Accommodating Anxiety in Children: What Primary Care Providers Should Know

Anxiety disorders have historically been the most common form of mental health issues among youth. The prevalence of these disorders increased dramatically during the coronavirus pandemic, according to research.

While anxiety disorders are certainly a concern among youth, children and teens shouldn’t necessarily avoid feeling anxiety. Anxiety can be a healthy and adaptive emotion as it’s key in anticipating and preparing for threatening situations. It also helps us to mobilize to accomplish important life tasks.

The cycle of anxiety avoidance

For some children, anxiety leads to a pattern called the “cycle of avoidance,” which creates issues in many aspects of daily life. For example, a child who is afraid of dogs may begin avoiding playing at friends’ houses if they have dogs. This avoidance behavior successfully brings down anxiety in the short-term but reinforces the notion that safety comes from carefully avoiding dogs. This leads to more anxious vigilance for dogs and of course, more avoidance.

Sometimes, caregivers end up getting roped into helping their child avoid anxiety-provoking situations. For example, a teen who is anxious about giving a speech might convince their parents to contact the teacher so they can complete an alternative assignment. While the parent’s intervention in the situation might reduce the teen’s anxiety initially, it sends the message that anxiety is something to be feared and that the teen was incapable of handling this anxiety without the parent’s help. Children and teens can then become trapped in an avoidance cycle that ultimately lowers their ability to develop distress tolerance skills and independence.

Anxiety accommodation in families

Family accommodation is the term mental health providers use to refer to the many changes that family members make to their behavior to help a child avoid or reduce anxiety-related distress. It can be further broken down into two forms:

• Participation: Actively engaging in behaviors that allow the child to avoid anxiety
• Example: A parent ordering for their shy child in a restaurant

• Modification: Changing family routines or expectations to minimize a child’s anxiety
• Example: A family stops going to restaurants because the child finds the experience stressful

Anxiety accommodation is extremely common among parents (but also siblings, loved ones, teachers and even healthcare providers) of youth with anxiety, likely because it’s instinctual and well-intentioned. Parents have been programmed by evolution to notice and minimize their child’s distress. Yet the scientific findings are clear: for youth with significant anxiety, accommodation makes things worse.

Studies of youth with anxiety or obsessive-compulsive disorder (OCD) have repeatedly shown that increased family accommodation is associated with more severe symptoms, greater impairment and worse outcomes over time for the child.

Supportive Parenting for Anxious Childhood Emotions (SPACE)

If accommodation makes things worse, what is the alternative? Guidance comes from a treatment approach by psychologist Eli Lebowitz, PhD, at Columbia University called Supportive Parenting for Anxious Childhood Emotions (SPACE).

This therapy model teaches caregivers to reduce accommodations and replace them with supportive responses that validate the child’s distress and demonstrate confidence in the child’s ability to cope with the anxiety.

For example, a supportive parent using this model might say, “I understand how scared you are feeling and I’m certain you can handle it.”

Replacing accommodations with these responses gives the child a chance to learn that previously avoided situations are actually safe, and that they are capable of handling distress. As a result, children feel more capable of overcoming some of life’s biggest obstacles and are more likely to demonstrate resilience and self-reliance. Initial findings for this approach were very encouraging: children of parents who completed the parent-only SPACE program showed significant improvements in anxiety, equal to children who received gold-standard cognitive behavioral individual therapy for their anxiety.

Care for pediatric anxiety

Children’s Hospital Colorado has recently launched the Colorado OCD and Anxiety Program (COAP). COAP is one of the few clinics in the Rocky Mountain region that offers intensive outpatient programs for children and adolescents with anxiety or OCD. These programs combine caregiver-focused interventions to reduce family accommodation with youth-focused interventions including exposure with response prevention. COAP also offers many outpatient groups and individual therapy for youth struggling with these conditions. Providers who would like to refer families for an evaluation and treatment can call 720-777-6200 or visit the Pediatric Mental Health Institute.

Other organizations such as The Anxiety and Depression Association of America and The Society of Clinical Child and Adolescent Psychology offer information about evidence-based interventions for children with mental health disorders.

Books for parents: 

• “Breaking Free of Child Anxiety and OCD” by Eli Lebowitz  
• “You and Your Anxious Child” by Anne Marie Albano  
• “Helping Your Anxious Child: A Step-by-Step Guide for Parents” by Ronald Rapee