Introduction
Childhood anxiety disorders are one of the most prevalent and debilitating difficulties facing children and their families. In their world-wide study, Polanczyk et al. (Reference Polanczyk, Salum, Sugaya, Caye and Rohde2015) estimated a mean prevalence rate of any child anxiety disorder at 6.5% based on studies conducted between 1985 and 2012. These anxiety difficulties are highly co-morbid with depression (Cummings et al., Reference Cummings, Caporino and Kendall2014; Rapee et al., Reference Rapee, Lyneham, Hudson, Kangas, Wuthrich and Schniering2013) and are associated with adverse future outcomes in social, educational and family domains even when anxiety symptoms are subthreshold (Copeland et al., Reference Copeland, Wolke, Shanahan and Costello2015). Research is consistent in specifying that inhibited temperament (Clauss and Blackford, Reference Clauss and Blackford2012) and having a parent with an anxiety disorder (Burstein et al., Reference Burstein, Ginsburg and Tein2010) are risk factors that can increase the likelihood of a child developing an anxiety disorder. Such probable bidirectional contributions have led to a better understanding of the environmental factors, namely parental behaviours in the management of child anxiety. Research has also focused on the reciprocal dynamic between child inhibition/temperament and parental over-control and how the bidirectionality of this relationship can act as a maintaining factor (Eley et al., Reference Eley, McAdams, Rijsdijk, Lichtenstein, Narusyte, Reiss, Spotts, Ganiban and Neiderhiser2015). Factors such as age of child, baseline anxiety and gender have also been cited as important (Breinholst et al., Reference Breinholst, Walczak and Esbjørn2019). Other relevant mechanisms, such as parental modelling and parental beliefs about anxiety have also been cited as maintaining factors, although the cross-sectional design of such studies tempers findings (Creswell et al., Reference Creswell, Waite and Hudson2020).
Family accommodation
Family accommodation (FA) is a clinical consideration that has garnered growing research attention in helping reduce child anxiety. FA refers to a number of behaviours that primary care givers, mainly parents, engage in to reduce child anxiety symptoms and improve functioning (Lebowitz et al., Reference Lebowitz, Woolston, Bar-Haim, Calvocoressi, Dauser, Warnick and Vitulano2013). Parents can engage in a number of FA behaviours, including facilitating avoidance, providing preferred items, and giving reassurance. These responses, when appropriate and not excessive, can be useful. However, such responses can prove problematic when relied on excessively (Iniesta-Sepúlveda et al., Reference Iniesta-Sepúlveda, Rodriguez-Jimenez, Lebowitz, Goodman and Storch2020). The phenomenon of FA has been extensively researched with families dealing with paediatric obsessive compulsive disorder (OCD; Freeman et al., Reference Freeman, Sapyta, Garcia, Compton, Khanna, Flessner and Harrison2014). Studies of child OCD have found high levels of FA. FA is linked to symptom severity and impairment, and is a key predictor in positive treatment outcome (Caporino et al., Reference Caporino, Morgan, Beckstead, Phares, Murphy and Storch2012; Garcia et al., Reference Garcia, Sapyta, Moore, Freeman, Franklin, March and Foa2010; Merlo et al., Reference Merlo, Lehmkuhl, Geffen and Storch2009). The attention given to children through FA is positively reinforcing and can increase the likelihood of further avoidance type behaviours with no opportunity to learn more adaptive ways of dealing with the feared stimuli (Storch et al., Reference Storch, Salloum, Johnco, Dane, Crawford, King, McBride and Lewin2015a).
FA has been found to be a relevant treatment target in the management of child anxiety. Rates of between 86 and 100% of parents have endorsed various forms of accommodation in the management of child anxiety (Benito et al., Reference Benito, Caporino, Frank, Ramanujam, Garcia, Freeman and Storch2015; Lebowitz et al., Reference Lebowitz, Woolston, Bar-Haim, Calvocoressi, Dauser, Warnick and Vitulano2013; Storch et al., Reference Storch, Salloum, Johnco, Dane, Crawford, King, McBride and Lewin2015a). Despite this, parents report experiencing distress when using FA (Lebowitz et al., Reference Lebowitz, Woolston, Bar-Haim, Calvocoressi, Dauser, Warnick and Vitulano2013). Iniesta-Sepúlveda et al. (Reference Iniesta-Sepúlveda, Rodriguez-Jimenez, Lebowitz, Goodman and Storch2020) report that providing reassurance and facilitating avoidance are two of the most common strategies used by parents in managing child anxiety. Among the various child anxiety disorders, separation anxiety has shown the strongest relationship with FA. Not surprisingly, this level of accommodation is often burdensome to family members and can lead to impairments in family relationships, increased arguments and conflict (Reuman and Abramowitz, Reference Reuman and Abramowitz2018).
The last decade has seen the development of a number of FA outcome measures including the Family Accommodation Scale Anxiety (FASA; Lebowitz et al., Reference Lebowitz, Woolston, Bar-Haim, Calvocoressi, Dauser, Warnick and Vitulano2013), the Paediatric Accommodation Scale (PAS; Benito et al., Reference Benito, Caporino, Frank, Ramanujam, Garcia, Freeman and Storch2015) and the Family Accommodation Checklist and Interference Scale (FACLIS; Thompson-Hollands et al., Reference Thompson-Hollands, Kerns, Pincus and Comer2014). Given the prevalence of FA and its association with child anxiety, a number of treatments have attempted to address the phenomenon. FA has been targeted as both a proxy measure for child anxiety within standard treatment protocols and also by specific treatments that were designed to target FA. Regarding the former, Kagan and colleagues (Reference Kagan, Peterman, Carper and Kendall2016) found that children and adolescents who completed a standard cognitive behavioural therapy programme evidenced reduced parental accommodation as measured by parent report, and that this reduction in parental FA was significantly associated with the severity of child anxiety at post-treatment. Similar reductions on measures of FA have also been reported for cognitive behavioural therapy (CBT) approaches for anxiety with children with autism (Storch et al., Reference Storch, Zavrou, Collier, Ung, Arnold, Mutch, Lewin and Murphy2015b). Treatments such as the Supportive Parenting for Anxious Childhood Emotions programme (SPACE; Lebowitz and Omer, Reference Lebowitz and Omer2013), a parent-only treatment, have been developed to focus specifically on FA. The programme includes a number of modules for parents including accessing supports, coping with threats to self, and teaching and modelling self-regulation. An open trial of the SPACE programme reported that it was feasible and acceptable, and demonstrated initial effectiveness in the treatment of child anxiety disorders (Lebowitz et al., Reference Lebowitz, Omer, Hermes and Scahill2014). A further randomised controlled non-inferiority trial reported that the effectiveness of the SPACE programme was comparable to CBT with similar rates of treatment response (87.5 vs 75.5%; Lebowitz et al., Reference Lebowitz, Marin, Martino, Shimshoni and Silverman2020).
The use of CBT in addressing FA and the development of specific programmes such as SPACE are exciting advancements in the area. However, research is clear that a sizeable proportion of children and families do not achieve diagnostic remission following CBT intervention (Ginsburg et al., Reference Ginsburg, Kendall, Sakolsky, Compton, Piacentini, Albano and Rynn2011; Kendall and Peterman, Reference Kendall and Peterman2015) and that relapse rates of over 50% have been reported at 6-year follow-up (Ginsburg et al., Reference Ginsburg, Becker, Keeton, Sakolsky, Piacentini, Albano and Kendall2014). Thus it is reasonable to conclude that CBT may not be effective for all parents and children in addressing child anxiety and FA. Consequently, it is important to consider other potential treatments that may address FA and lead to lasting improvements in child anxiety and improved parent–child relationships. One potential treatment that may address FA is acceptance and commitment therapy (ACT; Hayes et al., Reference Hayes, Strosahl and Wilson2011). ACT is a widely disseminated psychological treatment that has shown to be effective for a wide range of psychological difficulties including anxiety (Swain et al., Reference Swain, Hancock, Hainsworth and Bowman2013), depression (Twohig and Levin, Reference Twohig and Levin2017) and chronic disease and long-term conditions (Graham et al., Reference Graham, Gouick, Krahe and Gillanders2016). ACT approaches have also been useful in the treatment of childhood psychological and physical difficulties (Swain et al., Reference Swain, Hancock, Dixon and Bowman2015) and as a potential treatment in helping shape parental behaviour in effectively managing childhood difficulties such as anxiety (Whittingham and Coyne, Reference Whittingham and Coyne2019).
Objective
The idea that ACT is an appropriate intervention for childhood anxiety and related difficulties is not new, and a number of ACT specific books have been developed focusing on ACT as a parenting intervention (Coyne and Murrell, Reference Coyne and Murrell2009; McCurry, Reference McCurry2015). McCurry (Reference McCurry2015) puts forward the idea of a reciprocal anxiety dance in making sense of how parents react to their child’s anxiety and how unhelpful strategies can maintain or exacerbate child anxiety. Despite this, the evidence base for ACT as a treatment for childhood anxiety is positive although tentative (Swain et al., Reference Swain, Hancock, Dixon and Bowman2015). However, little ACT research to date has focused on the possible contribution of parents in helping manage child anxiety (Byrne et al., Reference Byrne, Ní Ghráda, O’Mahony and Brennan2020) and the potential of ACT to address FA specifically. The possibility of adapting an ACT approach for parents and how the core ACT processes may address differing facets of FA is of particular interest. The unique elements of ACT and what processes this can bring to the parent–child relationship such as defusion, willingness and values work may be particularly effective in addressing FA. The objective of this article is to provide a conceptual and theoretical overview of the six core processes of ACT and how these may shift and change FA relevant to child anxiety. To the author’s knowledge no other research has focused on how ACT may be a suitable intervention in targeting FA. Given the role of FA in child anxiety it is important to conceptualise how ACT may address FA behaviours in a manner consistent with the model.
Distinctive elements of ACT for FA
ACT is a therapeutic approach that draws on a number of related theoretical orientations including functional contextualism (Hayes, Reference Hayes2004), relational frame theory (Hayes et al., Reference Hayes, Barnes-Holmes and Roche2001) and applied behavioural analysis (ABA). ACT views psychological difficulties within a dynamic context that includes verbal, social, emotional and other direct sensory influences on behaviour. ACT places a particular emphasis on how suffering emerges predominantly within the uniquely human abilities of language and thought. ACT differs from more traditional forms of cognitive behavioural therapy in a number of ways but, fundamentally, ACT places an emphasis on the function and context of thoughts, feelings and sensations rather than the content and form of such thoughts, feelings and sensations (Blackledge et al., Reference Blackledge, Ciarrochi and Deane2009). This fostering of psychological flexibility is facilitated by addressing six core processes through the use of present moment awareness, willingness, defusion, self-as-context, committed action and values (Luoma et al., Reference Luoma, Hayes and Walser2007). The concept of psychological flexibility refers to an ability to stay grounded with inner experiences, allowing such experiences to be there when useful, to view thoughts as thoughts and not get hooked by the meaning of same, having a strong sense of life direction, and pursuing the things in life that are meaningful (Hayes, Reference Hayes2019; Twohig and Levin, Reference Twohig and Levin2017).
ACT places an explicit focus on experiencing emotions in an intentionally open, flexible and receptive posture (Hayes et al., Reference Hayes, Strosahl and Wilson2011). FA and the behaviours associated with it are characterised by rigid and inflexible demands on the part of the anxious child and parents responding in a manner focused on, amongst other things, parent and child symptom reduction and management. ACT suggests changing how an individual approaches psychological events. This approach entails openness, flexibility and compassion. For example, a parent may rely exclusively on FA as a means of experiential avoidance of frustration and upset over their child’s anxiety instead of taking appropriate actions that are underpinned by valued actions. Experiential avoidance may be a short-term, self-protective strategy to manage an emotional response and associated distress. However, parents report that accommodating to their child’s anxiety results in subsequent distress (Lebowitz et al., Reference Lebowitz, Panza, Su and Bloch2012). Thus such approaches may exacerbate emotional distress among both parents and children even though FA is used, at least initially, as a means of controlling and managing emotions.
Parental psychological flexibility may have an important role to play in positively influencing child mental well-being. Psychological flexibility has been found to be associated with higher levels of responsiveness and parental adjustment (Evans et al., Reference Evans, Whittingham and Boyd2012). Brassell and colleagues (Reference Brassell, Rosenberg, Parent, Rough, Fondacaro and Seehuus2016) reported on a model of association between general psychological flexibility, parental flexibility, adaptive parenting practices and child anxiety and behavioural difficulties across a 14-year age range. Findings indicated that general psychological flexibility was associated with higher parenting psychological flexibility and positively predicted adaptive parenting practices. In addition, higher levels of parental psychological flexibility were indirectly associated with low rates of youth externalising and internalising behaviours through adaptive parenting approaches. The authors contended that fostering parental psychological flexibility may help parents engage in adaptive and non-reactive strategies to manage child difficulties and increase family harmony. The cultivation of psychological flexibility may therefore by a useful strategy in helping parents increase awareness and knowledge of FA behaviours, especially if such behaviours are linked to beliefs around being a compassionate and committed parent (Reuman and Abramowitz, Reference Reuman and Abramowitz2018).
ACT skills for FA
Present moment awareness skills
Present moment awareness is a core skill within ACT. The focus of present moment awareness skills aims to help the individual stay in the present moment and promote flexible attentional processes. When in contact with the present moment, individuals are responsive and flexible which promotes future learning opportunities (Luoma et al., Reference Luoma, Hayes and Walser2007). The use of this in helping parents stay present and reduce the tendency to attend to threatening information and become locked on future-orientated thought is a particularly relevant skill, especially in the management of FA. Parents attuned to their own emotional state, mindfully aware of thoughts, and showing a marked interest and curiosity in what is occurring for their child (core components of mindful parenting; Duncan et al., Reference Duncan, Coastworth and Greenberg2009) may be better able to make different choices in how to respond effectively.
A number of prior reviews have highlighted the possible beneficial effects of present moment awareness for parenting and its potential use for certain child presentations (Burgdorf et al., Reference Burgdorf, Szabo and Abbott2019; Townshend et al., Reference Townshend, Jordan, Stephenson and Tsey2016). There is also theoretical and empirical support in helping parents stay present-focused in helping manage their children’s anxiety. Mindful parenting programmes, which rely on present moment awareness skills, have been found to help reduce both parental and child internalising difficulties (Bögels et al., Reference Bögels, Hellemans, van Deursen, Römer and van der Meulen2014). Such skills may help parents be more aware of high stress situations and prevent them from reverting to automatic patterns of interaction, such as FA.
Limited research to date has focused on present moment awareness as relevant in the management of FA. Present moment awareness approaches may aid parents to become aware of anxious thoughts related to FA. It may also be of help in allowing parents to note a range of differing and potentially conflicting emotions arising from FA, such as relief and compassion. For example, a parent may be able to reflect on their child’s anxiety, and instead of mindlessly reacting in their hope of reducing it, they could instead choose an alternative manner in responding to both their child’s anxiety and reflections of their own responses and reactions. Prior research has indicated that varying types of accommodation can reinforce avoidant behaviours in both parents and children (Storch et al., Reference Storch, Salloum, Johnco, Dane, Crawford, King, McBride and Lewin2015a) and that this can then increase the likelihood for not only FA but other parental behaviours, such as giving attention. Present moment awareness skills are useful in helping promote psychological flexibility by broadening awareness to both the internal state and external information (Roemer and Orsillo, Reference Roemer, Orsillo, Orsillo and Roemer2005). The reciprocal dynamic inherent in FA requires this dual awareness in helping understand the parental emotional response in a non-judgemental, responsive manner, rather than a reactive approach. Amongst the most common forms of FA is excessive parental reassurance. Research suggests that parental reassurance can be a largely ineffective mechanism in the face of feared situations such as child immunisation and that parents who rely on this can themselves become distressed (Manimala et al., Reference Manimala, Blount and Cohen2000). Present moment awareness may help parents increase awareness of this pattern before offering ineffective reassurance as a default setting in order to help parents respond in a more adaptive manner.
Defusion
Defusion relates to the process of reducing the automatic emotional and behavioural function of thoughts by increasing awareness of thinking as a process rather than looking at the literal meaning of it (Hayes and Strosahl, Reference Hayes and Strosahl2004). When defusing from thoughts, individuals are asked to adopt a stance of voluntary cognitive flexibility. When individuals become fused they lose the ability to observe their own behaviour in terms of direct environmental contingencies as verbal contingencies guide behaviour. FA involves fusion to beliefs and rules about danger and uncertainty, judgements about what a parent should do when a child is exposed to an anxious situation, and beliefs about themselves as parents.
Instead of challenging or restructuring thought processes common in CBT programmes, ACT instead asks individuals to see thoughts as thoughts and not become entangled by them. In a fused state, a parent may follow the same rule regarding FA repeatedly (e.g. I will allow my child into my bed during the night to help reduce anxiety) but not recognise that the desired outcomes are not evident and then may enact even more rules in attempting to achieve such an outcome. Coyne and Wilson (Reference Coyne and Wilson2004) have also suggested that cognitive fusion is linked to experiential avoidance because fusion with verbal rules and the private experience associated with the thought can lead to more coercive behaviours and this article would argue more FA. Defusion techniques, within an ACT framework, have been used widely with parents for a range of childhood difficulties including chronic pain, neurodevelopmental difficulties and anxiety (Byrne et al., Reference Byrne, Ní Ghráda, O’Mahony and Brennan2020). Although FA was not directly targeted in the only ACT specific anxiety programme that included a parental component (Hancock et al., Reference Hancock, Swain, Hainsworth, Dixon, Koo and Munro2018), the ACT treatment manual used in the study included information on limiting reassurance and encouraging child autonomy and competence. It would be interesting to see if defusion could help parents unhook from such rules and beliefs in future ACT treatment studies.
Finally, defusion may be particularly apt in helping parents unhook from difficult thoughts related to FA and associated behaviours for difficulties that are not amenable to immediate change. Defusion may be particularly helpful for individuals who face adversity and challenges that are unchangeable (Losada et al., Reference Losada, Marquez-Gonzalez, Romero-Moreno, Mausbach, Lopez, Fernandez-Fernandez and Nogales-Gonzalez2015). For example, children with neurodevelopmental difficulties and associated anxiety may present with challenges that cannot be changed in the immediate future. Instead of attempting to modify or dispute such thoughts related to the child’s difficulties or try help change thoughts regarding FA, defusion may help parents recognise and respond to such thoughts instead of automatically reacting to them. In summary, defusion can weaken the impact exerted by the literal meaning of language and is a relevant treatment goal in weakening the cognitive hold of thoughts around FA.
Willingness
At its core, willingness is the process of cultivating acceptance while undermining the dominance of emotional control and avoidance. Willingness is not about wallowing in distress or the adaption of control strategies in attempting to tolerate or manage emotional struggles. Instead, willingness asks the individual to let go of needless struggle and to make space for difficult emotions as they fluctuate naturally. Willingness offers another option rather than relying on experiential avoidance or inappropriate emotional control strategies. FA may provide parents with a means of actively avoiding their own anxiety or discomfort in having to face their child’s anxiety. Parental experiential avoidance has been cited as a relevant factor and a significant predictor of child anxiety, after controlling for parent anxiety and control (Emerson et al., Reference Emerson, Ogielda and Rowse2019). Meyer et al. (Reference Meyer, Clapp, Whiteside, Dammann, Kriegshauser, Hale, Jacobi, Riemann and Deacon2018) reported that parental use of FA may be related to parental beliefs that not providing FA would result in the child losing behavioural and emotional control.
ACT may be effective in promoting willingness and is a potential mechanism of change in helping parents open up to difficult thoughts and feelings. Parent-led anxiety programmes may benefit from targeting experiential avoidance strategies that parents use in the management of their own anxiety. This is a helpful link in then addressing FA, which at its core entails a number of experiential avoidant techniques. For example, parents may use distractions as a means of avoiding not only their own anxiety but that of their child’s. Parents using FA may also encourage their children to opt-out of difficult anxiety provoking situations which may also reduce, in the short-term, parents’ anxiety. Willingness may help parents increase attention to the relatively subtle aspects of the avoided situation, while also making space for the accompanying difficult emotions. This could help parents demonstrate a different emotional reaction to feared situations or events to their child. A recent systematic review of ACT informed parenting treatments completed by Byrne and colleagues (Reference Byrne, Ní Ghráda, O’Mahony and Brennan2020) reported that the majority of studies that included a measure of parental acceptance and willingness indicated an improvement at treatment end suggesting that parental willingness can be addressed and modified. Future research would benefit from assessing if increased parental willingness is linked to a reduction in FA.
Self-as-context
Self-as-context refers to the process by which an individual can make contact with a deeper sense of self that can act as context for experiencing feelings and thoughts instead of the individual being defined by thoughts and feelings (Walser, Reference Walser2019). This form of perspective taking may be important in cultivating a compassionate and flexible stance in relation to psychological and emotional suffering. This context through which emotions, thoughts and physiological sensations flow, allows distance and perspective thus reducing attachment to one’s own experience (Coyne et al., Reference Coyne, McHugh and Martinez2011). ACT helps individuals contact this sense of self-as-context, which is a secure and continuous space. From this point, individuals can experience such events while also being distinct from them.
Self-as-context aims to help clients flexibly respond to and adapt to different contexts and experiences. Helping parents to distinguish between that who experiences and what is experienced can help them observe and not become entangled by their own narrative or story. This transcendent self can help parents observe their narrative (e.g. the anxious parent) and gain from the thoughts and feelings around this while also becoming aware that such thoughts and feelings cannot harm them. The therapist may help the parent contact with their self-as-context and embrace a more encompassing, broader sense of themselves and not become attached to an overly restrictive narrative and what this entails.
Recent research has suggested that it may not be parental distress per se that influences FA but parental perceptions of child anxiety symptoms. O’Connor et al. (Reference O’Connor, Holly, Chevalier, Pincus and Langer2020) reported that contrary to expectations and not in line with other studies, FA was not linked to parental distress or emotional regulatory difficulties in the sample of parents of anxious children. Instead, findings indicated that maternal perception of child distress was more influential in determining the level of FA. Self-as-context may be a useful process in helping parents see their child just as they are without the judgement and justification that can be present. In doing so parents may be better able to identify and weaken social contingencies and break the perseverance of a conceptualised self, such as the ‘protecting parent’ and what this label would entail in relation to behaviours used to shield the child from anxiety. Interventions that aim to help parents notice the continuous flow of experience and flexibility of perspective taking may help reduce the need to rely on FA as a coping response but to the author’s knowledge no such research has been completed to date.
Values
In ACT, values are identified and freely chosen, verbally constructed patterns of activities that usually involve a number of important categories such as family, friends, community and work. Values are considered the linchpin of ACT (Luoma et al., Reference Luoma, Hayes and Walser2007) as the utility of the model is dependent on them. Willingness, defusion, self-as-context and being present are not ends in themselves, but instead they provide the roadmap for a more values-consistent life.
ACT may be able to help parents pivot towards valued guided behaviours instead of accommodating to the child’s excessive reassurance seeking and requests to avoid the anxiety provoking situation. In helping parents pivot towards values-driven behaviour, ACT attempts to help parents to be in contact with values and a sense of life’s meaning and direction, as well as giving parents a choice in selecting among a range of alternatives in responding to their child’s anxiety rather than reacting. The integration of values work can be challenging as contact with values involves contact with vulnerabilities (Wilson and Sandoz, Reference Wilson, Sandoz, Hick and Bein2008). Parents may misinterpret a value judgement, such as being a protective parent and instead fuse with beliefs around this, limiting learning opportunities and reducing exposure to feared events or situations for them and their child. Values work may help parents clarify what is the purpose of FA and to help parents separate values from unfulfilling and unrealistic societal pressures regarding parenting a child with heightened levels of anxiety and what this entails. Many parents are aware of the short term-gains of FA and the accompanying conflicting emotions such as anxiety, stress and relief felt when using FA (Lebowitz et al., Reference Lebowitz, Woolston, Bar-Haim, Calvocoressi, Dauser, Warnick and Vitulano2013). Engaging parents in this work may be particularly useful in reducing the coercive elements many parents may face in ‘having to’ do something about their child’s anxiety and may come in contact with long suppressed values regarding parenting. Even in the midst of this emotional response, parents can be shown that there is a choice to act in accordance with their values and if this act aligns with the use of FA.
Committed action
Committed action relates to the act of creating a life that is true to one’s wishes, longings and values. It requires both change and persistence, calling for what is needed in helping the parent establish larger patterns of values informed actions. Committed action requires using a range of behaviours in helping move towards valued directions. This often requires flexibility in helping move from unworkable to workable. Luoma and colleagues (Reference Luoma, Hayes and Walser2007) note that a specific committed action is dependent on what the situation affords and what would be deemed to be the effective course of action in that context. The pursuit of valued goals in the face of discomfort lies at the heart of the ACT model of psychological flexibility. ACT is an exposure-based therapy based on behavioural principles. Committed action refers to a broad range of techniques that could include exposure, skills acquisition and goal setting. FA has been shown to interfere with the mechanisms of exposure such as reducing avoidance and making space for discomfort (Peterman et al., Reference Peterman, Read, Wei and Kendall2015). Thus committed action is a key process in targeting FA.
Committed action may provide parents with the opportunity to practise and foster the capacity to choose to be willing over and over again. Committed action would usually follow on from the exploration of the parents’ valued directions. Parents, for example, could be asked to apply their values in a moment when their mind is suggesting that FA is the only answer. A parent whose values include compassion and openness could choose to respond to the child’s want to opt out of the situation or event with a compassionate stance that aims to both understand the child’s upset but still insist on engaging with the feared situation or event. This may help shift parents away from a purely goal-oriented viewpoint, such as reducing my child’s anxiety to a process of living a meaningful life as a parent and what this entails.
Regarding FA, clinicians may not need to be overly focused or concerned if parents are unwilling to eliminate all FA, at least initially, as long as the parent and child can explicitly test their fear-based expectancies through exposure with the feared situation or event. Instead of the metric of success being reduction in affect, the development of new non-threat associations and the enhancement of accessible and retrievable newly learned associations may increase the effectiveness of exposure (Blakey et al., Reference Blakey, Abramowitz, Buchholz, Jessup, Jacoby, Reuman and Pentel2019). Thus the goal of exposure within the ACT framework mirrors that of inhibitory learning theory in that the individual learns to act with the feared situation in a more functional manner so that the individual moves in the direction of values and things that are important and that are currently disrupted (Twohig et al., Reference Twohig, Abramowitz, Bluett, Fabricant, Jacoby, Morrison, Lillian and Smith2015), in this case the parent–child relationship.
Finally, committed action requires continued commitment to engage in values-based behaviours. Committed action is a values-based action that occurs at a particular moment and is linked to creating a pattern of action that serves the value (Hayes et al., Reference Hayes, Strosahl and Wilson2011). This requires living in a moment-by-moment way and is linked to an expanding pattern of workable actions. This process may be particularly useful in helping parents understand that even if they use FA strategies that this does not negate the possibility of refraining from using FA when the next opportunity presents.
Discussion
The past number of years has seen an increase in interest of the third wave generation of cognitive behavioural therapy in contributing to parenting (Whittingham and Coyne, Reference Whittingham and Coyne2019). Research has indicated the use of ACT approaches in helping parents manage a range of childhood psychological and physical difficulties (Byrne et al., Reference Byrne, Ní Ghráda, O’Mahony and Brennan2020; Swain et al., Reference Swain, Hancock, Dixon and Bowman2015). Despite this, there has been a relative dearth of ACT-focused interventions that include parental components for childhood anxiety. One facet of childhood anxiety that has garnered a growing evidence base is FA given the reciprocal and dynamic nature of the phenomenon and negative impact this has on treatment outcomes amongst children with obsessive compulsive disorder and general anxiety. In response to this, general parent-led CBT programmes and specialised treatment packages have been developed to address behaviours often seen with FA and in general have proven effective (Kagan et al., Reference Kagan, Peterman, Carper and Kendall2016; Lebowitz et al., Reference Lebowitz, Marin, Martino, Shimshoni and Silverman2020). This article discusses the potential advantages and distinctive elements of ACT for FA and evaluated the theoretical support for ACT in addressing this difficulty.
The skilful use of ACT processes has been shown to be effective in helping clients make sense of psychological suffering (A-Tjak et al., Reference ATjak, Davis, Morina, Powers, Smits and Emmelkamp2015). The current article contends that these processes are ideally suited in helping parents rely less on FA behaviours that are, at their core, means for experiential avoidance. FA can be as ubiquitous as providing excessive reassurance (Storch et al., Reference Storch, Salloum, Johnco, Dane, Crawford, King, McBride and Lewin2015a) to more complex accommodations involving families engaging in multi-step and debilitating compulsions related to child obsessive compulsive disorder (Lebowitz et al., Reference Lebowitz, Panza, Su and Bloch2012). Despite the varying types of behaviour parents and children engage in when using FA and its link to the particular type of anxiety present, functional contextualism provides a clear prism in which parent and child can become aware of this damaging reciprocal dance by looking at the act and its context in helping formulate appropriate treatment goals guided by valued actions.
This article posits that the mechanisms of change inherent to ACT are suited to deal with the difficulties that arise from FA. Nevertheless, these conclusions are tentative at this stage as the effectiveness of ACT in addressing FA is speculative and has not been investigated as an intervention. Although ACT shares similarities with CBT treatments that have demonstrated effectiveness with FA, CBT differs in its theoretical underpinnings and its treatment focus although there is increasing overlap between ACT and more recent CBT models (Harley, Reference Harley2015). Targeting FA from an ACT perspective may require helping parents unhook from thoughts about danger and beliefs about protecting their child. In addition, ACT also aims to address and specify relevant parental values and aiding parents in taking values-led committed action in helping children with their anxiety. Other research focusing on CBT for child anxiety has found that improvements in coping efficacy was a mediator for treatment change whereas improvements in anxious self-talk was not (Kendall et al., Reference Kendall, Cummings, Villabo, Narayanan, Treadwell, Birmaher, Compton, Piacentini, Sherill, Walkup, Gosch, Keeton, Ginsburg, Suvey and Albano2016). This finding tallies with other research which suggests that the inclusion of anxiety management skills before exposure was not linked to an increase in treatment efficacy (Ale et al., Reference Ale, McCarthy, Rothschild and Whiteside2015). The above findings from both an ACT and CBT perspective again stress the importance of recognising treatment components and when these are implemented to maximise effectiveness.
A number of factors need to be taken into account when considering who may benefit from ACT in addressing child anxiety and FA. The potential benefits and effectiveness of parent-led interventions for child anxiety have been reported previously but such research has primarily focused on CBT-based approaches (Creswell et al., Reference Creswell, Parkinson, Thirlwall and Willetts2019; McKinnon et al., Reference McKinnon, Keers, Coleman, Lester, Roberts, Arendt and Hudson2018). Limited research to date has looked at the potential of parent-led ACT programmes for child anxiety and FA. A consideration for family or parent inclusion into ACT may be non-response to another treatment, namely CBT. Research to date indicates that an ACT-informed intervention for childhood anxiety that included both parent and child treatment components was broadly commensurate with regard to effectiveness when compared with a CBT equivalent intervention (Hancock et al., Reference Hancock, Swain, Hainsworth, Dixon, Koo and Munro2018). However, no data at present are available to the author’s knowledge that specifically address FA through the use of ACT. At present the author is comparing a parent-led ACT approach to that of CBT with FA as one of the primary outcome measures. It is hoped that the research will help highlight the potential use of ACT in addressing FA and if specific ACT process measures act as moderators of change for FA.
Conclusions
Childhood anxiety disorders are prevalent and can cause long-term adverse effects in a range of differing domains. FA is increasingly being seen as an important treatment consideration given the deleterious impact FA has on the course of child anxiety and prognosis (Iniesta-Sepúlveda et al., Reference Iniesta-Sepúlveda, Rodriguez-Jimenez, Lebowitz, Goodman and Storch2020). A number of interventions to date have shown to be effective in reducing FA in child anxiety. The current article contends that ACT may be a useful intervention in addressing child anxiety and specifically FA. This review has summarised the theoretical support for the application of the six ACT processes in addressing the multi-faceted components of FA. Parent-led approaches for childhood anxiety have increased in use and popularity as evidenced by the growth in research studies using such treatment designs. ACT informed parent-led approaches show promise but a recent practitioner review has suggested that there is not strong enough evidence to conclude that psychological interventions other than CBT are effective for child anxiety (Creswell et al., Reference Creswell, Waite and Hudson2020). It is important for future research to investigate ACT as a treatment for child anxiety using parent involvement and measuring FA as a treatment outcome measure.
Acknowledgements
None.
Financial support
None.
Conflict of interest
The author reports no conflicts of interest.
Data availability
Data sharing is not applicable as no new data were created or analysed in this study.
Key practice points
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(1) FA has been found to be a relevant treatment target in the management of child anxiety.
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(2) There is growing evidence that FA can be addressed through the use of both generalised and specialised treatments.
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(3) Acceptance and commitment therapy (ACT) may be a useful treatment in addressing FA.
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(4) The six core ACT processes can address the multifaceted components of FA.
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