In the past decade, research from randomized clinical trials has produced strong and consistent evidence showing that cognitive-behavioral therapy (CBT) can play an important role in reducing social phobia, separation anxiety and generalized anxiety disorder (GAD) in children and adolescents (see Silverman and Berman [2001] for review).
This article presents the main therapeutic procedures and strategies used in CBT along three phases: education, application and relapse prevention. In practice, however, there is overlap among the procedures and strategies used across these different phases.
The PhasesEducation. In the education phase, children first receive information that anxiety may manifest in three ways. One way involves "feelings in their bodies," such as heart beating fast, sweating or "butterflies in the stomach." Another manifestation involves certain behaviors, namely avoiding or staying away from situations or events that are anxiety-provoking. A third way involves thinking or what we "say to ourselves." In this phase, the therapist explains to the child that they will learn to recognize the specific reactions they get when they feel anxious, and they will learn to manage or reduce these reactions in therapy.
The situations avoided and the anxious thoughts vary among patients with social phobia, separation anxiety and GAD. During the education phase, children learn to identify the situations and the nature of their thoughts. In social phobia, children generally avoid situations that involve social evaluation and/or performance in front of people. For example, children may fear giving an oral presentation in class, attending parties, or belonging to clubs or teams. The thoughts generally pertain to fears of social humiliation or embarrassment (e.g., "People will laugh at me"; "I will make a mistake and look stupid"). In separation anxiety disorder, children generally avoid situations in which parents or loved ones will be away from them or situations in which they need to be away from parents or loved ones. For example, children may avoid going to school, sleeping alone at night or being left alone with a baby-sitter. The thoughts generally pertain to fears of harm befalling either themselves or their parents/loved ones (e.g., "I might get kidnapped or killed and then I wouldn't be able to see my parents again"; "My parents may get into an accident and be killed, and I would never see them again"). In GAD, children engage in frequent, uncontrollable worry. The worry thoughts vary and may focus on everything and anything or specific areas, such as personal health, parents' health, their performance in school, world events or "little things" (e.g., "Maybe I said something that will be taken the wrong way"). Children with GAD also may show avoidant behaviors (e.g., not eating in restaurants due to a fear of getting sick, not attending school because there might be a terrorist attack).
For children who experience bodily reactions when feeling anxious, the education phase might involve teaching relaxation strategies. This may be particularly helpful for children with GAD, for which physiological reactions are part of the diagnostic criteria. In this phase, primary emphasis is placed on informing children about the importance of "facing one's fears" rather than avoiding them. They are taught that by facing the fears, they have the opportunity to learn that the feared events are not bad after all. This, in turn, can help reduce their anxiety. The therapist explains to the child that exposures to anxiety-provoking situations/objects will be done in a gradual or graded fashion, not all at once, and children are reassured that they will not be asked to face their fear in a way they feel they cannot handle.
Also during the education phase, the therapist tries to elicit as much information as possible about the avoided situations. For children with GAD, this may also involve eliciting the child's worries. This information will be included on the ladder or fear/anxiety hierarchy. The therapist explains that, as part of therapy, the child will be asked to complete each rung on the ladder or experience each exposure.
Although parental involvement is not essential for positive treatment response, therapists may decide that parental involvement may be helpful in some cases. This may be particularly true for parents who seem to encourage avoidance behaviors or when working with young children. If parents are involved, they are taught behavioral strategies that are to be used to help increase child exposure and decrease child avoidance. One behavioral strategy taught is contingency management, which involves teaching parents basic concepts of positive reinforcement and the proper delivery of reinforcement. The importance of consistency and follow-through, as well as potential difficulties in effective follow-through, is explained. It also is important to differentiate among types of rewards (i.e., social, tangible, activity) and highlight the use of social and activity rewards in therapy.
