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ANXIETY

Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services

Practice Elements


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Practice Elements

  • Relaxation

  • Cognitive/Coping

  • Modeling

  • Exposure


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Treatment Manuals for Anxiety

  • Coping Cat (Kendall & Hedtke, 2006)

    • Cognitive-Behavioral Therapy for Anxious Children

  • The C.A.T. Project (Kendal, et al., 2002)

    • Cognitive Behavioral Treatment of Anxious Adolescents


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What is Relaxation?

  • Techniques or exercises designed to induce physiological calming, including muscle relaxation, breathing exercises, meditation, and similar activities.

  • Guided imagery exclusively for the purpose of physical relaxation is considered relaxation.


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Relaxation: Deep Breathing

  • Breathe from the stomach rather than from the lungs

  • Can be used in class without anyone noticing

  • Can be used during stressful moments such as taking an exam or while trying to relax at home


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Relaxation: Deep Breathing Tips

  • Teach students to breathe in slowly through the nose, and out through the mouth

  • Children should breathe in to the count of 5, and out to the count of 5

    • “Breathe in, two, three, four, five, and out, two, three, four, five” (at a rate of about one count per second or two)

  • Adolescents should breathe in and out to the count of 8

  • Have them take 3 normal breaths in between deep breaths

  • Have them imagine a balloon filling with air, then totally emptying


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Relaxation: Mental Imagery/Visualization

  • Can enhance other relaxation techniques or be used on its own

  • Provides relief from troubling thoughts, emotions, or feelings

  • Evokes a pleasing, calming mental image (e.g., the beach, park, forest, playing with a favorite pet)


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Relaxation: Mental Imagery/Visualization Tips

  • Have the student close his/her eyes and imagine a relaxing place of their choosing

  • While the imagine this, describe the place to them, including what they see, hear, feel, and smell

  • Younger students may use a picture or drawing to help them


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Relaxation: Progressive Muscle Relaxation

  • Alternating between states of muscle tension and relaxation helps differentiate between the two states and helps habituate a process of relaxing muscles that are tensed

  • Many good tapes/c.d.’s available on relaxation


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Relaxation for Children

Coping Cat, Session 5

  • Purpose: Review the cues that indicate that the child is tense and anxious. Introduce relaxation training and its use in controlling tension associated with anxiety.


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Relaxation for Children - Steps

  • Discuss how many feeling associated with anxiety involve muscle tension

  • Introduce relaxation and practice techniques

  • Discuss how/when relaxation might be useful

  • Practice with student and parents


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Relaxation for Children - Tips

  • Gently point out muscle tightness that you notice

  • Do the exercises along with the student

  • Try different scripts/strategies

  • Explain the procedure to parents


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Relaxation for Adolescents

The C.A.T. Project, Session 3

  • Purpose: For youth to learn about somatic responses to anxiety and identify own responses. Introduce relaxation training and its use in controlling tension associated with anxiety.


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Relaxation for Adolescents - Steps

  • Discuss somatic responses to anxiety

  • Discuss the association between anxiety and muscle tension

  • Introduce relaxation – discuss how it affects the body

  • Practice relaxation

  • Reinforce how/when relaxation might be helpful


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Relaxation for Adolescents - Tips

  • Point out muscle tightness that you notice

  • Assure students that it might seem uncomfortable at first but will get easier with practice

  • Do exercises along with student

  • Encourage student to practice, practice, practice!


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What is Cognitive/Coping?

  • Any techniques designed to alter interpretations of events through examination of the student’s reported thoughts, typically through the generation and rehearsal of alternative counter-statements.

  • Can include exercises designed to compare the “truth” of the original thoughts and the alternative thoughts through the gathering or review of relevant information.

    • “Which is more true?”


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Cognitive/Coping with Children

Coping Cat, Session 6

  • Purpose: Discuss how thoughts impact anxiety-provoking situations. Help child recognize his self-talk in anxious situations and develop coping self-talk.


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Cognitive/Coping with Children - Steps

  • Introduce concept of thoughts (self-talk)

  • Discuss self-talk in anxiety-provoking situations

  • Differentiate anxious self-talk from coping self-talk

  • Help child answer the question “What do I expect to happen?”

  • Practice coping self-talk


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Cognitive/Coping with Children - Tips

  • Ask the child to draw himself in an anxious situation

  • Provide examples of TV shows in which the main character is the narrator (e.g., Everyone Hates Chris, Lizzie Maguire)

  • Check with child to see if he believes his coping thoughts


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Cognitive/Coping with Children - Tips

  • Identify people whom the child admires as “good at coping” and use as model

  • Don’t fall in the trap of trying to convince a child that the scary event is not likely to happen

  • Make a list of thinking traps that the child typically uses


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Cognitive/Coping with Adolescents

The C.A.T. Project, Session 5

  • Purpose: Introduce function of personal thoughts and their impact on response in anxiety-provoking situations. Help teen recognize self-talk and learn to produce coping thoughts.


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Cognitive/Coping with Adolescents Steps

  • Introduce concept of thoughts (self-talk)

  • Help teen answer the question “What do I expect to happen?”

  • Discuss challenging self-talk and introduce concept of coping thoughts

  • Have teen document anxious experiences throughout the week and pay attention to thoughts


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Cognitive/Coping with Adolescents Tips

  • Check with teen about whether s/he believes what s/he is saying to him/herself

  • Have teen identify people whom they admire as good “copers” and use as model


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What is Modeling?

  • Demonstration of a desired behavior by a therapist, peer, or someone else to promote the imitation and subsequent performance of that behavior by the anxious student


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What is Modeling?

  • Learning from observing and imitating role models

  • Learning about rewards and punishments that result from behavior

  • Can be used to strengthen OR weaken behavior


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Types of Modeling

  • Participant modeling – Therapist acts out anxiety-provoking behaviors & prompts student to engage in behavior

  • Covert modeling – Student uses imagination to visualize particular behavior

  • Symbolic modeling – Using videotape, picture books, plays, etc. demonstrating target behavior


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Modeling – Cuentos Therapy

  • Storytelling/Folktales

  • Taken from Puerto Rican culture; used historical heroic characters

  • Used to foster imaginative behavior that youth are likely to imitate

  • More effective when youth is attracted to and identifies w/the model


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Modeling - Tips

  • Clearly demonstrate target behavior without unnecessary details

  • Start with the least difficult level of behavior and work up to difficult behaviors

  • Incorporate a number of models to perform same target behavior


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Modeling – Tips

Use Role Playing

  • Provide feedback – good and bad

  • Encourage use of newly learned skills

  • Coach student to move them closer to target behavior, one step at a time


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Resources for Modeling

  • Psychosocial Treatments for Child and Adolescent Disorders (Eds., E. D. Hibbs & P. S. Jensen), 1996

  • www.minddisoders.com/Kau-Nu/Modeling


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What is Exposure?

  • Exercises that involve direct or imagined experience with the feared stimulus, whether performed gradually or suddenly, and with or without the therapist’s elaboration or intensification of the stimulus


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Systematic Desensitization

  • Anxiety reducing strategy involving a graduated exposure of the phobic student to the feared object or situation.

  • The student learns to tolerate the feared object by means of a series of steps beginning with the least anxiety producing aspect of the process and ending with the most difficult step.

  • Begin with construction of the Anxiety Hierarchy


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Exposure with Children

Coping Cat, Sessions 10-15

  • Purpose: Practice 4-step coping plan under low and, eventually, high anxiety-provoking situations

    • Feeling frightened?

    • Expecting bad things to happen?

    • Attitudes and Actions that can help

    • Results and Rewards


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Exposure with Children - Steps

  • Review idea of progressing from learning to practicing new skill

  • Practice using imagined exposure in anxiety-provoking situations

  • Practice in-vivo (live) exposure task in anxiety-provoking situations

  • Review relaxation exercises

  • Decide on a situation where child will practice


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Exposure with Children - Tips

  • Be encouraging, supportive, and display confidence

  • Note for the child how imagining situations is helpful

  • Continue with imagined exposure until anxiety level is reduced

  • Increase child’s involvement by soliciting suggestions


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Exposure with Children - Tips

  • Do not be drawn to “protect” the child from his negative emotions

  • Be aware of “subtle avoidance” behavior

  • Various in-vivo experiences can be arranged in the office

  • Many natural-occurring exposure tasks can occur in public places


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Exposure with Adolescents

The C.A.T. Project, Sessions 10-16

  • Purpose: Practice the 4-step coping plan under low and, eventually, high anxiety-provoking conditions.

    1. Feeling frightened?

    • Expecting bad things to happen?

    • Attitudes and Actions that can help

    • Results and Rewards


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Exposure with Adolescents - Steps

  • Shift focus from learning new skills to practicing them in real situations

  • Imaginal practice with anxiety-provoking situations

  • In-vivo practice with anxiety-provoking situations

  • Decide on situation that will be practiced next

  • Have teen record 1 anxious experience, including 4 steps


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Exposure with Adolescents - Tips

  • Continue to imaginal exposure until anxiety level is reduced

  • Present a situation and ask teen to rate level of anxiety (0-8 scale)

  • Various in-vivo experiences can be arranged in the office

  • Many natural-occurring exposure tasks can occur in public places


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Exposure with Adolescents - Tips

  • Refrain from comforting the teen when they become anxious – allow them to develop independent coping skills

  • Teens may enlist a friend as a support. Encourage the selection of a trustworthy peer

  • Solicit suggestions from the teen in planning exposure tasks


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