Evidence
Alert

Treatment of mother-child interaction might be of value for childhood anxiety disorder

Child cognitive behavioural therapy helps children with anxiety disorders. But children of mothers with anxiety disorder are less likely to improve.

This trial (MaCH) found that treating maternal anxiety disorder at the same time as the child’s provided no additional treatment benefit. The treatments tested were maternal cognitive behavioural therapy or a new treatment focused on mother-child interactions. All groups improved up to a year, but none significantly more than others.

Surprisingly, given the lack of a treatment benefit for the main outcome, economic analysis suggested that adding mother-child interaction treatment was more cost-effective (at NHS thresholds) than child cognitive behavioural therapy alone up to a year. This might indicate that adding this focus on interactions improves quality of life and is good value for money for commissioners. The analysis was done using standard child quality of life scores from a health system perspective.

The researchers advised caution in this interpretation due to high drop-out rates from the study. The economic evaluation relies on some modelling of data collected during the trial.  Unlike the mother-child interactions treatment, child and mother cognitive behavioural therapy was unlikely to be more cost-effective than child cognitive behavioural therapy alone.

Why was this study needed?

Anxiety disorders are the most common psychological disorders in children. They affect about 2.6% to 5.2% of children in the UK. Anxiety disorders have a negative impact on children’s lives, school performance, and raise the risk of mental health problems when older. Cognitive behavioural therapy (CBT) has been shown to work in adults and children. But previous research shows about 40% of children are still not free of their anxiety diagnosis after CBT. Children with anxiety disorders whose mothers also suffered from anxiety are particularly at risk of poorer treatment responses. One possible reason is that maternal anxiety, or parenting practices like overprotection, could reinforce or maintain the child disorder.

This trial, called MaCH, was managed by the NIHR and jointly funded by the Medical Research Council and Berkshire Healthcare Foundation Trust. It aimed to establish whether supplementing child CBT with interventions targeting maternal anxiety or mother-child interactions would lead to better treatment outcomes for the child.

What did this study do?

MaCH was a randomised controlled trial (RCT) testing the impact of supplementing individual child CBT with either CBT for maternal anxiety, or a new treatment focusing on mother-child interactions. The new treatment included a combination of strategies from existing family interventions for childhood anxiety and video-feedback techniques developed by the trial investigators.

MaCH included 211 children and their mothers, both diagnosed with anxiety disorder. All children received individual CBT over eight weekly sessions. Mothers received eight weekly sessions of CBT or 10 sessions on mother-child interactions (two with the child, and eight on their own). Additional therapist sessions of non-directive counselling were provided to each group to ensure the same amount of therapist contact time. A limitation of this trial is the high drop-out rate, with 84% completing the post-treatment assessment, 72% assessed at six months, and 65% at 12 months.

What did it find?

  • There was no significant difference in the proportion of children free of their primary anxiety diagnosis across the three treatment groups after eight weeks treatment (48% for child CBT, 58% for child and mother CBT, and 60% for child CBT and mother-child interactions).
  • The proportion of children “much” or “very much” improved after eight weeks treatment was also not significantly different across the groups (64% child CBT, 80% child and mother CBT, and 76% child CBT and mother-child interactions).
  • Neither maternal treatment group differed significantly from the child CBT only group for these outcomes at six and 12 month follow-up.
  • Child CBT plus mother-child interaction treatment was more cost effective compared with child CBT alone. Mother and child CBT was not.

What does current guidance say on this issue?

The 2013 NICE guideline on recognition, assessment and treatment of social anxiety disorder recommends individual or group CBT for children and young people delivered in 8 to 12 sessions. The guideline says that involving parents or carers to ensure the effective delivery of the intervention, particularly in young children, should be considered.

What are the implications?

Supplementing child only CBT with maternal anxiety treatments did not significantly improve child anxiety outcomes. But supplementing child CBT with a treatment focused on mother-child interactions did appear more cost-effective than child CBT alone.

Supplementing child CBT with maternal CBT is unlikely to be cost-effective.

These results should be interpreted with caution due to the high drop-out rates at six and 12 months.

Services offering treatment to children with anxiety disorders usually assess parental anxiety disorder status and if present could consider offering the additional mother-child interactions intervention

Citation

Creswell C, Cruddace S, Gerry S, et al. Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis. Health Technol Assess. 2015;19(38):1-184.

This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership (09/800/17).

Bibliography

James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for
anxiety disorders in children and adolescents.
Cochrane Database of Systematic
Reviews 2015, Issue 2. Art. No.: CD004690.

Kendall PC. Treating anxiety disorders in children: results of a randomized clinical
trial
. J Consult Clin Psychol 1994;62:100–10.

National Collaborating Centre for Mental Health. Obsessive compulsive disorder: core interventions in the
treatment of obsessive compulsive disorder and body dysmorphic disorder
. [CG
31] London: National Institute for Health and Care Excellence, British
Psychological Society and Royal College of Psychiatrists; 2005

NICE. Social anxiety disorder: recognition, assessment and
treatment
. [CG 159]
London: National Institute for Health and Care Excellence; 2013

Royal College of Psychiatrists.
Cognitive Behavioural Therapy. London:  Royal College of Psychiatrists; 2013

YoungMinds. Mental health statistics. London: YoungMinds; 2015

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Definitions

Cognitive Behavioural Therapy (CBT), a talking therapy, is a
collaborative psychological treatment that can be delivered in various formats
– individual, group, parents or family. In this trial CBT was delivered by
qualified clinical psychologists or cognitive–behaviour therapists, following a
manual adapted from the widely used ‘Cool Kids’ programme. The treatment
included psychoeducation, identification and modification of anxious thoughts,
and graded exposure to feared situations/stimuli. The adaptations involved
reducing the number of sessions to eight (from nine) as the content could be covered
more quickly on an individual basis, and altering exercises and practices so
that they worked well on an individual basis using strategies from the ‘Coping
Cat’ programme first used in 1994.

 

Commentaries

Author commentary

Anxiety disorders in children are common, persistent and associated with long-term impairment. Cognitive Behaviour Therapy (CBT) is effective, but less so where parents also have an anxiety disorder. The MaCH trial evaluated the benefits of supplementing child CBT with (i) additional CBT for the mother for her own anxiety disorder or (ii) an intervention focused on parenting responses (MCI). The supplementary treatments did not improve child anxiety outcomes significantly more than child CBT alone. However, CBT supplemented with the MCI intervention provided good value for money compared with CBT alone. Services offering treatment to children with anxiety disorders should assess parental anxiety disorder status and consider offering the adjunct MCI intervention.

Professors Cathy Creswell and Peter Cooper, School of Psychology & Clinical Language Sciences, University of Reading