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Cognitive-Behavioral Techniques with Anxious Children and Adolescents. Yeo Lay See. Outline. What is CBT? Is CBT biblical? Anxiety Disorders Relaxation Training Anxiety Hierarchy & Desensitization Cognitive strategies. What is CBT?.

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Cognitive-Behavioral Techniques with Anxious Children and Adolescents

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  • What is CBT?
  • Is CBT biblical?
  • Anxiety Disorders
  • Relaxation Training
  • Anxiety Hierarchy & Desensitization
  • Cognitive strategies
what is cbt
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.
two levers of change in cbt

Alter ways of thinking for the better

E.g., change perceptions of / attitude toward a particular situation


Take some action that is likely to prove beneficial and instructive

E.g., relaxation to cope with anxiety

Two Levers of Change in CBT
cbt techniques
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
cbt techniques1
CBT Techniques
  • Behavioral Techniques
    • Activity scheduling and modeling
    • Graded task assignments
    • Behavioral experiments to test out thoughts and beliefs
    • Exposure tasks
    • Relaxation
why cbt
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
is cbt for every client
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.
cognitive restructuring
Cognitive Restructuring
  • Help an anxious person change negative, extreme, unrealistic, irrational, distorted, catastrophic thinking into more realistic and accurate thinking.
is there a biblical basis for cbt
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)
activity 1
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?
features of anxiety
Features of Anxiety
  • Physiological distress
  • Cognitive distress
  • Emotional distress
  • Significant impairment of daily functioning
normative development
Normative Development
  • 7-9 months: ___________ anxiety
  • Age 2-3 years: ___________ anxiety
  • Preschool years: ___________ fears
  • Adolescence: ___________ fears
anxiety disorders
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.
anxiety disorders1
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
how scared would you be
How scared would you be?
  • How scared would you be (2).doc
our internal alarm system
Our Internal Alarm System




Real danger

Genuine lack of resources


Danger perceived as high

Resources perceived as low






  • 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.
cognitive perspective on anxiety disorders
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.
factors that maintain anxiety
Factors that maintain anxiety

Three vicious circles:

  • Selective attention
  • Physiological change
  • Change in behavior
safety seeking behaviors
Safety-seeking behaviors

Three categories:

    • Avoidance
    • Escape
    • Some Action
  • Problem: Prevent disconfirmation of the feared catastrophes
the panic circle
The Panic Circle

Trigger Stimulus

Perceived Threat

Misinterpretation of sensations as catastrophic


Bodily Sensations

general cbt strategies

Altering maladaptive self-talk (building a cognitive coping template, Kendall)

Self-Instructional Training

Modeling & behavior rehearsal

Problem solving


Systematic Desensitization

Relaxation training

Anxiety hierarchy

Gradual exposure


Restructuring contingencies

General CBT Strategies
experiencing anxiety physically
Experiencing Anxiety Physically
  • For clients who experience anxiety as somatic disturbance or arousal, use Relaxation or Arousal-reducing Stress Inoculation
relaxation training
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
activity 2
Activity 2
  • Deep breathing
  • Progressive Muscle Relaxation
cbt strategies for anxiety
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
anxiety hierarchy
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)
eg of anxiety hierarchy for a school refusing child
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
anxiety hierarchy1
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
desensitization graded exposure
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
  • Two types of exposure:
    • Imaginal (low risk of an extreme anxiety reaction)
    • In vivo (can be extremely stressful)
imaginal desensitization
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.
imaginal desensitization1
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.
imaginal desensitization2
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
  • As clients pair being relaxed with imagining the feared situations in the hierarchy, they become increasingly “desensitized” to these situations.
in vivo desensitization
In Vivo Desensitization
  • Not recommended for unskilled therapists
  • Only exception is treatment of school phobia or school refusal behavior.
experiencing anxiety cognitively
Experiencing Anxiety Cognitively
  • For clients who experience anxiety as cognitive distress, teach adaptive self-instruction.
frost nichols 1999
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.
frost nichols 19991
FROST (Nichols, 1999)
  • F Feel OK?
  • R REWARD me?
  • O Keep me OUT of trouble?  
  • S Keep me SAFE?
  • T Is that thought TRUE?
teach thought testing
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?
activity 3
Activity 3
  • Apply FROST to the situation you described in Activity 1.
self instructional training
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
activity 4
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?
case study tj
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”)
working with tj
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