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Parent Training for Childhood Anxiety Disorders: the SPACE Program

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Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in children’s therapy, training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment manual are included with the hope of “bringing the treatment to life” and conveying a rich sense of the therapeutic process. Parents participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the child’s motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may be effective in improving childhood anxiety.
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Parent Training for Childhood Anxiety Disorders: The SPACE Program
Eli R. Lebowitz, Yale Child Study Center
Haim Omer, Tel Aviv University
Holly Hermes and Lawrence Scahill, Yale Child Study Center
Anxiety disorders are the most prevalent disorders of childhood and adolescence. Cognitive behavioral therapy (CBT) for anxiety poses a
challenge for clinicians as it requires active client participation, and many children either decline or do not adequately comply with
treatment. In addition, even after treatment with CBT, up to 50% of children remain symptomatic, and many still meet diagnostic
criteria. Parent-directed clinical work has been advocated as a potential enhancer of treatment outcomes, and exclusively parent-based
interventions might replace child treatment when the child is reluctant. However, parent involvement has yet to be shown to significantly
improve outcomes, relative to child-only therapy. Studies so far have focused mainly on including parents in childrens therapy,
training parents as lay therapists, or teaching parenting skills. Parent training focused on parental behaviors specific to childhood
anxiety, such as family accommodation, may be more effective. In this treatment development report we present the theoretical
foundation, structure, and strategies of a novel parent-based intervention for childhood anxiety disorders. We will also present the
results of an open trial of the treatment, with an emphasis on feasibility, acceptability, and initial outcomes. Participants in the trial
were parents of 10 children, aged 9 to 13. Children had declined individual child treatment. Multiple excerpts from the treatment
manual are included with the hope of bringing the treatment to lifeand conveying a rich sense of the therapeutic process. Parents
participated in 10 weekly sessions. Significant improvement was reported in child anxiety and family accommodation as well as in the
childs motivation for individual treatment. No parents dropped out and satisfaction was high. The SPACE Program (Supportive
Parenting for Anxious Childhood Emotions) is a novel, manualized parent-based intervention that is feasible and acceptable and may
be effective in improving childhood anxiety.
ANXIETY disorders constitute the most prevalent group
of child psychiatric disorders (Costello, Egger, &
Angold, 2005). Anxiety disorders have negative implica-
tions for child development and functioning, create
burden for parents and family members, and carry sig-
nificant societal cost (Creswell & Cartwright-Hatton, 2007;
de Abreu Ramos-Cerqueira, Torres, Torresan, Negreiros,
& Vitorino, 2008; Essau, Conradt, & Petermann, 2000;
Newman, 2000). Cognitive-behavior therapy (CBT)
has been strongly supported as an effective treatment
for childhood anxiety, but many children continue to
meet diagnostic criteria after treatment and many
more continue to have significant symptoms of anxiety
(Compton et al., 2004; Rapee, Schniering, & Hudson,
2009). CBT involves teaching skills to identify and
challenge maladaptive thoughts, self-regulate anxiety,
and systematically engage in previously avoided situations.
As such, successful CBT requires active collaboration
between child and therapist, a degree of participation that
is frequently unattainable. Furthermore, many patients
decline to participate in treatment altogether (Krebs &
Heyman, 2010; Walkup et al., 2008). Some children are
too anxious to agree to participate in a treatment that will
require them to confront their fears, others are loath to
recognize that they have a problem at all and others may
be aided in avoiding the anxiety through family accom-
modation of their symptoms. Oppositional tendencies
may also preclude a productive alliance of clinician and
child (Garcia et al., 2010).
When child participation in treatment is not possible,
or when a child is not responding to treatment, parent
training may offer a more viable alternative. Various
parent and family factors have been tied to the de-
velopment and maintenance of childhood anxiety disor-
ders (Dadds, Barrett, Rapee, & Ryan, 1996; Ginsburg,
Siqueland, Masia-Warner, & Hedtke, 2004; Rapee, 1997;
Siqueland, Kendall, & Steinberg, 1996; Wood, McLeod,
Sigman, Hwang, & Chu, 2003), and family variables have
been shown to predict outcomes for child treatment
Keywords: anxiety disorders; parent training; treatment outcomes;
family accommodation
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Cognitive and Behavioral Practice 21 (2014) 456-469
(Crawford & Manassis, 2001; Southam-Gerow, Kendall, &
Weersing, 2001). Parent training has also been effective in
the treatment of other disorders. In externalizing
disorders, for example, in which child motivation for
treatment is often low, parent training has been an
effective, evidence-based method of treatment (Eyberg,
Nelson, & Boggs, 2008; Kaminski, Valle, Filene, & Boyle,
2008). The evidence supporting a role for family factors
in the etiology of child anxiety, the data tying family
variables to child outcomes, and the success of parent
work in other disorders have all led to a common assump-
tion that parent involvement in treating childhood anxiety
would enhance treatment outcomes. However, in the case
of anxiety disorders, parent involvement in treatment has
not yet produced the desired results. A number of clinical
trials have compared child treatment with parental
involvement to child only treatment and have failed to
convincingly show superior results for the inclusion of
parents (Barmish & Kendall, 2005; Breinholst, Esbjorn,
Reinholdt-Dunne, & Stallard, 2012; Reynolds, Wilson,
Austin, & Hooper, 2012; Silverman, Pina, & Viswesvaran,
2008). Overall, child therapy with parent involvement has
been largely equally effective to child-alone treatment, but
not more so.
Of the approximately 10 randomized control trials
(RCTs) that have compared outcomes for childhood
anxiety with and without parental involvement in treat-
ment, one has shown clear benefit of including parents
(Barrett, Dadds, & Rapee, 1996), while other have shown
nonsignificant trends in this direction (Cobham, Dadds, &
Spence, 1998; Heyne et al., 2002; Mendlowitz et al., 1999;
Spence, 2000; Wood, Piacentini, Southam-Gerow, Chu, &
Sigman, 2006), no effect (Nauta, Scholing, Emmelkamp,
& Minderaa, 2001; Nauta, Scholing, Emmelkamp, &
Minderaa, 2003; Siqueland, 2005), or even an advantage
for child-only treatment (Bodden et al., 2008). Very
few studies have tested parent-only interventions for
childhood anxiety and among the few existing studies
(Cartwright-Hatton et al., 2011; Lyneham & Rapee, 2006;
Thienemann, Moore, & Tompkins, 2006) the emphasis has
been on training parents as lay therapists to implement
CBT with the child.
One explanation for the underwhelming results of
including parents in child CBT may be in the lack of
theory-driven interventions that target parental behaviors
specific to the context of childhood anxiety. Parent
inclusion in treatment has so far focused primarily on
making parents more involved in the childs treatment
(for example, by having parents attend child sessions),
training parents as lay CBT therapists, and teaching
generic parenting skills such as problem-solving. A recent
study of childhood obsessive-compulsive disorder
(OCD), which reported significantly improved response
rates when including parents in treatment (Peris &
Piacentini, 2012), stands out with its theory-driven focus
on particular aspects of the parent-child relationship and
its concentration on cases that otherwise are likely to be
refractory.
In the case of most anxiety disorders, a relatively small
number of programs have focused on modifying parental
behavior specific to the context of a childs anxiety
symptoms. Among these are such programs as Timid to
Tiger (Cartwright-Hatton, 2010; Merry, 2011) and mod-
ifications of Parent Child Interaction Therapy (PCIT) for
use with anxiety disorders (Pincus, Santucci, Ehrenreich,
& Eyberg, 2008; Puliafico, Comer, & Pincus, 2012). These
interventions integrate the parent training know-how
developed in the areas of parent management and
treatment of disruptive behaviors within the framework
of a therapy for childhood anxiety. However, these
interventions are aimed primarily at younger children.
PCIT modifications such as the CALM program (Puliafico
et al., 2012) are aimed at children up to age 7, and Timid
to Tiger is geared to children through age 8. PCIT relies
on child participation in the treatment sessions, and
although this can be difficult, it is a challenge that can
generally be overcome with young children. Timid to
Tiger does not actively involve children, but it is a group
intervention and also focuses on younger ages.
This report presents a manualized parent-based treat-
ment intervention (Lebowitz & Omer, 2013). The SPACE
Program (Supportive Parenting for Anxious Childhood
Emotions) moves away from teaching parents specific sets
of skills and aims to target the fundamental dynamics
underlying the interaction between parents and anxious
children. SPACE has shown promise in parent-based
treatment of childhood and adolescent OCD (Lebowitz,
2013). SPACE is designed to be implemented with school-
age children and adolescents and is exclusively parent-
based, allowing for treatment delivery without the need
for child collaboration.
Theoretical Foundation
Anxiety as a Systemic Phenomenon
Like most mammals, children are born physically and
psychologically unprepared to contend with danger.
Rather, they rely on caretakers (typically, though not
exclusively, biological parentsas we will henceforth
refer to them) for many of the basic functions involved in
dealing with threat. Parents provide protection from
threat, reassurance of safety when appropriate, and aid
in the regulation of inner states of arousal. Various
theoretical perspectives, such as attachment theory have
described the bond between parents and children, and
the ways in which anxiety activatesthose bonds, causing
children to seek parental soothing or protection and
parents to provide them (J. Bowlby, 1969;R.Bowlby &
King, 2004). In Harlows seminal experiments on primate
457Parent Training for Childhood Anxiety
attachment, for instance, fear was used to trigger the
attachment response in young monkeys (Harlow &
Zimmermann, 1959).
Elements of the anxiety response are generally
adaptive and desirable when an individual is faced with
actual threat, but become maladaptive when repeatedly
activated by realistically innocuous stimuli in the context
of an anxiety disorder. This is generally accepted to be
true of elements of the anxiety responsefor example,
physiological and cognitive shifts that occur within the
individual (e.g., Beck, Emery, & Greenberg, 2005)but
the principle can also be applied to the interpersonal
and systemic aspects of anxiety. Parental responses to a
childs anxiety could be characterized as repeated
triggeringof the attachment system, leading parents
to act protectively, provide reassurance, aid in regulation
of arousal and negative affect, and assist in avoiding
anxiety-provoking stimuli.
However, these responses are mostly counter to the
cognitive and behavioral principles of overcoming anxiety
and may impede progress in CBT. Where CBT aims to
promote coping, minimize avoidance, encourage deliber-
ate exposure, and decatastrophize the experience of
anxiety (Lebowitz & Omer, 2013), parentsprotective
responses may do the opposite. Children with anxiety
disorders also typically exhibit difficulty with the self-
regulation of emotion (Suveg, Sood, Comer, & Kendall,
2009; Suveg & Zeman, 2004), and protectiveness may
encourage the ongoing reliance on parents for regulating
or avoiding their inner affective state. The SPACE Program
aims to address these core aspects of the parent-child
relationship shaped by the recurring anxiety. One concept
that captures many of the ways in which parents are drawn
into their childsanxietyisfamily accommodation.
Family Accommodation
Family accommodation, which was first studied in
relation to OCD (Calvocoressi et al., 1995; Lebowitz,
Panza, Su, & Bloch, 2012; Storch et al., 2007) and more
recently across anxiety disorders (Lebowitz et al., 2013),
describes parental behaviors aimed at helping a child to
avoid the distress caused by their disorder. Accommoda-
tion can include both active participation in the childs
anxious symptoms, and modification to the parentsor
familys routines caused by the childs anxiety. Examples
of participation include answering reassurance-seeking
questions for a child with generalized anxiety or sleeping
next to a child with separation anxiety. An example of
modifications would be not inviting guests to the home
when a child has social phobia. Family accommodation
has been shown to be a significant predictor of poor
treatment outcomes (Crawford & Manassis, 2001; Garcia
et al., 2010). In one study (Storch et al., 2010), family-
based treatment for childhood OCD that targeted
parental accommodation to the childs symptoms was
effective in reducing the accommodation and improving
OCD symptoms even among children who were classified
as medication nonresponders. In another study, using the
SPACE approach described here, parent-based treatment
aimed at reducing accommodation led to significant
improvement in children who resisted individual therapy
(Lebowitz, 2013).
Nonviolent Resistance and ParentsAbility to
Take Action
A child who is very anxious or who has come to rely
extensively on family accommodation may resist or
actively oppose any changes that threaten to reduce the
accommodation. Reports on children with OCD have
indicated that children often forcefully impose accom-
modation on their parents. Many children even react
violently, with physical or verbal aggression, to infringe-
mentsof the accommodation (Lebowitz, Omer, &
Leckman, 2011; Lebowitz, Vitulano, Mataix-Cols, &
Leckman, 2011; Lebowitz, Vitulano, & Omer, 2011).
These outbursts can be conceptualized as extinction
burstsand present a serious challenge to parents
attempting to limit the accommodation to the childs
symptoms. Other children may respond with dramatic
displays of distress, threats toward themselves, or accusa-
tory remarks toward parents (e.g., You dont love me).
Parentsability to modify their responses is therefore
often contingent on their ability to act without the childs
collaboration, and even in the face of significant
opposition. However, equally important is the need to
avoid escalating the aggression or responding in kind
for instance, becoming entrenched in shouting matches,
arguments, power struggles, or physical altercations.
One theoretical and conceptual framework uniquely
suited to overcoming this difficulty is that of Non-Violent
Resistance (NVR). NVR was pioneered in the geopolitical
sphere by movements such as those led by Gandhi and
Martin Luther King, Jr. (Gandhi, 1951; King, 2003) and
has been adapted to the family context by Omer (2004,
2011). The core principle of NVR is that in a situation of
conflict or disagreement, the choice to focus on changing
the other leads to obstinate resistance and escalation, and
causes the individual to miss opportunities to act
productively by shaping their own behavior. In an NVR
process the question of How can I make you do thisis
replaced with How can I stand by my own beliefs, without
attacking or giving in?Abiding resolutely to this principle
may help parents avoid being drawn in by the childs
strong affect or impulsive acts, allowing them to diffuse
many otherwise explosive situations. NVR responses can
include the deliberate ignoring of undesirable behaviors
458 Lebowitz et al.
similar to that used in other behavioral programs, but can
also include other, more activesteps taken to resist
unacceptable behaviors.
Translations of the NVR approach have shown
initial effectiveness in helping parents to cope with self-
destructive or aggressive behaviors of youth (Weinblatt &
Omer, 2008), as well as with demands of highly de-
pendent young adults (Lebowitz, Dolberger, Nortov, &
Omer, 2012). Like child anxiety disorders, these situa-
tions present complex dilemmas in which behavioral
approaches aimed at directly changing the childs
behavior may lead to counterproductive and rapidly
escalating results. The SPACE Program applies the
principles of NVR to help parents reduce their own
accommodating behavior in the context of a childs
anxiety and to cope with the childs distress or resistance,
while maintaining a supportive stance toward the child.
The SPACE Program integrates this theoretical foun-
dation in an attempt to operationalize a conceptual shift
in parent-based interventions for childhood anxiety. It
does not focus on teaching parents specific skills such as
positive reinforcement or problem solving, nor does it
attempt to use parents as lay therapists in order to modify
the childs behavior. Rather, it explicitly focuses on
changing parent responses to the childs anxious states,
gradually withdrawing the accommodating behaviors on
which the child has come to rely. In doing so it adopts a
systemic rather than purely individual view of childhood
anxiety. The program adopts principles and tools
developed in other contexts, such as NVR, to provide
parents with practical tools for acting in a unilateral
fashion, neither encouraging maladaptive behavior nor
acquiescing to it. Like PCIT for anxiety and similar
programs (Cartwright-Hatton, 2010; Comer et al., 2012;
Puliafico et al., 2012), SPACE integrates tools that are
useful for dealing with externalizing behaviors into a
treatment for anxiety. However, it provides a framework
for dealing with the developmentally distinct challenges
of older children. It also does not rely on the childs
participation in treatment, which can be harder to
achieve with children beyond early childhood. The
increased focus on family accommodation in SPACE
expands on the systemic conceptualization of anxiety by
targeting the core attachment dynamic: childrens need
for, and parentstendency to provide, protection and
regulation of negative affect. Parents learn to anchor
themselves more effectively in the face of the childs
distress and provide the child with an anchor to withstand
their own powerful emotions (Omer, Steinmetz, Carthy,
& von Schlippe, 2013).
Treatment Procedure and Clinical Vignettes
The SPACE Program treatment manual is both
structured and flexible. Treatment proceeds along a
series of steps that are consistent across cases. Treatment
modules are implemented as needed during the course of
therapy to address particular issues or difficulties. The
first step in treatment is an introductory phase during
which parents are introduced to the systemic conceptu-
alization of childhood anxiety and to the rationale and
principles of treatment. During this phase many parent
questions (e.g., Why am I here and not my child?
Does this mean that it is my fault?) are addressed. The
following are two excerpts from The SPACE Program
manual introducing the notion of parent change as a tool
for treatment, and the idea of acting without a childs
collaboration:
Ask parents to describe prior attempts at directly changing child
behavior, thought, or emotion and the results that this had. Discuss
the reasons that this approach has not been successful and help
parents to see that it is not because they have been doing it wrong.
It is important that you understand that those attempts did
not fail because you didnt think of the right thing to say, or
because the wrong person said them. We simply cant make
someone different, unless they ask us to help them change.
That is why in this treatment we have something better. We
have a tool so powerful that if we use it your child will almost
certainly start to get better. And the wonderful thing is that
this tool is one you actually can control. What is it? It is your
own behavior! We know that if you can change your own
behavior in some important ways then you can help your
child to cope much better with anxiety!
Some children may feel compelled to resist the changes you
make, because of their anxiety. This is normal and to be
expected. If children were able to take the long view and act
in their own long-term best interests all the time they
wouldnt be children at all. They would be quite remarkable
adults. However, it is important that you remind yourself that
you are acting in your childrens best interests and that the
steps you take will not harm them. As we plan the steps you
take, we will also talk about how to respond in a productive
and supportive way to your childs reactions to the process.
The next step involves parents and therapist meticu-
lously reviewing the familys daily schedule and habits,
identifying accommodating behaviors, systematically
charting and monitoring these over the course of the
week, and then choosing particular target problems to
address. Then, parents are advised on how to inform the
child that they will be working to change their behavior in
the targeted domain. Below is an excerpt from the
manual describing how parents might inform the child:
Find a time when you and your child are both calm and relaxed. It is
important to have both of you present for this discussion, so make sure
to pick a time when you are both free of other obligations and
distractions. You may need to arrange for someone to watch the other
siblings while you are having this conversation, or perhaps choose a
time when they are out of the home. This part of the process should
never be done at the moment at which your childs anxiety has been
triggered. In other words, if your child is afraid of going down into
the basement alone and has just come up after a failed attempt to go
459Parent Training for Childhood Anxiety
there, dont take that moment as the opportunity to say, You know,
we really need to talk about thatwe are going to be working on that
very fear.Rather, wait for a time when your child is not acting
fearful and you are not feeling frustrated by his avoidance.
Sit down with him in a relaxed way and say, We know how difficult
it is for you to do ____________ (fill in as appropriate). We
understand it makes you feel really anxious or afraid. We want you to
know that this is perfectly natural and everyone feels afraid some of
the time. But we also want you to know that it is our job as your
parents to help you get better at things that are hard for you, and we
have decided to do exactly that. We are going to be working on this for
a while and we know it will probably take time, but we love you too
much not to help you when you need help. Soon well talk about it
again and we will have some ideas for things to do that will make you
get better at handling ______________. We are really very proud of
you!
Parents are often encouraged to use written rather
than verbal communication. This is particularly useful
when relations are strained or they anticipate a hostile
reaction. The treatment manual includes specific instruc-
tions on formulating the written message and dealing with
childrens reactions to it. For parents who have not yet
informed the child that they are participating in
treatment, this step will also serve that purpose. Through-
out the SPACE Program parents are encouraged to be
open and transparent with the child about their plans.
In the next step the therapist and parents plan specific
changes to the targeted parental behavior and inform the
child of the particular changes they will make. Below is an
example of a plan formulated for a child with generalized
and separation anxiety who was calling her mothers
phone multiple times per day. Included is the suggested
text for informing her of the planned changes:
Plan:
Mother and father will each not respond to more than one
phone call a day.
Mother and father will each call child one time per day.
Mother will call at 2 P.M. and father will call at 4 P.M.
Child will be rewardedone Disney princess cardfor
every day they do not call each parent more than one time.
Child will be informed of this in advance.
Child will be instructed to send a text message in case of
urgent need to communicate with parents. The text message
must include the specific reason for calling. Any other
messages will not be responded to.
Text:
Monica, last week we told you we were going to be thinking about
ways to help you get better at handling the worry-thoughts you have
every day. We know those thoughts make you really scared and are
proud of you for doing so well at school and dance despite the
thoughts. Even though you think you really need to talk to us on the
phone when you have those thoughts, we are sure that you will
actually be okay even if you dont talk to us. We believe that 100%.
Thats why from now on Mom and Dad are not going to answer the
phone when you call us at work more than one time. You can talk to
each of us one time and after that we will not answer any more.
Because we know how hard it might be for you we will also call you
one time every day. Mom will call you at 2 and Dad will call you at
4. When you manage not to call each of us more than one time you
will get a prizeone Disney princess card. If it is too hard for you one
day and you call us more often than one time you can always try
again the next day. But even if you do call we will not answer after
the first time. If you have something that is really urgent to tell us you
can send mom or dad a text message and tell us what the matter is.
We will decide if we should call you or not. We know this could be
hard and we are not trying to punish you or hurt you. We love you
and want to help.
Note that although the gradual steps described in this
plan are similar to those constructed in other treatments
for anxiety, the SPACE plan focuses entirely on the
parentsbehavior. The child is not required to change her
behavior (although she is rewarded if she does) and
therefore the plans success does not hinge on the childs
cooperation. Instead, the parents make it clear that they
will change their behavior (not answering the phone) and
only they are responsible for the implementation.
Over the remainder of treatment additional target
problems are addressed and parents are encouraged to
increasingly take initiative in choosing the problems and
formulating the plans. The actual accommodation is
carefully monitored and difficulties in accomplishing the
planned changes are discussed. At the end of treatment
the overall changes are reviewed and the parents plan for
dealing with similar problems in the future.
Supplemental Modules and Tools for Troubleshooting
the SPACE Program
Increasing Collaboration Between Parents
This module includes tools for overcoming difficulties
in creating a collaborative process that engages both
parents, addressing differing points of view, and main-
taining a unified stance with regard to the child. One
common challenge occurs when one parent focuses on
accepting the childs difficulties and providing warm
empathy while the other feels strongly that accommodat-
ing the symptoms encourages the childs avoidance. The
therapist integrates both parentspoints of view and
emphasizes that supporting the child requires both
empathic acceptance and reducing accommodation in a
way that conveys confidence in the childs abilities. The
therapist introduces exercises such as role-play and
creating dedicated times for communication. Below is
an example of the way role-playing is used to increase
collaboration:
For one night I would like to ask you to change places,to switch
roles. You, Mom, have been working so hard to make sure that Kyle
feels comforted at night and that he can rely on you. You will be
responsiblefor just this one nightfor helping Kyle to see that he
can handle being anxious even if he doesnt sleep next to you.
460 Lebowitz et al.
Remember, this is only for just the one night. You, Dad, have been
trying hard to make sure Kyle overcomes his fear and does not rely too
much on your presence or reassurance. Just for tonight, you will have
another jobyou will simply try to help him to feel loved, accepted,
and comforted. For this one night you will not try to make him better,
only make him feel better.
Accessing Support
The SPACE Program encourages parents to enlist the
support of others from outside the immediate nuclear
family who can bolster the parentsefforts, reinforce their
messages to the child, act as mediators when a child
responds with hostility, encourage and aid the child in
coping withthe changes, and support the parents in dealing
with the difficult process. Parents create a list of potential
supporters and are guided in asking for their help and
assigning specific roles they can play. The manual includes
suggested texts for addressing parentsinhibitions
around engaging others in the process, such as the fear of
condemnation, trepidation about the childs reactions, or
embarrassment at washing their dirty laundry in public.
Dealing With Disruptive Behavior
This session module is deployed when parents fear a
child will respond aggressively to the planned changes, or
when this has occurred over the course of treatment.
Extinction bursts brought on by the reduced accommo-
dation can challenge the parentsdetermination and the
aim of this module is to equip with the parents with
effective tools for weathering these episodes. The tools
draw on other helpful implementations of NVR for
destructive and explosive behaviors of youth. They
include teaching parents to delay their response lowering
the likelihood of impulsive reactions parents may regret
later, to utilize supporters in order to ensure the childs
behavior is publicizedoutside of the immediate family,
to convey to the child the severity of the behavior in a
serious but not accusatory way, and to demonstrate the
determined but nonviolent opposition to these behaviors.
Below are two excerpts of sample texts that supporters can
use to convey to the child their response to violent or
explosive behaviors:
Fiona, I really like you and think youre a great kid. I heard from your
mom and dad that you acted violently the other day. You hit them and
used words like asshole.I want you to know that even if you were feeling
bad that kind of behavioris not something thats ever okay. I know your
parents are trying to help you get better at handling things and I really
support them. I also would really like to help you if I can. If there is any
way I might help at all please let me know.
Gary, I knowyou are a good boy. The pastfew nights I have heard from
my house the way you have been acting. I even saw you runinto the street
after your parents. I know you must have been really upset but that kind
of behavior is not good. It is dangerous. I think your parents are doing
their job, trying to help you, but if I can help in some wayI would love to
try. Perhaps there is something youdlikemetotellthem?
Coping With Threats to Self
This module instructs parents on maintaining safety
and responding appropriately when a child expresses
threats toward himself as a result of the parentsactions.
Parents learn the importance of not disregarding such
threats and of not allowing the threat to undermine their
determination to help the child overcome anxiety. What
follows is an example of text used by parents to inform a
child of the seriousness with which they are taking threats
of self-injury and of their plans to act in order to protect
the child from harm.
What you said earlier, about killing yourself, is very serious. We love
you very much and as your parents it is always our job to keep you
safe. We will do anything we can to make sure you do not get hurt,
even from yourself. We have decided that we must supervise you to
make sure nothing bad happens to you. We will watch you for
24 hours and then decide how to proceed. Because we need to keep
you absolutely safe we will get help from relatives or friends who care
about you and will help us to protect you. For the next 24 hours you
will not be alone. This is not a punishment and you should definitely
tell us if you think about suicide so that we can help you to stay safe
and get better.
Teaching and Modeling Self-Regulation
Parents learn cognitive and physiological tools and
practice them with the child. Relaxing breathing and
progressive muscle relaxation target the need for somatic
regulation. Cognitive restructuring, self-talk, and the use
of imagery target the cognitive and emotional aspects of
anxiety. The use of these tools in SPACE is different from
that in CBT for anxiety and in other parent interventions.
In SPACE, the tools are only implemented when a child is
receptive, and the treatment relies primarily on the
reduced accommodation in the parentsbehavior. This is
in contrast to CBT for anxiety, which relies primarily on
modifying the childs behavior through the use of these
skills and through exposures. In accordance with the
parental emphasis of the SPACE Program, parents are
encouraged to model the use of self-regulation skills to
better cope with the childs distress. By applying the tools
to themselves, when feeling overwhelmed by the childs
anxiety, the cycle linking parent and child anxiety can be
interrupted. A therapist can introduce this goal in the
following way:
In the past, you often reacted very anxiously when your child became
fearful. Thats normal, but reacting like that can actually increase
your childs fear as well. He can sense that you are afraid of his fear.
It would be helpful for you to learn to control your own reactions, so
you can better withstand his anxiety. We will learn some simple
exercises that will help you do that. Then you can say to your child: I
didnt used to think that you can cope with anxiety. I would get very
afraid for you, and I know that made you more afraid as well. Now I
understand that you are stronger than I thought. I have become sure
that you can cope. So now, when I feel afraid for you I take a deep
breath and that helps me to calm down. I tell myself that you are
strong. I would like to help you to use tools like that as well.’”
461Parent Training for Childhood Anxiety
Open Trial of the Space Program
We now present results from an open trial and fea-
sibility study of the SPACE Program. In accordance with
accepted guidelines for the development of evidence-
based interventions, we conducted this open pilot be-
fore undertaking more systematic, larger or controlled
trials of the program in order to gauge its feasibility,
acceptability, and potential efficacy, as well as to allow for
fine-tuning of the manual, which had been largely
developed in earlier piloting stages (Rounsaville, Carroll,
& Onken, 2001). The goals therefore were to assess
treatment integrity, adherence, and acceptability, as well
the changes in child symptomatology. We chose to focus,
for the purposes of this trial, on parents of children
who had refused individual treatment because this is a
population of anxious children much in need of novel
interventions.
Materials and Methods
Participants
This study was conducted at the Yale Child Study
Center Program for Anxiety Disorders. Participants were
the parents of 10 children, aged 9 to 13, (Mage = 11.2;
50% male). Inclusion criteria included (a) primary
DSM-IV-TR (American Psychiatric Association, 2000)
diagnosis of either generalized anxiety disorder (GAD),
separation anxiety disorder (SAD), social phobia (SoP) or
OCD; (b) a score of 13 or more on the Pediatric Anxiety
Rating Scale (PARS) (RUPP Anxiety Study Group, 2002)
to reflect clinically significant anxiety; (c) child was
offered the opportunity to participate in individual CBT
and refused, or child refused to attend the assessment per
parent report; (d) significant family accommodation as
indicated by a score above 13 on the items from the
Family Accommodation ScaleAnxiety (FASA; Lebowitz
et al., 2013); (e) child had not been diagnosed with and
did not meet criteria for a bipolar disorder or schizo-
phrenia spectrum disorder or pervasive development
disorder; (f) child was either not taking psychotropic
medication or was kept on a stable dose for the duration
of the trial. Parents of 14 children were offered
participation, 11 completed all baseline assessments and
were eligible. Parents of 10 children chose to participate.
Of these children, 4 were taking psychotropic medication
(4 SSRI and of these 1 also was taking an atypical
antipsychotic), 90% were identified as Caucasian and 10%
as Latino, 70% came from intact marriages (with both
parents participating in all sessions) and 30% from
single-parent homes (with only the mother participating).
Of these 3 cases, 1 was a divorced mother (child had
contact with father but father chose not to participate)
and in the remaining 2 cases there was no identified
biological father. Eight families were of medium to
medium-high socioeconomic situations, based on income
and parent education, and two families of low to
medium-low situation. Four of the children (40%) had
previously participated in psychotherapy without signifi-
cant improvement (treatment was described as CBT but
we were not able to adequately establish treatment
content). Five (50%) children met criteria for SAD, 1
(10%) for SoP, 5 (50%) for GAD, 4 (40%) for OCD,
2 (20%) for panic disorder. In addition, 2 children (20%)
met DSM-IV-TR criteria for Tourette Syndrome and the
same number met criteria for an attention-deficit disorder
or for oppositional-defiant disorder.
Measures
Diagnosing anxiety disorders. The Anxiety Disorders
Interview Schedule (ADIS)Parent Version was the main
tool for establishing diagnosis and eligibility (Silverman,
Saavedra, & Pina, 2001). The ADIS is a semistructured
diagnostic interview that has repeatedly shown reliability
and good psychometric qualities. We relied on the parent
version because this study focused on children who refused
treatment and could also refuse to participate in assessment
of anxiety symptoms. Raters were at the postgraduate level
and had been trained by experienced senior team
members on the use of the ADIS.
Assessing severity of anxiety symptoms. The Pediatric
Anxiety Rating Scale (PARS) (RUPP Anxiety Study
Group, 2002) and the Clinical Global Impression Scale
(CGI) severity/improvement (Guy W Editor, 1985) were
the primary outcome measures. The PARS has adequate
internal consistency (α.64.91) and interrater reliability
(ICCs .78.97), sensitivity to change in treatment studies,
and convergent validity (RUPPAnxiety Study Group,2002;
Walkup et al., 2008). Following established procedure
(Walkup et al.), scores were calculated based on the
summation of the six items for anxiety severity, frequency,
distress, avoidance, and interference during the previous
week. Total scores can range from 0 to 30, with scores above
13 indicative of clinically meaningful anxiety. Reductions of
35% to 50% posttreatment have been shown to be optimally
associated with remission (Caporino et al., 2013). The CGI
is a global measure of symptom severity widely used as an
outcome measure in clinical trials and shown to be sensitive
to treatment effects. Scores range from 1 to 7, with scores of
1 or 2 reflecting clinically meaningful improvement.
Assessing family accommodation. The Family Accommo-
dation ScaleAnxiety (FASA) (Lebowitz et al., 2013)
includes 9 items that query the frequency of participation
in child symptoms (5 items) and modification of schedules
and routines (4 items). Items are rated from 0 (never)to4
(daily). The accommodation score is calculated as the sum
of these 9 items. The scale also includes 1 item about parent
462 Lebowitz et al.
distress relating to the accommodation and 3 items that
address child response to parents not accommodating.
FASA has good internal consistency (α= .9) as well as
convergent and divergent validity (Lebowitz et al., 2013).
Assessing additional symptoms. The Child Behavior
Checklist (CBCL) parent report was completed at baseline
and is a widely used and well-established screening
instrument that covers the range of childhood psychopa-
thology and functioning (Achenbach, 1994). The Child
Depression Inventory: Parent Version (CDI:P; Kovacs,
1992) is a 17-item instrument for assessing depression in
children between the ages of 7 to 17 and has good internal
reliability (Feng et al., 2012). Parents also completed a
self-report of their own anxiety, the Beck Anxiety Inventory
(BAI; Steer & Beck, 1997). The BAI includes 21 anxiety-
related items, has good internal reliability (αN.92) and
good test-retest reliability (Beck, Epstein, Brown, & Steer,
1988). Child OCD symptoms were assessed using the
Child Yale Brown Obsessive Compulsive Scale (CYBOCS;
Scahill, Riddle, McSwigginHardin, & Ort, 1997), a clinician-
administered rating of obsessive-compulsive symptoms and
their severity. The Coercive and Disruptive Behavior Scale
for Pediatric OCD (CD-POC; Lebowitz, Omer, et al., 2011)
is an 18-item parent report checklist that assesses co-
ercive imposition of accommodation by the child on the
parents. The CD-POC has good internal reliability (α=.87;
Lebowitz, Omer, et al., 2011).
Treatment integrity. To assess the degree to which
treatment adhered to the session outline, the therapist
completed a form describing the planned and actual
focus of each session. For each session goal the therapist
indicated whether it had been adhered to on a scale of 0
(not addressed)to5(completely accomplished). The sessions
were also reviewed and outlines were revised if necessary
to contribute to the final manualization process.
Attendance and satisfaction. Parent satisfaction was
assessed with the Client Satisfaction Questionnaire (CSQ;
Attkisson & Zwick, 1982), a 12-item questionnaire rated 1 to
4withitemssuchasIf a friend were in need of similar help,
would you recommend this service to him or her?;Have the
services you received helped you to deal more effectively with your
problems?;In an overall, general sense, how satisfied are you
with the service you received?Attendance was measured by
calculating the total number of sessions attended by
parents. The number of rescheduled appointments was
also calculated. All families completed treatment.
Procedure
Recruitment, assessment and consent. The study was
carried out with the approval of the Institutional Review
Board. Subjects were recruited through ongoing referrals
to the clinic. Potential subjects were introduced to the
study design and rationale and then signed informed
consent forms before completing the baseline assessment
including interviews and self-report measures. All inter-
views and ratings, including the administration of the
self-report measures, were done by independent raters
trained on the respective procedures and no assessments
were conducted in the presence of a therapist. Parents
completed a midtreatment assessment after 5 treatment
sessions and a final assessment after the 10th weekly
session.
Treatment. The SPACE Program is a parent-only inter-
vention designed for 10 to 12 weekly sessions and is
intended to be both consistent across cases as well as flexible
enough to allow for individual treatment tailoring. These
goals are achieved through a manualized treatment process
that includes eight treatment parts, which are consistent
across all cases, and an additional five session modules, which
are implemented as needed in accordance with therapist
judgment (Lebowitz & Omer, 2013). The treatment parts
focus on charting and reducing accommodation in
supportive ways: (1) setting the stage, (2) charting
accommodation, (3) choosing a target problem, (4) formu-
lating a plan, (5) reducing accommodationcontinued,
(6) additional targets, parents take the lead, (7) additional
targetscontinued, (8) summary and termination. The
session modules provide practical tools for overcoming
difficulties that might hamper this process: (1) teaching
and modeling self-regulation, (2) coping with disruptive
behavior, (3) coping with threats to self, (4) accessing
support, (5) improving collaboration between parents. See
Figure 1 for a graphic representation of the sequential and
flexible elements of the SPACE Program. The treatment
focuses explicitly on modifying parent behavior with the
goal of helping parents to assume a less protective and
accommodating stance toward the child and replacing it
with a supportive one that fosters the childsabilityfor
coping and self-regulation.
Results
Treatment Integrity, Attendance, Dropout,
and Satisfaction
All participants completed all 10 sessions. Out of 100
sessions (10 sessions × 10 cases) 13 had to be rescheduled
due to participant request (an average of 1.3 per family).
Of these, 6 were rescheduled for another day within the
same week (and then the next session was completed on
time) and 7 had to be rescheduled for the following week
(skipped week). This does not include planned absences
or holidays. Therapist post-session forms showed overall
high adherence to the session outlines across sessions and
patients. The average score for each session goal overall
was 4.1 (4 reflected the statement Goal mostly accomplished;
463Parent Training for Childhood Anxiety
5 reflected Completely accomplished). Client satisfaction as
reported through the CSQ was exceedingly high for this
open trial. Average ratings per item on the scale ranged
from 3.8 to the maximum of 4 and the average total rating
was 59.1 out of a maximum of 60.
Session Module Deployment
Following the SPACE Program manual, all treatments
included the eight treatment parts. Session modules were
deployed based on the needs of individual cases, as
assessed by the therapist. Table 1 summarizes the
frequency with which each module was implemented
and the average session number in which it was employed.
1. Introduction
• Why parents?
• Defining support
• Discussing family boundaries
2. Charting
Accommodation
• Defining accommodation
• Mapping and Charting
accommodation
3. Choosing Targets
• What's a 'good target?'
• Informing the child
• Written communictaion
4. Formulating Plan
• Detailed
• Practical
• Informing child of plan
5. Implementation
• Review of week
• Reinforce progress
• Problem-solve
6. Choosing Additional
Target
• Parents take lead
7. Implementation
• Parents take lead
• Review of week
• Problem-solve
8. Summary and
Termination
• Summary
• Planning ahead
Accessing
Support
Modules:
Coping
with
Disruptive
Behavior
Coping with
Threats to
Self
Improving
Parent
Coperation
Teaching
and
Modeling
Self-
Regulation
Figure 1. Treatment Sequence and Flexible Modules.
Table 1
Frequency and Timing of the Implementation of Session
Modules
Session Module N (%)
a
Average Session
Number
b
Teaching and modeling self-regulation 4(40%) 8.3
Coping with disruptive behavior 6(60%) 4
Coping with threats to self 2(20%) 5.5
Accessing support 9(90%) 3.5
Improving collaboration between parents 5(50%) 6
a
Number (%) of cases in which each module was implemented.
b
Average session number (out of 10) when each module was
implemented.
464 Lebowitz et al.
Clinical outcomes
Six children (60%) were designated as responders based
on CGI-Improvement scale score of either 1 (very much
improved;20%)or2(much improved; 40%). The remaining
four children all had a score of 3 (minimally improved).
Paired sample ttests were used to compare clinical measure
before and after treatment. The average change on PARS
score at post- compared to pretreatment was a significant
improvement of 8.2 points (SD 7.0), t
(df = 9)
=3.7,pb0.01.
This was equal to an average improvement of 38.4% on
PARS, a degree of improvement indicative of response or
remission (Caporino et al., 2013). Family accommodation,
as calculated by the 9 accommodation items on FASA,
was reduced posttreatment by an average of 11 points
(SD 6.4) out of the maximum possible 36 points, t
(df = 9)
=
5.4, pb0.01. Child depressive symptoms showed a small
improvement of 2.8 points (SD 4.6), which approached
significance, t
(df = 9)
= 1.9, p= 0.086. Parent self-reported
anxiety manifested a nonsignificant reduction of an
average 4.1 points (SD 7.63) on BAI total score, t
(df = 9)
=
1.7, p= 0.12. See Table 2 for a summary of clinical measures
at each of the three time points. Following treatment, 70%
of parents reported increased motivation and willingness
for individual treatment on the part of the child, relative to
before treatment.
Discussion
This report presents the theoretical foundation,
structure, and strategies of a novel parent-based interven-
tion for childhood anxiety disorders. The report also
presents results of an open trial of the treatment, with an
emphasis on feasibility, acceptability, and initial out-
comes. We include multiple excerpts from the treatment
manual with the hope of bringing the treatment to life
and conveying a rich sense of the therapeutic process.
Participants in the trial were the parents of children with
moderate to severe anxiety who had declined individual
therapy (or refused to attend the evaluation). We chose to
specifically target treatment-refusing children because
this is a significant population for whom there is very little
to offer outside of pharmacotherapy, and some children
refuse medication as well. In our experience, parents of
children who decline treatment feel frustrated and
exasperated but helpless to take action to help their
child. Additionally, parents are typically engaged in
significant accommodation, unwittingly or unwillingly
contributing to the perpetuation of the anxiety. Parent
treatment that empowers parents to replace this situation
with the ability to actively support their childs improve-
ment may be very welcome. However, the treatment
piloted in this trial is not exclusive to treatment-refusing
children and could be equally beneficial in less exigent
circumstances.
The treatment approach piloted in this study was
developed to address parental behavior specific to the
interaction with anxious children, and to target core aspects
of the dyadic and systemic dynamics at play in the familiesof
children suffering from anxiety. Earlier attempts to involve
parents in the treatment of childhood anxiety have focused,
with some notable exceptions, on teaching more generic
parenting skills such as problem solving, training parents as
lay CBT therapists, or simply increasing the involvement of
parents in their childsindividualtreatment(Barmish &
Kendall, 2005; Silverman, Kurtines, Jaccard, & Pina, 2009).
Empirical evidence has not supported the hypothesis that
this approach enhances outcomes beyond what is achieved
by treating a child individually (Barmish & Kendall, 2005;
Breinholst et al., 2012; Reynolds et al., 2012). Moreover,
these approaches are predicated on the child participating
in and complying with the therapeutic process, a condition
that excludes treatment of children who do not recognize
the need for change, are too anxious to attempt it, or have
come to rely on parent accommodation. By focusing on
parent rather than child behavior, the SPACE Program
Table 2
Clinical Measures at Baseline, Mid- and Posttreatment
Measure Pre Treatment
Week 0
Mid Treatment
Week 5
Post Treatment
Week 10
Mean SD Mean SD Mean SD
PARS 20.3 3.9 15.5 4.7 12.1 5.9
CGI-S 4.9 1.3 4.2 1.6 3 1.2
FASA Total Score 31.2 13.6 20.1 11.4 14.8 8.5
FASA 9 Item Accommodation Score 20.5 8.7 11.8 8.4 9.5 5.6
CYBOCS 27.4 3.6 23.7 5.8 16 6.6
CDI:P 23.1 4.9 20.8 3.5 20.3 4.2
BAI 8.3 6.3 4.2 3.3 4.2 4.8
Note. PARS = Pediatric Anxiety Rating Scale; CGI-S = Clinical Global Impression Scale Severity; FASA = Family Accommodation Scale
Anxiety; CYBOCS = Child Yale-Brown Obsessive Compulsive Scale; CDI:P = Child Depression Inventory: Parent; BAI = Beck Anxiety
Inventory.
CYBOCS scores are calculated only for children with obsessive-compulsive disorder (N = 4).
465Parent Training for Childhood Anxiety
avoids the axiom of child collaboration making it a
welcome, butnot crucial, aspect of the therapeutic process.
The focus on parent-specific aspects of the dynamic
typically surrounding an anxious child can increase the
unique contribution of parent training for childhood
anxiety.
The SPACE Program is not the first to address systemic
aspects of childhood anxiety disorders, nor is it unique in
aiming to reduce accommodation. However, other
programs that share these characteristics differ in two
important ways. First, they have been aimed almost
exclusively at young children, typically younger than
school age. Undertaking the challenge of modifying the
interaction patterns of parents with older children
requires different tools. The childs presence in treatment
cannot be taken for granted and tools such as sticker
charts, time-out, and special time are hard to implement
with older children or adolescents. The SPACE Program
uses the NVR framework to equip parents with tools for
addressing the challenges in developmentally appropriate
ways. This approach is supported by the finding that
parent training utilizing an NVR approach can be
effective even with highly dependent adult children,
many of whom suffer from anxiety disorders (Lebowitz,
Dolberger, et al., 2012). Second, SPACE places a stronger
emphasis on reducing parent accommodation than
earlier programs. By making accommodation the central
theme of treatment, the focus shifts away from the child
and on to the parentspotentially paving the way for
treatment in cases that do not lend themselves to CBT or
other child-focused treatments.
Limitations
The results of this study should be interpreted in
light of all the limitations typical of this stage of research,
such as the small sample size, the absence of any control
condition, and the fact that therapy in all cases was
conducted by a single clinician. These limitations
are offset, but not corrected, by the employment of
independent raters, the combination of reliable struc-
tured interviews and parent self-report, and the fact that
the main goal at this stage is more to pilot feasibility than
to demonstrate efficacy. Despite the limitations, this study
is unique in reporting on a novel parent-based inter-
vention targeting specific parent factors with known
importance for the development and course of childhood
anxiety disorders.
Conclusions and Clinical Implications
Despite the limitations discussed above, the results of
this study support the feasibility and acceptability of the
SPACE Program. No parents dropped out after beginning
treatment and satisfaction was very high following treat-
ment. This is particularly important as the treatment not
only focuses on parents, who might naturally prefer that the
child be the patient, but requires that they make significant
changes in their own behavior. The improvement reported
by parents in child symptomatology and their own
accommodating behavior following treatment supports
the importance of future investigations and more con-
trolled studies of this program. These preliminary results
are unique in highlighting the possibility of a promising
treatment for children who otherwise are the least likely
candidates to benefit from traditional forms of treatment
for anxiety. The increased willingness and motivation for
treatment on the part of the children whose parents
participated in the study is a promising outcome. Given that
the participants in this study had been recruited based on
their childrens choice to decline treatment, the SPACE
Program points to the potential of focused parent training
to improve the likelihood of children benefiting from their
own individual therapy.
Reducing parental accommodation may act to increase
motivation in various 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 dis-
cover themselves more capable of self-regulation than
they had thought.
Additional and more controlled studies are necessary
to further investigate the efficacy of this program. Further
research could also address the question of which families
are most likely to benefit from a parent-based approach of
the kind piloted here. It seems likely that children whose
parents are highly accommodating would benefit more
than those whose parents accommodate less. Incorporat-
ing a measure of family accommodation (Lebowitz et al.,
2013) into assessment procedures and using detailed
charting of accommodation such as those in the SPACE
manual could help to identify likely patients. Children
who either refuse to participate in other treatment such as
CBT or have not sufficiently benefited from them, such as
those included in the current sample, are also likely
candidates to benefit from SPACE. On the other hand,
children whose anxiety symptoms do not manifest at
home, or do not appear to significantly involve their
parents, are probably less likely to benefit from this kind
of intervention. Additional moderators of outcome will
emerge through further research. The SPACE Program is
intended for use with school-age children in the K12
grade range. Our clinical experience indicates that it
is suitable across this range but research is needed to
466 Lebowitz et al.
confirm this empirically. Parent and family variables, such
as parent anxiety and other psychopathology, could also
potentially impact the ability to benefit from SPACE.
Reports so far have indicated that while parent anxiety
can moderate the effect offamily-basedCBT, the long-term
outcomes may not actually be moderated(Cobham, Dadds,
Spence, & McDermott, 2010). The SPACE Program does
not directly target reducing parent anxiety as an objective of
treatment, and though parent anxiety in the pilot sample
did decrease, the change was not statistically significant.
Given the relatively low baseline anxiety level in this small
sample size, however, it is still unclear to what extent SPACE
brings about reductions in parent anxiety.
An additional direction for future research relates to
the neurobiology of parental behavior, especially parental
responses to child distress. The neural circuitry and
neuroendocrinology involved in parental responsiveness
is only slowly becoming familiar (Strathearn, Fonagy,
Amico, & Montague, 2009; Swain, 2011). As the relation
between the neurobiology of parental responsiveness to
child distress, and patterns of family accommodation of
childhood anxiety becomes clearer, biomarkers moderat-
ing treatment outcomes for interventions targeting those
patterns may emerge.
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Eli R. Lebowitz gratefully acknowledges the support of the Messer
Anxiety Program at the Yale Child Study Center.
Address correspondence to Eli R. Lebowitz, Ph.D., 230 S. Frontage
Rd., New Haven, CT, 06520; e-mail: eli.lebowitz@yale.edu
Received: March 27, 2013
Accepted: October 22, 2013
Available online 11 November 2013
469Parent Training for Childhood Anxiety
... In fact, a recent study found that FA mediated the association between pediatric anxiety and functional impairment (de Barros et al., 2020). Furthermore, parent-based treatments specifically targeting FA have been shown to effectively reduce pediatric anxiety (Lebowitz et al., 2014. Considering the importance of this association between FA and anxiety symptoms in youths, understanding related behavioral and cognitive factors could provide important insight into ways to further optimize interventions that target FA. ...
... Disproportionate or maladaptive avoidance is a key feature of anxiety and has been linked with maintenance of anxiety and worsened overall functioning (Elliot et al., 2013;Treanor & Barry, 2017). Addressing maladaptive avoidance behavior through exposure therapy plays a central role across several treatments for pediatric anxiety with established efficacy (Kendall et al., 2008;Lebowitz et al., 2014). Nevertheless, little research to date has measured this theoretical association between FA and youths' avoidance. ...
... Based on these findings, clarifying the dynamics between these common approaches to measuring avoidance in youth remains an important goal for future research. Maladaptive avoidance represents a treatment target across several therapeutic approaches (Kendall et al., 2008;Lebowitz et al., 2014). Characterizing the nuances in youths' avoidance, as well as identifying familial and cognitive mechanisms that may contribute to distinct components of avoidance, could enhance our understanding of how best to effectively treat youths across a range of unique presentations of avoidance. ...
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Pediatric anxiety disorders are common, impairing, and chronic when not effectively treated. A growing body of research implicates family accommodation in the maintenance of pediatric anxiety. The present study aimed to quantify previously untested relations among family accommodation and two theoretically linked constructs: avoidance and self-efficacy. Eighty youths between ages 8 and 17 (53 with anxiety disorders, 27 non-anxious controls) completed measures of family accommodation and self-efficacy. In addition, avoidance was assessed using two distinct measures of avoidance: a clinician rating of real-world behaviors and a laboratory task-based index. As predicted, youths with anxiety disorders reported greater family accommodation than non-anxious controls. Across the sample, greater family accommodation was associated with greater avoidance, as measured using both clinician rating and the laboratory task, as well as with lower self-efficacy. In an exploratory mediation model, self-efficacy partially mediated the relation between family accommodation and clinician-rated avoidance; however, it did not mediate the relation between family accommodation and task-based avoidance. Considering the robust association between family accommodation and anxiety in youths, this addition to our understanding of related cognitive and behavioral factors provides important preliminary insight, which can guide future research on potential targets for early identification and intervention for pediatric anxiety.
... In clinical samples, almost all parents of children with anxiety problems have reported frequent use of accommodations to alleviate child distress (Lebowitz et al., 2013;Storch et al., 2015). There is evidence suggesting that parent-focused interventions designed to reduce parental accommodation reduce children's anxiety symptoms after treatment (Kagan et al., 2016;Lebowitz, Omer, Hermes, & Scahill, 2014), indicating that parental accommodation may be an important target in the prevention and treatment of anxiety problems. ...
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Behavioral Inhibition is a temperament identified in the first years of life that enhances the risk for development of anxiety during late childhood and adolescence. Amongst children characterized with this temperament, only around 40 percent go on to develop anxiety disorders, meaning that more than half of these children do not. Over the past 20 years, research has documented within‐child and socio‐contextual factors that support differing developmental pathways. This review provides a historical perspective on the research documenting the origins of this temperament, its biological correlates, and the factors that enhance or mitigate risk for development of anxiety. We review as well, research findings from two longitudinal cohorts that have identified moderators of behavioral inhibition in understanding pathways to anxiety. Research on these moderators has led us to develop the Detection and Dual Control (DDC) framework to understand differing developmental trajectories among behaviorally inhibited children. In this review, we use this framework to explain why and how specific cognitive and socio‐contextual factors influence differential pathways to anxiety versus resilience.
... So, in such cases, fear of separation interferes with daily activities like going to school or participating in activities related to the age (6). Effective childhood intervention not only improves current adjustment, but also significantly reduces future psychological trauma (7). ...
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... In addition to the above-mentioned studies, there is promising research in the area of parent mediated cognitive behavior therapy (Cook et al., 2019;Lebowitz et al., 2014). ...
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Autism spectrum disorder is a complex and heterogenous, neurodevelopmental disorder. Applied behavior analysis (ABA) is a common treatment modality for children with autism with marked improvements demonstrated in communication, social, and adaptive functioning. The most common implementation of ABA is a practitioner-led model, whereby a paraprofessional directly implements treatment with the oversight of a Board Certified Behavior Analyst®. Parent mediated treatments are another model proving to be efficacious for children with autism and their parents. While this model is applied in therapeutic treatments such as speech pathology, early intervention, and other behavioral approaches (e.g., ESDM, PRT), parent mediated treatment has not been widely applied in the field of ABA. For this reason, this study, with a foundation in behavioral theory and Bandura’s unifying theory of behavior change, investigated the effectiveness of a parent mediated approach knowns as parent-led ABA. To evaluate this, an archival analysis was conducted for children with autism who received parent-led ABA and practitioner-led ABA as a comparison. Results of this analysis revealed parent-led ABA to be no different in treatment outcome to practitioner delivered treatment. Specifically, while both parentled ABA and practitioner-led ABA demonstrated a significant change in outcome on both the Vineland-3 (ps < .05) and the VB-MAPP (p < .05), there were no significant group differences observed (ps > .05). This produces positive social change as parents are taught to implement an efficacious treatment for their child, which can have a daily and lifelong impact for these families by positively impacting parenting skills, increasing parent’s self-efficacy, and ultimately making a lasting impact in their child’s life.
... Very few other studies have specifically investigated the feasibility and acceptability of parent-only interventions for child anxiety (Chavira et al., 2014(Chavira et al., , 2018Creswell et al., 2010;Lebowitz et al., 2014). These studies demonstrated that interventions were feasible and acceptable to parents, dropout rates were low and parents reported high satisfaction as well as improvements in child anxiety symptoms. ...
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Background Parent-only psychological interventions can be effective treatments for child anxiety. Involving parents in treatment may be beneficial for children, ensuring that interventions are delivered effectively in a supportive environment. Few studies have investigated the feasibility and acceptability of parent-only interventions for child anxiety. Objective In this study, we report on feasibility, acceptability and preliminary clinical outcomes of a brief cognitive behavioural group intervention for parents of children (4- to 10-years-olds) experiencing anxiety in the absence of a diagnosed anxiety disorder. Method Parent participants attended a three-session group intervention delivered online. We collected feasibility information (recruitment and retention rates); parents and children (when appropriate) completed acceptability and clinical outcome measures after each session. Participants were also interviewed about the acceptability of the intervention and study processes. Results Nineteen parents consented to take part (child mean age 6.47, SD 1.23). Participant retention rates (68.4%) and intervention satisfaction (total mean CSQ score 28.52) were high . Calculated effect sizes were moderate to large for parent-rated outcomes, small for child self-reported anxiety, and small to moderate for parent confidence/efficacy. Thematic analysis of interview data identified benefits, such as connecting with parents and learning strategies, as well as challenges associated with the intervention. Conclusions Attendance appeared to be associated with positive changes for parents and children. Overall, participants found this to be an acceptable and useful intervention. These findings demonstrated the potential benefit of a brief intervention for parents of anxious children. A larger trial is required to further investigate these preliminary findings.
... CBT entails some combination of cognitive restructuring, behavioral exposure, and skill-building, with or without group or family involvement (Higa-McMillan et al., 2016;Silverman et al., 2008). The present study compares individual CBT to SPACE (Supportive Parenting for Anxious Childhood Emotions; Lebowitz et al., 2014), a completely parent-based treatment. SPACE focuses on increasing supportive (i.e., validating and confident) parental responses to youth distress and reducing parental accommodation, or behavior changes intended to help alleviate youth's anxiety symptoms. ...
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Research has uncovered a wide range of predictors of youth anxiety treatment outcome (i.e., symptom severity and diagnostic remission). Youth's social functioning is one predictor that has been rarely studied, however, which is a significant gap given its importance to development and clinical functioning. We address this gap by examining two aspects of youth's social functioning as predictors of anxiety treatment outcome: (1) positive social interactions and (2) social skills. We further examined the moderating roles of treatment arm (child- or parent-based treatment), diagnosis (presence or absence of social anxiety disorder), and youth gender, between each of the two predictors and treatment response and remission. Participants were 96 youths with anxiety disorders (6-16 years; 54% girls) and their mothers, who completed diagnostic interviews and questionnaires at baseline and posttreatment. Multiple regression models revealed that higher baseline parent-reports of their child's social skills predicted lower posttreatment anxiety symptom severity for youth with social anxiety disorder. Modified linear probability models revealed that baseline youth-reports of their social skills predicted remission from anxiety diagnoses for youths assigned to the parent-based treatment. Baseline youth-reports of their positive social interactions and parent-reports of youth social skills predicted remission from anxiety diagnoses for girls. Results contribute to the predictor literature by highlighting the importance of youth social functioning to anxiety treatment outcome.
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The term Failure to launch (FTL) has been used to describe abled adults who do not work, do not attend school, and live with— and at the expense of—their parents. FTL can be beneficially addressed through parent training, a treatment method that is rarely used with adults (i.e., individuals past the age of majority). The authors first review the goals of parent training programs offered to parents of adults. The review demonstrates that these goals dovetail with key aspects of FTL. The authors then describe a new parent training approach for parents of individuals with FTL, based on SPACE (Supportive Parenting for Anxious Childhood Emotions). They highlight five key components of SPACE-FTL: Psychoeducation, Reducing Parental Accommodation, Increasing Parental Support, De-Escalation, and Engaging Supporters. The authors conclude by discussing SPACE-FTL in relation and comparison to other parent training programs and their components.
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This article provides an introduction and overview of the cognitive-behavioral treatment approach to anxiety disorders in children and adolescents. We first provide an introduction to the cognitive-behavioral conceptualization of anxiety, emphasizing the tripartite model of emotions: cognitions, physiological arousal, and avoidance behaviors. We then provide an overview of the basic principles of cognitive behavioral treatment for anxiety disorders in children and adolescents, including generalized, social, and separation anxiety, and specific phobia. We follow this introduction and overview with a discussion of the structure and goals of treatment, including the three phases of treatment (psychoeducation, application, and relapse prevention). In the context of discussing application, we focus primarily on implementation strategies relating to behavioral exposures and cognitive restructuring. We conclude with a summary of different formats wherein cognitive-behavioral treatment can be implemented, including child-only, peer-group, parent-involved, and telehealth.
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Sixty-seven children aged 7 to 14 who met diagnostic criteria for an anxiety disorder were assigned to conditions according to parental anxiety level. Within these conditions, children were randomly assigned to I of 2 treatments: child-focused cognitive-behavioral therapy (CBT) or child-focused CBT plus parental anxiety management (CBT + PAM). At posttreatment, results indicated that within the child-anxiety-only condition, 82% of the children in the CBT condition no longer met criteria for an anxiety disorder compared with 80% in the CBT + PAM condition. Within the child + parental anxiety condition, 39% in the CBT condition no longer met criteria compared with 77% in the CBT + PAM condition. At follow-up, these differences were maintained, with some weakening over time. Results were not consistent across outcome measures. The interpretation and potential clinical implications of these findings are discussed.
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Beginning with an examination of Gandhi's nonviolent resistance and its application to the family context, Haim Omer presents a model of violence escalation processes between parents and children, as well as ways to overcome escalation. Non-Violent Resistance includes a step-by-step instruction manual for parents and special topics include: *dealing with violence against siblings; *dealing with children who take control of the house; *building alliances between parents and teachers; *community uses of the approach. Haim Omer is Professor of Psychology at Tel Aviv University, He is the author (with Nahi Alon) of Constructing Therapeutic Narratives (Jason Aronson, 1997) and Parental Presence (Zeig, Tucker and Theisen, 2000), which was a Bestseller in Israel.
Chapter
Self-regulation describes the system by which an individual returns to a state of equilibrium after an event has caused a disruption in some element of functioning. This chapter explores the relationship between childhood anxiety and emotion regulation, including the parental role in fostering more effective regulation by an anxious child. Both biological and environmental factors can impact the effectiveness with which children self-regulate their emotional states. Negative environmental factors include early exposure to prolonged or extreme stressful situations, whereas positive factors include sensitive parenting that acknowledges the children's feelings and recognizes their inner states. Environmental and family factors, such as the way parents regulate their own emotions or respond to a child's anxiety, can potentially contribute to the link between emotion regulation and anxiety in the child. This chapter discusses the parent–child interaction in the face of regulation challenges, and the role played by parent guidance as a tool for promoting better emotion regulation in children.
Chapter
(from the book) summarize several years of research with rhesus monkeys and surrogate mothers / [demonstrate] that characteristics of mothers other than food resources are important for attachment / when presented with a wire surrogate where milk could be obtained and with a terry cloth mother without milk, infants spent most of their time with the terry cloth surrogate / when the infants were placed in a novel environment or threatened with a strange object, these monkeys appeared to derive comfort from the cloth surrogate / concluded that this effect could not be explained by secondary reinforcement from feeding and that other biological drives must make contact comfort reinforcing