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Changing problematic parent–child interaction in child anxiety disorders: The promise of Acceptance and Commitment Therapy (ACT)

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Highlights

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    We review the literature on parenting in child anxiety disorders and on parenting interventions that have been used in the treatment of child anxiety

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    We note the limitations of the parent intervention literature in child anxiety and present the Acceptance and Commitment Therapy (ACT) treatment model as a potentially helpful model in addressing these limitations

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    We review the current literature on ACT for parenting and for child anxiety

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    We review how ACT concepts apply to changing problematic parenting behaviors in families of anxious children.

Abstract

Anxiety disorders present a significant concern for children, affecting up to 20% of those under 12 years old. The importance of parenting behavior in the development and maintenance of childhood anxiety disorders has been established both theoretically and empirically. We review the literature on cognitive-behavioral parenting interventions aimed at reducing child anxiety and discuss the limitations of this approach and of the research to date. We then present Acceptance and Commitment Therapy (ACT) as a treatment model that holds promise for shifting problematic parent–child interactions, and we review the relevant theoretical and empirical literature supporting this promise.

Introduction

With an estimated prevalence of 10–20%, anxiety disorders are among the most common childhood psychological problems (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Moreover, anxiety disorders in childhood are associated with risks across a multitude of domains, including risk for social and academic challenges (Pine, 1997, Wood, 2006), adult anxiety (Kim-Cohen et al., 2003), secondary mental health problems such as substance abuse (Kushner et al., 2012), and major depression (Avenevoli, Stolar, Li, Dierker, & Ries, 2001). While established treatments exist for anxious children, there is a significant subgroup, approximately 30–40% of children with anxiety disorders for whom empirically-supported cognitive-behavioral therapy (CBT) models fail to produce a meaningful reduction in anxiety symptoms (Kendall, Settipani, & Cummings, 2012). Given that problematic parent–child interactions, such as controlling parental behavior (Barber, 1996; Steinberg, Elmer & Mounts, 1989), may amplify and maintain child anxiety (Wood, McLeod, Sigman, Hwang, & Chu, 2003), it stands to reason that one avenue for improving interventions would be to effectively target parent behavior. This paper discusses the promise of Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, & Wilson, 1999) for addressing problematic parent–child processes that may impede treatment progress for anxious children. In this study, we focus specifically on anxiety among children under 12 years old and here to refer to this as child anxiety.

Section snippets

Parent behavior in child anxiety disorders

Research points to the role of parenting in the development and maintenance of childhood anxiety (Chorpita and Barlow, 1998, Hudson and Rapee, 2004, Manassis and Bradley, 1994, Rapee and Spence, 2004, Rubin et al., 2009). In particular, parental over-control (or lack of autonomy granting) has been consistently cited as a factor that contributes to and/or exacerbates children's anxiety symptoms (McLeod et al., 2007, Rapee, 1997), and may play a role in treatment outcome (

Changing parent behavior in families affected by child anxiety: current literature

These empirical findings suggest that effecting change in parental over-control may be an effective intervention for anxious children, especially given some limited data suggesting that a reduction in parental psychological control is associated with later decreases in child anxiety (Settipani, O'Neil, Podell, Beidas, & Kendall, 2013). Interestingly, Settipani and colleagues found that parental anxiety decreased after, rather than before, child anxiety decreased, suggesting that child behavior

The assumption of psychological flexibility

First, parenting interventions for childhood anxiety currently evaluated in the literature generally focus on delivering CBT-related content, but do not attend to within-parent factors that may make it difficult to change problematic parenting behavior. Many parent-focused protocols take a coaching approach in encouraging parents to support their child′s CBT program. The content of these parent-focused modules has tended to closely follow the child-focused CBT sessions, focusing on providing

Lack of information on change in parenting behavior

A second limitation of this literature on parent interventions in childhood anxiety is the lack of post-treatment evaluation of parent–child interactions. Studies have focused on child anxiety outcomes (e.g., Shortt et al., 2001; Toren et al., 2000; Wood et al., 2006) but do not measure whether parent interventions actually changed (or failed to change) parenting behaviors. Overall, changes in parent behavior during parent–child interactions have not been systematically evaluated, leading to

Acceptance and Commitment Therapy for parents of anxious children

Acceptance and Commitment Therapy (ACT) (Hayes et al., 1999) may offer an innovative approach for addressing parent–child dynamic patterns such as over-control which may support avoidance and maintain anxiety in children. ACT is grounded in Relational Frame Theory (Hayes, Barnes-Holmes, & Roche, 2001), a behavior-analytic account of verbal behavior, and as such, provides a model for elucidating the role of verbal behavior in unhelpful parenting patterns. ACT specifically addresses three

Verbal rules

First, ACT directly targets behavior that comes under the control of “verbal rules”. Greco, Blackledge, Coyne, and Enreheich (2005a) propose that most parents have “stories” that work as verbal rules about what their child′s experience of anxiety must be like (e.g., “Anxiety is intolerable”) and their child′s capacity to cope with the anxiety (e.g., “It′s too much for him to manage.”) (See Greco et al., 2005a, Greco et al., 2005b). Moreover, parents may also have rules about their own

Experiential avoidance

Second, ACT targets a construct known as experiential avoidance. Although parental experiential avoidance has been positively correlated with parents′ use of over-control strategies (Cheron et al., 2009) and has been found to negatively impact maternal attachment, psychological symptoms, and responsiveness among mothers of preterm infants (Evans, Whittingham, & Boyd, 2012), no known treatment program has directly targeted this psychological process in parents of anxious children. ACT may do so

Valuing

Lastly, ACT involves a specific treatment component that helps to motivate, organize, and sustain behavior, even in the context of challenging emotions. “Valuing” refers to making psychological contact with what matters most to parents, and engaging in behaviors to move them in that direction, even in the presence of discomfort. For example, a parent might be willing to remain engaged in difficult exposure work if such work provided the possibility for his child to experience life more fully.

Impact of ACT-related processes

A number of studies have shown links between parent experiential avoidance and child internalizing problems (eg, Cheron et al. 2009). Moreover, at least one study has shown that parent experiential avoidance mediated the experience of a traumatic event and the development of child PTSD symptoms (Polusny et al., 2011). Recent empirical work suggests that ACT-relevant concepts such as experiential avoidance and cognitive fusion in parents may influence parenting behaviors, the quality of

Summary and conclusions

The possibility of changing problematic parent–child processes in childhood anxiety seems to hold great promise for helping families affected by this common disorder. However, shifting such complex behavioral interaction patterns presents a therapeutic challenge. Traditional instructive CBT approaches for parents, even those directly instructing parents to change controlling behaviors, have shown limited helpfulness in reducing child anxiety, and research paradigms have failed to evaluate the

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