When a child shows signs of anxiety, we tend to think it will go away—she’s just nervous or shy, and she’ll grow out of it. But when the anxiety becomes so intense that it’s seriously interfering with a child’s life, and the life of her family, it’s important to get help.
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.
Medication is often prescribed for children with anxiety, as it is for adults. And medication—antidepressants are usually our first choice—often helps reduce anxiety. But what many people don’t know is that cognitive behavioral therapy (CBT) can be very effective for kids who are anxious. In fact, research over more than 20 years has shown that CBT is the most effective treatment for reducing symptoms of severe anxiety. And unlike taking medication, the therapy gives children the tools to manage the anxiety themselves, now and in the future.
What is cognitive behavioral therapy?
Cognitive behavioral therapy is based on the idea that how we think and act both affect how we feel. By changing thinking that is distorted, and behavior that is dysfunctional, we can change our emotions. With younger children, focusing first on the behavioral part of CBT can be most effective. The goal is, essentially, to unlearn avoidant behavior.
One of the most important techniques in CBT for children with anxiety is called exposure and response prevention. The basic idea is that kids 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 patient and a therapist might explore the roots of the anxiety, in hopes of changing her behavior. In exposure therapy we try to change the behavior to get rid of the fear.
Exposure therapy is effective on many different kinds of anxiety, including separation anxiety, phobias, obsessive-compulsive disorder (OCD), and social anxiety.
The Bully in the Brain
For children with 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. One way I do this is by having them conceptualize it as a “bully in the brain,” and I encourage kids to give the bully a name and talk back to him. Kids I’ve worked with have called him the Witch, Mr. Bossy, Chucky, the Joker, and, in the case of some teenagers, names I cannot repeat here.
We explain that we are going to teach skills to handle the bully, giving children the idea that they can control their anxiety rather than it controlling them.
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