Mindfulness-based childbirth and parenting for pregnant women with high fear of childbirth and their partners: outcomes of a randomized controlled trial assessing short- and longer-term effects on psychological well-being, birth and pregnancy experience.

OBJECTIVES: Mindfulness-Based Childbirth and Parenting (MBCP) reduces mothers' anticipated fear of childbirth (FOC), nonurgent obstetric interventions during childbirth and may improve childbirth outcomes in women with high FOC (Veringa-Skiba et al, 2022). The aim of this study was to examine the short- and longer-term outcomes of MBCP on psychological well-being, pregnancy and birth experience, as compared to enhanced care-as-usual (ECAU), in pregnant women with high FOC and their partners. DESIGN: Participants were randomly assigned to MBCP or ECAU and completed questionnaires preintervention (T1), immediately after intervention (T2), two to four weeks after childbirth (T3) and 16-20 weeks after childbirth (T4). Both intention-to-treat and per-protocol analyses were conducted. SETTING: The courses were provided by trained midwives. PARTICIPANTS: Participants included 141 pregnant women and 120 partners. INTERVENTION: MBCP comprised a nine-weekly three-hour session mindfulness group course for pregnant couples; ECAU consisted of two 90-minute individual couple consultation sessions. MEASUREMENTS: Measures of psychological well-being included measures like stress, depression, anxiety and fatigue. Measures of pregnancy and birth experience concerned experiencing uplifts during pregnancy, experienced fear of childbirth, labour pain and satisfaction with childbirth. FINDINGS: No differences between MBCP and ECAU in the total group of birthing women were found. However, women with (at least an onset of) labour that participated in MBCP reported a better birth experience compared to ECAU at T3. Concerning the total partner group only one difference between MBCP and ECAU was found at T4; MBCP partners reported an increase in fatigue. However, in the partner risk group (i.e., partners with lower psychological well-being before intervention) partners experienced better psychological well-being at T2 and T3 after MBCP than ECAU. KEY CONCLUSIONS: MBCP and ECAU demonstrate similar effects on psychological well-being, birth and pregnancy experience. However, MBCP appears superior to ECAU for labouring women in having a better childbirth experience and for partners at risk for psychological complaints in increasing their psychological well-being. IMPLICATIONS FOR PRACTICE: MBCP only positively affects the childbirth experience of those who experience (onset of) natural birth. It might be advisable to include partners at risk for psychological complaints in the MBCP.

The role of parental anxiety symptoms in the treatment of childhood social anxiety disorder.

The study investigated the role of parental anxiety symptoms in treatment outcomes for children with a primary social anxiety disorder compared to children with other primary anxiety disorders. Participants were 152 children between 7 and 18 years and their parents (146 mothers, 123 fathers). Anxiety was assessed pretreatment, posttreatment, and at three months and one year follow ups. There were no baseline differences in parental anxiety symptoms between the two groups. In both groups parental anxiety symptoms decreased from pretreatment to posttreatment, and only mothers' anxiety symptoms decreased further from posttreatment to the one year follow up. Parental anxiety symptoms before the treatment were not related to the being free of all anxiety diagnoses in the children at posttreatment. However, some indications were found for greater improvements during treatment when parents had higher anxiety symptoms before treatment. Changes in parental anxiety symptoms were found to be related to changes in child anxiety symptoms. This was not found for the total clinical severity of all inclusion anxiety disorders. This relation was visible independently in fathers or mothers, or in groups of children with a primary social anxiety disorder or with another primary anxiety disorder. In conclusion, we did not find clear indications that parental anxiety symptoms explain the differences in treatment outcomes for children with a primary social anxiety disorder compared to children with other primary anxiety disorders. More research with larger samples is needed to draw stronger conclusions.

Context matters: The role of subjective arousal during Attentional Bias Modification targeting socially anxious students.

BACKGROUND AND OBJECTIVES: Attentional Bias Modification (ABM) paradigms targeting anxiety aim to reduce attentional biases for threatening stimuli and thereby reduce anxiety. Based on cognitive theories of performance and learning, elevated levels of arousal during ABM might enhance its effectiveness by making training more engaging and activating fear schemas. This study investigated whether elevated levels of arousal during ABM would increase its effectiveness in reducing attentional bias, stress reactivity, and post-event processing. METHOD: We randomly assigned 79 high socially anxious students to a session of ABM or control training preceded by either a social stress or control induction to manipulate arousal. Training outcomes were attentional bias, stress reactivity, and post-event processing. Subjective arousal was assessed before, during, and after training. RESULTS: Results indicated that ABM was not successful in reducing attentional bias, stress reactivity or post-event processing, and that the effects of ABM were not moderated by subjective arousal. There was a trend towards ABM being more effective than control training in reducing attentional bias directly after training when participants were more aroused. However, this effect was not maintained one day after the training. LIMITATIONS: The arousal manipulation did not result in significant between-group differences in subjective arousal. CONCLUSIONS: This study did not provide support for the moderating role of arousal in ABM training effects. Replications with more effective mood induction procedures and more power are needed as a trend finding was observed suggesting that higher levels of arousal improved the direct ABM effects on attentional bias.

Associations between Psychopathology in Mothers, Fathers and Their Children: A Structural Modeling Approach.

This study investigated associations between parental and child psychopathology with parenting stress as a possible mediator, in order to get more insight in mothers' and fathers' roles in the development of psychopathology in children. Parents of 272 clinically referred (aged 6-20, 66% boys) reported about their own and their child's behavioral problems, and about parenting stress. Data were analyzed using Structural Equation Modeling. Outcomes of path models demonstrated that mothers' higher internalizing and externalizing problems were associated with respectively children's higher internalizing and externalizing problems. Fathers' higher externalizing problems were associated with both children's higher internalizing and externalizing problems, but fathers' internalizing problems were only associated with children's lower externalizing problems. Parenting stress fully mediated the relation between mothers' and children's externalizing problems, and partly mediated the relation between mothers' and children's internalizing problems. For fathers, parenting stress partly mediated the relation between fathers' internalizing problems and children's externalizing problems. Findings indicate that for mothers, the association between parental and child psychopathology is specific, whereas for fathers it is non-specific. Furthermore, results suggest that reducing parenting stress may decrease child problem behavior. Longitudinal studies are needed in order to gain more insight in the direction and underlying mechanisms of the relation between parental and child psychopathology, including parental stress.

Risk factors for parental psychopathology: a study in families with children or adolescents with psychopathology.

The parents of children with psychopathology are at increased risk for psychiatric symptoms. To investigate which parents are mostly at risk, we assessed in a clinical sample of families with children with psychopathology, whether parental symptom scores can be predicted by offspring psychiatric diagnoses and other child, parent and family characteristics. Parental depressive, anxiety, avoidant personality, attention-deficit/hyperactivity (ADHD), and antisocial personality symptoms were measured with the Adult Self Report in 1805 mothers and 1361 fathers of 1866 children with a psychiatric diagnosis as assessed in a child and adolescent psychiatric outpatient clinic. In a multivariate model, including all parental symptom scores as outcome variables, all offspring psychiatric diagnoses, offspring comorbidity and age, parental age, parental educational attainment, employment, and relationship status were simultaneously tested as predictors. Both 35.7% of mothers and 32.8% of fathers scored (sub)clinical for at least one symptom domain, mainly depressive symptoms, ADHD symptoms or, only in fathers, avoidant personality symptoms. Parental psychiatric symptoms were predicted by unemployment. Parental depressive and ADHD symptoms were further predicted by offspring depression and offspring ADHD, respectively, as well as by not living together with the other parent. Finally, parental avoidant personality symptoms were also predicted by offspring autism spectrum disorders. In families with children referred to child and adolescent psychiatric outpatient clinics, parental symptom scores are associated with adverse circumstances and with similar psychopathology in their offspring. This signifies, without implying causality, that some families are particularly vulnerable, with multiple family members affected and living in adverse circumstances.

Predictors of Treatment Effectiveness for Youth with ASD and Comorbid Anxiety Disorders: It all Depends on the Family?

The study aimed to explore predictors of treatment effectiveness in a sample of 79 children with ASD who received cognitive behavioral therapy (CBT) for their anxiety disorders. Severity of anxiety disorders and anxiety symptoms were used to measure treatment effectiveness and was assessed pre-treatment, post-treatment, 3 months-, 1 and 2 years after CBT. Child characteristics and maternal anxiety did not predict treatment effect. Children with anxious fathers and children in 'un-involved' families had less anxiety symptoms at pre-treatment and displayed a less steep decline. Children from 'authoritarian' families showed higher pre-treatment anxiety levels but responded quite well to treatment. Findings stress the importance of parent (father) and family factors in the treatment of anxiety disorders in youth with ASD.

CBT for anxiety disorders in children with and without autism spectrum disorders.

OBJECTIVE: The effectiveness of cognitive-behavioral therapy (CBT) for anxiety disorders in children with autism spectrum disorders (ASD) was examined, and compared with children without ASD. METHOD: Children with ASD and comorbid anxiety disorders (n = 79, 58 boys; Mage = 11.76) and children with anxiety disorders (n = 95, 46 boys; Mage = 12.85), and their parents, participated. All families were referred to 1 of 7 mental health care centers and received the same CBT. Anxiety, quality of life, ASD-like behaviors, and emotional-behavioral problems were measured at waitlist (ASD-group only, n = 17), pretest, posttest, and 3 months, 1 year, and 2 years after CBT. RESULTS: CBT was more effective than waitlist for treating anxiety disorders (d = -1.45) and anxiety symptoms (d = -0.48) in children with ASD. At 2 years follow-up, 61% of the children with and 64% without ASD were free of their primary anxiety disorder (percentages not significantly different). The decrease in severity of anxiety disorders after CBT (d values ranging between -1.05 and -1.46) was not different for children with and without ASD. Improvements were less in children with ASD for (only) 2 out of 7 continuous outcomes measures: anxiety symptoms (d values ranging between -0.68 and -0.94 vs. d values ranging between -0.98 and -1.25) and quality of life (d values ranging between 0.39 and 0.56 vs. d values ranging between 0.77 and 0.98). CONCLUSIONS: CBT for anxiety disorders is effective for children with ASD, also in the long-term. Treatment gains may be somewhat less compared with children without ASD.

Parenting clinically anxious versus healthy control children aged 4-12 years.

This study investigated whether parenting behaviors differed between parents of 68 clinically anxious children and 106 healthy control children aged 4-12 years. The effects of parent gender, child gender and child age on parenting were explored. Mothers and fathers completed a questionnaire to assess parenting behaviors in for children hypothetically anxious situations. Results showed that parents of clinically anxious children reported more anxiety-enhancing parenting (reinforcement of dependency and punishment) as well as more positive parenting (positive reinforcement). For the clinical sample, fathers reported using more modeling/reassurance than mothers, and parents reported using more force with their 4-7-year-olds than with their 8-12-year-olds. No interaction effects were found for child gender with child anxiety status on parenting. Results indicate that for intervention, it is important to measure parenting behaviors, and to take into account father and mother differences and the age of the child.

Specificity of interpretation and judgemental biases in social phobia versus depression.

OBJECTIVES: A body of studies shows that social phobia is characterized by content specific interpretation and judgmental biases. That is, they show bias in social situations but not in non-social situations. Comorbid depression, one of the major comorbid disorders in social phobia, might account for these biases in social phobia since depression also is characterized by cognitive distortions in social situations. This study hypothesized that, despite comorbid depression, patients with social phobia would suffer from contentspecific biases. DESIGN: Participants filled out the Interpretation and Judgmental Questionnaire (IJQ) to assess interpretation bias (using open-ended responses and forced-interpretations) and judgmental bias in social and non-social situations. METHOD: Four groups participated: social phobic patients with high (N=38) and low (N=47) depressive symptoms, depressed patients (N=22) and normal controls (N=33). RESULTS: We found both social phobic groups to interpret social situations more negatively and judge social situations as more threatening than non-social situations relative to depressed patients and normal controls. As expected, depressive symptoms related to increased general interpretation and judgmental biases across social and non-social situations. In contrast to expectations, we did not find these patterns for the open-ended measure of interpretation bias. CONCLUSIONS: The content-specific biases for social situations distinguished social phobic patients from depressive patients. This speaks for the importance of establishing the primary diagnosis in patients with mixed depression and social anxiety complaints.

The causal role of self-awareness in blushing-anxious, socially-anxious and social phobics individuals.

This study examined the effect of attentional focus on social anxiety in three groups of subjects: high versus low blushing-anxious participants (n=48); high versus low socially anxious participants (n=60); and social phobic patients compared to patients with other anxiety disorders (n=48). Participants were asked to imagine two series of social situations, in which the hero was in the centre of others' attention. In the first series of stories, the type of feedback from the audience (positive, negative and neutral) and the direction of attention of the hero (self- versus task-focused) were manipulated, and in the second series of stories, the presence or absence of blushing and the direction of attention of the hero were manipulated. In line with the expectations, self-focused attention (SFA) led to more social anxiety than task-focused attention (TFA) in all the three experiments, and high blushing-anxious, socially anxious, and social phobic groups reported higher levels of self-awareness than their low-anxious comparison groups. No evidence was found for the idea that self-focusing is specifically detrimental for participants who are already socially anxious, blushing-anxious, or socially phobic. Also, attentional focus did not interact with the valence of social feedback. Finally, results provided some support for the hypothesis that fear of blushing is mediated by self-focusing. The results suggest that irrespective of trait social anxiety, and irrespective of the outcome of a social situation (positive, neutral or negative), SFA increases state social anxiety, or TFA decreases state social anxiety.

Fear of blushing: effects of task concentration training versus exposure in vivo on fear and physiology.

Patients with fear of blushing as the predominant complaint (N = 31) were randomly assigned to (1) exposure in vivo (EXP), or (2) task concentration training (TCT), in order to test the effect of redirecting attention above exposure only. In addition, it was investigated whether treatment reduced actual blush behavior; therefore, physiological parameters of blushing were measured during two behavioral tests. Half of the patients served as waiting-list controls first. Assessments were held before and after treatment, at 6-weeks, and at 1-year follow-up. Both treatments appeared to be effective in reducing fear of blushing and realizing cognitive change. Yet, at posttest, TCT tended to produce better results with respect to fear of blushing. At 6-weeks follow-up, TCT produced significantly more cognitive change. At 1-year follow-up, patients further improved, while differential effects had disappeared. The reduction in fear of blushing was not paralleled by a reduction in actual blush behavior during the behavioral assessments. Thus, it seems that fear of blushing reflects a fearful preoccupation, irrespective of actual facial coloration.

Assessment of self-statements in agoraphobic situations construction and psychometric evaluation of the Agoraphobic Self-Statements Questionnaire (ASQ).

The study describes the development and psychometric evaluation of a self-report questionnaire for use in both treatment-outcome research and process studies: the Agoraphobic Self-Statements Questionnaire (ASQ). The ASQ comprises two subscales: a positive self-statements subscale and a negative self-statements subscale. Confirmatory factor analysis showed that, with the exception of one item, the proposed bidimensional structure of the ASQ reappeared in a second agoraphobic patient sample. Internal consistency of both subscales was satisfactory. Both subscales appeared to be sensitive to change in treatment and discriminated between agoraphobic patients and normal controls. Construct validity of the negative subscale was satisfactory, whilst additional validation of the positive subscale is required. Findings also revealed that positive thinking may serve as a coping device and that the occurrence of negative self-statements might be considered a sine qua non for the occurrence of positive self-statements. It is concluded that the ASQ can contribute to the understanding of cognitive processes during treatment of agoraphobia.

Familial correlates of social anxiety in children and adolescents.

Retrospective studies suggest a relationship between parental rearing practices and social phobia. The present study investigated whether socially anxious children perceive their current parental rearing as rejecting, overprotective, and lacking emotional warmth, and as emphasizing the importance of other's opinion, and de-emphasizing social initiatives and family sociability. Furthermore, we examined whether parents of socially anxious children report to rely on such rearing practices, and suffer themselves from social fears. A regression analysis as well as extreme group comparisons were applied. Little support was found for the presumed role of the assessed family rearing aspects in the development of social anxiety in children. Solely family sociability (children's and mothers' report) and children's perception of overprotection of the mother predicted social anxiety in the regression analysis. Given the influence of the mentioned rearing practices, social anxiety of the mother still significantly predicted social anxiety of the child. In the extreme group comparisons, differences in the expected direction were found between socially anxious and normal children on parental rejection, emotional warmth, and family sociability. However, the lack of differences between socially anxious and clinical control children suggests that these variables do not form a specific pathway to social fears.

Dysfunctional cognitions in children with social phobia, separation anxiety disorder, and generalized anxiety disorder.

According to cognitive theories of anxiety, anxious adults interpret ambiguous situations in a negative way: They overestimate danger and underestimate their abilities to cope with danger. The present study investigated whether children with social phobia, separation anxiety disorder, and generalized anxiety disorder have such a bias, compared to a clinical and a normal control group. Children were exposed to stories in which ambiguous situations were described, and asked to give their interpretations, using open and closed responses. Results showed that anxious children reported more negative cognitions than control children. However, anxious children did not overestimate danger on the free responses, but they did judge the situations as more dangerous on the closed responses. Anxious children had lower estimations of their own competency to cope with danger than the control groups on both open and closed responses. The results indicate that children with anxiety disorders have dysfunctional cognitions about ambiguous situations.

Learning history in fear of blushing.

Two studies, investigating the learning history (i.e. traumatic conditioning experiences, vicarious learning, informational learning) of individuals with and without fear of blushing, are presented. In study 1, individuals high (n = 61) and low (n = 59) in fear of blushing completed the (revised) Phobic Origin Questionnaire [POQ; Ost, L. G., & Hugdahl, K. (1981). Acquisition of phobias and anxiety response patterns in clinical patients. Behavior Research and Therapy, 19, 439-447]. In study 2, individuals who applied for treatment for fear of blushing (n = 31) and a nonfearful, matched control group (n = 31) were interviewed with the same instrument, taking into account only specific memories. High fearful individuals reported more negative learning experiences in connection with blushing than low fearful individuals, irrespective of the type of questioning. Meanwhile, study 1 (written POQ) produced higher percentages of negative learning experiences for both high and low fearful individuals than study 2 (interview). It is concluded that the POQ interview showed a more realistic picture than the written POQ. The possible role of learning history in the acquisition of fear of blushing is discussed.

Fear of blushing: fearful preoccupation irrespective of facial coloration.

Women, with high (n = 29) and low (n = 28) fear of blushing, were exposed to a mild social stressor (watching a television test card in the presence of two male confederates) and to an intense social stressor (watching their own prerecorded 'sing' video, in the presence of two male confederates). Facial coloration and facial temperature were measured and participants rated their own blush intensity. No differences in actual blushing emerged between both groups. Meanwhile, high fearful individuals' self-reported blush intensity was significantly higher than that of low fearful individuals. Thus, fear of blushing seems to reflect a fearful preoccupation, irrespective of differential facial coloration. The present findings concord with cognitive models of social phobia.

Social phobia: individual response patterns and the effects of behavioral and cognitive interventions.

In the present study, the role of individual response patterns in the treatment of social phobic patients was investigated. Seventy-four patients were diagnosed as social phobics. On the basis of extreme scores on a behavioral test (the Simulated Social Interaction Test) and on a cognitive measure (the Rational Behavior Inventory), the response patterns of 39 patients were analyzed, and the patients themselves were classified as either 'behavioral reactors' or 'cognitive reactors'. Half of the patients with each response pattern received a behavioral focused treatment, i.e. social skills training (SST), while the other half received a cognitive oriented treatment, i.e. rational emotive therapy (RET). Patients received group therapy in eight weekly sessions. Within-group differences showed a considerable improvement in all treatment groups. Between-group differences failed to lend support to the hypothesis that treatment that fits a response pattern (i.e. SST for behavioral reactors and RET for cognitive reactors) will result in a greater improvement than one that does not.