Sam, 8 years old, constantly worries about being contaminated by other people's germs. As a result he won't touch doorknobs in school and insists on wearing gloves. Would it be helpful to make him touch doorknobs?

Cindy, 12 years old, is so concerned about looking perfect that she won't join a study group or go to a party because she's concerned about what people will think of her. Would it be helpful to make her join a study group?

Jason, 7 years old, is afraid of spiders and won't go to the neighborhood playground because he's afraid he may see a spider. Would it be helpful to make him go to the playground?

Sam, Cindy, and Jason would benefit from Cognitive Behavior Therapy.

What is Cognitive Behavior Therapy?

Research has shown that CBT is a form of therapy that's effective for childhood anxiety and other disorders. A major aim of CBT and behavioral therapy is to lessen the child's anxiety by changing the beliefs or behaviors that help to keep the anxiety going. During CBT the child learns that thoughts cause feelings and moods which can influence behavior. If a child is experiencing unwanted feelings or has problematic behaviors, the therapist works to identify the underlying thinking that is causing them. The therapist then helps the child replace this thinking with thoughts that result in more appropriate feelings and behaviors. CBT works by using exercises and other active techniques that teach a child to respond differently to anxiety.

CBT has two essential features:

  • The cognitive component helps children change how they think about a situation; and
  • The behavioral component helps children change how they react to the situation. An essential element of behavioral therapy is helping children gradually confront the situation or thing that they are afraid of.

What forms of mental health problems respond to CBT?

Many types of anxiety, such as specific phobias, social anxiety, as well as depression and obsessive-compulsive disorders, can be helped with CBT. For example, a child with a specific phobia avoids what she "thinks" is dangerous, and unfortunately, the avoidance keeps anxiety going. Exposure therapy targets the avoidance and is the most important component of CBT for specific phobia, because it involves helping children approach a scary object or go into a scary situation gradually. The procedure allows them to slowly gather evidence that will help them to challenge their false beliefs about a particular thing or situation, e.g., "all dogs bite" or "If a bee stings me I'll die!"

By gradually putting them in these situations they learn that they can manage the situation by using their coping skills (e.g., deep breathing) and cognitive skills (e.g., problem solving and positive self-talk). Kids also learn that what they feared was exaggerated and unrealistic.

CBT is also effective in alleviating a child's depression by changing the beliefs or behaviors that help to keep the depression going. Everyone has thoughts that "automatically" pop into their heads, but depressed children and teens tend to have more "negative" ones. The first step in controlling "negative" thoughts is to learn to become aware of them and to identify the ones they have most often. CBT can also help teens develop better social skills, problem-solving skills, and assertiveness skills to help them succeed in their relationships. These are excellent life skills to add to anyone's tool box.

How does CBT treatment typically proceed?

Phase I—This involves psychoeducation; the therapist teaches children and their families about anxiety and the cognitive behavioral model of treatment. The techniques that will be practiced in therapy are introduced as "tools" that the child will acquire to "boss back" the anxiety symptom and reclaim areas of their lives that the anxiety currently disrupts.

Phase II—This involves collaborative work between the child and therapist as they "map out" the child's anxiety symptoms, generate an exposure hierarchy, and begin supplementing EX/RP (exposure/response prevention) during subsequent sessions. The child is put in activities that expose him to the feared object or situation and prevents him from performing the avoidance he uses to reduce the anxiety. Although the exposure deliberately arouses anxiety, it does so in a controlled and gradual way.

For example, Sam, described above, would be asked to touch a doorknob. This act is called an exposure, because it exposes him to his fear of contamination and creates anxiety. The response prevents him from washing his hands, the act that reduces his anxiety. The anxiety levels get higher temporarily and then subside. This exposure is repeated several times and then followed by more challenging exposures.

The child and therapist work as partners against a common enemy—anxiety—which enhances the trust a child may have in the therapist as exposures get underway. Typically, therapy sessions are used for exposures that the child is trying for the first time, and then independent sessions are planned for home so that the child can further master the skills and continue to "shrink" the symptom.

Phase III—The therapist prepares children and their families for the cessation of active treatment. The likelihood of an eventual reemergence of symptoms is discussed explicitly, both to normalize the experience as well as to encourage children to take on more independence in planning and executing remaining exposures. In the last few sessions, therapists work carefully with children to develop a plan for relapse prevention, emphasizing that the same skills the children have mastered in therapy are those that they can use on their own whenever the need arises. Moreover, booster sessions are scheduled so that therapists and children can reconnect at regular intervals to address any problems or simply to check in and celebrate continued good health.

Effective EX/RP leads to 'habituation.' When the child repeats the same act over and over again and sees that nothing happens, they build up a tolerance and anxiety levels go down. Treatment sometimes leads to a near- or total attenuation of symptoms. Most of the time anxiety disorders have a chronic waxing and waning course. Symptoms may reoccur during times of stress, fatigue, or physical illness—and sometimes just out of the blue. This does not mean that the child will experience a complete relapse. Rather, a reemergence of symptoms can serve as a signal to children that it is time to revisit the skills they learned in therapy and implement them as needed.

It is in this way that CBT teaches adaptable coping skills that children will be able to use for the rest of their lives. For instance, the ability to recognize problems that are getting out of hand then develop thoughtful plans to solve them is a general skill that children will find they can apply to a host of situations. This in turn will promote feelings of confidence and self-efficacy that can enhance positive development and good mental health throughout childhood and beyond.

How parents can help

Most parents want to help their children avoid experiencing discomfort of unhappiness. Helping your child avoid an anxiety-provoking situation, however, actually reinforces anxious behavior because you are inadvertently communicating that there is something to be afraid of. We know that avoidance keeps anxiety going, and the next time your child is faced with the same situation, he will remember that he was not able to cope with it last time. You are inadvertently teaching your child that the way to reduce anxiety is to avoid what makes him anxious. This prevents the anxious child from developing his own strategies for coping with everyday situations, particularly those that may be difficult or challenging.

Never dismiss your child's fears as "silly" and never say "it's all in your head." Instead, empathize with your child's worries using a neutral, matter-of-fact tone, communicating confidence. For example, "I understand that you are afraid, but I know that you can handle this, and I am here to help you. Let's solve this problem together. What can you do first?"

Parents need to find a balance between keeping their children safe and granting them autonomy. The goals for encouraging healthy growth is for your children to develop as happy individuals, allowing them to explore their environments, and master the resources they will need in order to become successful adults.

About the NYU Child Study Center

The New York University Child Study Center is dedicated to increasing the awareness of child and adolescent psychiatric disorders and improving the research necessary to advance the prevention, identification, and treatment of these disorders on a national scale. The Center offers expert psychiatric services for children, adolescents, young adults, and families with emphasis on early diagnosis and intervention. The Center's mission is to bridge the gap between science and practice, integrating the finest research with patient care and state-of-the-art training utilizing the resources of the New York University School of Medicine. The Child Study Center was founded in 1997 and established as the Department of Child and Adolescent Psychiatry within the NYU School of Medicine in 2006. For more information, please call us at (212) 263-6622 or visit us at http://www.aboutourkids.org.