Bright & Quirky Child Summit 2021: Tame The Overwhelm was a 5-day free online summit which aimed to help twice exceptional (2e) children - gifted children with ADHD, autism, learning differences like dyslexia, anxiety and/or depression. The conference featured 28 educators and psychologists who shared science-informed actionable strategies that promote social, emotional, and academic thriving even in tough times. The summit was hosted by Debbie Steinberg Kuntz, a licensed marriage and family therapist as well as the Founder of Bright & Quirky. Day 1 focused on taming stress, anxiety, and worry.
Reduce Your Child's Anxiety or OCD: The New SPACE Program for Parents of Anxious or Worried Kids - Eli Lebowitz, PhD
Professor Lebowitz studies and treats childhood and adolescent anxiety at the Yale Child Study Center. His research focuses on the development, neurobiology, and treatment of anxiety and related disorders, with special emphasis on family dynamics and the role of parents in these problems. Dr. Lebowitz is the lead investigator on multiple funded research projects, and is the author of research papers, books and chapters on childhood and adolescent anxiety. He is also the father of three great boys.
Many years ago, Dr. Lebowitz worked in two programmes simultaneously in a large children's hospital. At the anxiety disorders clinic, he conducted cognitive behavioural therapy (CBT) for anxious children who were motivated to participate directly in therapy. At the parent guidance clinic, he worked exclusively with parents of children with externalising behaviour problems, giving parents the tools to be the agent of change. He became frustrated about why he had so little to offer parents of anxious children, when in other areas it was assumed that parents were going to be the main clients. This led him to think about working more with parents of anxiety and/or obsessive-compulsive disorder. The Supportive Parenting for Anxious Childhood Emotions (SPACE) treatment is a parent-based programme that focuses on changes that parents can make to their own behaviour, instead of making their anxious child change. The two main changes that parents learn to make are to respond more supportively to their anxious child, and to reduce the accommodations they have been making to the child’s symptoms.
In the book 'Breaking Free of Child Anxiety and OCD: A Scientifically Proven Program for Parents', Dr. Lebowitz wrote, 'A child who is anxious is typically going to overestimate the likelihood of negative events and to downplay the likelihood of positive ones. An anxious child also is probably going to view negative events as extremely negative, more so than might seem reasonable to a less anxious person.' 2e children often have generalised anxiety disorders or chronic worry, as well as perfectionism and self-criticism. This frustration can be fuelled internally by the expectation that they have to constantly do well and the sense that they should be able to perform much better. This frustration can also be fuelled externally, as they often run into a mismatch between their actual performance and others’ assumptions of what they should be able to achieve academically or socially.
Dr. Lebowitz debunked the harmful myth that children are anxious due to the way they have been parented. The field of mental health has a history of blaming parents for child problems. Although such theories may have some intuitive appeal, empirical research fails to support the hypotheses. It is possible for parents to behave in such an awful way – such as serious neglect or abuse – that they have negative impacts on their child’s mental health. However, in the vast majority of cases, parents and parenting styles are not the cause of children's anxiety disorders. The more common reason for most cases of child anxiety is a natural and innate predisposition and vulnerability, the wiring that children are born with. If a child is not predisposed to anxiety, even if the parent is very protective, it will not make the child an anxious child. On the other hand, if the child is predisposed to anxiety, then how the parent responds to the child does matter, either helping the child to cope better or making things harder for them. Nonetheless, that is not the same as the mistaken assumption that parents cause anxiety disorder in first place. Debbie noted that it is a healing message for parents of anxious children to know that it is not parents’ fault at all.
Dr. Lebowitz also wrote, 'Many parents of children who struggle with high levels of anxiety describe their children as rigid, inflexible, and hating change. Your child’s anxiety can make him feel that his life is like a minefield, full of the potential for danger and catastrophe. Of course he doesn't want to take extra steps, doing as little as possible. Staying away from dangerous experiences is just common sense. You may feel frustrated that your child is not willing to try new things or needs everything to always go exactly the same way. Before a child in a minefield, this comes naturally.' Dr. Lebowitz elaborated that anxious children, especially autistic children, are often so-called rigid and controlling. Their behaviour may seem frustrating and irritating to the people around them, who may not have the same level of anxiety or may not be anxious about the same things. Nevertheless, it is natural that when we feel anxious, we look for things that give us a sense of control, because being able to shape or predict what is going to happen next makes us feel safe. Thus, anxious children may seek familiarity, patterns, and repetition. They may exert control over other people, needing everybody to play along. They may also be averse to novelty and change. It may be fun to let go of some control over our environment when we know that we are safe and that things will work out fine. For example, we like to explore foreign streets on vacation because we know we can get a taxi back to the hotel. However, we do not want to relinquish control when we know that there are many ways in which things could turn out disastrous. For example, we do not want to get lost on our way to an important job interview.
Dr. Lebowitz added that when we are anxious or scared, we usually stay away from the things that will trigger anxiety. Over time, we tend to broaden the circle of things that we are avoiding, otherwise known as 'avoidance creep'. Using an example of a child with a phobia of dogs, he may not want to approach dogs at first. Soon, he may not want to walk down a street where there is a dog. Over time, he may reach a point where he does not want to leave the house at all, because he never knows where there might be a dog.
Moreover, if we put together the idea of avoidance creep and parents’ accommodation, there is a risk that anxious children begin to avoid everything outside the home environment. Parents sometimes fall into the habit of trying to pre-emptively avoid the things that might make their child anxious. The more parents create a home environment that is calibrated to avoid triggering anxious children, the more the world outside the home can become scary for anxious children, making it harder for them to cope with anxiety. If anxious children only feel safe at home, going to school starts to feel challenging. If anxious children only interact with accommodating family members, interacting with other human beings who may be less accommodating starts to feel daunting. This ultimately makes it harder for anxious children to cope with anxiety.
On the topic of avoidance, in the modern world, technology is set up in ways that enable avoidance of social interaction with other people and the challenges that accompany it. For example, to get food, instead of going to the store or ordering via a phone call, we can now order via apps and arrange for contactless deliveries. When we have an extended occupation with the virtual world, we do so at the expense of practising the ability to interact in the real world. Especially during the ongoing COVID-19 pandemic when we are sheltering at home, many children are staying in their bedrooms alone and spending a lot of time online, such as playing video games. It can get tricky to tease apart online time with the avoidance of real life.
In the book, Dr. Lebowitz also discussed ways that anxiety can impact the family. Parents can become the reassurers-in-chief, avoiding going to certain places or doing certain things to make their child feel better. While it feels natural for parents to want to protect their child, accommodating the child’s difficulties actually does not decrease the anxiety in the long run. Dr. Lebowitz elaborated that across all species of mammals, adults respond to fear with a classic fight or flight response, whereas immature members are unable to tackle the threat or run away. Newborn infants are born defenceless, unable to fend for themselves. Hence, when newborn infants feel threatened, their natural response is to signal somebody else to help handle the threat for them. Parents’ nature is to notice newborn infants’ cries and step in to soothe them. While such a response is natural, it becomes problematic in the context of a child with anxiety disorder. When a child chronically feels anxious, he chronically looks to his parents to provide these protective and regulatory functions. A child with separation anxiety stays near his parents where he feels safe. A child with social anxiety wants his parents to speak and mediate social interactions on his behalf. A child with generalised anxiety asks his parents many questions, seeking reassurance for all his worries. In actual fact, as young children develop, they do gain the ability to cope with anxiety. However, when parents always accommodate anxious children to help them not feel anxious, what happens is that the anxious children do not practise their own ability to cope with anxiety. They become entirely dependent on their parents, and learn that they cannot handle anxiety on their own. This leads them to feel more rather than less anxious over time.
Parents can ask themselves some questions to notice some of the ways in which they are accommodating their anxious child.
How much of my time has been taken over by the need to help this child not feel anxious?
Is my personal space impacted by my child’s anxiety?
What are the things that I do differently with this child, compared with how I would be with another child of the same age?
Am I doing things not because I want to do them, but because otherwise my child would be anxious?
What happens when I do not behave this way? Does my child get more anxious, irritable, and scared?
If parents realise that they have been overaccommodating their anxious child, there is no need to feel ashamed or guilty about it. It is not the exception, as based on questionnaires, between 97 and 100% of parents of anxious children around the world indicate that they frequently accommodate their child. Moreover, being sensitive to the child’s discomfort and distress as well as helping the child means the parents love and care about the child. It is just that the child’s anxiety can cause the child and parents to behave erratically. Anxiety hijacks normal healthy systems, causing them to start running wild. At the level of the child, with a normal healthy anxiety system, his heart races and his breathing speeds up when he feels scared. However, when the child has an anxiety disorder, the child’s normal healthy anxiety system gets hijacked, so his heart is always racing, his breathing is always fast, and he always feel scared. At the level of the adult, it is a normal healthy reaction for parents to respond to their child protectively when the child is in danger. However, when the child has an anxiety disorder, the parents’ normal healthy protective response gets hijacked, so parents keep helping in situations that do not involve real danger and do not actually require protection.
One of the points Dr. Lebowitz made in the book is that it is not the parents’ job to make their child’s lives as comfortable as possible. Everyday anxiety is not as dangerous as parents might believe. Teaching the child not to fear anxiety and to take it in stride is one of the biggest gifts a parent can give the anxious child. Dr. Lebowitz observed that there is no specific age at which babies are no longer helpless, as it involves a gradual developmental process. For every age, parents should consider what the child can be expected to handle. Regardless, even babies have the ability to cope with some discomfort, and can develop their ability for self-regulation through practice as they grow. Although parents do not want their child to be uncomfortable, there is bound to be some discomfort in the child’s life. Since the child has to experience and handle some anxiety in life, parents need to believe it is alright for the child to be uncomfortable some of the time, as well as set the child up for better coping and less anxiety in their lives. Otherwise, the child will be limited in every domain in life, including academic functioning, social functioning, family life, and personal wellbeing. The root of the impairment in childhood anxiety is in believing that it is not alright to feel anxious and that he cannot handle anxiety. For example, two children may be equally scared if they encounter a big barking dog while walking down the street and a big dog barks and scares them. However, the child that thinks, 'Ugh, that was so awful, I never want to feel like that again,' will be more likely to avoid that street the next day and become increasingly impaired by his fear.
Dr. Lebowitz gave the analogy of a child born with low muscle tone, who would find it harder to learn to sit up, crawl, stand, or walk. Yet, the solution is not for the parents to carry them everywhere all the time, saying, 'I have to wait until their muscles are really strong, and then I will let them do things independently.' If parents always pick up their child with low muscle tone, the child’s muscles will not get strong, as he lacks practice to develop that ability. Instead, a physiotherapist would advise, ‘It is not that your child doesn’t have muscles. Your child does have muscles, but they're weaker right now, so some actions are a bigger challenge for them. Your child needs this work in order to build up that ability.’ Likewise, it is not that an anxious child lacks the ability to tolerate anxiety. It can be harder for the child to cope with anxiety because their regulatory functions are more challenged and they have more anxiety to deal with. Yet, the solution is not to remove all the anxiety from their lives. Instead, parents should pick one area to start with and let the child experience coping with anxiety in that domain. It gets easier with time as the child further develops his ability to cope with anxiety. Not only will that trigger become less anxiety-provoking to the child, the child will also start to change their beliefs and see themselves as being strong enough to handle things.
Parents often receive advice that they have to make their child behave in a certain way, but that is easier said than done. It is difficult for parents to ask their child to do something that he does not want to do, especially if he is anxious. If parents get frustrated and become more forceful, the child will push back all the more. This leads to conflict and escalation. On the other hand, the SPACE treatment does not require parents to make their child start or stop doing something differently; it is the parents who make a paradigm shift.
The SPACE treatment is not easy and can be challenging, because parents now have to make decisions about their own behaviour, based on what they believe is going to be helpful for the child instead of what is going to be popular with the child. When parents decide to accommodate less, their child may become upset if he misunderstands that his parents no longer love him. However, parents can respond empathetically and helpfully to their anxious child by conveying strengthening messages of supportive statements. ‘When responding to a child who is anxious, support means showing your child two things - acceptance and confidence. It is like a very simple recipe that has only two ingredients, but both ingredients are necessary if the result is going to be supportive.’ Parents can show their acceptance of the child’s genuine distress and their confidence in the child’s ability to cope by saying, 'I get that this is a hard challenge for you. You feel anxious and scared. But I know you will get through it. I believe that you can handle anxiety.' Parents are like a mirror that their child looks into to see who they are. When parents give these messages of supportive statements, the child sees a reflection of themselves as being strong, confident, and competent, and the child will start to believe that about themselves.
Accommodation is driven in large part by parents’ feeling of not wanting their child to suffer. Although it is challenging for both the parents and child to reduce accommodations, the way to help an anxious child is not to rescue him immediately, but to let him learn that he does not need rescuing. From the child's perspective, while if may feel nice to have somebody who always rescues you, it can feel vulnerable to be somebody who always needs to be rescued. For example, a child with social anxiety may have difficulty speaking for himself, and parents may accommodate by speaking for them. When the waiter tries to take the child’s order at a restaurant, the child may look away and whisper to the parents, and the parents may habitually order on the child’s behalf. However, parents can decide to believe in their child’s ability to handle anxiety and reduce their accommodation, choosing not to order for the child but also not forcing the child to order on their own. Parents can say, 'I know it makes you feel uncomfortable to talk to a new person. I believe you can handle it.' The child might not order on his own the first time the parents do that, and might end up eating at home instead of eating the restaurant meal. Regardless, as the child practises and tries harder the next time, the child will eventually learn to order for himself. By reducing the accommodation, parents can help the child see himself as being able to cope independently.
Parents of anxious children face a constant dilemma, not knowing whether to give in at the risk of overhelping, or push at the risk of overwhelming the child by asking too much of him. It is unproductive to swing back and forth between the two. Instead, parents need to focus on one specific area to work on, and have a clear and systematic plan. Like so many things in life, this process is a matter of the short-term pain for the long term gain. Nonetheless, if parents implement this kind of change consistently in a thoughtful way, improvement in the child’s anxiety can usually be seen within weeks.
Anxious children often dislike surprises. If parents abruptly stop accommodating and leave things open to the anxious child’s interpretation, the child may misunderstand that the parents are angry and trying to punish him. This is in fact the opposite of the truth, as the parents are trying to help because they care about their child and want him to feel better. Parents can be resolute in changing their behaviour, while still having a respectful upfront conversation with the anxious child so he knows what is coming. Therefore, the book guides parents on how to choose which accommodations to focus on reducing as a start, since it is not a realistic goal to suddenly stop all accommodations. Most parents and children would find it overwhelming and distressing if parents remove all accommodations at once. However, if parents pick one specific area to work on, the child is likely to be able to handle it.
The book also guides parents on how to inform their anxious child in a clear and transparent but warm and supportive way about what they plan to do and why, as well as how to cope if the child reacts in an upset manner initially. For instance, parents can tell their anxious child, 'I don’t think the things that I have been doing have been helping you. I'm going to be doing things differently now and you'll see different things. That's because I've learnt a different way to do things that can help you better.'
Dr. Lebowitz highlighted that there is a strong evidence base for the efficacy of the SPACE treatment, with published research articles that can be found in the website’s resources tab. The team has conducted clinical trial research, including large randomised control trials. For instance, one of their studies was published in the Journal of the American Academy of Child and Adolescent Psychiatry, comparing the efficacy of the SPACE treatment and CBT for anxiety. The study participants consisted of over 120 children with anxiety disorder, who were randomly assigned to either treatment. The findings indicated that SPACE treatment was equally as efficacious as CBT in treating child anxiety disorder, based on clinician ratings, parent ratings, and children’s own ratings of their symptoms. This was despite the fact that children who were randomly assigned to the SPACE treatment never met with a therapist directly; only their parents met a therapist. Dr. Lebowitz explained that while children do have the tools and capacity to cope with anxiety, what they sometimes lack is the belief that they can cope with anxiety. As such, anxious children need to practise coping with anxiety-provoking situations. This has some overlap with exposure, which is one of the skills taught in CBT. If an anxious child is willing to participate in therapy directly, a combination of the SPACE treatment and CBT may be beneficial.
Dr. Lebowitz’s colleague, Dr. Yaara Shimshoni, also developed a version of the SPACE treatment called SPACE-ARFID, adapted to address clinically picky eating, otherwise termed avoidant/restrictive food intake disorder in the DSM-5. Children with ARFID often experience a lot of impairment in their ability to function normally in life, such as being unable to eat at restaurants or go for playdates. This can result in conflicts and stress in families of children with ARFID. The team published a case study describing the SPACE-ARFID treatment and a clinical trial for SPACE-ARFID with good outcomes. The team found that children with ARFID whose parents underwent SPACE-ARFID not only showed increased eating and flexibility in eating, but also improved socio-emotional outcomes.
So far, the team has not conducted clinical trial research with autistic children as participants. The team has just launched the first clinical trial of the SPACE treatment for children with autism spectrum disorder, though it will take time for the research to be completed before the team can confidently discuss the efficacy of the SPACE treatment for autistic children. Nonetheless, outside of clinical research, the team has had clinical experience working with families of autistic children, with relatively successful outcomes. Dr. Lebowitz speculated that this may be because autistic children commonly also have anxiety, and parents of autistic children commonly also provide a lot of accommodation for the autism symptoms such as repetitive and restricted behaviours as well as picky eating due to sensory issues.
Not everybody has access to a trained therapist, especially since working with a trained therapist can be expensive and time-consuming. Dr. Lebowitz’s goal is for parents to be able to work through the SPACE treatment on their own just by using his book and the resources available on the website. However, if parents struggle to complete the SPACE treatment on their own or find that their child is still anxious, it may make sense to work with providers who have received SPACE training.
Dr. Lebowitz wrapped up by emphasising that anxiety disorders do not tend to go away on their own, but can be treatable with help. If anxiety has been a feature of a child’s life for a significant amount of time – more than a few weeks or months – there is a strong argument to do something about it. He reminded parents to stay supportive of their anxious child, remembering the simple recipe of acceptance and confidence.
All blogposts on Bright & Quirky Child Summit 2021:
Day 1 Talk 4 A Quick, Shareable Overview of Twice Exceptional (2e) Kids - Dan Peters, PhD
Day 2 Talk 8 Understanding High IQ Kids With ADHD and Co-Occurring Diagnoses - Thomas E. Brown, PhD
Day 3 Talk 13 How to Know When It's Time to Change Schools or Homeschool - Colleen Kessler, MEd
Day 4 Talk 17 How to Help Bright Kids Avoid Autistic Burnout - Kieran Rose
Day 4 Talk 19 How Different Kinds of Minds Can Become Inventors and Engineers - Temple Grandin, PhD
Watch this space for more blogposts from the Bright & Quirky Child Summit 2021!