The Society for Clinical Child and Adolescent Psychology (SCCAP):

Initiative for Dissemination of Evidence-based Treatments for Childhood and Adolescent

Mental Health Problems

With additional support from Florida International University and The Children’s Trust.

Workshop Evidence-based Treatment for Child Anxiety Problems: Cognitive Behavioral Strategies

Wendy Silverman, Ph.D. Professor of Psychology and Director of Clinical Training

Director, Child Anxiety and Phobia Program Florida International University

Acknowledgments

FIU Faculty: Jim Jaccard, Bill Kurtines

Past Post docs: Steve Berman (UCF), Golda Ginsburg (Johns Hopkins), Brian Rabian (Penn State), Andreas Dick-Niederhauser (Bern, Switzerland)

Current Post docs: Carla Marin, Yasmin Rey

Current FIU graduate students: Ayce CiCi-Goltkun, Jessica Dahan, Cristina Del Busto, Irina Fredricks, Devi Hausman, Maria Pienkowski, Ileana Hernandez, Luci Motoca,

FIU undergraduate students

NIMH Research Grants: R29MH44781, R01MH49680, R21MH 54690, R01MH63997, R01 MH079943

NIMH Midcareer Development Award: K24MH73696

Additional Acknowledgments

Anne Marie Albano

CAMS Team (Golda Ginsburg)

Debbie Beidel

Eliot Goldman

Christopher Kearney

Phil Kendall

Ron Rapee

Tom Ollendick

Michael Southam-Gerow

The Reach Institute (Peter Jensen and colleagues)

Workshop Overview

Prevalence

Diagnosing and assessing

Etiological theories

Overview of treatment

Treatment nuts and bolts

Cases and questions

Background Information

Anxiety disorders of childhood and adolescence are one of the most, if not the most prevalent problems.

Most prevalent problems in adults.

PREVALENCE OF CHILD DISORDERS (ANDERSON ET AL. ,1987)

DIAGNOSIS PERCENT

OPPOSITIONAL 2.2 : 1 5.7

SEPARATION 3.5

CONDUCT 3.4

OVERANXIOUS 2.9

SIMPLE PHOBIA 0. 2.4

MOOD 1.8

SOCIAL PHOBIA 0.9

ALL CONDUCT 2.8 : 1 9.1

ALL ANXIETY 0.7 : 1 9.7

Demographic Factors

AGE – Any (onset around ages 5 to 7)

SEX – Both boys and girls, with age > girls

ETHNICITY/RACE – Any

SES – Any

MARITAL – Any

FAMILY SIZE – Average

PARENTS – Higher in anxiety

Anxiety problems are highly prevalent,

but…

least likely to be detected and referred

Why the low detection and referral rates?

The Internalizing versus Externalizing distinction (the kids who cause the ‘trouble’ get our attention).

Assumption that most childhood anxiety is a transient or temporary, fleeting event.

Transient episodes of anxiety

Are expected and cause relatively little interference in

functioning for the average child or adolescent

Are associated with new or unexpected events (e.g.,

thunder; first day of school)

Can be handled with minimal reassurance or

encouragement

But anxiety disorders in children do not necessarily

remit over time.

Anxiety disorders are also associated

with substantial impairment

Family

Friends

School

Personal Distress

Assessing for impairment…

FISH

Frequency? Every day? once a week? Once a month?

Intensity or Severity?

How long has this been going on? A week? A month? Duration?

Get a rating!

Rates of Diagnosis and Impairment

(N=1,015; ages 9, 11, 13)

Diagnosis/ Diagnosis/ Impaired/

Impaired Not Impaired Not Diagnosed

13.7 % 14 % 20 %

from Angold et al. (1999)

Gateway to other Psychopathologic

Conditions: Developmental Patterns in

Onset

Specific phobia

Separation anxiety disorder

Social phobia

Generalized anxiety disorder

Panic disorder

Depressive disorder

Substance use disorder

Anxiety disorders also are associated with suicidal ideation (Carter, Silverman et al., 2008)

Summary reasons for treating

anxiety disorders in youth

Quiet distress and significant impairment

Do not remit with time

“Gateway” to other disorders including anxiety disorders, dysthymia/depression, and substance use/abuse problems

Successful implementation of

evidence based anxiety treatment

depends on careful conceptualization and

understanding of child’s anxiety problems

DIAGNOSIS & ASSESSMENT OF ANXIETY DISORDERS

DSM-IV Anxiety Disorders

Other disorders of Infancy, Childhood, or Adolescence ◦ Separation Anxiety Disorder

Anxiety Disorders ◦ Specific Phobia

◦ Social Phobia (Social Anxiety Disorder)

◦ Obsessive-Compulsive Disorder

◦ Posttraumatic Stress Disorder

◦ Generalized Anxiety Disorder

◦ Panic Disorder with Agoraphobia

◦ Panic Disorder without Agoraphobia

◦ Agoraphobia without History of Panic Disorder

Sue

Sue, a 4th grader, has stopped attending school. She went the first couple of days with a huge fuss in morning, which continued for a few hours in the classroom. Parents were told that Sue can’t stay in school if this is how she is going to behave. Now things have gotten worse and now she refuses to even get out of bed in the morning. She vomits at night and reports having terrible stomach aches in the morning. She is afraid to sleep alone in her bedroom at night; she has been sleeping in her parents’ bed for over two years.

Separation Anxiety Disorder

Fear of separation from major attachment figures (possible harm)

Avoidance of being left alone

Excessive worry about separation

Physical symptoms on separation

Common fears

◦ Going to school

◦ Being left with sitter

◦ Sleeping away from home

Kevin

Kevin, just transitioned from elementary school to middle school. He is beginning to show increases in absenteeism. When carefully questioned, he revealed that he ‘can’t handle’ the idea that kids are probably laughing at him behind his back. He says ‘he hates having to walk through the hallways between classes, knowing that other people are looking at him.’ He worries constantly what the other kids are thinking about him and he is worried that he might say something or do something ‘dumb’.

Social Phobia

Fear of doing something embarrassing

Avoidance of situations involving potential evaluation

Worry about what others think

Self consciousness

Limited friends

Common fears: ◦ Meeting new people

◦ Speaking in groups (class)

◦ Speaking to authority (teachers)

◦ Standing out

Antonio

Antonio, a 3rd grader, is worried about the FCATs and other tests. On Fridays, test days, the teacher notices that he looks upset and almost as though he might break down and cry. He reports a fear of not being able to move on to 4th grade if he does poorly on the FCAT. He constantly asks his mother and teacher for reassurance that he won’t be retained. No matter what Antonio is told, he still worries. Antonio performs satisfactorily (grade level) in math and reading. He is often absent due to frequent headaches, especially on Fridays.

Generalized Anxiety Disorder

Excessive worry about everyday life issues

Excessive reassurance seeking

Stomach aches, headaches, etc.

Irritability, poor concentration

Common fears:

◦ novelty

◦ Making mistakes

◦ Performance (school sports)

◦ Negative news

Social Phobia vs. GAD

Social Phobia

◦ Worry is focused on performance and social/evaluative situations

◦ The anxiety dissipates upon avoidance or escape of the situation

◦ Difficulty making or keeping friends

◦ Focus is on what other people think

GAD

◦ Worry in areas other than performance or interpersonal

◦ The worry does not stop, even with active avoidance or escape

◦ Friendships are not typically problematic

◦ Focus is usually on a self-imposed, unrealistic standard

Social Phobia vs. SAD

Avoiding social situations because child

does not want to be separated by parent

(SAD) versus child stays away because of

excessive fear of social evaluation (Social

Phobia).

Other common anxiety related

problems

Selective Mutism

School Refusal Behavior

Test Anxiety

Selective Mutism

Consistent failure to speak in specific social situations,

such as school, despite speaking in other situations

Interferes with educational functioning or with social

communication

Symptoms must last at least one month

Mutism not due to lack of knowledge or comfort with

spoken language

Mutism not due to communication disorder, pervasive

developmental delays, or psychosis

Additional Features (subtypes?)

Excessively shy/timid/sensitive/inhibited

Fear of social embarrassment

Social isolation and withdrawal

Clingy/reticent

Compulsive traits/anxious

Negativism/depression

Temper tantrums

Controlling/oppositional behaviors

Traumatized

Is selective mutism a more severe form

of social phobia?

% with SP Diagnosis

Kristensen (2000) 68%

Manassis et al. (2007) 62%

Arie et al. (2006) 44%

Black & Uhde (1995) 97%

Vecchio & Kearney (2005) 100%

School Refusal Behavior

Consists of youth who are completely or partially

absent from school

OR

who show morning misbehaviors to avoid school

OR

attend school under significant distress

Prevalence

average - 8.2% of population

Equally seen in boys and girls

Most common age of presentation – 10 to 13 years

More common among minority populations

School Refusal Behavior (heterogeneous problem)

Wants/needs to be with mom? (Separation Anxiety Disorder, 60%)

Can’t escape if have a panic attack? (Panic Disorder with Agoraphobia, 60%)

Excessive and uncontrollable worry about things (Generalized Anxiety Disorder, 30%)

Social evaluation of kids, teachers (Social Anxiety Disorder, 20%)

Irrational fear about something specific (e.g., loud sound of school bell; Must pass a large dog on way to school) (Specific Phobia, 20%)

Test Anxiety

(heterogeneous problem)

Prevalence - 10 to 41% in school age children

Girls report significantly higher test anxiety than boys

African Americans report significantly higher test anxiety than European Americans

Test Anxiety

“I need to be perfect. I won’t get into college.” (Generalized Anxiety Disorder)

“Others will think I am dumb. My teacher/mom will be disappointed in me.” (Social Anxiety Disorder)

“Taking tests makes me scared (and only tests).” (Specific Phobia)

“I may get those panic attacks during the test.” (Panic Disorder)

Does test anxiety affect high stakes

test scores?

Yes: in a sample of African American

elementary school children, children who

reported high levels of physical symptoms of

anxiety and social anxiety symptoms also

reported high levels of test anxiety. These

children, in turn, received low achievement

levels on the FCAT reading

(Carter, Silverman, & Jaccard, 2011)

Guide for Diagnosing

Anxiety Disorders Interview Schedule for

Children

◦ Child and Parent Versions

◦ Reliability data

◦ Interference ratings for primary,

secondary, etc.

Separation Anxiety Disorder

Social Phobia

Social Phobia

Screening Measures

Multidimensional Anxiety Scale for

Children (March et al., 1997)

Screen for Child Anxiety Related

Emotional Disorders (Birmaher et

al.,1997)

Spence Children’s Anxiety Scale (Spence,

1998)

Spence Children’s Anxiety Scale

www.scaswebsite.com 38-item questionnaire Child version for ages 8-15 Parent version for ages 6-18 Responses are scored: ◦ Never = 0 ◦ Sometimes = 1 ◦ Often = 2 ◦ Always =3

Spence Children’s Anxiety Scale

Interpretation – Child Version

Spence Children’s Anxiety Scale

Interpretation - Parent

No T-scores available

Norms for anxiety disordered and

nonclinic referred children available on

website

Parent Ratings

Child Behavior Checklist (CBCL)

Subscales

* CBCL Internalizing T

* CBCL Anxiety/Depression Scale

* CBCL-A (anxiety-specific scale)

Reliability data

Teacher Ratings

Teacher Report Form (TRF)

Subscales

* TRF Internalizing T

* TRF Anxiety/Depression Scale

* CBCL Withdrawn Scale

* CBCL-A (anxiety-specific scale)

Reliability data

ETIOLOGY AND MAINTENANCE OF ANXIETY DISORDERS

Hypothesized Risk Factors for Phobic and

Anxiety Disorders

Genetics

Temperament

Learning Pathways

Cognitive Influences

Parental Influences

Neural Circuitry

Genetics

Anxiety is clearly heritable, but the

precise heritability depends on numerous

factors including type of anxiety, the age

and sex of the population, how anxiety is

assessed, and whether anxiety is

considered as a personality trait or a

psychiatric disorder.

Temperament: Behavioral Inhibition

A temperamental characteristic,

observable as early as toddlerhood,

consisting of a relatively stable tendency

to be cautious, quiet, and behaviorally

restrained in situations of novelty.

Estimated to occur in 10% to 15% of

children.

Learning

Classical Conditioning

◦ Little Albert

Operant Conditioning

Vicarious Conditioning

◦ Rhesus Monkeys

Information Transfer

◦ Being told something was dangerous

Youth Who Reported “A Lot” of Fear and Three

Pathways of Acquisition

Fear Item Direct

Conditioning Modeling

Information/

Instruction

Not able to breathe 30% 46% 76%

Hit by car or truck 12% 66% 92%

Fires 5% 59% 96%

Snakes 34% 65% 89%

Earthquakes 6% 43% 93%

Note: Percents do not add up to 100 since subjects could endorse more than one source of fear.

(Ollendick & King, 1991)

Cognitive Influences

Distorted - mistaken processing

- Dysfunctional distortion

-Functional distortion

Deficiencies - absence of processing

The links among cognition, behavior, and

emotion

Cognitive deficiencies - externalizing

behavior and limited emotional distress

Cognitive distortions - internalizing

behavior and greater emotional distress

Cognitive Dysfunction

Disorder Distortion Deficiency

Anxiety 6 0

Depression 9 0

ADHD 0 9

Aggression 23 27

Parental Influences

Parenting Skills - less granting of

psychological autonomy (over-controlling)

and more encouraging of avoidant

behaviors (over-protective)

Mother -Child Relationships - negative

and critical

Father – Child Relationships - limited

risk-taking play behavior; unpredictable,

punitive, explosive

Neural circuits….

Genetic Influences

A. Brain Circuits

Dorsal PFC-Based Circuits

PFC-Striatum-Based Circuits

Ventro-lateral PFC-

Amygdala-Based Circuits

B. Psychological

Processes

Working Memory

Response Inhibition

Threat Influences on

Attention Orienting

C. Phenotype

Groups of…

Psychotic Disorders

Behavior Disorders

Anxiety Disorders

Environmental Influences Evolving over the context of development

Pine et al. 2008

Fig. 1 Schema of mechanisms underlying associations among neural circuits (A), psychological processes (B),

and clinical phenotypes (C), as influenced by genes, environments, and development. PFC = Prefrontal Cortex.

EVIDENCE-BASED

TREATMENTS FOR CHILD

ANXIETY DISORDERS

EBTs for Child Anxiety Disorders -

Research

Over 25 randomized controlled clinical

trials have been conducted.

Cognitive Behavioral Treatment

Cognitive-Behavioral Treatment of

Anxiety Disorders in Youth

Behavioral: practice exposure tasks in session and out of session, positive consequences for successful efforts (rewards)

Cognitive: concern with information processing, self statements,

Emotional: addresses feelings

Social: involves parents and can involve peers

Cognitive-behavioral is not…

A passive therapist

A know it all therapist

An unimportant therapeutic alliance

A cookbook approach or ignoring of

emerging issues

Providing interpretations but helping child

to develop understanding of

generalizations of his/her behaviors,

thoughts, feelings

Treatment Formats

Group

Individual

Parent Involvement

CBT for Anxiety Disorders

Education Phase

Application Phase

Relapse Prevention Phase

Adjunctive Strategies (e.g., relaxation

skills, social skills, time management skills)

Education Phase

Collaborative or joint effort

Tri-partite view of anxiety (behavioral, cognitive,

physiological)

Rationale of treatment and key change-producing

procedure - exposure

Devise fear/anxiety hierarchy

Behavioral procedures

◦ Contingency management

◦ Parent training

Cognitive procedures

◦ Child self-control training and cognitive restructuring

Application Phase

Gradual exposure tasks: in-session and

out-of- session

Use of behavioral and cognitive

procedures

Use of adjunctive strategies

Practice and review

Relapse Prevention Phase

Emphasize importance of Practice,

Practice, Practice

Handling slips

Role of Therapist

Coach

Consultant

Collaborator (in developing tasks; in understanding shared experiences)

Tri-partite view of anxiety

Behavioral

Cognitive

Physiological

HOW ANXIETY SHOWS ITSELF?

Thoughts

Behavior -- AVOID

Bodily

Reactions

Rationale of treatment….

Links of thoughts, feelings, and behaviors

DAILY DIARY

What happened?

What Were My Thoughts?

My Fear Rating?

Key change-producing procedure -

Exposure

Conducted in graded or gradual fashion

Either live/in vivo or imaginal

Exposure

All current EBTs for anxiety disorders include

the need for child coming into contact with

the feared object, situation, or event

Exposure is a procedure, not the scientific

basis for fear reduction

“Typical” Anxious Response*

0

1

2

3

4

5

6

7

Base 5 10 15

TIME

SU

DS

Anxiety

SUDS, subjective units of distress

*This is a hypothetical clinical illustration.

How Feeling Better Can Make Anxiety

Worse

Two-Factor Theory of Acquisition/Maintenance

When an individual repeatedly confronts a fear-

producing situation, the fear response is

strengthened through the process of classical

conditioning

Avoidance behavior is reinforced through the

process of operant conditioning (negative

reinforcement)

Within Session Habituation*

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

0 10 20 30 40 50 60 70 80 90

Time of Session

SU

DS

SUDS

*This is a hypothetical clinical illustration.

Between Session Habituation*

*This is a hypothetical clinical illustration.

Session #

Other theoretical models for why

Exposure?

Allowing child to re-experience the anxiety or fear

provoking event in a safe, secure environment

enhances child’s feelings of self efficacy, competency,

and coping

Cognitive restructuring is made more relevant by addressing the anxious automatic thoughts that are elicited during exposures.

Possible diagnoses/targets for exposure

Specific Phobia (dogs) – Expose child to different types of dogs

in different contexts

Social Anxiety Disorder – Expose child to social situations such

as speaking in groups

Separation Anxiety Disorder – Expose child to separation

situations

Generalized Anxiety Disorder - Expose child to situations that

will provide incompatible information with worries

To What is One to be Exposed?

The core fear(s):

◦ Emphasize need for thorough understanding of the

psychopathology

◦ And need to conduct a thorough assessment

Conducting In Vivo Exposures

Assess baseline anxiety or fear ratings using Fear Thermometer (or subjective units of distress; SUDS)

Expose at highest level child agrees on that for that session or between sessions (“worst fear”)

Obtain fear or SUDS ratings few times during exposure tasks

Try to stay in situation until ratings return to baseline (within session habituation)

Do not allow coping or distraction

Repeat until situation no longer elicits distress (between session habituation)

Conducting Imaginal Exposures

Determine if imagery can be used

Conduct imagery training if necessary

Construct scenes with child assistance especially

including “core fear”

Scene should include all aspects of fear including

physiology and negative cognitions

Conduct session

Differences Between Treatment and Natural

Encounters with the Phobic Object

Natural Encounters

◦ Unplanned

◦ Ungraded

◦ Uncontrolled

◦ Very Brief

◦ Patient Alone

Therapy Situation

◦ Planned

◦ Graded

◦ Controlled

◦ Prolonged

◦ Team Work

Doing Effective Exposure

The team work relationship

The therapist will never do anything unplanned in the therapy room. ◦ Description

◦ Demonstration

◦ Permission to do it

A high level of anxiety is not a goal in itself.

Doing Effective Exposure (cont)

The child makes a commitment to remain in the

exposure situation until the anxiety fades away.

The child is encouraged to approach the phobic

stimulus and to remain in contact with it until

the anxiety has decreased.

The therapy session is not ended until the

anxiety level has been reduced.

Doing Effective Exposure (cont)

The exposures are set up as a series of behavioral tests

or experiments.

The child’s catastrophic cognitions concerning what

might happen upon presentation of the phobic stimulus

is confronted and challenged.

Education Phase

Meet with parents alone to discuss:

◦ Encouraging courageous vs. anxious behavior

◦ Breaking down anxious or undesirable behavior

◦ Non-physical punishment

◦ Distinguishing between anxious and oppositional

behavior

General rules for creating hierarchies

Get list from child (and check in with parent as

necessary) of all the situations and the particulars of

the situations that are hard for him/her

Get the details such as duration of time; frequency

during week; anyone accompanies child?; who is

around; etc.

Ensure list contains very easy to very hard

Once items for list is obtained put items in order

from easiest to hardest

Rank each item from 1 to 8

THE LADDER 15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

General rules for creating hierarchies (cont.)

Unlikely to need to conduct exposures that are 1 and

2; probably start with 3 or 4 (depending on case)

Ensure that the “hardest” items (e.g., 8) are situations

and tasks that are important to do for “successful”

treatment

General rules for creating hierarchies (cont.)

Typically, situations provided by child/parent need to

be “broken down” further because to difficult to do

as one step

Need to decide with child/parent which areas are

interfering most and therefore should take priority

for targeting in treatment

Fear Hierarchy – Social Phobia

Feared Situations Fear

Ask someone (not friend) to be partner in

class 8

Ask to play with a group of kids at

playground 7

Give friend birthday present and say

hello to parents at party 6

Ask someone to sit with me at lunch 6

Say hello to friends at school 5

Say hello to mothers at school 4

Fear Hierarchy – Agoraphobia

Feared Situation (from ADIS) Fear

School cafeteria 7

Classroom 7

Movie theaters 6

Waiting in line at store 6

Public transportation (e.g. train) 5

Restaurants 5

Church or temple 4

Stores or malls 4

“Breaking hierarchy down” (as

necessary)

Perhaps “Stores or malls” is difficult to do

in one shot; need to break down into

smaller steps

Find out if “stores or malls” make a

difference

Which is easier? Which is harder?

Stores

Make a trip back and forth to store (no

entry)

Walk into store and walk right out

Walk into store and stay for xx minutes

Walk into store and stay for xxx minutes

Walk into store and buy something

Etc….

Fear Hierarchy – Social Phobia

Feared Situation (from ADIS) Fear

Oral reports/reading aloud 8

Asking the teacher a question 7

Asking the teacher for help 6

Joining a group of kids 6

Starting or joining a conversation (w/

classmates)

6

Inviting a friend to get together 5

Fear Hierarchy – Joining a group (perhaps add minutes…)

Feared Situations Fear

Participate in meeting 7

Meet someone at meeting 7

Go to meeting – sit in front 6

Go into meeting – sit at side 5

Go to setting 5

Making a longer inquiry 4

Making a short inquiry call 3

Looking up information 2

Fear Hierarchy – Specific Phobia of Dogs

Feared Situation Fear

Petting a large dog that is running loose 8

Going over to a friend’s house and staying in the

same room with the dog loose

7

Petting a medium size dog which is running loose; 7

Allowing a medium size dog which is on a leash to

lick his hand

6

Petting a medium size dog which is on a leash 5

Going to a pet shop and petting a small puppy

which is being held by somebody

5

Going to a pet shop and looking at a dog through

the window

4

Fear Hierarchy – Separation Anxiety Disorder

Feared Situation Fear

Stay home alone (60 mins) 8

Stay home alone (30 mins) 7

Ride bus alone (all week) 7

Ride bus alone (2 times) 6

Stay after school without friends 6

Take out trash at night alone 5

Stay alone in bedroom (30 mins) 5

Stay alone when someone is in the shower 4

Contingency Management - Parent-Child

Contracts (facilitate exposures)

Let it be known that on this Tues day, the 24 of May in the year

2001, a contract between (child’s name) and mother/father

(parent’s name) concerning the child’s fear of being in crowded

places was signed, witnessed by Dr. Silverman.

The above parent and child hereby agree that if (child’s name)

successfully stays in Dadeland Mall for 15 minutes with Mom then

(child’s name) will stay up an extra ½ hr on Thursday night. This

task is to be done by the child on Thursday, and the parent is to

give child the above mentioned reward on Thursday.

Parent training

The “Protection Trap”

Importance of getting out of the trap by

attending to, or rewarding, child approach

or nonavoidance

Parents as models

Mastery modeling: demonstrating successful performance from onset

**Coping modeling: demonstrating strategies to overcome the problem, then demonstrating successful performance

Cognitive Strategies

Self control training and coping

Changing self-talk

Problem solving

Self control training and coping

Self observation

Self change (modify behavior, thoughts, self

talk)

Self evaluation and reward

Scared?

Thoughts

Other thoughts or Other things I can do

Praise

My T’s and My O’s

My T’s My O’s

Common Cognitive Distortions

Magnification

Minimization

Overgeneralization

Selective Abstraction

Catastrophizing (“what if…”)

(Importance of non-negative thinking, not necessarily positive ……)

THINKING TRAPS

Burnt Cookie Concept

Catastrophizing

Mind Reading

Fortune Telling

Over-generalizing First report Card Second Report Card Third Report Card

“Should”ing

“I should this….

I should that…

I should this…

I should that…

I should this…”

Perfectionism

Math: B- Math: ? Math: ?

Changing Self Talk Gather evidence by asking yourself the following questions…

1. Do I know for sure this is going to happen?

2. What else might happen, other than what I first thought?

3. Has it happened before?

4. Has this happened to anyone I know?

5. How many times has it happened before?

6. After collecting the evidence, what are the odds of ___________?

7. So, what is a coping thought I can have in this situation?

Additional questions to consider:

1. Is worrying about this helping?

2. What am I missing out on because I am worrying?

Optimizing gains

Assessment and targeting the core fear(s)

Directed discovery

Involvement

Cooperation/collaboration

Relapse prevention (dealing with frustration)

Working for generalization

Arranging termination

Individualizing the program

Therapist flexibility (within fidelity)

Interfering with gains

Teachy-preachy style

Forcing youth to talk about feelings (Creed & Kendall, JCCP, 2005)

Excessive focus on tasks

Mechanical self-talk

“Wimpy” exposures

Way too scary exposures

Child depression?

Conflictual relations?

For more information, please go to the main website and browse for more videos on this topic or check out our additional resources.

Additional Resources Online resources: 1. Society of Clinical Child and Adolescent Psychology website: http://effectivechildtherapy.com/sccap/ 2. Spence Children’s Anxiety Scale: www.scaswebsite.com

Books: 1. Silverman, W.K. & Field, A. P. (2011). Anxiety Disorders in Children and Adolescents (2nd Ed.)New York, NY: Cambridge University Press. 2. Silverman, W.K., & Albano, A.M. (1996). The Anxiety Disorders Interview Schedule for Children for DSM-IV: (Child and Parent Versions). San Antonio, TX: Psychological Corporation.

Peer-reviewed Journal Articles: 1. Carter, R., Silverman, W.K., & Jaccard, J. (2011). Sex variations in youth anxiety symptoms: Effects of pubertal development and gender role orientation. Journal of Clinical Child & Adolescent Psychology, 730-741. 2. Creed, T. A., & Kendall, P.C. (2005). Therapist alliance-building behavioral within a cognitive-behavioral treatment for anxiety in youth. Journal of Consulting and Clinical Psychology, 73(3), 498-505. 3. Ollendick, T., & King, N.J. (1991). Origins of childhood fears: An evaluation of Rachman’s theory of fear acquisition. Behaviour Research and Therapy. 29(2), 117-123. 4. Pine, D.S., Helfinstein, S. M., Bar-Haim, Y., Nelson, E., & Fox, N. A. (2008). Challenges in developing novel treatments for childhood disorders: Lessons from research anxiety. Neuropsychopharmacology, 34,213-228. 5. Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37, 105-130.