LA JOLLA, CALIF. – In the clinical opinion of Andrea Barmish Mazza, Ph.D., involving parents in some capacity is important to enhance exposure therapy in children with anxiety disorders.
"There are a number of different reasons for this," said Dr. Mazza, a clinical psychologist at the Deerfield, Ill.–based Center for Anxiety and OCD. "Children with anxiety disorders often have parents with anxiety disorders. There’s a high risk of modeling anxiety, or accidental reinforcement of anxiety, and parent overprotection."
Dr. Andrea Barmish Mazza
At the annual conference of the Anxiety and Depression Association of America, Dr. Mazza and her colleague, Erica Wagner-Heimann, Psy.D., acknowledged that the path to achieving buy-in from parents for exposure therapy – which is considered the best treatment for anxiety – can be a rocky one. Common "sound bites" they hear from parents include the following: "I don’t want to upset him this week. He has finals!" "Isn’t she supposed to take ownership of this?" "We’ve done CBT before, and it doesn’t work." "I don’t have time to come in, too. I’m just dropping him off."
One common barrier to effective parental participation stems from misunderstanding the rationale for exposure. Using the analogy of jumping into a cold swimming pool is often an effective way to describe exposure therapy, Dr. Wagner-Heimann said. "When you first jump in, what does it feel like?" she’ll ask her clients and their parents. "It may feel cold at first, but what happens if you swim around for awhile? You start to get used to it, and it doesn’t feel as cold anymore even though the temperature of the water didn’t change."
She also describes exposure therapy as akin to learning a new sport: "The more you practice, the easier it gets." The phrase "if you change the way you look at things, the things you look at change," also captures the notion that changing one’s perception can be helpful when facing fears.
Dr. Erica Wagner Heimann
Unrealistic expectations from parents about exposure therapy also can pose a barrier. This might include comments such as "My child should feel better," Dr. Wagner-Heimann said. "Oftentimes, we’ll say to parents ‘it’s not about feeling better, it’s about getting better at feeling – being able to tolerate the anxiety, the distress.’ " Other sentiments commonly expressed by parents include "It’s a self-esteem issue." "We need to wait until my child feels ready to [whatever]." "Fix it." "This is taking too long."
The parents’ own anxiety or difficulty tolerating their child’s distress also can impede their involvement. Other factors that might come into play include overscheduled families/kids, parental psychopathology, marital conflict, financial concerns, siblings, or a medical problem in the family.
"An important point is not to mistake some of these barriers as a lack of willingness by parents to involve themselves," Dr. Mazza noted. "Being mindful of these barriers prior to starting therapy is important. That doesn’t necessarily mean you won’t be addressing some of these barriers throughout treatment, but there is a lot of groundwork you can do to set the foundation to minimize the interfering behaviors and to maximize effective parent involvement, even in the most provocative of exposure tasks."
In a thorough assessment of the parent and the child, barriers "will come to the forefront," Dr. Wagner-Heimann said. The first step in addressing barriers involves "setting a good foundation from the get-go, and figuring out how to talk to parents about exposure therapy so you can set yourself up for success as well as the parent and the child," she explained. Other steps in the process include deciding the appropriate level of parent involvement, considering the child’s developmental stage and diagnosis, and determining the format and structure of sessions. Then it’s time to "empower the child to build skills and be brave," she said.
Neither Dr. Mazza nor Dr. Wagner-Heimann had relevant financial conflicts to disclose.