title: Mindful Parenting and Parenting Stress among Parents of Young Children with Anxiety Disorders: An Examination of Theoretical Mechanisms, Intervention Feasibility and Response
Creators: name: Nabinger De Diaz, Natalja A
Publisher: name: Griffith University
Year: 2022
Subjects: subject: Parenting Stress
subject: Anxiety Disorder
subject: child anxiety
subject: parenting behaviours

description: Despite its rewards, parenting is a challenging role, frequently associated with heightened stress. Parents of children with mental health conditions, such as childhood anxiety disorders (ADs), commonly report even higher levels of parenting stress and increased problems with their own mental health. These parents may also experience greater emotion dysregulation (ED) and may engage in more “negative” parenting behaviours (e.g., criticism, rejection); all of which are in turn associated with greater child anxiety symptoms and poorer child anxiety-focused therapy outcomes. In contrast, several “positive” parenting behaviours (e.g., warmth, responsiveness) have been shown to be associated with better long-term outcomes for clinically anxious children and appear to play an important protective role among families. Recently, it has been suggested that parent’s capacity for mindfulness and mindful parenting is related to parents adopting more positive parenting practices that may result in more favourable parent and child outcomes. This may be particularly relevant for parents of young children with ADs given the important role parents play for their emotional and behavioural adjustment during early childhood years. Yet, there is a paucity of research examining these parent factors (including ED, parenting stress, parenting behaviours, and mindful parenting) among parents of young clinically anxious children. Given the challenges that many parents face in parenting a clinically anxious child, there is a need for interventions that aim to provide greater support to parents in hopes to improve therapeutic outcomes for both parents and children with ADs. Indeed, mindful parenting interventions (MPIs) have been proposed as one such support for parents. A key aim of MPIs is to address parenting stress through teaching mindfulness and mindful parenting techniques. Although the evidence-base has increased, much is yet to be learned about the theoretical assumptions underlying mindful parenting interventions. Moreover, little is known about the extent to which MPIs are feasible among specific populations, and who may benefit most from these types of interventions. Therefore, the main objective of this doctoral research project was to advance knowledge of the MPI literature for parents of young clinically anxious children. Firstly, Study 1 examined theoretical mechanisms of mindful parenting and parenting stress among a sample of 83 parents of young clinically anxious children (aged 3- to 7 years) utilising a cross-sectional study design. Child diagnostic status was determined with diagnostic interviews with parents. Key variables of interest were parent factors that appear to be associated with the development and/or maintenance of anxiety in children, including parental ED, parenting stress, and parenting behaviours, which were measured using commonly used self-report questionnaires. Specifically, this study evaluated the relationships between parental ED and parenting behaviours (including warmth, rejection) within an integrative model with mindful parenting and parenting stress as sequential mediators to determine independent and combined mediation effects. It was hypothesised that mindful parenting would be positively associated with parental warmth, and negatively associated with ED, parenting stress, and parental rejection, while it was expected to find inverse associations of these variables with parenting stress. Secondly, it was expected that mindful parenting and parenting stress would emerge as significant independent mediators in respective simple mediation models. Finally, we hypothesise that mindful parenting and parenting stress sequentially mediate the links between ED and parenting behaviours. Overall, results of this study largely supported hypotheses, showing associations in expected directions and single mediation effects of parental rejection and warmth. Results of sequential mediation revealed the links between ED and warmth and rejection, respectively, were sequentially mediated via mindful parenting and parenting stress; and that mindful parenting also had direct unique associations with rejection (and to a lesser extent, warmth). Findings of this study suggest that ED affects parenting behaviours via mindful parenting and parenting stress. Moreover, in the sequential mediation models mindful parenting showed unique direct effects on parental rejection, and to a somewhat lesser extent, parental warmth. This demonstrates the potentially protective role of greater parental capacity for mindful parenting and provides evidence in support of theory. This study concludes that mindful parenting and parenting stress may serve as potential targets for intervention among parents of young clinically anxious children. Thus, trialling MPIs among this population is warranted. Study 2 examines and compares the feasibility of an in-person versus online delivered group MPI among 83 parents of clinically anxious children (aged 3- to 7-years) and explored associations between baseline parent and child characteristics with adherence to the MPI. Feasibility was defined as adherence (indicated by facilitator-rated parental session attendance and self-reported home-practice compliance), acceptability (weekly session acceptability, overall program satisfaction, and program component evaluations), and limited effectiveness on key outcomes (self-reported parenting stress and parent-reported child anxiety severity). The study showed that there was no difference in indices of feasibility between the in-person and online modalities, except for online participants rating the session content on average as more useful. Outcomes provide evidence for effectiveness across modalities with reductions in parenting stress and child anxiety severity from baseline to post-intervention and short-term follow-up. However, dropout and non-adherence (46%) to both programs were high among parents. Further, adherence (as indexed by an average of 53% session attendance across parents and home-practice compliance estimated as low) to the MPIs was found to be average to low compared to prior MPI trials. Anecdotally reported barriers to engagement are discussed. Parents who were deemed adherers to the MPIs were found to be more distressed and less mindful at baseline relative to parents who were deemed non-adherers to the MPI, and their children tended to have fewer comorbid or externalising disorders. Finally, Study 3 examined predictors of response among 45 mothers who completed the MPIs by comparing parents who achieved reliable change on measures of self-reported parenting stress (i.e., responders) relative to parents who did not demonstrate reliable change following the MPI (i.e., non-responders). Secondary to this aim, this study investigated whether mother’s response would be associated with reliable change in parent-reported child anxiety severity, and whether changes in parenting stress would predict reductions in child anxiety at short-term follow-up. It was found that overall, approximately 50% of mothers experienced reliable improvements in their parenting stress following the MPI. Moreover, mothers’ positive response to the MPI was associated with reliable improvements in child anxiety severity. Relative to non-responders, mothers who had a positive response to the MPI were less overprotective in their parenting; and their child had higher comorbidity and more externalising disorders at baseline. Although no baseline predictors of parental response emerged, it was found that reductions in parenting stress from baseline to post-intervention were associated with decreased child anxiety severity at short-term follow-up. Moreover, the study showed that change in parents’ negative attitudes about the child being “difficult” to take care of predicted reduced child anxiety. Taken together, the findings presented in these three empirical studies inform the utility of addressing parent factors commonly associated with child anxiety and provide evidence for the importance of including parenting stress and mindful parenting in explanatory models. Indeed, findings offer support for theoretical notions of mindful parenting and support the potential utility of MPIs to improve the wellbeing of both parents and their young clinically anxious children. Both MPIs appeared to be acceptable and effective for parents of young anxious children; however, adherence rates were not optimal. Therefore, barriers to adherence need to be considered prior to recommending MPIs. Parents of clinically anxious children with more co-occurring disorders and externalising disorders, who were experiencing heightened distress themselves were more likely to adhere to the MPIs. However, this thesis also demonstrated that of those who adhered, parents who have children with more co-occurring disorders including externalising disorders, may be more likely to benefit from MPIs. Given that adherers were also found to be characterised by lower dispositional mindfulness and mindful parenting, it could be speculated that parents may be more likely to adhere well to MPIs for the right reasons: to improve their own levels of distress and mindfulness. However, more research is needed to confirm this interpretation. Taken together, the results from studies of this doctoral research project are promising; thus, larger clinical trial studies are warranted to replicate findings and to overcome limitations of the present studies. Overall, it has been concluded that more research is needed to advance the larger child anxiety and parenting literature. Parenting behaviours associated with child anxiety have long been accepted as explanatory factors in models of child anxiety; however, other parent factors such as parenting stress have been largely neglected in basic and applied intervention research. This doctoral thesis showed that mindful parenting and parenting stress seem to be relevant to the explanation of how parental ED affects parenting behaviours among parents of clinically anxious children, all of which may contribute to the explanation of intergenerational transmission of anxiety. Hence, more research in this field is warranted. Indeed, helping parents of young clinically anxious children to better manage their own wellbeing is important for future intervention efforts. However, problems with feasibility of parent-focused interventions at large, including MPIs, have been demonstrated. Therefore, more research and work need to be done to address these problems to be better able to reach and support these stressed parents of young anxious children. In fact, finding better ways to support these families is of importance given that parent factors, such as heightened parenting stress, not only exacerbate child anxiety but directly interfere with the success of child anxiety-focused therapies (e.g., dropout, attenuated response). MPIs appear to be acceptable to parents of young children with ADs. Therefore, offering MPIs as an adjunct or modifying traditional child-focused anxiety therapies to include MPI components may be beneficial. However, the problems of feasibility need to be addressed. Novel approaches to target parenting stress via MPIs in brief formats, or with multi-modes (e.g., more intensive workshop days combined with therapist assisted app support) might result in greater adherence, more access for parents and better child outcomes.