Family functioning and anxiety in children: a narrative review

Abstract

Background and Objective

Anxiety is a prevalent emotional problem in children, with family functioning serving as a protective factor. This review examines the relationship between family functioning and childhood anxiety to inform the development of interventions aimed at reducing childhood anxiety within the theoretical framework of family systems.

Methods

A literature search was conducted in the PubMed and China National Knowledge Infrastructure (CNKI) electronic databases. The search included Chinese- and English-language studies on family functioning and anxiety in children, with publication dates ranging from the inception of the databases to January 1, 2025.

Key Content and Findings

The reviewed literature indicates a bidirectional relationship between family functioning and childhood anxiety. Healthy family functioning is associated with a lower risk of childhood anxiety, whereas childhood anxiety can negatively impact parental emotions and contribute to poor family functioning. The parent-child attachment relationship appears to mediate the link between family functioning and anxiety. Secure attachment relationships may mitigate the detrimental effects of specific family structures (e.g., single-parent and grandparent-headed households) and adverse parenting practices (e.g., overindulgence, neglect, and indifference) on children’s mental health. However, existing research has predominantly focused on the cohesion and adaptability dimensions of family functioning, identifying cohesion as a significant predictor of childhood anxiety.

Conclusions

Future research should further investigate how different dimensions of family functioning and secure attachment relationships can reduce the risk of childhood anxiety. Additionally, future studies should explore the multifaceted pathways through which other aspects of family functioning influence childhood anxiety and consider strategies that integrate the strengths of families, schools, and communities to promote children’s mental health. From a clinical psychotherapy perspective, this review offers insights and practical guidance on the impact of family functioning on childhood anxiety, with the overarching goal of mitigating the risk of mental health problems.

Introduction

Anxiety is a significant public health problem. A meta-analysis indicates the global prevalence of anxiety symptoms in children is 20.5% (1), while in China, the rate ranges from 15% to 24% (2). Given its pervasiveness, potential to develop into an anxiety disorder if left untreated, and high comorbidity with conditions like insomnia, childhood anxiety can exacerbate physical and mental health problems, diminish quality of life, and impair social functioning (3,4).

The family is the primary microsystem influencing a child’s physical and mental development. Family functioning describes the processes within a family—such as emotional bonds, communication patterns, and established rules—that influence its members, encompassing aspects like family structure and parenting styles (5). Evidence indicates that healthy family functioning positively impacts children’s mental health by reducing the risk of anxiety, depression, and behavioral problems (2,6,7). Research also links family structure to children’s mental health; for instance, children from single-parent families may be more likely to experience anxiety (8). Furthermore, a network analysis study found that certain parenting styles, particularly the “punishment-denial” mode, are strongly associated with childhood anxiety (9).

Previous reviews and meta-analyses have firmly established a significant negative correlation between overall family functioning and childhood anxiety, identifying healthy functioning as a key protective factor (10,11). The literature also consistently demonstrates that specific parenting styles—particularly those characterized by high levels of control and criticism or low levels of warmth—are potent risk factors for the development and maintenance of anxiety in children. Furthermore, this relationship is often bidirectional; not only do family dynamics influence a child’s anxiety, but a child’s symptoms can in turn increase parental stress and disrupt family processes.

In terms of treatment, family involvement is recognized as best practice, with many established protocols, such as cognitive-behavioral therapy (CBT), incorporating parental components to modify family interactions that maintain anxiety. However, while these individual links are well-documented, a comprehensive approach that uses family systems theory to develop practical and multi-level interventions is still lacking. This represents a pressing need given the public health significance of childhood anxiety (12). This review aims to fill this gap by summarizing current research on the relationship between family functioning and childhood anxiety. The ultimate goal is to offer recommendations for future research and the design of child mental health services that leverage a family functioning framework, thereby improving the mental well-being of children.

This review is grounded in family systems theory. Using this framework, we will explore the mechanisms linking family functioning to childhood anxiety and propose potential intervention strategies. While the core theories discussed are broadly applicable, this review will pay special attention to how these dynamics manifest within the Chinese cultural context, using it as a primary example to explore the interplay between universal psychological principles and specific cultural factors.

Accordingly, this review is guided by three central questions:

1. What are the primary mechanisms, such as attachment styles and parenting practices, through which family functioning influences the development and maintenance of childhood anxiety?

2. Based on these mechanisms, what specific intervention strategies targeting different dimensions of family functioning (e.g., cohesion, adaptability, communication) can be proposed to prevent or mitigate childhood anxiety?

3. How can these family-centered interventions be culturally adapted—with a particular focus on the Chinese context—and integrated into a broader, collaborative framework involving schools and communities to effectively support children’s mental health?

To systematically address our research questions, this review is organized around three central themes. First, we examine the core internal processes of the family system, focusing on foundational dimensions such as family cohesion (emotional closeness), adaptability (flexibility in the face of stress), and communication. Second, we analyze the pivotal role of the parent-child attachment relationship as a primary mechanism through which these broader family dynamics are translated into a child’s experience of security or anxiety. Third, we consider how family structure and specific contextual factors (e.g., single-parent households, the ‘left-behind’ child phenomenon) moderate the impact of family functioning on child mental health. By examining these interconnected themes, the review builds a foundation for proposing targeted and effective intervention strategies. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-324/rc).

Methods

A literature search was conducted in two major databases: PubMed (primarily English-language) and the China National Knowledge Infrastructure (CNKI; Chinese-language). The search included publications from the inception of each database to January 1, 2025. This review considered quantitative and qualitative studies, published in either English or Chinese, that focused on the relationship between family functioning and anxiety in children. Ultimately, 45 articles were selected for inclusion in this study. The search strategy is summarized in Table 1.

Table 1. Summary of the literature search strategy.

Items	Specification
Date of search	January 1, 2025
Databases and other sources searched	PubMed, China National Knowledge Infrastructure
Search terms used	Use “child”, “adolesc*”, “family functioning”, and “anxiety” as keywords that appear in the article title, abstract, or keywords
Timeframe	Inception to January 1, 2025
Inclusion and exclusion criteria	Inclusion criteria: studies—including but not limited to qualitative and quantitative research—that pertain to children’s anxiety and family functioning, and that are published in English or Chinese
	Exclusion criteria: studies that do not examine the relationship between family functioning and children’s anxiety (or mental health more broadly) or that focus on anxiety in mixed samples of children and adults
Selection process	Two authors (Z.Y.Y. and Z.Y.H.) independently screened the search results according to the predefined inclusion and exclusion criteria. When discrepancies arose, a third reviewer (B.L.Z.) was consulted to provide an impartial resolution, ensuring academic rigor and consistency in the selection process

Conception of family functioning

Family functioning refers to a family’s ability to provide a supportive environment that meets the developmental and socialization needs of its members (13). Healthy functioning creates a secure psychological foundation, whereas dysfunction—marked by issues such as poor communication or unstable roles—can leave members’ basic psychological needs unmet, contributing to mental health problems (14). In line with both Family Systems Theory and Ecological Systems Theory, family functioning is understood to critically impact children’s mental health, with anxiety often emerging as a key indicator of distress at the family level (13,15,16).

Theories of family functioning

Theories of family functioning provide frameworks for understanding its core components. Several prominent models offer distinct yet overlapping perspectives:

The Olson Circumplex Model posits that family functioning is determined by three key dimensions: cohesion, adaptability, and communication. This model proposes an inverted-U relationship for the first two dimensions, where optimal functioning is associated with moderate levels of cohesion and adaptability, rather than with extremely high or low levels (17).

The Beavers Systems Model also emphasizes a family’s capacity for adaptation as crucial for effective functioning. This adaptability is primarily manifested in the family’s structure and its flexibility in responding to developmental needs and situational stress (18).

The Skinner Family Process Model proposes that families function and grow by collaboratively completing essential tasks. This model evaluates functioning across seven interrelated dimensions: task accomplishment, role performance, communication, emotional expression, involvement, control, and values (19).

The McMaster Model of Family Functioning similarly suggests that functionality is achieved through the family’s ability to complete a series of tasks. It assesses family functioning across six core domains: problem-solving, communication, roles, affective responsiveness, affective involvement, and behavior control (20).

In summary, while these four models have distinct emphases, they collectively assert that effective family functioning is fundamental to the mental health of its members. Together, they outline the potential pathways—such as through communication, adaptability, and role fulfillment—by which family processes can influence childhood anxiety.

This review adopts Family Systems Theory as its primary organizing framework. This theory posits that the family is a complex, interconnected emotional unit where the functioning of any member cannot be understood in isolation from the system as a whole. Within this broad framework, we integrate several related concepts. Key dimensions of the family system, such as cohesion and adaptability, are utilized to describe the system’s structural properties. We conceptualize attachment theory as a critical lens for understanding the dyadic (parent-child) relationships that operate within the family system, serving as a primary mechanism through which the system’s emotional climate affects the child. Finally, specific parenting styles are viewed as the behavioral expression of the family’s underlying rules, beliefs, and emotional dynamics. By nesting these concepts within Family Systems Theory, we can create a more cohesive and multi-level analysis of how family life contributes to or protects against childhood anxiety.

The protective role of family functioning

A substantial body of evidence establishes family functioning as a critical protective factor for children’s mental health, linked to improved subjective well-being, life satisfaction, self-confidence, and self-efficacy (21). Longitudinal research demonstrates that the quality of family functioning in childhood has lasting effects that extend into adulthood (22,23). For instance, poor family functioning during childhood can impede the development of healthy interpersonal relationships and communication skills later in life, thereby impacting adult social interactions and overall mental health (24).

From a behavioral standpoint, poor family functioning is a significant predictor of childhood behavioral problems. Research shows that it increases the likelihood of externalizing problems, such as aggressive behavior (25). Dysfunctional family environments, often marked by parent-child conflict and marital discord, can deplete a child’s psychological resources. Consequently, children in these settings may engage in social avoidance, which can hinder peer acceptance and the development of prosocial behaviors—a domain significantly influenced by family cohesion (26,27).

The link between family functioning and children’s internalizing problems is equally strong. A healthy family environment fosters secure attachment and meets a child’s developmental needs (28). In such families, children learn to seek support and communicate effectively when facing challenges, creating a positive feedback loop that strengthens their interpersonal skills and personality development (29). Conversely, intense family conflict reduces communication and emotional support, leaving children more vulnerable to external stressors like school bullying (30). While the predictive role of family adaptability on internalizing problems is debated, research consistently shows that family cohesion is a negative predictor of such issues, particularly social anxiety (31-33). Furthermore, poor family functioning is associated with a cascade of negative emotional states, including heightened social sensitivity and a perceived lack of familial warmth. The unresolved accumulation of these emotions can manifest as anxiety, depression, and, in severe cases, self-harm or suicidal behaviors (34).

In summary, these findings illuminate the psychological mechanisms through which family functioning operates as a protective factor. Its influence is not only profound but also long-lasting, shaping development from childhood into adulthood (23). By affecting both externalizing behaviors (e.g., aggression) and internalizing problems (e.g., anxiety), family functioning stands out as a fundamental determinant of a child’s overall well-being.

Family function and anxiety

The family serves a dual role in a child’s development. It is often the most significant source of social support, providing the practical care and emotional communication essential for physical and psychological well-being (35). However, it can also be a primary environmental factor contributing to stress and anxiety (32). Empirical studies confirm this link, showing a significant association between family dysfunction and childhood anxiety symptoms, with these effects varying by gender and sociocultural context (23,32,36,37). This connection can be so profound that anxiety may act as a mediator between poor family functioning and more severe outcomes like suicidal behavior (38,39).

Several dimensions of family functioning are implicated in the development of anxiety. A poor division of family roles, for instance, can create system rigidity and hinder communication, preventing children from receiving the support needed to cope with stress and potentially leading to emotional dysregulation or learned helplessness (40). Similarly, parenting styles characterized by excessive control, negative feedback, or a lack of autonomy support are consistently identified as risk factors for childhood anxiety (2). Cultural context shapes these dynamics; for example, some parenting patterns in Chinese families, where mothers provide intensive emotional support and fathers act as providers, can sometimes lead to unhealthy levels of maternal control, which is itself a form of dysfunction linked to social anxiety (2,41,42).

Furthermore, the relationship is not unidirectional. A child’s anxiety symptoms can strain parental self-efficacy and disrupt family processes, which in turn exacerbates the child’s anxiety, creating a detrimental feedback loop (43-45). The impact of dysfunction is also amplified by factors like parental absence, which is associated with deficits in children’s emotional regulation abilities (46). This is supported by research in China, which found that “left-behind” middle school students report lower family functioning—particularly in adaptability and cohesion—and higher anxiety levels than their peers (15,47).

Conversely, healthy family functioning acts as a powerful protective buffer. By fostering secure attachment, enhancing a sense of belonging, and providing reliable social and emotional support, a well-functioning family can mitigate the psychological impact of major stressors, thereby reducing the risk of anxiety (48). Warm, responsive, and democratic parenting styles are fundamental to building this secure attachment, strengthening the parent-child bond and enhancing overall family resilience (49). Interestingly, some research suggests that perceived family care can be more impactful than continuous physical presence, indicating that the quality of connection may override other factors (50). This helps explain why children in diverse family structures, such as single-parent or same-sex parent homes, are not inherently at higher risk; warm and effective parenting can successfully mitigate challenges related to family structure by establishing secure attachments (51).

Strategies for improving family functioning

Improvements to family functioning can be implemented at multiple levels, from within the family unit to broader community efforts.

Family-level interventions

At the family level, parents can directly improve functioning by cultivating positive parent-child relationships that enhance both intimacy and adaptability (32). This is primarily achieved through a warm and democratic parenting style characterized by emotional support, open communication, and prompt responsiveness to a child’s needs (28,52). By being physically and emotionally present while also encouraging autonomy, parents help their children develop effective emotional regulation strategies and build secure attachments (2,53). This approach helps buffer children against stress and is particularly effective in unique family structures—such as single-parent, blended, or grandparent-led households—where it can help mitigate the impact of absent family roles (49).

School-based interventions

Educational institutions can play a critical role in supporting students and their families. Schools can offer family guidance services, parenting workshops, and psychology courses designed to improve family dynamics. These programs are especially valuable for providing targeted support to children from dysfunctional family environments, helping to address issues before they escalate (53).

Community and societal support

Broader community involvement is also essential. Community organizations and social workers can promote mental health literacy to reduce stigma, connect families to crucial psychological resources, and implement targeted interventions for children and families in need. These efforts create a supportive societal network that reinforces healthy family functioning (54).

Discussion and future directions

The evidence reviewed suggests a clear conclusion: higher-quality family functioning is linked to stronger emotional development and social adaptability in children. As illustrated by the proposed model (Figure 1), secure attachment appears to be a critical protective mechanism mediating the pathway from healthy family functioning to lower levels of childhood anxiety. This finding points to the potential of interventions like attachment-based family therapy as an effective strategy for treating childhood anxiety symptoms (39).

Figure 1.

Relationship between family functioning and childhood anxiety.

However, several questions remain unanswered. A key area for future research is to move beyond general associations and directly investigate whether targeted interventions on specific dimensions of family functioning can prevent or reduce childhood anxiety. While studies often highlight the roles of cohesion and adaptability, their relative importance and interplay require further clarification (54). For instance, adaptability’s influence on anxiety might be mediated by the level of family intimacy (cohesion), a hypothesis that warrants dedicated investigation (55). Future studies should aim to delineate the specific roles of different family functioning dimensions to identify the most potent intervention pathways.

Furthermore, this research must account for specific family structures and cultural contexts. The challenges faced by “left-behind” children in China, for example, often involve parental absence and grandparent-led caregiving, which can lead to role confusion, emotional deprivation, and insecure attachment—all significant stressors that impair family functioning (47,56,57). Therefore, a crucial research direction is to explore whether interventions designed to strengthen attachment relationships can effectively mitigate the negative impacts of parental absence and role confusion on childhood anxiety in such vulnerable populations (42,49,58).

Practical implications

These findings call for a synergistic, multi-system approach to support children’s mental health (59). Based on the evidence, we propose the following strategies:

For families: parents should be equipped with skills to foster warm, democratic, and responsive parenting styles. The goal is to build secure attachments that can buffer children from stress and promote emotional regulation (60).

For schools: educational institutions can proactively support this goal by implementing parent-child activity programs that strengthen family bonds and enhance parental competence.

For communities: community organizations should work to identify and support families facing unique challenges (e.g., single-parent or non-traditional households), connecting them with targeted resources and reducing stigma.

Ultimately, improving family functioning is a shared responsibility. A collaborative partnership between families, schools, and communities is essential for creating an environment where children can thrive emotionally and psychologically.

Practical implications for clinical practice

The findings synthesized in this review also offer several concrete directions for clinicians working with children experiencing anxiety. Translating these theoretical concepts into practice can enhance the effectiveness of assessment and intervention.

Systemic assessment: clinicians should extend their assessment beyond the individual child’s symptoms to include an evaluation of the entire family system. Using tools to measure family cohesion and adaptability can help identify whether a family is operating at the dysfunctional extremes of the inverted-U continuum (e.g., enmeshed vs. disengaged; rigid vs. chaotic). This provides a clearer target for intervention.

Parent psychoeducation: a primary intervention strategy should involve educating parents about the inverted-U model of family functioning. Helping parents understand that both excessive control (rigidity) and a lack of rules (chaos), or extreme emotional distance and a lack of personal boundaries (enmeshment), can contribute to their child’s anxiety can empower them to seek a healthier balance.

Targeting specific family dynamics: therapeutic interventions should focus on modifying maladaptive family patterns. For instance, in rigid families, therapy might aim to increase flexibility in rules and roles. In enmeshed families, the focus would be on establishing clearer interpersonal boundaries and fostering individual autonomy. For disengaged families, interventions would target increasing emotional expressiveness and shared time.

Culturally-informed interventions: when working with families from specific cultural backgrounds, such as in China, clinicians must deliver these interventions with cultural sensitivity. For example, psychoeducation should acknowledge and respect cultural values related to parental devotion and academic achievement while illustrating how a balanced, less controlling parenting style can actually support those long-term goals by fostering resilience and well-being in the child (61).

Preventative strategies: the principles outlined can inform family-based prevention programs. School and community workshops can proactively teach parents about the importance of balanced cohesion and adaptability, equipping them with the skills to build a supportive home environment that buffers against the development of anxiety disorders.

Conclusions

The evidence presented confirms that poor family functioning, characterized by factors such as parental neglect and a lack of emotional support, is a significant risk factor for childhood anxiety and other behavioral problems (49,51). Therefore, interventions aimed at improving family functioning should be considered a cornerstone of children’s mental health services.

This review highlights secure attachment as a key mechanism and primary target for intervention (62). A warm, democratic parenting style and consistent parental companionship are fundamental to building these secure attachment relationships, which in turn enhance overall family functioning (32). Strengthening this parent-child bond can mitigate the negative effects of challenges like role confusion or inconsistent parenting. This approach is especially valuable in unique family structures, such as single-parent or grandparent-led households, where fostering secure attachment can provide a crucial buffer against instability.

In summary, this review provides practical directions for addressing childhood anxiety from a family systems perspective. To build on this, future research should focus on several key areas:

1. Exploring other influential dimensions of family functioning beyond those discussed.

2. Identifying a wider range of effective and accessible intervention strategies tailored to diverse family needs.

3. Investigating the specific pathways through which these interventions improve child mental health outcomes.

4. By continuing to investigate these dynamics, researchers and clinicians can better equip families to serve as a foundational source of resilience and well-being for children.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.