Study after study has shown that if you can get anxious individuals to gradually face their fears (a treatment called gradual exposure), their anxiety will decrease, and they will no longer be controlled by their fear. That is the science of treatment, to gradually face fears. But how do you get someone with overwhelming anxiety to do that? The art of treatment is figuring out what to do to persuade someone to gradually face fears. In my book Overcoming Anxiety in Children and Teens (Baker, 2015), I spell out some of the steps involved in helping young people face their fears. All the steps are appropriate for verbal clients, yet steps 3 and 5 can be used effectively for those clients with less language capability.
Step 1: Motivating Clients to Want to Address Anxiety
Therapy can be threatening, especially if you are being forced into it by others. There is an unspoken message that something is wrong with you that needs to be fixed. For verbal clients, I prefer to begin therapy with what is right about them to help them see their value and feel optimistic about the future. From this position of strength, we can talk about challenges that get in the way (like anxiety symptoms).
I start by explaining that everyone has a profile of strengths and challenges. Begin by making a list of their strengths (at least 7) and a smaller list of challenges (3 and under). Strengths include any special knowledge, traits, and characteristics they possess. Strengths are things that lead to successful careers and relationships. Challenges are things that can get in the way of reaching those goals. We do not need to totally overcome challenges like anxiety; we just need to get to the point where they are no longer in the way.
Step 2: Learning About Alarm System
All of us have an alarm system to help us survive in the face of perceived danger. When a significant threat is detected, we are wired to react automatically with an intense emotional response to fight, flee, or freeze as if our lives depended on it. Daniel Goleman, in his book titled Emotional Intelligence, refers to these moments as a state of being “hijacked by emotions.” It is as if the emotion center (the limbic system) has taken over the rest of the brain so that we don’t have easy access to our reasoning ability. This quick, non-thinking response certainly has survival value. When walking down the street, if a car suddenly veers off the road into your direction, this is not a time to reflect. You must move quickly to a safer place. This is a TRUE ALARM. Yet in a world where perceived threats may not always be life threatening, the fight, flight, or freeze response can lead to FALSE ALARMS, causing us to become emotionally reactive when no actual danger is present. Some of us may inherit a more sensitive alarm system that can set off many FALSE ALARMS.
Step 3: Identifying Fears: Creating a Fear Ladder
This is crucial since treatment will focus on gradual exposure to the very things that are feared. In Overcoming Anxiety in Children and Teens (Baker, 2015), I cover some of the major anxiety disorders for children and teens including: simple phobias, social phobia, selective mutism, separation anxiety, school phobia, panic disorder, generalized anxiety disorder, somatic symptom disorder and illness anxiety disorder, obsessive compulsive disorder, and other common fears like perfectionism, fear of loud environments, and medical procedure phobias.
Create the “Fear Ladder”
For each type of fear, make a list of situations from least fearful to most fearful. Then the child can gradually face those fears. For example, my clients who are afraid of arranging a get-together with a peer might break up the task into smaller steps (“rungs on the ladder”). The first step might be just say “Hi” at lunch. At another time, find out which video games they both like, then another time ask for a phone number in case they want to talk about video games, and then ask the peer if he or she wants to hang out to play video games. Finally, have the get-together.
Reward Facing Each Fear on the Ladder
There are two broad categories of rewards for facing fears: intrinsic rewards and extrinsic rewards.
Intrinsic rewards are the naturally occurring rewards for facing fears. Feeling pride and knowing that you are able to do so much more than you used to do are intrinsic rewards of facing fears. We can help clients see the payoff of being able to break out of their patterns of avoidance. We can help them feel proud of themselves for no longer letting anxiety control them.
Extrinsic rewards refer to providing contrived reward after facing a fear. This might be something like getting to play a video game or purchasing special items as a reward for taking a step towards facing a fear. For younger kids, and those students with greater cognitive challenges who may not comprehend the intrinsic payoff of overcoming anxiety, external rewards may be especially useful to motivate change.
Step 4: Use Cognitive Behavior Therapy to Combat Worries
The basic concept of Cognitive Therapy (CBT) for anxiety is to use logic and scientific reasoning to challenge the validity of the worrisome thoughts that maintain a high state of anxiety. To simplify matters for children, Rapee et al. (2008) focuses on just two ways of thinking to evaluate anxious thinking: overestimating the probability of negative events and/or overestimating the consequences of those negative events. I prefer to excuse kids from copious record keeping of their anxious and alternative thoughts and instead, write a brief summary for them of ways to “Think Like a Scientist.” The essence of CBT is to behave like a scientist and collect evidence to determine the actual probability and/or consequences of anticipated negative events.
For example, Ellie was a relatively typical nine-year-old afraid of bees and wasps. She often missed out on outside play with others during the summer months because she was afraid of being stung. She had never been stung, but she had heard some people have allergies and could go into anaphylactic shock and maybe even die from a sting! Her parents had taken her to an allergist who confirmed that Ellie was not allergic to insect bites.
To help her combat her worrisome thoughts and begin to face the fear of going outside in summer months, we created the following summary:
“Think Like a Scientist”
Feared Situation: Getting stung by a bee or wasp
1) Being outdoors in the summer makes it likely to be stung.
2) Getting stung really hurts and maybe I could even die
1) Bees and wasps are not aggressive away from nests. Not likely to sting unless swatted, hit, or stepped on. If I avoid nests, wear shoes when walking in leaves, and do not swat, I am not likely to be stung. I can also cover up food or stay away from garbage cans where those insects gather.
2) It is not possible for me to die because I am not allergic. I can reduce the pain by immediately flicking or taking out the stinger to limit the venom and apply ice for the swelling. I have had injections before and stings are actually less painful.
By researching the actual scientific evidence of the dangers of bee and wasp stings, she was able to gradually face fears on a fear ladder, involving staying outside for increasing amounts of time with her friends.
Step 5: Using Biological and Physical Interventions to Lower Anxiety
Exercise, physical activity, and sensory soothing actions can all reduce anxiety. Studies show the positive effects of exercise on increasing confidence and reducing anxiety. Several studies show exercise to be at least as effective as antidepressant medications. It seems that aerobic exercise may have the largest effect, followed by weight training. Therefore, many experts recommend that individuals with anxiety begin a regular exercise program, particularly one that involves an aerobic component such as jogging, walking, swimming, biking, or other sports that require aerobic activity.
There are times, however, when it is not possible to be physically active, such as when confined during travel or when going to bed at night. Therefore, we need ways to calm ourselves when our bodies are quieter. Many of the repetitive sensory movements and special interests of children with autism also serve to reduce anxiety and can be incorporated into the child’s schedule to reduce stress.
Meditation and mindfulness stress reduction embrace strategies to bring calmness to mind and body in a way that does not depend on movement. These practices involve learning to focus one’s attention to what’s happening in the moment, whether something experienced with the five senses (such as a taste, smell, sound, touch, or sight) or an internal sensation, such as the feeling of one’s breathing or even the awareness of having a particular thought. Periods of time allocated to focusing the mind on the present moment are associated with a sense of well-being and reduced anxiety.
Though “mindfulness” is considered a way of trying to live one’s life rather than a specific tool, there are some mindfulness strategies that can reduce anxiety. Progressive Muscle Relaxation, involves the tensing, and then relaxing, of the muscles of the body, one group at a time. Deep belly breathing can also induce a state of relaxation. One can find scripts for progressive muscle relaxation, deep breathing, and mindfulness guides in my book (Baker, 2015). The interested reader will find many more resources by searching for “free meditation guides” online.
Putting It All Together
Anxiety itself is not always a problem, yet when it disrupts one’s life with unnecessary worries, or causes one to avoid desired activities, then it becomes a problem. The purpose of calming strategies is to increase a sense of well-being and lower anxiety enough so that individuals no longer avoid non-dangerous situations. Here are recommendations for using the calming tools:
- Active calming: All readers are encouraged to start an exercise program. This is cost-free; reduces anxiety; and can increase attention, memory, and learning, as well. Keeping busy with desirable activities like playing music, games, reading, and watching shows can also reduce stress Such activities must be balanced with required activities like homework, dinner, and bedtime.
- Quiet calming: Readers should experiment with progressive muscle relaxation, deep breathing, and mindfulness meditation to see which strategies are easier for them and which strategies reduce stress. These strategies should become part of a daily practice, for example at bedtime, upon awaking, and certainly at anxious moments (before, during, and after facing a feared situation).
- Using CBT to challenge anxious thinking is useful for all verbal children. Learning to combat the tendency to overestimate the frequency and consequences of negative events is crucial to this process. Caregivers are encouraged to create “Think Like a Scientist” cards for their children to use as a reminder of how to combat their particular worrisome thoughts.
- Together, caregivers and children can create the “fear ladders” to identify situations to face in an effort to gradually overcome those fears. For young children (12 and under), or those less willing to face the feared situations on the ladder, external rewards should be identified to use as incentives for confronting a situation.
- If the strategies and lifestyle changes described above do not sufficiently reduce anxiety, consider the use of neurofeedback and/or medication to further lower anxiety. Neurofeedback is quite safe in general, yet there is a cost and time commitment that may not make it everyone’s first choice. Medications can be quite helpful, yet should not be a first choice since they carry the risk of side effects.
© 2017 AHA Association. Further reproduction of this article is prohibited without express written permission of AHA. This article was reprinted with permission and was originally published in the Spring 2017 issue of AHA Association’s On The Spectrum. For more information, visit www.ahany.org.