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Family accommodation and youth anxiety: the roles of familial and child factors
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Family accommodation and youth anxiety: the roles of familial and child factors
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Copyright 2024 Aridenne A. Dews
FAMILY ACCOMMODATION AND YOUTH ANXIETY: THE ROLES OF FAMILIAL AND
CHILD FACTORS
by
Aridenne A. Dews, B.A.
A Thesis Presented to the
FACULTY OF THE USC DORNSIFE COLLEGE OF LETTERS, ARTS, AND SCIENCES
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MARTER OF SCIENCE
(PSYCHOLOGY)
December 2024
ii
Table of Contents
List of Tables……………………………………………………………………….…….....……iv
List of Figures……………………………………………………………………….…………….v
Abstract……………………………………………………………………….………...….…..…vi
Chapter 1: Introduction……………………………………………………….………...................1
1.1. Differences in family accommodation across age and gender…………….……….... 1
1.2. Impact of family accommodation on anxiety severity.............................……….……2
1.3. Familial influences on family accommodation ………........................................……2
1.3.1. Parental mental health ………........................................….........……................ 2
1.3.2. Family functioning……........................................….........……...........................3
1.3.3. Cultural and sociodemographic factors.......................….........…….....................5
1.4. Child correlates of family accommodation and anxiety.........................……..............5
1.4.1. Avoidance..........….........……..........….................................................................6
1.4.2 .Self-efficacy..................……..........….........…….................................................6
1.4.3. Emotion regulation.......….........……..........…...............................…...................7
1.5. The present study. ...….........……..........….........…….................................................8
Chapter 2: Method……………………………………………………….………........................10
2.1. Participants…………………………………………………….……….....................10
2.2. Procedure..................………………………………………………….……….........11
2.3. Measures.................………………………………………………….………...........11
2.3.1. Parent-report measures……………………………………………….….…….11
2.3.1.1. Family accommodation……………………………………………….…11
2.3.1.2. Parental anxiety……………………………………………….…............12
2.3.1.3. Parent-rated child anxiety………………....……………….………........12
2.3.1.4.Demographics……………....……………….…………....………….......13
2.3.2 Youth-report measures…………....……………….………....…………….......12
2.3.2.1. Child anxiety…………....……………….………....……………............12
2.3.2.2. Anxiety avoidance…………....……………….………....……………...13
2.3.2.3. Self-efficacy......………....……………….………....……………...........13
2.3.2.4. Family functioning....………....……………….………....…...................14
2.3.2.5. Emotion regulation..................……..........…...............................….........14
2.4. Analysis..................……..........…...............................…............................................15
Chapter 3: Results……………………………………………………….……….........................17
3.1 Descriptives and correlations of family accommodation and anxiety.........................17
3.2. Aim 1: Relationship of parental mental health and family functioning on family
accommodation...........................................................................................................17
3.3. Aim 2: The mediating role of family accommodation................................................18
3.3.1. Family accommodation as a mediator of parent-child anxiety..........................18
3.3.2. Family accommodation as mediator of family functioning on child anxiety....19
iii
3.4. Aim 3: Anxious avoidance, self-efficacy, and emotion regulation as mediators
of family accommodation and child anxiety .. ..........................................................20
3.5. Aim 4: Demographic moderators of the relationship between family
accommodation and child anxiety.............................................................................21
Chapter 4: Discussion……………………………………………………….……….................. 24
References……………………………………………………….……….....................................33
Appendix A: Tables……………………………………………….………..................................40
A.1 Table A1. Sample demographic characteristics..........................................................40
A.2 Table A2. Pairwise Correlations between constructs..................................................41
A.3. Table A3. Means and standard deviation for measures by sex..................................42
Appendix B: Figures......................................................................................................................44
B1. Figure B1. Associations with family accommodation................................................44
B2. Figure B2. Mediation models.....................................................................................45
B3. Figure B3. Parallel mediation models.........................................................................46
B4: Figure B4. Moderation models...................................................................................47
Appendix C: Model Outputs..........................................................................................................48
C.1. Table C1. Model outputs for Aim 1...........................................................................48
C.2. Table C2. Model outputs for Aim 2...........................................................................49
C.3. Table C3. Model outputs for Aim 3...........................................................................50
C.4. Table C4. Model outputs for Aim 4...........................................................................51
iv
List of Tables
Table A1. Sample demographic characteristics.............................................................................40
Table A2. Pairwise Correlations between constructs....................................................................41
Table A3. Means and standard deviation for measures by sex......................................................42
Table C1. Model outputs for Aim 1...............................................................................................47
Table C2. Model outputs for Aim 2...............................................................................................48
Table C3. Model outputs for Aim 3...............................................................................................49
Table C4. Model outputs for Aim 4...............................................................................................50
v
List of Figures
Figure B1. Associations with family accommodation...................................................................43
Figure B2. Mediation models........................................................................................................44
Figure B3. Parallel mediation models............................................................................................45
Figure B4. Moderation models......................................................................................................46
vi
Abstract
Background: Family accommodation is recognized to contribute to the maintenance of
pediatric anxiety. Despite its importance, research examining correlates of family
accommodation in the context of youth anxiety remains limited, with even fewer studies
investigating these relationships among representative samples. This study aimed to elucidate
associations among familial and child correlates of family accommodation and youth anxiety
within a sociodemographically diverse sample of youth.
Method: Clinically anxious youth 8-18 years were recruited in the context of a trial
investigating anxiety treatment sequencing. Children and their parents completed questionnaires
used to investigate the associations of familial and child factors with family accommodation and
youth anxiety. We also examined potential sociodemographic moderators of the association
between family accommodation and youth anxiety.
Results: Parental mental health was strongly associated with family accommodation.
Further, family accommodation mediated the link between parental and self-reported youth
anxiety. Emotion regulation difficulties partially mediated the association between family
accommodation and self-reported youth anxiety. We did not find evidence for sociodemographic
moderators of the relationship between family accommodation and youth anxiety.
Significance: This study provides new insights into the relationships among factors
critical to understanding family accommodation and child anxiety. Our results highlight the role
of family accommodation in the link between parental and child anxiety. Furthermore, these
findings underscore the importance of emotion regulation in the relationship between family
accommodation and youth anxiety. By investigating these associations among diverse youth, this
vii
study further extends the literature to reflect a more inclusive understanding of family
accommodation in youth anxiety.
1
Chapter 1: Introduction
Family can play a critical role in the development and maintenance of pediatric anxiety
disorders (Bögels & Brechman-Toussaint, 2006; Ginsburg et al., 2004). While the roots of youth
anxiety are often complex, psychological research has repeatedly underscored the importance of
factors within the family environment on a child’s anxiety. Specifically, recent studies have
identified family accommodation as a significant component in understanding youth anxiety
(e.g., Lebowitz et al., 2013; Storch et al., 2015; Thompson-Hollands et al., 2014).
Family accommodation refers to the practice whereby family members (often parents)
modify routines and behaviors to alleviate or prevent a child’s distress resulting from anxiety
(Lebowitz et al., 2013). Examples of family accommodation can range from significant
modifications in the family’s routine (e.g., driving long distances for a child scared of flying) to
minor adjustments (e.g., allowing a child afraid of the dark to sleep with a nightlight; ThompsonHollands et al., 2014). Originally studied in the context of obsessive-compulsive disorder (OCD),
family accommodation has gained interest in youth anxiety research more broadly over the past
decade. Family accommodation is highly prevalent in families with anxious children (Lebowitz
et al., 2013; Storch et al., 2015), and anxious youth report greater family accommodation than
their non-anxious peers (Kitt et al., 2022). Across pediatric anxiety diagnoses, family
accommodation is most strongly associated with generalized anxiety disorder (GAD) and
separation anxiety, with separation anxiety predicting the highest levels of family
accommodation (Lebowitz et al., 2013; Storch et al., 2015; Thompson-Hollands et al., 2014).
1.1. Differences in family accommodation across age and gender
While some studies find no association between age and family accommodation
(Lebowitz et al., 2013), others have linked aspects of family accommodation to younger age
2
(Thompson-Hollands et al., 2014). It is logical that family accommodation may be greater among
parents of younger children compared to those of adolescents, as younger children tend to be
more reliant on their parents, and some level of anxiety accommodation may be more
developmentally appropriate for younger children (Thompson-Hollands et al., 2014). However, a
recent study suggests the relationship between age and family accommodation may be more
nuanced, finding gender-moderated differences such that younger male (but not female) children
tended to reported greater levels of family accommodation (Zilcha-Mano et al., 2021).
Meanwhile, other studies have found parents of clinically anxious female children to report
higher levels of family accommodation (Lebowitz et al., 2013). Such discrepancies in findings
highlight the need to further elucidate differences in family accommodation by age and gender.
1.2. Impact of family accommodation on anxiety severity
While family accommodation is often well-intentioned and can provide short-term relief
for children, it is detrimental to youth anxiety over time. In fact, family accommodation has been
linked to increased anxiety severity and functional impairment in youth anxiety disorders (Storch
et al., 2015). Further, family accommodation has been associated with lower odds of remission at
the end of treatment, suggesting it may interfere with treatment directly. Specifically, family
accommodation is theorized to be incompatible with the goals of many established treatments for
youth anxiety (e.g., exposure therapy), as efforts to accommodate youth anxiety inherently
facilitate, and thus reinforce, a child’s avoidance of certain triggers, impeding the development
of adaptive coping and corrective learning experiences typically accomplished through treatment
(Jones et al., 2015; Lebowitz et al., 2013; Storch et al., 2015; Thompson-Hollands et al., 2014).
1.3. Familial influences on family accommodation
1.3.1. Parental mental health
3
Although research on factors influencing family accommodation is limited, several
familial factors related to youth anxiety may contribute to differences in family accommodation.
First, parental mental health has been implicated as a significant factor in the research on youth
anxiety (e.g., Burstein et al., 2010). Studies suggest youth of parents with anxiety disorders
display increased levels of anxiety (Bernstein & Borchardt, 1991), and the degree of a child’s
anxious impairment is related to their parents’ anxiety (Manassis & Hood, 1998). While several
explanations for such relationships between parental and child anxiety may be plausible, research
suggests parental behaviors and attitudes towards anxiety to be particularly consequential.
Children with anxiety are more likely than their non-anxious peers to have parents who model
anxiety (Ginsburg et al., 2004). Moreover, parents’ own beliefs about anxiety are predictive of
their children’s anxiety (Francis & Chorpita, 2011). It may be that anxious parents engage in
more anxiety-enhancing parenting behaviors that make their child more susceptible to
developing anxiety or that reinforce a child’s existing anxiety (Ginsburg et al., 2004). For
example, a parent who believes anxiety to be harmful due to their own experiences with anxiety
may engage in efforts to protect their child from similarly distressing experiences with anxiety
(i.e., family accommodation). Such findings suggest a possible framework by which parental
anxiety contributes to child anxiety through family accommodation. Indeed, Jones and
colleagues (2015) found that parents who endorse greater anxiety themselves tend to report
increased levels of family accommodation. Additionally, one study found maternal anxiety to be
associated with the occurrence of family accommodation across more settings (ThompsonHollands et al., 2014). These findings further suggest parental mental health to play a role in
differences among family accommodation.
1.3.2. Family functioning
4
Another mechanism through which familial factors may impact family accommodation is
family functioning, which refers to a family’s ability to effectively communicate, problem solve,
and foster relationships with one another (Epstein et al., 1983). Family functioning is strongly
correlated with child anxiety severity (Hughes et al., 2008). Moreover, child ratings of family
dysfunction predict lack of improvement in self-reported anxiety following treatment (Crawford
& Manassis, 2001). While research on family functioning and family accommodation in the
context of youth anxiety disorders is scant, some studies suggest family functioning to relate to
family accommodation for individuals with OCD (Calvocoressi et al., 1995; Peris et al., 2008,
2012). Although the mechanisms linking family functioning and family accommodation are not
fully understood, a study by Peris et al. (2008) suggests higher levels of family conflict to
associate with family accommodation. Further, it is possible that families characterized by
dysfunction experience elevated levels of stress, which may make them more likely to give into
accommodating anxiety to limit additional sources of stress. Alternatively, some families’
dysfunction may be marked by parental over-involvement and overprotection, which have been
linked to youth anxiety (Wood et al., 2003). According to Bögels and Brechman-Toussaint
(2006), such parental behaviors may interfere with a child’s development of autonomy and may
foster the belief that the child’s environment is uncontrollable and they are unable to manage
anxiety on their own. This can then reinforce parental over-involvement and overprotection,
which may manifest as actions that resemble and include family accommodation. Finally, family
dysfunction may be a result of poor parental mental health. In one study, families with at least
one parent with generalized anxiety disorder (GAD) had lower family functioning than families
without an anxious parent (Ben-Noun, 1998). Such findings suggest that parental mental health
and family functioning may contribute to variation in family accommodation.
5
1.3.3. Cultural and sociodemographic factors
Cultural and sociodemographic factors may also contribute to differences in the
relationships between family accommodation and youth anxiety. Research indicates that both
conceptualizations and experiences of anxiety may vary among cultural groups (e.g., Kirmayer et
al., 1995). As such, it is possible that family responses to youth anxiety may also differ by
cultural and/or racial-ethnic norms and experiences. While few studies have directly investigated
differences in family accommodation by cultural and/or racial-ethnic subgroups, there is
evidence that these factors may influence parenting behaviors and youth anxiety. Research posits
certain parenting characteristics such as parental control to be linked to cultural values among
Hispanic families (Halgunseth et al., 2006). Prior work has further observed associations
between parental control and youth anxiety (Varela et al., 2009), with a recent study linking
parental control to family accommodation among Hispanic mothers specifically (Seligman et al.,
2023). These findings provide preliminary evidence for potential differences in family
accommodation among cultural groups. Despite the considerable literature on child anxiety and
family accommodation, most studies have focused on high socioeconomic status (SES) White
children and their families, limiting the generalizability of findings to more representative
populations. Given the diversity of values, norms, and experiences surrounding anxiety among
different cultural and racial-ethnic groups, it is important to consider how these factors and other
sociodemographic characteristics (e.g., SES) may further impact the relationship between family
accommodation and child anxiety.
1.4. Child correlates of family accommodation and anxiety
While the link between family accommodation and youth anxiety is well-established in
the literature, the mechanisms underlying this relationship have yet to be elucidated. Particularly,
6
the potential for child factors to contribute to changes in anxiety observed in the context of
family accommodation remains largely unexplored.
1.4.1. Avoidance
A core characteristic of youth anxiety is avoidance, a maladaptive coping response where
a child avoids or withdraws from situations that may trigger anxiety and distress. Avoidance has
been linked to increased self-reported anxiety symptoms in youth before and after treatment,
underscoring its importance for understanding child anxiety (Lehrbach et al., 2023). Recent work
by Kitt and colleagues (2022) is the only study thus far to investigate the relationship between
avoidance and family accommodation, finding child avoidance to positively correlate with
family accommodation. As previously detailed, family accommodation may facilitate a child’s
anxious avoidance and is thus theorized to play a role in the maintenance of anxiety. Preliminary
findings such as those by Kitt et al (2022) provide initial empirical support for the theoretical
link between family accommodation and child avoidance. However, whether avoidance may be a
potential mechanism through which family accommodation ultimately impacts youth anxiety is
still undetermined.
1.4.2. Self-efficacy
Another factor that may be important to understanding the relationship between family
accommodation and anxiety is self-efficacy, or an individual’s belief in their own ability to
successfully accomplish a goal (Bandura, 1977). Kitt and colleagues (2022) found support for
the association between family accommodation and self-efficacy in their recent study, such that
family accommodation negatively correlated with levels of youth self-efficacy. Although Kitt et
al. (2022) investigated the mediating potential of self-efficacy on family accommodation and
avoidance, the authors did not investigate self-efficacy as a mediator of the relationship between
7
family accommodation and anxiety severity. This possibility is worth exploring, as some
findings have suggested lower self-efficacy to predict increased anxiety severity after treatment
(Lewis et al., 2020). Given that family accommodation correlates with both self-efficacy and
anxiety severity, and self-efficacy predicts anxiety severity, it is possible that self-efficacy may
be another mechanism by which family accommodation influences youth anxiety.
Despite Kitt and colleagues (2022) providing an empirical basis for the relationships
between avoidance, self-efficacy, and family accommodation, it is important to note that such
findings may lack generalizability considering the limited sociodemographic diversity within
their study sample. As discussed above, sociodemographic diversity may present additional
considerations for the relationship between family accommodation and youth anxiety. Thus, it is
important to further explore these associations across more representative samples of youth and
families.
1.4.3. Emotion regulation
A final correlate that may be important to the relationship between family
accommodation and anxiety severity is emotion regulation (i.e., an individual’s ability to
modulate their own emotional states). Difficulties in effective emotion regulation are common
among anxious youth (Carthy et al., 2010) and may relate to family accommodation. For
instance, if a child feels distress from their anxiety and has trouble regulating this emotional
experience, a parent may respond by stepping in and accommodating their child’s anxiety in a
way that further perpetuates poor emotion regulation skills and worsens anxiety. Despite this
theoretical relationship, no studies have investigated the role emotion regulation difficulties may
have in the relationship between family accommodation and anxiety severity. However,
interventions aimed at addressing family accommodation have been associated with
8
improvements in emotion regulation and anxiety severity (Hassanzadeh-Avval et al., 2022).
Further, a recent meta-analysis demonstrated emotion regulation to mediate associations between
a broad range of familial factors (e.g., psychological control, attachment, family conflict) and
youth internalizing symptoms (Lin et al., 2024). Such findings provide support for the
involvement of emotion regulation in the relationship between family accommodation and child
anxiety.
1.5. The present study
The present study aimed to address important gaps in the current literature by
characterizing relationships among familial, child, and sociodemographic correlates of family
accommodation and youth anxiety. Specifically, our first aim was to investigate how parental
mental health and family functioning related to family accommodation. Informed by prior
findings on parental anxiety and family accommodation, we predicted greater parental anxiety to
correspond to higher levels of family accommodation. Similarly, as worse family functioning has
been implicated in family accommodation of pediatric OCD, we expected lower family
functioning to associate with greater family accommodation. Our second objective was to test
family accommodation as a potential mechanism underlying the relationships between a) parent
and child anxiety and b) family functioning and child anxiety. Based on extant literature linking
parent and child anxiety, as well as the theoretical relationship between family accommodation
and parent and child anxiety, we hypothesized family accommodation to mediate a positive
relationship between parent and child anxiety. Furthermore, in line with prior findings linking
family functioning to child anxiety and family accommodation in other populations, we expected
family accommodation to mediate a negative relationship between family functioning and child
anxiety. Our third aim was to explore the mediating potential of child anxious avoidance, self-
9
efficacy, and emotion regulation on the relationship between family accommodation and youth
anxiety. We hypothesized that greater family accommodation would correspond to increased
anxious avoidance, decreased self-efficacy, and increased emotion regulation difficulties. In turn,
we expected that each of these constructs would be associated with greater anxiety severity.
Further, we hypothesized anxious avoidance, self-efficacy, and emotion regulation difficulties
would mediate the relationship between family accommodation and youth anxiety. Our final aim
was to investigate whether family accommodation and its impact on child anxiety was moderated
by sociodemographic characteristics. We predicted younger age would correspond to greater
levels of family accommodation and that age would moderate the relationship between family
accommodation and child anxiety. Due to conflicting findings in the research on gender and
family accommodation, we did not have specific hypotheses around sex-differences in family
accommodation. Similarly, in the relative absence of literature to guide our hypotheses on
cultural and racial-ethnic factors, these analyses were exploratory in nature. In elucidating
relationships among familial, child, and sociodemographic characteristics within a diverse
sample of youth, this study offers new insights into pertinent influences on family
accommodation and pediatric anxiety.
10
Chapter 2: Method
2.1. Participants
Study participants (N = 335; 70.5% female) included youth between 8-18 years (M =
13.02 years, SD = 2.69) recruited as part of a multi-site randomized controlled effectiveness trial
investigating the sequencing of cognitive behavioral therapy (CBT) and selective serotonin
reuptake inhibitors (SSRI) treatment for predominantly underserved ethnic minority youth with
anxiety disorders (Peterson et al., 2021). The study was conducted in Los Angeles County across
9 treatment sites serving diverse community mental health and pediatric primary care
populations. Our sample identified as predominately Hispanic/Latino (67%) with 35% of parents
reporting Spanish as their preferred language. The median annual income within our sample was
$50,000 and 57% of families were insured by Medi-Cal, California’s Medicaid health care
program.
Participants were recruited via standard clinical visits to one of the recruitment sites,
medical record reviews, community outreach efforts, and recruitment materials, including flyers
and social media posts. Interested participants underwent a two-phase eligibility screening
process. Youth met initial eligibility criteria if they or their caregiver scored > 3 on the Screen
for Child Anxiety Related Emotional Disorders (SCARED-5) screener. Following the initial
screening phase, the research team assessed full eligibility using the following criteria: 1) a
diagnosis of a DSM-5 anxiety disorder (i.e., GAD, separation anxiety disorder, panic disorder, or
social anxiety disorder) as determined by the Kiddie Schedule for Affective Disorders and
Schizophrenia, Computerized version (K-SADS-COMP; Townsend et al., 2020), a web-based
diagnostic interview; 2) at least moderate anxiety impairment as determined by a score > 8 on the
Child Anxiety Impact Scale (CAIS); 3) a score > 25 on the SCARED-41-P or SCARED-41-C; 4)
11
caregiver fluency in English or Spanish; and 5) child fluency in English. Participants were
excluded from the study based on the following criteria: 1) currently taking psychotropic
medication; 2) receiving psychotherapy and unwilling to pause for study duration; 3) current
diagnosis of OCD or post-traumatic stress disorder (PTSD); 4) history of bipolar disorder or
mania; 5) active psychosis; 6) currently experiencing significant suicidal behavior with intent
and plan; 7) diagnosis of neurological disorder or other unstable medical condition; 8) currently
pregnant or sexually active and not using birth control; 9) in foster care; 10) cognitive
functioning below age 8 years; 11) a caregiver not fluent in English or Spanish; or 12) child not
fluent in English.
2.2. Procedure
All procedures were approved by the Institutional Review Board (IRB) of the lead study
site. Families provided informed consent (parents) and assent (youth) at the time of study
enrollment and were compensated for their participation. All questionnaires were administered
via the online survey platform REDCap (Harris et al., 2019). Parent-report measures were given
in either English or Spanish based on the parent’s preferred language. All child-report
questionnaires were administered in English. The SCARED-5, SCARED-41, K-SADS-COMP,
CAIS, and basic demographics (e.g., child age, race, ethnicity, education) were collected as part
of the initial screening process. All other measures were completed at baseline.
2.3. Measures
2.3.1 Parent-report measures
2.3.1.1 Family accommodation. Family accommodation was assessed using the Family
Accommodation Scale – Anxiety (FASA; Lebowitz et al., 2013; Lebowitz, Marin, & Silverman,
2020). The FASA is a 13-item self-report instrument measuring a caregiver’s accommodation of
12
their child’s anxiety (e.g., “Have you avoided doing things, going places, or being with people
because of your child’s anxiety?”) The first 9 items assess the frequency of accommodation on a
5-point rating scale from 0 (“Never”) to 4 (“Daily”) while the remaining items assess child
responses to not receiving accommodation and caregiver distress associated with
accommodation. The first 9 items are summed into a total accommodation score with possible
scores ranging from 0-36. Higher scores indicate a greater degree of family accommodation. The
FASA demonstrates good to excellent internal consistency across validation studies (Cronbach’s
α = 0.87 – 0.91; Lebowitz et al., 2013, 2020). Within our sample, the FASA displays good
internal consistency in English (α = 0.86) and excellent internal consistency in Spanish (α =
0.91).
2.3.1.2 Parental anxiety. We measured parental anxiety using the Generalized Anxiety
Disorder scale (GAD-7; Spitzer et al., 2006), a 7-item self-report instrument for anxiety
symptoms. Items on the GAD-7 are rated using a 4-point scale from 0 to 3 (“Not at all” to
“Nearly every day”), indicating the frequency of a symptom during the previous two weeks (e.g.,
“Feeling nervous, anxious or on edge”). Total scores range from 0-21, with higher scores
indicating greater anxiety symptom severity. The GAD-7 shows excellent internal consistency in
validation samples (Cronbach’s α = 0.92; Spitzer et al., 2006) and good reliability in the current
sample in English (α = 0.88) and Spanish (α = 0.88).
2.3.1.3 Parent-rated child anxiety. Parents reported their child’s anxiety symptoms
using the Screen for Child Anxiety Related Disorders (SCARED-P), a 41-item self-report
instrument. Items include statements such as, “When my child feels frightened, it is hard for
him/her to breathe,” which parents rate on a scale from 0 to 2 (“Not true” to “Very true”). Total
scores range from 0-82, with higher scores indicating greater anxiety symptoms. The parent
13
version of the SCARED shows excellent reliability in validation studies (Cronbach’s α = 0.90;
Birmaher et al., 1999) and within our sample (English: α = 0.91; Spanish: α = 0.92).
2.3.1.4 Demographics. Parents completed a short demographics questionnaire on
preferred language(s), parents’ levels of education, race, ethnicity, income, and insurance status.
2.3.2. Youth-report measures
2.3.2.1. Child anxiety. Youth rated their own anxiety using the child version of the
Screen for Child Anxiety Related Disorders (SCARED-C), a self-report instrument assessing
anxiety symptoms. Youth answered items on a 3-point scale (0 = “Not true” to 2 = “Very true”).
The SCARED-C includes 41 items (e.g., "I get really frightened for no reason at all.") and has a
total possible score range of 0-82. The SCARED-C demonstrates excellent reliability from
validation studies (Cronbach’s α = 0.90; Birmaher et al., 1999) as well as in the current sample
(α = 0.91).
2.3.2.2. Anxiety avoidance. Anxiety avoidance was assessed by the self-report version of
the Child Avoidance Measure (CAMS; Whiteside et al., 2013). The CAMS consists of 8 items
on behavioral avoidance rated on a scale of 0-3 (“Almost never” to “Almost always”) for
frequency (e.g., “When I feel scared or worried about something I refuse to do it.”) Total scores
range from 0-24, with higher scores indicating greater behavioral avoidance. The CAMS has
good internal reliability in validation studies (Cronbach’s α = 0.89; Whiteside et al., 2013) and
within our sample (α = 0.81).
2.3.2.3. Self-efficacy. Youth self-efficacy was measured using the 10-item NIH Toolbox
Self-Efficacy Scale (Salsman et al., 2013). Children respond to statements such as “"I can
manage to solve difficult problems if I try hard enough" using a 5-point scale (1 = “Never” to 5 =
“Very Often”). Raw scores range from 10-50, with higher scores indicating higher self-efficacy.
14
To compare scores across age categories, raw scores were converted to unstandardized T scores
using the NIH Toolbox scoring manual (Scoring Instructions for NIH Toolbox® Emotion
Measures, 2019). The NIH Toolbox Self-Efficacy Scale demonstrates excellent internal
consistency with Cronbach’s α = 0.90 from validation studies (Salsman et al., 2013). Internal
consistency within the current sample was excellent for youth ages 8-12 (α = 0.92) and good for
youth ages 13-18 (α = 0.87).
2.3.2.4. Family functioning. Youth reported family functioning using the Family
Assessment Device - General Functioning Scale (FAD-12; Boterhoven de Haan et al., 2015).
The FAD-12 is a 12-item self-report questionnaire rated on a 4-point Likert scale from 1
(“Strongly agree”) to 4 (“Strongly disagree”). Items assess for aspects of both healthy family
functioning (e.g., “In times of crisis we can turn to each other for support”) and unhealthy family
functioning (e.g., “Planning family activities is difficult because we misunderstand each other.”)
Item responses are summed (even numbered items are reverse scored) and divided by 12 to
produce a total family functioning score between 1.0-4.0, with scores of 2.0 or higher suggesting
problematic family functioning. The FAD-12 displays excellent reliability in validation studies
(Cronbach’s α = 0.92; Epstein et al., 1983) and good reliability in the current sample (α = 0.89).
2.3.2.5. Emotion regulation. Emotion regulation was assessed by the Brief Version of
the Difficulties in Emotion Regulation Scale (DERS-16; Bjureberg et al., 2016). The DERS-16
contains 16 items rated on a 5-point scale from 1 (“Almost never”) to 5 (“Almost always”).
Example items include “When I am upset, I believe that I will remain that way for a long time.”
Total scores range from 16-80, with higher scores indicating greater difficulties with emotion
regulation. The DERS-16 displays excellent internal consistency in validation studies
(Cronbach’s α = 0.92; Bjureberg et al., 2016) and within our sample (α = 0.95).
15
2.4. Analysis
Data were analyzed with RStudio (version 4.2.2; R Core Team, 2022) using the
PROCESS macro for R (version 4.3.1) to perform mediation and moderation analyses (Hayes,
2022). Child age, sex, SES (i.e., family income), and ethnicity were included as covariates in all
models. As a result of low cell counts across several racial categories, race was not entered as a
covariate. To account for the potential effects of multiple observations from the same family,
only one child from each family was included in analyses. Bivariate correlations were run for all
variables to assess relationships between constructs. Continuous variables were scaled prior to
running models. To address our first aim, a regression model was used to estimate the effects of
parental anxiety and family functioning on family accommodation. For our second aim, we
conducted mediation analyses investigating the role of family accommodation across
relationships with youth anxiety. In the first set of models, family accommodation was assessed
as a mediator in the association between parental and child anxiety. The second set of models
investigated family accommodation as a mediator linking family functioning and child anxiety.
Considering the ongoing discourse within the field regarding the use of child versus parent
informants for youth psychopathology, separate models were run with child and parent-reported
anxiety as the outcome measure for all analyses involving child anxiety. To evaluate our third
aim, we ran a parallel mediation model predicting child anxiety from family accommodation
with self-efficacy, anxious avoidance, and emotion regulation as mediators. Mediation models in
Aims 2 and 3 were estimated using 10,000 bootstrapped samples to produce standardized
coefficients and 95% confidence intervals (CIs) for all pathways of each model. The proportion
mediated was also calculated for all significant mediation models. For our final aim, we
performed multiple linear regression followed by moderation analyses to investigate the effects
16
of child age, sex, SES, and ethnicity on the relationship between family accommodation and
child anxiety. Moderation models were run with 10,000 bias-corrected bootstrapped samples to
approximate standardized coefficients and 95% CIs. Robust standard errors were also calculated
to account for assumptions of homoskedasticity.
17
Chapter 3: Results
Demographic information for the full sample is provided in Table A1. Ninety participants
were excluded from analyses due to missing questionnaire or demographic data. Relative to the
analyzed sample (n = 245), participants with missing data reported on average lower annual
income (p = 0.03) and lower levels of family accommodation (p = 0.04). There were no
differences in age (p = 0.51), sex (p = 0.09), ethnicity (p = .55), preferred parent language (p = 1)
or child anxiety severity (SCARED-C: p = 0.21; SCARED-P: p = 0.54) between analyzed youth
and youth excluded due to missingness.
3.1 Descriptives and correlations of family accommodation and anxiety
Parent and child-report of youth anxiety were significantly positively correlated (r = 0.38,
p < .001; see Table A2 for pairwise correlations between constructs). Family accommodation
was strongly associated with parent-rated child anxiety (r = 0.39, p < .001), but not child selfreported anxiety. Family accommodation also demonstrated a negative relationship with age,
such that parents of older children reported less family accommodation (r = - 0.16), although this
relationship did not reach statistical significance after adjusting for multiple comparisons.
Female youth self-reported significantly higher anxiety compared to males in the sample, t(243)
= 3.26, p < .01 (see Table A3 for outcome descriptive statistics by sex). However, there were no
sex differences in reported levels of family accommodation, t(243) = -1.86, p = .06.
3.2. Aim 1: Relationship of parental mental health and family functioning on family
accommodation
We first characterized the associations between parental mental health and family
functioning with family accommodation (see Figure 1). Parental anxiety was positively related to
family accommodation after controlling for family functioning, child age, sex, ethnicity, and SES
18
(! = 0.383, SE = 0.061, p < .0001, CI [0.264, 0.503]). However, family functioning was not
significantly associated with family accommodation after controlling for parental mental health
and covariates (! = 0.054, SE = 0.062, p = 0.380, CI [-0.067, 0.176]; See Table C1 for model
output).
3.3. Aim 2: The mediating role of family accommodation
Next, we investigated whether family accommodation mediated the relationship between
parental anxiety and child anxiety. Given the theoretical rationale of family accommodation as a
potential mediator of the relationship between family functioning and child anxiety, we
conducted this analysis as outlined despite the Aim 1 results. Separate models were run with selfreported and parent-reported child anxiety each as the outcome while controlling for child age,
sex, ethnicity, and SES. All models were performed using PROCESS Model 4.
3.3.1 Family accommodation as a mediator of parent-child anxiety. The first model explored
family accommodation as a mediator of the relationship between parental anxiety and selfreported child anxiety (see Figure B2a). Parental anxiety was positively associated with youth
anxiety (! = .152, SE = 0.064, p = .018, CI [0.026, 0.277]) and family accommodation (! = .387,
SE = 0.060, p < .001, CI [0.270, 0.508]). Family accommodation was also positively related to
child anxiety severity (! = .170, SE = 0.068 p = .012, CI [0.034, 0.299]). As hypothesized,
parental anxiety demonstrated a significant indirect effect on child anxiety through family
accommodation (! = .066, SE = 0.028, CI [0.013, 0.125]). After accounting for the effects of
family accommodation, the direct effect of parental anxiety on child anxiety was non-significant
(! = .086, SE = 0.068, p = .210, CI [-0.049, 0.220]). The calculated proportion mediated
suggested family accommodation to account for approximately 43% of the variance in the
19
association parental anxiety and self-reported child anxiety (PM = [c-c’]/c = [0.1516-
0.0859]/0.1516 = 0.4333).
When considering parent-rated child anxiety as the outcome, parental anxiety also
significantly associated with parent-reported child anxiety (! = .348, SE = 0.062, p < .001, CI
[0.227, 0.470]), as well as family accommodation (! = .387, SE = 0.060, p < .001, CI [0.270,
0.508]; see Figure 2b). Family accommodation was positively related to child anxiety (! = .278,
SE = 0.068, p < .001, CI [0.149, 0.416]). As in the previous model, parental anxiety had a
significant indirect effect on child anxiety through family accommodation (! = .107, SE = 0.032,
CI [0.052, 0.176]). Once we adjusted for family accommodation, the direct effect of parental
anxiety on youth anxiety decreased in magnitude but remained significant (! = .241, SE = 0.064,
p < .001, CI [0.114, 0.367]), suggesting partial mediation of the relationship. Analyses revealed
31% of the total effect of parental anxiety on parent-rated youth anxiety to be accounted for by
family accommodation (PM = [0.3481 – 0.2408]/0.3481 = 0.3082).
3.3.2. Family accommodation as mediator of family functioning on child anxiety. We then
tested whether the relationship between family functioning and child anxiety was mediated by
family accommodation (see Figure B2c). Family functioning problems and family
accommodation were significantly associated with youth self-reported anxiety (! = .134, SE =
0.061, p = .038, CI [0.012, 0.250] and ! = .193, SE = 0.062, p = .002, CI [0.070, 0.312],
respectively). However, family functioning did not significantly associate with family
accommodation (! = .078, SE = 0.073, p = .240, CI [-0.068, 0.219]). As such, we did not detect
an indirect effect of family functioning on child anxiety through family accommodation (! =
.015, SE = 0.016, CI [-0.012, 0.053]), suggesting no presence of mediation.
20
In the model with parent-rated youth anxiety, family functioning was not significantly
related to youth anxiety (! = .050, SE = 0.068, p = .423, CI [-0.082, 0.182]) or family
accommodation (! = .078, SE = 0.073, p = .240, CI [-0.068, 0.219]; see Figure 2d). Family
accommodation, however, was significantly related to youth anxiety (! = .365, SE = .065, p <
.001, CI [0.242, 0.495]). A test of the indirect effect similarly indicated no mediation of family
functioning on child anxiety through family accommodation (! = .029, SE = 0.028, CI [ -0.025,
0.0.87]). See Table C2 for Aim 2 model outputs.
3.4. Aim 3: Anxious avoidance, self-efficacy, and emotion regulation as mediators of family
accommodation and child anxiety
Anxious avoidance, self-efficacy, and emotion regulation were entered into a parallel
mediation model estimating youth anxiety from family accommodation. As outlined in Aim 2,
separate models were conducted with self-reported and parent-reported youth anxiety each
serving as the outcome, adjusting for child age, sex, ethnicity, and SES.
In the first model with youth-reported anxiety, family accommodation significantly
associated with youth anxiety (! = .202, SE = 0.062, p = .001, CI [0.079, 0.325]) and emotion
regulation difficulties (! = .177, SE = 0.063, p = .006, CI [0.053, 0.303]), but not self-efficacy (!
= -.025, SE = 0.063, p = .692, CI [-0.151, 0.098]) or child anxious avoidance (! = .115, SE =
0.072, p = .071, CI [-0.030, 0.249]). Youth anxiety was positively related to emotion regulation
difficulties (! = .361, SE = 0.062, p < .001, CI [0.241, 0.486]) and anxious avoidance (! = .262,
SE = 0.061, p < .001, CI [0.145, 0.381]), but not self-efficacy (! = -.084, SE = 0.061, p = .135,
CI [-0.208, 0.034]). After accounting for self-efficacy, anxious avoidance, and emotion
regulation difficulties as mediators, the direct effect of family accommodation on youth anxiety
reduced in size but retained statistical significance (! = .106, SE = .054, p = .049, CI [0.000,
21
0.212]), implying partial mediation. Analyses revealed a significant indirect effect for emotion
regulation difficulties (! = .064, SE = 0.025, CI [0.019, 0.117]), but not self-efficacy (! = .002,
SE = 0.007, CI [-0.010, 0.018]) or anxious avoidance (! = .030, SE = 0.020, CI [-0.008, 0.072]),
suggesting emotion regulation difficulties to be responsible for the mediation effects of the
model. Proportion mediated analyses suggested the mediators to account for 47% of the total
effect of family accommodation on youth anxiety (PM = [0.2024 – 0.1064]/0.2024 = 0.4743).
Model results are shown in Figure B3a.
With parent-reported anxiety as the model outcome, family accommodation was similarly
significantly related to youth anxiety (! = .368, SE = .060, p < .001, CI [0.250, 0.487]). As in the
first model, family accommodation significantly associated with emotion regulation difficulties
(! = .177, SE = .063, p = .006, CI [0.053, 0.303]), but not self-efficacy (! = -.025, SE = .063, p =
.692, CI [-0.151, 0.098]) or anxious avoidance (! = .115, SE = .072, p = .077, CI [-0.030, 0.249];
see Figure 3b). Self-efficacy was related to youth anxiety but not robust due to bootstrapping (!
= -.139, SE = .074, p = .028, CI [-0.288, 0.003]). Emotion regulation difficulties and anxious
avoidance were not associated with youth anxiety (DERS: ! = .014, SE = .069, p = .826, CI [-
0.120, 0.151]; CAMS: ! = .080, SE = .064, p = .200, CI [-0.047, 0.203]). No significant indirect
effects were detected for emotion regulation difficulties (! = .003, SE = .013, CI [-0.024, 0.030),
self-efficacy (! = .004, SE = .010, CI [-0.016, 0.026]), or anxious avoidance (! = .009, SE =
.010, CI [-0.007, 0.033]). See Table C3 for model outputs.
3.5. Aim 4: Demographic moderators of the relationship between family accommodation
and child anxiety
Moderation analyses were performed to assess whether family accommodation and its
relationship with child anxiety differed by sociodemographic characteristics. First, multiple
22
linear regression was used to evaluate the relationship between youth anxiety (child and parentreported) and family accommodation while including sociodemographic characteristics (i.e., age,
sex, ethnicity, and SES) as covariates. Self-reported child anxiety was related to family
accommodation (! = .202, SE = .062, p = .001, CI [0.079, 0.325]), child age (! = .169, SE =
.063, p = .008, CI [0.045., 0.294]), and sex (! = - .451, SE = .142, p = .002, CI [-0.731, -0.172]).
However, parent-reported youth anxiety was only significantly related to family accommodation
(! = .368, SE = .060, p < .001, CI [0.250, 0.487]). Neither model suggested youth anxiety or
family accommodation to be significantly associated with ethnicity or SES. Following these
initial analyses, we ran two double moderation models using PROCESS Model 2 including age
and sex as moderators of the relationship between family accommodation and youth anxiety (self
and parent-reported) while controlling for ethnicity and SES as covariates.
In the first model, family accommodation, age, and sex independently associated with
self-reported youth anxiety (FASA: ! = .158, SE = .073, p = .037, CI [0.017, 0.306]; Age: (! =
.169, SE = .065, p = .010, CI [-0.045, 0.301]; Sex: ! = - .477, SE = .157, p = .003, CI [-0.768, -
0.154]). However, the interaction between family accommodation and age was not significant (!
= .081, SE = .062, p = .194, CI [-0.043, 0.198]), suggesting no moderating effect of age on the
relationship between family accommodation and youth self-reported anxiety. Similarly, the
interaction between family accommodation and sex was non-significant, indicating no
moderation of sex on the association between family accommodation and self-reported youth
anxiety (! = .143, SE = .151, p = .359, CI [-0.165, -0.436]; see Figure B4a).
In the second model using parent-reported youth anxiety as the outcome, family
accommodation was associated with youth anxiety (! = .342, SE = .080, p < .001, CI [0.185,
0.500]), but age and sex were not (Age: (! = - .040, SE = .061, p = .520, CI [-0.158, 0.083]; Sex:
23
! = - .164, SE = .131, p = .217, CI [-0.417, 0.104]). The interactions between family
accommodation and age and family accommodation and sex were also not significant,
suggesting no moderating effect (FASA x Age: (! = - .029, SE = .067, p = .684, CI [-0.163,
0.099]; FASA x Sex: ! = .088, SE = .138, p = .546, CI [-0.174, -0.368]). See Table C4 for model
outputs.
24
Chapter 4: Discussion
The current study investigated familial and child correlates of family accommodation and
youth anxiety in a large sociodemographically diverse sample of youth. These findings extend
prior research by elucidating connections among established and previously unexplored
constructs in the context of family accommodation, broadening our understanding of factors
important to the presentation and course of pediatric anxiety.
Consistent with prior research, parental anxiety significantly associated with youth
anxiety (child and parent-rated) and family accommodation. Furthermore, family
accommodation fully mediated the relationship between parental anxiety and youth self-reported
anxiety and partially mediated the relationship between parental anxiety and parent-reported
youth anxiety, providing preliminary support for a framework through which parental anxiety
contributes to child anxiety outcomes. Further in line with previous findings, family functioning
significantly related to youth self-reported anxiety. Despite research linking family functioning
and family accommodation in studies of OCD, we did not find evidence of this relationship in
our sample. As such, family accommodation was not found to mediate the association between
family functioning and youth anxiety.
As hypothesized, family accommodation was significantly associated with both child and
parent reports of youth anxiety. Moreover, our analyses revealed child emotion regulation
difficulties to partially explain the relationship between family accommodation and self-reported
youth anxiety. This finding provides new insight for understanding the link between family
accommodation and child anxiety by identifying emotion regulation as a potential mechanism
underlying this association. Further, this relationship is specific to emotion regulation, as we did
25
not find evidence for self-efficacy or child anxious avoidance to mediate the relation between
family accommodation and youth anxiety.
Finally, we sought to understand sociodemographic differences in family accommodation
and whether its association with child anxiety depended on sociodemographic characteristics. As
hypothesized, family accommodation was associated with younger age after accounting for child
and parent-rated youth anxiety. However, age did not moderate the association between family
accommodation and child anxiety. Further, we found no differences in family accommodation by
sex, ethnicity, or SES.
This study is the first to our knowledge to examine familial and child correlates of family
accommodation in the context of pediatric anxiety among a sociodemographically diverse
sample of youth. Previous research on family accommodation of youth anxiety and its correlates
has focused on predominately White and high SES samples, potentially limiting the
generalizability of findings to more diverse and representative populations. The current sample
identified as predominately Hispanic/Latino and encompassed a wide range of socioeconomic
backgrounds.
Although we did not observe differences in family accommodation by ethnicity, it is
important to note our sample lacked sufficient power to examine differences across all racial
categories, which necessitated grouping by ethnicity and may have resulted in the loss of
meaningful group differences. However, it is also critical to acknowledge the heterogenous
nature of cultural experiences within racial and ethnic groups and the limitations of using racial
and ethnic identity as a proxy for cultural experiences (Acevedo et al., 2020). Subsequent
research on family accommodation should include direct measures of culture to understand how
family accommodation may vary across cultural subgroups. Despite this limitation, the diversity
26
of participants in the current study advances the literature on family accommodation to reflect
more inclusive samples of youth. Future studies should prioritize inclusion of participants from
all backgrounds to provide greater insights into our understanding of the experiences of family
accommodation and anxiety for historically underserved and understudied racially and ethnically
minoritized youth.
Furthermore, we did not find associations between SES and child anxiety or family
accommodation. While existing studies on family accommodation have not identified
associations with SES (Lebowitz et al., 2013), previous research has found associations between
SES and youth anxiety (Farrell et al., 2009; Lemstra et al., 2008; Zhu et al., 2019). Our absence
of findings related to SES may be due to the use of income as our sole proxy for SES. Research
suggests alternative indicators of SES such as parental educational attainment and occupation to
be more accurate and less prone than reports of income to response bias (Diemer et al., 2013),
which may have affected the observed associations among our constructs of interest. As such, it
is important for future studies investigating these relationships to consider incorporating
additional measures of SES.
While we did not find associations with between family accommodation and ethnicity or
SES, we did see associations between family accommodation and age. Younger age
corresponded to higher levels of family accommodation in our sample, consistent with some
previous work (Thompson-Hollands et al., 2014). However, age did not moderate the
relationship between family accommodation and child anxiety in contrast to our hypotheses. One
explanation for this finding may be that while younger age is associated with greater levels of
family accommodation, the impact of family accommodation persists throughout development
due to other factors maintaining its effect on youth anxiety. For instance, our finding that
27
emotion regulation difficulties mediate the association between family accommodation and
youth anxiety while controlling for age may indicate that emotion regulation difficulties sustain
this relationship regardless of a child’s age. Further, we did not observe associations between
family accommodation and sex. Although parents of male children reported higher average
family accommodation compared to parents of female youth, this association was not significant
after controlling for age, youth anxiety, ethnicity, and SES.
In contrast to the work on family accommodation and OCD, we did not observe an
association between family functioning and family accommodation. This may be related to
differences in the manifestation of symptoms and requests for accommodation between
disorders. For instance, pediatric OCD symptoms may involve behaviors that more directly
disrupt routines and cause stress (e.g., checking), thus compelling parents to accommodate more
readily to prevent further disruption or conflict. In fact, findings suggest families with greater
levels of conflict to have more trouble refraining from participating in OCD rituals (Peris et al.,
2012). It is plausible that it is more challenging for families with lower levels of functioning to
resist engaging in the types of accommodations common to OCD (e.g., participating in rituals)
compared to those typically associated with pediatric anxiety. Future research studies should
seek to further understand these differences.
Our study yielded two primary findings: first, family accommodation mediates the
association between parental anxiety and child anxiety. Second, the relation between family
accommodation and child anxiety is partially explained by emotion regulation difficulties. The
identification of family accommodation as a potential mechanism connecting parental and child
anxiety underscores family accommodation as an important intervention target for promoting
youth mental health, particularly in families with anxious parents. While anxious parents engage
28
in a range of behaviors linked to worsened anxiety outcomes for their children (Ginsburg et al.,
2004), family accommodation is shown to be particularly responsive to intervention. Recent
work aimed at reducing family accommodation has found family accommodation interventions
to be as effective in reducing child anxiety as Coping Cat, a well-established CBT anxiety
intervention (Kagan et al., 2023). Such findings provide further evidence for the significant role
of family accommodation in maintaining child anxiety. Moreover, our results identify additional
factors relevant to the maintenance of youth anxiety through family accommodation.
Specifically, emotion regulation may be a key component in understanding why reductions in
family accommodation correspond to improvements in child anxiety. In fact, one study of a
family accommodation intervention showed reductions in family accommodation to be linked to
improvements in both child emotion regulation and anxiety (Hassanzadeh-Avval et al., 2022).
Our results offer an empirical framework for understanding this pattern. While further study is
needed to identify the precise manner through which emotion regulation difficulties mediate this
relationship, it is possible that acts of family accommodation limit opportunities for youth to
develop effective emotion regulation skills, making it more challenging for them to manage their
anxiety successfully.
Although self-efficacy and anxious avoidance were strongly correlated with self-reported
child anxiety in our sample, neither demonstrated a statistically significant association with
family accommodation nor mediated the relationship between family accommodation and youth
anxiety. These findings partially reflect prior work. For example, Kitt et al. (2022) did not find a
statistically significant association between family accommodation and self-efficacy after
controlling for anxiety symptoms. However, they did see an association between anxious
avoidance and youth anxiety. It is unclear why we did not this same relationship in our sample.
29
This may be due to our use of a youth self-report avoidance measure whereas as Kitt et al. (2022)
used clinician ratings and behavioral tasks to measure avoidance. As theorized by Kitt and
colleagues (2022), it is possible different measures of avoidance assess separate aspects of a
larger construct of avoidance. Further, the absence of a relationship between anxious avoidance
and family accommodation could be related to our use of both parent and child-report measures
to assess the associations among family accommodation, youth anxiety, and child mediators.
That is, our hypothesized mediating variables were measured via youth self-report, while family
accommodation relied on parent-report, and both parent and child-report were used to assess
anxiety. While measures completed by the same informant in our study demonstrated a high
degree of intercorrelation among themselves, we did not observe strong associations for crossinformant measures apart from the SCARED. Some research on parent-child reporting suggests
evidence of this phenomenon for youth psychopathology reporting (Kazdin et al., 1983). Future
studies may mitigate these concerns by using a consistent informant across constructs.
Furthermore, we did not observe the same patterns of results across models with selfreport youth anxiety and parent-report youth anxiety as the outcome. Specifically, family
accommodation partially mediated the association between parental anxiety and parent-rated
youth anxiety but fully mediated this association when modeling youth self-reported anxiety.
Similarly, emotion regulation difficulties mediated the relationship between family
accommodation and self-reported youth anxiety but not parent-reported youth anxiety. Although
these findings were unexpected, research on parent-child informant discrepancies may offer
insight into these patterns. Parent-child informant discrepancies are common among studies of
the SCARED and reports of youth psychopathology more broadly (Behrens et al., 2019; De Los
Reyes, 2011). Importantly, these discrepancies may provide meaningful information, helping to
30
inform a more comprehensive picture of youth psychopathology than the consideration of either
parent or child reports alone (De Los Reyes, 2011). Youth social anxiety research has
demonstrated parent and child-reports of the SCARED to differentially predict symptoms across
varying contexts, suggesting parent and child-reports to offer distinct but valuable perspectives
that both warrant consideration (Bowers et al., 2020). The differential associations observed in
our models using parent vs. child-reported SCARED may also provide meaningful information
about family accommodation and its correlates, highlighting the potential for further study.
This study possesses several strengths, yet its limitations must also be noted. First, the
cross-sectional design of our study is correlational in nature, limiting any conclusions about
causality or directionality from our mediation analyses. As a result, there can be multiple
interpretations regarding the directions of relationships between constructs, particularly in the
context of our mediation analyses (e.g., increased family accommodation could lead to increased
emotion regulation difficulties or emotion regulation difficulties could result in increased family
accommodation). In fact, recent research has suggested there to be a bidirectional relationship
between family accommodation and child anxiety, such that they elicit and reinforce one another
(Bertelsen et al., 2023). Given our findings, it is possible that emotion regulation may contribute
to this dynamic. Future investigations should assess these constructs at multiple time points to
explore the role of emotion regulation in the bidirectional relationship between family
accommodation and youth anxiety. Moreover, future studies should examine the associations
between parental anxiety, family accommodation, and child anxiety longitudinally to clarify
temporal precedence and directionality of relationships.
The present study is further limited by its use of self-report data, which may reflect
respondent biases (Paulhus & Vazire, 2007). As detailed above, some of our findings were not
31
observed across both child and parent-reported youth anxiety, raising questions about the
meaningfulness of informant discrepancies in the context of these relationships. Future studies
should consider utilizing alternatives to self-report to measure constructs (e.g., observational
and/or behavioral measures). This may get at a “truer” measure of these constructs and eliminate
the need for reconciling reporter discrepancies.
In conclusion, this study provides insights into the relationships among factors important
to understanding family accommodation and pediatric anxiety. Specifically, these findings
underscore the importance of considering both familial and child factors in the maintenance of
youth anxiety and treatment planning. In identifying the mediating role of family
accommodation in the link between parental and child anxiety, this study sheds light on the
processes through which parental mental health influences child mental health outcomes.
Further, this finding may highlight the value of utilizing collaborative youth therapy approaches
involving parents, particularly in identifying and addressing patterns of accommodation for
anxious parents that may inadvertently reinforce or exacerbate their child’s anxiety. By tailoring
interventions to anxious parents and providing psychoeducation that enables them to recognize
how their own behaviors contribute to their child’s anxiety, clinicians can guide parents toward
more effective and supportive responses to their child’s anxiety. Further, our identification of
emotion regulation as a potential mechanism underlying the association between family
accommodation has promise to inform individualized treatment planning. For youth whose
parents tend to engage in family accommodation, emotion regulation training may be a
particularly important focus area to equip youth with skills to manage their own anxiety more
effectively and mitigate the impact of family accommodation. Taken together, these findings
32
offer meaningful insights into the interplay of familial and child factors in the context of youth
anxiety with potential to inform future intervention efforts.
33
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Appendix A: Tables
A.1. Table 1 Sample demographic characteristics.
Full sample
(N = 335)
Analyzed sample
(n = 245)
n % n %
Sex
Female 236 70.4 180 73.5
Male 99 29.6 65 26.5
Age [M SD] 13.02 2.7 12.97 2.6
Race
American Indian or Alaska Native 2 0.6 2 0.8
Asian 10 3.0 5 2.0
Black or African American 18 5.4 10 4.1
Native Hawaiian or Other Pacific Islander 2 0.6 2 0.8
White 92 27.5 77 31.4
Multiracial 18 5.4 15 6.1
Other 6 1.8 5 2.0
Hispanic: No race stated 182 54.3 129 52.7
Missing 4 1.2 0 0
Ethnicity
Hispanic, Latino, or Spanish 225 67.2 164 66.9
Non-Hispanic 105 31.3 81 33.1
Missing 5 1.5 0 0
Preferred Language
English 218 65.1 159 64.9
Spanish 117 34.9 86 35.1
Annual Household Income
< 20,000 71 21.2 58 23.7
20,000 – 49,999 69 20.6 60 24.5
50,000 – 89,999 47 14.0 30 16.3
90,000 – 119,999 23 6.9 21 8.6
> 120,000 71 21.2 66 26.9
Missing 54 16.1 0 0
Insurance Provider
Children’s Health Insurance Program (CHIP) 2 0.6 2 0.8
Exclusive Provider Organization (EPO) 2 0.6 2 0.8
Health Maintenance Organization (HMO) 53 15.8 41 16.7
Medi-Cal 191 57.0 143 58.4
Point of Service (POS) 65 19.4 55 2.5
Preferred Provider Organization (PPO) 8 2.4 2 0.8
Missing 14 4.18 0 0
41
A.2. Table 2 Pairwise correlations between constructs.
Child
Anxiety
(Self-Report)
Child Anxiety
(ParentReport) Family Accommodation Family Functioning Parental Anxiety Self- Efficacy Emotion Regulation Anxious Avoidance Income Age Sex Ethnicity
Child Anxiety (Self-Report) -
Child Anxiety (Parent-Report) 0.38*** -
Family Accommodation 0.15 0.37*** -
Family Functioning 0.19 0.09 0.04 -
Parental Anxiety 0.12 0.34*** 0.39*** 0.04 -
Self-Efficacy - 0.27*** - 0.15 0.02 - 0.35*** - 0.05 -
Emotion Regulation 0.49*** 0.11 0.14 0.30*** 0.16 - 0.27*** -
Anxious Avoidance 0.39*** 0.14 0.11 0.02 0.09 - 0.16** 0.27*** -
Income - 0.04 - 0.13 - 0.04 - 0.16 - 0.17 0.06 0.07 0.05 -
Age 0.17 - 0.07 - 0.16 0.24** - 0.10 - 0.24** 0.15 - 0.08 - 0.06 -
Sex - 0.28** - 0.03 0.16 - 0.11 0.14 0.19** - 0.12 - 0.16 - 0.05 - 0.24** -
Ethnicity 0.04 0.18* 0.01 0.26*** - 0.03 - 0.09 - 0.04 - 0.09 - 0.67*** 0.11 - 0.04 -
P values for correlations between continuous variables are adjusted for multiple comparisons using the Holm method. *p < .05; **p < .01; ***p < .001. Sex: 0 = Female, 1 = Male;
Ethnicity: 0 = Non-Hispanic, 1 = Hispanic.
42
A.3. Table 3 Means and standard deviations for measures by sex (n = 245).
Total Sample Females Males Test of Difference
Child Anxiety (Self-Report) (SCAREDC) 42.89 (14.08) 44.62 (13.44) 38.11 (14.80) t(243) = 3.26**
Child Anxiety (Parent-Report)
(SCARED-P) 38.53 (14.39) 38.70 (14.16) 38.08 (15.09) t(243) = 0.30
Family Accommodation (FASA) 13.68 (8.02) 13.11 (7.77) 15.26 (8.54) t(243) = -1.86
Family Functioning (FAD-12) 2.04 (0.56) 2.07 (0.57) 1.97 (0.55) t(243) = 1.26
Parental Anxiety (GAD-7) 6.54 (4.91) 6.23 (4.78) 7.38 (5.18) t(243) = -1.63
Self-Efficacy (NIHTB-SE) 40.33 (9.51) 39.53 (9.71) 42.55 (8.59) t(243) = -2.21*
Emotion Regulation (DERS) 44.07 (15.99) 44.89 (15.83) 41.79 (16.32) t(243) = 1.35
Anxious Avoidance (CAMS) 14.37 (4.88) 14.71 (4.79) 13.43 (5.03) t(243) = 1.81
Means and standard deviations for study measures in analyzed sample grouped by sex. T-tests were
conducted to examine sex differences. *p < .05; **p < .01.
43
Appendix B: Figures
B.1. Figure 1. Parental anxiety, but not family functioning, significantly associated with family
accommodation. Values reflect standardized coefficients. Dotted lines denote insignificant paths.
***p < .001.
44
B.2. Figure 2. Family accommodation fully mediated the association between parental anxiety
and self-reported child anxiety (model A; indirect effect: ! = .066) and partially mediated the
association between parental anxiety and parent-reported child anxiety (model B; indirect effect:
! = .107). Family accommodation did not mediate the relation between family functioning and
self-reported child anxiety (model C; indirect effect: ! = .015) or parent-reported child anxiety
(model D; indirect effect: ! = .029). Dotted lines denote insignificant paths. *p < .05;
***p < .001.
Parental Anxiety Child Anxiety
(Parent-Report)
Family
Accommodation
c’ = .241***
a = .387***
c = .348***
b = .278***
b.
Parental Anxiety Child Anxiety
(Self-Report)
Family
Accommodation
c = .152*
c’ = .086
a= .387***
b = .170*
a.
Child Anxiety
(Parent-Report)
Family
Accommodation
Family
Functioning
c’ = .050
a = .078
c = .079
b = .365***
d.
Family
Functioning
Child Anxiety
(Self-Report)
Family
Accommodation
c’ = .134*
a = .078
c = .149*
b = .193**
c.
45
B.3. Figure 3. Self-efficacy, emotion regulation, and anxious avoidance partially mediated the
association between family accommodation and child self-reported anxiety. This effect was not
observed for parent-reported child anxiety. Model A indirect effects: Self-efficacy (SE): ! =
.002; Emotion regulation (ER): ! = .064; Anxious avoidance (AA): ! = .030. Model B indirect
effects: SE: ! = .004; ER: ! = .003; AA: ! = .009. Dotted lines denote insignificant paths.
*p < .05; **p < .01; ***p < .001.
Family
accommodation
Self-efficacy
Anxious avoidance
Emotion regulation
c = .202*
c’ = .106*
Child Anxiety
(Self-Report)
a1
= -.025
a2
= .177**
a3 = .115
b1 = -
b
.084
2 = .361***
b3 = .262***
a.
Family
accommodation
Self-efficacy
Anxious avoidance
Emotion regulation
c = .368***
c’ = .353***
Child Anxiety
(Parent-Report)
b1 = -
b
.139*
2 = .014
b3 = .080
a1
= -.025
a2 = .177**
a3 = .115
b.
46
B.4. Figure 4. Age and sex did not moderate the association between family accommodation and
child anxiety (self or parent-reported). Dotted lines denote insignificant paths. *p < .05;
**p < .01; ***p < .001.
Family
accommodation
Child Anxiety
(Self-Report)
Age
! = 0.158*
! = 0.081
Sex
! = 0.143
! = 0.169*
! = - .477**
a.
Family
accommodation
Child Anxiety
(Parent-Report)
Age
! = 0.342***
! = - .029
Sex
! = 0.088
! = - 0.040
! = - .164
b.
47
Appendix C: Model Outputs
C.1. Table C1 Model outputs for Aim 1.
95% CI
Model Dependent Variable Predictor Variable Estimate (!) SE BootLLCI BootULCI p
1 Family Accommodation Parental Anxiety .383 0.061 0.264 0.503 < .001
Family Functioning .054 0.062 - 0.067 0.176 .380
Sex .146 0.136 - 0.122 0.413 .285
Age - .124 .062 - 0.245 - 0.002 .046
Ethnicity .101 .148 - 0.191 0.393 .498
Income .051 .070 - 0.088 0.190 .471
SE = standard error, BootLLCI = bootstrapped lower limit confidence interval, BootULCI = bootstrapped upper limit confidence interval.
48
C.2. Table C2 Model outputs for Aim 2.
95% CI
Model Dependent Variable Predictor Variable Estimate (!) SE BootLLCI BootULCI p
2a/b Family Accommodation Parental Anxiety .387 .060 0.270 0.508 < .001
Sex .140 .139 - 0.126 0.415 .303
Age - .112 .059 -0.229 0.002 .064
Ethnicity .118 .134 -0.148 0.378 .424
Income .048 .077 -0.110 0.196 .498
2a Child Anxiety (Self-Report) Parental Anxiety .086 .067 -0.048 0.215 .210
Family Accommodation .170 .068 .034 0.299 .012
Sex - .459 .153 -0.754 -0.157 .001
Age .172 .065 0.045 0.299 .007
Ethnicity .005 .147 -0.278 0.296 .974
Income - .013 .071 -0.122 0.164 .860
Total Effect (c) .152 .064 0.026 0.277 .018
Direct Effect (c’) .086 .068 -0.049 0.220 .210
Indirect Effect (a*b) .066 .028 0.013 0.125 -
2b Child Anxiety (Parent-Report) Parental Anxiety .241 .070 0.103 0.376 < .001
Family Accommodation .278 .068 0.149 0.416 < .001
Sex -.177 .131 -0.438 0.077 .186
Age - .028 .059 -0.145 0.088 .642
Ethnicity .297 .141 0.021 0.572 .041
Income - .008 .059 -0.114 0.117 .905
Total Effect (c) .348 .062 0.227 0.470 < .001
Direct Effect (c’) .241 .064 0.114 0.367 < .001
Indirect Effect (a*b) .107 .032 0.052 0.176 -
2c/d Family Accommodation Family Functioning .078 .073 -0.068 0.219 .240
Sex .213 .152 -0.083 0.514 .147
Age - .162 .066 -0.290 -0.035 .015
Ethnicity - .017 .138 -0.298 0.249 .915
Income - .039 .078 -0.195 0.108 .601
2c Child Anxiety (Self-Report) Family Functioning .134 .061 0.012 0.250 .038
Family Accommodation .193 .062 0.070 0.312 .002
Sex - .437 .152 - 0.731 - 0.139 .002
Age .139 .066 0.008 0.271 .032
Ethnicity - .060 .146 -0.344 0.230 .696
Income - .023 .068 - 0.124 0.147 .752
Total Effect (c) .149 .065 0.021 0.277 .023
Direct Effect (c’) .134 .064 0.008 0.260 .038
Indirect Effect (a*b) .015 .016 - 0.012 0.053 -
2d Child Anxiety (Parent-Report) Family Functioning .050 .068 -0.082 0.182 .423
Family Accommodation .365 .065 0.242 0.495 < .001
Sex - .150 .134 - 0.418 0.112 .277
Age - .046 .063 -0.169 0.076 .461
Ethnicity .213 .139 -0.061 0.480 .154
Income - .058 .053 - 0.158 0.058 .404
Total Effect (c) .079 .067 - 0.053 0.210 .239
Direct Effect (c’) .050 .062 - 0.073 0.173 .423
Indirect Effect (a*b) .029 .028 - 0.025 0.087 -
SE = standard error, BootLLCI = bootstrapped lower limit confidence interval, BootULCI = bootstrapped upper limit confidence interval.
49
C.3. Table C3 Model outputs for Aim 3.
95% CI
Model Dependent Variable Predictor Variable Estimate (!) SE BootLLCI BootULCI p
3a/b Self-Efficacy (SE) Family Accommodation - .025 .063 - 0.151 0.098 .692
Sex .237 .136 -0.027 0.505 .101
Age - .219 .068 - 0.351 -0.085 < .001
Ethnicity - .054 .143 - 0.336 0.231 .729
Income .039 .058 -0.082 0.153 .591
Emotion Regulation Difficulties (ER) Family Accommodation .177 .063 0.053 0.303 .006
Sex - .168 .155 - 0.467 0.145 .249
Age .166 .064 0.040 0.291 .011
Ethnicity - .011 .144 -0.297 0.266 .946
Income .080 .066 -0.067 0.197 .280
Anxious Avoidance (AA) Family Accommodation .115 .072 - 0.030 0.249 .077
Sex - .330 .151 - 0.624 - 0.032 .025
Age - .084 .069 - 0.219 0.052 .197
Ethnicity - .136 .145 - 0.426 0.136 .388
Income .012 .064 - 0.132 0.122 .876
3a Child Anxiety (Self-Report) Family Accommodation .106 .051 .008 .207 .049
Self-Efficacy - .084 .061 - 0.208 0.034 .135
Emotion Regulation Difficulties .361 .062 0.241 0.486 < .001
Anxious Avoidance .262 .061 0.145 0.381 < .001
Sex - .285 .129 -0.536 - 0.033 .020
Age .113 .056 .002 .222 .044
Ethnicity .015 .133 - 0.240 0.279 .908
Income - . 060 .071 - 0.164 0.118 .323
Total Effect (c) .202 .062 0.079 0.325 .001
Direct Effect (c’) .106 .054 0.000 0.212 .049
Indirect Effect of SE (a1*b1) .002 .007 - 0.010 0.018 -
Indirect Effect of ER (a2*b2) .064 .025 0.019 0.117 -
Indirect Effect of AA (a3*b3) .030 .020 -0.008 0.072 -
3b Child Anxiety (Parent-Report) Family Accommodation .353 .064 0.232 0.484 < .001
Self-Efficacy - .139 .074 - 0.288 0.003 .028
Emotion Regulation Difficulties .014 .069 - 0.120 0.151 .826
Anxious Avoidance .080 .064 - 0.047 .203 .200
Sex - .093 .136 - 0.364 0.170 .498
Age - .061 .061 - 0.179 0.059 .332
Ethnicity .231 .135 - 0.041 0.486 .115
Income - .058 .052 -0.155 0.053 .398
Total Effect (c) .368 .060 0.250 0.487 < .001
Direct Effect (c’) .353 .061 0.234 0.473 < .001
Indirect Effect of SE (a1*b1) .004 .010 - 0.016 0.026 -
Indirect Effect of ER (a2*b2) .003 .013 - 0.024 0.030 -
Indirect Effect of AA (a3*b3) .009 .010 - 0.007 0.033 -
SE = standard error, BootLLCI = bootstrapped lower limit confidence interval, BootULCI = bootstrapped upper limit confidence interval.
50
C.4. Table C4 Model outputs for Aim 4.
95% CI
Model Dependent Variable Predictor Variable Estimate (!) SE BootLLCI BootULCI p
4a Child Anxiety (Self-Report) Family Accommodation .158 .073 0.017 0.306 .037
Age .169 .065 0.045 0.301 .010
Family Accommodation x Age .081 .062 - 0.043 0.198 .194
Sex - .477 .157 - 0.768 - 0.154 .003
Family Accommodation x Sex .143 .151 - 0.165 0.436 .359
Ethnicity - .017 .145 - 0.313 0.254 .910
Income - .028 .068 - 0.133 0.137 .710
4b Child Anxiety (Parent-Report) Family Accommodation .342 .080 0.185 0.500 < .001
Age - .040 .061 - 0.158 0.083 .520
Family Accommodation x Age - .029 .067 - 0.163 0.099 .684
Sex - .164 .131 - 0.417 0.104 .217
Family Accommodation x Sex .088 .138 - 0.174 0.368 .546
Ethnicity .223 .135 - 0.054 0.478 .107
Income - .061 .053 - 0.162 0.049 .203
SE = standard error, BootLLCI = bootstrapped lower limit confidence interval, BootULCI = bootstrapped upper limit confidence interval.
Abstract (if available)
Abstract
Background: Family accommodation is recognized to contribute to the maintenance of pediatric anxiety. Despite its importance, research examining correlates of family accommodation in the context of youth anxiety remains limited, with even fewer studies investigating these relationships among representative samples. This study aimed to elucidate associations among familial and child correlates of family accommodation and youth anxiety within a sociodemographically diverse sample of youth.
Method: Clinically anxious youth 8-18 years were recruited in the context of a trial investigating anxiety treatment sequencing. Children and their parents completed questionnaires used to investigate the associations of familial and child factors with family accommodation and youth anxiety. We also examined potential sociodemographic moderators of the association between family accommodation and youth anxiety.
Results: Parental mental health was strongly associated with family accommodation. Further, family accommodation mediated the link between parental and self-reported youth anxiety. Emotion regulation difficulties partially mediated the association between family accommodation and self-reported youth anxiety. We did not find evidence for sociodemographic moderators of the relationship between family accommodation and youth anxiety.
Significance: This study provides new insights into the relationships among factors critical to understanding family accommodation and child anxiety. Our results highlight the role of family accommodation in the link between parental and child anxiety. Furthermore, these findings underscore the importance of emotion regulation in the relationship between family accommodation and youth anxiety. By investigating these associations among diverse youth, this study further extends the literature to reflect a more inclusive understanding of family accommodation in youth anxiety.
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Dews, Aridenne Alanna
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Core Title
Family accommodation and youth anxiety: the roles of familial and child factors
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College of Letters, Arts and Sciences
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Master of Science
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Psychology
Degree Conferral Date
2024-12
Publication Date
01/10/2025
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04/24/2024
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family accommodation
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