Parent-Only Treatment for Child Anxiety

Introduction

Anxiety disorders represent the most prevalent category of mental health problems, impacting up to one third of all children and adolescents (i.e., children), leading to substantial impairment across critical areas of functioning¹. It is common for children with anxiety to have multiple anxiety disorders and/or other co-occurring mental health conditions like depression and ADHD². When left untreated, anxiety often persists well into adolescence or adulthood and is associated with adverse outcomes in various domains, including physical and mental health, financial well-being, and interpersonal relationships³.

Child-focused cognitive behavioral therapy (CBT) currently stands as the most robustly researched evidence-based treatment for anxiety disorders, demonstrating recovery rates ranging from 46% to 79% among participating children^4,5. Despite the strong support for CBT in anxious children, this approach is not without limitations. CBT is time and resource intensive and rising demand contributes to long wait lists. The treatment itself requires insight and motivation on the part of the child, and when lacking this may compromise active participation and success of the treatment process⁶. Currently, fewer than 20% of children with anxiety disorders receive specialized anxiety-focused treatment and relapse following even successful treatment remains a prevalent concern^7,8. These limitations underscore the need for ongoing development and empirical examination of additional treatment options and approaches for child anxiety.

In an effort to improve outcomes for child-focused CBT, some randomized controlled trials focused on including parents as active participants in the treatment process. The rationale for involving parents in treatment stems, in part, from consistently reported associations between child anxiety and various parent factors, suggesting that these factors could be contributing to the maintenance of the symptom and that addressing them could enhance treatment gains^9,10. For example, it is common for anxious children to have anxious parents and likewise, for anxious parents to have anxious children¹¹. Anxiety in children is also associated with parenting practices such as exhibiting critical, controlling, or overprotective behavior¹², and anxious parents may model avoidant behavior, thereby increasing children’s anxious tendencies¹³.

Most studies involving parents in child-focused CBT examined the efficacy of adjunctive parent components, by comparing child treatment with an added parent component to child-only treatment⁵. These studies involved parents in various ways including, teaching parents to remove reinforcement of the child’s anxiety behavior¹⁴, teaching parents to better cope with their own anxiety and model coping behavior¹⁵, and teaching parents to reduce family conflict by improving communication and problem solving¹⁶. Taken together, results have been inconsistent, failing to reliably support the notion that child-focused CBT with these adjunctive parent components is superior to child-only treatment¹⁷. These inconsistencies can be attributed to various factors, including variability in the adjunctive parent component, differences in the format and quantity of parent and child sessions, and variations in child age, primary diagnosis, and selected outcome measures¹⁰.

The inconclusive findings relating to the added value of adjunctive parent components to child centered treatment on the one hand, and the significance of parent factors for the risk and course of child anxiety on the other, have led to the development and examination of parent-only interventions for child anxiety. Parent-only interventions have profound potential benefits. Considering treatment accessibility, parent-only interventions are generally shorter in duration compared with interventions focused on the child. Moreover, they are conducive to group or telehealth delivery formats, which aligns with resource conservation and improved access to care¹⁸. Delivering parent-only interventions also enables clinicians to help anxious children who are unable or unmotivated to participate in therapy themselves, consequently increasing the number of children who can benefit from specialized anxiety treatment. In addition to enhancing access to treatment, working with parents allows treatment to target parent-related anxiety maintaining mechanisms, such as controlling and overprotective parenting or family accommodation, thereby generating systemic changes that may have long term benefits for the anxious child and the family system as a whole⁵.

Among the available parent-only interventions for child anxiety, some clinical trials have focused on delivery of CBT-related strategies in a transfer of control model whereby the therapist instructs the parents who then utilize the tools with the child. These interventions encourage parents to apply strategies such as, psychoeducation, cognitive restructuring, and graded exposure, and may also utilize bibliotherapy strategies¹⁸. Evidence also supports SPACE (Supportive Parenting for Anxious Childhood Emotions), which highlights the interpersonal, systemic aspect of child anxiety and focuses on the interactions between parents and child¹⁹. Other approaches with less robust empirical support include parent-led play therapy, which encourages parents to utilize games, role play and books to help challenge the anxiety²⁰ and parent-led cognitive bias modification training, which focuses on training parents to challenge and modify their child’s interpretations of ambiguous scenarios²¹.

A recent review and meta-analysis examined whether parent-only interventions for child anxiety are effective in reducing anxiety symptoms compared with child-only interventions, parent-child interventions, and wait-list control¹⁸. This review included 29 studies that vary across numerous factors such as study designs (e.g., randomized controlled trials, case series), duration of treatment, child age, and format (e.g., group, individual, phone calls, self-help materials). Results of this meta-analysis indicated that parent-only treatment can be an effective approach for child anxiety, as symptoms were reduced following treatment, and it was found superior to wait-list control. Yet, a significant treatment effect for parent-only interventions compared with other types of interventions was not found; anxiety symptoms were reduced in all active treatment types (i.e., barring wait-list control condition). In line with Jewell, Wittkowski, Pratt¹⁸, a review and meta-analysis of six randomized controlled trials of parent-only group CBT for child anxiety reported significant treatment effects for parent interventions compared with wail-list control, though no significant differences between parent-only CBT and child-focused CBT were found²². Both reviews highlight substantial heterogeneity among studies across various measures, including treatment types and components, and underscore the persisting uncertainty regarding the optimal approach to parent involvement in treating child anxiety.

The current paper aims to review the utilization of parents in two evidence-based parent-only treatment approaches for child anxiety: parent-led CBT (e.g., Timid to Tiger) and Supportive Parenting for Anxious Childhood Emotions (SPACE), including the theoretical foundations for these approaches, the role of parents in the treatment process, and the proposed mechanisms of change. The main points of comparison are summarized in Table 1. Additionally, a brief case description is presented to illustrate how these two approaches may address a similar case.

Table 1.

Comparison of Parent-led CBT and SPACE Interventions for Child Anxiety

	Parent-led CBT	SPACE
Conceptualization of child anxiety	Anxiety is understood as intrapersonal physiological, behavioral, and cognitive responses within the child that they must learn to control.	Child anxiety is understood as a systemic, interpersonal phenomenon. Attachment-driven processes lead children to turn to parents for regulation of their anxiety and parents respond by providing accommodations
Role of parents in treatment	Parents assume the role of the therapist and actively practice CBT skills with the child. Parents are facilitators of strategies to help children manage their personal distress.	Parents focus on their own responses to the child’s anxiety and aim to present a supportive attitude and to systematically reduce accommodations.
Who participates in treatment	Parents participate in the sessions and engage the child as an active participant at home, in-between sessions	Parents participate in the sessions and make behavioral changes between sessions. Child does not have to agree to actively participate or cooperate with the changes parents make.
Theorized mechanism of change	Knowledge and anxiety management skills are transferred from the therapist to parents to the child (i.e., Transfer of Control model). Through their role as a “lay therapist,” parents send the message to the child, you have been avoiding facing your fears. That has maintained your anxiety. I will help you think differently about your fears and practice doing scary things so that you can feel better. When children are able to successfully change their thinking patterns and face their fears, they can better control their anxiety.	Change in the parents’ perceptions of the child and in their responses when the child is anxious advance changes in the child’s self-perception and anxiety related behavior. The combination of the supportive attitude and the reduction of accommodations send the message to the child, you think that only we can regulate your anxiety. When we do that, it actually maintains your anxiety. Because we believe that you can handle it we’re not going to regulate your anxiety for you. We know that you will find a way. When this message is internalized by the child, this modified perception of themselves allows them to cope better with anxiety.
Examples of treatment components	Parents encourage child to engage in behavioral exposures and cognitive restructuring. Parents use rewards, consequences, and selective attention to help their child engage in or disengage from certain behaviors. They may also learn strategies for improving the parent-child relationship and family functioning, which may further alleviate child anxiety.	Parents focus on their own responses to the child’s anxiety and avoid asking the child to actively face their fears. Parents practice expressing supportive messages and implement detailed plans to reduce accommodations of the anxiety. They also learn strategies to disengage to reduce escalation and praise the child for coping with the changes they make.

Parent-led CBT

Conceptualization of Child Anxiety

Parent-led CBT for child anxiety relies on a conceptualization of anxiety that emphasizes connections between thoughts, feelings, and behaviors (see Figure 1). The child’s anxiety is understood to comprise exaggerated and maladaptive physiological (e.g., increased heartrate), cognitive (e.g., worry thoughts), and behavioral (e.g., avoidance) responses. These responses to anxiety are conceptualized as intrapersonal in nature (i.e., occurring within the individual). They are also conceptualized as universal, occurring in similar ways in all anxious individuals, both children and adults. In order to treat the anxiety, these different responses must be targeted directly. Specifically, the anxious individual must learn how to regulate their physiological symptoms (e.g., through deep breathing, muscle relaxation), identify and change their worry thoughts (e.g., through cognitive restructuring), and approach rather than avoid their fears (e.g., through exposure, behavioral experiments). In therapist-led CBT, the child learns these strategies directly from the therapist. In parent-led CBT, the goal is for parents to learn how to help their child adopt these strategies. This is consistent with the “Transfer of Control” model, which elucidates how children can come to independently control their anxiety by learning skills transferred through the therapist via the parent²³.

Figure 1.

The CBT model of anxiety

Overview of Approach

Parent-led CBT approaches focus on providing information and tools to parents, which they in turn implement with their child. Because children are not present for therapy sessions, the parents apply these strategies in the context of daily life, between sessions. The format in which parents learn CBT strategies, and the specific nature of the strategies, vary considerably across treatment protocols. This variability is highlighted in a recent review of the extant randomized clinical trials of parent-led CBT²⁴. Regarding format, some parent-led CBT is delivered through bibliotherapy or ‘guided’ therapy, in which parents are given books or other resources accompanied by varying levels of therapist support e.g.,²⁵. Parent-led CBT is also commonly delivered in group format e.g., Fear-Less Triple P;²⁶. Regarding content, all approaches include psychoeducation about child anxiety, cognitive distortions, and behavioral exposure. The amount of time and guidance dedicated to training parents to implement the CBT strategies with their child varies, as does the inclusion or exclusion of other parenting skills. The following example illustrates a group-based approach that includes a high level of guidance on CBT strategies and also introduces other parenting strategies hypothesized to have a positive effect on child anxiety.

An Illustrative Example: Timid to Tiger

Timid to Tiger is a group-based manualized parent-led CBT treatment²⁷ protocol. The treatment entails 10, 2-hour sessions. In each session, the first hour is dedicated to review of prior content and home practice, and the second hour is dedicated to new material. The treatment has two overarching goals: (1) to improve the home environment by increasing warmth, predictability, and positive discipline; (2) to help parents manage children’s anxiety using cognitive-behavioral skills, including graded exposure, problem solving, and behavioral experiments. Both targets are posited to have positive impacts on reducing the child’s anxiety.

The first session focuses on psychoeducation about topics including the role of parental attention in childhood behavior, causes of anxiety disorders, the connection between thoughts, feelings, and behaviors, and tips on self-care (e.g., diet, routines). The second session focuses on the parent-child relationship and on improving child self-esteem through child-centered play, or ‘special time.’ The third session focuses further on anxiety psychoeducation, including the fight or flight response, the role of behavioral avoidance, and parental modeling of anxiety. The fourth session focuses on developing fear hierarchies to help children face their fears, and on effective use of praise. The fifth session focuses on using rewards and star charts to reinforce positive and ‘brave’ behaviors. The sixth session focuses on behavior management and limit-setting, including using effective commands. The seventh session focuses on using ignoring to extinguish problem behaviors and anxious reassurance-seeking. The eighth session focuses on skills for managing children’s worry, including listening, problem solving, behavioral experiments, distraction, and ‘worry time.’ The ninth session focuses on consequences for undesirable behaviors (e.g., time-out). Finally, the tenth session focuses on review, relapse prevention, and celebration.

Role of Parents

In parent-led CBT such as Timid to Tiger, the role of parents is to shape the child’s behavior. This is evident in the overarching goals or targets of treatment, and in the specific techniques and strategies taught. For example, upon receiving psychoeducation, parents’ role is to transfer the information to their child, or to use the information when implementing other strategies with their child. After learning about fear hierarchies, parents are expected to engage their child in a graded process of facing their fears. The use of rewards and consequences to encourage brave behavior and discourage avoidant behavior also place clear emphasis on the parent shaping the child’s behavior. Some parent-led CBT approaches also include techniques that more directly focus on shaping the parents’ behavior, such as teaching parents to model non-anxious behaviors or challenge their own anxious thoughts that might interfere in treatment. However, the goal of these strategies is ultimately still focused on eliciting change within the child (i.e., to engage in similar strategies).

Theorized Mechanism of Change

The theorized mechanisms of change in parent-led CBT are essentially the same as therapist-led CBT: reductions in anxious cognitions, improved physical regulation, and reductions in behavioral avoidance. One study directly compared parent-led CBT to child-only (therapist-led) CBT and found child outcomes (e.g., decreases in avoidant behavior) improved in both arms, and did not significantly differ between them²⁸. Considering the overlapping theorized mechanisms of change, it is plausible that children would benefit similarly from these approaches. Further, the same children who are willing and able to engage in CBT with a therapist and work on regulating their own thoughts, physiological reactions, and behaviors, may also be willing to do so with a parent.

While some treatment protocols only address clinical targets directly related to anxiety²⁵, others (including Timid to Tiger) also include targets such as behavioral management (e.g., time out) and positive relationship building (e.g., special play time). As mechanistic research is still needed for child anxiety treatment broadly, and especially for parent-based treatments¹⁷, it is unknown which specific strategies explain the efficacy of parent-led CBT. For example, it may be that improvements in family functioning or relationship quality explain reductions in child anxiety, but this remains an empirical question. Further research on this topic would help inform the content of treatment protocols, including which targets and associated strategies to include, and the relative emphasis to place on each.

SPACE: Supportive Parenting for Anxious Childhood Emotions

Conceptualization of Child Anxiety

Research in recent years has facilitated a shift in conceptualizing child anxiety away from the individual, intrapersonal model to one that emphasizes interpersonal and systemic aspects, as well as the unique role of parents in addressing this issue¹⁹. The interpersonal view of child anxiety, informed by evolutionary biology and attachment theory²⁹, provide a foundation for understanding how children’s reactions to fear and anxiety differ meaningfully from those of adults, and in turn highlight key aspects of child anxiety disorders. In adults, activation of the threat detection system triggers responses centered primarily around confrontation or avoidance (i.e., ‘fight or flight’). In children however, as in other immature mammals, anxiety responses include attachment-centric behaviors, such as seeking physical proximity to the parent or asking the parent for reassurance. Parents, in turn, generally respond to these attachment-driven behaviors in ways that alleviate distress or facilitate avoidance of feared situations or stimuli^5,30. The construct that best captures these parental responses to child anxiety is family accommodation (FA). In the context of child anxiety, FA refers to changes in parent behavior and routines that are intended to help the child avoid or alleviate distress related to the anxiety^31,32. In the last decade the construct of FA has garnered extensive theoretical, empirical, and clinical attention. Theoretically, it is suggested that FA contributes to maintenance of the child’s anxiety through a cycle of negative reinforcement that leads to further increasing levels of accommodation and ever more severe symptoms over time. Through this process, the child continues to rely heavily on the accommodations and does not practice more independent coping abilities^31,33. Figure 2 illustrates the conceptual model pertaining to FA and the systemic nature of child anxiety.

Figure 2.

Conceptual model of family accommodation and the systemic nature of child anxiety in SPACE.

Empirical findings support this theoretical conceptualization, with extensive research showing that FA is highly prevalent among parents of anxious children³⁴ and that higher levels of accommodation are associated with greater child anxiety severity and related impairment³⁵. The rapidly growing body of research on FA implicates it as a central characteristic of child anxiety, highlighting the relevance of addressing FA in child anxiety treatment. It has been shown for example, that FA levels decreased following CBT for child anxiety³⁶ and parent-led exposure treatment³⁷. It has also been demonstrated that pre-treatment levels of FA predicted anxiety treatment outcomes, with higher pre-treatment levels of FA predicting poorer outcomes (such as higher symptom severity and poorer treatment response). These findings have been reported in clinical trials of different modalities of treatment including, family-based CBT for OCD³⁸, CBT or pharmacotherapy for OCD³⁹, and CBT for child anxiety⁴⁰.

Among the child anxiety treatments that address FA, SPACE⁴¹ uniquely focuses on systematically assisting parents in reducing FA. A randomized-controlled trial comparing SPACE to CBT in a sample of children with primary anxiety disorders (N = 124, ages 7–14 years), found SPACE to be as efficacious as CBT. Post-treatment reductions in FA were reported in both treatment conditions, with significantly greater reductions following SPACE¹⁹. Another recently completed randomized-controlled trial compared two versions of SPACE: ‘standard SPACE’ (12 weekly sessions with a clinician) and ‘SPACE-light’ (bibliotherapy plus 4 telehealth sessions with a clinician) in a sample of children with primary anxiety/OCD (N = 68, ages 7–17 years). Findings indicated significant reductions in anxiety/OCD symptom severity and functional impairment following both conditions, and provide further support for the efficacy of SPACE. In both conditions change in family accommodation was associated with change in anxiety severity, supporting the centrality of reducing FA in the process of treatment,⁴².

Overview of Approach

SPACE⁴¹ is a manualized, evidence-based, parent-only treatment for child anxiety and obsessive-compulsive disorder. Treatment is conducted with the parents over the span of 10–14 weeks and begins with setting the stage for the parent work, introducing the rationale for treatment and it’s underlying principles and addressing any concerns parents may have about the treatment. Following this psychoeducational step, parents are introduced to two key concepts that are the focus of treatment: Support and Family Accommodation. Supportive responses to the child’s anxiety are defined in SPACE as responses that convey to the child both acceptance/validation of the child’s distress, and confidence in the child’s ability to cope with and tolerate distress. Parents are trained on the use of supportive statements in response to the child’s symptoms. FA is defined as any change the parents have been making to their behavior to help the child avoid or alleviate anxiety. FA is carefully and comprehensively mapped out and a target accommodation is selected for reduction. A detailed plan is formulated for how the parents will modify their behavior to reduce or remove the accommodation. This plan is then communicated to the child in an open, transparent, and supportive manner. When parents begin implementing the accommodation reduction plan, treatment focuses on troubleshooting and problem-solving challenges that arise in its implementation. Modules of SPACE aimed at equipping parents with tools to cope with difficult child reactions are implemented as needed. Frequently, once significant progress has been made in the first accommodation, a second target accommodation is undertaken. The process is repeated until termination of treatment which includes a review of gains and of tools learned and guidance on relapse prevention.

Role of Parents

In contrast to parent-led CBT, in SPACE parents are not expected to replace the clinician in administering treatment to the child (e.g., teach the child regulation skills, challenge automatic negative thoughts, or facilitate exposures). Instead, SPACE focuses on the ways in which parents are involved in regulating the child’s anxiety symptoms and aims to bring about changes in the parents’ perceptions and behaviors that are likely to result in positive changes in the child’s anxiety. Parents in SPACE are encouraged to acknowledge the limitations of their control over the child’s behavior and concentrate on modifying their own responses to their child’s anxiety. For instance, in the case of a child who experiences anxiety about speaking in social situations, parents would refrain from imposing the expectation that the child must confront their fears and speak. Instead, they would communicate to the child that they will no longer accommodate by speaking on the child’s behalf. Parents reinforce this behavioral change with supportive messages that validate the emotional challenge and instill confidence in the child’s ability to endure this challenge, thereby offering a clear rationale for reducing this accommodation.

This focus on modifying parent behavior is informed by the theoretical frameworks of attachment theory²⁹ and nonviolent resistance NVR;⁴³. NVR emphasizes changing one’s own behavior to promote a process of change rather than attempting to directly impose change on others, which is often ineffective and can lead to escalating conflict. NVR as a therapeutic approach has been used primarily to help parents manage youth aggressive and destructive behaviors⁴⁴, and in SPACE this principle of changing one’s own behavior instead of forcing change on another person is applied to the process of reducing FA.

Theorized Mechanism of Change

Conceptualizing child anxiety as a systemic and interpersonal phenomenon in which parental responses play key roles sets the stage for treatment that focuses on modifying parental responses as a means of reducing child anxiety symptoms. An underlying premise of SPACE is that parents’ responses and perceptions of their child’s ability to cope with anxiety, and their communication of these perceptions to the child, shape the child’s perception of themselves. When parents in SPACE reduce their accommodating behaviors, they provide opportunities for their child to discover that they are capable of coping with anxiety independently, leading to less anxiety and less impairment over time. By framing the reduction in accommodation within an overall supportive attitude toward the child, parents are signaling to the child the message that, ‘although anxiety is uncomfortable, we know that you are able to tolerate it.’ Internalizing this message further bolsters the child’s belief in their own ability to cope, leading to less anxiety over time. Furthermore, this message, once internalized, is applied by the child across anxiety domains, leading to generalization of treatment gains.

Brief Case Example

The following clinical illustration briefly showcases how each treatment approach could be applied to the same case.

Greg and Emma were exhausted, frustrated, and worried. Their 9-year-old son Daniel was terrified that burglars would break into the house at night, take his things, or harm him. During the daytime Daniel seemed happy and carefree, but as nightfall drew near, he became visibly worried, clingy, and agitated. When it was time to go to bed he would walk around the house and lock all the windows and doors. He would then ask the parents many questions relating to safety and inquire repeatedly about their plans for the night, until they promised not to leave the house, that no burglars will come, and that they will keep the windows locked and take turns staying awake throughout the night just to make sure the house was secure. One night Daniel woke up and ‘caught’ his parents sleeping. He responded with panic and fury, yelling and crying for hours. Following that incident, Daniel started to wake up several times during the night to make sure that his parents were awake and guarding the house and Greg and Emma, in turn, made an effort to stay awake as much as they could.

Hypothetical Outline of Timid to Tiger

In parent-led CBT, Greg and Emma were taught how Daniels’ anxiety manifests in terms of physiological, behavioral, and cognitive responses, and how these all influenced each other. Emma and Greg were able to identify how Daniel’s anxiety triggers a state of ‘fight or flight,’ explaining his angry and panicked reactions. They learned to see the illogical nature of his thinking when he was anxious, such as overestimating the likelihood of bad things happening to him. They also learned to conceptualize his behaviors, such as locking the doors and windows, as avoidant safety behaviors that allow him to escape his anxiety momentarily, while ultimately maintaining it over time.

Treatment focused on how Emma and Greg could engage Daniel in learning and implementing strategies to better cope with, and ultimately reduce his anxious responses. They were coached to teach ‘confident thoughts’ to Daniel, such as ‘bad things don’t usually happen to you,’ whenever they heard him express an anxious thought about himself or the world. They set up daily a ‘worry time’ during which Daniel was encouraged to discuss his anxiety with parents. They also began spending 5 minutes per day engaging him in child-directed play (‘special time’) to enhance their relationship. Next, Emma and Greg were coached to engage Daniel in creating a ‘fear stairway’ to guide exposure tasks, such as not checking the windows one night. They created a system to reinforce Daniel’s positive progress, including earning stickers for each completed exposure and a prize for completing several exposures by the end of the week. They were taught how to ignore attention-seeking anxious behaviors, such as when Daniel would repeatedly demand to know their plans for the night. Emma and Greg also learned how to use ‘time-out’ to reduce some of Daniel’s more disruptive responses, such as when he knocked over and broke a lamp when he found out they were not awake ‘guarding’ the house. Throughout treatment Emma and Greg also reflected on how their own thoughts about Daniel and his anxiety were impacting their feelings and behaviors. They learned to model non-anxious responses (e.g., keeping a calm demeanor), even when Daniel was very upset.

Hypothetical outline of SPACE

In SPACE Greg and Emma learned about the systemic nature of Daniel’s anxiety. Treatment focused on understanding how their perceptions of Daniel and responses to his worries impact his anxiety, and on making changes to these responses. They reflected on their perception of Daniel as a fragile child who can’t handle uncertainty and on how awful it must be for him to go through life overwhelmed with anxiety. They also shared feeling tired, frustrated, and helpless; nothing they did seemed to help. Though they made many accommodations in an effort to quiet Daniel’s worries, he was still very anxious, they were all getting too little sleep, and this was affecting their work, and Daniel’s mood and functioning.

Through treatment Greg and Emma understood that although the accommodations they were providing were well-intentioned and perhaps helpful in the short run (i.e., making promises and providing reassurance helped Daniel to fall asleep each night), they actually worked to maintain his anxiety overall all by facilitating avoidance and reinforcing Daniel’s maladaptive beliefs that he is not safe in their home and that only his parents can regulate his anxiety. They formulated supportive messages that integrated validation of Daniel’s worries with confidence in his ability to tolerate these uncomfortable feelings and practiced using them between sessions. For example, ‘we know you get worried about burglars breaking into the house, and we know that you can handle feeling this way’. The first accommodation parents worked on was making promises related to burglars. They planned no longer to promise to keep the windows shut, and they notified Daniel about their plan in a loving, supportive, and clear way. In the following weeks treatment focused on helping Greg and Emma cope supportively with Daniel’s responses to this change. When implementation of this plan stabilized, a second accommodation was chosen (‘not staying up all night’) and addressed in a similar way.

Summary

Evidence exists for the efficacy of parent-only interventions for child anxiety disorders. Different theoretical formulations and understanding of child anxiety and its disorders point to different translational implementations of how to work with parents of anxious children. The conceptualizing model of child anxiety that informs individual CBT also informs parent-led CBT. Parents are taught skills to then teach to and practice with their child, consistent with a Transfer of Control approach. SPACE is informed by an interpersonal, systemic view of child anxiety that emphasizes children’s reliance on parents for safety and protection and the role of FA in child anxiety problems. SPACE aims to modify parental behavior by increasing supportive parental responses to child anxiety and reducing family accommodation. Research is needed to directly compare the efficacy of these two approaches and empirically test their hypothesized mechanisms of change. Identifying moderators of treatment response could lead to more personalized treatment recommendations and better overall outcomes in the treatment of these common, impairing, and chronic problems.

Synopsis:

Parent-only interventions for child anxiety offer potential advantages by enhancing treatment accessibility and conserving resources. Clinical trials investigating the effectiveness of parent-only treatments for child anxiety have demonstrated comparable efficacy to child-centered approaches. However, heterogeneity across studies contributes to uncertainty regarding the optimal approach to parent involvement in treatment for child anxiety. This paper aims to review the utilization of parents in two evidence-based parent-only treatment modalities for child anxiety: parent-led cognitive-behavioral therapy (CBT) and Supportive Parenting for Anxious Childhood Emotions (SPACE). Discussion includes the exploration of the theoretical foundations for these approaches, the role of parents in the treatment process, and potential mechanisms of change. Additionally, a brief case description illustrates how these two approaches may address a similar case.

Clinics Care Points:

• Anxiety disorders are the most common group of mental health concerns, affecting approximately 15–30% of children and adolescents.

• The best supported evidence-based treatment approach for child anxiety disorders is cognitive-behavioral therapy (CBT). Not all children benefit from CBT, which requires access to specialized treatment, and motivation, and insight in the child.

• In recent years, parent-only treatment approaches, such as parent-led CBT and SPACE, have gained empirical support and do not require direct child participation.

Key Points.

• Evidence supports the efficacy of parent-only interventions for child anxiety disorders. Parent-only interventions offer potential advantages, including enhancing treatment accessibility and conserving resources.

• In parent-led cognitive-behavioral therapy (CBT), parents assume the role of the child’s therapist and actively practice CBT skills with the child.

• In SPACE (Supportive Parenting for Anxious Childhood Emotions), anxiety is conceptualized as a systemic, interpersonal phenomenon. Parents focus on their responses to the child’s anxiety, aiming to respond with support and to systematically reduce their accommodations of the anxiety.

• Further research comparing the efficacy of these approaches and identifying moderators of treatment response could lead to more personalized treatment recommendations and to better overall treatment outcomes.