-referred (often asymptomatic) children, we
chose to devise an intervention that did not directly involve children. Therefore, a
preventive/early intervention targeted at anxious parents, but which did not
depend on parents’ recovery, was favoured. Because the evidence suggests that
anxiety is transmitted in large part via environmental processes, an intervention
that targeted anxiogenic parenting processes seemed likely to have benefit. There
is now a small body of evidence suggesting that we can work very effectively on
these parenting processes, to reduce anxiety in children. For example, Cartwright-
Hatton and colleagues (Cartwright-Hatton, 2010; Cartwright-Hatton et al., 2011)
developed a purely parenting-based intervention (From Timid to Tiger) for young
children with anxiety disorders. After a 10-week (20-hr) course, children in the
active condition were significantly more likely to be anxiety-free than a control
group. Other studies have also reported substantial impacts on child anxiety, after
working with parents alone (Thirlwall et al., 2013; Waters, Ford, Wharton, &
Cobham, 2009).
According to a recent systematic review of the area (Lawrence, Rooke, & Creswell,
2017), just one existing intervention for preventing anxiety in the offspring of anxious
parents has been evaluated (Ginsburg, Drake, Tein, Teetsel, & Riddle, 2015). This US-
based, 11-session cognitive-behaviourally based programme demonstrated a medium-to-
large effect size (0.81 at 6 months, 0.57 at 12 months) in preventing anxiety in children of
anxious parents. However, we wanted the intervention to be short and inexpensive, to
maximize engagement from potential service-users, and from cost-conscious UK-based
service-providers. Therefore, a very brief, group-based intervention, delivered in 1 day
(5 hrs, including breaks), was devised.
There is evidence that good, general, parenting skills, focusing on behaviour
management, are effective in reducing internalizing symptoms in young children
(Cartwright-Hatton, McNally, White, & Verduyn, 2005) but that these skills are less
likely to be used by anxious parents (Laskey & Cartwright-Hatton, 2009; Robinson &
Cartwright-Hatton, 2008). Therefore, the first half of the session was focused on
general parenting techniques, such as child-centred play, praise and reward, effective
limit setting, and consequences. The second half focused on parenting issues that
are particularly pertinent to parents who live with anxiety, in particular, overpro-
tection, perfectionism, transmission of fears/worries, and opportunities that may be
denied to the child of an anxious parent (e.g., varied social encounters). Parents
were helped to devise strategies for minimizing the impact of these factors. For
example, parents with fears and phobias were helped to identify an adult close to
the child who might spend time with the child, providing positive exposure
experiences to stimuli of which the parent was afraid. The second part concluded
with guidance on constructing fear hierarchies to manage mild to moderate fears,
and information on further sources of support.
4 Sam Cartwright-Hatton et al.

Aims
The study was intended as a feasibility study and was not powered to detect group
differences. We hypothesized that the group workshops would be acceptable to
participants and that sufficient recruitment and retention would be feasible. In addition,
we aimed to produce a preliminary estimate of the effectiveness of the intervention.

Method
Design
This was a Feasibility Randomized Controlled Trial. All parents were referred from Mental
Health Services or Primary Care Services. The trial took place at NHS/University sites
across England.
This study was approved by East London NHS Research Ethics Committee (11/LO/
0759). It is registered as ISRCTN57199411. The full protocol is available from the first
author.

Participants
See CONSORT Diagram (Figure 1).
We recruited 100 parents (15 male) aged 26–66 years (mean 37.1, SD = 6.92) and
their 100 children (59 male) aged 3–9 years (mean 5.5 years; SD = 1.99) from a range of
adult mental health services in England. Parents identified their ethnicity as: ‘White’
(British, Irish, Other) = 85%; ‘Black’ (British African, British Caribbean, Other) = 5%;
‘Asian’ (British Indian, British Pakistani, Other) = 4%; ‘Other’ = 4%; 2% no information.
Parents described their financial status as ‘comfortable’ (21%); ‘managing’ (50%);
‘struggling’ (25%); no information (4%). Parents described their educational qualifications
as ‘postgraduate’ (15%); ‘degree or equivalent’ (38%); ‘A’ Level or equivalent’ (passed
exams at 18 years – 23%); ‘GCSE or equivalent’ (passed examinations at previous
minimum school leaving age of 16 – 16%); ‘some secondary’ (5%); no information (3%).
The evidence strongly favoured the groups being equivalent on all measures (see
Data S1).

Inclusion and exclusion criteria

Both child and parent had no major developmental or intellectual disability; parent had
good English.
Parents had any anxiety disorder, as verified by a diagnostic interview (Anxiety
Disorders Interview Schedule – ADIS; Brown, DiNardo, & Barlow, 1994) with a trained
Clinical Research Coordinator.
The study was designed to have few exclusion criteria, because the intervention was
intended for pragmatic use in services, with as wide a range of clients as possible.
Therefore, referrers were asked to exclude only participants who, in their opinion, lacked
the capacity to consent to participation, or whose needs were inappropriate for a group-
based intervention (e.g., current active psychosis, severe depression; current manic state;
certain Axis II conditions). These criteria were intended to produce a pool of participants
that reflected those who might participate in the intervention if it were eventually rolled
out to adult mental health services.
Parents’ anxiety diagnoses are reported in Table 1.
 Preventing family transmission of anxiety 5

Figure 1. Consort diagram.

Randomization and masking

Participants were randomized to the new intervention, or to control group. Email
randomization (with concealed allocation) was conducted by an independent agency
who generated the sequence, and assigned to groups, but had no further involvement in
the trial. Participants were randomized (after consenting and completing baseline
assessments) in a ratio 1:1 using the method of minimization, balancing for child gender
(M/F), with an 80% probability. Subsequently, all assessments were conducted by
assessors who were blind to allocation. However, participants and workshop leader were
6 Sam Cartwright-Hatton et al.

Table 1. Parental anxiety diagnoses

Diagnosis Number of parents (%)

Agoraphobia 40 (40)
Panic disorder 49 (49)
Social anxiety disorder 55 (55)
Generalized anxiety disorder 74 (74)
Obsessive-compulsive disorder 26 (26)
Posttraumatic stress disorder 16 (16)
Specific phobia 35 (35)
Health anxiety 7 (7)

aware of allocation. One participant was randomized (in error) before any baseline
measures and eligibility checks were completed and none could subsequently be
obtained; therefore, this participant was excluded.

Procedure
Initially, participants were identified by their treating clinician. Subsequently, they were
offered an eligibility/consenting interview, where they were further assessed against
inclusion/exclusion criteria by a clinical research coordinator, the study was explained in
detail and written consent was taken. At this session, one index child was identified for
participation. Where parents had more than one child who met criteria, one child was
selected for participation using a remote, Internet-based random selector. Children aged
five and over, and who were present at this interview, were invited to complete outcome
measure themselves, and where they agreed, written consent was taken.
Subsequently, parents completed the adult ADIS and the self-report questionnaires
measuring child anxiety, as described above. Note that to run a highly efficient trial
(mindful of very large sample size likely to be needed in any substantive trial), we did not
complete the child ADIS at this baseline assessment. Participants were reimbursed £25
against expenses.
Three months after completion of the workshop (or 3 months after the next
workshop that would have been available to them, for those in the control group),
participants completed a 3-month follow-up assessment online. This was identical to the
pre-participation assessment except that the adult ADIS was not completed.
Twelve months after completion of the workshop (or 12 months after the next
workshop that would have been available to them, for those in the control group),
participants completed a 12-month follow-up assessment by telephone with a research
assistant (ADIS) and online (self-report measures). Parents completed the child ADIS and
self-report anxiety questionnaires (FSSC and SCAS) on behalf of their child, and children
aged five or over were invited to complete the FSSC and SCAS.
All participants were invited to provide 3- and 12-month follow-up data, regardless of
whether they had attended the intervention or not.

Interventions
One-day workshop
The workshops ran from approximately 9.30 am to 3.00 pm, with breaks.
 Preventing family transmission of anxiety 7

Table 2. Workshop programme

Introduction: Sharing names

Getting to know each other Ground rules
Format of the day Format of the day
All about anxiety: Fight/Flight response
A basic CBT understanding of what happens in anxiety, as a Avoidance
foundation for later discussions Thinking in anxiety (The Seven Confident
Thoughts)
How dangerous is the world?: Risk statistics
National statistics are shared to illustrate the very low risk  Child death rates
of serious harm that British children face  Violent crime rates
 Child cancer
 Child murder
 Child injury
General behaviour management: Parental attention
A brief overview of parenting skills, with a focus on Child-centred play
behaviour management skills, to be used to encourage Praise
good and confident behaviour Reward
Planned ignoring
Giving commands
Consequences
Parenting for anxious parents: Overprotection
Issues in parenting that are particularly pertinent to Perfectionism
parents living with anxiety Transmitting fears and worries
Missed experiences
Managing early signs of anxiety: Fear hierarchies
How to manage early signs of anxiety in children Where to go for further help

The intervention was intended to be non-blaming and non-stigmatizing, and to be

highly engaging. Much use was made of role-plays, humour and games, and it was highly
interactive throughout.
Children did not attend the session, which were delivered by a single clinical child
psychologist. Up to six parents attended each course. Table 2 provides an overview of the
material. Participants were given access to further telephone and email support for
1 month after the intervention, but only one participant made (very brief) use of this
resource. Participants were reimbursed £15 towards travel expenses for attendance (as
courses were often run at some distance from where they would normally attend for their
care).

Control condition
Parents in the control condition did not receive any intervention as part of this
study. However, they continued with the treatment that they were receiving for
their own anxiety. For ethical reasons, they were sent a booklet of information
about child anxiety. This booklet contained brief information on the causes and
symptoms of childhood anxiety, and the treatment options (medical and psycho-
logical) that are available. Overlap with content from the intervention arm was
avoided.
8 Sam Cartwright-Hatton et al.

Measures
As this was a feasibility trial, a range of measures were employed, with none being
identified a priori as primary or secondary. To maximize efficiency, after face-to-face
baseline assessments, all outcome measures were collected via the Internet (self-report
instruments – NB one participant completed by post), or telephone (ADIS).

Eligibility Measure
Parental anxiety diagnoses – The ADIS (Brown et al., 1994). This was completed by a
trained Clinical Research Coordinator, with parents, to confirm their anxiety diagnosis.
The following sections were used: panic disorder, agoraphobia, social phobia, generalized
anxiety disorder, obsessive-compulsive disorder, specific phobia, posttraumatic stress
disorder, health anxiety. Interviews were audio-recorded and a random 20% re-rated by
blind research assistants, yielding 95% reliability; therefore, initial ratings were retained.

Outcome Measures
Children’s Anxiety Diagnoses (ADIS-PV; Silverman & Albano, 1996). Parents were
interviewed using the Anxiety Disorders Interview Schedule for Children and Parents–IV
(parent version). This assesses for DSM-IV childhood anxiety diagnoses and screens for
other common diagnoses. It is designed for use by trained research assistants and is highly
reliable and valid. Interviews were conducted by research assistants (trained by a clinical
child psychologist) and blind to group allocation. Diagnoses were assigned only if
significant interference was reported. Interviews were audio-recorded, and an indepen-
dent researcher re-rated a random 20%, yielding good reliability on the presence of anxiety
disorder (95%); therefore, the first raters’ diagnoses were retained.
Parent report questionnaires: Parents completed the Fear Survey Schedule for
Children-II, plus either the Spence Children’s Anxiety Scale (children aged five and over)
or the Spence Pre-school Anxiety Scale (children aged below 5 years).
Spence Children’s Anxiety Scale – Parent Report (SCAS-P; Spence, 1998). The SCAS-P
is a parent-reported assessment of child anxiety, which includes symptoms of panic and
agoraphobia, separation anxiety, physical injury fears, social phobia, obsessive-
compulsive disorder, and generalized anxiety disorder. The SCAS-P has 38 items, rated
on a 4-point scale with scores of 0–3 representing ‘never’, ‘sometimes’, ‘often’, and
‘always’, respectively. This scale has good properties of internal consistency and validity
(Nauta et al., 2004).
Spence Pre-school Anxiety Scale – Parent Report (SCAS-Pre; Spence, Rapee,
McDonald, & Ingram, 2001). This is an adaptation of the SCAS for pre-school children.
The 28-item measure has five subscales (generalized anxiety, social anxiety, obsessive-
compulsive disorder, physical injury fears and separation anxiety), rated on a 5-point
scale, scored 0–4 (‘Not at all’, ‘Seldom true’, ‘Sometimes true’, ‘Quite often true’, ‘Very
often true’). The scale has good properties of reliability and validity (Edwards, Rapee,
Kennedy, & Spence, 2010).
Fear Survey Schedule for Children – II-Parent Version (FSSC-II-PV; Bouldin & Pratt,
1998). The FSSC-II-PV is a parent-rated measure of children’s fears across 94 items (eight
factors) on a 4-point scale (‘not scared’, ‘scared’, ‘very scared’, ‘not applicable’). Two
items were adapted to meet the needs of a British sample (i.e., ‘dingoes’ altered to ‘dogs’;
‘bees’ altered to ‘bees and wasps’). The scale has good properties of reliability and validity
(Bouldin & Pratt, 1998).
 Preventing family transmission of anxiety 9

Workshop satisfaction. At the end of the workshop, participants who attended

completed a five-item satisfaction questionnaire. Four of these were rated on a 5-point
scale (‘Not at all’ to ‘Very’): (1) ‘How much have you enjoyed coming to the workshop?’; (2)
‘How easy was it to understand what was talked about in the workshop?’; (3) ‘How much do
you think coming today will help you to prevent your child developing anxiety?’; (4) ‘To
what extent were you already familiar with the information in the workshop?’ and one item
with a yes/no response format: ‘Would you recommend the workshop to an anxious friend
with children?’. Note that participants who failed to attend and who, instead, received
workshop materials by post, did not complete the satisfaction questionnaire.
Child report: Spence Children’s Anxiety Scale (Spence, 1998). This instrument
(administered only to children aged five and over) measures general self-report child
anxiety symptoms. It comprises 44 items (six fillers) measuring symptoms of panic/
agoraphobia, separation anxiety disorder, generalized anxiety disorder, social phobia,
obsessive-compulsive disorder, and physical injury fears, rated on a 4-point scale (‘never’
to ‘always’). Good properties of reliability and validity have been reported (Spence, 1998).
The Fear Survey Schedule for Children – Revised (FSSC-R; Ollendick, 1983). This
instrument (administered only to children aged five and over) measures children’s self-
reported fears across 80 items, on a 3-point response scale (‘none’, ‘some’, ‘a lot’). Good
properties of reliability and validity have been reported (Ollendick, 1983).

Statistical analyses
In line with accepted practice for feasibility studies, no power analysis was conducted and
all analyses were exploratory only.

Results
Recruitment took place over 13 months and stopped once the target number of
participants was reached.
At baseline, some questionnaires had missing values for some items. Where the
number of missing items was <10% on a given measure, missing values were imputed
using the mice package in R (van Buuren & Groothuis-Oudshoorn, 2011) before scale
totals were calculated.
At both follow-up points (3 and 12 months), as all measures were administered online,
outcome measures were always either completed in full or not completed at all. Where
scale totals were missing at 3- and 12-month follow-up, the last available score was carried
forward, in line with an intention to treat approach.
Some parents completed the SCAS and others the SCAS pre-school, which have a
different number of items (38 and 28, respectively). Because T-scores are not available for
the SCAS pre-school, scores on each scale were converted to z-scores to make them
comparable.
Baseline characteristics of the two conditions are reported in Table 3.

Acceptability of the intervention

Attendance
Of those randomized to receive the intervention, 59% attended a workshop. The
remainder (except two participants who dropped out early) were sent comprehensive
10 Sam Cartwright-Hatton et al.

Table 3. Baseline and demographic information by condition

Intervention Control Bayes

group group Classical test factor (%)

Child age Years (SD) 5.53 (2.03) 5.45 (1.96) tYuen (53.84) = 0.30, p = .76 0.21  0.03
Parent Female 41 44 v2 (1) = 1.07, p = .30 0.76  0
gender Male 10 5
Child gender Female 22 19 v2 (1) = 0.06, p = .81 0.27  0
Male 29 30
Financial Comfortable 10 11 v2 (2) = 0.49, p = .78 0.11  0
status Managing 24 26
Struggling 14 11
Child ‘White’ 42 34 v2 (1) = 1.65, p = .20 0.87  0
ethnicity ‘Other’ 9 15
Parent ‘White’ 45 40 v2 (1) = 0.42, p = .52 0.50  0
ethnicity ‘Other’ 6 9
Parent Educated to 10 11 v2 (1) = 0.01, p = .92 0.31  0
education minimum
school
leaving age
(MSLA)
Educated 41 38
beyond
MSLA

Notes. T-test is a robust variant proposed by Yuen and implemented using the functions by Wilcox (2012);
Bayes factors computed with the BayesFactor package in R (Morey & Rouder, 2014) using the default
priors. A Bayes Factor = 1 represents equal evidence for the null and alternative hypotheses; values
below 1 (as in this table) suggest more evidence for the null than for the alternative hypothesis.

Table 4. Parents’ responses to satisfaction questionnaire

Mean (SD)
Question Range

How much have you enjoyed the workshop? 3.65 (0.61)

2–4
How easy was it to understand what we talked 3.82 (0.43)
about in this workshop? 2–4
How much do you think that coming today will 3.1 (0.89)
help you to prevent your child developing anxiety? 1–4

Note. The scale ran from 0 (‘not at all’) to 4 (‘very much’).

workshop materials. This low uptake rate was largely driven by sites where just one or two
workshops were offered, limiting accessibility of the intervention. In the local area, where
there was more choice of workshop dates, attendance was 69%.
The end-of-workshop questionnaire showed excellent acceptability and satisfaction.
See Table 4.
All but one parent agreed that they would recommend the workshop to another
anxious parent (this was a missing response).
 Preventing family transmission of anxiety 11

Feasibility
Parent data. An encouraging 85% of parents participated in at least one post-
intervention outcome assessment.
However, at 3-month follow-up, only 57% of parents participated. Although this was a
relatively low response rate, this is not unusual for Internet-based outcome data collection
(Mathieu, McGeechan, Barratt, & Herbert, 2013).
With some adjustments to the process, participation increased to 81% at 12 months –
in particular, we encouraged parents to complete their outcome measures even if they
could not persuade their child to do theirs.
There did not appear to be any substantial differential attrition by condition (18% in
intervention condition, 20% in control, at 12 months).

Child-report data. Receipt of data from children was very low at both baseline and at
follow-ups. This was not unexpected and was driven by three key factors: (1) children not
attending intake session with parents or refusing to participate (13%); (2) children aged
below five were not asked to provide self-reports (38%); and (3) our dependence on
parents for children’s engagement at follow-up – in many cases, parents provided data
using our Internet form, but their children did not. At both 3- and 12-month follow-up,
only 20% of children (32% of those eligible) returned data.
It appears that adequate data collection from children in this context is not feasible.

Cost. An estimate of the cost of this intervention (using Unit Costs of Health and Social
Care, 2015; Curtis & Burns, 2015) and assuming five consecutive sessions of an IAPT
professional’s time comes to £525 per workshop. The workshop was run with up to six
participants (and could be run with around 10), giving a cost per parent of under £90, and
considerably less per child, if we assume that many parents will have more than one child.

Outcomes
Scores for outcome variables by the condition are reproduced in Table 5.
NB:
(1). Parents completed either the SCAS or the SCAS pre-school (according to child’s
age), which have different items. Therefore, scores were converted to z-scores to
make them comparable (assuming configural measurement invariance).

Table 5. Outcomes by condition

Baseline (SE) 3 Months (SE) 12 Months (SE)

Spence Child Anxiety Scale – Parent Report (z-scores) (lower score = fewer symptoms)
Intervention 0.0751 (0.141) 0.254 (0.112) 0.241 (0.120)
Control 0.0689 (0.152) 0.138 (0.160) 0.213 (0.166)
Fear Survey Schedule for Children – Parent Report
Intervention 138 (4.20) 132 (3.92) 130 (3.54)
Control 138 (3.84) 136 (4.25) 132 (4.19)
Proportion with anxiety diagnosis
Intervention 51.5%
Control 60.5%
12 Sam Cartwright-Hatton et al.

(2). Given the very low return rate from children, we do not report their self-report data.
(3). The study was not designed to test the efficacy of the intervention and, therefore,
not powered a priori for significance tests.
Table 5 shows that children’s symptom scores fell from baseline, and this reduction
appears to be greater for the intervention group. There were also 16.5% more diagnoses at
12 months in the control group than in the intervention group.
The study was not powered to test differences between groups using classical
statistical models; however, Bayesian models were fit to ascertain plausible values of the
effect of the intervention and are reported in Data S1.
There were no reports of adverse events.

Discussion
This study showed that an RCT of a brief group-based, parenting intervention aimed at
reducing risk of anxiety in children of parents with anxiety disorders was feasible. Early
signs of effectiveness were found.
For those who attended the workshop, satisfaction with the intervention was
excellent. The vast majority of participants enjoyed the intervention, found the material
easy to understand, and thought that it would help them prevent anxiety in their children.
All but one participant stated that they would recommend the workshop to an anxious
friend (the participant did not complete this item). However, attendance levels were
modest: Overall, 59% of those randomized to attend a workshop did so. This was higher in
the local area (69%), which had the greatest choice of workshop dates. For many external
trust participants, and those recruited at the end of the study, there was very limited
choice of workshop dates, and this impacted on uptake. However, it should be noted that
all non-attenders were sent comprehensive written materials (handouts from the
workshop) and these may have had a positive impact for those families. Reasons given
for non-attendance were almost exclusively pragmatic (lack of childcare, unable to take
time off work). However, it is possible that anxiety prevented attendance by many. This
attendance rate is not as high as we had hoped for (although typical for community-based
interventions), and in future, efforts should be made to address the barriers to access that
clearly face many parents. Potential solutions that we are considering for future iterations
of the workshop include as follows: running the workshop at a range of different days and
times of day; running a creche alongside the workshop; and developing an online version
of the intervention, to allow parents to access the material in their own time and without
having to be part of a group.
We wanted to find out whether we could keep loss to follow-up at an acceptable level
after an intervention that was light touch, and preventative (many parents had no
concerns about their children at baseline). Eighty-five per cent of parents participated in at
least one follow-up assessment. However, the return of outcome data at 3-month follow-
up was modest – 57% of parents completed measures. Although not unusual for studies
using online outcome data collection (Mathieu et al., 2013), we were disappointed with
this response rate. In response, changes were made to procedures at 12-month follow-up:
We made more strenuous efforts to contact participants and encouraged parents to
provide data themselves even if their children did not wish to do so themselves. These
changes boosted response rates at 12 months to 81%. We would recommend that any
future trial considers dropping the 3-month follow-up and concentrating efforts on the 12-
month assessment. Given the 12-month results, and a fast-evolving methodology for
 Preventing family transmission of anxiety 13

collecting data online (e.g., Bailey et al., 2013), we believe that excellent follow-up (of
parents) to 12 months is feasible. Critically, there was no evidence of differential attrition
by condition.
We wanted to test the feasibility of capturing not just parents’ ratings of children’s
anxiety, but children’s ratings too. However, this did not prove to be feasible. Children
under 5 years were excluded from these measurements for practical reasons (38% were
ineligible for this reason), which reduced the potential pool. Second, children were not
always present at baseline assessment (13%). As a result, baseline data were available for
little over half of all participants, a rate that fell to just 20% at each subsequent assessment.
Therefore, these data are not reported, and we recommend that future studies focus
efforts on collecting reports on children from parents only, as is usual in trials of parenting
interventions for this age group. Alternatively, studies could attempt to gather a full set of
much less detailed data (e.g., a single short anxiety questionnaire) from children.
This study was not powered to detect statistically significant differences between
groups. However, for all of the outcome measures, the results were in the predicted
direction. That is, children’s mean anxiety symptoms and anxiety diagnoses were lower at
12 months in the intervention group than in the control group. Notably, for children
whose parents were in the intervention group, 51.5% were found to have an anxiety
disorder at follow-up. This figure was 60% for those whose parents had been in the
intervention condition, representing 16.5% more diagnoses in the control group than in
the intervention group. However, it should be noted that sample sizes were small and
there is therefore imprecision in these estimates (see Data S1 for Bayesian estimates of the
plausible effect sizes of the intervention for each outcome measure).
This study is the first attempt to prevent anxiety in the children of parents with anxiety
disorders using a light-touch approach. This approach appears to be inexpensive, easy to
administer, and highly palatable to clients.
The study has a number of strengths, including good retention at 12 months, and no
differential attrition. However, it has a number of limitations. Most of these arose in an
effort to keep resource use to a manageable level, mindful that any substantive trial of this
intervention is likely to need a very large sample size. Therefore, we did not conduct a
children’s diagnostic interview at baseline, relying instead on questionnaire data to
determine that our groups were similar at intake. As expected, the groups were very
similar at baseline on these measures, and it is likely therefore that children will have
entered the study with similar levels of anxiety diagnoses. However, without baseline
diagnostic interviews, we cannot be absolutely sure of this. As a result of not measuring
diagnoses at baseline, it was also not possible to use a ‘last observation carried forward’
approach to managing missing diagnostic data (as was used for the questionnaire data),
and, therefore, the results presented for diagnoses cannot be ‘Intention to Treat’.
As discussed above, we experienced a high level of missing data at the 3-month time
point. However, this was resolved very successfully at 12 months and we now have
confidence that any subsequent substantive study could collect sufficient data for valid
analysis.
It should be noted that the intervention was delivered by a single clinical child
psychologist who specializes in anxiety of childhood. However, the material is relatively
simple to deliver and it is anticipated that it could be delivered by most mental health
professionals with a modest amount of training. A manual, to allow delivery by other
professionals, is in preparation.
Finally, we attempted to collect data from children, to reduce the dependence on
parents who may have reporting biases. In event, too little data were collected from
14 Sam Cartwright-Hatton et al.

children to analyse meaningfully. Similar difficulties have been reported in related studies
of young children (Cartwright-Hatton et al., 2011), and indeed, studies of parenting
interventions for this age group typically do not attempt to gather child self-reports. We do
not think that it is feasible, or cost-effective, to collect this in any future, larger study.
In conclusion, we have shown that it is feasible, with some modification, to run and to
evaluate a brief, parenting-based, preventative intervention for parents with anxiety
disorders. The intervention was appealing to parents and appears to have some impact on
children’s anxiety symptoms and diagnoses. A much larger, longer-term study is now
required, to thoroughly evaluate the effectiveness and cost-effectiveness of this
intervention.

Acknowledgements
This report is independent research arising from an NIHR Career Development Award
supported by the National Institute for Health Research. The views expressed in this
publication are those of the authors and not necessarily those of the NHS, the National Institute
for Health Research or the Department of Health. This study was supported by the United
Kingdom Clinical Research Collaboration-registered King’s Clinical Trials Unit at King’s
Health Partners, which is part-funded by the NIHR Biomedical Research Centre for Mental
Health at South London and Maudsley NHS Foundation Trust and King’s College London and
the NIHR Evaluation, Trials and Studies Coordinating Centre.

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Received 30 October 2017; revised version received 19 January 2018

Supporting Information
The following supporting information may be found in the online edition of the article:
Data S1. Statistical models.