Attention Magazine June 2018

EXPERTS estimate that up to thirty percent of children with ADHD experience a co-occurring anxiety disorder. Unfortunately, not all highly anxious children will agree to participate in treatment, no matter how effective the treatment might be in reducing their suffering. And even when they do agree to participate, not all of these otherwise effective treatments will be effective for all highly anxious children. The SPACE Program–Supportive Parenting for Anxious Childhood Emotions–may provide a remedy.

A unique, parent-based intervention, SPACE provides parents of highly anxious children specific tools to help reduce their child’s anxiety-related symptoms. What’s particularly novel about this model is that children need not be involved in the treatment process. The reason, according to the model’s author, Eli Lebowitz, PhD, is that a child’s anxiety-related symptoms will often decrease in response to new ways that parents learn to interact with them. Lebowitz, associate director of the Anxiety and Mood Disorders Program at the Yale Child Study Center, says this starts with new ways to address the phenomenon of “family accommodation.”

To help prevent their highly anxious child from experiencing emotional distress, it’s very normal for parents to spend a great deal of time engaging in “accommodating” behavior. These are behaviors that shield their child from situations known to trigger emotional distress. The problem is that accommodating behavior can also prevent highly anxious children from learning to better manage their anxiety, something they will need to learn in order better handle day-to-day real-world demands. It’s an awful bind, one that can cause parents to feel trapped and unsure how best to help their child.

SPACE is designed to provide parents with tools to resolve this thorny dilemma. By the end of treatment, parents see that there are ways to express empathic acceptance of their child’s distressing symptoms and also gradually reduce accommodating behavior in ways that help their child cope more effectively with situations that previously triggered highly anxious reactions.

How it works

In helping parents achieve this outcome, SPACE draws upon principles of nonviolent resistance (NVR), a framework pioneered by leading peace activists decades ago. Through an NVR lens, it’s not about “How can I make you do this,” but rather, “How can I stand by my own beliefs, without attacking or giving in.” Parents learn how they can act in a unilateral fashion that neither encourages behaviors they wish to decrease, nor acquiesces to them.

Parents learn how to do this during the course of ten to twelve weekly sessions that are comprised of eight treatment parts. Treatment begins with an overview of the program. Parents learn that while they are not to blame for their child’s anxiety disorder, research shows that they can be the solution. By making small changes in their own behavior– changes that are clear and understandable to their child–they can help their child learn to change as well.

Parents are introduced to ways to begin rephrasing statements to their child in ways that communicate support and confidence. Rather than saying, “That’s not really frightening,” the better message might be, “It scared you, but I am sure you’ll be okay.” As treatment proceeds, parents are provided tools for identifying and charting accommodating behavior, tools for gradually reducing accommodating behavior, tools for helping a highly anxious child adapt safely and successfully to these gradual reductions, and tools that can help the child achieve further growth following the completion of treatment.

SPACE also includes four session modules, with one or more of these modules weaved into these eight treatment parts in accordance with each child’s unique treatment needs. Session modules are designed to address the common and sometimes disproportionately strong emotional and behavior reactions that can occur once parents gradually decrease accommodating behavior. These can include overly aggressive or explosive reactions as well as threats of self-harm. Session modules are typically introduced by the fourth or fifth session, but can be introduced earlier on an as-needed basis.

Results and effectiveness

SPACE is intended for parents of children in grades K through 12, but has been successfully implemented in much younger children as well. It is designed to treat all anxiety disorders as well as obsessive-compulsive disorder. Lebowitz’s team has also been doing SPACE for cases of avoidant restricted food intake disorder. Lebowitz also finds that some of the NVR principles used in the program are helpful to parents of highly anxious young adults who experience difficulty living away from home. (See the Promising Practices column, “Failure to Launch: Treating It as a Process, Not a Failure,” in the April 2018 Attention.)

A large randomized controlled study of SPACE’s effectiveness will be completed in the near future. Two earlier pilot studies showed promising results, although Lebowitz cited several limitations to these studies and recommended largerscale randomized controlled studies, such as the one nearing completion. Anecdotal accounts from treatment providers using the program in the US and abroad strongly support its effectiveness. SPACE is currently being implemented in clinical and research settings in the US and several countries overseas, including Singapore, Japan, Israel, Brazil, Canada, Germany, and England.

Lebowitz is scheduled to speak about his work at the 2018 International Conference on ADHD in St. Louis, Missouri, this November. Readers can learn more from Treating Childhood and Adolescent Anxiety: A Guide for Caregivers (Wiley, 2013), coauthored by Lebowitz and Haim Omer, PhD. The book includes a detailed manual on how to implement SPACE.

A clinical and consulting psychologist, Mark Katz, PhD, is the director of Learning Development Services, an educational, psychological, and neuropsychological center in San Diego, California. As a contributing editor to Attention magazine, he writes the Promising Practices column and serves on the editorial advisory board. He is also a former member of CHADD’s professional advisory board and a recipient of the CHADD Hall of Fame Award.