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Anxiety

How Family Accommodation Worsens Child Anxiety and Function

New research sheds light on how the family system fuels poor outcomes for kids.

Childhood anxiety and mood disorders are on the rise, as reported by the CDC. COVID-19 is hitting children and adolescents hard (Singh et al., 2020), highlighting the critical importance of a secure family, modeling of positive coping, and cultivating constructive ways to bolster resilience in youth1

When children are anxious, the way the people closest to them respond is critical. While sub-optimal parental responses are not consider maltreatment per se (i.e. Adverse Childhood Experiences or "ACEs"), they contribute to developmental difficulties rather than mitigating against them.

Yet parents face their own challenges, and pressure to be better parents especially when adults are under great strain can lead to a downward spiral, harming all. Understanding what helps and what gets in the way allows us to make informed decisions about where to apply limited resources to make things better for all involved.

Adding fuel to the fire

Prior research in the Journal of Clinical Psychiatry (2020, reviewed here) found correlations between increased anxiety and intolerance of ambiguity in children whose parents accommodated excessively to their children’s unhelpful thoughts and behaviors. Accommodation is measured with questions2 probing how often parents avoid triggers or participate in children’s anxious responses, from both parent and child perspective.

Parental over-accommodation is correlated with poorer child emotional and psychological well-being. However, to date, research has been based on statistical associations which suggests but does not provide stronger evidence for causal connection.

In order to move the needle on this critical research subject, a group of researchers from Yale University in the United States, the University of Sao Paulo, Brazil, and the Medical University of Warsaw published more robust research on the subject in the Journal of Anxiety Disorders (2020).

Parents and children don't see things the same

Using a statistical approach called Structural Equation Modelling (SEM), researchers analyzed data from 425 mother-child pairs. SEM does not establish causality in the way a prospective study would (i.e. following participants over a period of years to see what factors earlier on actually predict future outcomes); SEM does provide more reliable statistical findings while also establishing a robust base for future studies.

Participants completed a battery of measures: assessment of child anxiety via the Anxiety Disorders Interview Schedule (ADIS, children and parent versions) and the Screen for Child Anxiety Related Emotional Disorders (SCARED, children and parent versions); family accommodation using the Family Accommodation Scale-Anxiety which looks at ways the family makes room for anxiety, how much the family enables anxiety-related behaviors, and what happens if the child’s anxiety is not accommodated in the short-run; the Child Impact Anxiety Scale (CAIS), in which parents rates to what extent anxiety affects the child’s psychosocial functioning in school, social and home spheres.

Findings

Authors analyzed the data from the perspective of the parents and children separately to generate and compare two models.

Overall, they found that increased family accommodation accounted for increased anxiety symptoms as rated by both mothers and children. Moreover, family accommodation was a significant moderating factor connecting anxiety symptoms with functional impairment in both models, showing that for both mothers and their children, maladaptive ways of responding to anxiety and anxiety-related behaviors did more harm than good.

In both models, family accommodation was a significant indirect contributor to child functional impairment, while age and degree of anxiety were direct contributors. Family accommodation contributed between 20 and 50 percent of functional problems related to increased child anxiety, highlighting how powerful the family environment is for the developing individual. The parent model showed a stronger connection between parent-rated child anxiety and accommodation.

Finally, while both child and parent models support the notion that over-accommodation interferes with healthy anxiety coping, representing maladaptive responses in the family system, the child and parent scores were only weakly correlated. Specifically, family accommodation in the child model had a substantially bigger moderating effect on functional outcomes than in the parent model (correlations respectively of 0.539 and 0.309 for child versus parent scores).

Maintaining an even keel

This work further highlights how key it is to look at context, avoiding the isolating lens of individual pathology. According to data from children and mothers in the same family, accommodation to anxiety and related behavior significantly accounts for negative outcomes in school, social and family functioning. Accommodation is associated with higher levels of anxiety and undesirable short-term responses, such as emotional dysregulation, poor coping, and the risk of longer-term impairment of resilience and emotional well-being. In the child-centered model, accommodation accounted for about as much functional problems as anxiety itself.

The next step in understanding the impact of the family environment would involve longer-term prospective studies which look at actual behavior in the family and long-term outcomes. Interventions designed to reduce over-accommodation would be expected to be associated with better outcomes. This is consistent with family therapy models which strive to change the family system, rather than focusing only on treating the child.

Clinicians often use the term “identified patient” to highlight how children may be singled-out when there are unrecognized family issues, including parental psychiatric problems, substance and alcohol use issues, and maltreatment.

In the long-term, such children often bear the brunt of the family problems, developing significant anxiety disorders, depression, addictive and compulsive behaviors. Problems are passed from generation to generation if unchecked. Children from dysfunctional homes are at risk for relationship problems later in life, including a higher chance of ending up in emotionally-abusive situations when they come from homes with poor psychological boundaries, a lack of appropriate behavioral guidance, and low emotional support.

Finally, it’s noteworthy that the child model showed a stronger connection with family accommodation, anxiety and functional impairment, and the parent model a stronger connection between child anxiety and accommodation.

Children’s data highlights the importance of a healthy environment in scaffolding resilient responses to distress, and the downsides of a family which provides inadequate support, behavioral containment, and emotional and psychological over-enmeshment. The disparity between parent and child stats, and the literature on how parental behavior shapes adult outcomes for children, supports the hypothesis that parents tend to downplay the negative impact of over-accommodation when children become anxious and dysregulated, avoiding embracing the implications of parenting decisions, and potentially impeding positive change.

Please see Footnotes below for 1) recommendations on assisting children and adolescents during stressful time and 2) information on accommodating behaviors.

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References

1. Guidelines (Singh, et al., 2020):

Young children

-Compared to adolescents, younger children demand more attention of their parents. They need their parents’ physical presence and need to engage in more indoor play related activities with them. Parents should devote time to provide the child with undivided, positive attention and reassurance.

-With the aim to increase children's awareness about COVID 19, it is crucial for parents to communicate with young children in an age appropriate manner by using simple terminologies about COVID-19. Children need to be given fact based information with the help of presentations and video material provided by authorized international organizations like WHO and UNICEF or government resources which have been tailor made especially for children.

-To alleviate the anxiety of children regarding the current uncertain situation, children's exposure to news should be limited and be through fact based neutral news channels only. The tabloid news should be avoided by all means.

-The parents are recommended to model appropriate preventive measures and coping mechanisms which the family as a team and children individually are motivated to follow. For this use of reminders through phone may also be used.

-Efforts should be made so that a consistent routine is followed by the child, with enough opportunities to play, read, rest and engage in physical activity. It is recommended that family plays board games and engages in indoor sports activities with the child to avoid longer durations of video games. Parents should ensure that particularly the bedtime of a child is consistent. It is possible that before the bed time children may need some more time and attention.

-Focus should be on the ‘good behaviour’ more than ‘bad behaviour’ of a child. Parents must tell more about options regarding what to do rather than what not to do. Provide more praise and social reinforcements to children compared to material reinforcements.

-It is quite possible that parents observe some amount of change in the behavior in children during the times of a pandemic. If the behavior problems are minor and not harmful for children and others, parents should consider ignoring and stop paying attention to them, this may lead to decrease in the recurrence in behavior and would also help in giving space to each other.

Adolescents

Apart from areas discussed above, certain areas which need especial focus in the phase of adolescence, are being described below:

-Parents are the best ‘role model’ for children and home is practically the best place to learn the ‘life skills’. Hence, this is the best time for parents to model the most important life skills i.e. coping with stress, coping with emotions, and problem-solving with their children. Due to the cancellation of exams handle disappointments and uncertainties more positively. For each disappointment and uncertainty, there should be an alternative. Moreover, to inculcate a sense of control in adolescents whenever possible, parents can include adolescents in the decision-making process especially in matters related to them.

-Adolescents are expected to have better knowledge about COVID 19 compared to young children. Therefore, communication has to be more open and non-directive. On the other hand, judgmental statements about adolescents should be avoided.

-This is an opportunity for older children to learn responsibility, accountability, involvement, and collaboration. By taking some responsibilities at home on an everyday basis, for instance maintenance of their belongings and utility items. They can learn some of the skills including cooking, managing money matters, learning first aid, organizing their room, contributing to managing chores like laundry, cleaning and cooking.

-Excessive internet use e.g. internet surfing related to COVID-19 should be avoided as it results in anxiety. Similarly, excessive and irresponsible use of social media or internet gaming should be cautioned against. Negotiations with adolescents to limit their time and internet-based activities are recommended. More non-gadget related in door activities and games are to be encouraged.

-In such conditions taking up creative pursuits like art, music, dance and others can help to manage mental health and well-being for everyone. Inculcating self-driven reading by making them select books of their choice and discussing about them helps in adolescent development.

-Adolescence is a phase of enthusiasm and risk-taking, hence some may feel invincible and try not to follow guidelines related to distancing and personal hygiene. This has to be addressed with adolescents assertively.

-It is crucial to value the peer support system of the adolescents. Parents should encourage adolescents who are introverts to keep in touch with their peers and communicate with them about their feelings and common problems they face. This may also lead a way for appropriate problem-solving.

-It is advised to parents to take care of their own mental health needs and try to cope with stress adaptively.

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2. Questions from Family Accommodation Scale-Anxiety (Flessner et al, 2011):

1. Have you modified your family routine because of the patient’s symptoms?

2. Have you avoided doing things, going, places, or being with people because of the patient’s

3. Have you modified your leisure activities because of the patient’s needs?

4. Have you modified your work schedule because of the patient’s needs?

5. Have you had to do some things for the family that are usually the patient’s responsibility?

6. How often did you assist the patient in avoiding things that might make him/her more anxious?

7. Has the patient become distressed/anxious when you have not provided assistance?

8. How often did you participate in behaviors related to patient’s compulsions?

9. Has the patient become angry/abusive when you have not provided assistance?

10. How often did you reassure the patient?

11. Has the patient spent more time completing rituals when you have not provided assistance?

12. How often did you provide items for patient’s compulsions?

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