Cognitive Behavioral Therapy
There are several points that are important to recognize when helping a child or adolescent with significant anxiety issues.
- It is often important that students “unlearn anxiety” that may have been caused partly by genes but partly by learned patterns of thought and behavior.
- The most effective technique in dealing with anxiety is Cognitive Behavioral Therapy supported by parents. CBT is geared toward unlearning patterns or habits, acknowledging that how we think and act both affect how we feel. It is by changing these negative thoughts that a more positive emotional state can emerge.
- CBT helps individuals “reframe” their thoughts and can be helpful for children, adolescents, and adults. CBT has been shown to be the most effective treatment for reducing symptoms of severe anxiety. For children it is often necessary to take the adult components of CBT and put them in child language. For example, teaching that some of the thoughts children “say to themselves” that lead to negative emotions can be conceptualized as “Junk Thought”. This could include phrases such as: “I must”, “I have to”, “I’ll just die if”, “He shouldn’t”, It’s just awful” , etc. Children learn to identify junk thought when they hear themselves saying it to themselves and learn alternate thoughts to replace them. They can also learn to replace irrational beliefs with facts and learn to distinguish between them. Through direct therapy they can also learn not to put irrational demands on themselves, to recognize when they are “copping out” or not taking responsibility for themselves, when they are overgeneralizing and when they are catastrophizing. The best work in this area that I have seen was done many years ago but is still so valid and helpful. It is the “Thinking, Changing, Rearranging program by Jill Anderson written for teachers and therapists. I highly recommend if you can find it that you use it.
- With children it is often helpful to begin by having the child and parents distance themselves from the anxiety by conceptualizing it as a “bully” or enemy in the brain. With children it is helpful to externalize and give the bully a name so that they can talk back to it. Whatever name they come up with is okay. Explain to the child that we are going to teach skills/strategies to handle the bully, which gives them the idea that they can control their anxiety rather than letting it control them.
- It is helpful to make a visual with the student about how the anxiety affects their life, so that they can get a full understanding of it. The only way around anxiety is through it and students need to slowly and systematically face their fears so that they can habituate to them rather than avoiding or escaping them. Avoidance and escape can take the form of social anxiety, ritualistic behaviors such as handwashing and withdrawal from interaction.
- First, it is necessary to identify “triggers”. It is a good idea to design a “hierarchy of fears” with the student rating a series of incremental challenges (e.g. scale of 1 to 10) about how difficult an experience may be. Next, the child may be exposed to the stressor in his mildest possible form with support given until the anxiety subsides. Fear, as with any other sensation, will diminish over time and a student can get a sense of mastery as they feel the anxiety lessen. They can be taught some personal strategies, e.g. deep breathing, the turtle technique that can become their particular strategy for dealing with anticipatory anxiety. Gradually increase up the hierarchy, including some interactions that may purposely draw negative attention in a different way. For example, the therapist and then the student may wear a silly wig and ask questions to strangers in a controlled environment. Once individuals learn that nothing terrible happens, they are better able to handle their anxiety.
- It is also important to recognize that students with social anxiety may not necessarily appear shy or inhibited in social interactions, but this anxiety can be what is behind more disruptive behavior or seeming willful aggression. Such children often have a great fear of being humiliated or embarrassed and can’t accept any type of criticism (or what they perceive as criticism.) Treatment for the core components of anxiety with CBT when done in an intensive and consistent manner can often be helpful.
- It is also important to recognize that parents may inadvertently reinforce fears and anxieties. It is not uncommon that even with the best intentions parents let children avoid what they fear, at times not allowing certain words, sounds or objects that trigger a child’s anxiety to be present or to allow the student to avoid any activity that he/she is anxious about. Rather, remembering the need to expose the child to the stressor in a milder form and gradually building up is necessary. So, if the student is afraid of going outside to get the mail, the parent could tell the student to open the front door. Or if the student is afraid of contamination by touching a doorknob, he could be advised to just sit with his anxiety for while, knowing it will pass, and he would be able to open the door himself.
- There are many anxious children and adolescents who could also benefit from medication, especially antidepressants, either alone or in combination with CBT. It is often helpful to begin with CBT done by a therapist well-versed in it and anxiety disorders first and decide about medication afterward.
For further information reference Jerry Bubrick in Scientific American Mind, March-April 2014 and Effects of Psychotherapy for Anxiety in Children and Adolescents: a Meta-Analytic Review, in Clinical Psychology Review, Vol. 32, No.4 Pages 251-262, June 2012.