Parental Engagement Enhances Children’s Therapy Experience and Outcomes

Anxiety is common in children. What methods effectively alleviate their anxiety? How do parents influence the treatment process? Can parents positively affect the treatment outcomes? 

In this episode, Under the Cortex features Wendy K. Silverman from Yale University School of Medicine and Jeremy W. Pettit from Florida International University who have recently published an article on this topic in APS’s journal Clinical Psychological Science. 

Özge Gürcanlı Fischer Baum starts the conversation with the history of anxiety and therapy in children. Silverman highlights how our current understanding and approach to the mental well-being of children have changed over the decades. As one of the leading researchers in the field, she explains how she established her research program from scratch and emphasizes the role of parental involvement in children’s therapy process.  

Unedited transcript

[00:00:08.860] – APS’s Özge G. Fischer Baum 

Anxiety is prevalent among children. What treatments are effective in addressing their anxiety. What role do parents play in the treatment process? Can parents positively contribute to or potentially impede the benefits of treatment? This is Under the Cortex. I am  Özge Gürcanlı Fischer Baum with the Association for Psychological Science. To discuss a recent study on parent involvement and treatment outcomes, I’m joined by Wendy Silverman from Yale University School of Medicine and Jeremy Pettit from Florida International University. Their work is published in APIS’s journal, Clinical Psychological Science. Wendy and Jeremy, thank you for joining me today. Welcome to Under the Cortex. 

[00:00:55.810] – Wendy Silverman 

Pleasure to be here. Thank you for inviting us. 

[00:00:58.160] – Jeremy Pettit 

Likewise. Thanks very much. 

[00:00:59.920] – APS’s Özge G. Fischer Baum 

I want to start with my questions right away. We are impressed by your research. My first question is, what got you into studying anxiety experience by kids? 

[00:01:14.070] – Wendy Silverman 

I’ll begin with that question because I actually began this work in the 1980s. I’ve been doing this work for a long time. What got me into doing it in the 1980s is that this might be really hard for many listeners who are younger to believe, but there wasn’t even something referred to as anxiety disorders of children and adolescents. I was beginning my career at this time. I’m trained as a clinical child psychologist. I was always interested in children’s stress and emotional problems. When I began my career, I was at the State University of New York at Albany, and there were a lot of very important adult anxiety researchers there. I was very much influenced by them. One of them was named David Bollow, who many listeners of this program might be familiar with because he is a pioneer in adult anxiety. I modeled some of my work on what he had done a decade earlier with adults. One of the very first things I did is to develop something called the Anxiety Disorders Interview Schedule for Children. It’s a tool. It provides a very thorough assessment, you can differentiate all the different types of anxiety problems because there are several types, which is for another conversation, perhaps. 

[00:02:39.310] – Wendy Silverman 

From there, I began doing, fortunately with funding from the NIMH, several clinical trials to figure out how can we best help children who suffer from anxiety. What has always been guiding this work is the research, but at the core the research is helping children develop effective treatments, provide guidance to parents. 

[00:03:09.190] – APS’s Özge G. Fischer Baum 

Yeah. Thank you, Randy, for giving us a little bit of history about how things were back then, definitely myself, who was a child in ’80s, can say that there was no studies about anxiety or knowledge. Kids were kids. A kid Seeing a mental health professional was not something that somebody would consider during those times, really. I would like to step into your research a little bit more. In your study, you mentioned positive reinforcement and negative reinforcement. Can you actually tell our listeners what you are referring to here? 

[00:03:54.320] – Wendy Silverman 

This is a really good question, and it is really important that the listener understands the concept of positive reinforcement and negative reinforcement. I said earlier, what characterizes all the anxiety disorders, at the end of the day, there’s an avoidant component. The most effective treatment is cognitive behavior therapy, which is what Jeremy and I have been studying. One of the core aspects of cognitive behavior therapy, the B in behavior therapy, is getting children to change their behavior and face the things that make them anxious and nervous and afraid. Because what happens is if you keep doing that, you actually learn that there really isn’t that much to be afraid of. It’s almost like the child who falls off the bike and they never get on the bike, on the bike. Well, you get back on the bike, you learn, Oh, I can get back on the bike. That’s the idea of exposure. It is really important to understand positive and negative reinforcement because in the context of our treatment, and most treatments, the goal is to use those reinforcement strategies to get the children to face their fear. Both positive and negative reinforcement is a way to increase behavior. 

[00:05:19.720] – Wendy Silverman 

But how we do so is different in terms of what the parent might do, for example. Let’s take the example of a specific phobia of a child who’s afraid of dogs. With positive reinforcement, it’s pretty simple. I mean, it’s like you work with the parent to say, Okay, this week, we’re going to ask the child to face their fear and confront the dog. Let’s provide a positive consequence. It’s a consequence. It’s not a bribe. It’s a consequence. You give this after the behavior. That’s the positive. The negative is, as I said, the child stays away. What happens when you stay away from something? When you stay away from something, it makes you feel less anxious, less afraid. The upshot is you stay away from things. That avoidance continues and continues and continues and continues because it helps reduce your fear and anxiety. That’s what keeps anxiety going. What we did with our parents and our trial is that we taught them not to permit the child to avoid. We trained the parents to reduce their use of negative reinforcement, to reduce their child’s avoidance. 

[00:06:43.740] – APS’s Özge G. Fischer Baum 

Yeah, let’s talk about that a little more. You already mentioned it in the PISC, but what was the treatment like for the people in your study? 

[00:06:53.090] – Wendy Silverman 

It was a controlled trial, Amanda and I. Basically, the first thing that happened is that families were First, randomized to three arms of the study: CBT, cognitive behavior therapy, another arm where they got cognitive behavior therapy plus training and reinforcement, and a Third, they got cognitive behavior therapy, and we trained them in relationship skills. I told you, CBT is the most effective treatment. It’s the most effective. But not everybody benefits from it. Sometimes no more than 50 to 60% of kids. You still have sometimes half of the people who receive CBT not benefiting from it. What happened was people, like myself, said, Oh, let’s add parents. Let’s add parents. I’m sure if you add parents to this, it’s going to improve. It’s going to enhance the effects of CBT. But do you know what, Asky? It didn’t. There were like 20 trials. Nobody was able to show that it could improve. What we did in terms of our study is that we made it simpler. We gave less to the parents in each condition. When the parents were put into either the CBT plus reinforcement, that is all they got. Very focused. When we did the relationship, that’s all they got. 

[00:08:19.910] – Wendy Silverman 

Basically, families were for the first time given very streamlined, very focused parent conditions, and they sat for 12 to 14 sessions for an hour. They were seen together with the child and the parent, and they were just instructed and taught very concrete strategies. 

[00:08:40.590] – APS’s Özge G. Fischer Baum 

What you are seeing is, for our listeners, I just want to paraphrase. Cognitive behavioral therapy is one of the most effective ones, but even with that, we only have 50% to 60% success. Your study is very important because you are also getting the parents involved and teaching them how to treat their children’s anxiety in a way. Giving them a toolbox. 

[00:09:11.220] – Jeremy Pettit 

Yeah, exactly. You made a good point. In a lot of research, they find that response rates are 50 to 60 %. In our study, we actually found that about 80 % of kids responded very well, which speaks to the quality of the CVT that was provided and also how really targeting and focusing in on specific parent skills can improve the outcomes that we see when we work with anxious kids. 

[00:09:41.160] – APS’s Özge G. Fischer Baum 

One other thing I want to ask you is the following. So your paper, your study had a very large sample size for a clinical study. How were you able to collect data from so many people? It is impressive. 

[00:09:55.050] – Jeremy Pettit 

Well, thank you. First of all, it was a very large sample size for a clinical trial. We attribute it to a few things. One is that anxiety disorders are very common in children, and unfortunately, it’s challenging and it’s costly for families to access evidence-based treatments such as CBT. Our trial provided CBT, developed by a leading expert in the field, Wendy, at no cost to all families. So the families were able to access the top-schelf treatment and access it at no cost. And that undoubtedly helped us in our recruitment efforts. Another factor that contributed to Large Sample is that we have an amazing team. We’re very fortunate to have a great team who works very hard to recruit families and make sure they have a positive experience and stay throughout the duration of the trial. The third thing that contributed to Large Sample, undoubtedly, is that we were fortunate to receive funding from the National Institute of Mental Health, which enabled us to compensate families for completing the study assessments at the different phases sizes and waves of the study. 

[00:11:02.760] – APS’s Özge G. Fischer Baum 

We talked about your study a little bit. We talked about the sample size a little bit. To catch our listeners up to speed, what did you find in your analysis of the data? 

[00:11:15.100] – Jeremy Pettit 

Yeah, in the first paper we published from this trial, we focused largely on outcomes and what we call mediators or possible mechanisms of how anxiety is reduced. And to provide some context, as Wendy had already mentioned, for a long time, it’s been assumed that involving parents in treatment of child anxiety would improve the outcomes. But the data just didn’t support that assumption across all these earlier trials. And we think that’s perhaps because some of these early trials may have tried to do too much when they involved parents in treatment, meaning that they targeted many different parents’ skills, and sometimes they also targeted parents’ own anxiety levels. And that’s hard to do well in 12 to 14 sessions. So we took a different approach. We precisely defined, conceptualized what we wanted our parents to do in treatment and focused on a narrow skill set. So we’re believers in the idea that less is more when it comes to parent involvement in treatment. Let’s identify a key skill that we think from theory and from prior research will be related to child anxiety and help parents really target that specifically. The data from our study support that idea. 

[00:12:34.040] – Jeremy Pettit 

The key finding is that children who were in the parent-involved conditions showed superior outcomes, greater reductions in anxiety, compared with the children who received individual treatment. This is the first or one of the first studies to show that we can involve parents in treatment and we can improve outcomes. The way we did that really was by targeting very specific parent skills. 

[00:13:00.760] – APS’s Özge G. Fischer Baum 

Yeah, that is very interesting. As a parent myself, I found it useful, too. I want to go a little bit deeper into your findings. One of your key findings was that children of parents who initially reported using a lot of negative reinforcement and who were in the condition emphasizing a reduction in negative reinforcement and an increase in positive enforcement reported lower anxiety. In this condition, basically, when you told parents, Hey, don’t do that negative reinforcement thing anymore. Try the positive reinforcement thing. It turns out it worked. Do you have anything else to add to that? 

[00:13:45.890] – Jeremy Pettit 

Yeah, you’re exactly right. And what we were really motivated by in that particular analysis is this question of which treatment works best for whom. We know that not everyone responds equally well to all treatments. And if we wanted to try to identify, are there variables, are there things we can assess before treatment starts that can inform which treatment a family should receive? We thought, based on how our study and our treatments were designed, that parents’ baseline levels of skills and negative reinforcement could be used to identify who would respond best to a treatment that targets that. Sure enough, what we found was that parents who were engaging more negative reinforcement, allowing their children to avoid more, responded better when we specifically targeted that in the treatment. So targeting in the treatment led to a reduction in the use of negative reinforcement, and that also led to reductions in child anxiety. 

[00:14:55.260] – APS’s Özge G. Fischer Baum 

Yeah. 

[00:14:56.010] – Wendy Silverman 

This might be a little bit more than we’d like, but I just want to Say something. 

[00:15:00.920] – APS’s Özge G. Fischer Baum 

Sure, please. Go ahead. 

[00:15:02.680] – Wendy Silverman 

Back in the ’90s, I actually wrote a little book with one of my very important collaborators. And in the book, we called something called the protection trap. The Protection Trap, the protection trap. The reason why we called it the protection trap is we talked about how the child gets relieved of their distress when they stay away from things. But as a parent, How do we feel when we are helping our child to stay away? We also are feeling relieved. As a parent, we don’t want to see our child anxious and afraid. When a child says, I don’t want to do this or go there, as a parent, our instinct is to protect the child and permit that. It’s actually a protection trap because It’s a negative reinforcement cycle. So part of what we do, clinically, is we explain to parents, this is because you really love your child. This is not parent blaming. You love your child. You have an instinct to protect your child, to help your child feel safe. And in the short term, everybody’s benefiting. Your child is feeling great because they can sleep in the bed with you, and you’re feeling great because your child is happy to be able to sleep in the bed with you and is not having a tantrum. 

[00:16:37.060] – Wendy Silverman 

In the short term, this protection trap, this cycle, is the reason why anxiety is so hard to eliminate. Clinically, that is a really important concept to explain to parents. Once the parents get it, that this is not blaming. This is coming from a good place, but you got to modulate it. 

[00:16:59.340] – APS’s Özge G. Fischer Baum 

Yeah. I like the term you use for it, protection trap. It explains my childhood and why I’m not into sports. I think I was, in most cases, anxious about using my body when I was swimming or riding a bike. My parents were protecting me because they were also anxious about me hurting myself. I think about my anxiety now I understand. I love what you said about it, it’s like providing these short-term benefits coming from love. There is nothing wrong with that. It is really coming from love, but that’s why it is something difficult to intervene because we are talking about a family context, basically. 

[00:17:43.820] – Wendy Silverman 

I do want to just add? We have in earlier studies and others in other studies have actually tried, and Jeremy had mentioned this, to reduce PAM and anxiety. But you know what? That does not mean that that would lead to a reduction in child anxiety. If you change something, does it actually do what you want to do, which is reduce the child anxiety? What we have found in our work and others, if you really want to get the biggest bang for your buck, go straight to the parent behavior of reducing the negative reinforcement, because that’s directly linked to the child behavior. 

[00:18:22.310] – APS’s Özge G. Fischer Baum 

I have one quick follow-up question. When we look at your study, most If one of the parents in your sample were mothers, do you think anything would be different with fathers? 

[00:18:37.460] – Jeremy Pettit 

It’s a great question. 

[00:18:39.560] – Wendy Silverman 

Especially because Jérôme is a father, so of course, it’s a great question. 

[00:18:43.660] – Jeremy Pettit 

I’m obligated We don’t need it to answer this one, right? We don’t need it. Yeah, it is a great question. The short answer is we don’t know. Most studies have not had enough fathers to analyze the data separately for father. And to a large extent, that’s because mothers typically are the ones who bring their kids in for treatment. Having said that, I don’t think the findings would be different with fathers because the same principles, the same skills should work with any caregiver, whether it’s a mother, a father, a grandparent, whomever is directly involved in providing childcare. If they learn and apply these skills, reduce the negative reinforcement, I’m confident that the child’s anxiety will decrease. 

[00:19:28.700] – APS’s Özge G. Fischer Baum 

Yeah. And Again, this was a great conversation. Is there anything else that you would like to share with our listeners? 

[00:19:38.600] – Wendy Silverman 

Well, first of all, I would say we really have enjoyed this, and these have been really excellent questions, and I hope it’s been helpful to the listener. The only thing I would add is that we are continuing this work. We are working on developing a digital intervention that we would be providing to parents that you could download on your phone or look on your computer, and they will have this all ready to go. They don’t just have to depend on a weekly meeting. They could regularly get instruction on what we talked about today to help reduce their use of the negative reinforcement. So we’re hoping more powerful, more frequent, more intense intervention will help improve and replicate even further. 

[00:20:25.390] – APS’s Özge G. Fischer Baum 

Yeah, that sounds like great news. Jeremy, do you have anything else to add? 

[00:20:30.390] – Jeremy Pettit 

Well, I would just, again, reiterate that this has been a lot of fun and very grateful for you having us on and asking us some really good questions, some insightful questions. And to emphasize to anyone who may be listening, if you are struggling with anxiety, your child is struggling with anxiety, there is help available. There are effective treatments. Reach out, look for CBT in particular. That includes exposure. Those are the things that have been demonstrated to be the most powerful and effective in helping children learn to manage their anxiety. 

[00:21:07.030] – APS’s Özge G. Fischer Baum 

Yeah. Thank you very much, Wendy and Jeremy. This is Ozege Gurjanli-Fischer-Bam with APS, and I have I’m speaking to Wendy Silverman from Yale University School of Medicine and Jeremy Pettet from Florida International University. If you want to know more about this research, visit psychologicalscience.org 

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