Wendy K. Silverman, PhD

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. 

Education. 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. 

Since exposure or staying in a scary situation is difficult, children need to be taught skills they can use so they can face their fears. This involves teaching children cognitive or self-control strategies. Children should be taught to recognize when they are feeling scared and to recognize their scary thoughts or beliefs; to learn to think of other thoughts or beliefs when scary thoughts surface; and to praise themselves for successfully substituting better thoughts. 

In teaching children self-control skills, the mnemonic STOP is often used: Scared, Thoughts, Other thoughts or 

 things I can do to handle my fear, and Praise myself for successful handling of my fear and exposure (e.g., "I'm really proud of myself"; "I am a brave boy/girl").

. In the application phase, children (and parents, if they are involved) practice the principles and procedures taught in the beginning sessions. This application occurs in the therapy session and out-of-session as homework assignments. The therapist's role is similar to a coach in terms of providing feedback, support and encouragement as the child engages in increasingly difficult anxiety-provoking exposure tasks. Children begin with the lowest (easiest) steps on the fear/anxiety hierarchy. The importance of staying with the feeling of fear/anxiety for as long as they can until the fear/anxiety is reduced is emphasized. At the same time, it should be emphasized that the exposure can be stopped if the feeling of fear/anxiety is more than the child feels willing or able to handle. However, if children are willing, they should stay in the situation almost until the exposure situation seems boring to ensure that the fear reaction will be successfully reduced on each step on the hierarchy. To help determine whether the fear has been reduced during the exposure, it is useful for children to rate their fear/anxiety on a rating scale or thermometer (i.e., 0 to 8 rating scale) before and throughout the exposure. The exposure can be terminated upon a successful reduction in the fear ratings (e.g., initial rating of 6 and a final rating of 1 or 2). 

If parents are involved, contingency management may be applied. The therapist helps the parent and child generate a contingency contract, which is a detailed written agreement about the specific exposure task that the child will try (e.g., what to do, when to do it, how long to do it), the specific reward the parent will provide for the child's successful attempt and/or completion of the task, and when the reward will be provided. 

Whether or not parents are involved in the treatment, it is important for children to apply the self-control strategies. In this way, children can ultimately be responsible for managing their own therapeutic change efforts. For example, if a child has a social phobia and the exposure involves going to parties, the child might practice STOP as follows: Yes, I feel Scared at the party; My Thoughts are that the other kids will think I am an idiot because I will say something stupid; Other thoughts or other things I can do include telling some of the new jokes I learned for kids' parties; and Praise myself because I should be really proud of myself for being brave and going to the party.

As much as possible, children with separation anxiety disorder and GAD should engage in in vivo exposures for those situations that commonly trouble them. For separation anxiety disorder cases, parents may be asked to leave the child alone or with a baby-sitter for increasingly longer time intervals. It also may involve the child staying at another child's house for increasingly longer time intervals. Using the previous example of the child with GAD who worried about getting sick from eating in restaurants, the exposure might involve having the child gradually visit and eat in restaurants. For the child who worried about terrorist attacks in school, the exposure might involve having the child gradually attend school. Emphasis in the sessions is on helping children to realize that their worst fears do not happen during the exposures. 

Although in vivo exposures are encouraged during the application phase, it may be difficult to devise an in vivo exposure for some patients with separation anxiety and GAD. In such cases, imaginal exposures can be used, where children imagine they are in a movie with anxiety-provoking scenes that involve a situation on their hierarchy. The details of the scene (e.g., clothes being worn, color of the room) should be elicited prior to having the exercise to help ensure a vivid image on the part of the child. The child should be asked to imagine the scene for as long as possible, but definitely until the anxiety decreases. 

The child can use STOP as needed to help decrease the anxiety response. For example, part of the T (anxious thoughts) for the child worried about eating in restaurants is that the bad thing may happen-children can get food poisoning in restaurants. In such instances, it helps to generate the O (other thoughts or other things to do) that the children can do to decrease the probability of this occurring (e.g., only eat in clean and established restaurants; if your food tastes funny, stop and ask someone else to try it for you). Also part of the O is to help children figure out that the probability of these things happening is considerably less than the probability of not happening. It also may be helpful to ask, "What if it did happen?"

. As the child meets with continued success, the therapist should begin discussing with the child issues relating to termination, including relapse prevention. Specifically, the importance of continued exposures is emphasized. However, children also should understand that like any accomplishment, if you don't use it, you lose it, and be warned of the possibility for slips. The analogy of a person on a diet who successfully loses 20 pounds but then eats a piece of cake at a party can be a helpful learning tool. Together, the child and the therapist should explore the different ways that the person could interpret their slip. This case is analyzed until it becomes evident that an adaptive interpretation is that the slip is a single event: "It does not mean that everything is blown or ruined. I need to pick myself back up and get back on the positive track I was on."

The treatment summarized in this article has empirical evidence for producing positive treatment response in children with social phobia, separation anxiety and generalized anxiety disorder. It would seem important, therefore, when working with children who present with these anxiety disorders to ensure that the main therapeutic procedures, particularly exposure exercises, are included in any treatment plan. The other strategies, such as the contingency contracting and self-control procedures, may be used to help facilitate the likelihood that children will engage in successful exposures (see Silverman and Kurtines [1996] for further details). 

Despite the evidence for the treatment, it is important that future research be conducted on examining the essential components of the exposure-based cognitive behavioral psychosocial interventions for use with anxiety disorders in children in terms of identifying and evaluating the main mediators of change. Also important is research on the moderators of changes in terms of identifying and evaluating for whom the treatment works. It also would be important that future research focus on comparing this treatment with other treatments, including other psychosocial interventions as well as psychopharmacological treatments. 

Silverman WK, Berman SL (2001), Psychosocial interventions for anxiety disorders in children: Status and future directions. In: Anxiety Disorders in Children and Adolescents: Research, Assessment and Intervention, Silverman WK, Treffers PDA, eds. Cambridge, U.K.: Cambridge University Press, pp313-334.
 

Silverman WK, Kurtines WM (1996), Anxiety and Phobic Disorders: A Pragmatic Approach. New York: Plenum Press.

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Children can now play a more active role in the treatment of their disorders. Using skills and information taught throughout the three treatment phases of cognitive-behavioral therapy (education, application and prevention relapse), they can be taught to understand and address the very fears that cause their disability.

Wendy K. Silverman, PhD

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