For busy pediatricians and primary care providers, anxiety is one of the most common concerns raised in problem visits. Anxiety disorders affect ~1 in 8 youth and parents frequently seek guidance from pediatricians first. Parents often ask what they can do differently at home, yet many feel stuck responding to their child’s distress with accommodations that, although well-intended, inadvertently reinforce anxiety. Traditional therapy can help, but waitlists are often long, access is uneven, and many anxious children refuse to participate in treatment at all. Many children are too young, resistant or unable for various reasons to engage in cognitive behavioral therapy (CBT), which is the first line therapy intervention for older children and teens with anxiety.
SPACE (Supportive Parenting for Anxious Childhood Emotions) offers an alternative, evidence-based pathway. Developed at Yale University by Eli Lebowitz, PhD, SPACE treats childhood anxiety indirectly by working primarily with parents rather than directly with the child. Research has shown that SPACE is as effective as CBT for childhood anxiety disorders including separation anxiety, social anxiety, generalized anxiety, selective mutism and school refusal. It is a tool for improving a child’s anxiety without direct child treatment. It can lead to improvements in family relationships as well.
The underlying principle focuses on parental accommodation. Parental behaviors play a central – and modifiable – role in maintaining anxiety in their child. When a child is anxious, parents naturally adjust the environment to prevent distress, because they believe they are protecting their child. Examples include providing constant reassurance, sleeping next to their child, speaking on their child’s behalf, and avoiding triggers (ex. school, social situations). Although these accommodations reduce distress in the moment, they unintentionally validate anxiety as dangerous, remove opportunities for coping, and prevent mastery and independence in their child. Anxiety thrives on avoidance, and while parents see one of their key jobs to protect their children from danger, discomfort is not dangerous, so parents don’t need to protect their children from discomfort.
SPACE works by improving parental support and then gradually reducing parental accommodations. Parental support focuses on communicating the message of “This is hard” and “We know you can handle hard things”. This blends empathy with confidence. The next step is to reduce one accommodation at a time. It is important to note that the change in behavior focuses on the parent(s) and the child is not asked to change any of their behavior but just understand that their parent is going to stop doing something in response to their anxiety. SPACE is accessible for families where children don’t want to cooperate with therapy.
Parents appreciate access to a therapeutic intervention like SPACE because they often feel helpless watching a child struggle. SPACE empowers caregivers when children decline or cannot participate in traditional therapy and gives them actionable steps, which can reduce parental guilt and improve family functioning. It can also be delivered by trained clinicians over 8–12 sessions (https://www.spacetreatment.net/space-providers ). Alternatively motivated parents can read about and implement the model on their own (https://www.spacetreatment.net/manual-and-books). There are some misconceptions parents might have about SPACE. They might worry that their child will feel abandoned but it is important to remind them that SPACE emphasizes empathy and connection first, before reducing accommodations.
In summary, SPACE (Supportive Parenting for Anxious Childhood Emotions) targets the parents’ accommodations and not the child’s behavior directly. SPACE gives provider a concrete, structured intervention to recommend. For providers faced with many anxiety visits, SPACE can offer a structured, parent-empowering tool that improves outcomes and restores family functioning. If you have a family that might be a good fit for this approach, consider referring them to the SmartCare Behavioral Health Consultation Services Parent Line (858-956-5900) for additional support finding a therapist.
Resources:
https://www.spacetreatment.net
https://iocdf.org/ocd-treatment-guide/space/
AUTHOR:
Dr. Charmi Patel Rao, MD
Medical Director, Vista Hill Foundation
Child, Adolescent and Adult Psychiatrist
Voluntary Assistant Clinical Professor, UCSD Department of Psychiatry