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Anxiety

Over-Accommodating a Child's Anxious Emotions Can Backfire

SPACE helps children and adolescents with anxiety by changing parent behavior. 

Vladislav Vasnetsov/Pexels
Source: Vladislav Vasnetsov/Pexels

Many parents with an anxiety-prone kid become overprotective; Mom and/or Dad will bend over backward to accommodate their child's anxiety by allowing him or her to avoid any situation that triggers anxious emotions.

Although some "parental accommodation" for anxious childhood emotions is healthy and helpful, a growing body of evidence (O'Connor et al., 2020) suggests that too much parental accommodation can make a child's anxiety symptoms worse over time and may lead to debilitating anxiety in adulthood.

What Is the "Supportive Parenting for Anxious Childhood Emotions" (SPACE) Program?

Researchers at Yale have pioneered a parent-based approach for treating childhood anxiety that teaches parents how to take a less "protective and accommodating" stance towards their child's anxiety symptoms in a "supportive manner that conveys acceptance of the child's genuine distress along with confidence in the child's ability to cope with anxiety."

This parent-based intervention for childhood anxiety is called "Supportive Parenting for Anxious Childhood Emotions" and is commonly referred to by the acronym SPACE.

Yale's "SPACE program" is the brainchild of Eli Lebowitz, who developed this novel parent-based treatment for childhood anxiety with his colleagues at the Yale Child Study Center (YCSC) in New Haven, Connecticut.

"There are currently two evidence-based treatments for anxiety—medication and cognitive behavioral therapy. Only half the children respond to these therapies, so there is a great need for alternate treatments," Lebowitz said in a Yale News interview last year. He also says that SPACE "helps parents handle issues arising from living with an anxious child."

Prior to the COVID-19 pandemic, Lebowitz and his YCSC colleagues conducted a randomized study comparing the efficacy of SPACE and cognitive-behavioral therapy (CBT) for treating childhood anxiety in 124 children ages 7-14 with existing clinical anxiety disorders. The primary research objective was to compare SPACE to CBT in a noninferiority trial.

Lebowitz et al. found that children with anxiety disorders "whose parents participated in 12 sessions of SPACE were as likely to overcome their anxiety disorder as children who participated in 12 sessions of CBT, the best-established evidence-based treatment for child anxiety." These findings were published online last year and appear in the March 2020 issue of the Journal of the American Academy of Child & Adolescent Psychiatry.

This study reports that a greater proportion (87.5% vs. 75.5%) of children with existing anxiety disorders whose parents participated in the SPACE program showed significant improvement to their anxiety symptoms in comparison to CBT. Notably, children and parents who participated in this study rated both SPACE and CBT treatments as "highly satisfactory."

Based on these findings, the authors conclude: "SPACE was noninferior, relative to CBT, on primary and secondary anxiety outcomes. SPACE is an acceptable and efficacious treatment for childhood anxiety disorders [that] provides an alternative strategy for treating anxiety in children."

How Does SPACE Work?

SPACE significantly reduces "over-accommodating" behavior by parents. As an example, parents who participated in SPACE counseling learned to be less overprotective but also reassuring by saying things like, "I know you're feeling upset and really stressed out right now, but I know you'll be OK." (See "Validation Is Key")

SPACE also helped some over-accommodating parents gradually reduce the number of text messages they sent to their anxiety-prone children from dozens a day down to just two or three.

Almost a decade ago (2012), Lebowitz and colleagues developed a nine-point scale for measuring parents' tendency to accommodate their child's anxiety called the Family Accommodation Scale—Anxiety (FASA). "The FASA is a brief, easily administered tool that shows promise as a means of assessing the presence, magnitude, and character of family accommodation in childhood anxiety disorders," Lebowitz and co-authors said.

The nine-item FASA questionnaire (included below) asks parents to rank the frequency of their accommodating behavior over the past month on a 1-5 scale. Here's the range: 1) Never; 2) One-to-three times a month; 3) One-to-two times a week; 4) Three-to-six times a week; 5) Daily.

If you're the parent of an anxious child or adolescent, how would you respond to the nine questions on the Family Accommodation Scale for Anxiety below based on a typical four-week period?

Family Accommodation Scale—Anxiety (FASA) by Eli Lebowitz et al.

  1. How often did you reassure your child?
  2. How often did you provide items needed because of anxiety?
  3. How often did you participate in behaviors related to your child's anxiety?
  4. How often did you assist your child in avoiding things that might make him/her more anxious?
  5. Have you avoided doing things, going places, or being with people because of your child's anxiety? (*If you're reading this during a "stay-at-home" order, see note below.)
  6. Have you modified your family routine because of your child's symptoms?
  7. Have you had to do some things that would usually be your child's responsibility?
  8. Have you modified your work schedule because of your child's anxiety?
  9. Have you modified your leisure activities because of your child's anxiety?

Lebowitz and co-authors speculate that reducing parental accommodation helps to combat anxious childhood emotions in a variety of ways:

First, children who have relied on accommodation to avoid feeling anxious may feel this is no longer a viable alternative, thereby leading to increased desire to learn skills that would help them to cope with feelings of anxiety. In addition, the decreased accommodation may have created opportunities for the child to experience themselves as better able to cope than they had believed. By diminishing the reliance on parental regulation of anxious states, children may discover themselves more capable of self-regulation than they had thought.

Now that the efficacy of SPACE has been established, Lebowitz hopes to begin training therapists to offer this program in the near future. In the meantime, he cautions that parents shouldn't ignore their children's anxiety and should seek some type of evidence-based treatment.

*Note: This post was written in April 2020. Please use common sense and filter SPACE and aspects of the FASA scale through a unique "time of coronavirus" lens if you're reading this post during a "stay-at-home" mandate. The spring and summer of 2020 may not be an appropriate time for parents to avoid being overprotective or accommodating.

The coronavirus pandemic has profoundly changed how we go about daily life and affects how each of us copes with our individual, familial, and collective anxiety. On March 30, 2020, the Yale School of Medicine published, "Kids and COVID-19: What Parents Should Know." There's also a regularly-updated Yale Medicine Resource Page for anyone seeking science-based answers to COVID-19 questions.

References

Eli R. Lebowitz, Carla Marin, Alyssa Martino, Yaara Shimshoni, Wendy K. Silverman. "Parent-Based Treatment as Efficacious as Cognitive-Behavioral Therapy for Childhood Anxiety: A Randomized Noninferiority Study of Supportive Parenting for Anxious Childhood Emotions." Journal of the American Academy of Child & Adolescent Psychiatry (First published online: March 7, 2019) DOI: 10.1016/j.jaac.2019.02.014

Eli R. Lebowitz, Haim Omer, Holly Hermes, Lawrence Scahill. "Parent Training for Childhood Anxiety Disorders: The SPACE Program" Cognitive and Behavioral Practice (First published online: November 11, 2013) DOI: 10.1016/j.cbpra.2013.10.004

Eli R. Lebowitz, Joseph Woolston, Yair Bar-Haim, Lisa Calvocoressi, Christine Dauser, Erin Warnick, Lawrence Scahill, Adi R. Chakir, Tomer Shechner, Holly Hermes, Lawrence A. Vitulano, Robert A. King, and James F. Leckman. "Family Accommodation in Pediatric Anxiety Disorders" Depression & Anxiety (First published online: September 12, 2012) DOI: 10.1002/da.21998

Johanna Thompson-Hollands, Caroline E. Kerns, Donna B. Pincus, and Jonathan S. Comer. "Parental Accommodation of Child Anxiety and Related Symptoms: Range, Impact, and Correlates." Journal of Anxiety Disorders (First published online: September 16, 2014) DOI: 10.1016%2Fj.janxdis.2014.09.007

Erin E. O'Connor, Lindsay E. Holly, Lydia L. Chevalier, Donna B. Pincus, David A. Langer. "Parent and Child Emotion and Distress Responses Associated With Parental Accommodation of Child Anxiety Symptoms." Journal of Clinical Psychology (First published: February 12, 2020) DOI: 10.1002/jclp.22941

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