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

Published on 19 August 2015

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.

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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

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

Treatment of childhood anxiety disorder in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis

Published on 26 May 2015

Creswell, C.,Cruddace, S.,Gerry, S.,Gitau, R.,McIntosh, E.,Mollison, J.,Murray, L.,Shafran, R.,Stein, A.,Violato, M.,Voysey, M.,Willetts, L.,Williams, N.,Yu, L. M.,Cooper, P. J.

Health Technol Assess Volume 19 , 2015

BACKGROUND: Cognitive-behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder. OBJECTIVES: This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated. DESIGN: Participants were randomised to receive (i) child cognitive-behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT + maternal cognitive-behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother-child interactions (MCIs) (CCBT + MCI). SETTING: A NHS university clinic in Berkshire, UK. PARTICIPANTS: Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder. INTERVENTIONS: All families received eight sessions of individual CCBT. Mothers in the CCBT + MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact. MAIN OUTCOME MEASURES: Primary clinical outcomes were the child's primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost-utility analysis framework with associated uncertainty. RESULTS: MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBT + MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBT + MCBT nor CCBT + MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, p = 0.29; adjusted RR CCBT + MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, p = 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, p = 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, p = 0.13). CCBT + MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBT + MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%. CONCLUSIONS: Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group. TRIAL REGISTRATION: Current Controlled Trials ISRCTN19762288. FUNDING: 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) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

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.

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