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SPACE is an increasingly popular, evidence-based, approach to the treatment of childhood OCD and anxiety. It is a 12 session program that empowers parents to support their child in overcoming their anxiety instead of accommodating anxious avoidance. Whereas classic Exposure and Response prevention (ERP) therapy (a form of Cognitive Behavioral Therapy or CBT) for children involves a therapist working directly with the child and includes the parents as necessary, SPACE has the therapist working exclusively with the parents. 

A few randomized control trials have demonstrated that despite not involving the child in the treatment, SPACE is no less effective than individual CBT in treating childhood anxiety. Dr. Lebowitz, the treatment’s developer, explained that SPACE should not be seen as the treatment for kids who refuse CBT, but as another first line treatment for child anxiety. 

In my own clinical experience I have been highly impressed by the clinical effectiveness of the treatment. Having been trained in both ERP for children and SPACE, the decision of which to use, or which to use first can be challenging.

Currently, to my knowledge, no research exists determining which factors would lead a therapist to choose one treatment over another. Until such research is conducted, I believe two factors; the degree of child motivation and the nature of the child’s compulsions (independent vs. dependent on parents), may be of particular imporance in making this determination. 

 The chart below (mobile and desktop version, respectively) lists all the permutations of these factors and the treatment approach I would use based on clinical experience.  

 

 

 

 

parent motivation child motivation parent accomodation independent compulsions in child clinical picture tx suggestion
high high high high parent and child both motivated for treatment, high degree of parental accomodations and independent compulsions in child Space would be helpful place to start for this presentation, after completing space, if child remains anxious and continues to compulse incentivize/motivate child for individual ERP.
high high high low parent and child both motivated for treatment, high degree of parental accomodations and low degree of independent compulsions in child ideal space case,
high high low high parent and child both motivated for treatment, low degree of parental accomodations and high degree of independent compulsions in child ideal ERP case for child, work with parents to help support child in ERP and improve compliance. Continue to assess for covert parental accomodations.
high high low low parent and child both motivated for treatment, low degree of parental accomodations and low degree of independent compulsions in child assess whether treatment is neccessary given the low degree of overall compulsive behavior. Assess what else may be going on that is leading parents to seek treatment. Are there extant compulsions not being identified
high low high high parent is motivated for treatment, but child is not or is tx refusing, high degree of parental accomodations and high degree of independent compulsions in child. Space is ideal for this presentation, after completing space, if child remains anxious and continues to compulse incentivize/motivate child for individual ERP.
high low high low parent is motivated for treatment, but child is not or is tx refusing, high degree of parental accomodations and low degree of independent compulsions in child. this is the clinical picture space is most helpful for. continue to assess for private compulsions in child if possible.
high low low high parent is motivated for treatment, but child is not or is tx refusing, low degree of parental accomodations and high degree of independent compulsions in child. further assess for hidden parental accomodations and start with space if appropriate. Incentivize child for individual ERP, supported by parents.
high low low low parent is motivated for treatment, but child is not or is tx refusing, high degree of parental accomodations and high degree of independent compulsions in child. assess whether treatment is neccessary given the low degree of overall compulsive behavior. Assess what else may be going on that is leading parents to seek treatment and why child is uninterested. Are there extant compulsions not being identified?
low high high high parent is not motivated for treatment or cannot engage for practical reasons, however the child is motivated for tx. There is a high degree of parental accomodations and high degree of independent compulsions in child. Start ERP with child, psychoeducate parents on the role of parental accomodations and motivate them to support child in treatment.
low high high low parent is not motivated for treatment or cannot engage for practical reasons, however the child is motivated for tx. There is a high degree of parental accomodations but low degree of independent compulsions in child. motivate parents to engage in SPACE, if no traction work with child independently with ERP focusing on RP of accomodation seeking behavior.
low high low high parent is not motivated for treatment or cannot engage for practical reasons, however the child is motivated for tx. There is a low degree of parental accomodations but high degree of independent compulsions in child. ERP with child.
low high low low parent is not motivated for treatment or cannot engage for practical reasons, however the child is motivated for tx. There is a low degree of parental accomodations and low degree of child accomodations (very rare) What else is up here that parents/child are seeking treatment. Any compulsions not being identified?
low low high high neither parent nor child are motivated for treatment. However there is significant parental accomodation and independent compulsions in the child. Motivational work with parent to engage in SPACE, incentivize child for ERP if anxiety remains and indepdent compulsions continue.
low low high low neither parent nor child are motivated for treatment. However there is significant parental accomodation and low levels of child independent compulsions motivational work with parents to engage in SPACE. Assess if ERP is neccessary following conclusion of treatment.
low low low high neither parent nor child are motivated for treatment. There is low degree of parental accomodation and high levels of child independent compulsions motivate parents to help incentivize their child to engage in ERP. Continue to assess for parental accomodations and address accordingly
low low low low neither parent nor child are motivated for treatment. There is low degree of parental accomodation and low degree of child independent compulsions What else is going on that is bringing family to treatment? Is it mandated? Are there unidentified compulsions. Continue to assess and choose treatment accordingly.