Worries and fears are a typical part of early childhood. Most children outgrow their fears with little or no impact on their social, emotional, or intellectual development. Little worriers, on the other hand, do not outgrow their fears and over time experience a myriad of problems. Most notable are academic difficulties due to school refusal or test anxiety. Little worriers typically worry about friendships, personal safety, performance, and health and world events. They worry that mommy and daddy will not return safely from an evening out. They worry that they will become ill and die. They complain of head and stomachaches and are self-conscious and overcautious. They are eager to please, frequently seek reassurance, hyper mature, and may procrastinate. Generalized anxiety disorder is more prevalent in older children (12-19 years) than younger children (5-11 years) who typically present with more separation anxiety or specific phobias. In particular, little worriers present with more phobic avoidance than their adult counterparts. Overanxious children may avoid trying new things if they are not certain they will succeed; they avoid playing sports for fear of being injured or spending time away from their caretakers. Here are several cognitive-behavioral interventions for the treatment of chronic worry that demonstrates how to adapt these interventions to children.
Psychoeducation. The cognitive-behavioral model assumes that misappraisals of events cause and maintain abnormal worry. Therefore, correction of misappraisals is an important component in the treatment of childhood anxiety. The challenge is to make such explanations clear and appropriate to the child’s developmental age. For example, Nikkei was a bright 6-year old girl who worried excessively about harm coming to her parents. I explained to Nikkei that her tendency to worry so much about something that wasn’t likely to happen was due to her Predictometer being “out of whack.” I then explained the concept of prediction and overestimation of unlikely events by asking her questions such as, “So, what do you think your Predictometer would say you’re most likely going to have for dinner tonight, macaroni and cheese and maybe some carrots or just a big bowl of slimy snails?” When Nikkei tells me macaroni and cheese and maybe some carrots, I then tell her that when her mom serves her macaroni and cheese instead of slimy snails tonight that means her Predictometer is working just fine. But, sometimes, I tell her, our Predictometer tells us something is going to happen and we really believe it, even though it’s not likely to happen, like her mother serving her a bowl of slimy snails. That’s when our Predictometer isn’t working so well, it’s out of whack. Then to help Nikkei understand this concept better, I send her home with a monitoring form that she (with her mom’s help) is to complete when she’s worried about something bad happening to her mom or dad. The form has two columns: what Nikkei’s Predictometer says will happen (e.g., mom will be killed in an auto accident) and what really happened (e.g., mom went to the store and came home just fine).
Self-control. Two of the most common self-control strategies children are taught in the treatment of anxiety disorders are somatic control strategies (e.g., diaphragmatic breathing, progressive muscle relaxation) and cognitive control strategies (e.g., evaluating and challenging anxious thoughts). When training children it is important to keep the procedures as simple as possible. For example, rather than 8 or 16 muscle group progressive muscle relaxation, we practice only 4 groups and I make an audiotape of the relaxation training session for them to listen to at bedtime. To train children to breathe diaphragmatically, I use ideas like a balloon (they choose the color) beneath their belly button that gets larger as they breathe in and smaller as they breathe out. I might rest a small stuffed animal over their belly buttons and ask them to give the animal a smooth ride. Or, I might record an audiotape of me singing a happy song with a tempo that matches the desired respiration rate (about 6 full respirations per minute).
Cognitive self-control strategies might include training Nikkei to examine the cognitions that contributed to maintaining her fear of harm coming to her parents. Nikkei and her mom would learn STOP (S stands for “Are you Scared?”; T stands for “What are you Thinking?”; O stands for “What Other thoughts can I think or other things can I do that would help?” and “P stands for “How can I Praise myself for a good job?”) to help her recognize when she was afraid or worried and to help her use more adaptive coping thoughts and behaviors, and to praise herself for doing so. I would then ask Nikkei (with her mom’s) help to practice using STOP during the week and to complete the STOP monitoring form that helps me see how she did.
Contingency management. Some form of contingency management is usually needed to encourage children to approach what they fear and to practice new skills for managing fears and worries. Typically, I use chip (for children 4-8 years old) or point systems (for children 9years and older). I explained the role of positive reinforcement to Nikkei and her mom and we generated a list of rewards and privileges together. Nikkei and I then made a chip bank using a plastic milk carton and colored paper, stickers, and crepe paper and Nikkei and her mom were asked to finish the project at home. Nikkei was eager to earn enough chips to get a new Game Boy. However, I counseled Nikkei’s mom to add to Nikkei’s reward list the privilege of using the Game Boy for a specific amount of time. Experience taught me that once children earn some object like a Game Boy they often lose their enthusiasm to practice future tasks or exposures. Part of each session was used to set up contracts in which Nikkei would receive a specific number of chips when she successfully practiced a skill or completed an exposure task. Contingency contracts were faded as Nikkei mastered the self-control strategies.
Graded exposure. A number of objects and situations triggered Nikkei’s worries that then became targets for prolonged exposure. I began by helping Nikkei and her mom develop an exposure hierarchy. Nikkei rank ordered a number of objects and situations using a fear thermometer to rate the degree of fear she would experience if she approached a specific situation. The fear thermometer is the child version of subjective units of distress (SUD) used by therapists treating adults to rate the degree of a client’s anxiety or fearfulness when engaging in an exposure task. Nikkei’s list included situations such as her parents going to dinner or her parents traveling without their cellular telephone so that Nikkei could not reach them when she was anxious. This exposure task was broken into subtasks according to variations in duration away, distance traveled, and how often Nikkei’s parents called her while they were away.