Parent Training as Effective for Childhood Anxiety as Therapy

Past research has shown that parent behavior influences the development and trajectory of childhood anxiety. Recently, research has been done to examine the impact of providing training for parents in combination with therapy for the child to reduce childhood anxiety. Now, a new study conducted at Yale University suggests that parents training alone may be just as effective at reducing childhood anxiety as interventions that provide cognitive behavioral therapy (CBT) to children.

The new study, conducted by Eli Lebowitz, Carla Marin, Alyssa Martino, Yaara Shimshoni, and Wendy Silverman, was published in the Journal of the American Academy of Child and Adolescent Psychiatry. The researchers compared the impact of the Supportive Parenting for Anxious Childhood Emotions (SPACE) parent training program with more a more traditional, historically supported child-based CBT approach.

They tested the effect of providing parent training in the absence of child-facing CBT on childhood anxiety symptoms. The parents training was developed with an emphasis on the reduction of family accommodation. Family accommodation refers to parental behaviors that reinforce children’s anxieties and unhelpful thinking patterns.

The parent training condition served to reduce child anxiety as effectively as the child-facing CBT condition according to the noninferiority method applied. The results suggest that altering a child’s environment and relational patterns may be useful as a treatment for clinically significant anxiety and that child-facing therapy may not be a critical ingredient of the treatment process.

Anxiety is often meaningful and useful. It can prepare our bodies for action in the context of potential danger, and can also increase motivation and optimize performance. However, clinically significant levels of anxiety can substantially compromise the day-to-day quality of life for sufferers.

At the same time, overarching trends in anxiety can reveal environmental patterns present in society that contribute to increased stress and fear. As a result, pathologizing anxiety may result in the treatment of larger-scale issues as if they are within-person or within-child problems.

Whatever the cause, systems of support are needed to reduce suffering as the prevalence of mood and anxiety disorders among children continue to increase. There is a well-established connection between anxiety, unexcused absence, and truancy, and between environmental features and anxiety levels (parenting qualities vs. genetic links). Although medication and CBT are popular evidence-based approaches to treatment, long-term treatment outcomes are questionable.

“In contrast to numerous randomized studies examining whether parent involvement enhances child-based treatment, it is unknown whether parent-based treatment alone, without child-based therapy, is efficacious,” the researchers write. “Whether parent-only treatment can be as efficacious as CBT for child anxiety remains unanswered.”

CBT is considered a well-established, gold standard treatment for childhood anxiety. Past research has established connections between parent behaviors and childhood anxiety levels, and that parent training can be a supportive component of broader treatment approaches to childhood anxiety. However, Lebowitz and colleagues’ work is the first to compare parent training alone to CBT with the rationale that, although CBT can be helpful, better treatment strategies are needed.

Most parent training programs focus on providing psychoeducation regarding CBT techniques for childhood anxiety. According to this approach, parents are provided with tools to coach their children through psychoeducation surrounding anxiety, facilitate strategies for coping with anxiety, and promote shifts in child behavior to promote inhibitory learning (in which perceptions of safety begin to outweigh fear through exposure to anxiety-provoking stimuli). Comparatively, the parent training program examined by Lebowitz and team, SPACE, emphasizes training to reduce family accommodation.

“Family accommodation refers to the myriad changes in parental behaviors and routines intended to help a child avoid or alleviate anxiety-related distress,” they explain. “Despite being well-intentioned, family accommodation is linked to more severe child anxiety and greater functional impairment, and may predict poorer response to CBT.”

A total of 124 children (and their parents) between seven and 14-years-of-age diagnosed with anxiety disorders were enrolled to participate and divided into both study conditions (a 12-session SPACE training for parents, or a 12-session CBT program for patients). Ninety-seven participants attended all required sessions and training, and attrition rates were generally even across conditions.

“The present investigation was a randomized controlled noninferiority trial to determine whether SPACE is as efficacious as CBT, the best-established, strongest evidence-based treatment for childhood anxiety disorders. Non-inferiority methodology was selected rather than the more commonly reported superiority testing because failure to show superiority of one treatment over another is insufficient evidence of treatment equivalence.”

Consistent with what had been predicted, the results established non-inferiority of the SPACE approach to parent training when compared with CBT for child participants across both primary (“clinician-rated measures of child anxiety”) and secondary outcomes (“child and parent ratings of child anxiety and of family accommodation, as well as a parent-rated measure of parenting stress”). The SPACE and CBT conditions, both reduced child anxieties, resulted in similar reductions in family accommodation and were acceptable and satisfactory by clients.

More research is needed to explore the generalizability of these results and to test the strength of various approaches to parent training. However, Lebowitz and colleagues’ work provides preliminary support and possible directions for parent training in the treatment of childhood anxiety.

Parent training may be a valuable option when child buy-in is absent, or when developmental or communication problems are such that child-based treatment isn’t viable. On a larger scale, attention to caregiver qualities also represents an acknowledgment that systems beyond a child’s internal processes and genetics inform the development and experience of anxiety. Importantly these systems may extend beyond the family unit, but caregivers represent one potential access point.

 

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Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y., & Silverman, W. K. (2019). 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. (Link)