Clin Child Fam Psychol Rev (2012) 15:6980

DOI 10.1007/s10567-011-0106-3

Family Factors in the Development and Management of Anxiety

Disorders
Ronald M. Rapee

Published online: 25 November 2011

Springer Science+Business Media, LLC 2011

Abstract Family variables are thought to play a key role

in a wide variety of psychopathology according to many
theories. Yet, specific models of the development of anxiety disorders place little emphasis on general family factors despite clear evidence that anxiety runs in families.
The current review examines evidence for the involvement
of a number of family-related variables in the development
of anxiety disorders as well as the importance of families in
their management. Evidence across most areas is shown to
be weak and inconsistent, with the one exception being an
extensive literature on the role of parenting in the development of anxiety. There is also currently little evidence
that family factors have a strong role to play in the treatment of anxiety, aside from research demonstrating the
value of parents and partners as non-critical supports in
therapy. The promises and hints in the literature, combined
with the currently inconsistent methods, suggest that considerably more research is needed to determine whether
specific family factors may yet be shown to play a key role
in the development and management of anxiety disorders.
Keywords Anxiety disorders
Family
Parenting

Abuse
Treatment

R. M. Rapee (&)
Centre for Emotional Health, Macquarie University, Sydney,
NSW 2109, Australia
e-mail: Ron.Rapee@mq.edu.au

Family Factors in the Development and Risk

for Anxiety
Family Transmission
There is little doubt that anxiety runs in families. A large
number of studies have shown evidence for higher levels of
anxiety and anxiety disorders among first-degree relatives
of people with anxiety disorders (Hettema et al. 2001). This
family concordance has been shown for adults with anxiety
disorders (Fyer et al. 1995; Stein et al. 1998), children with
anxiety disorders (Last et al. 1991; Lieb et al. 2000), and
people high on trait anxiousness (Jardine et al. 1984).
Hettema and colleagues (2001) conducted a meta-analysis of family concordance for anxiety disorders, primarily
focused on clinical populations. Based on very careful
study selection criteria, they concluded that there is substantial family concordance for panic disorder, generalised
anxiety disorder, obsessive compulsive disorder, and the
phobias (including social phobia, agoraphobia, and specific
phobias). Across anxiety disorders, they estimated that for
a given proband with an anxiety disorder, the odds of
having a first-degree relative with an anxiety disorder is
around 46.
Since this review, several population level studies have
supported these conclusions. For example, a data linkage
study of over 20,000 people in the Danish population with
a psychiatric record indicated an individual with an anxiety
disorder was 6.8 times more likely to have a first-degree
relative with another disorder (Steinhausen et al. 2009).
Similar probabilities were demonstrated regardless of
whether the relative was a parent, sibling, or child of the
proband. A similar population data linkage study in Sweden
looked at parentchild concordance (Li et al. 2008). The
risk of a child having an anxiety disorder if their parent had

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an anxiety disorder was around 2, regardless of whether the

parent with anxiety was the mother or father. If both parents had an anxiety disorder, the risk increased to 5.1.
Although these studies utilise clinical diagnoses that are
potentially unreliable and restrict themselves to the relatively small proportion of anxiety sufferers who seek professional help, their impressive sample sizes provide clear
support to the more carefully conducted earlier family
studies (Hettema et al. 2001).
One of the key questions concerning family transmission is the specificity of these effects. In other words, does
having a relative with an anxiety disorder increase the risk
for the same specific disorder, any anxiety disorder, or any
psychopathology? Fewer studies have addressed these
questions, but those that have indicate a moderate degree of
specificity within particular anxiety disorders, although
results are not entirely consistent. One of the only studies
that examined this issue across a range of anxiety disorders
compared diagnoses in first-degree relatives of probands
with social phobia, agoraphobia, simple phobia, and controls, based on DSM-III-R criteria (Fyer et al. 1995).
Specific family transmission was demonstratedprobands
with each of the anxiety disorders had increased odds to
have relatives with the same anxiety disorder but not with
other anxiety disorders. Similar specificity has been shown
in a number of other studies for social phobia (Coelho et al.
2007; Low et al. 2008; Stein et al. 1998), panic disorder
(Low et al. 2008; Mendlewicz et al. 1993; Noyes et al.
1986), and OCD (Carter et al. 2004; Fyer et al. 2005).
Studies on the familial aggregation of GAD have shown
less clear specificity (Beesdo et al. 2010; Coelho et al.
2007; Mendlewicz et al. 1993), perhaps due to the lower
diagnostic reliability for this disorder.
Clearly, the family aggregation of anxiety disorders
reflects a strong genetic penetrance. Twin studies estimate
the heritability for anxiety at around 3040% or higher
(Hettema et al. 2001). However, few twin studies estimate
marked variability due to disorder-specific genes, but
instead conclude that the majority of the genetic influence
is general across anxiety and even related disorders
(Gregory and Eley 2007). This discrepancy between the
conclusions from family and twin studies is intriguing and
might point to a general heritable component to anxiety
that is shaped into specific disorders by family-related
variables. In contrast to such a conclusion, data from twin
studies indicate little whether any variance in anxiety is
attributable to common environmental components (such
as family factors), at least for adult anxiety disorders
(Hettema et al. 2001). For child anxiety disorders, the data
are less clear and several studies attribute significant variance to influence from the common environment (Eley
et al. 2003; Feigon et al. 2001; Topolski et al. 1997).
Further, a main effect of either genetic or environmental

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factors is highly improbable for any disorder, and it is far

more likely that anxiety disorders are a product of complex
gene-environment correlations and interactions, which are
very hard to model from twin data (Eley and Lau 2005).
What appears to be true is that there is a strong genetic
basis to anxiety disorders that is nevertheless weaker than
for some disorders such as schizophrenia or bipolar disorder. There may also be some influence from shared
environmental and family factors, but this is likely to be
considerably weaker than for certain disorders such as
externalising disorders or substance abuse and almost
certainly interacts with the childs genetic makeup. There
has also been considerably less research into environmental
contributors to anxiety disorders than for many other disorders. The remainder of this paper will summarise some of
the limited evidence on the association between familyrelated variables and anxiety disorders. Given that anxiety
disorders are chronic problems that commonly begin in
childhood or adolescence, family factors during childhood
are likely to have the greatest (if any) influence. Parents
and other family members are also likely to be more
influential in the development of psychopathology and
related behaviour during the childhood years. Therefore,
the majority of relevant research and the majority of this
review will focus on family influence on childhood anxiety.
However, family support and related factors during adulthood may play a role in the maintenance of the disorder
and also need to be evaluated.
Family Demographics
Perhaps surprisingly, there is little evidence that family
demographical factors including family size, composition,
birth order, or living circumstances are strongly associated
with anxiety. Several large epidemiological studies have
failed to report consistent relationships between diagnoses
of anxiety disorders in childhood and demographical factors such as these (Canino et al. 2004; Ford et al. 2004;
Lewinsohn et al. 1993). The only exception is data that
suggest a possible relationship between low socioeconomic
status and the existence of anxiety in childhood, although
results have not been completely consistent (Cronk et al.
2004; Ford et al. 2004; Medina-Mora et al. 2005; Xue et al.
2005). Support for this relationship has also been shown in
one longitudinal study that demonstrated that low socioeconomic status during childhood assessed by maternal and
paternal employment level was a significant predictor of a
diagnosis of generalised anxiety disorder in adulthood
(Moffitt et al. 2007).
As mentioned, there is little evidence that other demographical factors increase risk for anxiety. Consistent evidence indicates that adults with anxiety, especially social
phobia, are less likely to be married or in a regular

Clin Child Fam Psychol Rev (2012) 15:6980

relationship than non-disordered populations (Hunt et al.

2002; Lampe et al. 2003; Magee et al. 1996), but this is
more likely a consequence than a cause of the disorder. Of
course, it is possible that lack of a romantic relationship
that occurs as a consequence of social anxiety may also
maintain or exacerbate the disorder, but this possibility has
not been evaluated.
Interparental Conflict, Violence, and Relationship
Satisfaction
A wealth of research has shown that parent relationship
factors such as marital distress and separation, interpersonal violence, and conflict are associated with child psychopathology (Hudson 2005). The majority of this research
has focused on child externalising problems, with considerably less interest in internalising difficulties as an outcome. In general, parent relationship difficulties, especially
interparental conflict and violence, have shown a slightly
stronger relationship with externalising than internalising
symptoms in offspring (Buehler et al. 1997; Hudson 2005).
Where internalising has been assessed, it has commonly
been measured as a single score that combines anxiety and
depression, and there have been few studies that have
included clear and distinct measures of anxiety. Nevertheless, the few studies that have assessed anxiety indicate
modest relationships between parent relationship difficulties and anxiety in offspring.
In a small study of 35 adolescents (aged 1115 years)
whose parents divorced, those whose parents continued to
engage in post-divorce conflict reported higher rates of
anxiety and withdrawal than those whose divorce did not
involve high conflict (Long et al. 1988). Mixed results were
shown in a cross-sectional study of 5- and 6-year-old
children whose mothers completed measures of marital
quality and their childs anxiety (Peleg-Popko and Dar
2001). Marital quality was negatively associated with two
specific fears but was not a significant predictor of social
anxiety. One of the more thorough studies was part of the
Christchurch longitudinal cohort (Fergusson and Horwood
1998). Over 1,200 young people at age 18 years completed
retrospective reports of interparental violence during their
childhood and were also carefully assessed for psychosocial outcomes and a number of relevant demographical and
family functioning variables. Adolescent-perceived violence displayed by both mother and father towards their
partner was significantly associated with anxiety disorders
in the adolescent; however, after controlling for significant
covariates, only paternal violence significantly predicted
anxiety disorders.
If interparental distress and aggression are shown to
predict anxiety, one of the key questions is what may
mediate these relationships. There has been little research

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to address this issue. In a cross-sectional study of 267

families, the relationship between parents depression and
childrens internalising symptoms shared common variance
with the extent to which parents reported fear, sadness, or
lacked problem solving during interparental conflict (Du
Rocher Schudlich and Cummings 2003). The authors
argued that marital conflict styles mediate the relationship
between parent dysphoria and child internalising. However,
it is also possible that parent emotionality may share a
genetic predisposition to child anxiousness that is independently associated with conflict styles. Along similar
lines, a temperamental predisposition to anxiety might be
reflected in research that has shown that the appraisals
made by children during interparental conflict may influence experienced symptoms (Hudson 2005). For example,
Dadds and colleague (Dadds et al. 1999) have shown that
children reporting self-blame and high perceived threat
during parental conflict are more likely to express internalising than externalising symptoms. Similar results,
particularly linking perceived threat during the conflict
with symptoms of anxiety, have been reported by others
(Grych et al. 2000; Jouriles et al. 2000).
These associations demonstrated in cross-sectional data
have been supported by a few longitudinal studies. For
example, parental separation or divorce early in a childs
life (prior to grade 6) has been shown to predict internalising symptoms by age 15 years (Lansford et al. 2006).
Similarly, in a small study of 37 families, marital satisfaction and well-being reported by parents and observed
parent harmony and discrepancy when the child was a year
old predicted teachers reports of the childs anxiety at the
age of 4 (McHale and Rasmussen 1998). Finally, in a verylong-term follow-up, offspring (aged between 6 and
23 years) of parents either suffering major depressive disorder or no disorder were assessed for psychopathology at
10 and 20 years after initial assessment (Nomura et al.
2002; Pilowsky et al. 2006). Poor marital adjustment
reported by parents at baseline predicted anxiety disorders
in their offspring 10 years later but only for parents who
had no psychiatric disorders. These results were not replicated 20 years later, and no effects on anxiety were found
by actual parent divorce.
The results in the preceding section indicate a small and
inconsistent influence of parental divorce and dissatisfaction on anxiety. It is possible that these results actually
reflect the interparental conflict and violence that are often
associated with marital dissatisfaction and divorce. Along
these lines, a study of 682 families demonstrated that
family violence witnessed by the child at age six was
associated with internalising symptoms; however, when
child internalising 2 years earlier was statistically controlled, these effects mostly disappeared (Litrownik et al.
2003). A carefully conducted study by Jekielek (1998)

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among 1,640 children aged 614 years whose parents

provided data over the preceding 4 years showed that both
parental divorce and interparental conflict predicted later
child anxiety. However, it was parental conflict that demonstrated the strongest and most consistent prediction of
later anxiety. Children from conflicted families whose
parents divorced more than 2 years earlier showed relatively low levels of anxiety. In contrast, children whose
parents did not divorce and were high in conflict showed
the highest levels of anxiety. Importantly, these data suggest that (understandably) living in a situation of high
conflict can result in concurrent (state) anxiousness among
children, but does not necessarily mean that it will produce
enduring (trait) anxiety.
Family Quality
Measures of family quality and distress as predictors of
psychopathology are likely to be non-specific variables,
likely reflecting a variety of factors including interparental
distress, stressful environments and life events, and the
perceptions and temperament of the index person. Nevertheless, the quality of the family environment has been
viewed as potentially influential in the development of
some forms of psychopathology (Hudson and Rapee 2005),
although it has not typically been emphasised in most
specific models of the development of anxiety disorders
(Chorpita and Barlow 1998; Hudson and Rapee 2004).
Perhaps for this reason, few empirical studies have evaluated the general family environment and its specific relationship with anxiety.
A number of studies that have examined the overall
association between anxiety and broad questionnaire
measures of family environment have demonstrated
inconsistent results. Some studies have reported poorer
overall family environments in adults or children with
anxiety disorders than in control groups (Warner et al.
1995), while other studies have failed to support this
association (Beidel et al. 1996; Knappe et al. 2009). One
small study demonstrated a significant difference between
children with anxiety disorders and controls on one subscale of the Family Environment Scale (expressiveness)
but not on another (control) (Suveg et al. 2005). In a crosssectional study of maternal reports of their young childs
anxiety (aged 56 years), greater family rigidity was related only to a fear of strangers and not to other fears (PelegPopko and Dar 2001). Interestingly in this study, greater
family cohesion was related positively to higher levels of
fearfulness and social anxiety. The authors related this
finding to research indicating greater overprotection in
families of anxious children (see below). In a larger population study of over 3,000 young people who were followed for 10 years, poor family environment was

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significantly associated with generalised anxiety disorder

but not with other anxiety disorders (Beesdo et al. 2010).
Examination of more specific family environment factors has been less common. In one longitudinal study of
around 1,000 adolescents in grades 711 at baseline, the
adolescents perception of arguments and conflict in the
family at baseline predicted a small proportion of variance
in the adolescents symptoms of anxiety (as well as
depression and physical symptoms) a year later (Mechanic
and Hansell 1989). Unfortunately, the assessment of conflict was based on a single item that was not well operationalised and was not rated independently of the
adolescent, and the assessment of anxiety was based on a
four-item measure developed by the authors. In a sample of
149 African American children aged 6 years at baseline,
child-reported (but not parent-reported) symptoms of the
childs anxiety 6 years later were significantly predicted by
a very broad measure of family environment that contained
items tapping marital distress, negative life events, and
parental psychopathology (Grover et al. 2005). In contrast
to these results, two very-long-term studies of depressed
parents (reported above) failed to demonstrate significant
prediction of symptoms of anxiety in offspring at 10 and
20 years by a measure of family cohesion (Nomura et al.
2002; Pilowsky et al. 2006).
There appears to be little evidence that a negative or
conflicted family environment is a major or specific predictor of anxiety. Admittedly however, this issue has not
been well researched to date. Measures have been inconsistent, and well-controlled longitudinal studies are very
rare. The influence of general family environment on the
maintenance of anxiety in adults has not been investigated.
Physical and Sexual Abuse
Abuse of a child is most likely to be perpetrated by a
family member, and hence, it is included here within an
examination of family influences on anxiety (although it is
recognised that not all child abuse reflects family influence). However, few studies of the effects of abuse on later
anxiety distinguish between intra- and extra-familial abuses, and hence, the evidence with respect to abuse specifically as a family factor is not entirely clear.
Several large, well-controlled studies have assessed
childhood sexual abuse and later disorders and have controlled for background family adversity variables (Fergusson
et al. 2008; Kendler et al. 2000; Nelson et al. 2002).
Anxiety disorders have generally been assessed using
structured diagnostic interviews, while childhood sexual
abuse was assessed using retrospective self-report. After
statistically controlling for family adversity and environment factors, most studies have demonstrated significant
relationships between childhood sexual abuse and a variety

Clin Child Fam Psychol Rev (2012) 15:6980

of anxiety disorders. The associations are more consistently

significant when the abuse involved genital contact and
especially intercourse. Importantly however, sexual abuse
is shown to be a risk factor for a variety of forms of psychopathology, and in general, it seems that the odds of
experiencing an anxiety disorder following childhood
sexual abuse is somewhat less than the odds of experiencing a number of other disorders (Fergusson et al. 2008;
Kendler et al. 2000). In one study, childhood sexual (and
physical) abuse was not significantly related to pure
anxiety and was only related to anxiety when it was
comorbid with depression (Levitan et al. 2003). Thus,
although childhood sexual abuse appears to be a risk factor
for anxiety, it perhaps plays a less significant role in this
disorder than in several others.
Considerably less research has addressed the importance
of physical abuse in the development of anxiety disorders,
and the results in general have been less consistent. One
study of 682 families showed that childrens internalising
symptoms at age 6 were predicted by parent verbal
aggression, even after controlling for the childs level of
internalising 2 years earlier (Litrownik et al. 2003). In
contrast, minor violence was not a significant predictor
of the childs internalising at age 6 once symptoms at age 4
were statistically controlled. In one longitudinal study of
375 participants, physical abuse was assessed at ages 15
and 18 and psychopathology was assessed when participants were aged 21 (Silverman et al. 1996). For both men
and women, experience of physical abuse before age 18
increased the risk for PTSD at age 21 but did not increase
the risk for the other anxiety disorders assessed (simple and
social phobia). In a larger study, over 1,200 young people
in New Zealand were assessed on retrospective reports of
physical and sexual abuse at ages 18 and 21 and were
assessed on a variety of forms of psychopathology at age
25 (Fergusson et al. 2008). A large number of relevant
covariates including family adversity, IQ, parent education,
and SES were also assessed. The results showed a moderate and highly significant relationship between childhood
physical abuse and later anxiety disorders. However, this
effect disappeared when the covariates, including sexual
abuse, were controlled. In contrast, the relationship
between childhood sexual abuse and anxiety disorders
remained significant even after controlling for covariates,
including physical abuse.
Overall, the current research seems to indicate that
sexual abuse during childhood does increase the risk for
anxiety disorders, but this effect is not specific to anxiety,
and sexual abuse appears to be less strongly linked with
anxiety disorder than with other forms of psychopathology.
Physical abuse appears to show an even less specific link
with anxiety disorders and seems to increase anxiety only
as part of a general increase in psychopathology and

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distress. Whether abuse leaves an enduring influence on

anxiety disorders years after it has ended has not received
much attention, and there are little data on whether anxiety
disorders in adulthood (aside from PTSD) can be maintained by an ongoing abusive relationship.
Parenting Styles
Of the various family relationship factors, childrearing or
parenting styles have been by far the most extensively
studied with respect to anxiety disorders. Almost by definition, parenting styles are only likely to be influential
during childhood and not later in development. A wealth of
empirical studies, using both retrospective questionnaire
and direct observational methods, has shown that the parentchild interactions of people with anxiety disorders are
different to that of non-anxious controls (McLeod et al.
2007; Rapee 1997; Colonnesi et al. 2011). The majority of
this research has suffered a number of methodological
limitations including small sample sizes, retrospective
reports, and inconsistent operationalisation of parenting
constructs. Nevertheless, the sheer volume of consistent
findings provides a reasonable degree of confidence in the
results. Few studies have compared anxious populations
with other forms of psychopathology. Those that have,
often failed to discriminate disordered groups on their
associated parenting, suggesting that certain parenting
styles may be associated with a variety of forms of psychopathology (Rapee 1997). However, as stated, the lack of
consistency of assessing parenting constructs, especially in
the earlier research, may contribute to the lack of specificity. In an early review of the parenting literature, it was
argued that the bulk of evidence suggested that parental
overprotection and control may be more consistently
associated with the anxiety disorders, while parental
rejection and lack of warmth may be more strongly associated with depression (Rapee 1997). Hence, theoretical
models have particularly highlighted parental overprotection as a key factor in the development of anxiety (Chorpita
and Barlow 1998; Hudson and Rapee 2004; Manassis and
Bradley 1994; Rubin et al. 2009). Consistent with these
suggestions, a recent longitudinal study of over 3,000
adolescents/young adults (aged 1424 years at baseline)
demonstrated that anxiety disorders were significantly
predicted by baseline reports of parent overprotection, but
not rejection or lack of warmth, while mood disorders were
predicted by rejection and lack of warmth, but not by
overprotection (Beesdo et al. 2010).
While the majority of research has utilised cross-sectional methodology, a few longitudinal studies have begun
to emerge (Edwards et al. 2010; Rapee 2009; Rubin et al.
2002). Most of these studies have been conducted with
very young (preschool-aged) children. Results have

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variously supported two different directions of relationshipoverprotection at time 1 predicting anxiety at a later
time and anxiety at time 1 predicting overprotection at a
later point. These results are consistent with most theoretical models that predict a reciprocal relationship
between parent overprotection and offspring anxiety
(Hudson and Rapee 2004; Rubin et al. 2009). One of the
few studies that has supported the reciprocal relationship
hypothesis within the one dataset assessed parents of over
600 children aged around 4 years at baseline and reassessed them 1 year later (Edwards et al. 2010). According
to mothers reports, baseline overprotection predicted child
anxiety 1 year later, while child anxiety predicted maternal
overprotection a year later. In contrast, paternal data supported the relationship only in the direction from overprotection to later anxiety.
Some pilot research has recently begun to demonstrate
that overprotective parental behaviours may actually cause
more anxious behaviour. In the first of these studies, 26
non-clinical children (aged 713 years) were asked to
present two brief speeches (de Wilde and Rapee 2008).
Mothers of the children were present while their child
prepared the first speech and were randomly allocated to
either act in a highly protective and controlling fashion or
in a minimally involved but supportive fashion. When
delivering the second speech that children prepared entirely
independently, children whose mothers had previously
acted in a more protective fashion demonstrated more overt
signs of anxiousness. This study has recently been replicated using a very similar method (Thirlwall and Creswell
2010). In this latter study, maternal control interacted with
child anxiety in that children high in trait anxiety whose
mothers were controlling demonstrated the highest levels
of anxiety in response to the speech.
Hence, current data appear to be relatively consistent in
demonstrating an influence of parental overprotection on
anxiety. However, demonstration of a causal association is
still relatively untested and requires considerably more
work. In addition, data from twin studies showing inconsistent support for the role of shared environment in anxiety suggest that any parental influence is likely to work
through interaction with the childs genes. Evidence for
such gene-environment interactions is still sparse.
Although other parenting styles such as criticism or lack of
warmth may also play a role in anxiety, their influence on
anxiety specifically has been less consistently established.
Modelling
Following conditioning theories of anxiety, it has long been
assumed that vicarious learning is one of the key paths to
the acquisition of fears (Field 2006; Merckelbach et al.
1996; Mineka and Zinbarg 2006). Given the assumed

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influence of families in the development and maintenance

of child anxiety, it has been something of a truism that
child anxieties may be influenced through modelling of
their parents fears. However, demonstration of this
mechanism has been extremely difficult, and evidence is
limited. This is especially true given that the importance of
modelling independent of shared genes has not been
demonstrated.
The potential for vicarious influence has been demonstrated in animal research that has shown that monkeys can
learn to fear previously neutral stimuli after observing a
partner reacts fearfully to that object (Cook and Mineka
1989). In humans, developmental research has shown that
infants will reflect their mothers fearful reactions to novel
objects (Hornik Parritz et al. 1992; Mumme and Fernald
1996). In a further development of this paradigm, it has
been shown that very young children (aged under 2 years)
can learn to fear and avoid a novel object following a
single fearful reaction to that object from their mother
(Dubi et al. 2008; Gerull and Rapee 2002). Of more direct
relevance to typical anxiety disorders, this modelled
acquisition of fear has been shown to apply to fearful
reactions to strangers (de Rosnay et al. 2006). Interestingly,
in this latter study, modelling interacted with the childs
temperament such that fear of strangers was most strongly
demonstrated in those children who had seen their mother
reacting fearfully and were characterised as having an
inhibited temperament.
Of course, this evidence does not demonstrate that such
learning actually occurs in anxious families. A closer
approximation to this link is found in the evidence
described earlier that parents of anxious children are more
likely to also be anxious. Thus, it is likely that anxious
parents will demonstrate overt fearful reactions more often
than other parents. In support of this suggestion, mothers of
anxious children self-report a greater tendency to express
anxiety and fearfulness in front of their child (Muris et al.
1996). In two related studies, Murray and colleagues
observed socially anxious and non-anxious mothers and
their children (10 weeks and 10 months) during natural
interactions with a stranger (Murray et al. 2007, 2008). In
both studies, fearfulness in response to the stranger
increased among the children of socially anxious mothers,
and this development was associated with the extent to
which the mothers expressed anxiety and social avoidance
in front of the infant.
From a slightly different perspective, a growing body of
research has shown that older children are able to learn to
fear a novel stimulus following overt, verbal expression
about its dangerous qualities (Muris and Field 2010). As
with the research on modelling, the assumption is that
anxious parents will express more threat and danger when
describing objects and experiences and this, in turn, will

Clin Child Fam Psychol Rev (2012) 15:6980

lead to fear acquisition among their children. Some

research has shown that biases towards threatening interpretations shown by anxious children are also shown by
their mothers (Creswell et al. 2005; Gifford et al. 2008).
However, it is very possible that this relationship simply
reflects the heightened anxiety that is shared between
anxious children and their mothers. At least one study has
shown that anxious children expect that their mothers will
interpret ambiguous material in a threat-consistent manner
(Lester et al. 2010).
There is growing evidence that verbal and/or behavioural expression of anxiety by a parent can increase anxiousness among their children, but whether this mechanism
accounts for a cause in the development of anxiety disorder
is still far from demonstrated. It might also be tempting to
speculate that similar expressions by say, romantic partners, might help to maintain anxiety in adulthood, but
hypotheses like this have not yet been tested.

The Influence of Family Factors on the Treatment

of Anxiety
Family Variables as Treatment Predictors
Evaluation of variables that predict treatment outcome
frequently results in inconsistent and non-significant results
for a variety of reasons including the fact that moderation
requires large effect sizes and that treatment studies are not
designed to test for prediction. Consistent with this truism, studies of the treatment of anxiety have rarely
identified family predictors of outcome that emerge in
more than one study.
Among research into the management of child anxiety,
several studies have indicated that various measures of
parent emotional distress (either maternal or paternal
anxiety and/or depression) predict worse outcome (Berman
et al. 2000; Bodden et al. 2008; Cooper et al. 2008; Kendall
et al. 2008; Rapee 2000). While parental emotionality may
influence the family environment in a number of ways, it is
very likely that these effects simply reflect a greater personality or genetic loading assessed by these measures
(Rapee et al. 2009).
Perhaps surprisingly, measures of the parent relationship
have rarely been included in treatment studies for child
anxiety and when they have, they have failed to significantly predict outcome. In a study of over 100 clinically
anxious children treated with a variety of broadly cognitive
behavioural strategies, Berman and colleagues failed to
find that the quality of the parents relationship predicted
treatment response (Berman et al. 2000).
Similarly, the overall family environment has also rarely
been assessed in studies of treatment outcome for

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childhood anxiety. In two studies of the treatment of OCD

in which family environment was assessed, results were
contradictory. In one study, family environment (based on
the McMaster Family Assessment Device) reported by both
the mother and father significantly predicted improvement
12 months after treatment (Barrett et al. 2005); however, in
another study, reports of family environment (based on a
single item developed by the authors) did not significantly
predict treatment response (Wever and Rey 1997).
In contrast to these findings, some research with adults
has shown that the extent to which relatives are perceived
as critical or hostile predicts worse response to treatment
(Chambless and Steketee 1999; Renshaw et al. 2003;
Steketee et al. 2007). For example, in one such study,
adults who were being treated for their OCD or agoraphobia completed weekly ratings of the extent to which
they perceived and were upset by criticism and hostility
from their relative (mostly spouses or parents) (Steketee
et al. 2007). Both weekly levels of anxiety and the extent of
distress in response to exposure were directly predicted by
the extent to which participants were upset by their partners criticism, and this latter variable was in turn predicted
by the extent of perceived criticism. Of course, it is unclear
from this study whether perceived criticism reflected actual
criticism. However, in an earlier study, Chambless and
Steketee (1999) showed that relatives hostility (as measured by the Camberwell Family Interview) negatively
predicted treatment outcome for agoraphobia and OCD.
Perceived criticism also predicted outcome, even after
controlling for actual criticism. Thus, it appears that both
the actual degree of hostility expressed by the relative and
the extent to which the patient themselves perceives criticism may influence response to treatment.
Given the wealth of research described above into parenting factors in child anxiety, it is surprising that little
research has examined whether the parentchild relationship predicts outcome. However, one study of adults with
OCD showed that family accommodation, that is the extent
to which families adapt to and allow obsessive compulsive
behaviours (a construct that is related to overprotection),
predicted worse outcome (Amir et al. 2000). Similar
research has also demonstrated that family accommodation
to obsessions and compulsions is a negative predictor of
treatment outcome in children with OCD (Merlo et al.
2009; Storch et al. 2010). From the opposite perspective,
Chambless and Steketee (1999) concluded that relatives
specific criticism of avoidant behaviours in the absence of
hostility towards the patient themselves could actually be
motivating and increase treatment response.
Hence, there is evidence that several factors reflecting
family, parent, and partner relationships, and behaviours
can influence treatment outcome for anxiety disorders in
both adults and children. However, research is still very

123

76

limited and a large range of questions remain to be

addressed and replicated. The field would benefit from a
theoretical overview of why and how family variables
would be expected to affect treatment response. It is also
unlikely that many of these factors will be specific to
treatment of anxiety, but evaluation of specificity of these
effects has not been conducted.
Importance of Including Families in Treatment
for Child Anxiety
A vexed question in the area of treatment of childhood
anxiety is whether there is benefit in including parents in
the treatment (Creswell and Cartwright-Hatton 2007;
Rapee et al. 2009). Overall reviews and meta-analyses have
indicated that programs in which parents of anxious children are incorporated into the treatment result in no greater
efficacy than programs targeting the child alone (In-Albon
and Schneider 2006; James et al. 2006). However, these
reviews do not typically consider differences in age of the
child, and in fact, there are few studies that either include a
sufficient age range or have sufficient power to detect
relevant differences (Creswell and Cartwright-Hatton
2007; Rapee et al. 2009). In a careful review of the literature, Creswell and Cartwright-Hatton (2007) concluded
that there are consistent hints in the literature that including
parents in treatment for anxious children does provide a
greater benefit, but that effects are small.
Of more importance to a review of family factors in
anxiety is whether it is possible to improve treatment
effects by specifically targeting theoretically important
family variables. The studies that have evaluated the benefit of including parents in treatment have utilised a wide
variety of methods of involvement, and few have tried to
specifically target key family variables. One exception is a
trial in which a very brief treatment for parental anxiety
was added to standard treatment for the childs anxiety
(Cobham et al. 1998). Results were somewhat mixed, with
only one measure (child anxiety diagnoses at post-treatment) showing stronger effects for children of anxious
parents who received the parent treatment and most measures failing to show differences between treatments. These
results were more consistent in a recent larger study that
included a slightly longer and more intensive parent anxiety management component (Hudson et al. 2009). Despite
the greater focus on parent anxiety in this latter study, the
results again failed to demonstrate larger effects on child
anxiety when parent anxiety was also treated. Treatments
that address other aspects of family functioning such as
parent depression, marital functioning, family quality, and
so on have not been conducted in the child anxiety area.
One exception is a focus on parental overprotection, which
is included in some programs (e.g. Cool Kids; Rapee et al.

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Clin Child Fam Psychol Rev (2012) 15:6980

2006), however, to date, there have been no controlled

studies that have compared effects of treatment for anxious
children that includes or does not include a focus on
parental overprotection.
Clinically, there appear to be several advantages to
including and incorporating parents into treatment for child
anxiety. Expert clinicians in the field would mostly argue
that including parents provides the greatest benefits for
practical reasons such as helping to ensure homework
compliance and assist with real-world generalisation and
that these factors are likely to be of greater importance for
younger children. The empirical evidence to date is contradictory, and this may be largely due to the fact that
studies have generally not identified specific parent roles in
therapy (such as homework compliance) and have not
sufficiently examined the influence of age.
Importance of Including Partners in Treatment
for Adult Anxiety
A number of studies have examined the value of including
partners into treatments for adult anxiety. Much of this
work has focused on agoraphobia following early suggestions that marital discord was an important factor in the
development of agoraphobia (see Emmelkamp and
Gerlsma 1994). Some parallel work has also focused on
OCD. In general, studies that have examined the inclusion
of partners into treatment for adult anxiety have demonstrated mixed results (see Emmelkamp and Gerlsma 1994;
Renshaw et al. 2005; Steketee and Shapiro 1995 for
reviews). However, as for the literature on the inclusion of
families in treatment for child anxiety reviewed above,
simply including or not including a partner in treatment may
not be the key issue. Rather, it may be more important to
look at how those partners are included and whether a focus
on specific skills and aspects of the couple relationship
might enhance outcomes (Renshaw et al. 2005; Steketee
and Shapiro 1995). As an example, several recent studies
have shown that the extent to which patients perceive criticism from their partner in addition to the extent of actual
hostility and negative attributions made by the partner can
both reduce the efficacy of exposure treatments for anxiety
(Renshaw et al. 2003, 2006; Steketee et al. 2007). Thus, it
may be that programs that specifically target partner criticism and hostility as well as teaching the patient to cope
better with that hostility may produce improved outcomes.

Summary and Conclusions

Research into the role of family factors in both the aetiology and treatment of anxiety disorders has been surprisingly limited. Surprising because family factors lie at

Clin Child Fam Psychol Rev (2012) 15:6980

the basis of many theories of psychopathology and have

been shown to play a key role in several forms of disorder.
But it appears that family factors may not play as large a
role in the development or treatment of anxiety disorders as
they do in other forms of psychopathology.
Few demographical factors appear to be related to the
development of anxiety disorders. Of the factors that have
been assessed, some evidence suggests that low socioeconomic status may predict later anxiety, but even this variable does not account for marked variance in later anxiety.
General family relationships and overall quality of family
life have not demonstrated marked or significant relationships with the development or the treatment of anxiety
disorders. Of course, this lack of effect may partly be due
to the poor operationalisation of family quality and the
wide variety and weak psychometric properties of many of
the measures. Future research that focuses more specifically on detailed and clearly operationalised aspects of
family quality may yet demonstrate some relationships.
One variable that has been carefully researched and has
demonstrated some contribution to variance in anxiety
disorders is childhood sexual abuse. It is interesting to note,
however, that even such a theoretically logical variable
(given its elicitation of unpredictable threat) appears to
account for considerably less variance in the development
of anxiety disorders than in several other forms of
psychopathology.
The most extensive research has linked anxiety disorders with parentchild interactions and especially with
parent overprotection. A wealth of research has demonstrated an association between parent overprotection and
anxiety in offspring, although concluding a causal association is still far from clear. Nevertheless, some longitudinal
and experimental studies are beginning to indicate a possible causal role of parent overprotection in later anxiety in
addition to a reciprocal elicitation of overprotection by
child anxiety. Future longitudinal studies that more carefully assess parent overprotection early in life may begin to
demonstrate some interesting effects.
Given the importance of families in the childrens
development, it is surprising that research has failed to
indicate a strong influence of family involvement or relationships on treatment outcomes for anxious children.
Some evidence clearly suggests that including parents in
the treatment of anxious children may be beneficial, but
this is more likely for very young children and is not
associated with very strong or marked effects. There are
key issues that remain to be addressed, such as importance
of specifically targeting parent overprotection within
treatment, but it is likely that the key role that parents may
play in treatment for child anxiety is to enhance treatment
adherence and real-world generalisation. Similarly, evidence has been mixed about the value of including partners

77

in treatment for adult anxiety, but more specific measurement has indicated that addressing perceived hostility and
criticism may produce benefits. Here as well, it is likely
that a key mediator is the added adherence to treatment
provided by a supportive and constructive partner. Clearly
if the couple relationship is poor, this is likely to interfere
with enhancement of treatment adherence and work on the
couples relationship is likely to be beneficial. Thus, clinical benefits may accrue through specific, targeted attention
to the couple interaction and ways in which the partner can
non-judgmentally and non-critically encourage the client to
participate in therapy.
The field, particularly with respect to intervention, is
lacking a comprehensive conceptual model that outlines
the ways in which parent, partner, and family variables
might influence the development, maintenance, and modification of anxiety disorders at different stages of development. Such a model would help to organise and focus
empirical research efforts. Avoidance and threat appraisals
lie at the heart of anxiety, and so it is likely that if family
factors have a role to play, it would be through their
influence on these core processes. For example, it may not
be that partner criticism broadly is important for treatment
outcome but more specifically criticism aimed at attempts
to engage in new approach behaviours. Similarly, sexual
abuse per se may be less influential in the development of
anxiety than sexual abuse by certain perpetrators at certain
times and in certain ways, which inflates estimates of threat
and vulnerability. There are clearly a vast number of
questions that remain to be addressed before the role of
families in the onset and management of anxiety disorders
can be understood.

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