Twenty three youth ages 7–17 years (14 males, 9 females; mean age 12.7) and their primary caregiver (20 mothers, 3 fathers, mean age 45 years) participated in this study. All participants were European American. Parents were highly educated, with 17% completing some college, 48% completing college, and 26% reporting post college education (education was not reported for 2 participants). All children had a primary anxiety disorder diagnosis as determined by the ADIS-C/P (The Anxiety Disorders Interview Schedule-Child and Parent version), and most common diagnoses were Specific Phobia (96%), Generalized Anxiety Disorder (52%), Obsessive-Compulsive Disorder (48%), Social Phobia (43%), and Separation Anxiety Disorder (22%). At study entry, 73% of children were taking psychiatric medication and 70% of children were engaged in psychotherapy.

Thirteen participants were recruited using flyers that targeted parents with a child struggling with anxiety or parents struggling to help their child cope with anxiety. Flyers were posted at a university based Pediatric OCD and Anxiety Disorders Clinic and advertised a 6-week parenting group and child anxiety assessment. Two participants were on the waitlist to begin treatment at the Pediatric OCD and Anxiety Disorders Clinic and were offered the opportunity to participate in this study while they awaited treatment. Eight participants were recruited through community therapist referrals, in which community therapists were asked by the research team to make referrals to parents looking for additional ways to support their child with anxiety. Families who expressed interest completed a brief phone screen about the child's anxiety diagnosis, treatment, and symptoms. Those who reported a previous anxiety disorder diagnosis, current or previous therapy for anxiety-related concerns, and/or high interference caused by anxiety symptoms participated in a diagnostic assessment using the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Version (ADIS-C/P). Based on the results of the ADIS-/CP, study clinicians determined whether children met criteria for the study, which required having a primary anxiety disorder diagnosis (diagnosis causing the most functional interference; children could have comorbid diagnoses). The following diagnosis met inclusion criteria: generalized anxiety disorder, obsessive-compulsive disorder, specific phobia, social anxiety disorder, separation anxiety disorder and agoraphobia. Comorbid diagnoses included persistent depressive disorder, major depressive disorder, ADHD inattentive type, ADHD combined type, and oppositional defiant disorder. Children were excluded if they needed inpatient services, were diagnosed with psychosis or if they experienced a new onset of suicidal ideation. Parents were excluded if they experienced a new onset of suicidal ideation. All procedures were approved by the University of Massachusetts Chan Medical School Institutional Review Board.

Demographics Form. Parents completed demographic information, including parent/child gender, race/ethnicity, and age.

One parent exceeded the clinical cut-off for depression (with a score of 12 or greater on the DASS). Five parents exceeded the clinical cut-off for anxiety (with a score of 5 or greater on the DASS).

There were no significant changes from pre-treatment to post-treatment among the Parent Symptoms measures (see Table 2, Figure 1 and Figure 2A). The Cognitive Fusion Questionnaire (CFQ) Total score showed a 2 point reduction during the treatment period [95% CI: −3.7, −0.3; t(22) = −2.3, uncorrected p = 0.03]. The Distraction and Suppression scale of the MEAQ was 1.5 points lower post-treatement [95% CI: −3.5, 0.5; t(22) = −1.5, p = 0.15].

Neither the ACT Parenting Measure nor the CFQ Total Score showed a significant change from pre-treatment across the weekly training sessions: the ACT Parenting measure increased 0.1 points at each assessment [95% CI: −0.8, 0.29; t(22.8) = 1.1, p = 0.3]; while the CFQ Total Score decreased 0.17 points at each assessment (95% CI: −0.4, 0.1); t(21.4) = −1.3, p = 0.2) ([see Figure 3, of scores at each week). However, when restricted to only the pre-treatment and post-treatment assessments, the CFQ Total score showed a 2 point reduction during the treatment period [95% CI: −3.7, −0.3; t(22) = −2.3, p = 0.03].

There were no significant changes from pre-treatment to post-treatment among the Child Symptoms measures (see Table 3 and Figure 2A). Modest effects (uncorrected p-values <0.1) were seen as the parent-rated CBCL t-scores for Internalizing symptoms were 1.8 points lower post-treatment [95% CI: −3.8, 0.1; t(22) = −1.8, p = 0.08] and the Obsessive Compulsive Disorder symptoms were 2.8 points lower post-treatment [95% CI: −5.7, 0.2; t(22) = −1.8, p = 0.08]. The child-rated YSR t-score for Obsessive Compulsive Disorder symptoms was also lower by 2.3 points [95% CI: −4.2, −0.4; t(3.1) = −2.3, p = 0.10].

Parent-rated scores on the SCARED were generally lower post-treatment than the child-rated scores. Though there were no significant differences between pre-treatment and post-treatment ratings, the Generalized Anxiety Disorder score was reduced on the parent-rated SCARED [−1.7 points, 95% CI: −3.5, 0.1; t(2.9) = −1.9, p = 0.16], but increased on the Child-rated SCARED [1.3 points, 95% CI: −0.2, 2.8; t(2.9) = 1.7, p = 0.19]. A similar pattern was seen for the Anxious/Depressed scale between the parent-rated CBCL and the child-rated YSR. The T scores were −2.4 points between pre-treatment and post-treatment for the parent ratings [95% CI: −4.6, −0.1; t(3.4) = −2.0, p = 0.12] and 0.2 points for the child-rated YSR [95% CI: −3.0, 3.3; t(2.5) = 0.1, p = 0.9].

Results indicated that parents were satisfied with the experience of ACT-PAC as reported on the Client Satisfaction Questionnaire [CSQ-8 (40)], M = 25.39, SD = 4.76 (scores range from 16 to 32). The group intervention was shown to be feasible for parents to attend. Parents attended 5 of 6 weekly sessions on average, and 91% of parents attended 4 or more sessions (see Figure 4).

There were several noteworthy limitations to this study. First, is the homogenous sample, which was not representative of the general population of parents of anxious children, in that it was white and highly educated. Further, our recruitment through a Pediatric OCD and Anxiety Disorders Clinic raises the possibility that patients in the sample had high treatment access, further limiting the generalizability of our study findings. It remains to be studied whether ACT-PAC would be acceptable to parents of different cultural groups or whether the effects of the group may differ among a diverse set of families, in terms of race/ethnicity, socioeconomic status, and presenting problems. Replication with other samples is a necessary next step.

Second, although client satisfaction surveys and high attendance rates point to an intervention that is both feasible to implement and acceptable to clients, future research, that may take the form of a focus group with participating families, should obtain additional parent feedback on the intervention and on study protocols. In particular, given that the intervention was delivered as a weekly group, without between-session support to help parents implement recommended changes in moments when they are acutely stressed, it would be important to assess whether participants had trouble remembering to use the techniques during times of acute distress. Newly developed technology (e.g., wearable biosensors) can alert parents when their physiological stress levels are rising and provide immediate reminders (via smartphone) to use the newly learned techniques in these moments of stress when the techniques might be most needed. Future research may explore with parents how this mobile technology might further support the usefulness of ACT-PAC.

Third, for the vast majority of our measures, our data only had two timepoints (pre/post). As a result, we were limited to only providing information about change, and could not assess additional information about the shape of change (e.g., linear, non-linear) or the timing of change. Further, in the absence of a comparison group (e.g., waitlist control or psychoeducational control group), we cannot draw any conclusions about the “active ingredient” driving intervention effects. It is entirely possible that the preliminary effects demonstrated in this study were due to the social support received from the interventions’ group setting or merely just the passage of time. A more rigorous study design in the form of a randomized clinical trial is necessary to better understand the mechanism of change to to explicitly determine whether the effects are due to non-specific factors (e.g., group support, opportunities for self-disclosure) or specific ACT content (e.g., mindfulness, cognitive defusion). Fourth, this study does not provide information about change in targeted parenting behaviors (e.g., autonomy support) through treatment. While our study included both child clinical outcomes and ACT-related measures, we did not measure whether the intervention changed parenting behaviors. Future research should systematically evaluate change in parent behavior during parent-child interactions as a result of this intervention and address the mechanisms through which ACT-PAC may be exerting its influence [e.g., by enhancing psychological flexibility and acceptance (22);]. Future research should also consider including multi-informant clinical outcomes, especially in light of the current findings showing increases in child-reported generalized anxiety disorder symptoms but decreases in the same symptoms when parents were the informant (although neither increase nor decrease reached statistical significance). This intervention may produce particularly salient effects for parent reported clinical outcomes, as the intervention may impact the lens through which parents are viewing their child.

In summary, in light of research highlighting that up to 40% of youth don't meaningfully benefit from treatment (8), this study suggests that ACT-PAC may uniquely address parent-child processes that may be impeding treatment progress. Results suggest that ACT may benefit anxiety affected families, improving both parents and children, and help families effectively engage in valued pursuits.