Mothers' and children's metacognitions and the development of childhood anxiety: a longitudinal investigation of transmission.

Theory and preliminary evidence suggests that parental beliefs and cognitions may be transmitted to their offspring. Transmission of maladaptive cognitions may play a role in the development of anxiety disorders in childhood. However, few studies have investigated such transmission using longitudinal designs. The objective of this study was to investigate the interaction between maternal and child metacognitions and their role in the development of childhood anxiety. We used a longitudinal design with self-report measures of maternal and child anxiety symptoms and metacognitions. Participants were 107 mothers and their children who were assessed when the children were between 7 and 12 years old and again 3 years later. Child metacognitions at baseline did not predict later child anxiety symptoms. Baseline maternal metacognitions approached significance in predicting anxiety symptoms in children at the follow-up, when controlling for known risk factors, including female gender and higher levels of anxiety in mother and child at baseline. Mediation analyses revealed that child metacognitions at baseline, as well as at follow-up fully mediated the relationship between maternal baseline metacognitions and child anxiety 3 years later. Examinations of how child and maternal metacognitions affect child anxiety levels after three years revealed that current levels of child metacognitions play a greater role in predicting child anxiety than child and maternal metacognitions at baseline.

Social anxiety disorder in children: investigating the relative contribution of automatic thoughts, repetitive negative thinking and metacognitions.

BACKGROUND: Social anxiety disorder (SAD) is common in youths. However, our understanding of SAD in children is inferior to that of SAD in adolescents or adults, and it is unclear if known adult SAD maintenance mechanisms may also operate in children with SAD. AIM: The paper sets out to investigate the specificity of positive automatic thoughts, social threat negative automatic thoughts, repetitive negative thinking, positive and negative metacognitions in predicting SAD symptoms and diagnoses in clinically anxious children. METHOD: We enrolled 122 clinically anxious children aged 7-13 years; of these, 33 had an SAD diagnosis. RESULTS: SAD symptoms correlated positively with social threat negative automatic thoughts, repetitive negative thinking, and negative metacognitions, and negatively with positive automatic thoughts. Linear regression indicated that, of these variables, only social threat negative automatic thoughts predicted social anxiety symptoms. Logistic regression indicated that social threat negative automatic thoughts, a higher number of diagnoses and negative metacognitive beliefs specifically predicted the presence of SAD diagnosis. CONCLUSIONS: Our findings suggest that content-specific social threat negative automatic thoughts was the only variable that specifically distinguished both higher levels of social anxiety symptoms and diagnoses.

Assessment of the cognitive attentional syndrome in children: an adaptation of the CAS-1.

BACKGROUND: Research suggests that the metacognitive model is applicable to clinical child populations. However, few measures related to the model are available for younger age groups. A key concept of the model is the cognitive attentional syndrome (CAS), which encompasses the individual's worry and rumination, maladaptive coping strategies, and metacognitive beliefs. While the CAS has been successfully measured in adults, this has not yet been attempted in children. AIMS: The aim of this study was to adapt a measure of the CAS for use with children and investigate the measure's associations with anxiety, worry, depression and metacognitions. METHODS: Our study included 127 children with anxiety disorders aged 7-13 years. The adult measure of CAS was adapted for use with children and administered at pre- and post-treatment. We examined the correlations between variables and the ability of the CAS measure to explain variance in anxious symptomatology, as well as the measure's sensitivity to treatment change. RESULTS: The adapted measure, CAS-1C, displayed strong associations with overall anxiety, depression, worry and metacognitions. The CAS-1C explained an additional small amount of variance in anxiety and worry symptoms after accounting for metacognitions, which may be due to the measure also assessing thinking styles and coping strategies. Furthermore, the measure displayed sensitivity to treatment change. CONCLUSIONS: The child measure of the CAS is a brief tool for collecting information on metacognitive beliefs and strategies that maintain psychopathology according to the metacognitive model, and it can be used to monitor treatment changes in these components.

Exploring the relationships between maternal and child metacognitions and child anxiety.

Research has shown that anxiety may be transmitted through verbal information pathways, for example, when parents share their anxious cognitions with their child. Less is known about the influence of parental metacognitions, that is, beliefs regarding thoughts, on child anxiety. We explored the relations between metacognitions in mothers and their children and anxiety in the children. Our study included 111 non-clinical children aged 8 to 12 years and their mothers. Children rated their metacognitions, worry and anxiety, and mothers rated their metacognitions. Results indicated agreement between maternal and child metacognitions. Maternal metacognitions were positively associated with children's anxiety symptoms and worry, and this relation was mediated by the children's metacognitions. Our results warrant further examination of the role of parental metacognitions in child anxiety.

The efficacy of metacognitive therapy for anxiety and depression: a meta-analytic review.

BACKGROUND: Metacognitive therapy (MCT) is a relatively new approach to treating mental disorders. The aim of the current meta-analysis was to examine the efficacy of MCT in patients with mental disorders. METHOD: A comprehensive literature search revealed 16 published as well as unpublished studies on the efficacy of MCT, of which nine were controlled trials. These studies report on 384 participants suffering from anxiety or depression. Treatment efficacy was examined using a random effects model. RESULTS: On primary outcome measures the aggregate within-group pre- to posttreatment and pretreatment to follow-up effect sizes for MCT were large (Hedges' g = 2.00 and 1.65, respectively). Within-group pre- to posttreatment changes in metacognitions were also large (Hedges' g = 1.18) and maintained at follow-up (Hedges' g = 1.31). Across the controlled trials, MCT was significantly more effective than both waitlist control groups (between-group Hedges' g = 1.81) as well as cognitive behavior therapy (CBT; between-group Hedges' g = 0.97). CONCLUSIONS: Results suggest that MCT is effective in treating disorders of anxiety and depression and is superior compared to waitlist control groups and CBT, although the latter finding should be interpreted with caution. The implications of these findings are limited by small sample sizes and few active control conditions. Future studies should include larger sample sizes and also include comparisons of MCT with other empirically supported therapies.

How do anxious children attempt to regulate worry? Results from a qualitative study with an experimental manipulation.

OBJECTIVE: The objective of this study was to explore how anxiety-disordered children attempt to regulate their worry. DESIGN: An experimental manipulation was applied, followed by a qualitative interview. METHODS: Thirty children aged 7-13 were enrolled in this study. Each child was presented with a black mystery box, was told that shortly he/she would have to feel what was inside the box, and was then left alone for 4 min, prior to commencing the task. The purpose of the experimental manipulation was to induce slight levels of worry in the child, so that he/she could better report on worry regulation strategies. Afterwards, an interview about how the child had regulated worry during the experimental manipulation and in everyday life was undertaken. The interviews were coded using thematic analysis. RESULTS: Five main themes were uncovered. These were (1) internal regulation of worry, for example, thinking about something else and self-reassurance talk, (2) external regulation of worry, for example, behavioural avoidance and distraction, (3) perceived effect of strategies, (4) shifting between strategies, and (5) absence of a strategy. CONCLUSIONS: Our results demonstrate that anxious children use a variety of behavioural and cognitive strategies to regulate worry. They use these strategies in combination, they generally perceive them as ineffective, and they sometimes do not report any strategy for attempting to regulate their worry. These results indicate that clinicians should be curious about which strategies anxious children use to regulate their worry, how these strategies interact with each other, and how they are implemented by the child. PRACTITIONER POINTS: Using an experimental manipulation followed by an interview, this study sought to investigate how anxious children seek to regulate their worries. Anxious children attempt to regulate their worry with use of behavioural regulation strategies, such as avoidance and distraction, and with use of cognitive regulation strategies, including thinking about something else, self-reassurance talk, and thought suppression. Sometimes, however, anxious children are not able to report a regulation strategy for a specific worry episode, suggesting that they may not always have a strategy or that they lack the introspective ability to report what they did. Clinicians should be aware that anxious children may use internal (cognitive) regulation strategies while at the same time using behavioural regulation strategies, such as avoidance.

Modeling the Relationships Between Metacognitive Beliefs, Attention Control and Symptoms in Children With and Without Anxiety Disorders: A Test of the S-REF Model.

In the metacognitive model, attentional control and metacognitive beliefs are key transdiagnostic mechanisms contributing to psychological disorder. The aim of the current study was to investigate the relative contribution of these mechanisms to symptoms of anxiety and depression in children with anxiety disorders and in non-clinical controls. In a cross-sectional design, 351 children (169 children diagnosed with a primary anxiety disorder and 182 community children) between 7 and 14 years of age completed self-report measures of symptoms, attention control and metacognitive beliefs. Clinically anxious children reported significantly higher levels of anxiety, lower levels of attention control and higher levels of maladaptive metacognitive beliefs than controls. Across groups, lower attention control and higher levels of maladaptive metacognitive beliefs were associated with stronger symptoms, and metacognitions were negatively associated with attention control. Domains of attention control and metacognitions explained unique variance in symptoms when these were entered in the same model within groups, and an interaction effect between metacognitions and attention control was found in the community group that explained additional variance in symptoms. In conclusion, the findings are consistent with predictions of the metacognitive model; metacognitive beliefs and individual differences in self-report attention control both contributed to psychological dysfunction in children and metacognitive beliefs appeared to be the strongest factor.

The Efficacy of Metacognitive Therapy: A Systematic Review and Meta-Analysis.

Background: Metacognitive therapy (MCT) continues to gain increased ground as a treatment for psychological complaints. During the last years, several clinical trials on the efficacy of MCT have been published. The aim of the current study was to provide an updated meta-analytic review of the effect of MCT for psychological complaints. Methods: We conducted a systematic search of trials on MCT for young and adult patients with psychological complaints published until January 2018, using PsycINFO, PubMed, the Cochrane Library, and Google Scholar. Trials with a minimum of 10 participants in the MCT condition were included. Results: A total of 25 studies that examined a variety of psychological complaints met our inclusion criteria, of which 15 were randomized controlled trials. We identified only one trial that was conducted with children and adolescents. In trials with adult patients, large uncontrolled effect size estimates from pre- to post-treatment and follow-up suggest that MCT is effective at reducing symptoms of the targeted primary complaints, anxiety, depression, and dysfunctional metacognitions. The comparison with waitlist control conditions also resulted in a large effect (Hedges' g = 2.06). The comparison of MCT to cognitive and behavioral interventions at post-treatment and at follow-up showed pooled effect sizes (Hedges' g) of 0.69 and 0.37 at post-treatment (k = 8) and follow-up (k = 7), respectively. Conclusions: Our findings indicate that MCT is an effective treatment for a range of psychological complaints. To date, strongest evidence exists for anxiety and depression. Current results suggest that MCT may be superior to other psychotherapies, including cognitive behavioral interventions. However, more trials with larger number of participants are needed in order to draw firm conclusions.

The efficacy of group metacognitive therapy for children (MCT-c) with generalized anxiety disorder: An open trial.

Metacognitive therapy is an effective treatment for anxiety disorders in adults. Studies have demonstrated that the underlying theoretical model is also supported in children. It has therefore been suggested that metacognitive therapy for children may be effective. Our study is an open trial of metacognitive therapy for children with generalized anxiety as their primary disorder. Therapy was provided in groups. Families were interviewed with the Anxiety Disorders Interview Schedule - child/parent versions. They reported on the child's anxiety levels using the Revised Childrens Anxiety and Depression Scale - child/parent versions. Children reported on metacognitive beliefs using the Metacognitions Questionnaire for Children - 30 item version. Fourty-four children aged 7-13 years (50% girls) were enrolled, and one family dropped out during treatment. Fifty percent of the children had received counseling or psychological treatment for their anxiety disorder previously. Following treatment, 86.4% of the children were free of their primary disorder and 72.7% were free of all anxiety disorders, the corresponding figures were 75% and 65.9% at 6-months follow-up. The effect sizes were large for all measures and clinically significant improvements were obtained for 70% of the children at posttest and 77% at follow-up. Our study suggests that metacognitive therapy for children with generalized anxiety disorder may be a highly promising treatment approach.

Adapting Metacognitive Therapy to Children with Generalised Anxiety Disorder: Suggestions for a Manual.

The metacognitive model and therapy has proven to be a promising theory and intervention for emotional disorders in adults. The model has also received empirical support in normal and clinical child samples. The purpose of the present study was to adapt metacognitive therapy to children (MCT-c) with generalised anxiety disorder (GAD) and create suggestions for an adapted manual. The adaptation was based on the structure and techniques used in MCT for adults with GAD. However, the developmental limitations of children were taken into account. For instance, therapy was aided with worksheets, practical exercises and delivered in a group format. Overall, the intervention relied heavily on practising MCT techniques in vivo with therapist assistance. A detailed description of how the manual was adapted for this age group is given, and examples from a group of four children are presented in a case series. Findings indicate that the adapted version of the metacognitive techniques and manual for children is feasible.

Parental changes after involvement in their anxious child's cognitive behavior therapy.

OBJECTIVE: Specific parental behaviors and cognitions are associated with child anxiety. Studies informing us of the directionality of the associations are lacking. We investigated the effect of parental involvement in children's anxiety treatment on parental behaviors and cognitions. METHOD: Children (N=54, 7-12 years) and parents were randomly allocated to different treatment groups (involved, not involved). Observed behavior, self-reported behavior and cognitions were assessed separately for mothers and fathers at pre-, posttreatment and follow-up. RESULTS: There were no differences over time for self-reported parental efficacy and observed negativity, but self-reported autonomy granting increased for both groups over time. Differential effects were found between groups for observed paternal over-involvement (fathers involved in treatment showed a more rapid decrease) and self-reported maternal autonomy-granting (non-involved mothers showed a greater increase). CONCLUSION: Our findings suggest that child anxiety significantly influences parental behaviors and cognitions. Child therapy may successfully change the family system.