Using parent directed treatment when working with kids and teens with anxiety disorders and OCD
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Using parent directed treatment when working with kids and teens with anxiety disorders and OCD
If you work in mental health with young people it will be no surprise to you that anxiety disorders in young people are common – although it is less common than the “self reported symptoms of anxiety” in young people (up to half of all kids and teens) – research suggests it is still a full 20% of kids and teens who meet the criteria for an anxiety disorder (GAD, Separation Anxiety Disorder, Social Anxiety Disorder or Specific Phobias). A further estimated 5-10% of children and teens meet the criteria for a diagnosis of Obsessive-compulsive disorder.
Since the 1980’s, the gold-standard psychosocial intervention for young people with anxiety disorders has been Cognitive Behavioral Therapy (CBT), and for OCD in particular, CBT plus (ERP). Several meta-analyses have found that about 70 to 80% of young people who go through treatment experience clinically meaningful improvement – and about half of them have their anxiety disorder or OCD entirely resolve. However, these treatments are not universally successful – as you can see from the above statistics - 20-30% don’t experience improvement and around half still experience at least some symptoms by the end of treatment. It’s also important to note that another group of children with anxiety disorders or OCD - around 20% to 30% of them – find they can’t even complete the treatment in the first place.
There are many reasons for this lack of response or ability to complete psychological treatment for some kids and teens. There might be financial or life difficulties which make it hard for the child and family to keep coming to treatment, the young person might be experiencing stressors and triggers in their life which perpetuates their anxiety despite treatment, young people in treatment might difficulties following the therapy homework, and of course there can be underlying physiological or medical causes for anxiety which are not always fully amenable to psychological therapy. And this is probably not going to be the most fun fact you read today, but as therapists we don’t always implement therapy well either – something like 50% of therapists underuse exposure in CBT treatment.
However, there are also some reasons that CBT and ERP don’t work for children and teens in particular. For example, CBT/ERP requires children and teens to be motivated enough to actively choose to tolerate distress in the short term to achieve longer term improvement – clearly hard for kids and teens who do not always have the ability to take this longer term perspective. A second child/teen specific reason for therapy challenges is a young person’s ability to understand and have insight into their thoughts and behaviours. If child doesn’t yet have the developmental ability to do this, it’s very hard for us to implement CBT and ERP effectively. Thirdly, children and teens sometimes live in family environments which accidentally maintain anxiety - which means that therapy might have limited power to make changes (I’m sure examples come to your mind like they do mine)
An alternative: Parent/caregiver directed therapy
A different type of therapy for anxiety for kids and teens is parent/caregiver directed therapy whereby we treat young people’s mental health problems via working entirely with their parents/caregivers. In other words, in parent directed treatment, the child/teen does not attend any of our therapy sessions at all, we don’t meet them nor ask their parents to try to get the child to complete any therapy tasks. Instead, we work solely with parents/caregivers to help them change how they respond to their child/teen's anxiety, and to make particular changes to the child’s environment.
The most well-known (and most rigorously) evaluated parent directed therapy for anxiety is a protocol called The Supportive Parenting for Anxious Childhood Emotions (SPACE). SPACE was developed by Dr. Eli Lebowitz at Yale and is underpinned by the theory that when parents change their behaviour and the child’s environment - this then helps children develop new coping mechanisms which reduce anxiety, obsessions and compulsions.
Let’s have a look in a bit more detail about how this works.
SPACE consists of two main components – the first is helping parents increase supportive communication, which includes a) statements of validation (authentically acknowledging a child's fear, and distress without minimising it, or showing irritation) AND b) increasing parents expressions of confidence in their child’s ability to cope with anxiety (SPACE therapists describe expressions of confidence as “unshakeable, explicit beliefs in the child's capacity to tolerate distress and survive the situation”).
It should be noted that we will be providing psycho-education to caregivers that validation and confidence are not the same as reassurance. We might explain to a parent that reassurance is telling a child/teen something encouraging about the future – for example “Don't worry, the dog won't bite you, I promise." Validation and confidence don’t talk about the future situation at all –instead in this situation validation would be something like: "I see how terrified you are of that dog, and I know your heart is racing right now. I also absolutely know you are strong enough to walk past him and handle this feeling."
The second component in SPACE is reducing family accommodations. Family accommodations are defined as repeated modifications parents make to the family environment to help a child avoid or reduce distress caused by their anxiety or obsessions. For example, family accommodations might include a parent always driving a child to school late on Fridays to help them avoid their fear of assemblies, always ordering food in a café on behalf of a socially anxious teenager, avoiding ever discussing certain topics at home to appease a child who is anxious about them, re-washing laundry to satisfy a teen’s contamination fears, or checking a child's homework repeatedly to comply with their worries about it.
Family accommodation is very common. One study found that over 95% of parents of anxious children referred to anxiety clinic were engaging in accommodation behaviours for their child/teen. This is no surprise - when kids and teens are highly anxious and distressed, a parent's deep seated, and evolutionarily based biological instincts is to reduce their child’s distress (not to mention that when children are distressed, parents usually are trying to get through something/get things done and are trying to fix things as quickly as possible). Add to this whole situation the fact that when kids are distressed, parents are too and are trying to calm themselves down. It is entirely understandable for a caregiver to do whatever they can to reduce a child’s or teen’s anxiety.
Unfortunately, however as we know - while accommodation makes sense in the short term – sometimes in the long-term results it has unhelpful consequences as it usually perpetuates the cycle of anxiety. Both conscious and unconscious mechanisms are involved in this perpetuation of anxiety and are beyond the scope of this article. But as an overview – we can tell a parent that accommodations can be thought of as often sending a message a young person which goes something like "You are right to be terrified, and you are too fragile to survive this without us making this easier."
It is important to acknowledge that accommodations for an anxious child are not always inappropriate and instead sometimes are entirely the right thing to do. It is appropriate to reduce expectations of a child or young person at times, depending on their capacity to cope, their age and the importance of the child’s fear or avoidance. For example, a parent making a modification to the evening routine to accommodate a very young children distressed about going to sleep on their own is an example of a developmentally appropriate and helpful accommodation. A parent choosing to reassure a child who needs reassurance about an occasional and big school play is appropriately empathic (and important) parenting.
However, as we know many ongoing accommodations are unhelpful. The types of accommodation which are more likely to be unhelpful are when they are about activities where a child’s avoidance leads to them experiencing a narrower or lower quality of life, or when they have a serious impact on someone else’s quality of life or when they are developmentally unusual for a child or young person of that age or capacity.
This means if we were implementing a SPACE protocol with a family, some work would be done helping a parent consider which of their accommodations might be unhelpful and when it is appropriate for them to be removed. Once this is done, we then guide them through a structured, gradual process to systematically withdraw these accommodations in ways which are still supportive and caring.
Let’s consider the fictionalised case of Chloe, age 10, who since watching a movie several months ago, has become extremely anxious about intruders getting into their house overnight. As a result of these worries, Chloe experiences panic in the hours leading up before bed and repeatedly asks her parents for reassurance – “have we locked the doors”, “do you have the cricket bat under the bed?”, “is there any news about robberies in our neighbourhood”. To calm her, Chloe’s Mum, Sue repeatedly reassures her every night and recently - in an understandable desperation to help Chloe sleep - has started sitting on the floor next to Chloe's bed until she falls asleep. Whenever Sue tries to leave the room before Chloe is asleep, she gets very distressed.
Let’s say Sue organised a therapy appointment for Chloe, but when Chloe met the therapist and heard her say that part of therapy would involve learning some “brave behaviours” - she refused to come back. And this was despite some pretty decent stickers and playing of Uno.
Let’s say Chloe’s therapist rang Sue after the appointment to talk about parent directed therapy and Sue decided to go ahead with this as a try. Over six fortnightly sessions, Sue came in to see the therapist on her own and worked through the SPACE protocol.
The first few sessions consisted of Sue and the therapist talking about what was causing and maintaining Chloe’s anxiety and discussing how Sue could increase her statements of validation and expressions of confidence, and also what accommodations to reduce and how. When Sue was ready, she used what SPACE calls “the announcement” (a pre-scripted supportive statement) to explain to Chloe what was going to happen. It went something like this: "Chloe, I know how hard bedtime is for you and how scared you feel when you go to sleep. I’m really sorry you are having to manage this feeling. But I also know that me constantly reassuring you and sleeping next to your bed is going to be making you feel more anxious about this in the long run. I also know that you are strong enough to handle your scary feelings and don’t need me to sleep next to you. So, starting this Monday, I will only reassure you about intruders once in the night, and I am also not going to sit in your room until you fall asleep. I will tuck you in, say goodnight, and go downstairs. I know this will feel very hard at first, but I am absolutely sure you can handle it and I also am sure that over time your scary feelings will gradually go away."
Chloe cried and begged her Mum to still sleep in her room. She said, “you hate me”, “I just need you so much” and “you are wrong, I can’t handle it”. She became very angry, trashed her room, and even dented her wall by throwing her chair. Sue and the therapist had prepared for this, and so Sue did not argue or give any more reasons for her decision and instead simply kept calmly repeating the script like a broken record, while trying to limit the damage to Chloe’s room. It was a very tough night.
That Monday afternoon as usual, Chloe started asking her Mum about intruders. Her Mum said “I’m sorry you feel scared. As you know, we have never had intruders, we lock all our doors at night, and it is very unlikely anyone will ever break into our house. I know you can handle your worries about this and I’m not going to talk about this anymore with you tonight”. Chloe continued to express her fears and every time, Sue just repeated “I’m not going to talk about this anymore”. Chloe became very angry and followed her Mum from room to room. Sue changed the topic several times and initiated other conversations – Chloe sometimes engaged in these conversations, and sometimes not. Chloe kept repeating various versions of her fears, but Sue did not respond.
At Chloe’s bedtime, Sue was already exhausted but determined to follow through. As usual, she read Chloe a chapter of her book, delivered the supportive script one final time, turned off the light and left the room. Chloe started crying and followed her back into the loungeroom. Following the plan Sue and the therapist had worked on, Sue did not get angry or insist Chloe go back to bed but just sat watching TV not responding to Chloe (other than to occasionally say I’m not discussing this with you – and you can go back to bed anytime you like). Not surprisingly, Chloe did not go back to her bedroom and instead sat in the lounge room crying on and off – and sometimes watching the TV from the corner. At 9.30pm, Sue went to her own bedroom and locked her door. Chloe sat crying on the floor outside Sue’s bedroom door. Every 10 minutes or so, Sue called through the door to say I am here and everything is okay (and you can go to bed whenever you want). At around 11pm Chloe fell asleep on the floor outside Sue’s bedroom, and Sue got up and carried her to bed.
The next few days went similarly, with Chloe sitting in the lounge room for the first part of the night and then falling asleep outside her Mum’s bedroom when she went to bed. However, within a week, Chloe started going to her bedroom when her Mum went to bed at 9.30pm. This was a great start, but Sue was worried about the fact Chloe was still sitting in the loungeroom until 9.30pm and not going to bed. She went back to the therapist at this point, and they together decided that Sue would go into her bedroom and read much earlier in the evening (around 8). They also decided to get Sue to add a lot of extra encouragement, thanks and affirmation to Chloe every time she looked like she was independently taking herself back to bed. The therapist encouraged Sue to keep practicing remaining calm, loving but 100% consistent. It took another month, but after that Chloe suddenly just stayed in bed from bedtime rather than coming out to the lounge and had stopped talking about intruders almost at all. When Sue asked her about it a few months later, Chloe rolled her eyes and said, “oh I’m not really worried about that anymore –it’s not that big a deal Mum”. Sue restrained herself from a few choice comments and just tried to be grateful for the improvement!
Let’s take another fictionalised example, this time of Julian, aged 14 with OCD. For the last 12 months Julian has struggled with fears about chemicals. His parents are both engineers and he is extremely anxious that they are picking up toxins at work – and has recently been insisting they change out of their work clothes immediately upon entering the house after work, place them directly into the washing machine and to have a shower – all before coming to talk with him. He also insisted they leave their bags and coats outside the house at all times. Julian’s parents have tried to stop doing all these things, but when they do Julian gets extremely distressed, locks himself in his room, and refuses to come out. To maintain peace therefore (as well as be able to spend time with him), Julian’s parents have reluctantly complied with his rules.
Like Chloe, Julian refuses to go to therapy to deal with his fears. He says they are reasonable fears and isn’t interested in trying to change. Julian’s therapist therefore talks to his parents and offers to try parent directed therapy. Similarly to Chloe’s Mum, the therapist first helps Julian’s parents to increase validation and start expressing confidence that Julian can manage his fears. The therapist then works with Julian’s parents to figure out what accommodation to target first – the showering, changing or storage of bags. They deicide the showering is the easiest target (and most disruptive for them) – so decide to remove this accommodation first. They too sit down with Julian one day to make their “announcement” which in this case went something like this. "Julian, we know how upset and scared you are about toxins. We love you and are really sorry you are managing this fear. But we also know we have no dangerous toxins on us, and also that us showering every night when we get home will in the long run make you more anxious. So, from now onwards, we are not going to do this. We will change out of our clothes, but we are not going to shower. We know this is going to be scary for a while, but we also know you are strong enough to manage your fears about this.”
Julian’s parents put this into place the next night. As predicted, Julian panics and goes into his room and refuses to come out. He is extremely angry about this as his usual evening activities include using the PlayStation and computer which are in the family room. He yells and throws thing around in his room. Prepared for this by the therapist, His parents maintain a neutral, loving stance without wavering. They send him texts to ask him about his day (which he ignores of course) and also tell him they have left his dinner on the table. After his parents go to bed, Julian then comes out and eats it. The next morning, Julian begs his parents to stop this insanity and to shower after work that night like they have been doing. They calmly refuse and everyone goes to work and school feeling upset and distressed. That afternoon, his parents do the same thing and as expected, the same happens: Julian retreats to his room with high anxiety and anger, yelling at his parents through the door, begging them to shower and telling them how upset he is and how much this is ruining his life. His parents calmly refuse, deliver the script and try to carry on with their night. Again, Julian only comes out after 10.30pm. This goes on for two weeks with no change. His parents and the therapist meet to discuss what to do and decide to carry on for a few more days without making any changes. Everyone is freaking out, including the therapist, although outwardly she shows complete calm and confidence in the process while frantically calling her supervisor (who tells her she is on the right track). Two days after the session, Julian’s parents get home from work and find him sitting in the family room playing the PlayStation, entirely ignoring them and not making a rapid retreat for his room. They go into their room and change out of their clothes and come and with careful nonchalance make casual conversation with Julian. He is gaming and so mostly grunts but does not go to his room until his game finished, about 30 minutes later. The next night, Julian stays in the family room for the whole night – again coming out to the kitchen to eat dinner after his parents go to bed. The next night, he comes into to eat at the table with his parents like nothing has happened. His parents wisely choose to make no comment on this but go back to the therapist jubilant, while the therapist pretends that she was never worried. Julian’s parents and the therapist work on a plan for them to be able to bring their bags and coats into the house - and this turns out to be a much easier process than the showering project.
Is it effective? The Efficacy of the SPACE Program
You might be thinking that these case studies sound far too simplistic. It is true that for the sake of brevity, I have removed many of the bumps and difficulties which come up and need a great deal of parent/therapist brainstorming to resolve and of course some families do not improve (or even come back after 2 sessions – more on this in a minute).
However, while the process can be tricky, research (and our clinical experience) has shown that parent directed therapy for anxiety can be very effective for many families. A randomized controlled study (published in the Journal of the American Academy of Child and Adolescent Psychiatry in 2020) provided one group of kids/teens with anxiety disorders/OCD with SPACE treatment (i.e. working with their parents only without the presence of the kids/teens themselves) and provided a second group of kids/teens with anxiety disorders/OCD with traditional child/teen focused CBT and ERT. The results found that SPACE program was found to be just as effective as CBT in reducing anxiety symptoms and diagnosis rates – with around 90% of both groups of kids/teens experiencing improvement in their symptoms (and 70% no longer meeting the criteria for an anxiety disorder). Remember that for the group who had their parents do parent directed treatment, not one of these children/teens were seen even once by the therapist, nor asked to do any kind of activity or homework themselves.
Since that time, there have been a few other studies examining the SPACE program. For instance, a pilot trial published in Autism examined how well SPACE works for anxious autistic children and found that 86.66% of the children (who had their parents do the parent directed treatment) showed reliable clinical improvement (also maintained at a two-month follow-up). Another 2025 study had therapists provide a group version of SPACE (by telehealth actually) to parents of 50 children with a range of anxiety disorders and OCD (and note that half of these children also had a co-occurring diagnosis of ADHD). This study found that after the 16-week intervention, 77% of the children experienced significant improvement in their anxiety symptoms.
Another study evaluated a program called Space Light - consisting of 4 (individual) parent sessions with a therapist. The outcomes for the children of these parents were compared to outcomes for the children of parents which undertook the full 16-week therapy program – and the results showed similar rates of improvement for both groups: 70% experiencing clinically significant improvement in their anxiety and nearly half no longer meeting criteria for an anxiety disorder.
All this research seems to suggest that if a child or young person has an anxiety disorder or OCD and cannot engage in treatment themselves - parent directed treatment may well be an effective treatment.
Cautions to keep in mind
While the above research shows that parent directed treatment for children with anxiety disorders is often very effective – it also shows that it is not a perfect solution for all families. Like most other psychological therapies, about 20-30% of children who had their parents undertake SPACE didn’t show much improvement – at least that comes through in the measurement straight after the program. Also – and again like most other psychological therapies, about 20% of parents “drop out” before the end of treatment – presumably not feeling it was right for them. If you are having one in five of your families not come back after session one or two – it should reassure you that even rigorously implemented research treatment trials like this have the same drop out rate.
We also don’t have a lot of long-term data yet on this type of treatment (typical of research on psychological treatment) nor do we have good data on who it works for exactly, and who doesn’t benefit. So further research is needed.
Pragmatics – the combining of Parent-Directed and Child-Directed Work
Despite the cautions above, parent directed treatment is likely to be an important and helpful treatment for many families. This is our experience in our clinic (private Australian based child/teen psychology service) – however we also know there are difficulties with this type of treatment. First, you probably know that very disappointingly, Medicare funding in Australia does not fund parent directed therapy – instead the child (even if very young) has to be in the room themselves (while Medicare allow for 2 parent only sessions annually this is of course not enough for anything which looks even close to a course of treatment). Although private health funds generally fund parent directed treatment and also some parents are able or willing to bear the cost of treatment, the lack of Medicare funding for this evidence based treatment is in my view appalling (and a situation often leads to damage to a child because parents have to discuss adult only topics in front of them) For more information on this situation and to sign a petition to change it please consider going here after you have read this article: fixmedicareforchildmentalhealth.com
Another challenge to be aware of with parent directed treatment is consent – if young people are mature minors (often when they are 15 years and older, deepening on the young person) – then therapists cannot (and appropriately so) proceed with parent directed treatment without the young person’s consent. A final challenge with parent directed treatment is that sometimes children and young people have SOME motivation and capacity to do at least some therapeutic work – and in this case using only parent directed therapy means missed opportunity to engage and support a young person.
Therefore it is often appropriate for us to use a combination of parent directed therapy and therapy with children and young people themselves. For children/young people with anxiety this often consists of us doing some work (sometimes crammed into the two Medicare sessions available – although we should usually tell parents that it is clinically indicated for them to have more than this) with parents to problem solve and brainstorm goals, increase their skills in validation and showing confidence and helping them to work out how to reduce family accommodations, and then some work with kids and teens to increase their skills, notice their thinking mistakes and take the initiative to increase their own brave behaviour.
Want to know more about parent directed therapy
If you would like to learn more about parent directed therapy, there are a few options. First, there are several professional books on the SPACE approach you might like to consider reading (google “Supportive Parenting for Anxious Childhood Experiences). Second, you might like find a psychologist supervisor who is familiar with this approach – and a shameless plug – the clinicians who provide supervision at our Dev Minds clinic are experienced and trained in this approach so feel free to go to developingminds.net.au/therapy-supervision for more information if you would like our support.
All the best with thinking about using parent directed therapy with the young people you see
- Kirrilie
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