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(p. 3) Introduction to Accommodation of Child Anxiety 

(p. 3) Introduction to Accommodation of Child Anxiety
Chapter:
(p. 3) Introduction to Accommodation of Child Anxiety
Author(s):

Eli R. Lebowitz

DOI:
10.1093/med-psych/9780190869984.003.0001
Page of

date: 23 September 2019

Family accommodation of childhood anxiety is the term used to describe the myriad changes that parents and other family members make to their behaviors and living patterns due to a child’s anxiety disorder. Parenting a child with any psychological disorder, or, indeed, with any medical or emotional condition, almost inevitably will lead to changes in parental behavior. But families of children with heightened vulnerability to anxiety and its disorders are particularly susceptible to the familial impact of their child’s difficulty, and accommodation of childhood anxiety is special and different from accommodation of other mental and physical problems. Children rely instinctively on parents for help in coping with anxiety, and parents are naturally attuned to fear and anxiety cues displayed by their children. This natural pattern of children relying on parental figures to alleviate anxiety and of parental motivation to “step-in” and provide protection and reassurance when a child is anxious sets the stage for the extremely high prevalence of family accommodation observed among families of anxious children. Moreover, while accommodation can be necessary and helpful in coping with many physical and emotional conditions, accommodation of childhood anxiety will usually have a negative impact in the long term, leading to increased anxiety over time. A key difference between accommodation of anxiety and of other problems is that independent coping is key to overcoming anxiety. Whereas a child with a physical disability may require accommodations to maximize their potential and be able to achieve on an even playing field with others who do not have the same problem, a child with anxiety will often require the opposite. By accommodating to the child’s anxiety symptoms, the likelihood of the child fulfilling their potential can actually be reduced. Of course, not all accommodation is detrimental, and this book provides useful guidelines for differentiating between helpful and nonhelpful accommodations. A rule of thumb for helping to make this distinction is that accommodations that help a child to gradually cope more independently, to increase functioning, and to lessen avoidance are usually helpful. In contrast, accommodations that help a child to avoid more, to reduce their independent (p. 4) functioning, or to become more dependent on parents or others are likely to be unhelpful over time.

It is also useful to note at this point that this book deals with the treatment of children with anxiety disorders whose daily functioning has been impaired by anxiety over a significant period of time. Many of the principles and tools described in the book apply well to children who are experiencing more normative or transient anxiety, and, indeed, application of these tools and principles may be useful in preventing the development of a more clinically impairing anxiety disorder. However, in the same way that it does not make sense to treat every manifestation of fearful avoidance as a problem or as a symptom to be vigorously addressed, it also does not make sense to see every accommodation of a child’s fear or anxiety as symptomatic of a larger problem or as a target for emphatic intervention. Every child will experience anxiety some of the time and while encouraging coping and refraining from accommodation is generally good advice, a healthy child who is not predisposed to more serious anxiety is unlikely to be harmed by parents’ natural inclination to accommodation or protective responses.

Research in recent years, conducted in large samples of parents of clinically anxious children from numerous locations around the world and with a variety of cultural and ethnic backgrounds, demonstrates that family accommodation of child anxiety is the rule and not exception. The preponderance of data from these studies point to the conclusion that, when coping with an anxious child, almost all parents engage in frequent accommodation of their child’s symptoms. This chapter provides an overview of some of the common ways in which anxious children are accommodated, focusing first on parents and then on others within, and even outside of, the family circle. The chapter then describes some of the key factors that drive these patterns of accommodation, including the desire to avoid or reduce a child’s suffering; common misconceptions about anxiety held by many parents (and sometimes reinforced by well-meaning but ultimately misguided providers); the need to facilitate functional goals for the child, parent, and family; and forceful demands for accommodation that are frequently made by the child.

What Is Accommodation

Family accommodation can take an infinite variety of forms, and clinicians working with anxious children and their families can usually recount many different examples of the accommodations they have encountered in their work. Just as there is no particular limit to the variety of stimuli that children can fear or to the situations they may avoid due to anxiety or to the content of the worried thoughts that plague anxious children, there is also no end to the ways in which those who love and care for anxious children may accommodate the child’s anxiety.

Family accommodation is conceptualized as a response to child anxiety (distinct from, although not unrelated to, parental styles or traits that may precipitate (p. 5) child anxiety, which are also discussed in this chapter). The simplest rule of thumb for describing the variety in family accommodation is a paraphrasing of Newton’s third law: For every child anxiety symptom, there is an equal accommodation of the child’s anxiety. Of course, not every parent will accommodate equally, and not every symptom a given child exhibits will elicit the same degree of accommodation, even in the same parent, but the potential to accommodate is no more limited than the child’s anxiety symptoms themselves.

Yet, just as with the symptoms of child anxiety, some accommodations are more common than others. Research dating back to the 1970s indicated that evolutionary predispositions and environmental factors contribute to the nonrandom distribution of fears in the population (Seligman, 1971). Fears of separation, the dark, animals, natural phenomena, and social evaluation and fears relating to the intense physical and psychological manifestations of anxiety itself, to cite a few prominent examples, are more common than fears of guns, electrical outlets, or cars, although these are all present in the environment and pose larger realistic threats to children’s safety and well-being. In similar fashion, through rich clinical experience and intense empirical research over recent years, predictable patterns of accommodation emerge, helping to guide the work of clinicians engaged in assessing or intervening with families of anxious children (Benito et al., 2015; Lebowitz, Panza, & Bloch, 2016; Lebowitz, Scharfstein, & Jones, 2014, 2015; Reuman & Abramowitz, 2017; Settipani, 2015; Storch et al., 2015; Thompson-Hollands, Kerns, Pincus, & Comer, 2014).

Two useful ways of organizing the tremendous variety in family accommodation are to categorize accommodations either by the form the accommodation takes or by the domain of child anxiety being accommodated. Several studies, building on work done originally in studying family accommodation of obsessive-compulsive disorder (OCD; Calvocoressi et al., 1995), have demonstrated the utility of dividing accommodation into two main forms: participation in anxiety-driven behaviors and modification of family routines and schedules. Table 1.1 categorizes some common accommodations based on form of accommodation and domain of child anxiety.

Table 1.1 Examples of Family Accommodations Organized by Domain of Child Anxiety and by Form of Accommodation (Participation and Modification)

Separation

Social

OCD

Panic

Generalized

Phobias

Participation

Sleeping in child’s bed

Responding to many phone calls each day

Not closing bathroom door when showering

Walking child into school each morning

Accompanying child in to the bathroom

Answering questions in place of child

Speaking softly in public

Asking teachers not to call on child

Rushing home to avoid public bathroom

Ordering for child in restaurants

Asking teachers for help in place of child

Washing hands with child supervision

Providing extra soap

Wearing special clothes

Listen to child’s “confessions”

Carrying child physically

Taking child to doctor visits or emergency room

Accompanying child places

Carrying water bottles or other “emergency” equipment

Providing repeated reassurance

Providing detailed schedules

Checking homework repeatedly

Providing detailed information about the family finances or health

Answering repeated questions

Planning child’s outfits for entire week ahead of time

Not saying the word snake

Checking whether forecast repeatedly

Not staying out after dark

Taking stairs instead of elevator

Modification

Refraining from work trips

Not going out in the evening

Stay with child at after school activities or parties

Not going to restaurants

Avoiding social gatherings

Driving child to school instead of using school bus

Avoiding malls

Keeping windows closed

Avoiding “contaminated” places

Providing special foods or meals

Driving special routes to avoid avoiding certain roads

Being late to work because of waiting for child to complete rituals

Coming home early from work

Picking up child early from school because of panic symptoms

Avoiding places where panic attacks have occurred

Avoiding changes to routines or schedules

Leaving early to make sure child is never late

Staying up late with child at night

Planning outings and vacation to avoid feared stimuli

Keeping lights on at night

Not visiting friends with dogs

Not taking child for shots or doctor visits

Driving places instead of flying

Participation and Modification

Participation

Parents who repeatedly check the homework of a child who is anxious and perfectionistic or accompany their child to class parties and stay for the duration of the event or stay in the bathroom while their child is showering or bring water bottles to every out-of-home excursion because their child fears being without them in case panic symptoms occur or sleep next to their child because of separation anxiety can all be thought of as accommodating by participating in anxiety-driven behaviors. Many parents become adept at anticipating their child’s anxious responses and will act preemptively, forestalling the difficult situation through (p. 6) (p. 7) (p. 8) their accommodation, as when a parent swiftly replies to a question posed to a socially anxious child.

In other cases, participation can occur when parents refrain from certain behaviors they know are likely to trigger their child’s anxiety. In other words, participation can be a passive, as well as an active, behavior. For example, when parents make sure not to have the news on television when their child is in the room because they know the child is prone to becoming anxious at reports about international conflicts, health concerns, or the economy. Other parents may refrain from using “trigger words” that make their child anxious or avoid opening windows at home because their child has a fear of insects or in the car because their child becomes distraught at the thought that others might hear them speaking.

Modifications

Family life can often appear to be organized around a child’s anxiety to a surprising degree. Mealtimes, work schedules, travel plans, bedtime routines, transportation choices, and leisure activities can all be shaped by the perceived need to steer clear of an anxious child’s symptoms. For example, parents may drive needlessly long routes that avoid freeways because of a child who becomes nervous and fears accidents or traffic. Or they may leave the house earlier than necessary because the child is fearful of being late. Parents frequently return home from work earlier than they otherwise might because a child is distressed if they are not home before dark or if they must remain home alone. Parents often plan the day’s activities down to the minute because a child is uncomfortable with any uncertainty in the schedule and may provide detailed information about the plans to the child (an example of participation). Many children have fears relating to food and eating, and these can cause significant disruption to mealtime routines. One parent may become solely responsible for preparing food because otherwise the child is anxious or avoids eating, or meals may be held at rigidly determined times because variation in the schedule causes upheaval and stress. When a child is afraid of insects, family outings may be modified to exclude picnics or nature, or if the child is uncomfortable in closed or crowded places, the family may avoid going to movies or malls.

There is no firm boundary between participations and modifications, and many of these accommodations may be viewed as representing one or the other, or both of these categories. But empirical data support the construct validity of these two modes of accommodation, and clinical research supports the usefulness of the complementary and overlapping categories of participation and modification in creating a structure for mapping out and identifying a family’s accommodations. Thoroughly assessing accommodation in the evaluation of child anxiety and in treatment planning is highly valuable and will be discussed in depth in a later chapter.

(p. 9) Domains of Anxiety

Another useful way of organizing the variety of accommodations encountered in clinical work, and even within a given family, is in relation to the domains of anxiety experienced by the child. Studies of childhood anxiety disorder consistently report that comorbidity between the anxiety disorders is very high, meaning that most children presenting for treatment with an anxiety disorder will actually meet diagnostic criteria for at least one, and often several, other comorbid anxiety disorders. There is often a chief presenting complaint that serves as the impetus for the family seeking professional help, but savvy clinicians know not to begin treatment before also assessing for additional anxiety problems. The current DSM-5 and ICD-10 nosologies classify anxiety disorders based primarily on the situations or stimuli that trigger excessive or inappropriate anxiety. Thus, a child who is fearful at the prospect of separation from primary attachment figures is classified as having separation anxiety disorder, a child who is concerned with negative evaluation and avoids social situations is described as having social phobia, and so forth. These distinctions are useful in capturing a child’s symptoms and facilitate productive assessment procedures, but they do not account for the shared underlying pathophysiology in neural circuitry and endocrinology, the genetic and nongenetic heritability of anxiety vulnerability, and the phenomenology that are common across the different anxiety disorders. Hypervigilance, deficits in self-regulation, predisposition to negative affectivity, and other functional and biological constructs cut across the anxiety disorders, contributing to the high co-occurrence of these disorders in children as well adults.

Each domain of elevated anxiety present in a child is typically going to be paralleled by family accommodations. And, like the child’s symptoms, some of which will relate to a particular domain of anxiety while others will relate more broadly to multiple domains, the accommodations will also be partly specific to particular domains and partly broadly relevant to a variety of domains. Categorizing the accommodations in relation to the domains of anxiety they help to avoid or alleviate can help to make sense of the many accommodations encountered by the clinician and facilitates assessment and treatment planning. An exhaustive list of possible accommodations is, of course, impossible. There follow some examples of frequently reported accommodations, organized by domains of common childhood anxiety disorders.

Generalized Anxiety

Children with generalized anxiety experience chronic and exhausting worry that interferes with physical and emotional well-being, disrupts age-appropriate functioning, and causes marked personal distress. The most common form of accommodation for children with generalized anxiety is the provision of repeated reassurance about their worries and concerns. Children with generalized (p. 10) anxiety seek reassurance through endless questions, often repeating the same questions many times over. Parents accommodate by replying to these questions, often “promising” or “swearing” that a feared event will not occur. In some cases, parents will engage in additional behaviors aimed at instilling confidence in a child that a catastrophizing thought is exaggerated and does not reflect a realistic threat assessment.

Mason was 11 years old and was constantly preoccupied with the possibility that his father, who smoked, would become seriously ill. Mason imagined his father having a heart attack and dying on the way to the hospital. Mason’s father, Liam, repeatedly reassured him that he was healthy and had even taken Mason with him to an annual physical so he could hear the doctor pronounce him in good health, but Liam continued to be worried that the doctor “may have missed something.” One morning, an exasperated Liam got on the family’s treadmill and told Mason, “Watch, I’m going to run a mile and you’ll see that my heart is just fine.” Mason was relieved when his father completed the mile and was hardly winded at all. The next morning as Liam was preparing to leave for work Mason asked him to run the mile again. An amused Liam acquiesced and ran a mile with Mason watching closely. Liam’s amusement was soon replaced with frustration as Mason began demanding to see his father run a mile every morning, in what soon became a new morning routine. Liam joked to the therapist that he was “now more fit than ever,” but was unsure how to stop the often-inconvenient routine. Mason became tearful and whiny if Liam attempted to leave the house without “doing the mile” under Mason’s supervision.

Generalized anxiety can also lead to other common forms of accommodation. Medical concerns can apply to the child themselves, as well as to loved ones, and the chronic stress of generalized anxiety contribute to actual somatic complaints in many children. Parents may find themselves taking children to unnecessary doctor appointments, providing “placebo” medications (such as vitamins that are given to reassure the child, rather than as a parental health choice), or staying home with a child who feels unwell in the morning after a restless night. Because many worries surface around bedtime, parents will often report engaging in lengthy nighttime rituals, at the expense of other activities and responsibilities.

Many parents accommodate by helping their child to avoid doubts about school work or grades, checking and rechecking work, sometimes late into the night. And because children with generalized anxiety are often highly sensitive to uncertainty and averse to change, family routines are often planned out to an excessive degree and rigidly adhered to, even when causing inconvenience. Children may demand to know in advance who will pick them up from school or what the weekend plans will be in detail, and they may react negatively to any deviation from the stated plans. And new activities, such as going skiing for the first time or traveling to a new destination, may be avoided because the child becomes overwhelmed when confronting a new experience. As a result, the child may be (p. 11) exposed to fewer activities and less stimulation, because the parents are apprehensive about enrolling them in extracurricular activities or sports.

Worries relating to family issues such as the parents’ relationship or the family’s finances can lead to other accommodations. Parents may feel they are tiptoeing around such issues. One example is feeling afraid to label a purchase as expensive or costly because their child interprets such statements as a sign that they do not have enough money and may soon experience poverty or homelessness.

Social Phobia

Children with social phobia fear being negatively evaluated by others and will avoid social situations that carry the potential for judgement or evaluation, or the child will endure such situations with considerable distress. Accommodation of socially anxious children often centers around two main points: helping the child to avoid social situations and interacting with others on the child’s behalf. Parents may engage teachers and school staff in the accommodation in ways such as asking teachers not to call on a child in class, requesting that the child be excused from oral presentations and assignments, or keeping the child home on days with presentations. Parents may also take phone calls in place of the child, “warn” the child when guests are coming to the home, refrain from going (or taking the child) to social encounters such as family gatherings or religious services, or otherwise help the child to avoid social encounters. During social situations, parents (or siblings) commonly speak in place of the child. For example, parents may place a child’s order in a restaurant, speak to a store clerk on behalf the child, or answer questions posed by friends, relatives, or others. The parent may feel compelled to accommodate the child because of the child’s distress and anxiety, but the parent’s own embarrassment about the child’s behavior can also contribute to the accommodation. The silence that ensues when a socially anxious child does not answer a question or greeting can feel like eternity, placing pressure on the parent to intervene. Selective mutism is closely related to social phobia and will often be accompanied by the same kinds of accommodations, in particular speaking in place of the child.

Janet always kept her daughter Paisley home on the first day of each school year and would bring her to school on the second day. Janet explained that the first day “always has lots of introductions and role calling,” and she knew it would be extra hard for Paisley. “It’s just easier for her to start on day two and just kind of slip into things.”

Separation Anxiety

Children with separation anxiety fear being separated from parents, try to avoid separations, and react to separation with distress including crying or physically (p. 12) clinging to the parent. Not surprisingly, parents of children with separation anxiety usually find themselves engaging in high levels of accommodation. Indeed, the nature of separation anxiety, with the inherent dependence on parental proximity, makes it difficult to imagine a child having separation anxiety without some significant degree of accommodation on the parents’ side. Because anxiety of almost any kind can be reduced in a child through proximity to a parent, children who are anxious about different things will often present with separation anxiety. For example, a child who is worried about their health (a symptom commonly associated with generalized anxiety) may show symptoms of separation anxiety because being close to their parent helps alleviate their worry, while being alone intensifies them. In this sense, almost all anxiety in children is also “separation anxiety” and can lead to accommodation in the separation anxiety domain. Parents of children with separation anxiety will frequently stay near them when in the home, for example, letting them know when they are moving to another room so the child can follow, keeping doors open so the child can maintain eye contact with them (sometimes even while the parent or child is using the bathroom), accompanying the child when the child must go to another room (e.g., when a child wants to go upstairs and get a game or a book), and refraining from sending the child to areas of the house away from the parent (e.g., not asking the child to go to the basement or attic).

Other common forms of accommodation in separation anxiety include limiting parental absences from home, maintaining contact over phone calls or texts during separations, limiting child outings without the parent, and being near the child during the night. Parents often limit their own absences from the house, either returning earlier than they otherwise would or not going out when the child is home. Many parents of children with separation anxiety will avoid both parents going out at the same time during the afternoon or evening, ensuring that at least one parent stays home with the child rather than engaging a babysitter (or leaving the child alone or with siblings when appropriate). Parents may also report that they inform the child ahead of time of even the smallest separations or regularly have to promise the child that no separation is planned. They may also accompany the child to places and events that a child would normally attend alone. This could include staying at school together with the child during school hours, going with them to peer parties, staying to wait during extracurriculars such as sport practice or art or music classes, always volunteering to host sleepovers so the child does not face sleeping at another child’s home, and waiting to leave for work until the child has been picked up by the school bus, among countless other examples. In many cases the parent will accommodate separation anxiety by helping the child to maintain contact with them during periods of separation. Responding to frequent phone calls, video chats, or text messages, even while at work or while a child is in school (or both) is not uncommon. One parent described waiting outside his child’s school at least 30 minutes before the end of each school day because his daughter was so anxious that he would not be there on time and she would be left alone.

(p. 13) Nighttime, with its opportunity for lengthy separation and hours of darkness, is often a time of elevated separation anxiety and, correspondingly, high family accommodation. Parents of children with separation anxiety often sleep next to their child, whether in the child’s bed or in their own, or remain with the child until the child has fallen asleep before leaving them alone. A child with separation anxiety may rely on a lengthy nighttime ritual, sometimes including countless repetitions of particular comforting phrases or endless hugs and kisses, which can be time-consuming and frustrating for the parent. Even after falling asleep, many children with separation anxiety will wake up during the night and either come to or call their parents, and the lengthy cycle of bedtime rituals may be repeated all over again before the child falls back asleep.

Julian and Hazel felt like they no longer had any life of their own. Their son Connor was nine years old, and it seemed like they never had a moment away from him. “He’s either in school or he’s with us,” explained Hazel. “And I don’t just mean at home with us. I mean literally WITH us. Like on top of us. If we try to leave a room he’s in, you would think he was being murdered! He’ll scream, in a panic, with terror in his eyes. So of course, we never leave him alone. He’ll only go to the bathroom without us if he can get his little brother to go sit in there with him. We know it’s crazy, but it seems like the times he’s in the bathroom with this brother are the only times we get to be just the two of us!” Julian added: “I used to feel like at least at work I can be focused on something else. Now even when I’m at work I’m either answering his calls, talking to him on FaceTime, or replying to his text messages. Yesterday he texted me 38 times!”

Specific Phobias

Children with specific phobias experience extreme and irrational fears of a particular object, animal, or situation. They will try to avoid exposure to the feared stimulus and will respond with fear and distress to potential or actual need to confront it. The accommodations to specific phobias are as varied as the possible phobias themselves but will generally entail some facilitation of the child’s avoidance of the phobic stimulus or situation. When a child fears dogs, for example, parents may avoid visiting homes or places with dogs or may even refrain from watching movies or shows that feature dogs. A friend of the author recently recounted a personal anecdote in which after being invited to visit some family friends, the invitation was sheepishly and apologetically rescinded by the hosts because their child knew that they owned a dog and was scared of the visit despite there being no intent to bring the dog along! Parents of children with fears of insects may avoid excursions to nature or keep windows shut in the summer; parents of children with fears of heights may avoid visiting certain destinations or driving over bridges; and parents of children with fears of storms may keep a child home from school during bad weather or provide excessive amounts of reassurance about (p. 14) possible storms. One parent described becoming a “weather channel junky” just to be able to answer all her child’s weather-related questions each day.

Piper was 14 years old and for several years had suffered from a severe phobia of needles and doctors. Her parents had not been able to get her to the doctor for check-ups or vaccinations, her teeth required urgent attention, and her school, which already excluded her from certain activities because of not having a health report, was now threatening not to allow Piper to attend school at all unless she saw a doctor. “But the straw that broke the camel’s back,” described Piper’s parents, “was that she is now demanding that her sister not go to the doctor either. We thought the problem would be that her sister would develop a fear as well just from listening to her carry on, but fortunately she seems fine with it. Piper, however, is now saying she can’t cope with anyone in the family going near a doctor. When we realized we were making plans to lie to her about where her sister was going we realized we’re in trouble. We need help!”

Panic and Agoraphobia

Children with panic disorder experience recurring unexpected panic attacks, or sudden surges in fear and anxiety, and become concerned with the possibility of additional attacks. Children with the closely related agoraphobia are fearful of developing panic symptoms in situations from which it would be hard to escape, such as public transportation or closed (or wide-open) spaces, and try to avoid those situations, especially when alone. Parents of children with panic and agoraphobia typically accommodate by either accompanying the child when they fear they will experience panic symptoms or facilitating the child’s avoidance of the feared situations, as well as by providing reassurance about the child’s physical health. Parents may request that a child be exempt from physical education in school because the child is afraid that exercise will trigger a panic attack. Or parents may drive the child to school each day because the child is afraid of having panic symptoms on the bus, not being able to escape, and being socially embarrassed or humiliated in front of peers. Frequently, parents will accompany the child to places the child would otherwise go alone. For example, driving a teenager to the mall because the teen is afraid to drive themselves or regularly volunteering to chaperone school outings because the child is nervous about being away from parents in case of a panic attack. In addition to avoiding being alone, many children with panic and agoraphobia will engage in other safety behaviors because of the fear of panic, and parents may accommodate by providing safety items or otherwise maintaining the safety behavior. Talking to a child on the phone when they are worried about having panic symptoms and always carrying antianxiety medication, water, or an inhaler are examples of safety behaviors that parents may be accommodating.

(p. 15)

“After Miguel’s first panic attack we were all so scared,” recall Alejandro and Lydia. “We thought he was very sick, and it was a big relief to learn it was just anxiety. But Miguel didn’t see it that way. He says we can’t understand how awful it feels to have a panic attack, and he’s right. We can’t really understand, but we know we want to help him never feel so bad again. We actually moved so he could walk to school in the morning and not have to ride the bus, where he says he’s sure to have a panic attack. And a lot of times we have to leave events early because he starts to feel panicky. It’s not convenient, but it’s worth it to us.”

Obsessive-Compulsive Disorder

The DSM-5, published in 2013, no longer classifies OCD as an anxiety disorder but continues to recognize the tight link between OCD and anxiety. For many intents and purposes, including with regards to family accommodation, OCD can still be thought of as an anxiety disorder. Indeed, research indicates a high degree of similarity in the prevalence and frequency of family accommodation in OCD and the other childhood anxiety disorders. Children with OCD experience intrusive thoughts and urges that cause them anxiety and distress and feel compelled to maintain rigid rules and rituals that can be time-consuming and interfering. Children with OCD usually have insight into the unrealistic nature of their thoughts and the irrational nature of their rituals but feel unable to control them. Family accommodation was studied initially in OCD (first in adults and then in children) and is as common in OCD as in other anxiety disorders. Parents of children with OCD often actively participate in rituals. These include performing repeated checks together with or on behalf of the child, listening to the child’s ritualized “confessions,” performing cleaning rituals such as excessive handwashing, and providing items that the child needs for the completion of their rituals such as buying extra soap or toilet paper. Parents also accommodate by providing reassurance about the thoughts, answering compulsive questions, making choices for a child who is compulsively doubtful and indecisive, avoiding the use of “special numbers” that have taken on a negative connotation in the child’s mind (e.g., only serving the child multiples of threes of any particular food item). Other obsessive-compulsive-related disorders are also commonly accommodated. Parents of a child with pathological hoarding, for example, may refrain from entering the child’s room or cleaning it, may agree not to throw things away, and may even save useless (or even offensive) items that the child feels compelled to keep. And parents of a child with a body dysmorphic disorder may take them to doctors, provide endless reassurance, or even allow them to undergo unnecessary medical procedures to correct a perceived flaw or imperfection.

(p. 16) Accommodation and Related Parenting Behavior

Many studies have examined possible links between parental behaviors, styles, and traits and anxiety and its disorders in children (Bögels & Brechman-Toussaint, 2006; Ginsburg, Siqueland, Masia-Warner, & Hedtke, 2004; Wood, McLeod, Sigman, Hwang, & Chu, 2003). While such links have frequently been reported, research in this area has notable limitations, and it is easy to overstate the actual evidence for the role of parental characteristics in the etiology, maintenance, or course of childhood anxiety. Most of the research examining parental behaviors and childhood anxiety outcomes has relied on cross-sectional data. That is to say, rather than examining parental behaviors in new or expecting parents and then following those families to observe which parents had children with anxiety disorders (longitudinal research), parents of children with anxiety disorders and parents of children without anxiety disorders are compared at a single time point and differences between the two groups are presumed to be linked to the phenomenon of child anxiety. This kind of cross-sectional research makes it impossible to draw valid inferences about the causal chain of events linking the parental behaviors to the child’s anxiety. It is plausible, for instance, that many of the differences observed between such groups of parents are at least as much a result of the child’s anxiety as they are the cause of the child’s anxiety. Another methodological challenge for much of the research in this area relates to the simple fact that parents frequently have more than one child. And so a parent who is being included in the “parents of anxious children” sample may, in fact, also be the parent of one or more not anxious children. While it is common to exclude parents of anxious children from the “healthy control” samples, it is less common to exclude parents from the “parents of anxious children” sample if they also have a healthy, nonanxious, child. These are only some of the challenges facing researchers studying the impact of parental behavior on the development of childhood anxiety. Additional challenges relate to measurement issues, such as the difficulty of accurately and objectively measuring parental behavior (rating scales are inherently subjective; behavior in a laboratory situation may differ from behavior in home), sample sizes, and more.

Even accounting for the many methodological challenges, a synthesis of research in this area suggests that the parental variables account for only a small amount of variation in childhood anxiety outcomes (Bögels & Brechman-Toussaint, 2006). The conclusion must be that either the most influential parental variables have yet to be adequately identified and studied or that parents play a limited role in determining whether a child will or will not experience an anxiety disorder.

Among the parental behaviors that have been most consistently linked to childhood anxiety are behaviors such as overcontrol, low autonomy granting, and overprotection. These closely related constructs refer to a parent’s tendency to allow their child to independently explore the world around them, making mistakes along the way and taking some reasonable risks, or to the opposite parental tendency to control a child’s behavior, intervene to prevent them from making errors, (p. 17) and take preemptive action to reduce even a low likelihood of them experiencing the slightest harm. Statistically, parents who fall on the more controlling, low-autonomy granting, and protective end of this continuum are more likely to have children with anxiety disorders than those who fall on the opposite end. Yet, as just mentioned, this conclusion should be stated with caution on two counts: First, while statistically significant relations have been found, these have tended to be weak associations such that the child of a controlling, low-autonomy granting, and overprotective parent is only a little more likely to have an anxiety disorder than their peer with very different parents. Second, child anxiety may be statistically linked to this style of parenting without being the outcome of the parenting behaviors. For example, it is plausible that these parental behaviors reflect a genetic predisposition to risk aversion, which is manifesting in one way in the parent and in another in the offspring (although the genetic contribution to the risk of childhood anxiety is modest as well).

As such, identifying extreme patterns in parental behaviors that have an outsized likelihood of contributing to a child’s well-being is certainly important.

But suggesting that parents are the cause of their child’s anxiety because they show a tendency toward over protectiveness and control is vastly overstating the facts.

Family accommodation, however, is meaningfully different from these parental behaviors and from others such as criticism or rejection, which have also been linked to risk for childhood anxiety. In what way is family accommodation different? Family accommodation is conceptualized as a response to childhood anxiety and must, by definition, follow the onset of a child’s anxiety symptoms (although not necessarily an anxiety disorder). Parents who are overly protective by trait may also be likely to provide more accommodation of their child’s anxiety, and empirical data indicate a small but significant relation between these variables, but the accommodation is not thought of as causing a child to develop anxiety. Simply put, if the child had no anxiety symptoms, there would be nothing for the parent to accommodate, regardless of their parental style and characteristics.

This distinction between parental style and family accommodation is important and is a useful one to convey to parents in beginning to address family accommodation in therapy. Rather than attributing blame by discussing the role of parents in the development of childhood anxiety, the therapist can focus on the natural parental responses to an anxious child.

Indeed, the relation between family accommodation and very desirable parental attributes such as sensitivity to the child, acceptance of the child, and positive regard for the child is stronger than the relation between family accommodation and parental overprotectiveness. Instead of caricaturizing parents as helicopter parents whose child is inevitably anxious due to a lack of autonomy, the therapist can cast the parents in the more generous, and more accurate, role of loving parents who are responding to a child’s distress in the most natural way.

(p. 18) Establishing this basis for the discussion of family accommodation makes it easier to continue the discussion of changes in parental behaviors that will further the aim of helping the child to overcome the anxiety. The clinician is likely to find they have forged a more effective therapeutic alliance with the parents of an anxious child if they approach the parents as caring (and often exasperated) caregivers who are doing their best and can benefit from additional expertise and suggestions, rather than as (possibly) well-meaning but inept parents who have stifled their child’s autonomy to the point of clinical anxiety.

Accommodation by Siblings, Teachers, and Others

Parents are the primary providers of family accommodation but not the exclusive ones. Any person who modifies their behavior to help an anxious child avoid or reduce anxiety can be said to be accommodating, but, of course, those with the most frequent contact with the child and those with the most direct responsibility for the child’s functioning are the most important to consider.

Siblings

There is very little research on accommodation of childhood anxiety by siblings (Storch et al., 2007), but clinical experience (and indeed common sense) indicate that siblings, both older and younger, frequently accommodate their anxious sibling. These accommodations can take as many different forms as the accommodations provided by parents but can be usefully divided into three categories, based on the impetus that drives them rather than on the form or function of the accommodation. One category describes accommodations willingly provided by a child, either knowingly or unknowingly, in response to their sibling’s anxiety. Siblings will often speak in place of a socially anxious or selectively mute brother or sister, for example. And siblings will commonly accompany a sibling with separation anxiety who avoids being alone. Such accommodations can often be provided unknowingly, meaning that the accommodating child does not perceive the behavior as being a response to anxiety but may see them as merely a request from their brother or sister or may just accept them unquestioningly as how things are. In working with families of anxious children, it is common to encounter children who rely on even very young siblings, oftentimes toddlers, for “accommodation.” The younger sibling, of course, does not see the accommodation as such and may even be thrilled by the attention they are receiving from an older, admired sibling.

A second category of accommodations involving siblings describes accommodations by parents that directly or indirectly impact the sibling. These will often engender a sense of resentment in the nonanxious sibling who may feel they are being made to pay an unfair price for their sibling’s problems and (p. 19) who, over time, may resist the accommodations. The sibling’s feelings of resentment can be further exacerbated if the accommodation is extreme or frequent, or if the parents’ motivations are not well explained, or if the sibling rightly or wrongly sees the anxious sibling as taking advantage and as a manipulator of the parent rather than as suffering from the anxiety. Examples of this kind of accommodation range from the benign to situations that border on (or indeed are) maltreatment of the anxious child’s sibling. In one example, parents would repeatedly leave movie theaters and restaurants early with both their children, because one child felt anxious about using a public restroom and wanted to return home. In another example, a younger sibling was required to drop a much-loved karate class because her older sister was experiencing panic and agoraphobia and did not feel able to be alone at home while the mother drove to the class. Other examples can include not serving the family foods that one child fears, forbidding a child from touching things their sibling with germ phobia uses, or asking a child not to invite friends over to play because it makes their sibling nervous.

These parent-driven sibling accommodations are a sensitive topic and ought to be broached delicately with parents. A later chapter deals with introducing parents to the topic of accommodation and carefully monitoring accommodation by parents as well as siblings. Here again, however, it is ill-advised to assume that parents are acting out of thoughtlessness or neglect for the well-being of the impacted sibling. When one child in a family is sick, it will often lead to necessary or even critical changes to the behavior of everyone else in the family, including siblings. Family members of children who suffer from severe allergies, diabetes, immunodeficiency illnesses, and many other conditions are generally required to make substantive changes in response to the illness. Parents of an anxious child may see things in similar light and require other children to adapt to the presence of the anxious child.

The critical distinction between accommodation of anxiety and of many other illnesses is that family accommodation of child anxiety is neither beneficial to the child nor necessary for recovery.

Understanding this distinction can be one key to helping parents achieve better balance between what they view as competing needs of their different children. The next chapter discusses this and other motivations that contribute to the high levels of accommodation typically reported by parents of anxious children.

The third category of accommodation provided by siblings are accommodations a sibling provides under duress. It is not rare to see children coerced into accommodating their sibling through fear of physical or psychological aggression. The next chapter deals in some depth with the issue of coercion and family accommodation of childhood anxiety. The chapter focuses primarily on coercion of parents, but siblings too may feel compelled to accommodate a sibling who forcefully demands that they do so. In these cases, it becomes the parents’ responsibility, with the help of the therapist, to intervene on behalf of the nonanxious (p. 20) child. Doing so is ultimately beneficial not only to that child but to their anxious (and coercive) sibling as well.

Teachers

The word accommodation is often used in the educational setting in a manner that is different from its usage here. In school, accommodations typically refer to individualized adaptations to instruction, requirements, or assessments that are made to support the education of a child with a disability. These accommodations are both necessary and beneficial; however, they are not the topic of this book. Distinguishing between helpful accommodations of this kind and the anxiety accommodations that are discussed here can be challenging. A child may, in fact, benefit from certain accommodations due to an anxiety disorder, and anxiety disorders are legitimate disabilities that must be accommodated in the United States under the Individuals with Disabilities Education Act (IDEA). Yet schools and teachers can also engage in the kind of accommodation that maintains a child’s anxiety, rather than improving it, and in those circumstances, accommodation is unhelpful rather than helpful.

One way to distinguish between helpful and unhelpful accommodation is to ask the following question: “Is this accommodation promoting gradually more coping and increased functioning in this child? Or is this accommodation promoting gradually more avoidance and decreased functioning in this child?” When an accommodation is one step on the way from low to high function or from avoiding to not avoiding, it can be helpful. When an accommodation is maintaining avoidance and facilitating increased impairment in an anxious child’s functioning, it is unhelpful. It is useful to remember that anxiety, in contrast to some of the conditions covered by IDEA, is a highly treatable condition and that avoidance is a hindrance rather than an aid to recovery. Thus, if a socially anxious child never speaks in class even when called on, and their teacher agrees to not call on them more than once, or to give them a signal prior to calling on them, or even to specifically arrange in advance when they will be called on, these can all be helpful accommodations helping this child to move from complete to partial avoidance. And once the improvement is established, the accommodation can generally be reduced or removed to support even better functioning in the child. Conversely, if a socially anxious child struggles to answer and is visibly uncomfortable when called on in class and a teacher resolves not to call on the child so as to not cause them distress, this is an accommodation that is likely to promote increased avoidance and further impairment. That child may soon feel unable to speak in class at all, even when called on by other teachers.

Communication between the therapist and parents, teachers, and other school personnel is usually key to formulating collaborative treatment plans that allow the child to continue to receive an education, while gradually overcoming their anxiety disorder.