For children with mild to moderate anxiety, the recommended treatment is CBT. For children with severe anxiety, the recommended treatment is CBT plus medication. And unlike taking medication alone, therapy gives children the tools to manage the anxiety themselves, now and in the future.

Understanding CBT- Cognitive Behavioral Therapy

Cognitive Behavioral Therapy is based on the idea that how we think and act both affect how we feel. By changing our distorted thinking and dysfunctional behavior, we can change our emotions. With younger children, focusing first on the behavioral part of CBT can be most effective.

To understand how CBT works, it helps to first understand how anxiety works. Serious, untreated anxiety tends to get worse over time, not better, because the child learns that avoidance works in reducing the anxiety, at least in the short run. But as the child — and, indeed, the whole family — work to avoid triggering those fears, they only grow more powerful. The goal in CBT is, essentially, to unlearn avoidant behavior.

One of the most important techniques in CBT for children with anxiety is exposure and response prevention. The basic idea is that children are exposed to the things that trigger their anxiety in structured, incremental steps and in a safe setting. As they become accustomed to each of the triggers in turn, the anxiety fades, and they are ready to take on increasingly powerful ones.

Exposure therapy is very different from traditional talk therapy, in which the client and a therapist might explore the roots of the anxiety, in hopes of changing their behavior. In Exposure therapy, we try to change behavior to get rid of the fear.

Exposure therapy is effective for many different kinds of anxiety, including separation anxiety, phobias, obsessive-compulsive disorder (OCD), and social anxiety.

Externalizing Anxiety Can Help Children

For children and anxiety disorders, the process begins by helping them and their parents get some distance from the anxiety and start thinking of it as a thing that is separate from who they are. Externalize it so they have some control over it.

We explain that we are going to teach skills to handle the external threat, giving children the idea that they can control their anxiety rather than it controlling them.

It’s also important to help children understand how their anxiety is affecting their lives. We may map out things a child can’t do because of their fears — like sleeping in their bed, or going to a friend’s house, or sharing meals with their own family — and how that makes them feel. Getting kids to understand how their anxiety works and gaining their trust is essential because the next step — facing down their fears — depends on them trusting us.

Exposure therapy slowly and systematically helps a child face their fears, so they can learn to tolerate their anxiety until it subsides rather than reacting by seeking reassurance, escaping, avoidance, or engaging in ritualistic behaviors such as hand washing.

Using Exposure Therapy with Care

The first step is identifying triggers. We design a “hierarchy of fears” — a series of incremental challenges, each of which is tolerable, and which together build to significant progress. Instead of thinking in black and white terms — I can’t touch a dog or I can’t cross a bridge — children are asked to consider degrees of difficulty. We might ask a child with contamination fears, for example, “On a scale of 1 to 10, how difficult would it be to touch the door handle with one finger? To touch and open the door?”

For a child with a fear of vomiting, we might ask: “How difficult would it be to write the word vomit?” If that is a 3, saying “I will vomit today” might be a 5. To see a cartoon of someone vomiting might rate a 7. To watch a real video of someone vomiting might be a 9. At the top of the hierarchy would likely be eating something the child thinks will make them vomit. By rating these different fears, kids come to see that some are less extreme and more manageable than they had thought.

Next, we expose the child to the trigger in its mildest possible form and support them until the anxiety subsides. Fear, like any sensation, diminishes over time, and children gain a sense of mastery as they feel the anxiety wane.

Severe Anxiety In Children

With a severely anxious child — who can, for instance, barely leave their room for fear that their parents will die or must wash their hands dozens of times a day to avoid contamination — we do exposures in the office and then, when a child is comfortable enough, do them outside.

For someone with social anxiety, for instance, we might go out wearing silly hats or walk a banana on a leash. For someone afraid of contamination, we might shake hands with strangers, then eat chips without washing our hands.

Once we have worked through some exposures and they are feeling more confident, we assign homework to practice what we did in the sessions. We want children to master their exposures before moving up the ladder. And parents are taught to help children progress by encouraging them to tolerate anxious feelings, rather than jumping in to protect them from their anxiety.

Treatment for mild to moderate levels of severity usually takes eight to 12 sessions, and some children make more progress if they are also taking medication to reduce their anxiety, which can make them more able to engage in therapy.

It’s important to understand that exposure therapy is hard work, both for children and their parents. But as fear diminishes, children get back to doing things they like to do, and the family gets back a child they feared they had lost — and that’s a great reward.

We’d be happy to continue the discussion with you. Visit our Therapy Center page to learn more.