Randomized trial comparing standard versus light intensity parent training for anxious youth.

OBJECTIVE: To examine the efficacy of the parent-led intervention Supportive Parenting for Anxious Childhood Emotions (SPACE) relative to a low-dose version of the protocol among children and adolescents with clinically significant anxiety and/or obsessive-compulsive disorder (OCD). METHOD: 68 youth (7-17) with anxiety/OCD and their parents were randomized to receive 12 weekly telehealth SPACE sessions (SPACE-Standard) or bibliotherapy plus 4 telehealth sessions over 12 weeks (SPACE-light). After screening, assessments were conducted via videoconferencing at baseline, post-treatment, and one-month follow-up. Independent evaluators were blind to treatment condition. RESULTS: Treatment condition did not predict whether a participant responded to the intervention (SPACE-Standard = 70%; SPACE-Light = 68%), nor was treatment condition a predictor of anxiety severity, parent-reported anxiety, or parent-/child-reported functional impairment at post-treatment or one-month follow-up. Youth in SPACE-Light self-reported higher post-treatment anxiety than youth in SPACE-standard, though this was no longer significant at one-month follow-up. Parent-reported family accommodation total change scores were associated with anxiety severity at post-treatment across both arms. CONCLUSION: This is the second randomized controlled trial (RCT) evaluating SPACE and provides further support for the efficacy of this intervention both in standard and low-dose formats. This study provides support for parent-led anxiety treatment targeting family accommodation as a primary mechanism of change and extends evidence of efficacy to a more clinically diverse sample. TRIAL REGISTRATION: ClinicalTrials.gov Registry: NCT04922502.https://classic. CLINICALTRIALS: gov/ct2/show/NCT04922502.

A Pilot Trial of SPACE (Supportive Parenting for Anxious Childhood Emotions) in Autism.

Family accommodation describes changes parents make to their behavior, intended to alleviate their child's distress, which stems from a psychopathology. In anxiety, studies show that accommodation alleviates distress in the short term but is associated with increased symptom severity, greater functional impairment, poorer treatment outcomes, increased caregiver burden and disruption to family functioning longitudinally. Research shows high prevalence of family accommodation of anxiety in autism. While the most common treatments for anxiety in autism are cognitive-behavior therapy and pharmacology, research is limited and other approaches must be considered. Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based, manualized treatment for anxiety targeting family accommodation, which has been found to be acceptable and efficacious in treating childhood anxiety. This pilot trial examined the feasibility, acceptability, treatment-satisfaction, and preliminary efficacy of SPACE for anxiety in autism. Parents of 15 autistic children (ages 6-10 years) with at least average cognitive abilities exhibiting high levels of anxiety participated in 13 weekly sessions of SPACE. Feasibility and acceptability were assessed through enrollment, attrition rates, and adverse events. Of 26 eligible families, 22 (84.62%) elected to participate, 15 of whom (68.18%) completed treatment. Parents rated the treatment as highly satisfactory. Anxiety symptom severity and family accommodation were significantly reduced following treatment, with 86.66% of participants showing reliable change post-treatment, and this reduction was preserved at 2-month follow-up. This study provides preliminary evidence that SPACE is feasible, acceptable, satisfactory, and produces improvement in anxiety in the autistic population.Trial registration number: NCT04747262 Date of registration: February 10, 2021.

Non-violent resistance and family accommodation: A trans-diagnostic solution to a highly prevalent problem.

The goal of this study is to integrate two areas in recent clinical theory, research, and practice: family accommodation and non-violent resistance (NVR). Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology to avoid or alleviate distress related to the disorder. Rapidly growing research on family accommodation has established its high prevalence and negative impact across disorders and the life span. NVR is a trans-diagnostic treatment approach that helps parents to cope with child externalizing, internalizing, and other problems in non-escalatory ways. This study reviews empirical research on family accommodation and NVR, and argues that the anchoring function of NVR, a central concept reflecting the stabilization of the parent-child relationship, may provide a uniquely suited framework for reducing family accommodation across disorders and development. The study discusses how the anchoring function may be applied to promote accommodation reduction through a detailed description of SPACE (Supportive Parenting for Anxious Childhood Emotions), an NVR-informed treatment for childhood anxiety and obsessive-compulsive disorder.

El objetivo de este artículo es integrar dos áreas en la teoría, la investigación y la práctica clínicas recientes: la adaptación familiar y la resistencia no violenta. La adaptación familiar describe cambios que hacen los miembros de la familia a su propia conducta para ayudar a su familiar que está enfrentando una psicopatología a fin de evitar o aliviar el distrés relacionado con el trastorno. Las investigaciones cada vez más frecuentes sobre adaptación familiar han establecido su alta prevalencia y su efecto negativo en distintos trastornos y en la expectativa de vida. La resistencia no violenta es un método de tratamiento transdiagnóstico que ayuda a los padres a afrontar los problemas de exteriorización y de interiorización de los niños y también otros problemas de maneras no intensificadoras. En este artículo se analiza la investigación empírica sobre adaptación familiar y resistencia no violenta, y se argumenta que la función de anclaje de la resistencia no violenta, un concepto fundamental que refleja la estabilización de la relación entre padres e hijos, puede proporcionar un marco particularmente adecuado para reducir la adaptación familiar entre diferentes trastornos y el desarrollo. En este artículo se debate cómo puede aplicarse la función de anclaje para promover la reducción de la adaptación mediante una descripción detallada de SPACE (siglas en inglés de crianza con apoyo para emociones ansiosas de la infancia), un tratamiento fundamentado por la resistencia no violenta para la ansiedad en la infancia y el trastorno obsesivo-compulsivo.

Moderators of response to child-based and parent-based child anxiety treatment: a machine learning-based analysis.

BACKGROUND: Identifying moderators of response to treatment for childhood anxiety can inform clinical decision-making and improve overall treatment efficacy. We examined moderators of response to child-based cognitive-behavioral therapy (CBT) and parent-based SPACE (Supportive Parenting for Anxious Childhood Emotions) in a recent randomized clinical trial. METHODS: We applied a machine learning approach to identify moderators of treatment response to CBT versus SPACE, in a clinical trial of 124 children with primary anxiety disorders. We tested the clinical benefit of prescribing treatment based on the identified moderators by comparing outcomes for children randomly assigned to their optimal and nonoptimal treatment conditions. We further applied machine learning to explore relations between moderators and shed light on how they interact to predict outcomes. Potential moderators included demographic, socioemotional, parenting, and biological variables. We examined moderation separately for child-reported, parent-reported, and independent-evaluator-reported outcomes. RESULTS: Parent-reported outcomes were moderated by parent negativity and child oxytocin levels. Child-reported outcomes were moderated by baseline anxiety, parent negativity, and parent oxytocin levels. Independent-evaluator-reported outcomes were moderated by baseline anxiety. Children assigned to their optimal treatment condition had significantly greater reduction in anxiety symptoms, compared with children assigned to their nonoptimal treatment. Significant interactions emerged between the identified moderators. CONCLUSIONS: Our findings represent an important step toward optimizing treatment selection and increasing treatment efficacy.

Parent-Child Agreement on Family Accommodation Differentially Predicts Outcomes of Child-Based and Parent-Based Child Anxiety Treatment.

Objectives: Family accommodation is linked to poor treatment outcomes for childhood anxiety. Progress in research on the role of accommodation in treatment has been hindered by the relatively weak association between child and parent reports on accommodation. In this study, we suggest that parent-child agreement on family accommodation may provide a dependable estimation of this construct, and investigated whether the level of parent-child agreement on family accommodation predicts subsequent treatment outcome. We further examined whether the effect was greater in Supportive Parenting for Anxious Childhood Emotions (SPACE), which directly targets family accommodation, than in individual child-focused cognitive behavioral therapy (CBT).Methods: Participants were 104 children (aged 6-15) with anxiety disorders, and their mothers, randomized to SPACE or CBT. Accommodation was rated by mothers and children before treatment, halfway through treatment, and at treatment end, using respective versions of Family Accommodation Scale-Anxiety. To accurately estimate agreement, we conducted multilevel response surface analysis by polynomial regression, with agreement on accommodation at each time point predicting subsequent child anxiety severity, over the course of treatment.Results: Parent-child agreement and disagreement on accommodation were significant predictors of subsequent anxiety symptom severity. Different results were obtained for SPACE and CBT, suggesting potentially distinct underlying mechanisms.Conclusions: The findings suggest treatment-specific roles of accommodation in SPACE vs. CBT. Multiple-informant assessment of accommodation provides important information, which may have important implications for optimal treatment personalization.

Using Evaluative Criteria to Review Youth Anxiety Measures, Part I: Self-Report.

Evidence-based assessment serves several critical functions in clinical child psychological science, including being a foundation for evidence-based treatment delivery. In this Evidence Base Update, we provide an evaluative review of the most widely used youth self-report measures assessing anxiety and its disorders. Guided by a set of evaluative criteria (De Los Reyes & Langer, 2018), we rate the measures as Excellent, Good, or Adequate across their psychometric properties (e.g., construct validity). For the eight measures evaluated, most ratings assigned were Good followed by Excellent, and the minority of ratings were Adequate. We view these results overall as positive and encouraging, as they show that these youth anxiety self-report measures can be used with relatively high confidence to accomplish key assessment functions. Recommendations and future directions for further advancements to the evidence base are discussed.

Childhood Avoidant/Restrictive Food Intake Disorder: Review of Treatments and a Novel Parent-Based Approach.

Avoidant/Restrictive food intake disorder (ARFID) is characterized by dietary restrictions that are not based on weight or shape concerns but that result in marked interference in feeding, growth, or psychosocial functioning (American Psychiatric Association, 2013; Eddy et al., 2019). The aim of the current article was to review available reports of treatment for childhood ARFID published since its inclusion in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and to introduce a novel parent-based treatment for child ARFID through a case presentation. Empirical support for psychosocial treatments for child ARFID currently stems from two small-scale pilot randomized control trials, one pilot open trial, case reports, case series, and retrospective chart reviews. Treatment approaches for outpatient care generally apply family-based therapy, child-centered cognitive behavioral therapy, or parent-based behavioral approaches. SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits. SPACE-ARFID aims to promote flexibility and adjustment in food related situations. The treatment helps parents to systematically reduce family accommodation, or changes that they make to their own behavior to help their child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms.

Anxious-Irritable Children: A Distinct Subtype of Childhood Anxiety?

Children with anxiety disorders often present with other co-occurring symptom clusters, of which irritability is among the most highly co-occurring. Despite compelling clinical and pathophysiological evidence linking anxiety and irritability, little is known regarding the clinical presentation and associated impairment of children with both anxiety and irritability. In this study, our aims were to confirm the preponderance of irritability in clinically anxious children and compare clinically anxious children with irritability to those without irritability across sociodemographic, clinical, psychosocial, and family domains. Participants were 230 children with anxiety disorders (ages 6-14 years) and their mothers, and 91 healthy controls (ages 6-17 years) and their mothers. Of the clinically anxious children, 121 were anxious and irritable; 109 were anxious but not irritable. Irritability levels were significantly higher in the clinically anxious children compared with the healthy controls. Children with anxiety disorders and irritability presented with greater severity and impairment across clinical phenomenology, psychosocial, and family domains relative to anxious children without irritability. Regression analysis findings were convergent in that greater severity and impairment across these same domains predicted higher irritability levels in the children with anxiety disorders. Results support the meaningful distinction between anxious children with and without irritability. Implications of the findings are discussed particularly in regard to assessment and treatment and future research directions are delineated.

SPACE-ARFID: A pilot trial of a novel parent-based treatment for avoidant/restrictive food intake disorder.

OBJECTIVE: This pilot trial aimed to assess the feasibility, acceptability, treatment-satisfaction, and preliminary efficacy of Supportive Parenting for Anxious Childhood Emotions adapted for avoidant/restrictive food intake disorder (SPACE-ARFID). SPACE-ARFID is a novel outpatient parent-based treatment that focuses on parental responses to child problematic eating habits and aims to promote food-related flexibility. METHOD: Parents of 15 children (ages 6-14 years) with ARFID participated in 12 weekly sessions of SPACE-ARFID. Feasibility and acceptability were assessed by calculating enrollment, attendance, attrition, and adverse events. Treatment-satisfaction was assessed with the Client Satisfaction Questionnaire (CSQ-8), administered posttreatment. ARFID symptom severity and impairment and family accommodation were assessed at baseline and posttreatment. RESULTS: Of 17 eligible families, 15 (88.24%) elected to participate in the trial. Of the 15 participating families, all except for 1 (6.67%) completed all 12 weekly treatment sessions. Both parents and children rated the treatment as highly satisfactory. ARFID symptom severity and impairment as well as family accommodation were significantly reduced from pre- to posttreatment. Increases in food-related flexibility are described. DISCUSSION: Findings provide preliminary evidence that SPACE-ARFID, a parent-based treatment that focuses on parental responses to the ARFID symptoms is feasible, acceptable, and satisfactory and produces improvement in clinical outcomes.

Parent-Based Treatment as Efficacious as Cognitive-Behavioral Therapy for Childhood Anxiety: A Randomized Noninferiority Study of Supportive Parenting for Anxious Childhood Emotions.

OBJECTIVE: Treatment for childhood anxiety disorders is insufficient in many cases. Parent involvement has been examined to augment child-based cognitive-behavioral therapy (CBT), but no studies have compared the efficacy of stand-alone parent-based treatment to CBT. Research implicates family accommodation in the maintenance and course of childhood anxiety. Supportive Parenting for Anxious Childhood Emotions (SPACE) is a parent-based treatment that reduces accommodation of childhood anxiety. This study compared SPACE to CBT in a noninferiority trial. METHOD: Participants were children with primary anxiety disorders (N = 124; 7-14 years of age; 53% female participants; 83% white), randomly assigned to either SPACE (n = 64) with no direct child-therapist contact, or CBT (n = 60) with no parent treatment. A total of 97 participants (78%) completed all treatment sessions and assessments. Attrition did not differ significantly between groups. Primary anxiety outcomes included diagnostic interview and clinician-rated scales. Secondary outcomes included parent and child ratings of anxiety severity, family accommodation, and parenting stress. Noninferiority margins were determined based on statistical and clinical considerations. Change in family accommodation and parenting stress were examined using mixed models analyses. RESULTS: SPACE was noninferior, relative to CBT, on primary and secondary anxiety outcomes, and based on ratings provided by independent evaluators, parents, and children. Family accommodation and parenting stress were significantly reduced in both treatments, with significantly greater reduction in family accommodation following SPACE compared to CBT. Treatment credibility and satisfaction were high. CONCLUSION: SPACE is an acceptable and efficacious treatment for childhood anxiety disorders, is noninferior to CBT, and provides an alternative strategy for treating anxiety in children. CLINICAL TRIAL REGISTRATION INFORMATION: Explanatory Clinical Trial of a Novel Parent Intervention for Childhood Anxiety (SPACE); https://clinicaltrials.gov; NCT02310152.

Family accommodation in psychopathology: A synthesized review.

Family accommodation describes changes that family members make to their own behavior, to help their relative who is dealing with psychopathology, and to avoid or alleviate distress related to the disorder. Research on family accommodation has expanded greatly in the past few years. The aim of this study was to provide a synthesized review of recent findings on family accommodation in psychopathology. Electronic databases were searched for available, peer-reviewed, English language papers, published between September 2015 and March 2018, cross-referencing psychiatric disorders with accommodation and other family-related terms. Ninety-one papers were identified and reviewed, of which 69 were included. In obsessive-compulsive disorder and anxiety disorders family accommodation has been linked to symptom severity, functional impairment, caregiver burden, and poorer treatment outcomes. Several randomized controlled trials explored the efficacy of treatments aimed at reducing family accommodation. A growing number of studies have reported family accommodation in eating disorders where it is associated with greater symptom severity and caregiver burden. Family accommodation has also been studied in other disorders, including autism spectrum disorders, tic disorders, and posttraumatic stress disorder. Research on family accommodation in psychopathology is advancing steadily, expanding across disorders. The study highlights the importance of addressing family accommodation in the assessment and treatment of various disorders.

Family accommodation mediates nightmares and sleep-related problems in anxious children.

Nightmares are commonly reported in clinically anxious children and are associated with the presence of other sleep-related problems. Family accommodation has been theorized as playing a central role in the sleep-related problems of anxious children, but empirical data is lacking. We examined associations between nightmares, maternal reports of family accommodation, and sleep-related problems in clinically anxious children. We also examined a hypothesized mediational pathway linking nightmares to other sleep-related problems, through increased family accommodation using structural equation modeling. Participants were 277 clinically anxious children (ages 6-17), and their mothers. Nightmares were reported in over three quarters of the children and were linked to higher mother-rated accommodation and to sleep-related problems. Fit indices for the structural equation model were excellent, and data supported the hypothesis that family accommodation mediates the association between nightmares and sleep-related problems in the anxious children. Results provide the first empirical evidence for the role of family accommodation in nightmares and other sleep-related problems in anxious children. Implications for assessment and treatment of childhood anxiety are discussed.

The SPACE program, a parent-based treatment for childhood and adolescent OCD: The case of Jasmine.

Current evidence-based treatments for obsessive-compulsive disorder in children and adolescents include cognitive-behavioral therapy, specifically exposure and response prevention, and psychopharmacological treatments. Despite the established efficacy of these treatments, many youth do not benefit from them, and barriers, including lack of motivation and resistance to treatment, prevent many youth from even attempting them. Parent-based treatments offer an alternative approach to child-based therapy. SPACE (Supportive Parenting for Anxious Childhood Emotions) is a parent-based treatment that focuses on systematically reducing family accommodation, or the changes that parents make to their own behavior to help a child avoid or alleviate distress related to the disorder, while increasing supportive responses to the child's symptoms. This article presents the theoretical background for SPACE and illustrates its implementation through a case description. Conclusions and knowledge to be gained from the case are discussed.

Maternal Acceptance Moderates Fear Ratings and Avoidance Behavior in Children.

Avoidance is a hallmark feature of anxiety disorders, and avoidance-related impairment is often key to meeting diagnostic criteria. In children and adolescents with anxiety disorders, levels of avoidance vary considerably. Using a novel motion-tracking measure of avoidance behavior, we examined whether maternal acceptance, characterized by warm and accepting responses to child feelings and behaviors, moderates the association between fear of spiders and behavioral avoidance of spider stimuli in 103 clinically anxious children. As hypothesized, maternal acceptance significantly moderated children's avoidance behavior. Child's fear of spiders was significantly associated with behavioral avoidance when mothers were low in acceptance, as rated by either mothers or children. When mothers were high in acceptance, as rated by either mothers or children, child self-rated fear of spiders was not significantly associated with child avoidance. These are the first results to empirically demonstrate the moderating role of maternal acceptance in anxious children's avoidance behavior.

Effects of parental vigilant care and feedback on novice driver risk.

Vigilant care aims at reducing adolescent risk behaviors while matching parental involvement to the level of alarm signs. This study examined the effect of parent training in vigilant care and technological feedback on driving risk of novice male drivers. A sample of 217 Israeli families was divided into four conditions: a) no-feedback, b) individual feedback, c) family feedback, and d) family feedback plus parent training in vigilant care. Feedback and risk assessment were conducted through in-vehicle data recorders. A significant difference was found in favor of the vigilant care group compared to the no feedback group. When only the drivers in the high risk percentiles were considered, the vigilant care group was found superior to the family feedback group. The findings suggest that parental training in vigilant care may help reduce driving risk.

Can providing feedback on driving behavior and training on parental vigilant care affect male teen drivers and their parents?

This study focuses on investigating the driving behavior of young novice male drivers during the first year of driving (three months of accompanied driving and the following nine months of solo driving). The study's objective is to examine the potential of various feedback forms on driving to affect young drivers' behavior and to mitigate the transition from accompanied to solo driving. The study examines also the utility of providing parents with guidance on how to exercise vigilant care regarding their teens' driving. Driving behavior was evaluated using data collected by In-Vehicle Data Recorders (IVDR), which document events of extreme g-forces measured in the vehicles. IVDR systems were installed in 242 cars of the families of young male drivers, however, only 217 families of young drivers aged 17-22 (M=17.5; SD=0.8) completed the one year period. The families were randomly allocated into 4 groups: (1) Family feedback: In which all the members of the family were exposed to feedback on their own driving and on that of the other family members; (2) Parental training: in which in addition to the family feedback, parents received personal guidance on ways to enhance vigilant care regarding their sons' driving; (3) Individual feedback: In which family members received feedback only on their own driving behavior (and were not exposed to the data on other family members); (4) CONTROL: Group that received no feedback at all. The feedback was provided to the different groups starting from the solo period, thus, the feedback was not provided during the supervised period. The data collected by the IVDRs was first analyzed using analysis of variance in order to compare the groups with respect to their monthly event rates. Events' rates are defined as the number of events in a trip divided by its duration. This was followed by the development and estimation of random effect negative binomial models that explain the monthly event rates of young drivers and their parents. The study showed that: (1) the Parental training group recorded significantly lower events rates (-29%) compared to the CONTROL group during the solo period; (2) although directed mainly at the novice drivers, the intervention positively affected also the behavior of parents, with both fathers and mothers in the Parental training group improving their driving (by -23% for both fathers and mothers) and mothers improving it also in the Family feedback group (by -30%). Thus, the intervention has broader impact effect beside the targeted population. It can be concluded that providing feedback on driving behavior and parental training in vigilant care significantly improves the driving behavior of young novice male drivers. Future research directions could include applying the intervention to a broader population, with larger diversity with respect to their driving records, culture, and behaviors. The challenge is to reach wide dissemination of IVDR for young drivers accompanied by parents' involvement, and to find the suitable incentives for its sustainability.

Insight in obsessive-compulsive disorder: a comparative study of insight measures in an Israeli clinical sample.

BACKGROUND AND OBJECTIVES: Attempts to identify the characteristics of OCD patients with poor insight have not produced a coherent picture. This may be related to the wide variety of the available insight assessment tools. The study aimed to compare five principal measure for assessing insight in OCD and to investigate the relationships between insight and central demographic and clinical variables. METHODS: Sixty outpatients diagnosed with OCD (36 men, 24 women) were assessed with the following insight measures: DSM-IV insight criterion, Over-Valued Ideas Scale (OVIS), Item 11 of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Brown Assessment of Beliefs Scale (BABS) and Beck Cognitive Insight Scale (BCIS). RESULTS: Correlation coefficients indicated high correspondence between all insight measures with the exception of the BCIS. At the same time, the relations of the various insight measures with demographic and clinical variables were distinctive and in some cases measure-specific. The most robust correlation was between insight and current medical treatment, so that medicated participants showed higher insight levels on most insight measures compared to non-medicated participants. Some insight measures were correlated with co-morbidity, onset age and gender. Insight levels did not correlate with OCD symptom severity. LIMITATIONS: Limitations of this study include its cross-sectional design, modest sample size and an incomplete representation of the available insight measures. CONCLUSIONS: The diversity of measures used in previous studies cannot account for the inconsistent findings on the role of insight in OCD.