Treating Anxiety in Kids by Working With Parents
In SPACE, children make gains as the therapist works with their parents
Clinical Expert: Qiuyuan Liu, LCSW, DSW
What You'll Learn
- How can therapy that works only with parents help reduce a child's anxiety?
- What kind of accommodations do parents make to kids' anxiety?
- How does reducing parental accommodations help children learn to cope with anxiety?
For children who are anxious, there is a surprising new form of therapy in which the therapist works only with the parents. It’s called SPACE (Supportive Parenting for Anxious Childhood Emotions). It works by changing the way parents respond to anxious behaviors in children, such as asking parents to stay with them until they fall asleep, or avoiding places and things that they are afraid of.
It’s natural for kids to turn to parents when they are anxious, and for parents to protect them from the things that upset them. Experts call things parents do to rescue kids from their fears “accommodations.” If a child is afraid of dogs, the parent agrees to walk down the other side of the street to avoid a dog. Accommodations help kids feel better temporarily, but the lesson they learn is that they need parents to protect them, and their anxiety gets worse.
In SPACE, parents are trained instead to assure children that even though the fear is uncomfortable, they can handle it. Parents gradually reduce the accommodations they have been doing for their kids, and express confidence that the child is strong enough to tolerate uncomfortable feelings. When kids practice coping with anxiety, they get better at it, their confidence grows, and their anxiety fades.
In studies, SPACE has been shown to be as effective as therapy in which the clinician works directly with the kids. It can be used for all anxiety disorders as well as OCD. It is especially helpful for younger kids, whose parents tend to do more accommodating.
When kids are severely anxious, they may need medication along with SPACE to change their behavior. And if kids are also depressed, engaging in self-harm, or suicidal, reducing accommodations may have to wait until the depression has been treated.
Treatment for children with anxiety always includes a role for parents. But there is now an effective form of therapy for anxious kids in which the therapist works only with the parents.
It’s called SPACE — Supportive Parenting for Anxious Childhood Emotions — and it was developed by a psychologist at the Yale Child Study Center named Eli Lebowitz, PhD.
In SPACE the therapist works with parents to change the way they respond to the behavior of their anxious child. That, in turn, helps reduce the child’s anxiety. Studies have shown SPACE to be as effective in treating kids’ anxiety as treatments in which the therapist works directly with the child. It can be used for all anxiety disorders as well as OCD.
How does SPACE work?
As Dr. Lebowitz explains, SPACE is based on the recognition that kids are hardwired to turn to parents when they are in distress, and parents are hardwired to respond to alleviate their distress. In the case of anxiety, kids turn to parents to protect them from the thing they fear: “Can I sleep in your bed? Can I stay home from school? Are you sure this won’t make me sick?”
A parent’s instinctual response is to protect the child from distressing feeling: “I’ll sit with you until you fall asleep. We can cross the street to avoid that dog. We don’t have to go to that party where there’s going to be a clown.” Those responses — which insulate the child from the thing they fear — are called accommodations. The child is relieved in the short run. But parents coming to the rescue only confirms to the child that they need someone strong to protect them, and it robs them of the chance to build resilience.
Kids look to their parents to see who they are, Dr. Leibowitz notes. So when parents reflect back to them that they are helpless in the face of anxiety, and need to be protected, that’s what kids learn to feel about themselves.
On the other hand, if parents respond by communicating that they’re confident the child can deal with the anxiety, even though it’s uncomfortable, the child learns, over time, how to get through anxiety-provoking situations. Practice coping with anxious feelings gradually makes the anxiety fade. And kids who are shown a reflection of themselves as strong and capable of handling their anxiety, without parental accommodation, see themselves that way.
“It’s an instinct that you want to save your kid from a stressful situation,” notes Qiuyuan Liu, LCSW, DSW, a clinical social worker at the Child Mind Institute who uses SPACE with families. “But you want to ask yourself whether with the accommodation you’re providing, are you helping them face their fear or are you helping them run away from it?”
In one study of parents of anxious kids, 97 percent reported that they resorted to accommodations. Reducing these accommodations has always been part of the most common treatments for anxious kids — CBT (cognitive behavioral therapy) or ERP (exposure and response prevention). What’s new with SPACE is that it can work without the kids participating directly.
Who is SPACE right for?
Dr. Liu says SPACE is especially helpful when an anxious child isn’t willing to participate in therapy. “For instance,” she notes, “a child who has separation anxiety, who wants to be with Mom every day, and who doesn’t want to go to bed by herself, may have no motivation to change her behavior as long as Mom is willing to be with her.”
SPACE is most appropriate for younger children and those whose parents are doing the most accommodating, she says. “With younger kids, parents are usually more protective and they’re accommodating more. And it’s good for parents who are more anxious themselves, and who are giving in to their kids’ anxiety as well.”
How SPACE is structured
SPACE is structured into 12 weekly sessions. The first step is to build rapport with parents and explain how SPACE works. Parents need to understand how accommodations keep children from mastering their fears. The clinician helps concerned parents get comfortable with the idea of doing less accommodation and develop confidence that they can change how they respond to a child’s discomfort.
Parents are guided to make a list of their accommodations — both things they are doing and the things they’re not doing because of their kids. Maybe they stay home from work or come home early to keep the child company, or they avoid traveling by plane, or going places with potential triggers, such as zoos or restaurants or movie theaters. Some of these actions may have become such habits that the parent may not realize they are accommodations, notes Dr. Liu.
IN SPACE, the clinician guides the parents to reduce those accommodations step by step as they move from being their child’s rescuer to a more supportive role.
The parents are asked to pick one accommodation to work on reducing first. “Usually, the parents want to focus on the biggest one, but that can be too hard,” says Dr. Liu. “So, I always suggest picking an easy one, one that they think will be easier to accept for them and the kids.”
Accommodations can be reduced incrementally. For instance, if your child calls you every day right after school, you can wait five minutes before you return that call. “And you can tell the child that from now on, I will return your call a little late. This is not because I don’t love you, this is not because I want to punish you — it’s because I want you to practice your ability to tolerate me not picking up your call, and I believe that you can tolerate these five minutes!” Dr. Liu says.
One reason to start with something easy is that there may be resistance. Kids may initially express more anxiety, and some will lash out and accuse their parents of abandoning them.
“Sometimes they will be angry, like, ‘Why are you doing this to me? I don’t understand.’ Or ‘You’re only doing this for yourself because you do not love me,’ or ‘You’re doing it because you don’t want to take me to school every day.’”
In SPACE, parents learn and rehearse ways to respond so they can feel comfortable about the change. One strategy that parents learn is active ignoring. The goal is to actively ignore the child’s anxious reactions as long as they’re not dangerous or destructive. Instead, parents are instructed to give more attention to the child’s progress. “And when we are able to successfully change one behavior,” adds Dr. Liu, “then parents can discuss with kids what behaviors they want to change next.”
A behavior plan can help by spelling out the specific behaviors being practiced each week and rewards for success in meeting those goals. “They’re doing hard work,” says Dr. Liu. “We want to reward them on that.”
Parents need to have a unified front
Dr. Liu stresses that for SPACE to work, it’s important for parents to work together. It’s common for one parent to be more accommodating. “There can be a lot of conflicts between the parents because one wants to push the kids — ‘You can do it yourself’ — when the other is thinking, ‘I don’t know if they can,’” she says.
Parents who spend more time with the children are often the ones providing more accommodations, she adds. That makes them the go-to person when kids are anxious. “This is why it’s super important for us to do this with both parents because we want a united front. We want the parents to make an announcement that from now on, it doesn’t matter if you go to Mom or Dad, we will respond the same way.”
Does SPACE work for severe anxiety?
For cases of severe anxiety, some form of therapy — SPACE, CBT, or ERP — is often paired with medication, usually an antidepressant called an SSRI.
Dr. Liu compares medication to a life jacket for a kid struggling in the water. “If you are in the water and struggling not to drown, you do not have the energy to swim to land. The medication is really something to hold your head above the water. Then therapy is something to teach you how to swim to land.”
SPACE can be especially challenging to use when a child with anxiety is also depressed, engaging in self-harm, or having suicidal ideation. “Even though we want to encourage the parents to reduce their accommodation, to encourage the kids to face their fears, safety is always the highest priority,” she says. “So sometimes we still do SPACE with parents but with the understanding that they are not making any changes at the moment. We just want to give you the idea behind it, but we want to treat the depression first. We want our kids to be stable and safe before we even make any moves.”