ReviewParental factors associated with depression and anxiety in young people: A systematic review and meta-analysis
Introduction
Mood and anxiety disorders are amongst the most prevalent lifetime mental disorders (3.3%–21.4% and 4.8%–31.0% respectively; Kessler et al., 2007). Of particular concern, the peak age of onset for these disorders is in the first few decades of life, and early onset disorders tend to become chronic or relapsing and forecast a wide range of psychosocial and vocational impairments, resulting in deleterious long-term sequelae (Caspi et al., 1988, Last et al., 1997, Rao et al., 1995). While intervention efforts for these disorders continue to progress, rates of professional help seeking remain low (Collins et al., 2005, Reavley et al., 2010). Even if help-seeking rates do increase drastically, current services are likely to be inadequate to meet the high level of need (Collins et al., 2005). Moreover, even with optimal treatment, a large proportion of the burden of disease is still unavertable (Andrews et al., 2004). With some evidence suggesting an increase in the rates of depression and anxiety symptoms in some countries (Collishaw, 2009), the push for a greater focus on prevention and early intervention has been stronger than ever, especially for young people (Patel et al., 2007).
Strategic settings for targeting preventive interventions for youth depression and anxiety include the print or broadcast media, internet (including social media and communication technologies), schools and families. The family setting, particularly parents, is the focus in this review because some of the key risk factors for depression and anxiety disorders in young people involve families (e.g., marital conflict) or can be detected early by parents (e.g., behavioral inhibition; Garber, 2006, Rapee et al., 2009, van Voorhees et al., 2008, Wood et al., 2003). Parents are also a good target for prevention because they may possess the foresight which helps them appreciate the value of prevention and early intervention, as well as the inherent motivation to take preventive actions. Moreover, extant evidence is unequivocal about the critical role that experiences within the family setting play in young people's vulnerability to, and protection against, depression and anxiety disorders (Bögels and Brechman-Toussaint, 2006, Knappe et al., 2010, McLeod et al., 2007a, McLeod et al., 2007c, McLeod et al., 2011, Rapee et al., 2009, Restifo and Bögels, 2009, van Voorhees et al., 2008).
To facilitate application of such evidence in preventive interventions, there is the need to focus on modifiable factors; i.e., factors influencing the development of depression and anxiety in young people that are potentially within a parent's capacity to alter or intervene with. This is in contrast to other known factors that are systemic, or difficult or impossible to change at the familial or individual level; e.g. family history of psychopathology, poverty or ethnicity. Although our knowledge of the specific parental factors by which parenting interventions have long-term impact on child mental health is at a rudimentary stage, there is emerging evidence that targeting specific parenting processes in family-based interventions can improve some aspects of parenting, and in turn, a range of long-term child outcomes including internalizing problems (Sandler et al., 2011a). Parenting factors that have been found to mediate program effects on youth outcomes include parental warmth (Zhou et al., 2008), authoritative parenting (Cowan et al., 2005), effective and consistent discipline (Bernat et al., 2007, Lochman and Wells, 2002, Zhou et al., 2008), parental monitoring (Dishion et al., 2003), and good family communication and problem solving (Brody et al., 2008, DeGarmo et al., 2009). Although child abuse (sexual and non-sexual) and neglect are factors that parents can potentially prevent or intervene with, we have not included studies of these in the current review, so as to avoid duplicating the four recently published systematic reviews of the long-term impact of abuse and neglect on depression and anxiety outcomes (Chen et al., 2010, Maniglio, 2010, Maniglio, 2013, Norman et al., 2012). It is also noteworthy that a recent systematic review and meta-analysis found that preventive interventions in parents with mental illness (which were mostly targeted within the family setting) seem to be effective in preventing new diagnoses of mental disorders and internalizing symptoms in their children (Siegenthaler et al., 2012). This suggests that despite the challenges of dealing with their own mental illness, there are preventive actions that these parents can and do take for the sake of their child's mental health, which family-based preventive interventions can facilitate.
There is also a need to integrate the vast and varied literature examining parental factors in the development of depression and anxiety in young people. Various reviews have attempted to do this, but are limited in a number of ways. Firstly, some reviews only include studies with a certain type of study design (e.g., cross-sectional only; McLeod et al., 2007a, McLeod et al., 2007c). This is mainly because there were too few studies with other designs (e.g., longitudinal) to include meaningfully in meta-analyses. Moreover, even when it is available, data from longitudinal studies are often difficult to extract for meta-analyses because of widely varying analytic approaches, including adjustments for different covariates (e.g., baseline symptoms) in analytic models. Secondly, some reviews follow a theoretical model or framework, and hence examine some parental factors comprehensively to the exclusion of others (e.g., Ballash et al., 2006, Esbjørn et al., 2012). Others are guided by the more commonly researched parenting factors, such as rejection and control (parent–child relationship factors or parental behaviors directed towards the target child; e.g., McLeod et al., 2007a, McLeod et al., 2007c, Rapee, 1997, Van Der Bruggen et al., 2008), to the neglect of other factors like marital conflict, monitoring or disciplinary styles. Furthermore, most reviews to date are largely narrative and selective, and do not follow or report a systematic search or coding protocol. This has limited the comparison and synthesis of findings across reviews, and hindered our understanding of discrepant conclusions that are made.
Finally, most reviews focus on depression or anxiety but not both. In addition to their phenomenological and diagnostic similarities, depression and anxiety disorders share some risk factors, including parental factors (Dozois et al., 2009, Wilamowska et al., 2010). Of note, extant evidence indicates that many parental factors examined in depression and anxiety research are not specific to either disorder (e.g., Bögels and Brechman-Toussaint, 2006, Restifo and Bögels, 2009). Consequently, an increasing number of researchers have called for transdiagnostic approaches to prevention (Dozois et al., 2009) and treatment (Craske, 2012, Wilamowska et al., 2010) of these disorders, because of their potential to enhance the efficacy, generalizability, and cost-effectiveness of such interventions, as well as to facilitate their implementation. Furthermore, to a parent wanting to protect their child's mental health, a transdiagnostic approach to prevention is much simpler and makes more sense. Hence, this review took a transdiagnostic approach by including both depression and anxiety as outcomes of interest.
Parental factors associated with depression and anxiety need to be considered in relation to particular phases of child development. Adolescence (defined here as between ages 12 and 18 years) is of particular interest because the incidence of depression and anxiety disorders starts to increase during this period of development (Angold et al., 1998, Cohen et al., 1993). Furthermore, it is a significant transition phase from dependence on parents to increasing autonomy and independence, with 18 years being the age of majority in many countries. Besides, most young people aged 12–18 years are in high school. The school setting facilitates the targeting of prevention and intervention programs, hence aligning the definition of adolescence to the high school age span is strategic. Importantly, some parental factors that are specifically relevant to this developmental phase are likely to differ from those that are more important in early childhood, but these differences may be overlooked or obscured in reviews of studies examining parenting of children from birth to adulthood. A review focused specifically on this age group will facilitate the translation of relevant research evidence into prevention and intervention programs, as well as further research into the etiological significance of specific parental factors.
The majority of existing prevention programs for depression and anxiety in young people still fail to specifically target many of the key parental factors that influence the development of these disorders (Creswell and Cartwright-Hatton, 2007, Garber, 2006, Rapee, 2012, Restifo and Bögels, 2009), although there are some notable exceptions that target at least a few factors in their programs (e.g. Beardslee et al., 2003, Ginsburg, 2009, Wolchik et al., 2000). Targeting more factors in combination within the same program may be particularly important given the potential for this to enhance the effectiveness of the program. Moreover, in many family-based programs, the parenting component often involves teaching parents what their child was being taught, rather than targeting parenting factors that might increase their child's risk for depression or anxiety (Weisz et al., 2006). Indeed, there has been a call for more effective translation of research evidence about the importance of family processes for youth depression and anxiety into preventive family interventions (Avenevoli and Merikangas, 2006, Fisak et al., 2011, Gladstone and Beardslee, 2009, Restifo and Bögels, 2009). To facilitate the translation of the extant body of evidence about the wide range of modifiable parental factors, a systematic synthesis of this burgeoning literature is required. The overall aim of this review is to identify factors that parents can potentially modify to prevent the development of depression and anxiety disorders in their adolescent child, by integrating evidence about parental risk and protective factors for young people aged 12–18 years.
Section snippets
Data sources
Between August 2010 and September 2011, a systematic search of the literature was conducted according to the PRISMA statement (Moher et al., 2009, Parker et al., 1979). Electronic databases PsycInfo, MEDLINE and Academic Search Complete were searched using the search terms (parenting) AND (depressi⁎ OR dysthym⁎ OR affective OR mood OR anxiety OR internalizing OR internalizing OR panic OR phobia OR phobic OR post-traumatic stress disorder OR acute stress disorder) AND (prevention). Where
Results
Fig. 1 summarizes the results of the different phases of the literature search. One hundred and eighty-one articles reporting 516 associations were identified via the systematic search for inclusion in this review. Of these, 140 articles reported 358 associations with depression, 17 articles reported 42 associations with anxiety, and 24 articles reported 58 associations with depression and 58 with anxiety. The findings are summarized under each theme in alphabetical order below. Table 2
Discussion
Generally, the evidence base for depression is larger and stronger than for anxiety, with more studies of each design (longitudinal, retrospective, and cross-sectional) found. Consequently, the highest level of evidence available for depression outcomes was longitudinal studies for 9 out of 12 parenting themes, this was the case for only 2 themes for anxiety outcomes. Findings from this review will be discussed with a focus on their translation and application into existing and future
Role of funding source
Funding for the review was provided by the National Health and Medical Research Council and beyondblue: the national depression initiative. The funding sources had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Conflict of interest
None declared.
Acknowledgments
Funding for this review was provided by National Health and Medical Research Council and beyondblue: the national depression and anxiety initiative. The authors would like to thank Miss Alicia Holborn, Miss Fiona Blee, Miss Anna Ross, and Miss Michelle Fowler for their assistance in cross-checking some of the data extraction. The authors would also like to acknowledge the statistical advice generously provided by Mr. Stefan Cvetkovski.
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