The Child Elf

Parenting is a tough gig. As a mum of three, I can honestly say that nothing in my everyday professional life comes close to the trials and tribulations of guiding small people through toddlerhood and beyond. Parenting advice comes thick and fast from all corners, most of it unsolicited, some of it anecdotal, much of it dubious to say the least (suppositories for potty training, anyone?). However, your kids’ hitting their teens is a total gamechanger (trust me), which forces a parent to recalibrate everything they think they know about childrearing. Whilst rummaging around in the murky depths of our parenting toolkit, desperately reconciling our inner disciplinarian with the memory of our own teenage frolics, we ultimately cross our fingers and hold on to the hope that it will all work out in the end and that our relationship with our kids won’t end up like Philip Larkin’s.

Enter Marie Yap and colleagues from Australia’s Monash University, who have conducted the first systematic review and meta-analysis to focus on modifiable parental factors which may influence the development of depression and anxiety disorders in adolescents aged 12-18 years (the peak age of onset). Using the outcomes of the systematic review together with those from a subsequent Delphi study aimed at evaluating parenting strategies for reducing the risk of adolescent depression and anxiety, Yap and her team have developed a set of evidence–based parenting guidelines – How to prevent depression and clinical anxiety in your teenager: Strategies for parents – which are freely available at http://www.parentingstrategies.net/depression.

Adolescent-onset depression and anxiety forecast a wide range of severe psychosocial and vocational impairments and Yap et al.’s holistic package of work extends previous, limited work in the field by aligning itself clearly with a focus on transdiagnostic preventative measures. It is widely acknowledged that experiences within the family environment play a critical role in exposing adolescents to both the risks and protective factors involved in the development of depression and anxiety disorders. The researchers explicitly underline the pressing need for increased translation of relevant evidence in the targeted setting of the family environment in order to optimise preventative interventions for youth anxiety and depression. As such, both the systematic review and Delphi study concentrate on modifiable parenting factors which can be actioned within the home environment.

Methods

Systematic review

• A systematic literature search was conducted, according to the PRISMA statement.
• Appropriate inclusion and exclusion criteria were applied to screen out irrelevant studies.
• Parenting factors were defined as variables potentially modifiable by the parent and were thematically grouped under two broad dimensions, Rejection (Withdrawal, Aversiveness, and Warmth) and Control (Over-involvement and Autonomy Granting). Supplementary themes were formulated to account for variables that were reported by at least two studies but did not fit into the themes.

• The volume of literature and the diverse range of statistical procedures and methodologies meant that a meta-analysis could only be conducted on a subset of the studies.
• To assist in the interpretation of multiple findings, study designs were ranked according to robustness: prospective cohort studies were considered to provide the highest level of evidence, followed by retrospective cohort or case-control studies, then cross-sectional studies.

Delphi study

• A literature search was conducted with the aim of developing a questionnaire covering the full range of possible strategies that parents could use to prevent or reduce risk of depression or anxiety in their adolescent.
• Through content analysis, 402 unique parenting strategies were identified and organised into 21 themes.
• The questionnaire was administered over three rounds to a panel of 27 international experts (researchers and clinicians), who were asked to rate the importance of items for preventing the development of adolescent depression or anxiety disorders.

Results

Systematic review

• 181 articles reporting 516 associations were identified: 140 reported 358 associations with depression, 17 reported 42 associations with anxiety, 24 reported 58 associations with depression and 58 associations with anxiety.
• 111 studies reporting 303 associations were included in the meta-analyses.

• Lower levels of parental warmth, and higher levels of inter-parental conflict, over-involvement, and aversiveness are associated with increased risk for both depression and anxiety outcomes.
• Lower levels of autonomy granting and high parental monitoring increase adolescent risk for depression only.
• The evidence base for depression is larger and stronger than for anxiety, with more studies of each design found.

Delphi study

• 90 strategies achieved >90% expert consensus.
• The 90 strategies were written into a document suitable for parents, categorised under 11 sub- headings.

Key strengths

• First systematic review with a focus on modifiable parental factors and their influence on the development of both depression and anxiety disorders.
• Use of rigorous PRISMA methodology.
• Transdiagnostic approach.
• Strong focus on pragmatic application of findings.
• Inclusion in the systematic review screening process of all types of peer-reviewed study which fitted the systematic review protocol.
• Production of a set of evidence-based parenting strategies which can be promoted in Western, English-speaking countries.

Key limitations

• Within the systematic review, micro-level interpretation of literature was sacrificed for macro-level overview.
• Highly restrictive inclusion criteria for systematic review literature search, due to volume of literature.
• Inability to conduct meta-analyses on all studies in the systematic review.
• Lack of generalisability across cultures for both the systematic review and the Delphi study.

Discussion

The packages of work have identified various parental factors as having a sound evidence base for predicting adolescent depression and anxiety. Some of the parental factors under investigation are already routinely incorporated into intervention programmes but the work by Yap et al. serves to highlight the importance of including all factors shown to exert an influence by the evidence.

The link between warmth and depression, for example, is well-established and is commonly incorporated into prevention and intervention work; however, factors such as authoritarian parenting style are also routinely incorporated into prevention work, despite a minimal evidence base. Yap et al.’s Delphi study takes the macro-level synthesis of the systematic review out into the field and offers parents a coherent, evidence-based toolkit to work with.

Links

Yap, M.B.H., Pilkington, P.D., Ryan, S. M., & Jorm, A.F. (2013). Parental factors associated with depression and anxiety in young people: A systematic review and meta-analysis. Journal of Affective Disorders. [PubMed abstract]

Yap, M.B.H., Pilkington, P.D., Ryan, S. M., Kelly, C.M., & Jorm, A.F., (2013). Parenting strategies for reducing the risk of adolescent depression and anxiety disorders: A Delphi consensus study. Journal of Affective Disorders. [PubMed abstract]

PRISMA statement: http://www.prisma-statement.org/

Delphi technique: Hsu & Sandford (2007). Delphi Technique, Practical Assessment, Research & Evaluation, Vol 12, No 10 (PDF)

The two papers report work recently completed in the process of developing new parenting guidelines “How to prevent depression and clinical anxiety in your teenager: Strategies for parents”. These guidelines are available for free download at www.parentingstrategies.net/depression. In the portal to this website, http://www.parentingstrategies.net, you will find another sister site which provides parenting guidelines on adolescent alcohol use, and a tailored parenting program which aims to support parents in implementing these guidelines with their teenagers.