Cognitive-Behavioral Techniques with Anxious Children and Adolescents

1. Cognitive-Behavioral Techniques with Anxious Children and Adolescents Yeo Lay See

2. Outline • What is CBT? • Is CBT biblical? • Anxiety Disorders • Relaxation Training • Anxiety Hierarchy & Desensitization • Cognitive strategies

3. What is CBT? • A form of therapy that uses cognitive mediation to effect change in feelings and behavior • It’s not about positive thinking but accurate and realistic thinking that will help clients manage life better.

4. Cognitive Alter ways of thinking for the better E.g., change perceptions of / attitude toward a particular situation Behavioral Take some action that is likely to prove beneficial and instructive E.g., relaxation to cope with anxiety Two Levers of Change in CBT

5. CBT Techniques • Cognitive techniques • Identify automatic thoughts and images • Use guided discovery to ascertain meaning (If this thought were true, what would it mean to you?) • Re-structure dysfunctional thoughts and beliefs • Use problem-solving

6. CBT Techniques • Behavioral Techniques • Activity scheduling and modeling • Graded task assignments • Behavioral experiments to test out thoughts and beliefs • Exposure tasks • Relaxation

7. Why CBT? • Strong research support • Present-centered; goal directed • Usually brief • Efficacious (replicated) • Efficient (cost-effective) • As effective as medication in treating both depression and anxiety

8. Is CBT for every client? • Problem was clearly identified • Problem could be conceptualized as thoughts and thought processes • Client was able to identify automatic thoughts and feelings • Client had sufficient understanding and motivation to work within CBT framework.

9. Think-Feel-Do Link

10. Cognitive Restructuring • Help an anxious person change negative, extreme, unrealistic, irrational, distorted, catastrophic thinking into more realistic and accurate thinking.

11. Is there a Biblical basis for CBT? • Biblical cognitive re-structuring • Renew our mind according to God’s truth in Scripture (Rom 12:2) • Focus on what is true, noble, right, pure, holy, admirable, excellent, and praiseworthy (Phil 4:8)

12. Activity 1 • Think of a situation that causes you to be anxious. Write down what it is. • How do you know you are feeling anxious? • Write one thought that is in your mind when you are feeling anxious?

13. Features of Anxiety • Physiological distress • Cognitive distress • Emotional distress • Significant impairment of daily functioning

14. Normative Development • 7-9 months: ___________ anxiety • Age 2-3 years: ___________ anxiety • Preschool years: ___________ fears • Adolescence: ___________ fears

15. Anxiety Disorders • Separation Anxiety Disorder (SAD) • Exclusively diagnosed in children • Anxiety/panic upon separation or in anticipation of separation from attachment figures • Generalized Anxiety Disorder (GAD) • Pervasive, diffused, uncontrollable worries that can occur in a variety of domains (at least 6 mths) • Social Phobia • Extreme shyness & withdrawal from new situations or from people • Panic Disorder • Recurrent unexpected panic attacks • Panic attack = a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, with feelings of impending gloom.

16. Anxiety Disorders • Obsessive-Compulsive Disorder (OCD) • Av. Age of onset: 22; can occur in children • 80-90% have both obsessions & compulsions • Obsessions: recurrent, persistent, intrusive, & upsetting t________ that provoke internal resistance (e.g. fear of hurting others) • Compulsions: excessive, repetitive behaviors or mental a________ that an individual feels compelled to perform in response to an obsession or according to rigid rules

17. Meet the Grizzly Bear

18. How scared would you be? • How scared would you be (2).doc

19. Our Internal Alarm System Risk/Danger Resources/Cope ALARM Real danger Genuine lack of resources ANXIETY Danger perceived as high Resources perceived as low FLEE, FIGHT, FREEEZE ANXIETY INACCURATE PERCEPTIONS FALSE ALARM

20. Goal • Help client obtain more _______ views of danger and resources. • This de-activates the false alarm, but leaves the alarm system connected for real danger – anxiety becomes a resource.

21. Risk/Resources Ratio

22. Cognitive perspective on anxiety disorders • People experiencing anxiety believe that they are threatened with either physical or social harm. • It is the i_____________ of a situation as a sign of personal threat that is essential to the experience of anxiety.

23. Factors that maintain anxiety Three vicious circles: • Selective attention • Physiological change • Change in behavior

24. Safety-seeking behaviors Three categories: • Avoidance • Escape • Some Action • Problem: Prevent disconfirmation of the feared catastrophes

25. The Panic Circle Trigger Stimulus Perceived Threat Misinterpretation of sensations as catastrophic Apprehension Bodily Sensations

26. Cognitive Altering maladaptive self-talk (building a cognitive coping template, Kendall) Self-Instructional Training Modeling & behavior rehearsal Problem solving Behavioral Systematic Desensitization Relaxation training Anxiety hierarchy Gradual exposure Flooding Restructuring contingencies General CBT Strategies

27. Experiencing Anxiety Physically • For clients who experience anxiety as somatic disturbance or arousal, use Relaxation or Arousal-reducing Stress Inoculation

28. Relaxation Training • Become aware of somatic reactions to anxiety (recognize “early warning signal”) • Develop control over physiological & muscular reactions to anxiety • Examples: • Deep breathing • Blowing bubbles to calm down (for children) • Progressive muscle relaxation • Mental imagery of calming scene

29. Activity 2 • Deep breathing • Progressive Muscle Relaxation

30. CBT Strategies For Anxiety • Kendall: Treatment of anxiety is to “go THROUGH it” and not to “go around it”. • Active ingredient: Exposure tasks • Place client in anxiety-provoking situations imaginably or in vivo to provide acclimatization and to practice coping skills

31. Anxiety Hierarchy With therapist’s help, client • makes a list of the things / scenarios that make him/her anxious (on 3 X 5 cards) • Describes situation in a few words • ranks order them from least to most anxiety-provoking • rates intensity of anxiety in each scenario on a scale from 10 to 100 (multiples of 10)

32. Eg of anxiety hierarchy for a school refusing child • 100 Getting lost in the halls • 90 Not having any friends • 80 Not being able to find my classes • 70 Taking the bus to school • 60 Being able to do homework • 50 Eating lunch in the canteen • 40 Finding a table in the canteen • 30 Going to the library • 20 Having all new teachers • 10 Having all classes with same teacher

33. Anxiety Hierarchy • Ensure that • The client’s most problematic fear-producing situation are included; • Intermediary situations are added; • Some zero-level situations are included; • Complete range of fear-producing values from 10 to 100 is represented

34. Desensitization (Graded Exposure) • Purpose: eliminate unwanted anxiety responses by helping the client experience relaxation in the presence of anxiety-provoking stimuli (imagined or real) • Developmental level: all ages, but particularly students in Primary 4 and higher • When to use: after client has sufficient practice in relaxation training

35. Desensitization • Two types of exposure: • Imaginal (low risk of an extreme anxiety reaction) • In vivo (can be extremely stressful)

36. Imaginal Desensitization • Have client spend 5 mins relaxing in a comfortable position • Ask client to signal with right index finger when he is relaxed • Ask client to close eyes, and present 1st scene – least feared situation • Present next scene. Ask him to raise right index finger when he starts to feel anxious.

37. Imaginal Desensitization • If signal is given, present zero-level scene until client is relaxed again and raises right index finger to indicate this. • Present problematic scene again – cycle continues until client can imagine the initial scene without fear or anxiety. • Do this 3 consecutive times, then ask client to imagine the next level scene – repeat cycle until new scene can be imagined without anxiety.

38. Imaginal Desensitization • Rule of thumb: • Each session:15-20 minutes; 3-4 scenes max • Present each hierarchy scene in ascending order (Least feared to most feared); relax for a few seconds between scenes • 3 or 4 times • Exposure time of 5 seconds for first presentation • Gradually increase to 10 seconds for subsequent presentations • End with short period of relaxation

39. Desensitizaton • As clients pair being relaxed with imagining the feared situations in the hierarchy, they become increasingly “desensitized” to these situations.

40. In Vivo Desensitization • Not recommended for unskilled therapists • Only exception is treatment of school phobia or school refusal behavior.

41. Experiencing Anxiety Cognitively • For clients who experience anxiety as cognitive distress, teach adaptive self-instruction.

42. FROST (Nichols, 1999) • A strategy that teaches individuals how to evaluate their own thinking. • Provides a structure to decide if a thought is worth keeping.

43. FROST (Nichols, 1999) • F Feel OK? • R REWARD me? • O Keep me OUT of trouble?   • S Keep me SAFE? • T Is that thought TRUE? • THE FROST TEST.doc

44. Teach Thought Testing • What is the evidence that this thought is true? • Is there another way of looking at the situation? • What is the worst thing that could happen? • Could I survive it? • What is the best thing that could happen? • What is the most realistic outcome? • What should I do?

45. Activity 3 • Apply FROST to the situation you described in Activity 1.

46. Self-Instructional Training • A thought is something we say to ourselves. • Modify private speech or internal dialogue. • In therapy, we model, practice, and repeat SIT. • ExampleLESLIE (Anxiety SIT Eg).doc

47. Activity 4 • How can you modify the one negative thought that is fueling your anxiety back in Activity 1? • What are some self-statements you can make?

48. Case Study: TJ • 10-year-old Caucasian male • In Day Treatment for separation anxiety disorder & school refusal • Engages in SIB (bites hands, knocks head against wall…); uncooperative (“leave me alone”, “you’re not my mom”)

49. Working with TJ • Forging a relationship • Projective testing • Relaxation training / Calming mental pix • Anxiety Hierarchy • Use of Positive Self-statements • Riding the bus game • The FROST testTJ's FROST.doc • Working with mom/school for transition to school