•Will Davidson, LMHC.

CBT and Play Therapy Treatment for Childhood Anxiety

IntroductionCBT - tool for youth anxiety (7 – 13 years old)

who meet criteria for Generalized Anxiety Disorder, Social Phobia, and/or Separation Anxiety Disorder.

FEAR Plan “F” : Feeling Frightened? Focuses on somatic

reactions to anxiety “E” : Expecting Bad Things to happen? Helps

youth identify anxious cognitions“A” : Attitudes and Actions that Can Help.

Provides coping skills for the youth implement (coping thoughts, problem-solving, relaxation, belly breathing)

“R” : Results and Rewards. Allows youth to rate their performance and effort and be rewarded for facing their fears.

Intervention Process Activity 1: Build Rapport. Play

personal facts game, the “Ungame”, Animal toss.

Activity 2: Provide overview of program. Talk about treatment goals. Do motivational interviewing. Encourage child’s participation. Normalize fear/anxiety. “Meet some other children with anxiety activity.” “My Anxiety activity.”

Activity 3: Identify different

feelings. Child and/or therapist act out feelings (Charades). Cut out pictures from magazines and write the feelings below each picture (feelings dictionary). Play cards with “Feelings Playing Cards.”

Activity 4: Identify somatic responses to anxiety. (F step) My body signals activity. Body drawing activity.

Activity 5: Develop a hierarchy of anxiety-provoking situations. “The worry scale.”

Activity 6: Fight or Flight –

Avoidance and anger. Tell a story that includes 3 reactions to anxiety – avoidance, anger and coping.

Activity 7: Relaxation – teach the difference between tense and relaxed. Introduce coping skills. Robot/Spaghetti activity. Making lemonade activity. Stomach breathing. Body scan. Tapping points. Relaxation place.

Activity 8: Help child recognize anxious thoughts. Act out different activities and have the child guess the self-talk that is going on.

Activity 9: Thoughts affect feelings. Sam and Tim activity. Bubble cartoon – have child think of a calm thought and anxious thought for each cartoon.

Activity 10: Thinking traps. Thinking trap activity.

Activity 11: Thought stopping and replacement/problem solving, (A step). Stopping the troll activity. Positive thoughts activity. Detective Evidence Sheet.

Intervention Process Activity 12: Introduce self-

evaluation and reward… “R” step of FEAR plan- Results and rewards. Rewarding yourself activity.

Activity 13: Rewards for trying hard. Make a list of rewards for trying hard.

Intervention ProcessHierarchical Exposure

Ladders to success

Use F.E.A.R. techniques Combine imaginal and in vivo

exposure on a graduated scale. Include rewards for trying.

Sample Exposures

Separation anxiety – play hide and seek with parent.

Perfectionism – practice doodling. Draw in the dark. Go outside with shirt inside out.

Social phobia – order an ice cream cone. Go to a crowded place.

Doesn't like attention – talk loud in the library. Sing a song in public.

Potential Barriers/Strategies to Overcome BarriersBarrier: Younger children (7-8 yrs old) – They may not

understand the feelings that you are trying to explain so use play and/or art to help discover feelings, thoughts, and behaviors. Strategy to Overcome the barrier: Games: Charades- Act

out the feelings. Feelings Dictionary. Spy Detective: Go around looking for different feelings. Drawing the feelings

Barrier: Kids with Social Skills DeficitStrategy to Overcome the barrier: Discuss basic

emotions, (Sad, afraid, happy). Challenge children to work on the “E step” thoughts and the “A step” actions. These children worry about fitting in which can be legitimate. Counselor should work on separating their realistic and unrealistic thoughts and then work on their actions (Exposure Task).

Potential Barriers/Strategies to Overcome BarriersBarrier: Inattentive/Hyperactive Kids

Strategy to Overcome barrier: High Structure with shorter intervals interspersed with short breaks. (breaks can include jumping jacks or a short game). Use a picture schedule with the breaks built in so that the child can see when they will get breaks. Increase interactions and engagements (use charades for the feelings part instead of collage or having a catch with a nerf ball while discussing feelings). Alter the setting so that there are minimal visual distractions. Work in a reward system.

32% comorbidity with Anxiety.

Potential Barriers/Strategies to Overcome BarriersBarrier: Depressive Symptoms

Strategies to Overcome: A child who is comorbid with anxiety and depression may not improve with just anxiety interventions. Increase the rapport building time to longer than just one session. Possibly spend the first 10 minutes of each session building rapport. Cognitive restructuring : When going over the automatic thoughts be on the lookout for negative cognitions and spend time on those thoughts. Attempt to increase their activity levels (Activity scheduling, Exposure therapy).

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References

Beidas, Rinad S., Benjamin, Courtney L., Puleo, Connor M., Edmunds, Julie M., Kendall, Philip C. (2010). Flexible applications of the Coping Cat Program for anxious youth. Cognitive and Behavioral Practice, 17, 142-153.

Podell, Jennifer L., Martin, Erin, D., Kendall, Philip C., (2009) Incorporating Play within a Manual-Based Treatment for Children and Adolescents with Anxiety Disorders. In: Blending Play Therapy with Cognitive Behavioral Therapy, Athena Drewes (Ed), Pg 165 – 178

Rapee, Ronald, Wignall, Ann D., Spence, Susan, Lyneham, Heidi, (2008) Helping Your Anxious Child: A Step-By-Step Guide for Parents