We are increasingly faced with alarming information regarding a surge of mental health problems among children and young people, as reflected in recent newspaper articles (e.g., here and here). Investing in prevention has been identified as a key potential solution to limit these increasing rates and mitigate the burden associated with youth mental ill-health (McGorry et al., 2024). However, to develop and implement effective prevention strategies, it is crucial to identify the risk factors contributing to youth mental ill-health.
Anxiety disorders are highly prevalent worldwide (Steel et al., 2014) and research has consistently shown that children of anxious parents are at increased risk for adverse mental health outcomes (Ahmadzadeh et al., 2021; Lawrence et al., 2019; Zecchinato et al., 2024). Although genetic factors are likely to be at least partially accountable for the intergenerational transmission of symptoms and disorders (Ahmadzadeh et al., 2021; Eley et al., 2015), a body of evidence indicates the potential causal role of environmental influences, and specifically of a range of anxiogenic parenting behaviours, such as modelling of fear and overcontrolling behaviours, in this transmission (Ginsburg et al., 2015; Thirlwall & Creswell, 2010).
Crucially, these parenting behaviours represent clear targets for preventive interventions. This is the focus of the online intervention tested by Dunn et al. (2024), aimed at highly anxious parents and designed to prevent the development of anxiety among their children.
Investing in the prevention of youth mental ill-health should be a priority and research shows that parental anxious behaviours can be an effective intervention target.
Methods
Dunn and colleagues (2024) conducted an online parallel-group randomised controlled trial (RCT) with two equal-sized arms to test the efficacy of an online course (intervention) compared to no intervention (control condition). The study was registered at ClinicalTrials.gov and the authors published the study protocol.
The sample comprised a self-referred UK-based community sample of parents (with children aged 2–11 years) with substantial self-reported anxiety levels.
The intervention included 8 online modules (each approximately 20 minutes in length), and participants progressed through the course at their own pace.
The primary outcome measure was change in parent-reported child anxiety, measured by the Spence Children’s Anxiety Scale–Parent Report (SCAS-P) or by the Spence Pre-School Anxiety Scale–Parent Report (Preschool SCAS).
The authors also assessed child internalising, externalising, and attentional symptoms (via the Pediatric Symptom Checklist, PSC), and parent anxiety via the SCARED-Adult (secondary outcomes).
Intervention effects at 6 months (primary analysis) and at 9 to 25-months’ follow-up (secondary analyses) were reported.
Results
The authors analysed data from 1,811 participants: 900 in the intervention group and 911 in the control group.
Primary outcomes
- The findings show that child anxiety levels were significantly lower in the intervention group compared to the control group at the 6-month assessment (Cohen’s d = −0.16 (95% CI [−0.23 to −0.08], p
- As emphasised by the study authors, this corresponds to a reduction of 0.15 standard deviations in the standardised SCAS score between arms.
- On the original scales, this equates to a mean reduction of 2.38 points (95% CI [-3.59 to -1.16]) on the SCAS-P scale (range: 0–114) and a mean reduction of 2.68 points (95% CI [-4.05 to -1.31]) on the Preschool SCAS scale (range: 0–112).
Secondary outcomes
Other child mental health outcomes at 6 months
- There was strong evidence that the intervention was associated with lowered PSC (Pediatric Symptom Checklist) internalising subscale score compared to control, with a small effect size of d = −0.10 (95% CI [−0.43 to −0.07], p = .007).
- However, no significant intervention effects were found for attention and externalising outcomes (both measured via the PSC).
Parental anxiety at 6 months
- The results provided strong evidence that the intervention improved parental anxiety symptoms (assessed via the SCARED-Adult) compared to control, with a small effect size of d = −0.17 (95% CI [−0.25 to −0.09], p
Outcomes at 9 to 25-month follow-up
- Effects were comparable to those from the analysis at the 6-month assessment, suggesting that the intervention effects, particularly on child anxiety and internalising symptoms, and parental anxiety, were maintained longer-term.
Adverse effects
“No adverse events were recorded during the trial.” “Responses to the study distress questionnaire indicated a similar magnitude of negative experiences reported by participants in both trial arms (See Supplementary Materials for details).”
Parents in the intervention arm reported significantly lower child anxiety and internalising symptoms compared to parents in the control arm at 6 months, and the effects were maintained over time.
Conclusions
Dunn et al. (2024) found that this resource-light, clinically unsupported online preventive intervention targeting highly anxious parents was effective in reducing anxiety and internalising symptoms in their children, as well as anxiety in parents, with results stable up to 2 years later.
The authors concluded that these results are,
a clear signal that an inexpensive, highly scalable, digital intervention can work to prevent the intergenerational transmission of problematic anxiety this intervention.
The intergenerational transmission of anxiety from parent to child is a public health concern and this online intervention has promise in limiting anxiety in children at-risk of developing it.
Strengths and limitations
In their study, Dunn and colleagues (2024) utilised a strong and rigorous design, pre-registered and published their protocol, and collected a large sample of participants. A large sample size enhances statistical power, reducing the likelihood of Type I and Type II errors, and improves the generalisability of findings to a wider population.
It was the first RCT testing an online intervention designed to limit the intergenerational transmission of anxiety, and it has some key strengths that make it an important step forward in the field, particularly:
- The low-cost and scalable approach – This online intervention does not require clinical supervision, making it a potentially cost-effective solution to addressing the transmission of anxiety from one generation to the other.
- The evidence base –The intervention was adapted from an existing evidence-based, face-to-face group intervention that had been successfully administered in mental health primary care settings (Cartwright-Hatton et al., 2011). Building on an established intervention allows researchers to replicate and refine effective strategies, increasing confidence in its effectiveness while expanding accessibility through a digital format.
- The longitudinal follow-up – The study assessed outcomes at both 6 months and between 9–25 months, showing that intervention effects were not just short-term but sustained over time. This is particularly important in mental health interventions, as it suggests that the benefits extend beyond the initial treatment period, supporting the intervention’s long-term effectiveness and real-world applicability.
The study also has some limitations that need to be considered and addressed in order to implement the intervention and reach anxious parents across the UK and beyond. In particular:
- The high attrition rate in the intervention group – Only 3% of the intervention group completed the primary outcome measure at 6 months, compared to 77.8% in the control group. This is key considering that the authors found a dose–response relationship, with those who completed all available modules showing an effect size on child anxiety levels (primary outcome) comparable to the effect sizes seen for face-to-face interventions for children with existing anxiety diagnoses.
- Low engagement rates – Only 19% of participants completed all 8 modules, indicating that real-world implementation could struggle with user retention. Going forward, it is crucial to investigate strategies to increase user engagement and make efforts to embed the intervention within existing services, considering that greater parental engagement with the intervention was shown to be associated with better child mental health outcomes
- Potentially limited generalisability – The study sample was 7% female, 85.3% White-British, and 66.8% university-educated, meaning that findings may not be applicable to more diverse populations. As the authors note, while digital interventions have the potential to increase accessibility, they may also reinforce existing disparities in mental health research and service provision. To address this, greater efforts are needed to engage currently under-represented groups. Additionally, testing the intervention on fathers is particularly important, considering their increasingly recognised importance for their children’s mental health
- Self-reported measures – Mental health symptoms in both children and parents were parent-reported, which introduces potential bias, as highly anxious parents may overestimate or underestimate their child’s anxiety
The authors tested a low-resource and scalable intervention using a robust design; however, efforts are needed to increase user engagement and include fathers and under-represented groups.
Implications for practice
Mental ill-health among children and young people is a pressing global concern, and preventing it represents an international health priority.
The findings of this study offer valuable insights for clinical practice and policymakers. Specifically, the effectiveness of a clinically unsupported, online intervention targeting anxious parents to prevent anxiety in their children suggests new opportunities for improving accessibility to mental health support, while also highlighting challenges that must be addressed for successful implementation.
This study emphasises the crucial role of parenting behaviours in the transmission of anxiety and suggests that targeting parental anxiety can reduce risk in children. The findings provide initial evidence that, if adopted on a larger scale, such interventions could represent a solution to limit the long-term burden of childhood anxiety disorders, leading to fewer clinical cases and reduced pressure on mental health services.
However, further research is warranted to test the effectiveness of the intervention among diverse populations and fathers. Moreover, implementation strategies must be refined to increase engagement with the intervention, maximise retention, and improve accessibility, addressing existing health disparities in mental health services.
The findings of this trial offer valuable insights for clinical practice, including potential challenges that must be addressed for this inexpensive, highly scalable, digital intervention for preventing the intergenerational transmission of anxiety to be successfully implemented.
Statement of interests
I have worked with one of the researchers on other projects, but have not been involved in this current study.
Links
Primary paper
Dunn, A., Alvarez, J., Arbon, A., Bremner, S., Elsby-Pearson, C., Emsley, R., Jones, C., Lawrence, P., Lester, K. J., Morson, N., Simner, J., Thomson, A., & Cartwright-Hatton, S. (2024). Effectiveness of an unguided modular online intervention for highly anxious parents in preventing anxiety in their children: a parallel group randomised controlled trial. The Lancet Regional Health – Europe, 45, 101038 10.1016/j.lanepe.2024.101038 (PDF)
Other references
Ahmadzadeh, Y. I., Schoeler, T., Han, M., Pingault, J.-B., Creswell, C., & McAdams, T. A. (2021). Systematic review and meta-analysis of genetically informed research: associations between parent anxiety and offspring internalizing problems. Journal of the American Academy of Child & Adolescent Psychiatry, 60(7), 823-840.
Cartwright-Hatton, S., McNally, D., Field, A. P., Rust, S., Laskey, B., Dixon, C., … & Woodham, A. (2011). A new parenting-based group intervention for young anxious children: Results of a randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 50(3), 242-251.
Eley, T. C., McAdams, T. A., Rijsdijk, F. V., Lichtenstein, P., Narusyte, J., Reiss, D., Spotts, E. L., Ganiban, J. M., & Neiderhiser, J. M. (2015). The intergenerational transmission of anxiety: a children-of-twins study. American Journal of Psychiatry, 172(7), 630-637.
Ginsburg, G. S., Drake, K. L., Tein, J.-Y., Teetsel, R., & Riddle, M. A. (2015). Preventing Onset of Anxiety Disorders in Offspring of Anxious Parents: A Randomized Controlled Trial of a Family-Based Intervention. American Journal of Psychiatry, 172(12), 1207-1214.
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McGorry, P. D., Mei, C., Dalal, N., Alvarez-Jimenez, M., Blakemore, S.-J., Browne, V., Dooley, B., Hickie, I. B., Jones, P. B., & McDaid, D. (2024). The Lancet Psychiatry Commission on youth mental health. The Lancet Psychiatry, 11(9), 731-774.
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Thirlwall, K., & Creswell, C. (2010). The impact of maternal control on children’s anxious cognitions, behaviours and affect: An experimental study. Behaviour Research and Therapy, 48(10), 1041-1046.
Zecchinato, F., Ahmadzadeh, Y. I., Kreppner, J. M., & Lawrence, P. J. (2024). A Systematic Review and Meta-Analysis: Paternal Anxiety and the Emotional and Behavioral Outcomes in Their Offspring. Journal of the American Academy of Child & Adolescent Psychiatry.
