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. Author manuscript; available in PMC: 2021 Dec 1.
Published in final edited form as: J Anxiety Disord. 2020 Sep 28;76:102318. doi: 10.1016/j.janxdis.2020.102318

Family accommodation mediates the impact of childhood anxiety on functional impairment.

Pedro Macul Ferreira de Barros 1, Natália Polga 1, Natalia Szejko 2, Eurípedes Constantino Miguel 1, James Frederick Leckman 3, Wendy K Silverman 3, Eli R Lebowitz 3
PMCID: PMC7680363  NIHMSID: NIHMS1634759  PMID: 33011554

Abstract

Background:

Anxiety disorders are the most common childhood-onset psychiatric disorders and are extensively associated with child functional impairment. Data suggest that family accommodation plays a role in the association between anxiety severity and functional impairment in children, but more empirical evidence is needed.

Methods:

Participants were 425 clinically anxious children (ages 6–17 years), and their mothers. We first examined associations between child anxiety symptom severity, family accommodation, and child functional impairment. Next, we investigated the hypothesized mediation pathway linking anxiety severity to child impairment through increased family accommodation using structural equation modeling. We tested two models: one using parent ratings of their child’s anxiety and the other using the child’s self-ratings. Finally, we estimated the effect sizes of the mediation pathway in both models.

Results:

Family accommodation was significantly correlated with all the study variables. Child functional impairment was significantly correlated with parent-rated and self-rated child anxiety severity. Both structural equation models provided excellent fit for the data and supported the theoretical model by which family accommodation significantly explains part of the association between anxiety symptoms and functional impairment. The indirect effect sizes indicate that family accommodation accounts for between a fifth and a half of the impairment associated with symptom severity.

Conclusions:

The data provide important empirical evidence that family accommodation mediates the association between child anxiety and functional impairment and accounts for up to 50% of this association. These findings contribute to the growing understanding of the critical role of family accommodation and underscore the importance of assessing accommodation when evaluating and treating anxious children.

Keywords: Anxiety, Family accommodation, Child and adolescent, Mediation analysis, Parenting

INTRODUCTION

Anxiety disorders are the most common childhood-onset psychiatric disorders (Costello, Egger, & Angold, 2005). If not successfully treated, their course is typically chronic, often reaching long into adulthood (Ramsawh, Chavira, & Stein, 2010). The impact of childhood anxiety on critical developmental skills – such as communicating, socializing, learning and regulating emotions – may echo throughout an individual’s lifespan and anxious children are at elevated risk of additional physical and psychiatric illnesses (Boden, Fergusson, & Horwood, 2007; Kaplow, Curran, Angold, & Costello, 2001; Kendall et al., 2010; Pine, Cohen, Gurley, Brook, & Ma, 1998; Woodward & Fergusson, 2001). The impact of anxiety is not restricted to the individual level, but extends to the societal level, posing tremendous public health burden: anxiety disorders are associated with increased school dropout, teenage childbearing, and loss of productivity in the workplace (Greenberg et al., 1999).

One phenomenon that has been linked to both anxiety severity and functional impairment is family accommodation (Lebowitz et al., 2013). Family accommodation is ubiquitous in childhood anxiety and refers to changes that parents make in their own behaviors to help their child avoid or lessen anxiety (Kagan, Frank, & Kendall, 2017; Reuman & Abramowitz, 2018; Zavrou, Rudy, Johnco, Storch, & Lewin, 2019). By sustaining the child’s avoidance behavior and decreasing independent coping, family accommodation may lead to and maintain anxiety-related impairment. For example, socially anxious children may have impaired social skills linked to their parents’ frequent accommodation in social situations, such as speaking in place of the child.

Previous research using mediation analysis provided initial support for the hypothesis that family accommodation may constitute an indirect pathway through which anxiety symptoms lead to increased functional impairment (La Buissonnière-Ariza et al., 2018; Storch et al., 2015). To date, two studies have found evidence of this indirect pathway. In one study, the analysis focused on the role of externalizing symptoms in anxious children and found that accommodation mediates the paths linking both externalizing symptoms and anxiety severity to functional impairment but did not test a model focused on anxiety severity alone. The second study demonstrated that family accommodation mediates the link between anxiety severity specifically, and functional impairment, but included a highly heterogenous sample of children undergoing intensive treatment and of whom only a minority had an anxiety disorder as their primary diagnosis. Furthermore, both studies relied on traditional regression methodology for examining mediation and thus were unable to reliably estimate the mediation effect size, or the proportion of the association mediated by family accommodation (Cogo-Moreira & Swardfager, 2019).

The aim of our study was to expand and build upon the previous research by using structural equation modeling (SEM) to test the mediating role of family accommodation in a substantially larger sample of children diagnosed with primary anxiety disorders who were not currently in treatment. Structural equation modeling has important benefits over the traditional method, fitting more adequately cross-sectional data and enabling the estimation of effect sizes for mediation pathways (Gunzler, Chen, Wu, & Zhang, 2013; Zhao et al., 2010).

Although mediation analyses of cross-sectional data cannot confidently establish causal effects, the use of SEM is regarded as a valuable preliminary step for providing initial proof-of-concept for theoretical models of the paths of associations between variables and can guide further research utilizing longitudinal data (Gaynor, 2017).

METHODS

2.1. Participants

Participants were 425 children, aged 6–17 years (Mean = 10.34 years; SD = 3.02; 49.2% females) and their mothers, who presented consecutively for evaluation at a specialty anxiety clinic at a large medical center in the Northeastern United States. Children presented with excessive fear and anxiety problems, and were diagnosed with DSM-5 (American Psychiatric Association, 2013) anxiety disorder diagnoses of: generalized anxiety disorder (64.9%), social phobia (56.6%), separation anxiety disorder (38.6%), specific phobia (26.5%), panic disorder (5.5%), agoraphobia (4.5%) and selective mutism (3.6%). Comorbid diagnoses included attention-deficit/hyperactivity disorder (22.7%), oppositional defiant disorder (14.9%), obsessive-compulsive disorder (14.0%), dysthymia (7.1%), major depression (6.1%), post-traumatic stress disorder (2.6%), enuresis (1.7%), sleep terror disorder (0.9%) and encopresis (0.2%). All participating children were enrolled in regular educational settings and were English speaking. Children were predominantly Non-Hispanic (88.9%) and most were White (86.0%) with a minority being African-American (4.0%), Asian (2.3%) or of mixed or other races (7.7%).

2.2. Procedure

The study was approved by the University Institutional Review Board. Informed consent and assent were obtained from mothers and children, respectively, before any additional procedures. Clinical interviews were conducted for mothers and children separately by experienced assessors with extensive training in the assessment of anxiety disorders in children. Children were aided by trained research personnel in completing questionnaires and study forms. Final diagnostic decisions were made under the supervision of a licensed clinical psychologist.

2.3. Measures

2.3.1. Child anxiety assessment

DSM-5 anxiety disorder diagnoses were established using the Anxiety Disorders Interview Schedule – Children and Parent versions (ADIS-C/P; Silverman, Saavedra, & Pina, 2001), administered separately to child and mother. ADIS-C/P is a semi-structured interview with excellent reliability for diagnoses (k = .80–.92) and strong correspondence with anxiety questionnaires (Wendy K. Silverman et al., 2001; Wood, Piacentini, Bergman, McCracken, & Barrios, 2002). The ADIS-C/P was administered by graduate-level clinicians, or licensed psychologists, trained to reliability by one of the instrument’s authors. As in past research, in cases of discordant parent and child reports, the expert clinician considered both informants’ views to derive a final diagnosis (W. K. Silverman et al., 1999; Wendy K. Silverman, Kurtines, Jaccard, & Pina, 2009).

The Screen for Child Anxiety Related Emotional Disorders – Children and Parent Version (SCARED-C/P; Birmaher et al., 1997) was used to assess the children’s anxiety severity. The SCARED is a widely-used and well-established (Monga et al., 2000) 41-item instrument, with parallel child and parent versions. Items assess the severity of childhood anxiety symptoms across several domains including generalized, separation, social, somatic, and school-related anxiety. Items are rated on a three-point scale (0 = never true; 1 = sometimes true; 2 = often true). SCARED has good psychometric properties including reliability and internal consistency (Birmaher et al., 1999). The Cronbach’s alphas have ranged in previous research from 0.74 to 0.94 (Muris, Dreessen, Bogels, Weckx, & van Melick, 2004). The test–retest reliability and intra-class correlation coefficients have ranged from 0.70 to 0.90 (Simon & Bogels, 2009). Internal consistency in the current study was α=0.89.

2.3.2. Family accommodation assessment

The Family Accommodation Scale–Anxiety (FASA; Lebowitz et al., 2013) is the most widely used instrument for assessing family accommodation of child anxiety symptoms. FASA comprises 13 parent-rated items that are rated on a 5-point Likert-type scale from 0 (“no accommodation or never”) to 4 (“daily”). Nine items assess the frequency of accommodation; of these, five items assess Participation in symptom-driven behaviors (e.g., “How often did you assist your child in avoiding things that might make him/her more anxious?”), and four items assess Modification of routines and schedules (e.g., “Have you modified your work schedule because of your child’s anxiety?”). Together these nine items generate the total accommodation score. One additional item assesses the degree of distress the accommodation causes the parent, and three additional items assess short-term negative child responses to not being accommodated, such as the child becoming more distressed, angry or abusive. FASA has been found to have strong psychometric properties including convergent and divergent validity, internal consistency, with Cronbach’s alphas values around 0.90 (Lebowitz et al., 2013), and test-retest reliability (Lebowitz, Marin, & Silverman, 2019). The FASA total accommodation score was used and internal consistency in the current study was α=0.88.

2.3.2. Child impairment assessment

The Child Anxiety Impact Scale (CAIS; A. K. Langley, Bergman, McCracken, & Piacentini, 2004) is a parent-rated instrument used to assess the impact of anxiety symptoms on the psychosocial functioning of children. Each of the CAIS’s 27 items queries the degree the child’s anxiety symptoms have caused problems and interference in specific areas of functioning during the past month. The items are divided into three subscales that correspond to three major domains of childhood functioning: school, social, and home/family. Items are scored on a 4-point scale ranging from 0 (“not at all”) to 3 (“very much”). The CAIS has been shown to have good internal consistency and convergent validity with other measures of child anxiety (Audra K. Langley et al., 2014). Internal consistency in the current study was α=0.87.

2.4. Data analytic strategy

Descriptive analyses, Pearson bivariate correlations and linear regressions were performed using SPSS version 24. Mediation analysis was performed using SEM in Mplus version 7.44 and conducted using the maximum-likelihood method (Muthén & Muthen, 2017).

We tested two models: one considering parent-rated child anxiety symptom severity and the other considering child self-rated anxiety severity. In both models, we controlled for child age, based on previous reports that family accommodation, anxiety symptoms and impairment vary across development, and based on significant bivariate correlations that emerged in the current sample between child age, anxiety and accommodation (Costello et al., 2005; Storch et al., 2015; Thompson-Hollands, Kerns, Pincus, & Comer, 2014). Since the CAIS was designed using an a priori three-factor theoretical structure, we analyzed child functional impairment as the latent variable accounting for the three CAIS subscales. The interaction between anxiety symptom ratings and family accommodation was tested but was not a significant predictor of functional impairment, and thus was not included in the models (Kline, 2015; MacKinnon, 2012). Alternative model specification procedures (Vandenberg & Grelle, 2009) were also performed and are included in the supplementary material.

A variety of fit indices were examined to evaluate model fit: Chi-squared test of model fit, Root Mean Square Error Approximation (RMSEA), Comparative Fit Index (CFI) and Standardized Root Mean Square Residual (SRMR). In line with the current literature, model interpretation was not based on the significance of individual pathway coefficients, which may lead to misleading results (Hayes, 2017; Rucker, Preacher, Tormala, & Petty, 2011). Instead, statistical significance was assessed by calculation of bias-corrected bootstrap confidence intervals, and effect sizes were assessed by calculating the percent of total effect mediated (Cogo-Moreira & Swardfager, 2019). Bias-corrected bootstrap confidence intervals were generated from repeated resampling (10,000 samples) of the observed data (Preacher & Hayes, 2008), and mediation was considered statistically significant when the 95% confidence interval did not span zero. The bootstrapped confidence interval method controls for the positive skew associated with indirect effects and is statistically more powerful than other methods (Fritz & MacKinnon, 2007).

RESULTS

The distribution and bivariate correlations between child age, parent-rated and self-rated child anxiety, family accommodation and child functional impairment are summarized in Table 1. Family accommodation was significantly correlated with all the other study variables. Additionally, child impairment was significantly correlated with both ratings of child anxiety and child age was significantly correlated with self-rated child anxiety.

TABLE 1.

Means, standard deviations and Pearson bivariate correlations for the study variables.

M (SD) 1 2 3 4
1. Child age 10.34 3.02
Child anxiety symptomsa
 2. Parent-rated 32.25 14.39 .00
 3. Self-rated 30.41 12.86 .16** .26**
4. Family accommodationb 16.52 8.65 −.18** .45** .12*
5. Child functional impairmentc .13 .70** .16* .53**
 School subscale 9.14 6.79
 Social subscale 6.72 6.16
 Home/family subscale 4.52 3.18
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*

P <.05;

**

P<.001

a

Based on the Screen for Child Anxiety Related Emotional Disorders (SCARED).

b

Based on the parent-rated Family Accommodation Scale - Anxiety (FASA).

c

Based on the latent variable analysis of the three subscales of the parent-rated Child Anxiety Impact Scale (CAIS).

The SEM models examining the mediating role of family accommodation for the relation between child anxiety symptoms and functional impairment are presented in Figs. 1–2. Figure 1 shows the model for parent-rated child anxiety and Figure 2 shows the model for self-rated child anxiety. Analyses of fit indices of both models revealed good fit (Hooper, Coughlan, & Mullen, 2008), and results are presented in Figs. 1–2 legends.

FIGURE 1.

FIGURE 1

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Structural equation model examining family accommodation as mediator of the relationship between parent-rated child anxiety and child functional impairment. Standardized coefficients are presented. χ2(6)=15.157; P=.019; CFI=0.972; RMSEA=.060; SRMR=0.043; p-close=0.285. *P <.05; **P<.001.

FIGURE 2.

FIGURE 2

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Structural equation model examining family accommodation as mediator of the relationship between self-rated child anxiety and child functional impairment. Standardized coefficients are presented. χ2(6)=13.919; P=0.030; CFI=0.952; RMSEA=0.056; SRMR=0.043; p-close=0.341. *P <.05; **P<.001.

Direct and indirect pathway coefficients and effect sizes from the SEM models, as well as bivariate correlation coefficients are summarized in Table 2. The indirect pathways (i.e. the effect of anxiety symptoms on functional impairment mediated by family accommodation) were significant in both the model using child-rated anxiety and the model using parent rated-anxiety, as ascertained by the bias-corrected bootstrap confidence intervals. When direct and indirect effects operate in the same direction and there is no interaction between the predictor and mediator variables, the portion of the association that is explained by the mediator variable can be calculated (Cogo-Moreira & Swardfager, 2019). This is the case for both models. In the parent-rated child anxiety model, family accommodation accounted for 20.1% of the impact of anxiety on child functioning. In the self-rated child anxiety model, family accommodation accounted for 48.5% of the impact of anxiety on child functioning.

TABLE 2.

Results of bivariate regressions and mediation analyses for predicting child functional impairmenta.

Bivariate Regression
 Structural Equation Model
Coefficient (CI) R-squared Direct Effect (CI) Indirect Effect (CI) Percent of Total Effect Mediated R-squared
Child anxiety symptomsb
 Parent-rated .692 (.573, .803) .478 .553 (.429, .673) .139 (.063, .219) 20.1% .571
 Self-rated .168 (.020, .316) .028 .085 (−.066, .233) .080 (.030, .141) 48.5% .319
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CI, bias-corrected bootstrap confidence interval (10,000 repeated resampling).

a

Based on the latent variable analysis of the three subscales of the parent-rated Child Anxiety Impact Scale (CAIS).

b

Based on the Screen for Child Anxiety Related Emotional Disorders (SCARED).

DISCUSSION

We applied, for the first time, SEM analysis to investigate the mediating role of family accommodation in linking child anxiety symptoms and functional impairment. Results strongly support the theoretical model that childhood anxiety symptoms entangle parents in increased family accommodation, and in turn lead to increased functional impairment for the child. One important implication of this conceptual model is that there is a greater risk of additional impairment if parents accommodate their children’s anxiety. The more heavily impaired child may experience worsening of anxiety symptoms, with the potential for a negative cycle of anxiety, accommodation and impairment.

The results of the SEM analyses suggest that the mediating role of family accommodation is not only statistically significant, but also substantial. This finding is novel as this is the first study to estimate the effect size of the mediation pathway. The data indicate that family accommodation accounts for up to half of children’s anxiety-related impairment. This finding raises a red flag for the need to assess for family accommodation when evaluating and treating childhood anxiety. Parent-based treatments that focus on reducing family accommodation have been developed and have been shown to be efficacious in clinical trials (Lebowitz, 2013; Lebowitz, Marin, Martino, Shimshoni, & Silverman, 2019; Lebowitz, Omer, Hermes, & Scahill, 2014).

In line with the vast literature on child mental health assessment, parent-rated and child-rated anxiety scores were significantly but weakly associated in our study (Achenbach, McConaughy, & Howell, 1987; A. De Los Reyes, 2011; Lebowitz, Scharfstein, & Jones, 2015; Rapee, Barrett, Dadds, & Evans, 1994). The weak correlation between parent and child reports is considered one of the most normative observations in mental health assessments. Literature reviews on this observation have frequently underscored the need to take into account information from both informants when analyzing data (Achenbach, 2011; Andres De Los Reyes et al., 2015). Our findings reveal that the mediating role of family accommodation was significant in both the model relying on parent-rated anxiety and the model relying on child-rated anxiety. This convergence in results bolsters confidence in the theory that family accommodation accounts for an important part of how anxiety leads to functional impairment.

Our findings should be interpreted in light of certain limitations. First, the sample was relatively homogeneous in terms of race and ethnicity. Further research is necessary to establish whether the results would be generalizable to more diverse samples. Second, participant age ranged fairly widely (6-17), but the considerable size of the sample and the inclusion of child age in the SEM analysis mitigate this concern. Third, parental data was obtained using maternal ratings only, as mothers have been the focus of most previous studies on childhood anxiety (McLeod, Wood, & Weisz, 2007; Wood, McLeod, Sigman, Hwang, & Chu, 2003). It is not possible to conclude whether the same pattern would be observed with father reports. Fourth, the study analyzed cross-sectional data and thus could only test if the proposed mediating model is a good fit for the data but cannot ascertain causal roles. While alternative model specifications (Figures S1 and S2 in the supplementary data) favor the conceptual framework that we examined, they do not alleviate this limitation. The positive findings provide initial proof-of-concept for the theoretical model and point to a robust result, but longitudinal data are necessary to strengthen causal inferences. Notwithstanding these limitations, our study builds on previous research by employing a solid statistical approach in a larger clinical sample. The findings constitute unique and important evidence for the role of family accommodation in childhood anxiety and functional impairment.

In conclusion, we found that family accommodation accounted for a large portion of the impact of anxiety symptoms on life functioning in anxious children. The results underscore the importance of addressing parent behaviors, such as accommodation, when assessing and treating children with anxiety disorders.

Supplementary Material

1

HIGHLIGHTS.

  • Higher child anxiety severity is associated with higher family accommodation and higher child functional impairment.

  • Family accommodation mediates the association between child anxiety severity and child functional impairment.

  • The mediation effect was significant when either parent-ratings or self-ratings of child anxiety were analyzed.

  • The magnitude by which family accommodation explains the relationship between anxiety severity and functional impairment is estimated to be between 20 and 50%.

Acknowledgements:

This research was supported by grants from NIMH (K23MH103555; 1R61MH115113-01A1).

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflict of interest:

No potential conflict of interest was reported by the authors.

References

  1. Achenbach TM (2011). Commentary: Definitely more than measurement error: but how should we understand and deal with informant discrepancies? Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 40(1), 80–86. doi: 10.1080/15374416.2011.533416 [DOI] [PubMed] [Google Scholar]
  2. Achenbach TM, McConaughy SH, & Howell CT (1987). Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychological bulletin, 101(2), 213–232. [PubMed] [Google Scholar]
  3. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC. [Google Scholar]
  4. Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, & Baugher M (1999). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry, 38(10), 1230–1236. doi: 10.1097/00004583-199910000-00011 [DOI] [PubMed] [Google Scholar]
  5. Birmaher B, Khetarpal S, Brent D, Cully M, Balach L, Kaufman J, & Neer SM (1997). The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry, 36(4), 545–553. doi: 10.1097/00004583-199704000-00018 [DOI] [PubMed] [Google Scholar]
  6. Boden JM, Fergusson DM, & Horwood LJ (2007). Anxiety disorders and suicidal behaviours in adolescence and young adulthood: findings from a longitudinal study. Psychol Med, 37(3), 431–440. doi: 10.1017/s0033291706009147 [DOI] [PubMed] [Google Scholar]
  7. Cogo-Moreira H, & Swardfager W (2019). On Mediation Models in Clinical Neurology StudiesOn Mediation Models in Clinical Neurology StudiesLetters. JAMA Neurology, 76(1), 116–117. doi: 10.1001/jamaneurol.2018.3884 [DOI] [PubMed] [Google Scholar]
  8. Costello EJ, Egger HL, & Angold A (2005). The developmental epidemiology of anxiety disorders: phenomenology, prevalence, and comorbidity. Child Adolesc Psychiatr Clin N Am, 14(4), 631–648, vii. doi: 10.1016/j.chc.2005.06.003 [DOI] [PubMed] [Google Scholar]
  9. De Los Reyes A (2011). Introduction to the special section: More than measurement error: Discovering meaning behind informant discrepancies in clinical assessments of children and adolescents. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 40(1), 1–9. doi: 10.1080/15374416.2011.533405 [DOI] [PubMed] [Google Scholar]
  10. De Los Reyes A, Augenstein TM, Wang M, Thomas SA, Drabick DAG, Burgers DE, & Rabinowitz J (2015). The validity of the multi-informant approach to assessing child and adolescent mental health. Psychological bulletin, 141(4), 858–900. doi: 10.1037/a0038498 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Fritz MS, & MacKinnon DP (2007). Required sample size to detect the mediated effect. Psychological science, 18(3), 233–239. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Gaynor ST (2017). Temporal precedence in the identification of mediators of change: A brief comment on “Mediators of change in the child/adolescent multimodal treatment study” (Kendall et al., 2016). Journal of Consulting and Clinical Psychology, 85(1), 77–79. doi: 10.1037/ccp0000108 [DOI] [PubMed] [Google Scholar]
  13. Greenberg PE, Sisitsky T, Kessler RC, Finkelstein SN, Berndt ER, Davidson JR, … Fyer AJ (1999). The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry, 60(7), 427–435. [DOI] [PubMed] [Google Scholar]
  14. Gunzler D, Chen T, Wu P, & Zhang H (2013). Introduction to mediation analysis with structural equation modeling. Shanghai archives of psychiatry, 25(6), 390–394. doi: 10.3969/j.issn.1002-0829.2013.06.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Hayes AF (2017). Introduction to Mediation, Moderation, and Conditional Process Analysis, Second Edition: A Regression-Based Approach. Guilford Publications. [Google Scholar]
  16. Hooper D, Coughlan J, & Mullen MR (2008). Structural equation modelling: Guidelines for determining model fit. Electronic journal of business research methods, 6(1), 53–60. [Google Scholar]
  17. Kagan ER, Frank HE, & Kendall PC (2017). Accommodation in youth with OCD and anxiety. Clinical Psychology: Science and Practice, 24(1), 78–98. [Google Scholar]
  18. Kaplow JB, Curran PJ, Angold A, & Costello EJ (2001). The prospective relation between dimensions of anxiety and the initiation of adolescent alcohol use. J Clin Child Psychol, 30(3), 316–326. doi: 10.1207/s15374424jccp3003_4 [DOI] [PubMed] [Google Scholar]
  19. Kendall PC, Compton SN, Walkup JT, Birmaher B, Albano AM, Sherrill J, … Piacentini J (2010). Clinical characteristics of anxiety disordered youth. J Anxiety Disord, 24(3), 360–365. doi: 10.1016/j.janxdis.2010.01.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Kline RB (2015). Principles and practice of structural equation modeling: Guilford publications. [Google Scholar]
  21. La Buissonnière-Ariza V, Schneider SC, Hojgaard D, Kay BC, Riemann BC, Eken SC, … Storch EA (2018). Family accommodation of anxiety symptoms in youth undergoing intensive multimodal treatment for anxiety disorders and obsessive-compulsive disorder: Nature, clinical correlates, and treatment response. Comprehensive Psychiatry, 80, 1–13. doi: 10.1016/j.comppsych.2017.07.012 [DOI] [PubMed] [Google Scholar]
  22. Langley AK, Bergman RL, McCracken J, & Piacentini JC (2004). Impairment in childhood anxiety disorders: preliminary examination of the child anxiety impact scale-parent version. J Child Adolesc Psychopharmacol, 14(1), 105–114. doi: 10.1089/104454604773840544 [DOI] [PubMed] [Google Scholar]
  23. Langley AK, Falk A, Peris T, Wiley JF, Kendall PC, Ginsburg G, … Piacentini J (2014). The child anxiety impact scale: examining parent- and child-reported impairment in child anxiety disorders. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 43(4), 579–591. doi: 10.1080/15374416.2013.817311 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Lebowitz ER (2013). Parent-based treatment for childhood and adolescent OCD. Journal of Obsessive-Compulsive and Related Disorders, 2(4), 425–431. doi: 10.1016/j.jocrd.2013.08.004 [DOI] [Google Scholar]
  25. Lebowitz ER, Marin C, Martino A, Shimshoni Y, & Silverman WK (2019). Parent-Based Treatment as Efficacious as Cognitive-Behavioral Therapy for Childhood Anxiety: A Randomized Noninferiority Study of Supportive Parenting for Anxious Childhood Emotions. J Am Acad Child Adolesc Psychiatry. doi: 10.1016/j.jaac.2019.02.014 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Lebowitz ER, Marin CE, & Silverman WK (2019). Measuring Family Accommodation of Childhood Anxiety: Confirmatory Factor Analysis, Validity, and Reliability of the Parent and Child Family Accommodation Scale – Anxiety. Journal of Clinical Child & Adolescent Psychology, 1–9. doi: 10.1080/15374416.2019.1614002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Lebowitz ER, Omer H, Hermes H, & Scahill L (2014). Parent Training for Childhood Anxiety Disorders: The SPACE Program. Cognitive and Behavioral Practice, 21(4), 456–469. doi: 10.1016/j.cbpra.2013.10.004 [DOI] [Google Scholar]
  28. Lebowitz ER, Scharfstein L, & Jones J (2015). Child-Report of Family Accommodation in Pediatric Anxiety Disorders: Comparison and Integration with Mother-Report. Child Psychiatry & Human Development, 46(4), 501–511. doi: 10.1007/s10578-014-0491-1 [DOI] [PubMed] [Google Scholar]
  29. Lebowitz ER, Woolston J, Bar-Haim Y, Calvocoressi L, Dauser C, Warnick E, … Leckman JF (2013). Family accommodation in pediatric anxiety disorders. Depress Anxiety, 30(1), 47–54. doi: 10.1002/da.21998 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. MacKinnon D (2012). Introduction to statistical mediation analysis: Routledge. [Google Scholar]
  31. McLeod BD, Wood JJ, & Weisz JR (2007). Examining the association between parenting and childhood anxiety: A meta-analysis. Clinical Psychology Review, 27(2), 155–172. doi: 10.1016/j.cpr.2006.09.002 [DOI] [PubMed] [Google Scholar]
  32. Monga S, Birmaher B, Chiappetta L, Brent D, Kaufman J, Bridge J, & Cully M (2000). Screen for Child Anxiety-Related Emotional Disorders (SCARED): convergent and divergent validity. Depress Anxiety, 12(2), 85–91. doi: [DOI] [PubMed] [Google Scholar]
  33. Muris P, Dreessen L, Bogels S, Weckx M, & van Melick M (2004). A questionnaire for screening a broad range of DSM-defined anxiety disorder symptoms in clinically referred children and adolescents. J Child Psychol Psychiatry, 45(4), 813–820. doi: 10.1111/j.1469-7610.2004.00274.x [DOI] [PubMed] [Google Scholar]
  34. Muthén LK, & Muthen B (2017). Mplus user’s guide: Statistical analysis with latent variables, user’s guide: Muthén & Muthén. [Google Scholar]
  35. Pine DS, Cohen P, Gurley D, Brook J, & Ma Y (1998). The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry, 55(1), 56–64. doi: 10.1001/archpsyc.55.1.56 [DOI] [PubMed] [Google Scholar]
  36. Preacher KJ, & Hayes AF (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior research methods, 40(3), 879–891. [DOI] [PubMed] [Google Scholar]
  37. Ramsawh HJ, Chavira DA, & Stein MB (2010). Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda. Arch Pediatr Adolesc Med, 164(10), 965–972. doi: 10.1001/archpediatrics.2010.170 [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Rapee RM, Barrett PM, Dadds MR, & Evans L (1994). Reliability of the DSM-III-R childhood anxiety disorders using structured interview: interrater and parent-child agreement. J Am Acad Child Adolesc Psychiatry, 33(7), 984–992. doi: 10.1097/00004583-199409000-00008 [DOI] [PubMed] [Google Scholar]
  39. Reuman L, & Abramowitz JS (2018). Predictors of accommodation among families affected by fear-based disorders. Child Psychiatry & Human Development, 49(1), 53–62. [DOI] [PubMed] [Google Scholar]
  40. Rucker D, Preacher K, Tormala Z, & Petty R (2011). Mediation Analysis in Social Psychology: Current Practices and New Recommendations. Social and Personality Psychology Compass, 5, 359–371. doi: 10.1111/j.1751-9004.2011.00355.x [DOI] [Google Scholar]
  41. Silverman WK, Kurtines WM, Ginsburg GS, Weems CF, Rabian B, & Serafini LT (1999). Contingency management, self-control, and education support in the treatment of childhood phobic disorders: a randomized clinical trial. J Consult Clin Psychol, 67(5), 675–687. doi: 10.1037//0022-006x.67.5.675 [DOI] [PubMed] [Google Scholar]
  42. Silverman WK, Kurtines WM, Jaccard J, & Pina AA (2009). Directionality of change in youth anxiety treatment involving parents: An initial examination. Journal of Consulting and Clinical Psychology, 77(3), 474–485. doi: 10.1037/a0015761 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Silverman WK, Saavedra LM, & Pina AA (2001). Test-Retest Reliability of Anxiety Symptoms and Diagnoses With the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. Journal of the American Academy of Child & Adolescent Psychiatry, 40(8), 937–944. doi: 10.1097/00004583-200108000-00016 [DOI] [PubMed] [Google Scholar]
  44. Simon E, & Bogels SM (2009). Screening for anxiety disorders in children. Eur Child Adolesc Psychiatry, 18(10), 625–634. doi: 10.1007/s00787-009-0023-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Storch EA, Salloum A, Johnco C, Dane BF, Crawford EA, King MA, … Lewin AB (2015). Phenomenology and clinical correlates of family accommodation in pediatric anxiety disorders. J Anxiety Disord, 35, 75–81. doi: 10.1016/j.janxdis.2015.09.001 [DOI] [PubMed] [Google Scholar]
  46. Thompson-Hollands J, Kerns CE, Pincus DB, & Comer JS (2014). Parental accommodation of child anxiety and related symptoms: range, impact, and correlates. J Anxiety Disord, 28(8), 765–773. doi: 10.1016/j.janxdis.2014.09.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Vandenberg RJ, & Grelle DM (2009). Alternative model specifications in structural equation modeling. Statistical and methodological myths and urban legends: Doctrine, verity and fable in the organizational and social sciences, 165–191. [Google Scholar]
  48. Wood JJ, McLeod BD, Sigman M, Hwang WC, & Chu BC (2003). Parenting and childhood anxiety: theory, empirical findings, and future directions. J Child Psychol Psychiatry, 44(1), 134–151. [DOI] [PubMed] [Google Scholar]
  49. Wood JJ, Piacentini JC, Bergman RL, McCracken J, & Barrios V (2002). Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 31(3), 335–342. doi: 10.1207/s15374424jccp3103_05 [DOI] [PubMed] [Google Scholar]
  50. Woodward LJ, & Fergusson DM (2001). Life course outcomes of young people with anxiety disorders in adolescence. J Am Acad Child Adolesc Psychiatry, 40(9), 1086–1093. doi: 10.1097/00004583-200109000-00018 [DOI] [PubMed] [Google Scholar]
  51. Zavrou S, Rudy B, Johnco C, Storch EA, & Lewin AB (2019). Preliminary study of family accommodation in 4-7 year-olds with anxiety: frequency, clinical correlates, and treatment response. Journal of mental health (Abingdon, England), 28(4), 365–371. doi: 10.1080/09638237.2018.1466034 [DOI] [PubMed] [Google Scholar]
  52. Zhao X, Lynch J, xa G, Chen Q, John Deighton served as, e., & Gavan Fitzsimons served as associate editor for this, a. (2010). Reconsidering Baron and Kenny: Myths and Truths about Mediation Analysis. Journal of Consumer Research, 37(2), 197–206. doi: 10.1086/651257 [DOI] [Google Scholar]

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