Parental Psychopathology and Treatment Outcome for Anxious Youth

12 Pages·2015·0.23 MB·English

JournalofConsultingandClinicalPsychology ©2014AmericanPsychologicalAssociation
2015,Vol.83,No.1,213–224 0022-006X/15/$12.00 http://dx.doi.org/10.1037/a0037935
Parental Psychopathology and Treatment Outcome for Anxious Youth:
Roles of Family Functioning and Caregiver Strain
Jessica L. Schleider Golda S. Ginsburg and Courtney P. Keeton
HarvardUniversity TheJohnsHopkinsUniversitySchoolofMedicine
John R. Weisz Boris Birmaher
HarvardUniversity UniversityofPittsburghandUniversityofPittsburgh
MedicalCenter
y.
s.adl
herbro Phillip C. Kendall John Piacentini
publisnated TempleUniversity SemelInUstnitiuvteersfiotryNofeuCroalsicfioernnciae,aLnodsHAunmgaenlesBehavior,
dmi
salliedisse Joel Sherrill John T. Walkup
eofittobe NationalInstituteofMentalHealth,Bethesda,Maryland WeillCornellHMoesdpiictaall,CNoelwlegYeoarnkd,NNeewwYYoorrkk–Presbyterian
onot
n
ors
i
ationand Ocabrejegcitvievre:strRaeinseoanrcthreahtamseenxtarmesipnoendsethineaenfxfeioctussoyfouptahrse.nAtaltlhposuygchhtohpeastehvoalorigayb,lefsamhaivlyesfhuonwctnioinnidnigv,idaunadl
cier
os linkstoyouthtreatmentresponse,theoreticalmodelsfortheircombinedeffectsremainunexplored.This
su
s
Aal studytestedthehypothesisthatimprovementsinfamilyfunctioningandreductionsincaregiverstrain
aldu explainedtheeffectsofparentalpsychopathologyonyouthtreatmentoutcomeinananxietytreatment
ologicindivi etrviaall.uaMtoerth(IoEd):,Apamreunltt,ipanledmyoeduitahtiionnfotremchanntisquine4w8a8syuoseudthtso,ategsetdth7e(cid:2)p1r7opyoesaersd(m50o%delfeamcraolses;minedaenpeangdee(cid:3)nt
he
ycth 10.7) meeting Diagnostic and Statistical Manual of Mental Disorders criteria for social phobia,
Psof separationanxiety,and/orgeneralizedanxietydisorder.Youthswererandomizedtoreceive12weeksof
ne
as cognitive-behavioraltreatment(CopingCat),medication(sertraline),theircombination,orapillplacebo.
cu
erial Atpre-andposttreatment,parentscompletedself-reportmeasuresofglobalpsychopathologysymptoms,
mn
Aso familyfunctioning,andcaregiverstrain;parents,youths,andIEsratedyouths’anxietysymptomseverity.
eer Results:Changesinfamilyfunctioningandcaregiverstrainjointlyexplainedrelationsbetweenparental
hp
ythe psychopathologyandreductionsinyouthanxiety.Specifically,acrossIEandparentinformants,families
yrightedbolelyfort wcpaairrteehgnhitvaigelhrpessrytrpcahrienot,preawathhtmoicleohngtiynppaturreerdnnitcaptlreepddsyigccrteheaodtpegarrtcehaaortleeorggiyyvoesurhtsohtwraaenidnximreetodyruercetiimdounpcsrtoiaovnnedsm,.ieFnnuttruitnrhnef,ra,gmrheiilagytheferurynpocrtuietothrneiaanntgmxiaeenntydt
ps reductions,basedonyouths’reportsoftheirownanxiety.Conclusions:Findingssuggestthatimprove-
coed ments in family functioning and reductions in caregiver strain can influence treatment outcomes for
sd
entinten anxiousyouths,especiallyamongyouthswithmoredistressedparents.
mi
docucleis
hisarti
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ThisarticlewaspublishedOnlineFirstSeptember15,2014. This study was supported by National Institute of Mental Health (NIMH)
JessicaL.Schleider,DepartmentofPsychology,HarvardUniversity;Golda Grants MH64089, MH64107, MH64003, MH63747, MH064092, and
S.GinsburgandCourtneyP.Keeton,PsychiatryandBehavioralSciences,The MH64088. Views expressed within this article represent those of the
JohnsHopkinsUniversitySchoolofMedicine;JohnR.Weisz,Departmentof authors and are not intended to represent the position of NIMH, the
Psychology,HarvardUniversity;BorisBirmaher,DepartmentofPsychiatry, NationalInstitutesofHealth,ortheDepartmentofHealthandHuman
UniversityofPittsburgh,andWesternPsychiatricInstituteandClinic,Uni- Services.BorisBirmaherreceivesbookroyaltiesfromRandomHouse,
versity of Pittsburgh Medical Center; Phillip C. Kendall, Department of Inc.,UpToDate,andLippincottWilliams&Wilkins.PhillipC.Kendall
Psychology,TempleUniversity;JohnPiacentini,DivisionofChildandAdo- receivesroyaltiesforthesaleofbooksandanxietytreatmentmaterials.
lescent Psychiatry, Semel Institute for Neuroscience and Human Behavior, John Piacentini receives research support from Pfizer Pharmaceuti-
UniversityofCalifornia,LosAngeles;JoelSherrill,DivisionofServicesand cals.
InterventionResearch,NationalInstituteofMentalHealth,Bethesda,Mary- Correspondence concerning this article should be addressed to Jes-
land; John T. Walkup, Department of Psychiatry, Weill Cornell Medical sica L. Schleider, Department of Psychology, Harvard University, 33
College, and Division of Child and Adolescent Psychiatry, New York– Kirkland Street, Cambridge, MA 02138. E-mail: jschleider@fas
PresbyterianHospital,NewYork,NewYork. .harvard.edu
213
214 SCHLEIDERETAL.
Whatisthepublichealthsignificanceofthisarticle?
Improvements in family functioning and caregiver strain can facilitate treatment outcomes for
anxiousyouths,especiallyinfamilieswithmorepsychiatricallydistressedparents.
Keywords:mediation,parentalpsychopathology,youthanxietytreatment,familyfunctioning
Anxietydisordersarethemostprevalentpsychiatricconditions anxious parent, compared to youths without an anxious parent,
among youths (Costello, Egger, & Angold, 2005), predictingaca- showed less improvement following group cognitive-behavioral
demic,interpersonal,andemotionaldifficulties(Piacentini,Peris,Berg- therapy (CBT). Southam-Gerow et al. (2001) found that anxious
man, Chang, & Jaffer, 2007). Fortunately, cognitive-behavioral youthswithadepressedmotherrespondedlessfavorablytoindi-
y. and medication-based treatments can reduce anxiety symptoms vidual CBT, compared to youths without a depressed mother.
s.adl and associated impairment (Ginsburg, Kendall, et al., 2011; Sil- Similarly, lower parent self-reported symptoms of psychopathol-
herbro verman, Pina, & Viswesvaran, 2008); however, some youths re- ogy predicted elimination of youth primary anxiety diagnosis as
s
blied spond more favorably to these treatments than others (Kendall, wellasreducedsymptomseverityinanexposure-basedtreatment
punat 1994; Southam-Gerow, Kendall, & Weersing, 2001). Identifica- trial (Berman, Weems, Silverman, & Kurtines, 2000). Another
dmi
salliedisse ttiroeantmofenptreredsipctoonrsevsarainadblecsanofifnefrosrmsomreefinienmsigenhttsintotoexdtiaffnetretrnetaiat-l sfoturdcylifnoiucnadl tdheaptryeossuitohns,obfumtowthheorshwadhonhoatdrreecceeiivveeddttrreeaattmmeenntt
ofitobe ments for specific subpopulations. For instance, family variables themselves,showeddecreasesinanxietysymptoms1yearlater
et such as parental psychopathology and family dysfunction have (Pilowsky et al., 2008).
onnot emerged as predictors of poorer treatment response for anxious However, these effects have not been fully consistent. For
ors
ationandi yGoiuntshbsur(gB,aSrirqeutte,laFnodx,,M&asiFa-aWrrealrln,e2r,0&05H; eBdikrme,a2h0e0r4e;tLiable.,r2et00al3.;, ipnrsetdaincctea,npxairoeunstsy’osuetlhf-sr’eptroeratetmdepnstycohuotcloogmiceailnsythmrpeetominsdefpaeilneddentot
ociser 2008; Southam-Gerow et al., 2001). An additional strategy for samplesinvolvingcognitiveandbehavioraltreatments(Crawford
su
Asal improvingandstreamliningtreatmentsforsubpopulationsofyouth &Manassis,2001;Liberetal.,2008;Victor,Bernat,Bernstein,&
aldu involves identifying variables that influence the strength of asso- Layne,2007).Moreover,findingsbasedonCAMSdatafoundno
hologiceindivi cmiaetniot.nWbehtewneecnonptrroeltlrienagtmfeonrtthfaecsteorvsaarinadbleosutcwoemakeesnasttphoestdtrireeact-t rtreelaattimonenbteotwuteceonmseeslf-(rCepoomrptetdonpaertenatla.,lp2s0y1c4h)oopratrheomloigssyioannd(Gacinuste-
ch
yt association, the variables are called mediators; when controlling burg, Keeton, Drazdowski, & Riddle, 2011) for anxious youth.
Psof
ne forthesevariablesstrengthensthedirectassociation,thevariables Thus, evidence is mixed regarding effects of parental psychopa-
as
mericnalu aRrueckcaelrl,ePdresaucphperre,sTsoorrsm(aMlaa,c&KiPnentotyn,,2K01ru1l;l,W&eisLzo,cNkwg,oRodu,tt,2L00a0u;, thoRloeggyardolnestsreaotfmwenhtetohuetrcoamdeisrefcotreafnfxeicotuspeyrosiustths.across studies,
eAerso &Masland,2013).Identifyingmediatorsandsuppressors,hence- parental psychopathology may influence youth treatment out-
hp
ythe forth referred to as candidate explanatory variables, can offer comes through mediating pathways. That is, parents’ psychopa-
bt insight into mechanisms of change, or the nature of the relation thology may spur changes in other factors, such as family func-
yrightedolelyfor buesetwdeaemnualtpipreledimcteodriavtairoinabtleechannidquthee,wohuitcchomtees.tsTfhoerbporethsesnutpsptruedsy- trieosnpionngseo.rIcnadreeegdi,vethrestqrauiann,tiwtahtiivceh pinsytcuhronloagffyecltiteyroaututhretrseuagtmgeesntst
scopdeds saimononagntdhrmeeedfaiamtiiolinalevfafericatbs,letsotheaxtahmaivneebteheennliantkueredtooftrreealatmtioennst tihnadtepthenerdeennteeadndnodtepbeenadesnitgnviafirciaabnlteszefroor-oardethreroerleattiicoanllybestwouenedn
in
entnte responseforanxiousyouth.Onthebasisoftheliterature,reviewed mediation analysis (MacKinnon, 2000; Preacher & Hayes, 2008;
documcleisi baneldowre,dwuectihoynpsotihnescizaeredgtihvaetrimstrparionveamcreonstssitnrefaatmmielnytfucnocntdioitnioinngs Zwhhaeoth,eLrypnacrhe,n&talCphseync,h2o0p1a0th).oTlohguys,mitaryeminafilnusenimcepoyrotaunthttaonpxaierstye
hisarti (cognitive-behavioraltreatment,medication,theircombination,or treatmentresponsethroughmediatingfactorsand,ifso,whatthe
This a pill placebo) would explain the relation between parental psy- directionofthecomponenteffectsmaybe.
T chopathology and child treatment response. This question was
testedwithasampleofclinicallyreferredyouthsfromthelargest
Family Functioning and Youth Treatment Response
comparative treatment trial for pediatric anxiety disorders: the
Child/AdolescentAnxietyMultimodalTreatmentStudy,orCAMS
Family functioning is a complex, multidimensional construct,
(Comptonetal.,2014;Ginsburg,Kendall,etal.,2011;Piacentini
encompassing several conceptual domains. The study of family
etal.,2014;Walkupetal.,2008).
functioning in the context of youth psychiatric problems has
largely relied on a framework outlined by Steinhauer and col-
leagues, labeled the Process Model (Skinner, Steinhauer, & Sita-
Parental Psychopathology and Youth
renios, 2000; Steinhauer, 1987; Steinhauer, Santa-Barbara, &
Treatment Response
Skinner,1984;seeSkinneretal.,2000,forareview).TheProcess
Severalstudieshaveexploreddirectrelationsbetweenparental Modeldescribesaconceptualframeworkforempiricallyassessing
psychopathology and youth anxiety treatment response. Cobham, family functioning according to seven dimensions: task accom-
Dadds, and Spence (1998) found that anxious youths with an plishment(families’organizingtoachievetasks),roleperformance
PARENTALPSYCHOPATHOLOGYYOUTHANXIETYOUTCOMES 215
(families’allocationandenactmentofresponsibilities),communi- Parental Psychopathology, Caregiver Strain, and
cation (families’ ability to achieve mutual understanding), affec- Family Functioning
tive expression (content, intensity, and timing of feelings ex-
Research suggests that parents higher in psychopathology tend
pressed among families), involvement (degree and quality of
toexperiencemoreseverecaregiverstrainandfamilydysfunction.
family members’ interest in one another), control (family mem-
For instance, mothers with depression have reported increased
bers’influenceovereachother),andvaluesandnorms(e.g.,scope
strain related to parenting responsibilities (Jackson & Huang,
allowedforfamilymemberstodecideindividualbehaviors).The
2000;Sarason,Johnson,&Siegel,1978).Further,parentalhistory
BriefFamilyAssessmentMeasure–III(BFAM–III;Skinner,Stein-
ofmentalhealthproblemshasstronglypredictedparents’percep-
hauer,&Santa-Barbara,1995),whichisusedinthepresentstudy,
tionofburdenrelatedtotheirchild’spsychiatricsymptomatology
was derived from the full Family Assessment Measure and as-
(Angoldetal.,1998).Overa10-yearperiod,parentswithcurrent
sesses parents’ perceived strengths and weaknesses in general
or past depression (versus never-depressed parents) were more
familyfunctioning.Thetotalscorerepresentsanoverallindexof
likely to experience an array of familial stressors related to poor
family functioning according to the domains assessed by the
y. familyfunctioning:poormaritaladjustment,lowfamilycohesion,
s.adl ProcessModel. parental divorce, and affectionless control (i.e., low warmth and
herbro Inlinewithfindingsassociatedwithparentalpsychopathology, high protection from parents; Nomura, Wickramaratne, Warner,
s
blied links between family functioning and anxious youths’ treatment Mufson,&Weissman,2002).Researchamongfamiliesofanxious
dpuminat response have been inconsistent. In a trial of 61 youths with youthspecificallyhasfoundpositiveassociationsbetweenparental
salliedisse d(aisagmnoesaesduraendxibeytytdhiesoBrdFeArsM, g–rIeIIatetortablasseclionree)fapmreidlyicdteydsfusmncatliloenr sdeylsff-urenpcotirotend(aHnuxgiehteys,anHdeddtekper,es&sivKeesnydmalpl,to2m0s08a)n.dTgheenreerfaolrefa,mpailry-
eofittobe cMliannicaisasnis-,ra2te0d01sy).mIpntoamnortehdeurctsitoundsya,chroigsshetrreaptrmeterneatt(mCernawt ffoarmdil&y ecnotpseewxiptehrideinffciicnugltpesvyecnhtosp(aet.hgo.,loagcyhimlda’ysmbeenletaslshweeallltheqpuroipbpleemdst)o,
onnot cohesion (emotional bonding and connectedness among family causingmorestrainanddysfunctioninfamilyinteractions.
ors
ociationserandi mtCreAeamMtmbSeerndst)a(tpaVreifcdotiuocnrtededttgharale.t,af2tae0mr0ii7ml)y.prHfouovnwecmteiovenenritn,sgainn(oiy.teoh.ue,rtBhsFtauAndxMyie–btyIaIsIaecdtroootsansl Effects of Parental Psychopathology, Family
Assalu score)didnotpredictyouthanxietytreatmentresponse(Compton Functioning, and Caregiver Strain on Youth
ologicalindividu eatndal.a,2se0p0a4r)a.tFeutrrtihaelr(,Cinrabwoftohrdth&eCMAaMnaSssdiast,a2(0K0e1e)t,oonveetraalll.,f2a0m1i3ly) Despite data demoTnrsetarattminegnbtivRaerisapteonresleations among paren-
he functioning (in addition to youth anxiety) was found to improve tal psychopathology, family functioning, caregiver strain, and
ch
Psyoft withcognitive-behavioralandmedication-basedtreatmentmodal- treatment response for anxious youths, a theoretical model
ne ities. Overall, evidence suggests that strong family functioning outliningthemechanismsbywhichthesevariablesaffectyouth
as
cu
erial mayfacilitatetreatmentoutcome,butadditionalresearchisneeded outcomeshasyettobetested.Thecurrentstudytestedwhether
Amson to clarify the role of family functioning in the context of other the relation between lower parental psychopathology and im-
heper salientfactors. proved youth anxiety treatment response was explained by
ythe improvementsinfamilyfunctioningandreductionsincaregiver
bt
pyrightedsolelyfor CCaraergeivgeirvesrtraSintrraeifnersantodnYegoautitvheTthroeuagthmtseanntdRfeeeslpinognss(ee.g., spmtaroradailnell.eliWsebfefaesecemtdspoolnofyttehhdeespaerecmmaunilsdteiipdtlahetaetmpeexadrpeilanatntisoatnworittyehcvlheansrisiqapubseleysct.ohoTtpheasis-t
coed stigma,guilt)aswellasconsequences(e.g.,financialdifficulties, thology may be better equipped emotionally to participate in
isnd treatmentrequirements,maintainpositiveoreasilymodifyneg-
entnte householddisruption)parentsexperienceasaresultofcaringfor ative family interactions, and support their child’s efforts dur-
mi a youth with emotional difficulties (Montgomery, Gonyea, &
docucleis Hooyman, 1985; Platt, 1985). Decades of research suggest that itnragintrineagtmefefnict.acInydfeoerd,yionutahmbeethaa-avnioarlaylsipsroonblpermeds,icmtoartseronfaplaprseyn-t
hisarti caregivers of individuals experiencing mental illness experience chopathology emerged as the most consistent predictor of
Ts caregiverstrainduetotheirincreasedresponsibilities(Clausen&
hi poorer youth treatment response (Reyno & McGrath, 2006).
T Yarrow, 1955; Fisher, Benson, & Tessler, 1990; Grad & Sains-
Theauthorssuggestedthatthisfindinglikelyreflectedthehigh
bury, 1968; Kreisman & Joy, 1974; Norbeck, Chaftez, Skodol-
taskdemandsinvolvedinparenttraining.Specifically,success-
Wilson,&Weiss,1991).OnestudyusingtheBurdenAssessment
ful outcomes required a high level of motivation, consistent
Scale (BAS; Reinhard, Gubman, Horwitz, & Minsky, 1994), the
implementation of behavior modification techniques, and
self-reportmeasureusedintheCAMStrial,hasdemonstratedthat changes in family interactions, all of which were more chal-
caregiverstrainpredictedunfavorabletreatmentoutcomeforclin- lengingforparentswithhighlevelsofpsychopathology.Others
ically anxious youths, possibly by disrupting parents’ capacity to have also suggested that parents experiencing more psychopa-
engagepositivelywiththeiryouths(Crawford&Manassis,2001). thology may be less emotionally equipped to work toward
Studies using CAMS data corroborated this finding (Compton improved family functioning and may have more difficulty
et al., 2004). CAMS data also demonstrated that, like family modifying family interactions during treatment (Southam-
dysfunction, overall caregiver strain measured with the BAS im- Gerowetal.,2001).Incontrast,parentslowinpsychopathology
proved over the course of cognitive-behavioral and medication- maybeabletomakequicker,moresustainedcoursecorrections
basedyouthanxietytreatments(Keetonetal.,2013). in family interactions (e.g., reducing accommodation) that re-
216 SCHLEIDERETAL.
duce strain associated with their child’s disorder and comple- functioning and caregiver strain may reasonably influence
ment treatment response. youth functioning regardless of what kind of treatment youths
Although the above model has intuitive appeal, alternative receive, we did not expect the model to differ by treatment
models are theoretically plausible (see Table 1). Correlational condition. Finally, to reduce the risk that single-informant id-
studies have established relations between family functioning, iosyncrasies regarding youth anxiety might affect findings, we
parentalpsychopathology,andcaregiverstrain;however,these conducted analyses separately for youth, parent, and indepen-
factorslikelyhavereciprocalinfluences(Cummings,Keller,& dentevaluator(IE)reportsofyouthanxiety,testingwhetherthe
Davies,2005).Therefore,itremainspossiblethathigherquality
proposed model was robust across informants.
baselinefamilyfunctioningmightpredictgreaterimprovements
across treatment in parental psychopathology and caregiver
strain (Model 1, Table 1). Parents in less dysfunctional homes Method
might more readily experience reductions in psychopathology
and strain across treatment; in turn, these reductions might
y. boost youth anxiety improvements. Similarly, lower baseline Procedure
shers.broadl cpasryecghiovpeartshtorlaoingymiagnhdt enfaamblielygrefuantecrtiiomnpinrgoveamcreonstss itnrepaatrmenentatl, ParticipantswerepartoftheCAMStrial,conductedacrosssix
publinated thereby facilitating youth treatment response (Model 2, Table menerdoilcleadl 4an8d8yaocuadthesm(iacgeinss7ti(cid:2)tu1ti7o)nwshinomtheetUDniaitgendosStitcateasn.dCSAtaMtisS-
dmi 1). Alternatively, given reciprocal links between parent im-
salliedisse pprroovveemmeennttss,aicnrcolsusdiynoguptharternetatpmseynctho(Spailtvheorlmogayn,,aKnudrtyinoeust,hJiamc-- tPicsyaclhMiaatrnicuaAl sosfoMciaetniotanl,D2i0s0o0rd)ecrsrit(e4rtiha efdo.r, gteexnterraelvi.z;edAmanerxiiceatny
oroneofitsnottobe ctthiaoerndri,enl&gataiPonindn/abo,ert2cw0ae0ree9ng),ipvyaeorreusntthtraalainnpxs(yiMecthoyodrpeealdsthu3octlaionogdnys4am,nTdigafhbatlmeini1lfy)l.ufeTunnhccae-t dtwhieseroierrdp7ea(cid:2)rr,e1ns2tosyc.ieMaalrespaonhlodab;giea4,9w.a6an%sd1/oo0rf.6ts9heepyaperaaarrtstiioc(niSpDaann(cid:3)txsi2wet.e8yr0e)d,fiseaomnrddale7er4,.aa2nn%dd
ationandi ipsa,rednetcsr’eassterasininryeolauttehdatnoxitehtyeirsycmhipltdo’mssanmxaieytydiraencdtlyimrepdrouvcee 7to8.h9i%ghwseorceioCeacuocnaosmiainc.Mstaotsutsp(aSrtEicSi)p,anatssi(n7d4i.c5a%te)dwbeyreaofscmoridedolef
sociuser familyfunctioning.Todeterminethespecificityoftheproposed 40(cid:2)66 on the Hollingshead Four-Factor Index of Social Status
s
Aal model, we tested these alternative models as part of the analy- (Hollingshead,1971).
ologicalindividu sesF.or both proposed and alternative models, we examined a quOesntieonpnaariernetboaftteeraicehs.yOofutthhecsoemppalreetendts,pr8e7-.0a%ndwpeorsettrmeaottmheernst,
chhe sample of clinically referred youths with anxiety disorders 81.0% shared parenting responsibilities with another adult, and
yt
Psof enrolledinCAMS(Comptonetal.,2014;Ginsburg,Kendall,et 19%weresingleparents.Indual-parenthouseholds,the“nonpri-
anse al., 2011; Kendall et al., 2011; Piacentini et al., 2014; Walkup mary”caregiverswere91.14%biologicalparents,6.29%steppar-
cu
erial et al., 2008). CAMS enrolled 488 youths and compared the ents,and2.27%nonmarriedpartners.
Amson relativeefficacyofcognitive-behavioraltreatment(CopingCat Study procedures were approved by each site’s institutional
eer program), medication (sertraline), their combination (COMB),
hp review board. Before completing study procedures, participants
bytthe or a pill placebo (PBO) for pediatric anxiety disorders; all signed informed consent. Diagnostic eligibility was determined
yrightedolelyfor alsatcurtgidveieeststrureesdiauntmcgtieConAntssMionSuydtopauetarthfofosrymumneddpttohPmaBtsOloanwadenrddicaaCgrOnegoMisveBesr.lSsetedrcaoitnnod(abthruyet wPaitrhentthse; pAanrtxiiceitpyanDtsiscoordmeprsleItnedterqvuieewstioSncnhaeidreuslebfeofrorCehbiledirnegnraannd-
ps domlyassignedto12weeksofyouth-focusedtreatmentinoneof
isconded nboetttepraryeonutathl posuytcchoompeasth(oCloogmypotornfaemtialyl.,fu2n0c1t4io),nianngd) pthraetdibcotethd four conditions. At posttreatment, diagnostic evaluations were
entnte family functioning and caregiver strain significantly improved repeated by an IE, and youths and parents repeated the question-
documcleisi finrogmPpBrOe-t(oKpeoestottnreaettmaeln.,t,2a0c1ro3s)s. tTrehaistmsetnutdcyonbduiitlidosnso,nintchluesde- nparaircetsit.ioIEnesr,wPehreDMpsAy-clheovleolgpisstysc,haonldogcihsitlsd,psosycicahliawtroirsktse,rws,haonwuersree
hisarti findings, testing whether improvements in familial stressors selected based on experience and predetermined background cri-
This might jointly explain relations between parental psychopathol- teria.IEsweretrainedtoreliabilityandengagedinregularsuper-
T
ogy and youth treatment response across treatment modalities. vision,bothwithinandacrosssites(Kendalletal.,2010).Detailed
We also tested whether treatment condition moderated the demographic data and diagnostic characteristics are described in
strength of these effects. However, because changes in family Kendalletal.(2010)andWalkupetal.(2008).
Table1
SummaryofAlternativeModels
Model Independentvariable Explanatoryvariables Dependentvariable
1 Baselinefamilyfunctioning Changeinparentalpsychopathology;changeincaregiverstrain Posttreatmentyouthanxietyseverity
2 Baselinecaregiverstrain Changeinparentalpsychopathology;changeinfamilyfunctioning Posttreatmentyouthanxietyseverity
3 Baselineyouthanxietyseverity Changeinparentalpsychopathology;changeincaregiverstrain Posttreatmentfamilyfunctioning
4 Baselineyouthanxietyseverity Changeinparentalpsychopathology;changeinfamilyfunctioning Posttreatmentcaregiverstrain
PARENTALPSYCHOPATHOLOGYYOUTHANXIETYOUTCOMES 217
Measures measuremaybebestusedasageneraldistressindicator;conver-
gentvalidityfortheGSIasameasureofgeneralpsychopathology
Youth anxiety. Global severity of youth anxiety symptoms
hasbeendemonstratedthroughcorrelationswithclinicalscaleson
and impairment was rated by an IE at baseline and 12 weeks
the Minnesota Multiphasic Personality Inventory and total scores
posttreatment using the one-item Clinical Global Impressions–
ontheSymptomChecklist–90–Revised(Derogatis,1977),awell-
SeverityScale(CGI–S;Guy,1976).Scoresrangefrom1(notatall
validated measure of psychopathology in adults (Boulet & Boss,
ill) to 7 (extremely ill). The CGI–S is a widely used measure of
1991; Derogatis, 1993). Thus, in this study, the GSI was used to
outcomes, especially in psychopharmacological pediatric clinical
assessgeneraldistressassociatedwithsymptomsofpsychopathol-
trials. The CGI–S is strongly related to self-report and clinician-
ogy. Derogatis and Melisaratos (1983) have reported both test–
administered measures of youth symptomatology and functional
retest(across2weeks)andinternalconsistencyreliabilitiesofthe
impairment (Zaider, Heimberg, Fresco, Schneier, & Liebowitz,
GSI, which ranged .68 to .91 and .71 to .90, respectively. In this
2003).
study,alphawas.95atpre-andposttreatmentassessments.
We also used the Pediatric Anxiety Rating Scale (PARS; The
Familyfunctioning. TheBFAM–III(Skinneretal.,1995)is
hers.broadly. RGIEer-osreuaatper,cd2h50U00-2ni)ittetsmooanasnsPxeeisdestiycyaostuyritmchpPtrtsoeyamctmhcoehpnehtcakrrelmisspatocaonnlsdoeg.iynTchAleundPxeAiseRtsyiSxSitasundaxny- afam14i-lyitefmunpcatiroennitnrgepdourrtinqguetshteiopnrneavirioeuasss2eswsienegksp.erTcheipstiionnsstruo-f
blised iety severity/impairment items specifically addressing the com- ment was created to provide an operational definition and
dpuminat binedsymptomsofanxietyacrossdisorders(e.g.,separationanx- mofeaFnasmoilfymFeuanscutriionnginthge; istevinecnlucdoenssttrwucotsitienmtsherePlraoticnegsstoMeoadcehl
ofitsallieobedisse isPeaAtmyReSdIiEshoaarsddmeerxi,nceigsletleenrneetrdailntihzteeerdrCaGatenIrx–riSeetlayinabddiitlshitoeyrdP(eA(cid:4)r,R.9Ss7o)tc,oiaaeslacwphheoyllboiuaast)h.s.aTTtihhsee- cttoaoknleisssttrteuoncott(looSnkegainctnhoeorwteohtreakrl”.t,ha2en0md00“o)Wu.tI”hteeamnresthssicunocgrhsedaasroe“nnW’ate5gt-aopkioneignthtwesectilamlleiet.
et factoryconvergentanddivergentvalidity:PARStotalscoreshave
onot Items are summed to create a total score that is converted into
n shownpositivecorrelationswithothermeasuresofyouthanxiety
ors aTscore.Individualswithapsychologicallyillfamilymember
ociationserandi ([miS.eeCa.,AsutRhreEesDS(]Cc;rheBielindrmrefaonhr’seCrDheeitlpdarle.A,ssn1ix9oi9ne7tIy)nbvRueentltnaotoreytd;wGEitmihnosybtoiuourntgha,ldKDeepiesrteoosrnsd,ieoernst hpasyvcehsohloogwicnalhlyighilelrfaBmFiAlyMmesmcobreers,dtheamnoinnsdtriavtiidnugaldsiswcriitmhoinuatnat
Assalu al.,2011;Kovacs,1978).PARSscoreshaveshownsensitivityto validity(Jacob,1995).Further,stronglinksbetweenMinnesota
aldu treatment, paralleling change in other measures of youth anxiety MultiphasicPersonalityInventoryspecialfamilyscalesandthe
hologiceindivi csyatmripctoPmsyscahnodphgalormbaalciomlopgroyveAmnexniett(yThSetuRdeyseGarrcohupU,n2it0s0o2n).PTedhie- BHFarAriMs, s1u9p8p4o).rtHthigehBerFABMFA’sMcosncostrreusctrevfalelicdtitgyre(aBtleoropmeqrcueisivte&d
Psycofth PARS was used as the primary outcome measure in the main faanmdi.l8y7daytsfpuonsctttiroena.tmInentht.isstudy,alphawas.80atpretreatment
ne CAMStrial.
ericaalus Additionally,wemeasuredpre-andposttreatmentyouthanxiety meCasaurreegsivcearresgtirvaeirn.straTinheas2s1o-citieamtedBwAiSth(hRaeviinnhgaradyeotuatlh.,w1i9t9h4a)
Amson using the SCARED (Birmaher et al., 1997), a 41-item youth and mentalhealthdisorder.Parentsindicatedthedegreetowhichtheir
eer parentreportinstrumentassessingyouthanxietysymptomsinthe
pyrightedbythsolelyforthep pw(SnaCoosrAttr3iRetrsEmuDaoeb/nhiotnahucrstld.uslPdylaeeresetpivscieuniprbgasncatratlsouleners)aet”fe)otoeroapnc2ahanii(tc3ve/e-msproyom(ienat.trgtiu.Lc,e,i“/kogIefewtrnetonesrrcarytalril/zueMeedf)yr.oacmnThxihli0de- ctrfgierhrooseinemladsnte’t(sf1reu.albg(nnu.dx,orii“ddteietmyaynot.pduaaCicslfotlre)unoeptnlte”tons)wt5aoosvvrp(akevel,rie”cdrtth“isytieymomfppfuaofascarcthmtt)2hoi.lenywAfeBlaiehfAmkeisg,Silhryooehnuraactsaistnicbsveoceisrate,eilneeassn,rdi”dagenn“meghimfoioinneowgs--
coed ety, social phobia, separation anxiety, and school phobia, as well strated:Caregiversforarelativewithmentalillnessreporthigher
isnd asatotalscore,withhigherscoresindicatingmoreanxiety.Both
entnte the subscales and total score have sufficient reliability and have BAS scores than caregivers for a relative without mental illness,
mi andBASscoresfortheformercaregivergroupdecreasefollowing
docucleis bexeetenrnsahloizwinngtoddiisfofredreenrstiaatnedbebtweteweeneynoudtihffearnexnitetyan,xdieeptryesdsiisvoer,daenrds treatmentfortheirrelative(Reinhardetal.,1994).Consistentwith
hisarti (Birmaheretal.,1999).Inthisstudy,weusedthetotalyouthand highinternalconsistencyininitialstudies(Reinhardetal.,1994),
This parentSCAREDscorestoassessbaselineandposttreatmentyouth alphaforthissamplewas.91atpretreatmentand.93atposttreat-
T ment.
anxiety.Alphasforthetotalscoreswere.93foryouthsand.90for
parents at baseline and .94 for youths and .93 for parents at
posttreatment.
CAMS Treatment Conditions
Parental psychopathology. Parents completed the Brief
Symptom Inventory (BSI; Derogatis 1993), a 53-item self-report Participantsreceivedpharmacotherapywithsertraline(SRT);
measure of distress associated with parental psychopathology. pharmacotherapy with a placebo drug (PBO); CBT protocol
Itemsaremeasuredona5-pointLikertscalefrom0(notatall)to usingtheCopingCatmanualforchildrenandthedevelopmen-
4(extremely);scalescoresarecalculatedbytakingthemeanitem tal modification, the CAT Project, for adolescents (Kendall,
rating. Scores are obtained on nine scales (e.g., Somatization, Choudhury,Hudson,&Webb,2002;Kendall&Hedtke,2006);
Obsessive-Compulsive).TheBSI’sGeneralSeverityIndex(GSI) or a combination treatment (COMB) including all components
is a weighted frequency score based on the sum of ratings the fromSRTandCBT.TheSRTandPBOconditionsweredouble-
subjecthasassignedtoeachsymptom.Duetosignificantintercor- blinded, dosing was determined by a pharmacotherapist, and
relationsamongBSIsymptomsubscales,researchsuggeststhatthe medication was dispensed by an investigational pharmacist.
218 SCHLEIDERETAL.
Acute treatments spanned a 12-week period. CBT involved 12 correctedconfidenceintervalforthetotalindirectparameteresti-
individual,youth-focusedsessionsandtwoparentsessionsover mate does not contain 0, then the total indirect effect can be
the course of 12 weeks. The first six sessions focused on consideredstatisticallysignificant,demonstratingmultiplemedia-
teaching the youth new skills (e.g., relaxation training, cogni- tion(Preacher&Hayes,2008).
tiverestructuring),andthesecondsixofferedtheyouthoppor- In the proposed model, parental psychopathology was spec-
tunities to practice anxiety management skills through graded ifiedastheindependentvariableandposttreatmentIE-,parent-,
exposures. Parent sessions focused on psychoeducation and or youth-rated youth anxiety as the dependent variable. Candi-
supporting the youth; parental psychopathology and familial date explanatory variables were z-change scores between pre-
stressorswerenotdirectlyaddressed.SeeComptonetal.(2010) and posttreatment family functioning and caregiver strain.
for more detailed descriptions of the treatment conditions. Scoreswerecalculatedaccordingtotheformula(M (cid:2)
pretreatment
Data analyses. We tested a multiple mediation model, M )/SD .Duetoestablishedintercorrelations
posttreatment pretreatment
which involves simultaneous indirect effects by multiple vari-
betweenrace,SES,andbothparentandyouthproblems(Daw-
ables (Preacher & Hayes, 2008, p. 880). Preacher and Hayes
son, 1991; Siegel, Aneshensel, Taub, Cantwell, & Driscoll,
y. (2008) recommended that testing a multiple mediation model
publishers.natedbroadl igunanvtdeoelrvineidsnivr(eeacs)ttiagenafftaienocantl)yosfainsadlolf(tbht)heeacntaontaadnlidailanytdesiirseexcoptfleasfnfpaeetcoctirfy(itchveainraidgaigbrerleecs-t 1Wfyo9oue9un8nad)gl,sedorwificefnhecirilnleudcndrlceeuenddse(yidSnooupautnahtrxheaianegmttey-raGatsrceeaeraotcamwonvedeantrftaiaralme.t,esip,2lyoa0sn0Ss1sEeo).SmfoTearossoatlcucdodcevioreauvsrniehatratsfevuosesr.
sallieddissemi etwofifrteyhctvstahr(eitahbsealeimn).deiNrseotcattatibeslftyifce,acsltuoptefpcreheanscsihqourssepsaenc(idRfiucmccekadeniradtieodtrastaeal.re,ex2pt0elas1nt1ea)d-. pcoonsstriobllleeddefomrotgreraaptmhiecntdsiiftfee.reFnincaelslya,cwroesscosntturdoyllesditfeosr,pwreetraelasto-
ite mentIE-rated,youth-rated,orparent-ratedyouthanxietyscores
oroneofisnottob Tnpilhqaenuraeetfoworryoeu,vludasriihnaegbllpPersiedmaecnihgteihfrtyabnwedhbHeetahsyteerdse’tshscimsriubsltetuidpdlyae’ssmscueadpnipadrteiidosasnotetresecxoh-r- iitnehteyo.rsdaRemerpetoomrtieundlvtierpseltseiuglamttseeditniracetlaiuotmdneepncrtoo-vrceaelrdaiautetredesctiohnatnaegnseatslythisneesya.olWtuetrehnauatnsievxde-
ationand mePdrieasteonrst wanitahlyinsetsheusmeoddbeli.as-corrected bootstrapping, a non- models (see Table 2). Finally, we used a moderated mediation
cier technique to test whether the indirect effects differed by treat-
sous parametric sampling procedure, to test the significance of both
Asal specificandtotalindirecteffects.Bootstrappinghastheadvan- mentcondition.Moderatedmediationoccurswhenthestrength
hologicaleindividu tnnaiogoruemsoaaflnitgayrlyeisanitsethroefstmsaatumilstptiiplcilnaelgmpdoeidswtiraeitrbouwrtsiioothnro,suluetpnpadsriesnsugsmoirtissneg(lMfmtaoullliptniavcrkasirrmoiadotte-, osintfuteadrnya,cintmidooinrdseecrbtaetetewfdfeemecnteddtreieapateitonmndeswnotoncuoltdhnedbileteiovenexlparonefdssatehvdeabrciyaanbsdliegid.naIitfneicteahxnis-t
ch
Psyoft Abraham, Wei, & Russell, 2006; Preacher & Hayes, 2008). An planatoryvariables(conditionbyimprovementsinfamilyfunc-
ne SPSS macro designed for multiple mediation models tested the tioning/caregiver strain). We followed Preacher and Hayes’s
as
ericalu proposedmodel(Preacher&Hayes,2008).Bootstrapanalysesuse (2008) guidelines to carry out this test, using the same SPSS
Amson the obtained sample to generate multiple random samples with macro as for the main multiple mediation analyses.
eer replacement that serve as the basis for repeatedly computing the Asmallamountofdatawasmissingfromthesample(lessthan
hp
ythe statisticunderinvestigation(Mallinckrodtetal.,2006).Totestfor 0.25%). To handle missing data, we used a sequential regression
bt
yrightedolelyfor itwnimidtiharteetchsteoierfffcteoocnttafslidoaefnndccaesnpidneitcdeiarftviecaleisnx,dpuilsraeinncagttoe1rf,yf0e0cv0tas–ri2aa0rbe,l0eg0se,0npreaarrnaatdmeodme,teasrlaoemnsg-- ma2s0us0ul2tmi)v.ianTrgiwatdeenattiaymppimuotipanuttistoendwaedlragetoamristeihstmssinwigneraetthgereaSnnAedroSamteIVd(;LEriwettsaluerlet&spoaRcfkumabguinel-,,
ps
coed ples. In the present study, 5,000 resamples were specified, per tiplemediationanalysesoneachimputeddatasetwerecombined
isnd Preacher and Hayes’s (2008) recommendations. If the 95% bias- basedonRubin’sguidelines(Little&Rubin,2002).
entnte
mi
docucleis Table2
hisarti Correlations,MeansandStandardDeviations,AllStudyVariables
Ts
Thi Variable M SD 1 2 3 4 5 6 7 8 9 10 11
1.Pretreatmentyouthanxietyseverity:IEreport/PARS 19.18 4.21 — .31(cid:2)(cid:2) .76(cid:2)(cid:2) .29(cid:2)(cid:2) .48(cid:2)(cid:2) .24(cid:2)(cid:2) .32(cid:2)(cid:2) .25(cid:2)(cid:2) .05 .14(cid:2)(cid:2) .09(cid:2)(cid:2)
2.Posttreatmentyouthanxietyseverity:IEreport/PARS 9.70 6.61 — .23(cid:2)(cid:2) .86(cid:2)(cid:2) .14(cid:2)(cid:2) .63(cid:2)(cid:2) .11(cid:2) .43(cid:2)(cid:2) .01 (cid:2).36(cid:2)(cid:2) (cid:2).12(cid:2)(cid:2)
3.Pretreatmentyouthanxietyseverity:IEreport/CGI–S 5.02 0.72 — .27(cid:2)(cid:2) .42(cid:2)(cid:2) .20(cid:2)(cid:2) .27(cid:2)(cid:2) .19(cid:2)(cid:2) .03 .09(cid:2) .08
4.Posttreatmentyouthanxietyseverity:IEreport/CGI–S 2.95 1.45 — .11(cid:2) .60(cid:2)(cid:2) .09(cid:2) .43(cid:2)(cid:2) .015 (cid:2).13(cid:2)(cid:2) (cid:2).35(cid:2)(cid:2)
5.Pretreatmentyouthanxietyseverity:Parentreport 32.12 12.83 — .30(cid:2)(cid:2) .41(cid:2)(cid:2) .22(cid:2)(cid:2) .16(cid:2)(cid:2) .05 .16(cid:2)(cid:2)
6.Posttreatmentyouthanxietyseverity:Parentreport 13.90 11.55 — .20(cid:2)(cid:2) .49(cid:2)(cid:2) .15(cid:2)(cid:2) (cid:2).12(cid:2)(cid:2) (cid:2).33(cid:2)(cid:2)
7.Pretreatmentyouthanxietyseverity:Youthreport 23.40 15.09 — .41(cid:2)(cid:2) .07 .02 .02
8.Posttreatmentyouthanxietyseverity:Youthreport 11.52 11.62 — .10(cid:2) (cid:2).04 (cid:2).20(cid:2)(cid:2)
9.Parentpsychopathology 0.48a 0.42b — .17(cid:2)(cid:2) .17(cid:2)(cid:2)
10.Changeinfamilyfunctioning 0.20 0.96 — .17(cid:2)(cid:2)
11.Changeincaregiverstrain 0.67 1.03 —
Note. IE(cid:3)independentevaluator;PARS(cid:3)PediatricAnxietyRatingScale;CGI–S(cid:3)ClinicalGlobalImpressions–SeverityScale.
aT(cid:3)58. bT(cid:3)66.12.
(cid:2)p(cid:5).05. (cid:2)(cid:2)p(cid:5).01.
PARENTALPSYCHOPATHOLOGYYOUTHANXIETYOUTCOMES 219
Results ietyseveritywassignificantthroughimprovementsinfamilyfunc-
tioning (95% CI [(cid:2)0.37, (cid:2)0.09]) and reductions in caregiver
Descriptives and Correlations strain(95%CI[(cid:2)0.14,(cid:2)0.02]).Bothconfidenceintervalssuggest
significant specific indirect effects. Specifically, higher baseline
Means, standard deviations, and correlations for parental psy- parentalpsychopathologypredictedgreaterimprovementsinfam-
chopathology;IE-,youth-,andparent-ratedyouthanxietyseverity ilyfunctioningandgreaterreductionsincaregiverstrain,whichin
pre-andposttreatment;familyfunctioning;andcaregiverstrainare turnpredictedlowerposttreatmentIE-ratedyouthanxiety.
presentedforthetotalsampleinTable2.Greaterimprovementsin The indirect effect of parental psychopathology on posttreat-
caregiverstraincorrelatedpositivelywithhigherpretreatmentpa- ment IE-rated youth anxiety severity through both candidate ex-
rental psychopathology and lower posttreatment IE- and parent- planatoryvariableshadabias-corrected,95%confidenceinterval
rated(butnotyouth-rated)youthanxiety.Greaterimprovementsin between(cid:2)0.45and(cid:2)0.15,suggestingasignificantindirecteffect
familyfunctioningcorrelatedpositivelywithhigherparentalpsy- for the full model. That is, parental psychopathology predicted
chopathologyandlowerposttreatmentyouthanxietyacrossinfor- posttreatment IE-rated youth anxiety severity through improve-
y. mants. Youth- and parent-rated (but not IE-rated) posttreatment ments in family functioning and reductions in caregiver strain,
shers.broadl yposyucthhoapnaxthieotlyogcyo.rPrealraetnetdswneitghatmivoerleypwsyitchhoppraetthroealotmgyenattbpaasreelnitnael a2s3s.e9s3s%edoifnvpaarriaalnlecle.Tinhpeomstotrdeealt’msteonttalyionudtihreacntxeifefteyctseavcecroiutyntoendtfhoer
dpubliminated rpe(cid:3)por.0te1d,agnredaftaemriimlypfruonvcetmioennintsg,int(4ca8r6e)g(cid:3)ive3r.1s1tr,apin(cid:5),t(.40816,)ac(cid:3)ros2s.7a2ll, vCaGriIa–nSce(Rw2as(cid:3)ex.p2l4a)i,newdhbeyrepasareonntlayl p9s.4y1ch%opoafthothloegmyoadnedl’tshetoctoa-l
salliedisse treatmentconditions. vtraeraitamteesn(tbasisteel,inaendIEr-aractee)dayloounteh(aRn2xi(cid:3)ety.0se9v).erTithyu,sS,EiSn,clyuoduitnhgatghee,
ite
ofob Proposed Model explanatoryvariablesinthemodelexplainedanadditional14.52%
oroneisnott tesItEf-orramteudltyipoluethmaendixaiteitoyn(pCrGedIi–cSti)n.g IAEs-rsahteodwynoiunthFiagnuxrieet1y,tshee- oefffethctemtoitnaulsmvoadriealnvcearieaxnpcleain(veadribaynciendeexppelnadineendt vbayritaobtalel ainnddirceoc-t
ationand veritybasedontheCGI–Srevealedanonsignificantdirecteffect vthaartiarteedsuacltoinoen)s.iAnccoanretrgaisvteorfsttrhaeinspaeccriofiscsitnredairtemcetnetffheacdtsaregvreeaalteedr
cier ofparentalpsychopathologyonyouthanxietyseverityatposttreat-
sous indirect effect on posttreatment youth anxiety severity than did
Asal ment(Pathc).Becauseindirecteffectscanoccurwithoutadirect improvementsinfamilyfunctioning(95%CI[(cid:2)0.30,(cid:2)0.01]).
ologicalindividu e(nMfofteaccetKviiondfnenothtne,t2hi0rno0du0eg;phePnrdedaiercnehtcetrvae&rfifaeHbcaltesyeaosl,no2n0teh0,e8w),deerepfpelnreodccteiennetgdevpdaarttiwearbintlhes basIeEd-roantedtheyoCuGthI–Sa,nxwieetyals(oPAteRstSe)d. thTisomcoordreolboprraetdeicftiinngdinthges
he IE-rated PARS. In this model, the indirect effect of parental
ch
yt plannedanalyses.Aftercontrollingforthecombinedeffectofboth
Psof candidateexplanatoryvariables,thepath(c=)remainednonsignif- psychopathology on posttreatment parent-rated youth anxiety se-
ne veritywassignificantthroughbothimprovementsinfamilyfunc-
as
eAmericersonalu ibpcaraosnevtle.imnBeeansptesadreinnotnaflamupnisslyytacnhfduoanprcadttiihzooenldionggryegarsneidgssniriofeindcuaccnottileoyfnfsipcirieenndtiscc,aterhdegigiivhmeer-r tspitaorraneiinnntga(l9(p59s%5y%cChoICpI[a(cid:2)th[(cid:2)1o.l80o2.g6,y7(cid:2),on0(cid:2).p40o5.0s])t8t.]r)eFauatmrntdheenrrt,eIdtEhu-ecrtaiitonenddsiryeioncutthceafarfneegcxtiiveoteyrf
ythhep strain across treatment, which both individually predicted lower throughbothcandidateexplanatoryvariableshadabias-corrected,
yrightedbolelyfort poofsptatrreeanttmalepnstyIcEh-oraptaetdhoyloougtyhoannxpioesttytreseavtmereintyt.ITEh-reatienddiyroecutthefafnexc-t 9smi5go%ndiefcli,coapnnafitrdeiennntdacilerpeicsnyttecerhfvofaeplcabtthefotowlroegetyhnep(cid:2)rfeu2dl.l1ic7mteadondpdeol(cid:2).st0tAr.e6sa5ti,mnseutnhgtegIeECs-tGirnaIgt–eSda
ps
coed youth anxiety through improvements in family functioning and
isnd reductions in caregiver strain, assessed in parallel. The model’s
entnte totalindirecteffectaccountedfor28.47%ofvarianceinposttreat-
mi
docucleis omfetnhtiysovuatrhiaanncxeiewtyaosnetxhpelaPiAneRdSb(yR2pa(cid:3)re.n2t8a)l,pwshyecrheoapsaothnolylo1g1y.6a4n%d
hisarti the covariates (baseline IE-rated youth anxiety severity, SES,
This youth age, treatment site, and race) alone (R2 (cid:3) .12). Thus,
T
including the explanatory variables in the model explained an
additional 16.83% of the total model variance. A contrast of the
specificindirecteffectsrevealedthatreductionsincaregiverstrain
across treatment had a greater indirect effect on posttreatment
youthanxietyseveritythandidimprovementsinfamilyfunction-
ing(95%CI[(cid:2)1.54,(cid:2)0.10]).
Figure 1. Multiple mediator model with unstandardized regression
Parent-rated youth anxiety. We next tested this model pre-
coefficients, predicting independent-evaluator-rated posttreatment
dictingparent-ratedposttreatmentyouthanxietyseverity(seeFig-
youth anxiety severity and controlling for pretreatment youth anxiety
ure 2), and results were quite similar to those based on IE-rated
severity.Parentalpsychopathologypredictedposttreatmentindependent-
outcome. Baseline parental psychopathology significantly pre-
evaluator-rated youth anxiety severity through improvements in family
functioning and reductions in caregiver strain, with their independent dictedimprovementsinfamilyfunctioningandreductionsincare-
effectsassessedinparallel.CGI–S(cid:3)ClinicalGlobalImpressions–Severity giver strain across treatment, which both individually predicted
Scale.(cid:2)(cid:2)p(cid:5).01.(cid:2)(cid:2)(cid:2)p(cid:5).001. lowerposttreatmentparent-ratedyouthanxietyseverity.Theindi-
220 SCHLEIDERETAL.
nificant through improvements in caregiver strain (95% CI
[(cid:2)1.98, (cid:2)0.47]). That is, higher baseline parental psychopathol-
ogypredictedgreaterreductionsincaregiverstrain,whichinturn
predictedlowerposttreatmentyouth-ratedyouthanxiety.Thespe-
cific indirect effect through improvements in family functioning
was not significant. Because we were unable to test whether
improvements in family functioning account for the relation be-
tween parental psychopathology and posttreatment youth anxiety
severity, we did not test the full proposed model using youth-
reportedoutcomes.
Alternativemodelsandmoderationbytreatmentcondition.
Wethentestedfouralternativemodelstoassessthespecificityof
Figure2. Multiplemediatormodelwithunstandardizedregressioncoef-
thepredictedconfigurationofvariables(summarizedinTable1).
ficients, predicting parent-rated posttreatment youth anxiety severity and
y. Thetotalindirecteffectsforallofthesemodels,acrossIE,parent,
dpublishers.minatedbroadl covcSoageCrnryAeittgrpyRoirvlEeltedihDnrircgo(cid:3)tsueftogdrSarhpcipnorire,smeetttwnprreerifaoatohtvtrmmeCmteehnhneetitnliydritnosAdiuneitnndhpxeeiapfnenatedxymneidneRiltetyey-nelatsvfteuaeevlndufecfarEetititcmooytrns.o-irPtnaiaaogtsrensedaaenlnsytasDdoeluidpsrtoehsyrdindacunehcrxoptsiipa.oerant(cid:2)aytshpllsoe(cid:5)ielln--. aipunnsntydieqcruyvheoaollupystahttehhrxoeaplptoloagiirynntscealdonufddtehypdrooousu0tthtg.rheaTanthcxmhuiasee,ntnygttehysseeovuierntheriltfaayatni,mxohiniealytdybe9fsut5ewnv%ceetericinotoynnipsnfaiegdreeemnanntecaddel
salliedisse .05.(cid:2)(cid:2)p(cid:5).01.(cid:2)(cid:2)(cid:2)p(cid:5).001. carFeigniavlelyr,stwraein.tested whether the proposed model differed by
ite
ofob treatmentcondition.Resultsofthisanalysisfoundnoevidencefor
oneott rect effect of parental psychopathology on posttreatment parent- moderation of the total indirect effect by treatment condition,
orsn ratedyouthanxietyseveritywassignificantthroughimprovements across the IE and parent report models. Additionally, when anal-
ationandi icnarfeagmivileyrfsutrnacitnio(n9i5n%g(C95I%[(cid:2)C2I.8[7(cid:2),1(cid:2).101.5,1(cid:2)])0..1B7o]t)h,acnodnfrieddeunccteioinnsteirn- ythseestowtaelreindruirnecstepefafreactetslyfofrorthyeopurtohpsoisnedeamchodterelsatwmeernetsciognndifiitcioannt,
cier
sous vals suggest significant specific indirect effects. Specifically, acrossalltreatmentconditions.
s
Aal higher baseline parental psychopathology predicted greater im-
ologicalindividu pgrivoevremsteranitns,iwnhfaicmhiliynftuunrnctiporneidnigcteadndlogwreearteprosrettdreuacttmioennstinpacreanret-- Discussion
he ratedyouthanxiety. This study assessed family functioning and caregiver strain as
ch
yt
Psof Further, the indirect effect of parental psychopathology on post- candidateexplanatoryvariablesbetweenbaselineparentalpsycho-
ne treatmentparent-ratedyouthanxietyseveritythroughbothcandidate pathologyandposttreatmentanxietyseverityinclinicallyanxious
as
ericalu explanatory variables was significant, (95% CI [(cid:2)3.54, (cid:2)0.97]), youths.Consistentwithhypotheses,resultsindicatedthatimprove-
Amson suggesting a significant indirect effect for the full model. That is, mentsinfamilyfunctioningandreductionsincaregiverstrainled
eer parental psychopathology predicted posttreatment parent-rated to lower posttreatment youth anxiety. However, in contrast to
hp
ythe youth anxiety severity through improvements in family function- initial predictions, families in which parents reported higher psy-
bt
yrightedolelyfor iminngopdoaensl’tdstretroaettdamulceitnnitodniprseacrietnnetfc-farearcetetgdaivcyecroouustnthrtaeaidnn,fxoiarests2ye9s.ss6ee4vd%eriinotyfpt(ahRrea2lvl(cid:3)ealr.i.a3Tn0hc)ee, ctaihtoeondlionggwiciatanhlddlriaesrtdgrueecsrstiosrnehdsouwccaetrideogngisrveeairtnesrtryiamoinup,trhwovhaeincmhxeineinttystuinrfnrofawmmaislpyarsefs-uonctcio--
ps
coed whereas only 13.33% of this variance was explained by parental posttreatment. This pattern was consistent across IE and parent
isnd psychopathology and the covariates (baseline parent-rated youth informants.Inyouthinformants,improvementsincaregiverstrain
entnte anxiety severity, SES, youth age, treatment site, and race) alone butnotinfamilyfunctioningexplainedindirectrelationsbetween
mi
docucleis (eRx2pl(cid:3)ain.1ed3).aTnhaudsd,iitnioclnuadlin1g6.t3h1e%exopflanthaetotroytavlarmiaobdleeslivnatrhiaenmceo.deAl hanigxhieetry.parental psychopathology and lower posttreatment youth
hisarti contrast of the specific indirect effects revealed that neither im- Importantly, the proposed model was significant for the pre-
This provementsinfamilyfunctioningnorreductionsincaregiverstrain dicted ordering of variables only—parental psychopathology ¡
T
hadastrongerindirecteffectthantheotheronposttreatmentyouth changesinfamilyfunctioning/caregiverstrain¡youthtreatment
anxietyseverity(95%CI[(cid:2)2.46,0.01]). response—not for alternative orderings that had some theoretical
Youth-rated youth anxiety. Next, we tested the model pre- support (see Table 1) or reductions in youth anxiety leading to
dictingyouth-ratedposttreatmentyouthanxietyseverity.Baseline changes in family variables. Although some evidence has sug-
parentalpsychopathologysignificantlypredictedimprovementsin gested the bidirectional dynamics of change in youth anxiety
bothfamilyfunctioningandcaregiverstrainacrosstreatment;the treatmentbetweenparentsandyouths(Silvermanetal.,2009),this
latter significantly predicted lower posttreatment youth-rated studycanspeaktoonlyoneofthesedirections.
youth anxiety, but the former did not. Because tests of indirect The partially unexpected finding regarding parental psychopa-
effects require a significant association between the candidate thology might have emerged for several reasons. Parents who
explanatoryvariableandtheoutcomevariable(Preacher&Hayes, experiencehighlevelsofpsychopathologymaybemoremotivated
2008), we tested only the specific indirect effect of parental psy- to improve the familial environment, and psychologically dis-
chopathologyonposttreatmentparent-ratedyouthanxietyseverity tressedparentsmighthavefeltgreaterreliefuponinitiatingtreat-
through improvements in caregiver strain. This indirect was sig- ment. Related, psychologically distressed parents may have had
PARENTALPSYCHOPATHOLOGYYOUTHANXIETYOUTCOMES 221
more “room to improve” with respect to their family functioning response in youths. Family functioning, caregiver strain, and pa-
andcaregivingstrain.However,regressiontothemeancouldnot rental psychopathology may be relevant to youth treatment out-
explain the indirect effects of parental psychopathology on post- comesacrossarangeofinterventionmodalities.
treatmentyouthanxietyseverity:Acrossinformants,youthanxiety This study has limitations that warrant mention and suggest
severity did not differ by parental psychopathology. That is, in future research. First, this study could not address all familial
homeswithmoredistressedparents,therelativelylargerimprove- stressors relevant to youth treatment outcome. For example, neg-
ments in family functioning and reductions in caregiver strain ativeparentingpractices,suchaspsychologicalcontrolandrejec-
benefitedbothparents(byimprovingthefamilyenvironment)and tion, have shown prospective relations to anxiety and treatment
youths (by facilitating reductions in anxiety). These findings fit outcome in youths (Schleider, Vélez, Krause, & Gillham, 2014).
withpriorresearchfromCAMS(Keetonetal.,2013)andseparate Indeed, improvements in parenting practices have been shown to
trials(Crawford&Manassis,2001;Victoretal.,2007),suggesting influenceyouths’anxietytreatmentresponse(Khanna&Kendall,
thatyouthanxietycanconfer“spillover”benefitsforfamilymem- 2009). Such improvements might be tested as explanatory vari-
bersandthatalleviationinfamilialstressorsacrosstreatmentcan ables in future studies. A second limitation, common in family-
y. improveyouthoutcomes.IntheCAMSsample,improvementsin based clinical research, is that the majority of parent participants
shers.broadl fyaomutihlisa’lpfraocgtorersss,mthigehretbhyavfaecihlietalptiendgpyaoruetnhtsimbperttoevremsuepnptos.rt their (to87e%xp)lworeereefmfeoctthseorsf.pTahreunst, wgeendlaecrkoendtshueffimcieecnhtasntiastmissticoablsperovweedr.
publinated Notably,acrossIE,parent,andyouthreportmodels,therelation Low paternal participation is an ongoing concern in intervention
dmi betweenpretreatmentparentalpsychopathologyandchildanxiety research with families (Phares, Lopez, Fields, Kamboukos, &
salliedisse actanpdoidstattreeaetxmpelanntagtorreywvasrtriaobnlgeesr. Ianftmeredcioantitoronl,litnhgisfroerlateioffnecitssexo-f Dfeumhailge,2c0a0re5g)i.vFeurstumreasytucdliaersifiyncpluodteinngtiallalrygednifufemrebnetrslionfkmsaalmeoanndg
ite
ofob pectedtogrowweakerafteraccountingforthesevariables.When mothers’ and fathers’ psychopathology, familial stressors, and
oneott the present pattern emerges, and when the direct and indirect youthtreatmentresponse.Additionally,thepresentstudyassessed
orsn effects have opposite signs, the total effect is described as sup- changes from pre- to posttreatment in family functioning and
i
ationand vparerisasbiolenin(McraecaKseisnnthoenperetdailc.t,iv2e00v0al)i.dSituypopfreasnsoiothnerovcacruirasblwehbeynitas caabrleegsiivnevrosltvreainin.tHeroimweavsesre,stshmeesnttropnogienstts:tetshtastoifs,emxpelaasnuarteomryenvtaroif-
cier
sous inclusioninaregressionequation(Tzelgov&Henik,1991).Inthis thesevariablesaftermeasurementoftheindependentvariable,but
s
Aal study, including improvements in familial stressors in the model beforemeasurementofthedependentvariable.Becausenointerim
ologicalindividu ctrleaaritfmieedntthreesproonleseo:fOpmairtetinntgalimpspyrcohvoepmaethnotsloignyfaimnilyyoufuthncatinoxniientyg acshsaensgsemescnotsreosfftohrefeaxmplialynaftuonryctivoanriinabgleasndwecraereagviavielarbsletr,awine. uTsheids
he and caregiver strain from the model undermined the effect of approach helped reduce the possibility that youth anxiety reduc-
ch
yt
Psof higher parental psychopathology on better youth treatment re- tions might have driven changes in explanatory variables. None-
ne sponse, whereas accounting for them revealed this effect. The theless, future studies might assess family functioning and care-
as
cu
erial presenceofsuppressioninthesemodelsrevealsthecomplexityof giverstrainatvariouspointsduringtreatmenttomoreconclusively
Amson linksbetweenparentpsychopathologyandyouthanxietytreatment establishcausal,explanatorymechanisms.Separately,becausethe
eer outcomes,whichmaybemorethancorrelationsalonecanidentify. BSI has been shown to be most useful as a measure of global
hp
ythe In this study, we identified indirect pathways that may carry distress associated with psychopathology (Boulet & Boss, 1991),
bt
yrightedolelyfor irwmeelaprteleicdaasttsoiooicnmisaptferoodrvcwelmiintheicnyatslouipntrhaccratiintcixceia:eltHfyaimgrehidelyurcpptriaoornecnes.stsTpeshsy,iscwhphoaipctathethrinnoltwougaryns wyseoeluf-tdrheidpoounrtotctosmytemesspt.teoFfmuferctshtcsearlo,efsth,sebpueGtcSilfiIitctcleopradrreaeltnaatteassryesmtarpovtnaoigmllaybclweluiosthtnerolsitnhokensr
ps
coed robust across IE and parent informants; the same effect emerged betweenGSIscoresandpsychiatricdiagnosesbasedonstructured
isnd foryouthinformants,butwithimprovementsincaregiverstrainas clinical interviews. Thus, as noted, GSI scores reflect general
entnte theonlysignificantsuppressorvariable. subjective distress rather than the presence of psychopathology.
mi
docucleis ingBsymsiugghgteinstfionrgmpcalritnicicuallardemciescihoannmisamksinogficnhyaonugteh,apnrxesieetnyttfrienadt-- Fpsuytuchreopstauthdoielsogmyigtohtteesmtpwlohyethcoermvparreihoeunssipvaeremnteassyumrepstoomfsp,aorerntthael
hisarti ment. Specifically, explicitly targeting family dysfunction and presenceofcertaindisorders,differentlyinfluenceyouthtreatment
Ts
hi caregiverstrainintreatmentmaybeespeciallyhelpfulforyouths response.Inaddition,althoughparents’GSIscoresrangedwidely
T
withmorepsychologicallydistressedparents,forwhomimprove- inthepresentsample,theaverageGSIscoredidnotreflectgreater
mentsinthefamilyenvironmentmorestronglypredictedreduced distress compared to other community adult samples (Boulet &
posttreatment anxiety severity. Indeed, the total indirect effect of Boss, 1991; Derogatis, 1993). Thus, present findings may not
the model tested in this study accounted for close to a quarter of extend to parent populations experiencing higher mean distress.
reductions in youth anxiety severity across all CAMS treatment Finally, the sample was largely Caucasian and of middle to high
conditionsinparentandIEinformants,withthechangesinfamily SES, limiting generalizability of findings to other ethnic and
functioningandcaregiverstrainontheirownaloneaccountingfor socioeconomicgroups.
about16%,despitethefactthatnoneoftheseconditionstargeted Thepresentstudyalsohasseveralstrengths.First,whileexist-
familial stressors. Interventions that do address these stressors ing literature demonstrates individual effects of parental psycho-
might lead to even greater improvements in family environment pathology,familydysfunction,andcaregiverstrainonyouthtreat-
and,inturn,morefavorableoutcomesforyouths(seeManassiset ment response, our study is the first, to our knowledge, to assess
al.,2014).Further,thatthemodelheldacrosstreatmentconditions their joint influences on youth treatment response. Second, few
suggests the general relevance of familial stressors to treatment studies on relations between parental psychopathology and youth
222 SCHLEIDERETAL.
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