Behavioral Treatment for Kids With Anxiety
Kids learn to handle the bully in the brain
by Jerry Bubrick, PhD
When a child shows signs of anxiety, we tend to think it will go away—she’s just nervous or shy, and she’ll grow out of it. But when the anxiety becomes so intense that it’s seriously interfering with a child’s life, and the life of her family, it’s important to get help.
Serious untreated anxiety tends to get worse over time, not better, because the child learns that avoidance works in reducing the anxiety, at least in the short run. But as the child—and, indeed, the whole family—work to avoid triggering those fears, they only grow more powerful.
Medication is often prescribed for children with anxiety, as it is for adults. And medication—antidepressants are usually our first choice—often helps reduce anxiety. But what many people don’t know is that cognitive behavioral therapy (CBT) can be very effective for kids who are anxious. In fact, research over more than 20 years has shown that CBT is the most effective treatment for reducing symptoms of severe anxiety. And unlike taking medication, the therapy gives children the tools to manage the anxiety themselves, now and in the future.
What is cognitive behavioral therapy?
Cognitive behavioral therapy is based on the idea that how we think and act both affect how we feel. By changing thinking that is distorted, and behavior that is dysfunctional, we can change our emotions. With younger children, focusing first on the behavioralpart of CBT can be most effective. The goal is, essentially, to unlearnavoidant behavior.
One of the most important techniques in CBT for children with anxiety is called exposure and response prevention. The basic idea is that kids are exposed to the things that trigger their anxiety in structured, incremental steps, and in a safe setting. As they become accustomed to each of the triggers in turn, the anxiety fades, and they are ready to take on increasingly powerful ones.
Exposure therapy is very different from traditional talk therapy, in which the patient and a therapist might explore the roots of the anxiety, in hopes of changing her behavior. In exposure therapy we try to change the behavior to get rid of the fear.
Exposure therapy is effective on many different kinds of anxiety, including separation anxiety, phobias, obsessive-compulsive disorder (OCD), and social anxiety.
The Bully in the Brain
For children with anxiety disorders, the process begins by helping them, and their parents, get some distance from the anxiety and start thinking of it as a thing that is separate from who they are. One way I do this is by having them conceptualize it as a “bully in the brain,” and I encourage kids to give the bully a name and talk back to him. Kids I’ve worked with have called him the Witch, Mr. Bossy, Chucky, the Joker, and, in the case of some teenagers, names I cannot repeat here.
We explain that we are going to teach skills to handle the bully, giving children the idea that they can control their anxiety rather than it controlling them.
It’s also important to help kids really understand how their anxiety is affecting their lives. I may actually map out things a child can’t do because of his fears—like sleeping in his own bed, or going to a friend’s house, or sharing meals with his own family—and how that makes him feel. Getting kids to understand how their anxiety works and gaining their trust is important because the next step—facing down their fears—depends on them trusting me.
Adopting Robert Frost’s observation that “the only way around is through,” exposure therapy slowly and systematically helps a child face his fears, so he can learn to tolerate his anxiety until it subsides rather than reacting by seeking reassurance, escaping, avoidance or engaging in ritualistic behaviors such as hand washing.
How does exposure therapy work?
The first step is identifying triggers. We design a “hierarchy of fears”—a series of incremental challenges, each of which is tolerable, and which together build to significant progress. Instead of thinking in black and white terms—I can’t touch a dog or I can’t cross a bridge—kids are asked to consider degrees of difficulty. We might ask a child with contamination fears, for example, “On a scale of 1 to 10, how difficult would it be to touch the door handle with one finger? To touch and open the door?”
For a child with a fear of vomiting, we might ask: “How difficult would it be to write the word vomit?” If that is a 3, saying “I will vomit today” might be a 5. To see a cartoon of someone vomiting might rate a 7. To watch a real video of someone vomiting might be a 9. At the top of the hierarchy would likely be eating something the child thinks will make him vomit. By rating these different fears, kids come to see that some are less extreme, and more manageable, than they had thought.
Next, we expose the child to the trigger in its mildest possible form, and support him until the anxiety subsides. Fear, like any sensation, diminishes over time, and children gain a sense of mastery as they feel the anxiety wane.
Intensive treatment
With a child who is severely anxious—who can, for instance, barely leave his room for fear that his parents will die, or must wash his hands dozens of times a day to avoid contamination—I may work with him several times a week, for several hours at a time. We do exposures in the office and then, when a child is comfortable enough, do them outside.
For someone with social anxiety, for instance, we might go out wearing silly hats, or walk a banana on a leash. For someone afraid of contamination, we might ride the bus together, or shake hands with strangers, then eat chips without washing.
Once we have worked through some exposures and he is feeling more confident, I assign homework to practice what we did in the sessions. We want kids to really master their exposures before moving up the ladder. And parents are taught to help kids progress by encouraging them to tolerate anxious feelings, rather than jumping in to protect them from their anxiety.
Treatment for mild to moderate levels of severity usually takes eight to 12 sessions, and some kids make more progress if they are also taking medication to reduce their anxiety, which can make them more able to engage in therapy.
It’s important to understand that exposure therapy is hard work, both for kids and their parents. But as fear diminishes, kids get back to doing things they like to do, and the family gets back a child they feared they had lost—and that’s a great reward.
Best Medications for Kids With Anxiety
Antidepressants trump all others as the most effective evidence-based choice
John T. Walkup, MD
We see a lot of the wrong medications being given to anxious kids because people who are treating them don’t really understand what these children are experiencing, and they don’t know what the evidence-based treatments are.
Anxious kids have a hard time paying attention. It’s not because they have attention deficit, it’s because their heads are full of worry. But their parents and teachers may only notice that they’re having trouble paying attention, and so they get misdiagnosed as having the inattentive subtype of ADHD and put on stimulants. Stimulants will help anybody feel a little bit more attentive, so they will help these kids concentrate better, but they might also have more stomachaches, and often they’re not happy, they’re not comfortable. The stimulants may actually make the anxiety a little bit worse. Plus anxious kids have trouble sleeping, and sometimes the stimulants makes sleeping even harder.
Another type of medicine some practitioners use, because they’re comfortable with it, is clonidine or guanfacine. These are alpha-two agonists; they calm, they lower arousal levels, but they don’t really treat anxiety.
The third group of medicines that we see people using are, believe it or not, antipsychotics. With the scare a few years ago about suicidal behavior on antidepressants, people moved away from the antidepressants and now they’re treating anxious kids with antipsychotics. Now, in someone’s mind that may be safe, but from an evidence-based point of view it’s terrible care.
Antidepressants
The clear medications of choice for treating anxiety in children are the serotonin reuptake inhibitors, the antidepressants. Study after study shows those are the medicines that are effective, and they can be extremely effective. With the right assessment, with the right youngster, the use of antidepressants for anxiety can be transformative. And it can happen relatively quickly; in our studies we often see kids better by the first week or two of treatment. They’re not completely well but they’re moving in the right direction, and that kind of response early on generates confidence in the anxiety treatment, makes moms and dads feel a little bit better and makes the kids feel pretty good.
Anxiety medication combined with therapy
The other evidence-based treatment for anxiety is cognitive behavioral therapy and it’s important to understand that in our big study, where we compared combination treatment of cognitive behavioral therapy and medication with either one of those treatments alone, that the combination beat them all handily. So when you’re thinking about the very best treatment you’ve got to be thinking in terms of medication plus a psychological intervention.
Anxiety medication combined with therapy
The other evidence-based treatment for anxiety is cognitive behavioral therapy and it’s important to understand that in our big study, where we compared combination treatment of cognitive behavioral therapy and medication with either one of those treatments alone, that the combination beat them all handily. So when you’re thinking about the very best treatment you’ve got to be thinking in terms of medication plus a psychological intervention.
Benzodiazepines
Finally, the benzodiazepines are the other treatment that I commonly see being used in kids with anxiety disorders. They are short-term, they can be extremely effective in reducing intense anxiety in youngsters who are really suffering and in distress. But the data supporting their long-term usefulness is very thin, even in adults.
There are kids who are so anxious and uncomfortable and are on the verge of school failure or disruption of the home or something like that where you just really need an acute way to bring down everybody’s anxiety, and in those cases the benzodiazepines can be very helpful. But sometimes they’re a little too helpful, because people begin to like how they feel on them and don’t really shift focus from those medicines onto the antidepressants, which really offer long-term, durable anxiety reduction without really any side effects or problems.
With benzodiazepines you can actually develop tolerance to them, so they might work the first month or two, but to keep them working in the long haul you often have to increase the dose. They manage anxiety, they offer anxiety relief, but they don’t really seem to have that kind of almost curative property that the antidepressants seem to have.
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