Anne Marie Albano, Ph.D., director of the Columbia University Clinic for Anxiety and Related Disorders, explains the best way parents can deal with their children's anxiety at home, to aid in the treatment process.
Jason is a 10-year-old who does well in school, has good friends, and loves to play basketball in gym. He’s happy when friends come to his house but not if he’s asked to go to theirs. Look just underneath his outgoing exterior and you’ll find a child who’s afraid to be away from his mom, except to (very reluctantly) go to school. Each morning there’s delaying and sometimes tears. At night, he makes excuses to have his mom lay down with him until he falls asleep, and then he climbs into his parents’ bed more nights than not. It’s very difficult for Jason when his mother tries to go out for an evening or to run an errand. No amount of reassurance seems to help, and giving him a cell phone for security just means continuous calls to his mom. Jason has separation anxiety disorder.
Cara is 12 and is very alone in the world. She is comfortable at home with her parents and younger sister, but she’s the child who sits inside the classroom during recess and is often found with her head buried in a book while all the kids around her are talking and playing together. Cara visibly shakes when she’s asked to read aloud; she often feels sick on test and oral report days. Her mother has turned down party invitations with false excuses so often that the other kids simply don’t invite Cara anymore. Cara is very worried about what other kids and adults think of her. She cries herself to sleep most nights, worried that she’s surely going to do something embarrassing to make her peers reject her or the teacher yell at her. Cara has social phobia, an anxiety disorder.
Gracie, 8, is known as the “little adult” in her family. She has a question for everything, usually in the form of “what if.” What if someone robs us while we’re away? What if daddy loses his job? What if my parents get a divorce? The teacher calls her “my assistant” because Gracie is always correcting the other children and tells on the kids who act up in some way. She worries constantly about all sorts of things, from her family’s and pet’s health to what will happen to her in the future, from whether her work is good enough to being on time. Her parents are constantly answering her anxious questions—even at 2am when she emails them from down the hall in her room! But no amount of reassurance can stop her worries, and Gracie has a great deal of trouble sleeping and feeling calm because of the persistent “what ifs.” Gracie has generalized anxiety disorder.
These children suffer with excessive anxiety, at the level of a clinical disorder. Their anxiety is keeping them from doing the things that children their age typically engage in: sleepovers with friends, oral reports, sports, plays, even relaxing and soothing themselves to sleep in their beds or heading off to school without a fuss. Their parents have tried everything from comforting them to making excuses for them, and have even gone as far as to bribe them to go with other kids, or to take on school with more ease and less upset, but to no avail. Teachers have commented and relatives ask “What’s wrong?” with great concern. And so what is a parent to do?
When Anxious Becomes a Cause for Concern
Typical childhood fears of separation or socializing should resolve within a few weeks, a month or two at most. Worry is not unusual in children, and most kids can be distracted or move their minds onto something else. Children who show persistent anxiety and fear, though—so much that they are unable to enjoy friendships or show greater independence as they age—are likely suffering with an anxiety disorder.
Anxiety disorders are the most common form of mental health problem affecting children and adolescents. Separation anxiety takes the form of extreme fear of being away from loved ones, characterized by a concern that something terrible will happen to prevent the child from seeing these people again. Social anxiety, or social phobia, is the fear of doing something so embarrassing or humiliating that you can’t face other people again or that you’ll be laughed at or rejected. Generalized anxiety is worry that’s out of a person’s control—that is, they can’t stop worrying no matter how much reassurance they get that things are, in fact, okay. Other anxiety disorders include specific phobias (of animals, insects, or doctors, for example) and panic disorder.
A Child's Fears, a Parent's Reality
When anxiety hits, its impact is felt not just by the child, but also by the parents. What is wrong with him? Why doesn’t she do what other kids do? How did this happen when our other child is just fine? What did we do wrong? What if what we try to do hurts him more than helps? These are some of the questions that haunt parents as they struggle to adapt their lives to their child’s anxiety.
Parents often find that they are very quickly drawn in by their attempts to calm their child. A mom may take on too much herself in covering for her son or making excuses, for instance. A dad might alternate between criticizing and cajoling his daughter to try and move her along, essentialy “doing the work” for her.
We have a natural tendency to comfort and protect our kids when they are in distress. We worry that it may be too risky to leave our child alone (so we find ourselves on the playground with a bagful of sweets to entice other kids to join our toddler in her play) or that opportunities will be missed (in which case we’re filling out our teen’s internship applications lest he be without strong experience when college apps role around). When faced with our child’s anxiety, that protective mode kicks into full gear. Parents swoop in again and again to rescue and reassure, and their child is able to avoid struggling with and managing situations on his own.
Most parents know intuitively what they have to do to help their anxious child: get her to confront, engage, and even enter into situations that upset her. Knowing this and letting it happen are two very different things, however. And letting your child confront anxiety may just be the toughest thing for you as a parent to do.
Exposure Therapy for Anxiety Disorders
That old adage “when you fall off a horse, get right back on” has real meaning in turning around anxiety. Parents of a child facing anxiety must discourage avoidance and encourage approach and courageousness—and must do so despite their child’s protests, anger, tears, and raw emotion, as well as their own feelings of guilt. Your child needs to be “exposed” to the things that he fears; only through exposure will he learn to manage his feelings and take on situations in a healthier way. Need convincing?
Anxiety is highly treatable—but not all treatments are created equal. Only one treatment has been consistently shown to teach children skills for mastering their anxiety and taking on the tasks and challenges of childhood: cognitive behavioral therapy. CBT has been demonstrated to help 60-80 percent of children and adolescents who suffer from anxiety disorders. Evidence from scientific studies suggests that the key process in CBT, called “exposure,” is what separates this treatment from other talk therapies—and what propels children to approach their fears while learning to overcome them.
Exposure means exactly that: exposure of your child to the situations or things that make him anxious. This doesn’t mean that you push a child with water phobia into the deep end of the pool without a life preserver. Rather, exposure therapy, when guided by an experienced and competent therapist, involves teaching your child skills for thinking calmly and realistically whilst assisting him with engaging in the situations that challenge him, again and again.
In other words, yes—for the child who has a severe water phobia, we begin by merely visiting the pool and getting comfortable with that. With a therapist’s assistance, the child will dip his toe in the water, then his foot, and eventually he will be jumping into the deeper end. Throughout the process, he learns swimming and diving skills, and any unrealistic fears (such as “the pool pump will make me drown,” or “I might get pulled under if other people are in the pool”) can be tested and disputed with experience and realistic information.
Bringing Therapy into Your Home
Just as a therapist uses exposure to help a child overcome anxiety, you as the parent also need to expose your child to what she fears and avoids. This means looking into your own thoughts for what makes you anxious about having your child confront his fear of sleeping alone, for example, and to steel yourself against what will be some crying or protests at first—but knowing that smiles and confidence will build with each exposure success.
Set a tone of high expectations: Expect your child to give it a try, and then map out a series of steps that work towards the overall goal of sleeping in his own bed. Maybe the first few nights involve your staying just inside the door of his room but not in his bed, until he falls asleep. The goal is for him to learn that he can fall asleep on his own; he will experience that he doesn’t need you right next to him to do that. Next comes your staying outside of the room. Then there’s turning off the overhead lights...and so it goes until your son is sleeping alone. He’ll learn that if he wakes up, he can simply roll over and fall back to sleep without needing you to be there.
For each step, you may want to pair some reinforcer that your child covets but does not have ready access to, such as extra time on the computer, a favorite snack or treat after breakfast, or his choice for a weekend family outing. Don’t bribe him with something big, because it’s not about the ‘prize,’ but about his accomplishment. (A big bribe would take the focus off his pride and courage—on which you really want to shine a light; a reinforcer provides incentive for him to tackle his anxiety head-on.)
Long-Term Goals for Therapy
As difficult as exposure may be for a parent to implement, having the longer view in mind helps. Understand that anxiety is not just a stage that your child will one day grow out of; rather, it can take hold and stick for the long term. Consider this when you are reluctant to encourage your child to lean in to and face his fears—his tears and discomfort now will minimize his anxiety down the road.
Through exposure, you are undoing the avoidance that allows anxiety to stick in place. By avoiding, your child does not gain experience in managing situations, and he is allowed to think the worst and feel unable to deal. Exposure gives your child experience with seeing that, Yes! I can be frightened but still do a good oral report—and with more practice his fears may get less and less.
Your daughter’s afraid to ask the teacher for help? Rather than calling the teacher yourself, role play with your child options for how to handle this concern; make time to listen to how she ultimately handles the situation; and then be ready with an exuberant high-five when she takes on the task. Keep steps small and simple, and build up to more challenging situations as she becomes comfortable. By staying calm and confident, you will convey to your child that she can in fact take on every step of exposure.
If your child is too anxious to do this with you, or if you don’t see her moving along and overcoming her fears, then contacting an experienced cognitive behavioral therapist can help move your child along to mastery of her anxieties and greater comfort and happiness in meeting the challenges of everyday life. As her parent, you’ll be helping to free your child from excessive anxiety, and in the process you’ll also be creating a happier and healthier relationship for you and your child to enjoy.
Anne Marie Albano, Ph.D., is director of the Columbia University Clinic for Anxiety and Related Disorders and is the co-author, with Leslie Pepper, of You and Your Anxious Child: Free Your Child from Fears and Worries and Create a Joyful Family Life (Avery, 2013). For information about Dr. Albano and the Columbia University Clinic for Anxiety and Related Disorders, visit anxietytreatmentnyc.org and annemariealbano.com.