ORIGINAL ARTICLE

Child-Report of Family Accommodation in Pediatric AnxietyDisorders: Comparison and Integration with Mother-Report

Eli R. Lebowitz • Lindsay Scharfstein •

Johnna Jones

� Springer Science+Business Media New York 2014

Abstract Reducing family accommodation (FA) may be

beneficial in cases of childhood anxiety disorders. Assess-

ment of FA has so far relied on single-informant maternal

report, which may be biased by factors including maternal

anxiety. We compared child and mother reports of FA, and

examined whether maternal anxiety moderates the associa-

tion between mother and child report. Participants were fifty

children with primary DSM-5 anxiety disorders, and their

mothers. Mother–child agreement was good for overall FA

and moderate for subdomains of FA. Mothers reported sig-

nificantly more FA than children. Maternal anxiety moder-

ated the association between mother and child report of FA,

such that the correlation was stronger in more anxious

mothers. Children agreed that FA helps them feel less anx-

ious and did not agree that parents should accommodate less.

FA is an important clinical characteristic of childhood

anxiety disorders and assessment can be enhanced through

child report and consideration of maternal anxiety.

Keywords Anxiety � Family accommodation �Parenting � Disorders of childhood � Measurement

Introduction

Anxiety disorders are the most common emotional disor-

ders of childhood [1]. If not treated successfully, anxiety

disorders cause significant short and long term impairment

and pose huge financial and societal costs through factors

such as increased school dropout, teenage childbearing,

and lost productivity in the workplace [2, 3]. Despite strong

evidence for the efficacy of cognitive-behavior therapy

(CBT) for childhood anxiety disorders, up to 50 % of

children remain symptomatic after treatment [2, 4]. Even

among children who remit during treatment, more than

one-third relapse in subsequent years [5]. It is therefore

necessary to identify factors that may lessen the likelihood

of successful treatment.

One area of research that has received considerable

attention is the role that parents play in the etiology and

maintenance of childhood anxiety disorders. The bulk of

this research has focused on parental anxiety and on par-

enting styles associated with the development of anxiety in

children. Several studies have supported a link between

anxiety in mothers and anxiety disorders in children,

showing that anxious children are more likely to have

parents that suffered from anxiety [6–8] and that mothers

with a history of anxiety disorders are more likely to have

children who have an anxiety disorder [9, 10]. Overpro-

tective parenting, hostile parenting, and low autonomy-

granting parenting have all been identified as possible

precursors to the development of child anxiety [11–17].

Despite the evidence for parental influences in the devel-

opment of child anxiety, involving parents in treatment has

not yet reliably enhanced outcomes for childhood anxiety

disorders [18–21], underscoring the need to identify addi-

tional targets for parent intervention.

Recent research has highlighted the importance of

considering how parents respond to the symptoms of an

existing anxiety disorder in a child. Children naturally look

to their parents for help when feeling distressed and parents

can become drawn into increasing involvement in a child’s

E. R. Lebowitz (&) � L. Scharfstein

Yale Child Study Center, 230 S. Frontage Rd., New Haven,

CT 06520, USA

e-mail: eli.lebowitz@yale.edu

J. Jones

University of Texas, Austin, TX, USA

123

Child Psychiatry Hum Dev

DOI 10.1007/s10578-014-0491-1

symptoms, through a process known as family accommo-

dation (FA) [22, 23]. FA was first studied in obsessive–

compulsive disorder (OCD), and was shown to be highly

prevalent among the parents of children with OCD. Cal-

vocoressi et al. [23, 24] published the first studies sys-

tematically measuring FA in OCD using a clinican-

administered instrument developed for that purpose—the

Family Accommodation Scale (FAS). The FAS assesses

caregivers’ participation in behaviors related to the OCD,

and modification of family routines and schedules aimed at

avoiding or alleviating distress related to the OCD.

Numerous other studies, using both clinician-administered

and parent-report versions of the FAS have confirmed the

prevalence and importance of the FA construct [25].

Greater degrees of FA have been shown to be associated

with more severe symptoms, greater impairment and

poorer treatment outcomes for both behavioral and psy-

chopharmacological interventions [25–27].

More recently, FA has been shown to be highly pre-

valent among the parents of children with anxiety dis-

orders. Lebowitz et al. [22] assessed the parents of 75

anxious children using the Family Accommodation Scale

Anxiety (FASA), a modified FAS adapted for use with

anxiety disorders. The items on the FASA closely

resemble the FAS items used to assess FA in OCD, with

relatively minor changes that are described elsewhere in

detail [22]. Almost all parents reported engaging in FA,

and degree of FA was found to correlate positively with

the severity of the children’s anxiety symptoms. The

total number of anxiety disorders diagnoses correlated

positively with the level of FA, but only separation

anxiety was specifically associated with higher FA.

Factor analysis of the FASA identified two factors which

have also been reported for the OCD FAS items: active

participation in symptom-driven behaviors (e.g., repeat-

edly answering worried questions or sleeping next to a

child), and modification of family routines and schedules

(e.g., returning home early from work) [22, 28]. In a

separate study, Lebowitz et al. [29] compared FA in

anxiety to FA in OCD as well as non-anxious youth.

Results indicated that FA is similar in both clinical

groups and significantly higher than in the non-anxious

controls.

Reducing family accommodation may be an important

goal to address with parents in the treatment of childhood

anxiety, whether in the context of a parent-only interven-

tion or as a component delivered alongside child CBT.

Theoretically, FA is contrary to the goals of CBT and

although it is intended to reduce anxiety in the short-term

FA may lead to increased anxiety and poorer treatment

response in the longer term. One central element of CBT

for child anxiety is exposure to anxiety provoking stimuli

which the patient typically prefers to avoid [30, 31]. FA

works in the opposite direction, by facilitating ongoing

avoidance and providing the child with an alternative to

facing the fears. CBT also focuses on teaching adaptive

strategies and coping mechanisms such as cognitive

restructuring or relaxation that enable the child to deal with

anxiety and to self-regulate the distress associated with the

disorder [21, 31]. FA encourages continued reliance on

caregivers for coping with uncomfortable situations and for

the regulation of negative affect. In addition, by helping the

child to avoid having to confront the anxiety or distress,

parents who engage in a lot of FA may undermine the

child’s motivation for a challenging treatment such as

CBT. Finally, parents who engage in FA may provide the

child with putative confirmation of their fears, thereby

reducing insight into the irrational nature of the anxious

thoughts [32].

For all these reasons reducing FA may lead to reductions

in child anxiety and may increase the likelihood of suc-

cessful treatment with the child. A number of treatment

protocols already include a focus on reducing FA [33–35].

The SPACE Program is one example of a parent-based

treatment highly focused on the reduction of FA that has

shown promise in both anxiety and OCD [35, 36]. Imple-

menting and testing such treatments is predicated on

careful measurement and assessment of FA.

So far, measurement of FA in childhood anxiety has

relied on single-informant caregiver report by mothers [22,

29]. No studies in childhood anxiety (or OCD), have

included child-report of family accommodation. Measuring

FA through parent-report only may limit the accuracy of

the assessment, whereas including both parent and child

report could enhance the accuracy of the assessment and

provide important information for a number of reasons, as

discussed next.

For parents to accurately report FA they must be aware

that the changes they are making in their behavior are in

fact responses to symptoms of anxiety in the child. But

parents may not always accurately recognize symptoms of

anxiety in their child, leading to less accurate report of FA

as well. Both over-identification and under-identification

of anxiety symptoms are possible. For example, a child

with separation anxiety may become upset if her parents

do not answer their mobile phone, causing the parents to

answer more promptly even if they do not consider it to

be an accommodation of an anxiety symptom. Research

shows that children frequently become aggressive or have

temper tantrums when their symptoms are not accommo-

dated, behaviors which may lead parents to engage in

more FA even if they do not view the behavior as

expressing anxiety [37–39]. Further supporting this pos-

sibility is the low agreement that has often been reported

between parent report and child report of child anxiety

symptoms [40–44].

Child Psychiatry Hum Dev

123

In other instances parents may have an exaggerated view

of their child’s anxiety and vulnerability. For example,

parents of a child who once became upset after hearing

something disturbing on the news may be careful never to

discuss the news near him—even if the child no longer

finds it stressful. In this case they might report engaging in

FA, even if the child would not actually feel anxious were

they to behave differently and would not view the behavior

as an accommodation. Parents’ have been found to report

higher anxiety [45] and more avoidance [40] in children,

than the children report themselves, making it plausible

that some parents may engage in FA even if the child is not

feeling anxious.

Parent-report of FA could also be biased by parents’

own anxiety, or by their desire to present their behavior in

the best possible light. Research on other aspects of

parental behavior relevant to childhood anxiety has indi-

cated that such reporting biases do exist [32, 45–48]. To

cite Schwartz et al. [49] ‘‘investigators whose measures of

parental child-rearing behavior are based on ratings by

single knowledgeable informants will be operating with

scores of inadequate validity’’. Bogels and van Melick

[48] for example, collected information on parental

autonomy-granting, overprotection and rejection and

concluded that using a single informant produced unsat-

isfactory and biased measurement. They found that

mothers tended to give more positive impressions of their

own rearing behavior compared to reports from children,

and that using a multiple informant approach greatly

reduced the problem of rater bias in assessing parental

behavior.

The present study aimed to address gaps in current

knowledge by conducting the first multiple-informant study

of FA in childhood anxiety disorders, examining reports

from both mothers and children, with the following specific

objectives and hypotheses. The first objective was to

examine mother–child agreement on FA. This includes

agreement for overall FA and the more specific domains of

participation and modification, as well as distress associ-

ated with the FA, and the negative reactions exhibited by

children when not accommodated. Based on the typically

low-to-moderate agreement between mothers and children

with regard to child anxiety it was hypothesized that

agreement on FA would be moderate at best. Agreement

for the participation subscale, which focuses on more

immediately evident behaviors, was predicted to be higher

than for the modification subscale, which queries changes

to routines and schedules that a child may not readily

perceive. The second objective was to examine the role of

maternal anxiety symptoms in multiple-informant assess-

ment of FA. We hypothesized that maternal anxiety would

moderate the association between mother and child reports

of FA, such that the association would be weaker in

mothers who reported more anxiety symptoms of their

own.

This study also had one secondary objective. Because

this was the first attempt to learn about children’s percep-

tion of FA, we also wanted to gain perspective on chil-

dren’s awareness of the potentially negative outcomes of

FA and on their willingness for parents to reduce the FA.

This question has meaningful implications for shaping

interventions that aim to reduce FA. If children perceive

FA as unhelpful in the long-term they may be more easily

allied with a therapeutic intervention that aims to reduce it.

If on the other hand, they perceive FA only as helpful to

them they may resist such efforts more staunchly. Based on

clinical experience we predicted that children would

identify FA as being helpful in the short-term, but would

also acknowledge that it does not lead to reduced anxiety in

the longer term.

Method

Participants

Participants were 50 consecutive treatment-seeking chil-

dren and their mothers, presenting at a specialty anxiety

clinic in the eastern United States and meeting DSM-5 [50]

criteria for a primary anxiety disorder. Children who pre-

sented with other psychiatric disorders (including OCD)

were included in the study as long as the comorbid con-

dition was of lesser severity. Children were between the

ages of six and seventeen years (Mean = 12.3, SD = 2.9)

and 65 % were identified as female. All mothers had at

least partial high school education, and most mothers

(58.4 %) had completed higher education at the college

level. All participants were fluent English speakers and

English was the primary language spoken in 78.3 % of

homes, with the remainder having Spanish as a primary

language. Children were identified as predominantly Non-

Hispanic White (82.1 %).

Procedure

The study was approved by the University Institutional

Review Board and signed consent and assent were obtained

from all parents and children respectively, before any

additional procedures were performed.

All measures were administered at intake, prior to the

start of treatment. Children completed questionnaires while

the mother was being interviewed, and vice versa. Child

questionnaires were administered in the presence of a

research assistant who was trained to answer questions and

clarify questionnaire items when necessary. Training

Child Psychiatry Hum Dev

123

included role-play in answering questions without biasing

child report, and learning answers to frequent questions

such as the meaning of difficult words.

Measures

Child Anxiety Diagnoses and Symptoms

Anxiety disorders interview schedule—children and parent

(ADIS C/P) [51]. The presence of a primary DSM-5 anx-

iety disorder diagnosis was established using the ADIS

C/P, administered separately to the child and the mother.

The ADIS C/P is a semi-structured interview with good to

excellent reliability for establishing diagnoses, and strong

correspondence with anxiety questionnaire ratings [51, 52].

Because the DSM-5 version of ADIS C/P is not yet

available, the DSM IV version was administered and

diagnoses were established according to DSM-5 criteria

(which closely resemble those in DSM IV for anxiety

disorders). The ADIS C/P was administered by graduate

level clinicians or licensed psychologists, trained in its use

by one of the instrument’s authors. Training included

observing live and videotaped samples, supervised

administration, and discussion of initial discrepancies. In

line with earlier research, in cases of discordance between

parent and child reports the clinician considered both

informants’ views to derive a final diagnosis [53, 54].

Decisions regarding diagnoses were made in consultation

with clinical psychologists, highly experienced in the

treatment and research of childhood anxiety.

Multidimensional anxiety scale for children (MASC2)

[55]. Mothers and children completed respective versions of

the 2nd edition MASC. MASC2 is a revision of the original

MASC and is a 50-item measure of anxiety in children.

Each item is scored on a 4-point Likert-type scale from 0 to

3 (‘Never’ to ‘Often’). MASC2 provides an overall anxiety

score based on all 50 items (range 0–150) and subscales for

specific domains of anxiety including the following: sepa-

ration anxiety (9 items; range 0–27), social anxiety (9 items;

range 0–27), physical symptoms (12 items; range 0–36),

harm avoidance (8 items; range 0–24), generalized anxiety

(10 items; range 0–30), and anxiety related to obsessive

compulsive symptoms (10 items; range 0–30). Normative

samples include 1,800 children representative of US chil-

dren in terms of ethnicity/race, gender, and age. The

MASC2 maintains the critical elements of the MASC [56]

and adds the subscales for generalized anxiety and OCD.

Internal consistency for the child MASC2 total score was

excellent (a = 0.95), and fair to excellent for the subscale

scores (a scores ranged from 0.72 to 0.88). Internal con-

sistency for the mother MASC2 total score was excellent

(a = 0.91) and acceptable to good for the subscale scores

(a scores ranged from 0.68 to 0.83).

Family Accommodation

Family accommodation scale anxiety (FASA) [22]. Moth-

ers completed the FASA which was previously adapted

from items used to measure FA in OCD [23, 24]. The

FASA includes 13 items rated on a 5-point Likert-type

scale from 0-to-4. FASA yields an overall Accommodation

score (9 items; range 0–36), and subscale scores for Par-

ticipation (5 items, range 0–20), Modification (4 items;

range 0–16), Distress (1 item; range 0–4), and Conse-

quences (3 items; range 0–12). The FASA has good

internal consistency and convergent and divergent validity

and is sensitive to detecting family accommodation among

various childhood anxiety disorders [22, 29]. In the current

sample internal consistency was good: a = 0.88 for the 9

accommodation items, a = 0.80 for the Participation sub-

scale, a = 0.85 for the Modification subscale, and

a = 0.87 for the Consequence subscale.

Family accommodation scale anxiety—child report

(FASA-CR) Children completed the FASA-CR, a modified

version of the FASA adapted for use with children. Items

were rephrased so that a child could respond about the

parents’ FA. For example, the parent item ‘How often did

you assist your child in avoiding things that might make

him/her more anxious?’ was rephrased to say: ‘How often

did your parent help you to avoid things that make you feel

anxious’. FASA-CR yields the same scores as FASA and is

scored the same way: an overall Accommodation score (9

items; range 0–36), and subscale scores for Participation (5

items, range 0–20), Modification (4 items; range 0–16),

Distress (1 item; range 0–4), and Consequences (3 items;

range 0–12).

The items for FASA-CR were piloted with preliminary

samples of anxious children in two anxiety specialty clinics

(N = 30). Children first completed the scale and were then

asked questions to ascertain their comprehension of the

items and were then given the opportunity to provide

additional feedback. The items were then revised and re-

piloted with another sample until satisfactory results were

achieved including internal consistency greater than

a = 0.8 for the nine accommodation items, no reports from

children of items being hard to comprehend, and children

demonstrating being able to describe the meaning of the

questions in their own words. Internal consistency in the

current sample was acceptable to good: a = 0.85 for the

nine accommodation items, a = 0.75 for the Participation

subscale and a = 0.73 for the Modification subscale, and

a = 0.86 for the Consequence subscale.

In addition to the 13 items that parallel those on the

FASA, 3 other items were added to FASA-CR to better get

at children’s thoughts and beliefs regarding the FA. These

three items included: ‘When my parent helps me in this

way, I feel less anxious’; ‘If my parent continues to help

Child Psychiatry Hum Dev

123

me in these ways, I will feel less anxious in the future’; and

‘I believe my parent should help me less in these ways,

when I’m anxious’. Children rated their agreement or

disagreement with each item on a 5-point scale. These

items are not included in the scoring for FASA-CR.

Maternal Anxiety Symptoms

Beck anxiety inventory (BAI) [57]. Mothers completed the

BAI, a 21 item scale that queries symptoms of anxiety in

adults. Items include cognitive (e.g., ‘fear of dying’; ‘fear

of worst happening’), physical (e.g., ‘face flushed’; ‘heart

pounding’) and emotional (e.g., ‘terrified or afraid’) aspects

of anxiety. Mothers indicated the degree to which they

were bothered by each item in the past month on a 4-point

scale from 0 to 3 (from ‘Not at all’ to ‘Severely—it

bothered me a lot’). Possible scores range from 0 to 63.

Good psychometric properties have been reported for the

BAI [57] and internal consistency in the current sample

was excellent (a = 0.96).

Data Analytic Plan

Intra-class correlation coefficients (ICC) and Pearson r

correlations were used to examine the level of agreement

between mother and child report of FA, and paired sample

t tests were used to test the significance of differences

between mother and child reports. The intra-class correla-

tion coefficient was calculated using a two-way mixed

effect model where the sample of children is random but

the raters are fixed, and testing for absolute agreement.

Bivariate Pearson r correlations were also used to examine

the associations between reports of FA and reports of child

anxiety symptoms.

To test the hypothesis that maternal anxiety moderates

the association between mother and child report of FA we

first conducted a hierarchical multiple linear regression,

with child report of FA as the predicted variable. In the first

step we included mothers’ report of FA and maternal

anxiety as measured by BAI. In the second step we added

the interaction term equal to the product of mothers’ report

of FA and maternal anxiety scores. Variables were centered

prior to the analysis to decrease collinearity [58]. Signifi-

cant change in explained variance in child report of FA

when the interaction term is included provides evidence of

moderation. We then used the Process macro for SPSS [59]

to calculate simple slopes for the association between

mothers’ report of FA and children’s report of FA for low

(1 SD below the mean), moderate (mean) and high (1 SD

above the mean) levels of maternal anxiety, and calculated

95 % confidence intervals for the effect sizes based on

bootstrapping procedures with 1,000 samples.

The secondary objective of gaining perspective on

children’s beliefs about FA was addressed by examining

the distribution of children’s responses to the three addi-

tional items added to FASA-CR.

Results

Children met DSM-5 [50] criteria for a primary diagnosis

of either generalized anxiety disorder (34 %), social phobia

(30 %), separation anxiety disorder (24 %), specific phobia

(6 %), or panic disorder (6 %). The average number of

anxiety diagnoses was 2.9 (SD = 1.31), and ranged from 1

to 5. Non-anxiety disorder comorbidity included: depres-

sion (32 %), OCD (12 %), attention deficit hyperactivity

disorder (16 %), and oppositional defiant disorder (8 %).

Males and females did not differ significantly on any of the

study variables, though average age was somewhat

younger for boys (Mean = 10.46) than for girls

(Mean = 13.29), t = 3.15, p \ 0.01.

Severity of child anxiety symptoms based on parent-

report MASC2 scores in the current sample ranged from 18

to 137 (Mean = 66.97; SD = 23.56) and based on child-

report ranged from 8 to 130 (Mean = 74.26; SD = 29.47).

Maternal anxiety scores as measured with the BAI ranged

from 0 to 59 (Mean = 9.95; SD = 11.94).

Comparing Mother and Child Ratings of Family

Accommodation

Table 1 summarizes and compares mother and child

reported FA. Both mothers and children reported highly

prevalent FA. All mothers (100 %) and almost all children

(96.3 %) reported at least one form of active participation

in the child’s symptom-driven behaviors. Almost all

mothers (92.7 %) and approximately two-thirds of children

(70.4 %) reported modifications to family routines and

schedules tied to the child’s anxiety symptoms. Mothers

and children agreed that providing reassurance was the

most frequent form of FA.

Agreement between mothers and children with regard to

FA variables ranged from good for the total accommoda-

tion score based on all nine accommodation items, to fair

for the modification and participation subscales, to poor for

the distress and consequence items (Table 1). Mothers’

scores on the FASA, including total accommodation score

and the participation and modification subscales, were

significantly higher than children’s scores.

Pearson correlation coefficients, after correcting for

multiple comparisons, indicated significant positive corre-

lations between mother and child report of total FA and the

participation and modification subscales. Mother and child

Child Psychiatry Hum Dev

123

scores on the distress and consequences subscales were not

significantly correlated.

Table 2 summarizes the bivariate correlations between

FA and child anxiety, as reported by mothers and children.

Mother report of FA was tightly correlated with mother

report of the child’s anxiety. Child report of FA was cor-

related with child report of child anxiety symptoms and

with mother report of separation anxiety specifically.

Does Maternal Anxiety Moderate the Association

Between Mother and Child Report of FA?

Hierarchical multiple regression predicting child report of

FA from mother report of FA and maternal anxiety showed

significant change in explained variance when the interac-

tion between mother report of FA and maternal anxiety was

added to the equation (Fchange = 5.081, p \ 0.05). The

increase in explained variance indicates that maternal anxi-

ety moderates the link between mother report of FA and child

report of FA. We next examined the slope of the association

between mother and child report of FA at different levels of

maternal anxiety and found that only the moderate and high

maternal anxiety slopes revealed a significant association

mother and child report of FA. The association was stronger

for high maternal anxiety (b = 0.611, 95 % CI 0.331–0.891,

p \ 0.001) than for moderate maternal anxiety (b = 0.375,

95 % CI 0.128 to 0.622, p \ 0.01) and was not significant

for mothers with low anxiety scores (b = 0.173, 95 %

CI -0.169 to 0.516, p = 0.31). Figure 1 plots the simple

slopes for the interaction.

Children’s Beliefs About Family Accommodation

Most children (69 %) reported that they feel less anxious

when they are accommodated, but fewer than half (40 %)

agreed that they would feel less anxious in the future if

their parents continued to accommodate. However, only

one quarter (25 %) endorsed the belief that their parents

should accommodate them less when they are anxious. See

Table 3 for a breakdown of children’s responses to the

statements probing their beliefs about FA.

Discussion

This is the first multiple-informant study of FA in child-

hood anxiety and the first to systematically measure chil-

dren’s perceptions of FA and integrate them with maternal

report. Consistent with previous research [22, 29], FA was

found to be highly prevalent among mothers of children

with anxiety disorders. Results indicate that overall, anx-

ious children do have an awareness of the ways in which

their anxiety is being accommodated by their parents. In

line with our hypothesis, children showed more awareness

of the ways in which parents actively participated in their

symptom-driven behaviors (e.g., answering reassuring

seeking questions) than of changes to family routines and

schedules caused by the anxiety (e.g., changing work

schedules). It seems likely that this is because parents’

active participation in the symptomatic behavior is more

immediately evident to the child, who may not be aware of

‘behind the scenes’ changes that parents are making to their

routines or schedules.

Mothers reported significantly higher rates of FA than

children, but a fair-to-good degree of agreement did exist

between mothers and children regarding the level of FA.

This pattern did not hold for reports of maternal distress

associated with the need to accommodate, and for reports

of negative child consequences related to children not

being accommodated. Mother and child reports of these

variables did not differ significantly, but were also not

significantly correlated with each other and agreement was

poor. This pattern of findings seems to imply that children

are more aware of the actual accommodation, than they are

of the distress that it causes or their own behaviors that

maintain it.

Table 1 Agreement and differences in child report and mother report of family accommodation

Child Mean

(SD)

Mother

mean (SD)

Intra-class

coefficient (95 % CI)

Pearson r correlation

coefficient

Paired

sample t test

Total accommodation (FASA/FASA-CR) 11.15 (6.86) 15.71 (8.23) 0.643 (0.33 to 0.80) 0.537** 3.840**

Participation 8.24 (4.31) 10.73 (4.96) 0.598 (0.30 to 0.076) 0.459** 2.913**

Modification 2.91 (3.01) 4.97 (4.03) 0.547 (0.21 to 0.74) 0.433** 3.518**

Distress 1.06 (1.13) 1.22 (1.08) 0.382 (-0.05 to 0.64) 0.246 0.495

Consequences 5.91 (3.38) 4.82 (3.40) 0.278 (-0.24 to 0.58) 0.161 1.029

Range of possible scores on FASA and FASA-CR: Total Accommodation: 0–36, Participation: 0–20, Modification: 0–16, Distress: 0–4,

Consequences: 0–12

FASA family accommodation scale anxiety, FASA-CR family accommodation scale anxiety—child report

* p \ 0.05; ** p \ 0.01

Child Psychiatry Hum Dev

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Child Psychiatry Hum Dev

123

The higher accommodation scores on the mother report

compared to the child report in the current study are in line

with earlier research on maternal overprotectiveness that

found that mother and child ratings were similar, but that

mothers’ rated themselves as more protective than did the

children [48]. Earlier studies have suggested that mothers

may provide reports biased by the desire to present their

parenting in the best possible light [47, 60]. In the current

study we utilized the parent and child versions of the FASA

which ask about specific behavioral patterns, without

attributing valence to those behaviors. However, it is pos-

sible that mothers’ higher accommodation reflect their

perception of FA as a positive expression of caring for the

child.

Separation anxiety was the only mother-reported aspect

of child anxiety associated with child report of FA. Sepa-

ration anxiety, by its very nature and core symptoms, tends

to directly and explicitly involve parents and it may be

easier for mothers to accurately gauge when they are

accommodating separation fears. This would be in line

with earlier research that found that separation anxiety

disorder was the only child anxiety diagnosis whose pre-

sence was specifically associated with the level of FA

reported by mothers [22].

In line with our hypothesis, maternal anxiety was found

to moderate the association between mother report and

child report of FA. Contrary to our hypothesis however, we

found that the correlation between mother and child report

of FA was stronger when mothers reported greater anxiety

symptoms of their own, than when mothers reported lower

anxiety symptoms. This finding seems to be at odds with

earlier research showing that maternal anxiety contributes

to discrepancies between mother and child reports of child

anxiety. Briggs-Gowan et al. [46] for example, compared

mother, child and teacher reports of child anxiety symp-

toms and found that mothers who reported more anxiety

symptoms in themselves also reported more anxiety

symptoms in their children that were not corroborated by

the child or the teacher report. Research in other domains

of childhood psychological problems have also found that

maternal anxiety biases mothers toward reporting more

symptoms in their child [61]. However, it is important to

bear in mind that the variable being measured in the current

study is not a report of child symptoms, but rather a report

of parental responses to the child’s symptoms. It is possible

that mothers who are anxious themselves are better attuned

to the child’s anxiety symptoms or are better at recognizing

FA as such, leading to tighter association between mother

and child report. Additional research is required to better

understand the pattern of associations emerging from the

current data but current results provide important support

for the inclusion of child as well as parent report of FA and

for considering parental anxiety in assessing reports of FA.

An exploratory objective of the current study was to gain

perspective on children’s beliefs about FA. Specifically we

sought to explore whether children felt that FA is helpful to

them in both the short and the long term, and we wanted to

Fig. 1 Separate regression slopes for the relation between mother

and child report of family accommodation, at low (b = 0.173, 95 %

CI -0.169 to 0.516, p = 0.31), moderate (b = 0.375, 95 % CI

0.128–0.622, p \ 0.01), and high (b = 0.611, 95 % CI 0.331–0.891,

p \ 0.001) levels of maternal anxiety

Table 3 Children’s responses to FASA-CR items probing their thoughts and beliefs about family accommodation

Mean SD Strongly

disagree (%)

Disagree

(%)

Neither agree nor

disagree (%)

Agree

(%)

Strongly

agree (%)

When my parent helps me in this way, I feel less

anxious

2.78 1.18 6.7 8.9 15.6 37.8 31.1

If my parent continues to help me in these ways, I will

feel less anxious in the future

2.29 1.14 6.7 15.6 37.8 22.2 17.8

I believe my parent should help me less in these ways,

when I’m anxious

1.64 1.26 24.4 20 31.1 15.6 8.9

Percentages (%) are frequency of responses out of the total sample of children (N = 50)

FASA-CR family accommodation scale anxiety—child report

Child Psychiatry Hum Dev

123

know whether children believed their parents should

accommodate them less or not. Children agreed that FA

helps them to feel better when they feel anxious, but were

less likely to endorse the statement that ongoing FA would

cause them to feel less anxious in the future. This implies that

the children have realized that FA provides immediate

symptom alleviation but does not bring about an overall

improvement in their anxiety. Despite this, only one quarter

of the children agreed with the statement that their parents

should accommodate them less. One possibility is that

despite recognizing that FA is not an adequate long-term

strategy, children are too anxious at the prospect of reduced

FA to agree that their parents should accommodate less.

The results of the current study must be considered in

light of certain limitations. First, only mothers were

included as the parent-participant in this study. Mothers

were chosen because they have been the informants in

earlier studies of FA in anxiety [22, 29], but inclusion of

fathers, or potentially siblings, as additional informants

may further enhance the measurement of FA and help to

understand the dynamics surrounding childhood anxiety. A

second limitation, inherent in the cross-sectional nature of

the study, is the inability to surmise the causal pathways

linking maternal anxiety, child anxiety, and FA. The

multivariate relations between these variables raise the

possibility of causal links such as parent anxiety leading to

more FA which in turn may lead to increased child anxiety.

Longitudinal studies of FA, and of other parental patterns

that have been linked to child anxiety, are needed to

advance the understanding of these causal pathways. These

limitations notwithstanding the current study provides the

first multiple-informant study of FA, provides new insight

into children’s perceptions of FA and highlights the role of

maternal anxiety in assessment of FA.

Clinical Implications

Identifying family-level constructs that may contribute to the

maintenance of childhood anxiety, or lower the likelihood of

successful treatment, is of prime importance. FA is one such

construct that has only recently begun to be systematically

measured in childhood anxiety. Results of the current study

indicate that assessment of FA may be enhanced through the

use of multiple informants and that children are able to

provide such measurement using the FASA-CR. In particu-

lar, the current results indicate that parental variables such as

maternal anxiety may interact to influence parental reporting

of FA. Careful assessment of child anxiety should likely

include both parent and child measurement of FA, and cli-

nicians can integrate the responses to arrive at the most

accurate clinical characterization.

Parent-based interventions that help parents to better

identify and reduce FA are currently being explored. One

such intervention, The SPACE Program, has reported

improvement in child anxiety symptoms after parents

practice monitoring and reducing FA [35, 36]. Improving

assessment of FA may help to better identify those cases

most likely to benefit from such treatments.

The current results support our clinical experience that

children often oppose efforts aimed at reducing FA.

Therapists should not assume that children will collaborate

with such a process and parents need to be prepared for

children to resist their efforts at reducing FA. However, the

current results also imply that many children do realize that

FA will ultimately not bring about improvement in their

symptoms. It may be possible through clinical work to

engage children in a process that is intended to provide

more long term alleviation of their anxiety.

Summary

This study assessed child reported FA using a modified

version of the FASA and compared mother and child

reports of FA. The study also tested the hypothesis that

maternal anxiety would moderate agreement between child

and mother reports of FA. Finally, the study provides a

preliminary examination of children’s beliefs regarding FA

of their anxiety. Children and mothers both reported highly

prevalent FA and mother report correlated significantly

with child report, though mothers reported significantly

greater FA than children. Maternal anxiety moderated the

association between mother and child report of FA, such

that agreement was higher for mothers who reported

greater anxiety of their own. Children agreed that FA helps

them to feel less anxious and did not agree that their par-

ents should accommodate less. FA is an important clinical

characteristic of childhood anxiety disorders and careful

assessment should include parent as well as child report.

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