Chapter 1

Understanding Anxiety

Emily had a secret problem. She was twelve years old and still afraid of the dark. At night, when her family was asleep, she would often hear strange noises outside and she would panic, imagining that they were being robbed or that they’d all be murdered while they slept. Emily still kept a night light on in her room and would often run to her parents’ room on particularly bad nights and slip into their bed. She’d never take the garbage out at night or go upstairs alone after dark, and she usually insisted on her parents checking her room before she went to sleep. Because of her fear, which was a secret to everyone except her parents, Emily never accepted invitations to sleep over at friends’ houses and found excuses to not go to summer camp. Emily’s parents had tried to push her to face her fears and sleep in the dark, but she became so upset and they had so many fights that eventually they just gave in to her fears. Now her parents feel frustrated at the limitations that Emily’s fear causes both in her own life and for everyone else in their family.

Ten-year-old Connor had a different problem. He was extremely shy. At home he would talk freely with his family. At school or with strangers, Connor was different. He was terrified that he would do the wrong thing and make a fool of himself. He hated to speak in front of the class. Even though he could play the piano beautifully, he was too scared to perform at the school concert. In the school yard he was usually alone, afraid to join in with the other children.

Problems like Emily’s and Connor’s are common, normal, and quite easily handled. But they can often cause unpleasant and ­potentially serious interference in children’s lives and in the lives of their families. Their stories give you a quick look at some of the many different ways that anxiety can affect children’s lives.

Fear, worry, and anxiety in children can take many forms. All children experience fears and phobias at particular stages of their lives, and this is a normal part of growing up. For example, we know that young infants will develop a fear of separating from their mothers at the same time they begin to fear strangers and new people. A little later, most children will be scared of the dark, and at some point, many young children begin to imagine monsters under the bed and burglars at the door. In the teenage years, self-consciousness and shyness become a very common and often annoying part of developing maturity. When these fears develop, they’re usually just part of the normal developmental process that we all go through. But sometimes, fears and worrying can reach a point where they start to cause a problem for the child. These excessive fears are often temporary and transient but may still cause such distress that as a parent, you want to help your child hurry through this stage. On the other hand, some children will experience fears and worries to a much greater degree than their peers, and some continue to experience fears long after other children their age have outgrown them.

Some fears can be very understandable and based on obvious causes. For example, children may be scared to go to school because they are being bullied; or they may be scared of the dark following a burglary at home. In other cases, the fears and worries that children experience are much harder for parents to understand. For example, the child who worries that he or she is stupid may be doing perfectly well at school and elsewhere in life. Or a child may be scared that Mom will be killed in a car accident even though Mom always makes sure she picks him or her up on time. Or a child may worry about and imagine every possible disaster even though nothing really bad has ever happened to him or her. In these cases the anxiety may be an entrenched part of the child’s personality, and you may feel as though your child has been sensitive and “high-strung” for all of his or her life.

Many adults believe that childhood is a time of carefree days and no responsibility. It may surprise you to know that in fact, anxiety is the most common problem reported by children of all ages. Diagnosable anxiety disorders are found in around one in ten children, and less extreme but still distressing fears are even more common. Anxiety and worry affect children of all ages, from infants to adolescents. Girls or boys, rich or poor, brilliant or average—it makes no difference—anxiety can affect anyone. Some parents may think, “So what? Everyone gets nervous sometimes. It doesn’t hurt anyone, so why all the fuss?” To some extent, these parents may be right. Anxiety is not as dramatic a problem as a child contemplating suicide or engaged in drug abuse. But anxiety is a sign of real personal suffering—it’s not an act or a way of getting sympathy (although in a few cases this can complicate the picture). Anxiety can also cause marked interference in children’s lives, bringing down their school performance, interfering with friendships, and affecting the whole family. In addition, in some cases, anxiety in childhood can be the beginning of a lifetime of anxiousness that, in severe cases, can lead to the more serious problems we just mentioned—drug and alcohol abuse, depression, and even suicide. If you’re a parent with an anxious child, you need not fret or worry excessively—anxiety can be managed—but it’s good to be motivated to do something to help your child.

Managing anxiousness and helping your child to develop confidence and control in life is much the same no matter what form the anxiety takes. In this book we will describe some of the common types of children’s anxieties, increase your understanding of children’s anxiety, and teach you how you can help your child master his or her fears. We will discuss all sorts of anxieties—from the minor, temporary fears that many children experience, to the longer, more severe, and invasive problems that can so extensively restrict a child’s life. Most importantly, we will describe, in detail, skills and strategies that you can use to help your child to learn to control his or her fears.

We will begin our discussion of anxious children by describing several children who we’ve seen and who have benefited from these strategies. We’ll come back to these children throughout the course of this book and use them to show how each of the techniques can be applied to the real world.

Some Real-Life Anxious Children

Talia’s Story

Talia is a typical nine-year-old with a big group of friends and a cheeky streak. She loves rock music, is a member of the school basketball team, and rarely worries about a thing. But Talia is scared of water. She learned to swim when she was five years old, but she’s never enjoyed it and has always avoided deep water as much as possible. When her father takes her out beyond where she can stand, she begins to panic, clings tightly to him, and begs him to take her back. No one can figure out why Talia is afraid of the water—she has never had a bad experience there and has never known anyone who has drowned. Both of her brothers love swimming and surfing. Yet something about the water has always been frightening to Talia, and, try as she might, she just can’t talk herself out of it. Now that Talia is getting older and starting to go to pool parties and the beach with friends, she is running out of excuses and her swimming phobia is beginning to become a problem.

Kurt’s Story

Ten-year-old Kurt is a worrier. He worries about his schoolwork, he worries about his parents’ health, and he worries that he will forget to feed his dog and she will starve. Kurt’s parents no longer let him watch the evening news because he spends the next two days worrying about all the tragic stories he has seen. They also don’t tell him about new things that he is going to have to do until the very last moment, because when they do, he pesters them mercilessly with his constant questions about what is going to happen. This interrogation also happens whenever Kurt has to do something unpleasant, such as take a test at school or go to the dentist. Kurt will ask his parents for information and reassurance hundreds of times.

Kurt also worries about germs. He’s scared when he touches certain things that germs have gotten onto his hands and that he will get sick and die. He worries about infections and all sorts of illnesses. As a result of his worries, Kurt washes his hands again and again all day long. For example, after going to the bathroom, Kurt will scrub his hands for several minutes. He will also rush off to wash whenever he has touched something he thinks may be contaminated, such as door handles and seats where other people have been sitting. Kurt refuses to go to certain places, such as hospitals or the cafeteria at his school, because of the germs he thinks are there. He will sometimes get particular ideas about things that are contaminated that will then become taboo. For example, he went through a phase of avoiding the backyard because the dog had once thrown up there. Last week, Kurt caught the train with his mother and they sat opposite a man who sneezed several times. When he got home, Kurt raced straight to the shower and washed for forty-five minutes.

George’s Story

Now that he’s twelve years old, George’s parents believe that he should be doing a lot of things by himself. But George has little self-confidence and worries a great deal about what other people think of him. He has always been a nervous, sensitive, and shy child and he grew up having very few friends. Since beginning middle school this year, George has retreated even more into his shell. It took him most of the year to make his first friend, Tony, who is also a bit of an outsider. In class, George’s teachers report that he rarely says a word and that he becomes very upset if he is asked to answer a question or speak in front of the class. At home, George is quite talkative with his family but becomes quiet if anyone he doesn’t know well comes over. George has very specific rules about what clothes he can and cannot wear, he will always get his parents to deal with sales clerks and cashiers, and he will never answer the telephone. Despite his parents’ urging, George has never joined a club or team and spends most of his time at home alone, building models. From time to time, George talks about feeling lonely, and he has gone through a few periods of feeling quite down and miserable.

Lashi’s Story

Lashi is a seven-year-old girl whose parents separated when she was five. Since the separation, Lashi has begun to worry a great deal about her mother. She is terrified that her mother will be killed in a car accident or by a burglar and that she will never see her again. Lashi cries whenever her mother leaves her, and she refuses to be left alone with a babysitter or even to sleep over at her grandmother’s home. As a result, Lashi’s mother has hardly been out since the separation. She is beginning to lose her friends and has no chance to meet other men. Sometimes Lashi is willing to stay overnight with her father, but she spends the whole time asking about her mother, and lately she hasn’t been willing to stay with him at all. Lashi’s parents still get on well despite the separation, and they agree that they need to work together to help Lashi overcome her worries. It is a real struggle every morning to get Lashi to go to school, and sometimes Lashi’s mother gives in and takes a day off work to let her stay at home. Lashi also worries about burglars breaking into the house and is scared of the dark. Over the past few weeks, she has begun to sleep in her mother’s bed, something her mother has allowed because it is just too much of a struggle to argue. Lashi’s mother loves her daughter very much, but just lately she has really begun to get fed up with the limitations on her life and is starting to feel angry and resentful.

In addition to her main anxiety, Lashi also has a fear of injections, doctors, and hospitals. Most of the time, this is not a big problem, but occasionally, it makes it very difficult for Lashi to go to the doctor’s for treatment and even to visit a sick friend. Having shots is the biggest problem—Lashi missed her last vaccination because she would not allow the nurse to give her an injection.

Jess’s Story

Jess is eleven. Her parents are worried about how Jess will ever cope when she goes to high school given how much she worries about everything. Jess worries when her parents go out, worries about keeping her friends, about doing well enough at school, about events from the past and in the future, and about possible dangers. She always expects things to go wrong and does not like to go outside her comfortable routine. Jess even worries about how much she worries. She has a couple of close friends at school but fears that one day they will suddenly decide that they don’t like her. She doesn’t want to make new friends in case that ruins her current friendships. Jess is a very bright girl, and she produces flawless work almost all of the time, spending hours making sure that everything is absolutely correct, but Jess performs very badly during long tests mostly because she gets stuck on an early question trying to make it the perfect answer and then doesn’t complete the rest of the questions.

Recently Jess has developed a very big fear of choking when she eats. This started after a bad case of tonsillitis. After that, she stopped eating certain foods such as hard fruits and many meats because she finds them difficult to swallow. All other foods have to be chewed for a long time before she can swallow them. She now has different dinners than her parents and sisters and has lost some weight. Her parents have tried to force her to eat, but Jess only panics and starts hitting people and throwing food across the room.

These children show just some of the ways that anxiety can affect a child’s life. There are many types of anxiety and many ways that children can show its effects. In fact, the forms that children’s worries can take are as varied as the number of children themselves. As you can see, fears do not always have to be “weird” or “crazy.” Many normal and common types of concerns can become a problem for children if they interfere with something children want or need to do. Fears and worries can also clearly vary in their intensity and effects.

The good news is that problems such as these can be managed very well. In the rest of this book we will describe the skills needed, including thinking realistically, facing up to fears, and learning better social interaction. Each skill will be described in detail, examples and activities will be provided, and we will apply the concepts to the cases of children we’ve introduced. Finally, we will discuss the future, what you can do to help your child maintain his or her gains and what to do if problems reemerge. Throughout the program your child will not only be building his or her confidence, but will also be earning rewards and time with you and the rest of the family. In our experience, most children going through the program enjoy learning the skills even if at times they get a bit scared of what they may have to do or embarrassed about what they think and feel.

Is Your Child’s Anxiety a Problem?

Everyone feels anxious from time to time. For most people, anxiety doesn’t really affect their day-to-day life. Understanding more about “normal” fears and worries, and the ways in which fears can affect a child, will help you to decide whether your child needs help.

Normal Fears

Fears are a normal and natural part of life. They are part of our evolution as a species and they emerge and develop at specific times in our lives. Fear of strangers and fear of separating from the main caregiver will typically show up in children at around six to nine months of age. Naturally, the exact age and the amount of fear will vary slightly from child to child, but all children will go through this stage and most fears will show up at similar times. As a child gets older, he or she will begin to show other natural fears. Fears of animals (e.g., dogs) and insects (e.g., spiders), fear of the water, fear of the dark, and fears of the supernatural (e.g., ghosts and monsters) often start to show up in young children in the toddler years and beyond. Around middle to late childhood, children begin to be more aware of other children and will begin to become self-conscious and develop a strong desire to fit in. These worries usually increase over the following years and peak in mid-adolescence, when how a teen looks and what the other kids think of him or her become the most important things in the world.

When Does Anxiety Become a Problem?

How do you decide if your child’s fear is “abnormal”? Quite ­simply—you don’t! There is no such thing as an “abnormal fear.” All fears are normal—some are simply more intense or more extensive than others. Even fears that might at first appear strange, such as a fear of germs that causes a child to wash a lot, can simply be seen as normal fears that have become too extreme. After all, most people worry at least a little about germs—just ask yourself if you would eat dinner out of your dog’s bowl! So children with anxiety problems can simply be thought of as having normal worries that have become extreme and more intrusive than the worries of other children.

A better way to think about these things is to consider whether your child’s anxiety is a problem for him or her. Does it interfere with or cause difficulties for your child? These difficulties may be many and varied. For example, it may simply be that your child’s fears cause him or her to be upset and distressed. Or they may stop your child from doing things that he or she likes or from making friends. Or it may be that worrying is affecting your child academically or on the playing field.

The bottom line is this: if your child’s anxiety is adversely affecting his or her life, then he or she will benefit from learning about how to overcome it. In making the decision to work on these skills, you should remember that change will take dedication, hard work, and commitment. But it can also often be enjoyable. The activities are not in any way harmful or dangerous, and they usually reap many additional benefits such as improved self-esteem, confidence, and general happiness.

How Common Are Anxiety Problems?

As we mentioned in the introduction, so-called anxiety disorders are the most common type of psychological problem found in children and adolescents. Approximately one in ten children meets the criteria for what is technically called an anxiety disorder. The particular disorders vary somewhat with age. Fears of separating from caregivers is more common at the younger ages, while social fears are more common at older ages.

Interestingly, even though anxiety disorders are so common in the real world, they are not the most common problem in child mental health clinics. Mental health centers for children are much more likely to see children with aggressive behaviors, attentional difficulties, eating disorders, or suicidal tendencies. What seems to be happening is that even though anxiety is common in children, most parents do not think of taking their anxious child to a professional for help. This may be because parents believe that anxiety is simply a part of their child’s personality and that there is nothing they can do about it. Or it may be because anxiety doesn’t affect the parent or teacher as much as these other problems, so they don’t realize how much the anxiety is affecting the child. In addition, in many areas mental health services for children are more prepared for, and used to dealing with, aggression problems than anxiety. As a result, parents often feel that they are making “mountains out of molehills” in worrying about their child and may be discouraged from seeking help.

How Does Anxiety Affect Children?

Overall, anxiety doesn’t have as dramatic an impact on a child’s life as problems like drug use or delinquency. But problems with anxiety can still affect a child’s life to quite an extent.

Anxious children tend to have fewer friends than other children their age. Because many are shy, they have difficulties meeting new children and joining clubs and groups. For this reason, they often have a limited number of friends and they may not interact with their friends as much as others do. In turn, lack of friendships can have an important impact later in life, increasing loneliness and reducing the opportunity for peer support.

Anxiety can also affect a child’s academic achievements. Many anxious children do very well at school because their conscientiousness and perfectionism make them try harder. But they may not be doing as well as they could. This is especially the case for those children who worry a great deal. We often find that these children delay homework and struggle with their lessons, not because they are incapable, but because their worry stops them from approaching the tasks confidently. Anxious children may also get less out of the class and the teacher because their anxiety stops them from making full use of the resources (e.g., they may not ask questions in class). In addition, many anxious children may do well in the classroom situation but fail when it comes to exams because their worry about failing stops them from being able to concentrate. In the longer run, research has shown that anxious children have more-restricted choices and opportunities in terms of careers. Many careers such as sales, media, or legal work may be out of the question for shy adolescents because of their worry about performing in front of others.

While many anxious children will change as they grow and mature and may well become confident, outgoing adults, some will develop into anxious adults. Anxiety disorders in adulthood can be a serious hindrance in life. Anxious adults are more likely to abuse drugs and alcohol, miss work or be unemployed, have illnesses and visit a variety of medical specialists, and be depressed and even suicidal. Depression is likely to start even earlier, usually during adolescence. We aren’t trying to suggest that this will happen to your child. But even if the effects of anxiety for your child are at the mild end—perhaps a few missed opportunities—it would be better to do something now than to wait until more severe problems develop.

Types of Anxiety

Everyone is individual, and no two anxious children will behave exactly the same way. But there are some broad similarities that we can describe.

What Does Anxiety in Children Look Like?

When children experience anxiety, they are likely to notice it affecting them in three ways. First, anxiety is experienced in the mental processes or thoughts that they have. Anxious children will have thoughts that center around some type of danger or threat. For example, they may worry that they’ll be hurt, that someone close to them may be hurt, or that they’ll be laughed at. Second, anxiety is experienced physically in the body. When a child becomes anxious, his or her body becomes more “pumped up” or aroused. Researchers often refer to this as the fight-or-flight response because its purpose is to help protect people by preparing them to combat or escape potential danger. The fight-or-flight response includes changes such as rapid heart rate, increased breathing, sweating, and nausea. Therefore, when worried, anxious children may complain of stomachaches, headaches, vomiting, diarrhea, or tiredness. Third, and probably most importantly, anxiety affects children’s behavior. When children are anxious, they may freeze, fidget, pace, cry, cling, and shake. In addition, anxiety usually involves some type of avoidance. This may be obvious avoidance (e.g., refusing to take the garbage out in the dark), or it might involve more subtle avoidance (e.g., helping all night with the music at a party so they don’t have to talk to anyone).

The amount of anxiety will vary from child to child. Some children are afraid of simply one or two things. For example, a child may be generally confident and outgoing but simply be scared of going to sleep with the light out. At the other end of the spectrum, some children may be worried about many areas of life and may seem generally nervous or sensitive. For example, a child may worry about any new situation; be scared to meet new children; be afraid of dogs, spiders, and the dark; and worry about his or her parents going out at night.

There are also certain common anxiety patterns that we see time and again, and we will describe these in the following sections.

Specific Phobias

A child with a specific phobia is afraid of a particular situation or object and usually tries very hard to avoid contact with the thing that frightens him or her. Some common specific phobias include the dark, dogs, heights, spiders, storms, and injections. Talia, who we introduced earlier, has a specific water phobia.

Separation Anxiety

Separation anxiety is the fear of being away from a main caregiver, most commonly, a child’s mother. Children with separation anxiety become very upset when they have to separate from their main caregiver for any reason. In severe cases they may follow the parent from room to room so as not even to be out of their parent’s sight. More commonly, these children will avoid going to school, get upset when their parents try to go out, refuse to sleep over at other people’s houses, and try to keep their parents with them at all times. Some children will report stomachaches or other physical problems when they separate, and many will throw tantrums when separation is threatened. The reason for this behavior seems to be a fear that something terrible will happen to the parent or the child while they are apart and that, consequently, they will never see each other again. Lashi, who we introduced earlier, developed separation anxiety after her parents separated, but many children don’t have such an obvious trigger.

Generalized Anxiety

Generalized anxiety is a general tendency to be worried or anxious about many areas of life. These children are often described by their parents as “worrywarts.” They worry about many general problems such as health, schoolwork, sport performance, bills, burglaries, and even their parents’ jobs. They are particularly concerned about any new or novel situation they have to face and will often go to their parents repeatedly to ask questions and to seek reassurance. Many parents report that television shows such as the evening news or police dramas will send their child into a fit of worrying for days. Kurt and Jess, who we introduced earlier, have generalized anxiety.

Social Anxiety or Social Phobia

Social anxiety or social phobia refers to fear and worry in situations where the child has to interact with other people or be the focus of attention. These children are more commonly described as shy, and the central problem is a fear that other people will think badly of them in some way. As a result, they may avoid many situations that involve interaction with other people, including meeting new people, talking on the telephone, joining teams or clubs, answering questions in class, or wearing the “wrong” clothes. George, who we mentioned earlier, has social anxiety.

Obsessive-Compulsive Disorder

In obsessive-compulsive disorder, the child will usually repeat certain actions or thoughts over and over again, often for long periods. Children with obsessive-compulsive problems may have particular thoughts or themes that play on their mind again and again. For example, they may worry about dirt or germs continuously, or they may continually be worried about keeping things orderly and neat. In addition, these children will usually perform some actions repeatedly, often in a superstitious or ritualistic way. For example, they may wash repeatedly in a particular pattern for long periods of time, or they may organize and reorganize their belongings in a very specific pattern. Kurt’s main problem is one of obsessive-compulsive disorder.

Panic Disorder

Panic disorder is a fear or worry about having panic attacks. Panic attacks involve a sudden rush of fear that comes with a number of physical symptoms (including racing heart, sweating, dizziness, tingling, and breathlessness). During a panic attack, children may believe that they are dying or that something terrible is happening to them. Panic disorder is not common in young children and is more likely to be found in older adolescents and young adults. Sometimes these adolescents will begin to avoid many situations because of their panic attacks, and, in these cases, the problem is referred to as panic disorder with agoraphobia.

To give you an example—Rosanne was fifteen when she experienced her first panic attack. She was at a friend’s party when she began to feel dizzy and sick. Her vision became blurry, and everything seemed to be happening from a long way off. Rosanne was convinced she was going to faint and yelled at her friends to call an ambulance. Many medical tests failed to find any physical problems, but from that time on, Rosanne began to be very afraid of any situations—such as flickering lights, fairground rides, or even exercise—that caused strange feelings in her body. Rosanne continues to have panicky feelings from time to time and is now starting to limit her life and avoids going anywhere that she fears might set off another attack.

Post-Traumatic Stress Disorder

Post-traumatic stress disorder is a reaction to a serious traumatic event in which the child was extremely afraid or injured. Events that might trigger such reactions include car accidents, natural disasters, sexual abuse, or being involved in a burglary. Most children will show some anxiety for a few weeks after a traumatic event. Usually, this reaction gradually disappears. However, in some cases, the reaction continues for many months or even years. Children may keep remembering the event or have bad dreams about it, perhaps even including the trauma in their play. They may suddenly act or feel as if the event is happening again and become very upset. They’ll often try hard to avoid situations that remind them of the trauma and may become distant in their feelings. They may show jumpiness, sleep difficulties, and irritability.

To give you an example—Danny is nine years old. When he was eight-and-a-half, he and his father were involved in a car accident. They were stopped at the head of a line of cars waiting at the traffic lights on a busy main road. All of a sudden, the driver of a car coming toward them lost control of his vehicle. Danny watched in terror as the car came toward him and crashed straight into the front of their car. He felt utterly helpless. Although he and his father both recovered physically from the accident, the emotional impact of the accident on Danny remains severe. Danny is often irritable and throws tantrums regularly, something he never did before. Many nights, he wakes in fright as he relives the terror of the accident. He is frightened of traveling in cars and often panics when stopped at traffic lights on busy intersections.

Why Is Your Child Anxious?

No one knows the complete answer to this question. But research has identified a number of factors that are likely to play a role in some way. The following sections discuss some of the things that might cause or at least keep anxiety going in children.

Genes

There is little doubt that anxiety runs in families. People who are anxious can often identify some close relative who always seems to be anxious, and it’s pretty common for at least one parent of anxious children to also be somewhat anxious. In some cases, this might involve a serious level of anxiety, while in others it might simply be that a parent tends to worry a little more than average. This is particularly likely to be seen in children with higher levels of anxiety. Children with only a single, specific phobia are much less likely to have anxious parents.

Research has shown that what is passed on from parent to child is not a specific tendency to be shy or to worry about the dark, but a general personality that is more emotionally sensitive than other people’s. Just as people vary in how tall they are or the color of their hair, people vary in how generally emotional they are. Anxious children tend to have a personality that is more emotional than the average. A large part of this is due to their genes. On the positive side, this means that they are likely to be more caring, kind, honest, and loving. But on the negative side, this emotionality means that they are more likely to worry, brood, feel down, and be fearful. There are both positives and negatives to any child’s personality, and we can’t and don’t want to change these. But the techniques in this book will show you how your child can learn to control some of the things that really interfere with his or her life.

Negative Thoughts

Once a child is anxious and has a “sensitive style,” the ways that he or she thinks and behaves play an extremely important part in keeping the anxiety going. In fact, these thoughts and behaviors are the keys to understanding your child’s anxiety, and we will focus the main part of the program on helping your child to change these patterns. First, anxious children mentally focus on any possible danger in the world. This includes physical danger (e.g., my parents will die; we will go broke) and social danger (e.g., other kids will laugh at me; I will make a mistake). Anxious children focus on these types of beliefs, often misinterpret unclear events as dangerous, focus their attention on any possible danger, and remember all the bad things, forgetting the good. Importantly, these ways of thinking keep their anxiety going because the world always seems like a dangerous place. Take the case of ten-year-old Kurt, who we described above. Kurt was constantly thinking about his parents getting sick or hurt, about making mistakes in his homework, and about his dog starving to death. In addition, he was always asking his parents about things that could go wrong, and if you asked Kurt about his last school test, he would always remember it as a negative experience. If Kurt heard a noise outside the house, he would assume it was something terrible. Because of all these thoughts and interpretations, the world really did seem like a very terrible place to poor Kurt, and it is no wonder that he was always scared.

Avoiding

Anxious children avoid things. This is a basic and automatic part of their personality—to run away. This might include obvious avoidance like not wanting to go to school or to a party, or it might include less obvious avoidance, such as working really hard on their homework so they never make a mistake or taking ages to decide what to wear so that they don’t look bad. But avoiding—whether it is obvious or subtle—is the key to keeping anxiety alive. Avoiding keeps the thoughts that we described above real because children never learn that those thoughts are not true. By avoiding anything that is a little frightening, children are not able to learn positive lessons such as, “I can cope,” “It’s not that bad,” or “It won’t hurt me.” Take the case of George whose main problem involves believing that other people will think he is stupid or incompetent. George would avoid talking to kids, would stay quiet and “hidden” in groups, and would make excuses not to talk on the phone or ask people for advice. But by avoiding all these things in both obvious and subtle ways, George was never able to learn that people would not think he is incompetent.

Parent Reaction

The way you react to or handle your child’s fears might also play some part in maintaining the anxiety. While all parents differ, some parents react to their anxious child in an overly protective way. This is very understandable. Parents love their children and so when faced with a child who is scared, vulnerable, and worried, parents only too naturally rush to his or her aid. But, in some cases, this helping behavior allows the child to avoid. Some parents begin to anticipate their child’s anxiety and will start to help their child even when it isn’t necessary. This is especially the case if the parent is also anxious. If this pattern becomes established, the child is not forced to face his or her fears and as a result may begin to learn that “The world really is dangerous” and “I cannot handle it myself.”

Parent Modeling

There is little doubt that children copy their parents. Just think of the young girl who walks out of Mommy’s room covered in makeup, wearing high heels and jewelry. It is reasonable, then, to expect that children may also copy their parents’ ways of coping with the world. If a parent is anxious and copes by avoiding situations, then the child may learn that this is the way to handle fears. We are not saying that you are entirely responsible for your child’s anxiety; there is no way that modeling could explain even the majority of anxious behavior. But if your child already has some anxious tendencies and either you or your partner is anxious, your child may pick up a few of these behaviors, and this may strengthen his or her already anxious nature.

Stressors

When a child is bitten by a dog, the child will become wary of dogs for a period of time. When a child’s parents separate and divorce, the child will often lose some confidence and become more sensitive for a time. These are natural responses that happen to most children after a stressful event. If a child experiences stressors like these and is already sensitive and anxious, then these stressors may have an even bigger impact than usual and may add to his or her anxiety. Common stressors include parental separation, family violence, death of a loved one, being bullied at school, doing badly in school, getting sick, and specific incidents (e.g., being in a car accident, being robbed, being bitten or stung, and being in a fire). Experiences like these cannot be identified in all or even the majority of cases of anxiety. But they may be important in triggering anxiety in some children.

In addition, we are starting to learn that people often create their own stressors. It appears that the very fears and worries that anxious children have can often lead to more stress in their lives, and this can increase their anxiety. For example, an anxious child may have some unusual behaviors that, in turn, lead other children to tease him or her. Or an anxious child may stop his or her parents going out at night, which may increase pressure on the parents and then lead to more tension in the family.

How Can You Help Your Anxious Child?

The skills you will learn in this program will all be aimed at the factors that we have just been talking about. Each of the skills and techniques for managing anxiety that your child will learn are aimed at some part of this model. Even if you don’t believe that one of the factors is important for your child’s anxiety, it may still help your child to learn that skill. So we strongly suggest that you and your child work on every one of the skills in this program.

To get a better idea of how it all fits together, see the following illustration, which shows you how each of the skills your child will learn fits with each of the factors that we have been talking about that maintain anxiety. We have included the name of the skill that we will be using for each factor in italics. As you can see, the key skill is to get your child to gradually and consistently face the things he or she is afraid of (see the discussion of stepladders in chapter 5). However, all of the other skills will help to improve and add to this skill so that the whole program works together.

Putting Together a Program for Your Child

Every child is different, and there is no single program or set of skills that will suit each child. If you work with a professional therapist, it is his or her job to help tailor and fit the best program for your child’s unique situation. If you are going to work through this program mostly by yourself, then you will need to do this. You may want to read ahead to see how the different skills and techniques that we cover in this program work together. Toward the end of the book, in chapter 9, we provide a detailed description of the specific programs that were used by each of the sample children whose stories we described earlier. It is a good idea for you to skip ahead and have a quick look at how these different programs are put together. To give you another view of the program, we describe below the structure that we use in our standard clinical program that we run at Macquarie University in Sydney, Australia. This program is run in ten sessions that are spread over twelve weeks. A description of what we cover each week is shown in the table below. This might give you an idea of an approximate timetable for running the program with your child.

In Summary

Anxious children believe that the world is a dangerous place. Because of this belief, they will often interpret very innocent events as examples of danger. For example, a normal noise outside at night might be interpreted as a burglar. In this way, this thinking style can help to maintain anxiety by “showing” the child that their fears are real. Most importantly, anxious children will usually avoid things they fear. Because of this avoidance, they never have an opportunity to find out that what they are scared of probably won’t happen and that they can cope if it does. Again, this maintains anxiety by not allowing children to learn that what they fear is usually not true. Where parents allow their children to avoid their anxieties—perhaps by doing things for them and protecting them from possible worry—parents are also allowing these beliefs to stay.

In this program we will help you to teach your child how to think more realistically about the world and to expect less danger in situations; we will teach you different ways of handling and ­interacting with your child; and we will show you how you can encourage your child to approach the situations he or she fears in a gradual and consistent manner. Together with these strategies, we will also cover some additional techniques that may be of help in some circumstances. These include coping strategies such as improved social skills, assertiveness, and dealing with teasing. At the end of the book, we have included an appendix about relaxation. This is not a key part of our program, but we have included it because some parents and children find relaxation a very useful way of dealing with anxiety and tension.

Motivating Your Child to Begin This Program

It can be difficult to get anxious children to try anything new. Usually they tend to expect the worst and feel nervous at the thought of having to do something that they haven’t tried before. They may worry that the program will be too difficult or that they will be forced to do frightening things that they feel they can’t do. Many anxious children also like to try to appear perfect in front of their parents (and peers) and so may have difficulty admitting their limitations. At the same time your child is probably aware of how uncomfortable it feels to be anxious and would most likely prefer to be free of anxiety.

At the same time, starting a program like this can be a little scary for a parent. Working through the anxiety management exercises in this book will not be easy. You will be asked to look at some of your own feelings and behaviors at some points. And you may have to be prepared to make some of your own changes if your child is really going to improve. Above all, working on this program will take time and energy—the program won’t work if you or your child are not fully committed.

Therefore, it is important to have your child’s full cooperation, and you will also need to make this program your number one priority for the next few months. The program will work best if you and your child see this as a combined adventure. The two of you will need to form a team, working toward some common goals. A good way to encourage your child’s cooperation and motivation is to discuss the negative aspects of being anxious and the benefits that might come from learning to control anxiety. Remember—most children love doing things with their parents. If you treat this as a game or adventure that you are going to do together, your child will be much more likely to go along with you.

It is a good idea to sit down with your child and talk about the program you are going to do together. Here are a few points to cover:

• Feeling anxious is normal, and there are many children who feel just the same way.
• You and your child will work on this program together—you are included every step of the way. You might describe it as an adventure in which the two (or three) of you will be a team.
• Your child will not be forced to do anything he or she doesn’t want to do.
• New skills will be learned one small step at a time.
• The program will be fun and will also include rewards that can be earned.
• At the end of the program, your child should feel more brave and confident.

Remember that this program will not take away all the normal protective anxieties that a child may have in certain situations (e.g., being scared of walking down a dark alley). Instead, it aims to teach skills to manage the bits of anxiety that are “over the top” and that get in the way of your child doing what he or she wants in life.

Getting the Most Out of the Program—Using the Children’s Activities

To get the most out of the program, it is very important that you and your child regularly work on the activities and practice tasks. Reward your child for his or her efforts in completing the work by consistently showing encouragement and interest in what he or she has written. If you stop paying attention to the tasks, your child will very quickly follow. Most children appreciate stamps, small stickers, or tokens that they can cash in later for bigger rewards. Giving your child a star or sticker each time he or she successfully completes an exercise is a good way to help make the program fun and to motivate your child to continue. However, attention and interest from you as well as your praise will be the most powerful rewards and the best ways to motivate your child. We will say more about using rewards later. One really simple principle is the “minute-for-minute exchange”—that is, for every minute your child spends working on the program, he or she gets a minute of an enjoyable activity such as computer time or story time with a parent.

Parent Activity: What Are Our Goals?

It’s time to think about what you might like to get out of the program. How far you get will depend on how much time you are prepared to put into it and how hard you and your child work at the new skills. Having goals in mind will help boost motivation and can also be used later to see how far you have progressed.

As we said earlier, this parent activity is designed for you, the parent, to do in order to help you to help your child during your anxiety management session together. In that session there will be a children’s activity (described below) where your child will get a chance to talk about his or her own goals.

What would you like your child to be able to do, which he or she currently doesn’t do because of anxiety (e.g., spend time with a friend after school, catch the bus every day, greet people when they say hello, fall asleep within a half-hour of going to bed, go to summer camp, visit friends who have dogs)?

1. ______________________________
2. ______________________________
3. ______________________________
4. ______________________________

What would you like your child not to do and how often does he or she do these things now (e.g., avoid going to school, sleep in your bed, ask questions, get stomachaches—every day, once a week)?

1. ______________________________
2. ______________________________
3. ______________________________
4. ______________________________

List broader goals that you would like to achieve (e.g., confidence in reacting to new situations).

______________________________

______________________________

______________________________

______________________________

We will look back at these goals at the end of the program (in chapter 10) to see how far your child has come and what you still want to achieve.

Finally, can you think of any practical barriers that might get in the way of running this program? For example, your child might be doing too many after-school activities to fit in something else, or you may have a partner who doesn’t support this program, and so on.

1. ______________________________
2. ______________________________
3. ______________________________
4. ______________________________

Spend a few minutes thinking about these barriers and then about ways you might try and overcome them. For example, if your child does too many activities after school, there may be another time to try this program that will work better, such as during school holidays.

______________________________

______________________________

______________________________

______________________________

Activities to Do with Your Child …

As we mentioned earlier, at the end of each chapter you will find activities to do with your child that will help you to teach anxiety management skills. Each activity will have a set of instructions to help you with what to discuss with your child, and descriptions of worksheets that you will need to create for your child to complete (with your help). You will need to base your discussions on what you read in the chapter and will be able to base your worksheets on the examples within the chapter. Alternatively, you can download a workbook from www.ceh.mq.edu.au/hyac.html. This workbook contains all of the activities to print out and use with your child as well as providing child-friendly explanations of each skill and blank worksheets for your child to complete, which will reduce the amount of preparation you need to do before sitting with your child for the anxiety management session. The parent instructions below are repeated in the workbook within each workbook activity.

Children’s Activity 1: What Is Anxiety?

Start off by talking with your child about worries and fears and how being anxious can sometimes be helpful (for example, by getting you scared if you smell smoke in the house or by revving you up for a big test or game).

Explain though that sometimes we get anxious when there really isn’t anything to be afraid of, such as getting scared by a noise outside at night that is being made by the next-door neighbor’s cat. Some kids, in fact, get a lot more anxious a lot more often than other kids and consequently they miss out on fun activities or spend a lot of time feeling bad.

Tell them about the three parts of anxiety: how the body reacts (e.g., fast heart beat), what the person thinks (e.g., that the dog in the park is dangerous), and what the person does (e.g., leaving the park so that the dog can’t get them). Try to use examples to help them to understand that when they feel anxious, they can tell that’s how they’re feeling by what happens to their body, what they think, and what they do.

Tell them that strong anxiety is common for about one in every ten kids, and explain that some people are more anxious than others partly because they were born that way and partly because they have learned to believe that the world is a dangerous place.

Finally explain that you will spend some time each week doing activities that will help you both to learn how to manage anxiety. Encourage them to ask questions and, if needed, reassure them that you will be working on managing anxiety together and will be taking it nice and slow.

Children’s Activity 2: Meet Some Other Children with Anxiety

Read stories with them about different children who have anxiety, either the ones from earlier in the chapter or from their workbook. Hopefully, this can get you started talking about their own fears and worries and how they are not alone and are not “crazy.”

Children’s Activity 3: Me and My Anxiety

Talk with your child about his or her own fears and worries. First list all the things that people could be afraid of or worried about (younger children might like to cut out pictures from magazines of the different situations). Then circle each one that you were afraid of when young (or even what worries you now) and then have your child circle each one that he or she finds difficult. Be very careful not to turn this into an “interview” and do not start telling your child to stop worrying about these things. Just accept your child’s view and ask questions so that you and your child can understand more about the fear.

Children’s Activity 4: My Goals

Begin by talking with your child about what he or she might get out of doing the program. A good way to phrase it might be to ask questions like, “Are there things that are hard for you to do now because they make you nervous?” or “Are there things that you would like to do without being scared?” Or you may focus on more concrete positives (especially if you have a younger child), for example, “Would you like to be able to make friends more easily?” While there may be lots of things that you personally want out of the program (like being able to leave your child with a sitter while you go out at night), you need to focus here on what positives your child might get out of the program (like becoming a “big” boy or girl, feeling more brave, and having more friends). Write down the main goals that your child comes up with on some brightly colored paper. It is a good idea to put this somewhere that you and your child will see regularly to remind yourselves of why you are doing the program, especially when things get a little tougher. Encourage your child to decorate these goals and be proud of where he or she is heading.

Children’s Activity 5: The Family Commitment

It is really useful to get your child to make a commitment to the program and to be supported by the family. Hopefully your child will want to continue with the program after talking about how things might be better without anxiety. A family commitment like this can really help to show how serious the next few months will be and how hard you and your child are going to have to work.

Create a contract for your child and you to sign (a pre-prepared contract is included in the workbook). The contract should state that you and your child (and any other person helping with the program) are going to learn to manage anxiety together and that you will work together once a week and a little bit each day to make this happen. You can write into the contract any reward that will be given for working each week on the program (for example, an extra hour on the computer).

You should plan a special activity that those signing the contract will do at the end of the program. This activity should be just for the parents and the child doing the program. The point is to make your child feel special and that his or her (and your) hard work is going to be rewarded. We suggest allowing three months to complete the program. The removal or loss of this activity should never be used as a threat during the program, but it can be used as a means of motivating everyone to remember that working on the anxiety is a commitment that will have benefits in the long run.

This contract represents your family commitment to the program. None of you should sign it if you do not want to commit. If your child is hesitant or does not want to commit, try to talk through why this is. It is likely that your child is afraid of what he or she will be made to do. After all, none of us likes to be made to do things we don’t want to do. You might begin by reminding your child of the positives he or she will get out of the program—in other words, the goals that will be reached. Then let your child know that he or she will be part of the program at every step and so will have a big say in exactly what and when to do things. If this still doesn’t work, you may need to write a “partial contract.” In other words, write a contract to commit only to the next few weeks, or, if necessary, even just the next week. If a short-term contract is needed, weekly rewards for working on the program will most likely be needed as well. If you can get your child to agree to at least begin, hopefully he or she will find it more fun as things move along.

Chapter Highlights

In this chapter, you and your child learned …

• That you can identify problematic fears by examining the impact that anxiety has on everyday life
• How anxiety affects three aspects of a person: their thoughts, their body, and their behavior
• That anxiety can be divided into several different types and that it is common for children to experience difficulties in more than one area
• That there are different factors that can cause or maintain anxiety, including genes, negative thinking, avoiding, parent reactions, parent modeling, and stressors
• How each anxiety management skill is targeted at a ­particular factor that keeps anxiety going

Your child will need to do the following:

• Complete the children’s activities with the help of a parent or other adult.
• Set goals and make a commitment to learning to manage anxiety.