Elaine Taylor-Klaus: Welcome back, everybody, to another fabulous episode of Parenting with Impact. We are really excited today to welcome Professor Eli Lebowitz from Yale University, specifically from the Yale Child Study Center.

It's a true pleasure to have him with us today. In his work, he treats childhood and adolescent anxiety, and his research focuses on development, neurobiology, and the treatment of anxiety and related disorders. As you can imagine, we’re thrilled to have him here today.

Dr. Lebowitz has a special emphasis on cross-generational and familial influences on these conditions, which is fascinating. He is the lead investigator on multiple funded research projects and the author of numerous papers, books, and chapters on childhood and adolescent development.

If I understand correctly, Dr. Lebowitz, not only are you the father of three wonderful boys, but you also have a new book and a program that we'd love for you to tell us about today. So, welcome, welcome! We are absolutely thrilled to have you here.

Eli Lebowitz: Thank you so much. It is great to be here. 

Elaine Taylor-Klaus:
It's so exciting! This has been a long time coming, right?

Diane Dempster:
Yeah, that's true. And we're so glad to have you as a new friend. Could you tell us a little bit about what you do with families of complex kids and how you came to focus on this work?

Eli Lebowitz:
Well, I’ve been working in the area of child anxiety and related problems, like obsessive-compulsive disorder (OCD), for many years now. I initially started focusing more on parents and families, in part through my work with parents of children with externalizing behavior problems.

In those cases, it’s very common to work directly with parents because children with serious behavioral problems aren’t always ideal candidates for individual therapy themselves. So, in that domain, working with parents is pretty common. But this also led me to think a lot about the role of parents in the anxiety domain as well.

Elaine Taylor-Klaus:
So, can I ask a clarifying question before we go any further? Could you explain the relationship between anxiety and OCD in a nutshell?

Eli Lebowitz:
In a nutshell, well, up until not that long ago—I'm talking about 2013, when the latest edition of the DSM, the diagnostic manual for mental health, came out—OCD was officially classified as an anxiety disorder. However, in the most recent version, it was promoted into its own chapter, now grouped under OCD and related conditions, which also includes issues like tic problems and other related conditions.

But really, OCD is still largely an anxiety disorder because the core issue driving OCD is anxiety. The fear that comes from having obsessive thoughts, the worries, the persistent doubting—what really fuels OCD is fear and anxiety. So, even though it’s no longer officially classified as an anxiety disorder, in most ways, it still really is. And the treatment for OCD is also very similar to that for other anxiety disorders.

Whether it’s behavioral treatment, parent-based treatment, or medications, the approaches tend to be quite similar. So, for most intents and purposes, I still think of OCD as an anxiety disorder.

Elaine Taylor-Klaus:
Super, and thank you! I've been looking for that clarification since the last DSM came out, so I really appreciate it. Go ahead, Di.

Diane Dempster: I was just going to say and I think that a lot of parents who are listening and professionals who are listening would like you to take a step further and talk about these three types of treatment just enough more of parent-based treatment, therapeutic based treatment medication, and how they tie in specifically with anxiety.

Eli Lebowitz: Sure, well, behavior treatment or cognitive behavioral treatment, often abbreviated to CBT is the best established and most researched and studied psychological treatment for anxiety and, for OCD as well, and focuses heavily on what's called exposure, which means doing the opposite of what your anxious brain is telling you to do. 

Elaine Taylor-Klaus: Avoiding. 

Eli Lebowitz: Exactly. It's like your brain is telling you to stay away from all these things that make you uncomfortable, that make you scared, nervous, worried, stressed, etc. "Stay away, stay away, stay away." That’s the primary purpose of our anxiety system—to tell us to avoid things.

That’s essentially what it's there for. And when it’s keeping us away from actual dangers, that’s pretty useful. But when you have an anxiety disorder, it keeps you away from things that scare you, but may not actually pose a real danger.

This leads to a lot of impairment and difficulty because your life can become quite limited by all the things you’re avoiding. You don't get the chance to learn that you could actually be okay in those situations because you're always staying away from them.

Behavioral treatment focuses a lot on exposure, which is the opposite of avoiding. It means purposefully putting yourself in proximity or contact with the things or situations that trigger your anxiety. This is a well-established treatment approach. Medications are also well-established treatments for anxiety, OCD, and other areas in mental health.

The most confusing thing about the whole medication discussion when it comes to anxiety is that the frontline medications recommended and prescribed for anxiety are not actually anti-anxiety medications. This can be bewildering and confusing for a lot of people because you go to the doctor and say, "My child has an anxiety problem, or I have an anxiety problem," and they prescribe an antidepressant. Exactly, an antidepressant.

People may think, "Wait, this doctor doesn't get it. I'm not depressed, I just have anxiety." But this is really just an accident of history. Medications are often labeled based on their first use, and then they just keep that name forever.

These antidepressants were initially used to treat depression, and now they’re forever called antidepressants. Unlike anti-anxiety medications, which are somewhat sedative and can be a little more habit-forming, antidepressants are effective for anxiety but don’t create the same dependency.

They tend to have very low side-effect profiles, and they’re not sedative, meaning they don’t make you sleepy. These are typically the medications prescribed for anxiety, and they’re mostly the so-called SSRIs (Selective Serotonin Reuptake Inhibitors).

Elaine Taylor-Klaus: So, as we clarify, I want to highlight the distinction you just made. SSRIs, typically known as antidepressants, are often used for ongoing treatment of anxiety as well. It's a medication that builds up in the system over time.

You begin taking it and take it consistently every day to maintain its presence in your system. On the other hand, the more sensitive types of anxiety medications you mentioned tend to be more situational. They’re not something that builds up, but something you take during an acute situation—maybe for a panic attack or something similar.

So, they're not something you take long-term, but they're targeted for an anxious moment. Is that correct?

Eli Lebowitz: Yeah, that is correct. Exactly. And that’s why, in most cases, we wouldn’t want to prescribe an anxiolytic, an anti-anxiety medication of that sedative kind, for someone to take every day on an ongoing basis.

But if you have a one-time event—say you need to get on an airplane and you're terrified of flying—you might take a pill like that, go to sleep, sleep through the flight, and not be too freaked out about it. But you wouldn’t want to take that pill every morning before going to school, because of all the issues we've discussed.

That’s where antidepressants are more likely to be prescribed and used. The third type of treatment I mentioned, which is the focus of my own work, is parent-based treatment.

Elaine Taylor-Klaus: Which is our favorite part! So, let’s really dive into this because that’s where our work in the world is as well. Tell us a little bit more about your treatment.

Eli Lebowitz: Yes, so the treatment I’m going to elaborate on the most is called SPACE. That’s an acronym for Supportive Parenting for Anxious Childhood Emotions, which is a bit of a mouthful, so we usually just say SPACE.

What’s really special about this treatment is that even though SPACE has been shown in clinical trial research and multiple studies to be just as effective as working directly with the child, it actually doesn’t require the child’s direct participation in therapy at all. And that’s a huge game changer for many families.

It’s not always easy to get your child into therapy or to have your child engaged, motivated, and collaborative in therapy. And even when they are, child-based therapy doesn’t always work. So having another option that doesn’t rely on the direct participation of the child is really a game changer for this field.

What’s also special about SPACE is that throughout the entire treatment, the focus is not on changing the child’s behavior, but on changing the parent’s behavior. I make a promise to parents when we start treatment with SPACE: I tell them something really simple. They don’t believe me at first, but then they see it’s true.

That is, throughout this entire treatment, I’m never going to ask you to make your child do anything, and I’m not going to ask you to make your child stop doing anything. That’s huge because it’s really easy to say to parents, “Get your child to do this,” or “Get your child to practice a skill or do an exposure,” for example. And sometimes, that might work great, but it doesn’t always. What if your child isn’t open to doing that? What if they’re not on board?

It’s really easy to tell parents to go home and get their child to do stuff, but you can’t. You can’t really decide what someone else is going to do. So by focusing the entire time only on my own responses as a parent—essentially changing the behavior of the one person I actually can control, which is myself—we can avoid a lot of the problems that might occur if we were trying to directly manipulate the child’s behavior.

And it turns out that doing this is just as effective. It works just as well as trying to work directly with the child. This has really been a landmark change in how we treat child anxiety problems.

Elaine Taylor-Klaus: So, can I check in on something? I think, Diane, we’ll say you’re speaking music to our ears because as coaches for parents, this is the work we’ve been doing for the last decade—really focusing on the parent and inviting them into the conversation to change the way they communicate with their child, because that sets the environment.

The term we learned a number of years ago is "behavior therapy training." And what’s recommended as treatment for kids with complex issues like executive function conditions, ADHD, and I believe also anxiety—please confirm that for me—is behavior therapy.

But what they really mean by behavior therapy, as we understand it, is actually training for the parents rather than therapy for the kid. So, is that what you're describing? Is this a manifestation of that?

Eli Lebowitz: Well, I think where it gets confusing is that usually, when we talk about behavior therapy in all of these contexts, even when we’re doing parent work, we’re talking about shaping the child’s behavior. For example, you might use rewards or consequences to change your child’s behavior.

So, let’s take a day-to-day situation: you want your child to argue with you less, or you want them to go to school, make their bed, do their homework, etc. Usually, when we talk about behavior therapy, the behavior we’re trying to change is the child’s behavior, and the parents are using a system like rewards, tokens, punishments, ignoring, or giving attention to shape that behavior.

SPACE is a behavior therapy because we are changing behavior. But the behavior we’re trying to shape is the parent’s behavior. We can talk about this more, but it turns out that the way anxiety works in children makes it such that changing the parents’ responses to their child—what am I doing, what am I saying, how am I responding—actually has a dramatic impact on the child’s anxiety symptoms.

Diane Dempster: So, what are some of the things that parents can do to have an impact on their kid's anxiety?

Eli Lebowitz: Let me set the stage briefly first, and then I promise to actually answer your question more directly. But if I could take a minute to talk about what makes child anxiety special, it will help you understand why we’re doing the things we are with parents.

For the longest time—really decades—we’ve thought, and by “we” I mean the field broadly, that child anxiety is essentially the same as adult anxiety. That’s how it’s taught in universities, how clinicians are trained. People learn a model of anxiety problems that, to put it really briefly, is based on distorted cognitions—things like biased thinking, thinking traps, etc.

It’s also based on dysregulated physiology—like a racing heart, clenched muscles, and so on—and it’s based on behavior, primarily avoidance. All of what I just said applies to both adults and children. And the treatments have been essentially the same: change those thoughts, change that behavior, teach physical regulation, like relaxation training.

And all of this is also correct. I’m not saying any of it is wrong. In fact, it’s not wrong, but it does leave out—

Elaine Taylor-Klaus: There's more.

Eli Lebowitz: Yeah, there’s more. Exactly, but there’s more. It leaves out an entire aspect of child anxiety that’s actually meaningfully different from adult anxiety. And that is, children don’t really respond to fears in the same way that adults do. This starts from infancy, as soon as we’re born. If you imagine a very young child who’s scared, what are they doing? They’re not doing what an adult does. They’re not engaging in that classic fight-or-flight response.

Babies, it turns out, aren’t very good at either fight or flight. They can’t fight, and they can’t run away, either. So, they really can’t respond in those mature, individual ways. What do children do when they’re scared? They look to their parents.

They rely on their parents. This is hard-wired and programmed into our brains, literally from birth. When a child is scared, their reaction is very much oriented toward their caregiver. It’s like, "I’m scared. Where’s my mom or dad to come and deal with this threat?"

And that makes child anxiety problems actually unique. What it also means is that when a child has an anxiety problem, and they’re chronically feeling scared, worried, or stressed, etc., they’re also chronically looking to their parents to help them, to step in—whether that means protecting them from whatever is scaring them, or whether it means reassuring them, calming them, soothing them, telling them it’s going to be okay, etc.

When we look at families of children with anxiety problems, what we see is a lot of parental entanglement in those anxiety problems. It’s actually rare to meet a family with a child who has any significant anxiety and not see a lot of entanglement on the parent’s side, because the child is constantly drawing them in. As a parent, you want to step in, you want to help your child feel better, and you want them not to be scared. So, you do the most natural thing in the world, which is to accommodate. You’re trying to help them avoid the fear.

Maybe your child is scared at night, so you sleep next to them. Maybe your child is chronically worried, so you’re always answering questions over and over again, reassuring them. Maybe your child is socially anxious, so you’re speaking in place of them. It goes on and on.

And that’s really important for understanding the answer to your actual question, which is: What would we recommend to parents?

Elaine Taylor-Klaus: And before you get to that, I want to take what you said and really ground people in it. It’s so important to understand that anxious kids will, in some way, almost cultivate an anxious parent engagement or entanglement, as you say.

As the mom of several kids with anxiety, and having lived through those first 10 years, you’ve just described me to a tee. So, what I want to say to parents who are listening is: this is hard, and yes, it can change. When you have a kid with anxiety, it pulls you in in a different way.

The work that you're talking about, and the work we do, is all about helping parents learn to respond differently. I just want to emphasize that it really can change. I promise you, you’re not stuck in this cycle. And if you’re feeling stuck in it at the moment, there’s a good reason, and what we’re talking about now—and will continue to talk about—will help you begin to shift that. So, I just needed that little "author’s message" moment.

Eli Lebowitz: That is so well said. And also, speaking as the father of three kids, including at least one with a lot of anxiety, yes, this is what happens, and it's not because you're a bad parent. It's not your fault that your child is anxious in the first place.

And this is something I want to emphasize: the reason we focus on working with parents is not because I think parents are the cause of children's anxiety disorders. It’s such an easy leap to make—well, if you want to work with parents, you probably think parents messed up their kid in the first place. Actually, that’s not the story for the vast majority of kids with anxiety.

Obviously, really bad parenting can have a truly harmful impact—if you're abusive, neglectful, or engage in maltreatment, those are horrible things that can obviously exert a detrimental impact on a child’s mental health. But most kids with anxiety disorders don’t have abusive, neglectful, or maltreating parents.

They have sensitive, loving, caring parents who are tearing their hair out and at their wit's end, exasperated because everything they’re doing to try to help their child, all these accommodations they might be pouring tons of time, energy, and resources—even money—into, aren’t solving the problem.

So, what do we recommend? It really boils down to two main changes that parents can make in their own behavior. And again, both of them can be done regardless of whether the child is more or less on board. It’s really two big-picture changes in the parents' own responses. The first one is cultivating a more supportive stance toward their child's anxiety—practicing support. And I think a lot of people hear that word and interpret it in different ways. But I have a really specific definition for what I mean by support when it comes to child anxiety.

That is, you are being supportive. Your responses to your child show them two things: you're giving them two messages, and you need both of them. The first is a message of acceptance, validation, or acknowledgment—acceptance of your child's genuine distress. This sounds obvious, but so many times, our natural, intuitive reactions don’t actually validate what the child is feeling.

Diane Dempster: You're fine. Don’t worry about it.

Eli Lebowitz: Exactly. It’s nothing, or sometimes even harsher, like, "Don’t be a baby. Grow up. Your older sister can handle this; you should be fine too." That acceptance is the first half of support.

You can't really be supportive if you're not willing to acknowledge that this is your child's experience, whether you share it or not. This is what they’re going through.

Elaine Taylor-Klaus: What they’re dealing with. It’s real.

Eli Lebowitz: Yeah, exactly. Even if their thoughts are completely irrational, it’s still the thought that’s in their head. That’s their experience. So, the first part of support is acceptance. The second part of support, though, and what really makes it supportive, is when you put the two things together.

The second part is confidence—meaning, I’m telling you, and I’m showing you, that I believe you can handle being anxious, at least some of the time. Having anxiety doesn’t mean that I expect you to change all your behavior overnight and suddenly not have a problem. If I expected that, I probably wouldn’t be very accepting.

But it means that I believe in your ability to tolerate, to get through it, to survive it, and come out okay on the other end. And that’s not trivial either. Because a lot of times, our reactions to children don’t show that kind of confidence.

When we rush to reassure, when we rush to preemptively protect them from anything that might cause distress, we’re inadvertently—perhaps—giving the message that we believe they can’t handle it. Sometimes we even say it explicitly, like, "My kid can’t handle stress," or "My kid goes to pieces."

Diane Dempster: Or I can help you. It's this sort of who's the focus that they can do. Is it I can do for you, or I can help you versus you can do it and I'm here to support you? 

Eli Lebowitz: Exactly.

Elaine Taylor-Klaus: And I want to be mindful of our time. I know you've got another point, but another observation that comes up for me is to make sure that when we’re holding that vision for them, we’re not adding more pressure.

I remember having a conversation with Jerry Schultz many years ago, who said, you don’t want it to become one more thing they’re not doing. So the language that I’ve adapted to that is a version of, “I believe in you.

I know you can do it, and I know you may not believe that yet, and that’s okay because I believe you can. I’m holding that for you, and you can.”

Eli Lebowitz: Yeah, that is perfect. The supportive statement is ultimately a statement about me. It’s about how I view you. It’s not really a statement about you. It’s also not an attempt at persuasion. So often, we try to say what we think, but really, what we want is for you to agree with us. We want you to echo what we think. It’s like, “Believe you can handle this.” “No, I can’t.” “Yes, you can.” “Come on.” [overlapping] “You can!” And I’m slipping back into persuasion.

Diane Dempster: Believe in yourself.

Elaine Taylor-Klaus: So we’re not convincing them. We’re empowering them to believe and move in that direction.

Eli Lebowitz: Exactly. But when a child consistently, over time, receives the message that when they look into the mirror of their parent's responses, what they see reflected back to them is a view of themselves as a child who is understood and accepted— but a child who is strong, rather than vulnerable; a child who is competent, rather than unable— that starts to change their own view of themselves as well.

So, that's the first of the two big-picture goals of SPACE: really practicing support. This means writing out the supportive statement that you're going to make and starting to use it when your child is anxious.

This is not an abstract thing; it's a very concrete, practical step— literally saying the words. And don’t assume that your child knows that you have confidence in them or that your child knows that you accept them. Show them. Tell them that because what you assume may not actually be what they think.

Elaine Taylor-Klaus: They’re good, but they’re not mind readers.

Eli Lebowitz: Yeah, exactly.

Elaine Taylor-Klaus: Let’s move on to the second one because I want to be mindful of our time, and believe it or not, we’re running close to the end of our time.

Eli Lebowitz: So, the second point is about accommodations. As I said before, almost every parent who has an anxious child is probably engaging in frequent accommodations of their child's anxiety. So, the second change that parents can make in their behavior is to take a look at what accommodations they are providing. What are the things that I'm doing to try to help my child not feel anxious, to help them escape or avoid those feelings of anxiety, and start reducing those accommodations? You don’t have to change them all overnight. You can pick one thing— just one thing. And if that’s too much, pick one thing for one part of the day. It doesn’t have to be a huge step all at once because that’s really hard. But pick something and start practicing not doing that accommodation, and be prepared for it to be a little bit hard. Your child may not immediately thank you.

Elaine Taylor-Klaus: You’ve got about 20 years for that, but it does circle back, I promise.

Eli Lebowitz: I would really go back to what I just said a moment ago, which is that this is a problem that is hard, frustrating, and difficult, but it can be improved. The bad news about anxiety is that if you don't treat it, it doesn't tend to go away on its own.

People who say it's just a phase they'll grow out of, or not to worry about it, are often wrong. I don’t mean that on the first day your child comes into your room at night and says there’s a monster under the bed, you need to give them Prozac—that’s not what I’m saying. Yes, lots of kids will have occasional fears. But if you have a child with a more persistent anxiety problem over weeks, months, or longer...

Elaine Taylor-Klaus: Persistent fears.

Eli Lebowitz: Yes, persistent. It’s actually not that likely to just go away on its own. In fact, it’s more likely to get worse if left untreated. The good news, however, is that there is no mental health problem that is more treatable than anxiety disorders.

So if you have a child who’s struggling with anxiety, get them help, and I think there’s a really good chance they’ll be living a better life soon.

Elaine Taylor-Klaus: I love that much. Thank you so much.

Diane Dempster: I really love that. To wrap things up, why don't you share with our audience a favorite quote or motto that you love?

Eli Lebowitz: You know, one thing I often say to parents, and I mentioned this briefly earlier, is: "You are the mirror your child looks into to see who they are."

Elaine Taylor-Klaus: I love that. "You are the mirror your child looks into to see who they are."

Diane Dempster: Mic drop.

Elaine Taylor-Klaus: Yeah, that was beautiful. Thank you. So, thank you all for tuning in. Our guest today was Dr. Eli Lebowitz from Yale University, who’s doing incredible work with parents, helping them support their kids in managing challenges with anxiety. We’re so thrilled to have had you here. Diane, anything else before we wrap up?

Diane Dempster: No. Thank you so much for your time today and for being here with our parents.

Eli Lebowitz: Well, thanks so much. That was fun.

Elaine Taylor-Klaus: And remember, that was for all of you listening. Thanks for all you're doing for your kids and for yourself. You are making a difference. Take care, everyone.

 

Helpful Links:

• Parent Expectations: 2 Steps to Success 
• Parenting is Leadership Guide