Parent-Child Relationships in Early Childhood and Development of Anxiety & Depression

Introduction

Parents play a role in shaping children’s emotional wellbeing, particularly in early childhood. Parental reactions to children’s emotions, their modelling of affect and expression of emotions are important for children’s emotion socialisation, and influence the development of children’s emotional regulation capacity and emotional understanding.¹ There is also evidence that parent-child relationships play a specific role in the development of anxiety and depression in young children. This research has focused on parent-child relationship factors that may increase the child’s sense of threat and limit opportunities for the child develop a sense of mastery over their environment. Broadly, these are categorised into: (1) parenting behaviours (control, rejection/low warmth); (2) modelling and/or information transfer and (3) insecure attachment.

Subject

The key feature of anxiety disorders is avoidance of feared stimuli. Parenting behaviours that reinforce a children’s avoidant behaviours, discourage independence or limit confidence in coping are likely to impact on the maintenance and development of anxiety disorders. For example, parental control (excessive regulation, overprotection, intrusiveness and low autonomy granting) may undermine children’s sense of autonomy and safety and reinforce avoidant behaviours, increasing the risk of anxiety.^2-6 Parental rejection (punitiveness, excessive criticism or dismissal) and low warmth (coldness or low support) may also lead children to believe their environment is hostile or threatening, and children are less likely to develop a sense of competence.^6,7 Parental rejection and low warmth also undermines children’s self-esteem and can lead to hopelessness and a negative sense of self, which may increase the risk of depression.^6,7

Parents who model anxious behaviour and/or verbally communicate threat-relevant information to their child may also increase a child’s fears and risk of developing anxiety disorders.^2,4 Parents who are anxious or depressed themselves are more likely to exhibit these kinds of behaviours. Although most research has focused on a top-down parent-effect (i.e., parents transferring risk to their child), it is well-recognised that children’s internalising symptoms might also affect parents (i.e., child eliciting parent behaviours).^2,4 Further, the effect of modelling/information transfer and overcontrol may be exacerbated when the child has an inhibited or anxious temperament.⁴

An insecure attachment has also been identified as a risk factor for the development of anxiety and depression.⁸ Attachment is defined as the intimate emotional bond that forms between a child and caregiver.⁹ An insecure attachment is one in which the child experiences the caregiver as unpredictable or unresponsive or does not experience comfort from the relationship. This can lead children to develop poor emotion regulation skills or a negative sense of self, which are both associated with anxiety and depression.^10-12

Problems

A significant problem in this area of study is the accurate measurement of parent-child relationships. Early research examining overcontrol and parental rejection/low warmth focused on retrospective reports from adults with anxiety and depression, leading to potentially biased reports.⁶ Prospective or contemporaneous questionnaire measures are also subject to response bias.^3,7 To overcome these difficulties, some researchers have used observational methods to assess these behaviours.^12-14 Observational methods, however, are not without problems, as parents may behave differently or more positively when being observed in a research laboratory or at home.

Research Context

Parenting is a valuable research target as it is a potentially modifiable risk factor for the development of anxiety and depression.  Despite this, meta-analyses indicate that overall parenting accounts for only 4% of child anxiety³ and 8% of child depression,⁴ which is smaller compared to other risk factors, such as genetic influences.¹⁵ However, there is a large amount of variation in the research literature, and the relationship between parenting and child anxiety and depression varies according to how parental control is operationalised and measured. For example, there are stronger effects between parenting and child anxiety/depression in studies that use observational measures compared to questionnaire measures.^3,4 Further, the majority of studies examining the relation between parenting behaviour and anxiety and depression are cross-sectional in design which limits their ability to test causality. A few longitudinal studies, and a small number of experimental studies, have been conducted allowing an improved estimate of the causal impact of parenting behaviour on anxiety and depression. Most research focuses on school-aged children but there are a few studies investigating parent-child relationships in younger children.

Key Research Questions

1. What parenting behaviours are associated with anxiety and depression in early childhood? 
2. Is there a causal relationship between parenting behaviours and anxiety and depression in early childhood? Is there a bidirectional relationship?
3. Is the impact of parenting behaviours greater for some children over others?  In other words, do these parenting behaviours increase the risk of anxiety and depression in all children or only in children already at risk for anxiety (e.g., inhibited children)?

Recent Research Results

A number of studies have shown that parental control is associated with child anxiety disorders. The majority of these studies are cross-sectional, however a few longitudinal studies have emerged showing that parental control (particularly overprotection) in early childhood is associated with later anxiety disorders.^16-18,20 For example, Hudson and Dodd¹⁶ followed a group of inhibited and uninhibited children from the age of 4 years. In this study, children’s anxiety at age 9 was predicted by the child’s anxiety and inhibition at age 4 but also by maternal anxiety and maternal control. Thus, greater maternal anxiety and maternal over-involvement predicted greater child anxiety. This suggests that the relationship between risk factors for child anxiety is additive (that is, the presence of one risk factor in the face of another risk factor does not affect either’s impact). When longer term outcomes were considered, Hudson et al.¹⁷ found evidence for interaction of risks (that is, the presence of one risk factor in the face of another alters its impact). Specifically, inhibited children at age 4 years predicted anxiety symptoms at age 12 years, but only for children whose mothers were controlling at 4 years. In these studies, the security of a child’s attachment and maternal negativity did not predict later anxiety.

Other longitudinal studies indicate that observed maternal controlling behaviour and negativity predicts preschoolers’ anxious symptoms one year later.¹⁸ In contrast, no such prediction is shown when the child is in early adolescence,¹⁹ which suggests that parental responses may have a greater impact on anxiety in early childhood.

Experimental studies have also provided support for a causal effect of parental control on child anxiety. In a study of non-clinical mother-child dyads (child at age 4-5 years), mothers were trained to behave in controlling ways while helping their child prepare to give a presentation. Children showed more anxiety when their mothers behaved with more control, although this relationship was only evident in children with higher trait anxiety.²⁰

There is also increasing evidence of a bidirectional relationship between child anxiety and parental control. For example, one study demonstrated reciprocal effects between maternal control and child anxiety based on maternal report across a one-year period in preschoolers. In contrast, paternal reports showed that control behaviours predicted later child anxiety.¹⁸

There have been a few studies demonstrating that parent anxiety can be transmitted through modelling and verbal transmission of threat and avoidant information.^21,22 In one experimental study, young infants showed increased fearfulness and avoidance of a stranger following exposure to a socially-anxious mother-stranger interaction, and the effect was stronger for children with an inhibited temperament.²¹ Naturalistic longitudinal studies have demonstrated similar findings, with higher maternal and paternal expressed social anxiety being associated with later infant avoidance of a stranger.^23,24 Research has also shown that early parental anxious modelling (at child age 12 months) predicted anxious responding in children at 30 months, although parent behaviour measured concurrently did not.²³ Again, this suggests that there may be sensitive periods for the impact of parent modelling.

Empirical evidence has demonstrated a relationship between insecure attachment to caregivers and higher anxiety and depressive symptoms in children, but results are mixed and inconsistent.^12,25,26 This is partly due to methodological variability across studies. One meta-analysis measured attachment in infancy through observational studies only and found that a child with an insecure attachment is twice as likely to have internalising problems as a child with secure attachment,¹² although the causal relationship is unknown. There is some evidence that there are differences between maternal and paternal influence on child outcomes;^26,27 with father-child attachment predicting clinical levels of anxiety whereas mother-child attachment did not.²⁶

Research Gaps

The majority of research remains questionnaire-based and cross-sectional. Although there are studies that have used longitudinal or experimental designs, more research is needed to assess the causal role of parental behaviours in the development of anxiety and depression. At the same time, far more sophisticated work is needed to understand the complex interplay between parent behaviours and the age of the child, informant source and parent gender. Indeed, research to date has focused mostly on mothers, although recent research investigating the unique role of fathers in the development of anxiety and depression in early childhood has emerged.^26,27 Most of the research has also been conducted in predominantly Western populations, and research on the relationship between parenting and emotional health across diverse cultures is needed. Another difficulty of research examining the role of parents in child anxiety and depression is to examine the impact of parental behaviours independent of the influence of shared genes.

Conclusions

Together, evidence shows that parent-child relationships have a small but significant impact on the development of anxiety and depression in young children. The most consistent evidence for this relationship has come from research examining maternal control and child anxiety. While higher parental control may be a normative response to a child’s anxious or inhibited behaviour, these behaviours may lead to an increased risk of a child developing anxiety and depression in some circumstances. Further research is needed to better understand the intricacies of this relationship and, particularly, its reciprocal nature, as well as the interplay with other factors.  

Evidence also supports the idea that parents can have an impact on their child through modelling anxiety and verbal transmission of threat information. Research which shows the impact of this modelling on anxiety development, over and above shared genes and across developmental stages, is needed.
The security of a child’s attachment with their parent has been linked to later psychopathology. Given the overlap with other constructs (such as the child’s temperament, other parenting behaviours) and wide variation in methods across studies, the degree to which attachment independently predicts child outcomes is uncertain.

Implications for Parents, Services and Policy

Understanding which parenting behaviours increase a child’s risk for later anxiety and depression has direct implications for early intervention. The findings to date suggest that reducing the degree of parental control and reducing anxious modelling/verbal transmission of threat and avoidance may be important for preventing later internalising problems. Parenting strategies that encourage children’s non-avoidant behaviours and increase opportunities to develop confidence in coping may particularly beneficial. Evidence indicates that these parenting strategies should be targeted at parents of at-risk children, namely children who are behaviourally inhibited. For a child who is uninhibited or displays low levels of anxious behaviours, the increased risk conferred by parenting behaviours may be inconsequential.

References

1. Morris AS, Silk JS, Steinberg L, Myers SS, Robinson LR. The role of the family context in the development of emotion regulation. Social Development (Oxford, England). 2007;16(2):361-388.
2. Rapee R. Family Factors in the Development and Management of Anxiety Disorders. Clinical Child and Family Psychology Review. 2012;15(1):69-80.
3. McLeod BD, Wood JJ, Weisz JR. Examining the association between parenting and childhood anxiety: A meta-analysis. Clinical Psychology Review. 2007;27(2):155-172.
4. Murray L, Creswell C, Cooper PJ. The development of anxiety disorders in childhood: an integrative review. Psychological Medicine. 2009;39(9):1413-1423.
5. Wei C, Kendall PC. Parental involvement: Contribution to childhood anxiety and its treatment. Clinical Child and Family Psychology Review. 2014;17(4):319-339.
6. Rapee RM. Potential role of childrearing practices in the development of anxiety and depression. Clinical Psychology Review. 1997;17(1):47-67.
7. 7.McLeod BD, Weisz JR, Wood JJ. Examining the association between parenting and childhood depression: A meta-analysis. Clinical Psychology Review. 2007;27(8):986-1003.
8. Warren SL, Huston L, Egeland B, Sroufe L. Child and adolescent anxiety disorders and early attachment. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(5):637-644.
9. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum; 1978.
10. Shamir-Essakow G, Ungerer JA, Rapee RM. Attachment, Behavioral Inhibition, and Anxiety in Preschool Children. Journal of Abnormal Child Psychology. 2005;33(2):131-143.
11. Bogels SM, Brechman-Toussaint ML. Family issues in child anxiety: Attachment, family functioning, parental rearing and beliefs. Clinical Psychology Review. 2006;26(7):834-856.
12. Madigan S, Atkinson L, Laurin K, Benoit D. Attachment and Internalizing Behavior in Early Childhood. Developmental Psychology. 2013;49(4):672-689.
13. Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: An observational study. Behaviour Research and Therapy. 2001;39(12):1411-1427.
14. Buss KA, Zhou AM, Trainer A. Bidirectional effects of toddler temperament and maternal overprotection on maternal and child anxiety symptoms across preschool. Depression and 
    Anxiety. 2021;38(12):1201-1210.
15. Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children and adolescents: Developmental issues and implications for DSM-V. Psychiatric Clinics of North America. 2009;32(3):483-524.
16. Hudson JL, Dodd HF. Informing early intervention: Preschool predictors of anxiety disorders in middle childhood. PLoS ONE. 2012;7(8):e42359.
17. Hudson JL, Murayama K, Meteyard L, Morris T, Dodd HF. Early childhood predictors of anxiety in early adolescence. Journal of Abnormal Child Psychology. 2019;47(7):1121-1133.
18. Edwards SL, Rapee RM, Kennedy S. Prediction of anxiety symptoms in preschool-aged children: Examination of maternal and paternal perspectives. Journal of Child Psychology and Psychiatry. 2010;51(3):313-321.
19. Johnco CJ, Magson NR, Fardouly J, Oar EL, Forbes MK, Richardson C, et al. The role of parenting behaviors in the bidirectional and intergenerational transmission of depression and anxiety between parents and early adolescent youth. Depression and Anxiety. 2021;38(12):1256-1266.
20. Thirlwall K, Creswell C. The impact of maternal control on children’s anxious cognitions, behaviours and affect: An experimental study. Behaviour Research and Therapy. 2010;48(10):1041-1046.
21. de Rosnay M, Cooper PJ, Tsigaras N, Murray L. Transmission of social anxiety from mother to infant: An experimental study using a social referencing paradigm. Behaviour Research and Therapy. 2006;44(8):1165-1175.
22. Gerull FC, Rapee RM. Mother knows best: The effects of maternal modeling on the acquisition of fear and avoidance behaviour in toddlers. Behaviour Research and Therapy. 2002;40(3):279-287.
23. Aktar E, Majdandžić M, de Vente W, Bögels SM. Parental social anxiety disorder prospectively predicts toddlers' fear/avoidance in a social referencing paradigm. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2014;55(1):77-87.
24. Murray L, de Rosnay M, Pearson J, Sack C, Schofield E, Royal-Lawson M, et al. Intergenerational transmission of social anxiety: The role of social referencing processes in infancy. Child Development. 2008;79(4):1049-1064.
25. Colonnesi C, Draijer EM, Stams GJ, Van der Bruggen CO, Bogels SM, Noom MJ. The relation between insecure attachment and child anxiety: A meta-analytic review. Journal of Clinical Child and Adolescent Psychology. 2011;40(4):630-645.
26. Breinholst S, Tolstrup M, Esbjorn BH. The direct and indirect effect of attachment insecurity and negative parental behavior on anxiety in clinically anxious children: It's down to dad. Child and Adolescent Mental Health. 2019;24(1):44-50.
27. Van der Bruggen CO, Stams GJJ, Bogels SM. Research review: The relation between child and parent anxiety and parental control: A meta-analytic review. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2008;49:1257-1269.