This is the final post in the 3-part series about helping kids with anxiety. I reserve the right to blog more about it in the future because it’s a big topic and this is so general. Onward! To the helping!
Cognitive Behavioral Therapy or CBT is the counseling modality of choice for kids (and adults) with anxiety. Research on effective anxiety therapies tend to focus on these three areas:
- Understanding and addressing the physical response to anxiety
- Recognizing and challenging the thinking errors that perpetuate anxiety
- Using controlled exposure to the anxiety-provoking situation and practicing the tools
Again this is super simplified and super general. Kids (and adults) have diverse learning styles, challenges, expectations and histories so how this works will look very very different depending on the child. But to help you get the gist, I’ll use Goldilocks as an example. We all know her story, right? On the very off-chance you don’t, you can check out this short version so we’re all on the same page.
So let’s say Goldilocks’s mom brings her to me because she’s gotten very anxious since her disastrous meet up with the three bears. She’s having trouble sleeping, she’s having some bad dreams, she is having tantrums at the drop of a hat and she hates leaving her mom to get on the school bus because she’s afraid the bears will come break into her house. She also can’t bear the thought of eating porridge ever again and will fall apart if her mom serves it at breakfast.
The first thing we would do is talk about Goldilocks’s physical experience of being anxious. We would talk about how being chased by bears would rev anyone up but now we need to help her calm her body back down. We would talk about how since this happened every time her heart starts beating or she starts breathing fast that her body immediately thinks BEARS! even if she’s faced with something much less concerning like shoes that are hard to tie or being a little bit late for school in the morning. We would work hard on helping her identify where in her body she feels the anxiety — is it in her stomach? Does her chest feel tight? Does she make fists with her hands or does her mouth go dry? We would talk about relaxation techniques and figure out which ones work for her. She might start keeping a worry diary or we might make a list of everything that makes her anxious.
What I tell kids is that we’re going to be detectives and we’re going to work together to solve the problem of their worries. I am very strengths based (that means I encourage focus on what’s going right even as we are talking about what’s going wrong) so we would also discuss times they have managed their anxiety in the past so we can figure out what shores them up.
The next thing we would do is look at thinking errors (also sometimes called “negative cognitions”). Here are some super common thinking errors:
- All or Nothing Thinking: If I make one mistake then I’m an idiot.
- Catastrophising: If I don’t turn in this one homework, I will flunk out of school.
- Overgeneralization: I fell down at the roller rink one; I will fall down forever.
- Personalizing: It rained on my birthday because nothing ever goes right for me.
- Discounting the Positive: Sure my best friend likes me but that doesn’t count because she’s my best friend.
- Mind Reading: I know everyone on my soccer team hates me.
- Labeling: I’m taking so long to learn to ride my bike because I’m uncoordinated.
- Should Statements: I shouldn’t have such a hard time learning math. I should know how to wrap this present without help.
- Emotional Reasoning: I am in pain therefore I am right and you are wrong. I feel guilty and that proves I’m a bad person.
There are more but you get the gist and probably these are familiar to you either because your child does them or because you do them yourself. (Some of these are so ingrained in our cultural way of thinking that to confront them can be like wandering around in the dark your whole life and then stumbling over a flashlight and realizing you can use it to find the light switch and actually turn on all the dang lights.)
This is where I think counseling can help. I know in my own family that I can tell my kids something over and over but when they hear it from somebody else they believe it. Part of this is that they get tired of the sound of our voices (I haven’t seen studies on this but anecdotally I can tell you that my children get tired of the sound of my voice) and part of it is because it’s easy to get defensive with our parents. At least it was for me when I was a kid and then a teenager. If my mom disagreed with me it was automatically an opportunity for me to argue with her but if another adult said the same thing, it was an opportunity for growth and better understanding.
Yeah, we parents get it coming and going.
BUT! Let’s not resort to Overgeneralization! Sometimes parents have a lot of success doing this work at home without a therapist and there are workbooks (note I haven’t reviewed these so I can’t recommend one in particular) to help parents help their kids. AND even when kids are in therapy, we really need the grown ups in their lives to help them do the work. (I see a child an hour a week. Their parents are the ones bearing witness to the other 167 hours.)
Anyway. That’s the cognitive part of CBT therapy and it can take awhile. We’re talking about challenging ingrained ideas that make perfect sense to the person thinking them. That’s HARD and it takes practice.
For lots of kids, this is when we’re really leaning on the play part of play therapy because every little step we take needs to be ensconced in trust, respect and acceptance, which means a lot of time just hanging out and enjoying each other. The play therapy space (and the talk therapy space) is a place to safety say anything and be anyone and sometimes anxious kids just need one place where they can come and PLAY away from their worries.
Particularly with anxious kids whose anxiety ends up all centralized in their need to Do Good and Be Good, too much CBT pushing just triggers their anxious need to perform well. So sometimes my office is all about creating an island where they can goof off a little and experience themselves in a new way.
I’m emphasizing the slow part of this time in therapy because sometimes parents get (understandably) frustrated. They want to see change. At the beginning they get some concrete tools (breathing, relaxation, etc.), which feels great and proactive but it’s not a cure all. And then at this point things slow down and they may not see the any progress. But progress really is happening. Not to mention that this is where grown ups start slowing down, too, because it’s one thing to hear about Personalizing but it’s another thing to really get it and see how that kind of thinking is actually impacting your life.
The other thing is that anxious kids (and adults) have had people trying to talk them out of being anxious for a long, long time and that can make people hold on to anxious feelings even more tightly. They don’t mean to do this but being anxious, which many of them see as being concerned or cautious or careful or responsible (“I study all of the time because I’m a good student and if I’m not anxious about it then I’m being irresponsible.”) and often they get a lot of praise for being “good” in other anxious ways. (Oh the perfectionist students I see in my office! The ones who are running themselves into the ground for the praise and academic rewards!) To ask them to give up this way of thinking, well, that’s scary. It takes time.
Goldilocks may say to me, “You know this is all well and good but the minute I let my guard down I’m pretty sure Papa Bear is going to come charging in here, paws waving, and I can’t risk it.”
And so we’d keep working on it.
The next step of CBT is taking it out into the world and confronting those anxieties. Remember we’re simplifying these steps and we’re making them look more clear cut than they are (although they’re presented pretty clear cut in the Coping Kids group because we have a curriculum but we will adjust it as needed).
Goldilocks and I would keep on playing detective, we’d see what’s working for her and where she gets stuck. Maybe her big issue is not being able to eat porridge. Maybe I would get an empty box of oatmeal to have in the play kitchen or maybe we’d pretend to feed breakfast to the dolls. When she’s ready maybe we’d have ourselves some porridge together. We’d go slow and we would be mindful of how it feels. We would see any small move forward as a victory even if she never actually gets the spoon in her mouth for a long, long time.
Maybe I’d ask her mom and dad to take her for a walk in the forest and practice her relaxation techniques and see how that goes. She and I might might write a game plan beforehand that confronts the “what ifs” and has strategies in place for whatever scenarios she can imagine. Again, we’d go slow. She might only get herself out the door the first time and we’d applaud that step even as we think about how to get her off the stoop next time.
Or maybe she’d need to play out what happened, putting the bears in the sand tray and working to make sense of the event by playing out the scene over and over again, trying out new ways of experiencing it and new outcomes.
There are other more specific ways to deal with particular kinds of anxiety. Treatment for OCD, for example, is more complex. Which brings me to medication.
Medication for kids is a tricky thing. Although many family practice and pediatricians will prescribe medication, it’s best to seek out help from a child psychiatrist. But this is hard. Columbus — like lots of other areas — has a dearth of child psychiatrists and parents don’t always have time to go search one out. I encourage parents to have an ongoing conversation with their family physician and to be aware that having a psychiatrist becomes even more important as the child gets older because hormones can make getting the right meds in the right dose super challenging (and things can turn on a dime if someone hits a growth spurt).
Not all anxiety disorders NEED medication but medication can certainly make sense if a child is completely hamstrung by his anxiety to the point that he isn’t going to be able to participate in his therapy. (Some kids are so anxious that relaxation techniques aren’t going to be enough to get them to a place where they can do the cognitive work.) Or if her behavior is so problematic (tantrums, rages, violence) that the rest of her life is at a standstill then medication can make sense.
Ultimately this is a parenting choice and I support parents in making their own informed choices for their kids. I do think, though, that medication alone isn’t enough. We all need to learn how to function as our best selves within the gifts and limits of our particular personality make-up. Medication can help us get functioning but we still need to understand ourselves and how we work. We need to know how to get help.
Eventually, too, our children will be adults and will make their own decisions about how to manage their anxiety (since for most anxious people it’s part of their lifetime experience since our personality can be molded but we are essentially who we are) and getting therapeutic support gives them options.
I like the idea of saying to kids, “Hey, counselors are there to help us when we need it. You need to know how to find the right one for you and how to do the work of therapy and I will help you do that when you’re young so you can help yourself when you’re older.” So we can teach them how to be good consumers of therapeutic support by helping them find someone they like and feel comfortable with (because it all comes down to the rapport in the relationship).
This is a positive way to talk about anxiety and anxious temperaments. After all, some of us more athletically gifted and some of us need more help. Some of us are terrific musicians out of the gate and some of us need more practice. Likewise some of us have more struggles with anxiety or depression and that’s why we have therapists and that’s why we learn about medication options and that’s why we learn to take good care of ourselves.
Have questions? Let me know. Want to sign your child up for Coping Kids? Let me know. (I’m trying to plan summer offerings so if Coping Kids is something you’d like your child to attend then, please let me know so I can email you when I get scheduled and also find out if there are particular days or times that might work for your family.)
First in the series: Anxiety in Kids
Second in the series: Child Anxiety Symptoms