Childhood anxiety and mood disorders are on the rise, as reported by the CDC. COVID-19 is hitting children and adolescents hard (Singh et al., 2020), highlighting the critical importance of a secure family, modeling of positive coping, and cultivating constructive ways to bolster resilience in youth1.

When children are anxious, the way the people closest to them respond is critical. Which sub-optimal parental responses are not consider maltreatment per se (i.e. Adverse Childhood Experiences or “ACEs”), they contribute to developmental difficulties rather than mitigating against them.

Yet parents face their own challenges, and pressure to be better parents especially when adults are under great strain can lead to a downward spiral, harming all. Understanding what helps and what gets in the way allows us to make informed decisions about where to apply limited resources to make things better for all involved.

Adding fuel to the fire

Prior research in the Journal of Clinical Psychiatry (2020, reviewed here) found correlations between increased anxiety and intolerance of ambiguity in children whose parents accommodated excessively to their children’s unhelpful thoughts and behaviors. Accommodation is measured with questions2 probing how often parents avoid triggers or participate in children’s anxious responses, from both parent and child perspective. 

Parental over-accommodation is correlated with poorer child emotional and psychological well-being. However, to date, research has been based on statistical associations which suggests but does not provide stronger evidence for causal connection.

In order to move the needle on this critical research subject, a group of researchers from Yale University in the United States, the University of Sao Paulo, Brazil, and the Medical University of Warsaw published more robust research on the subject in the Journal of Anxiety Disorders (2020).

Parents and children don’t see things the same

Using a statistical approach called Structural Equation Modelling (SEM), researchers analyzed data from 425 mother-child pairs. SEM does not establish causality in the way a prospective study would (i.e. following participants over a period of years to see what factors earlier on actually predict future outcomes), SEM does provide more reliable statistical findings while also establishing a robust base for future studies.

Participants completed a battery of measures: assessment of child anxiety via the Anxiety Disorders Interview Schedule (ADIS, children and parent versions) and the Screen for Child Anxiety Related Emotional Disorders (SCARED, children and parent versions); family accommodation using the Family Accommodation Scale-Anxiety which looks at ways the family makes room for anxiety, how much the family enables anxiety-related behaviors, and what happens if the child’s anxiety is not accommodated in the short-run; the Child Impact Anxiety Scale (CAIS), in which parents rates to what extent anxiety affects the child’s psychosocial functioning in school, social and home spheres.

Findings

Authors analyzed the data from the perspective of the parents and children separately to generate and compare two models.

Overall, they found that increased family accommodation accounted for increased anxiety symptoms as rated by both mothers and children. Moreover, family accommodation was a significant moderating factor connecting anxiety symptoms with functional impairment in both models, showing that for both mothers and their children, maladaptive ways of responding to anxiety and anxiety-related behaviors did more harm than good. 

In both models, family accommodation was an significant indirect contributor to child functional impairment, while age and degree of anxiety were direct contributors. Family accommodation contributed between 20 and 50 percent of functional problems related to increased child anxiety, highlighting how powerful the family environment is for the developing individual. The parent model showed a stronger connection between parent-rated child anxiety and accommodation.

Finally, while both child and parent models support the notion that over-accommodation interferes with healthy anxiety coping, representing maladaptive responses in the family system, the child and parent scores were only weakly correlated. Specifically, family accommodation in the child model had a substantially bigger moderating effect on functional outcomes than in the parent model (correlations respectively of 0.539 and 0.309 for child versus parent scores).

Maintaining an even keel

This work further highlights how key it is to look at context, and not solely through the lens of individual pathology. According to data from children and mothers in the same family, accommodation to anxiety and related behavior significantly accounts for negative outcomes in school, social and family functioning. Accommodation is associated with higher levels of anxiety and undesirable short-term responses, such as emotional dysregulation, poor coping, and the risk of longer-term impairment of resilience and emotional well-being. In the child-centered model, accommodation accounted for about as much functional problems as anxiety itself.

The next step in understanding the impact of the family environment would involve longer-term prospective studies which look at actual behavior in the family and long-term outcomes. Interventions designed to reduce over-accommodation would be expected to be associated with better outcomes. This is consistent with family therapy models which strive to change the family system, rather than focusing only on treating the child. 

Clinicians often use the term “identified patient” to highlight how children may be singled-out when there are unrecognized family issues, including parental psychiatric problems, substance and alcohol use issues, and maltreatment.

In the long-term, such children often bear the brunt of the family problems, developing significant anxiety disorders, depression, addictive and compulsive behaviors. Problems are passed from generation to generation if unchecked. Children from dysfunctional homes are at risk for relationship problems later in life, including a higher chance of ending up in emotionally-abusive situations when they come from homes with poor psychological boundaries, a lack of appropriate behavioral guidance, and low emotional support.

Finally, it’s noteworthy that the child model showed a stronger connection with family accommodation, anxiety and functional impairment, and the parent model a stronger connection between child anxiety and accommodation.

Children’s data highlights the importance of a healthy environment in scaffolding resilient responses to distress, and the downsides of a family which provides inadequate support, behavioral containment, and emotional and psychological over-enmeshment. The disparity between parent and child stats, and the literature on how parental behavior shapes adult outcomes for children, supports the hypothesis that parents tend to downplay the negative impact of over-accommodation when children become anxious and dysregulated, avoiding embracing the implications of parenting decisions, and potentially impeding positive change.

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