Lynne Siqueland, PhD - Children's and Adult Center for OCD and Anxiety
It is useful to consider three levels of family involvement when conceptualizing and planning treatment of child and adolescent anxiety: education, coaching parents and other family members and caregivers, and improving family relationships. This conceptualization has been useful for assessment of needs and clinical decision making by articulating levels of intervention for the treatment of childhood anxiety and related disorders. These three levels of intervention have also been suggested by other clinical investigators who have written about family factors relevant in child anxiety (Rapee, 2012). In what follows, straight forward language is offered that can be used by clinicians and other providers when speaking directly to parents and children in practice.
Psychoeducation about anxiety
Cognitive-behavioral therapists overall rely on psychoeducation as an essential part of their work. The first level of intervention then is psychoeducation about the nature of anxiety in children and an understanding of what ameliorates or exacerbates anxiety. This is the starting point and often essential for all families. It is useful to teach parents about what anxiety looks like in children and teens in terms of body reactions, thoughts and behavior. Many children and parents are not aware of the links between physical symptoms and anxiety. It helps for them to notice patterns. If, for example, a child is complaining of stomach pain each school day morning but does not have difficulty or pain during the school day or after school in the afternoons or weekends then there is likely a link to anxiety or separation fears rather than stomach condition alone.
Also clarifying for parents that the discomfort or pain is real but will often be relieved by managing anxiety rather than treating the stomach or other regions of the gastrointestinal system with medications can be helpful. Or addressing anxiety first can help clarify physical symptoms that remain after anxiety is lessened. Headaches and stomachaches are the most common physical symptoms reported along with vague physical complaints. Finally sleep issues are common in anxiety, especially around falling asleep. If sleep issues are caused primarily by anxiety then treating worry or separation anxiety in the daylight hours is often essential before there can be success in sleep difficulties. Another important psychoeducation issue is the reverse. Too little or disrupted sleep can cause anxiety and treating sleep issues may significantly reduce anxiety without formal treatment of the anxiety. Indeed psychoeducation and information alone has been helpful in child anxiety (Ginsburg, Drake, Tien et al., 2015). For some children and families education may be all they need to address concerns.
Cognitive-behavioral therapy (CBT) can be especially helpful in teaching youth and parents to recognize that there are thinking patterns that arise when anxiety is present, including beliefs that anxiety is problematic or dangerous. The first reaction the child shows is the anxiety reaction – it is automatic and often inaccurate or “false alarm”. For children and teens, that anxiety reaction is either a “freak-out” as kids often call it, or a “No” or refusal to do something or a combination of both. It helps parents and other caregivers to recognize this first response as the anxiety reaction and not how their child thinks or feels when not anxious. While it is clear that the child may not be able to help the first reaction, the child is expected to learn, and the parents are to help their child cultivate, another more reasonable response. It helps everyone to not be surprised or disappointed or to panic if the anxiety reaction occurs. Instead they can respond by calmly saying, “We thought this might happen and we have a plan.”
Finally the major issue for parents to understand is how avoidance maintains anxiety. Many parents understand this at higher levels of avoidance but not in the subtler versions of day-to-day living. It really helps for parents to understand that it is true that the anxiety goes down in the short run if they take over for a child (contact a friend or teachers for them) or allow a child to not attend a planned activity or event. However, avoidance maintains and exacerbates the anxiety in the long-run. Both prevention and intervention trials have targeted working with parents alone and providing educational information with good outcomes (e.g. Ginsburg, Drake, Tein, et al., 2015); Thirlwall, Cooper, Karalus,, Voysey, Willetts & Creswell, 2013).
Coaching Caregivers to Coach Children
The second component of coaching children during anxious moments comes into the clinical plan and is usually needed to some extent for all child and teen clients and their parents. If parents have a way to help their children rather than the past options of trying to force their child, getting angry, or letting their child avoid, then parents feel that they can do something. Also kids feel empowered because they also have something useful and different to do in the moment so often they are more willing to approach situations. The therapist reminds parents and child clients that humans forget or do not use their therapeutic strategies at first and especially in times of stress if the strategies have not been sufficiently practiced. It takes repeated practice for new skills to become available in times of stress. So it is important to review tools non-reactively and before they are needed, including after stressful events in anticipation of the next time. Overall, therapists want both kids and parents to know that anxiety disorders are no-fault conditions. Everyone is doing the best they can but in treatment parents and kids are asked to do some things differently based on what mental health professionals know about the nature of anxiety.
It is important to educate children, teens and their parents about the nature of exposures to feared situations and symptoms. There is no force involved but instead the therapist, child and parent are work together to make a plan to face fears step by step. Children and teens should be told ahead of time what is going to happen, and informed that parents are going to do things differently. Everyone in the family is told that it can be hard at first and uncomfortable but gets better with practice and time. One essential fact to learn about anxiety is that it often goes away on its own with doing next to nothing. The reaction to the anxiety is the problem more than the anxiety itself. Parents and kids see that you often do not have to use all cognitive or behavioral approaches for anxiety to change if you just expose yourself to the feared situation and pay attention to the actual objective outcome. The anxiety goes up and down on its own. One of the pieces of coaching advice is that “this bad feeling will pass.” Anxiety does not mean you have to do something. This fact alleviates pressure on children, teens and their families alike.
Parents and their children have a role in CBT treatment. Parents’ role in exposures is making time for exposures at home, taking kids places to do them and setting up plans like playdates. In this new role, parents are limiting reassurance, working to stay calm, and encouraging a different way of asking for help. Most importantly, therapists help parents pay a lot of attention to kids’ healthy coping responses and a lot less to anxiety. They can help their children use the CBT strategies or just simply help their children continue or return to what they would be doing if anxiety were not getting in the way. Psychologist Deborah Ledley, Ph.D. describes the child’s primary instruction as “just do it”- try the exposures planned, use your strategies and do not get too mad at your parents for taking you to treatment or asking you to do homework.
Many parents, with the psychoeducation and coaching, can do a great job and rather quickly take over the role as an encouraging side-by-side coach or background coach for their children. However some parents and families have difficulty doing this. If one or both parents have significant anxiety, and especially if the anxiety is untreated, they may be modeling an anxious response in words or other behaviors or may not be able to complete exposures. Many parents with anxiety who have formally received treatment or found their own ways to challenge themselves despite anxiety can be excellent coaches.
Parents very appropriately model for their kids coping by speaking out loud in the moment how they cope or describe how they coped in past situations. A parent might say, “I was pretty nervous to talk to someone at work about something I did not like because I did not want them to be mad at me or I did not want to look stupid. So I thought about how I wanted to say it and looked for a good time to talk to my coworker. It was hard because they were a little upset when I talked to them, but later at lunch we were able to talk again comfortably.” Often parents who cannot manage their own anxiety particularly well can still provide support and coaching for their child.
Other parents with or without anxiety might have strongly held beliefs either about parenting or anxiety that make it hard for them to feel that it is ok or safe for their child to be anxious. Oftentimes a session or two with parents alone focused on hearing their concerns with patience and understanding can lead these to be evaluated and challenged by attending to their child’s actual experience in treatment. It can be really enlightening for a parent to see a child either do an exposure with the therapist or come back from an exposure and report to the parent what they did. For example, parents will be surprised sometimes to hear the child did an exposure such as asking for a book in a bookstore or talking to another child in the waiting room. Seeing their child actually competent in doing these tasks helps challenge the belief about the child or anxiety. Also if there is one parent who is less anxious, that parent can do the exposures alone with the child first to help the child feel confident and competent and then transition to practicing with the more anxious parent.
Family accommodation has been well documented to directly relate to severity of OCD and anxiety symptoms. Improvements in limiting family accommodation lead to improvements in OCD and anxiety symptoms. Whereas in OCD family accommodation is often related to involvement in rituals, in the other anxiety disorders accommodation can take forms such as allowing avoidance or doing things for the child rather than promoting independence (Liebowitz, Scharfstein & Jones,2014; Merlo, Lehmkuhl, Geffken & Storch, 2009).
Improving Relationships with Caregivers
The third level of intervention is work on improving family relationships including improving communication, lowering conflict and promoting autonomy and independence. In some families, the level of conflict or anger or difficulties in communication can really limit the ability to do the CBT treatment. Therapists can decide if they have the interest in and experience working with families on these issues prior to or concurrent with CBT treatment. Otherwise families can be referred to individual, couples or family treatment with another provider. Both research studies and clinical experience show that many children and teens can make major improvements in CBT treatment even if their family does not change so it is important to keep offering the individual treatment option even in the family is not willing to engage in family work. The main difficulties that can arise when just an individual treatment model is used include therapy-interfering behaviors that take the form of parent accommodation, avoidance or parental difficulty helping children in anxious moments.
However other therapists can decide to take on the often rewarding and crucial work in some cases to meet with different family members to improve communication, lower conflict, increase closeness and attachment. Especially teens, but also younger children, are amazing at telling their parents how they feel when their parent reacts in a certain way. They might be able to tell parents how they feel when their parent gets anxious, or how it feels when the parent is mad when the child cannot help their anxiety reaction. For some families individuation and contrasting beliefs or choices are compromised for fear of conflict, hurting others feelings, or guilt. This family work is best done carefully and thoughtfully and working with child, parents / caregivers or dyads separately to plan for different kinds of conversations. Therapists can evaluate for kids and teens whether it is safe or useful for a child or teen to express their feelings and whether or not the parent is willing to listen and can be helped to hear. Families can be helped to promote competence and independence in their children and to “enact” different conversations and interactions (Bogels & Siqueland, 2016). Parents also need a safe place to discuss any differences in parenting philosophy or beliefs about anxiety that are limiting their ability to help their child. Therapists can often help parents to find a compromise approach or to respectfully tag team using different strengths and contributions of each parent. This third level of intervention is not needed for all families.
Bogels, S & Siqueland, L. (2006). Family cognitive behavioral therapy for children and adolescents with clinical anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 45(2) 134-141.
Ginsburg, GS, Drake KL, Tein JY Teetsle, R and Riddle, M. (2015). Preventing Onset of Anxiety Disorders in Offspring of Anxious Parents: A Randomized Controlled Trial of a Family-Based Intervention. American Journal of Psychiatry, 172:1207-1213.
Lebowitz ER, Scharfstein LA and Jones. J. (2014). Comparing family accommodation in pediatric obsessive-compulsive disorder, anxiety disorders, and nonanxious children, Depression and Anxiety, 31(12):1018-25.
Manassis K., Lee, T.C., Bennett, K., et al (2014). Types of parental involvement in CBT with anxious youth: a preliminary meta-analysis. Journal of Consulting and Clinical Psychology, 82 (6):1163–1172.
Merlo, L, Lehmkuhl, HD, Geffken, GR & Storch, E A (2009). Decreased family accommodation associated with improved therapy outcome in pediatric obsessive–compulsive disorder, Journal of Consulting and Clinical Psychology, Vol 77(2), 355-360.
Rapee, RM (2012). Family Factors in the Development and Management of Anxiety Disorders, Clinical Child and Family Psychology Review, Volume 15 (1) pp 69-80
Thirlwall, K, Cooper, PJ, Karalus, J, Voysey, M, Willetts L, Creswell C (2013). Treatment of child anxiety disorders via guided parent-delivered cognitive-behavioural therapy: randomised controlled trial. British Journal of Psychiatry. Dec; 203(6): 436-44.
Note: This article is based on the PBTA workshop entitled, “Family involvement in the treatment of children with anxiety disorders,” that was given by Lynne Siqueland, Ph.D. and Deborah Ledley, Ph.D. http://philabta.org/event-1878131
Published February 3, 2018