1. ANXIETY Practice Elements Developed by the Center for School Mental Health with support provided in part from grant 1R01MH71015-01A1 from the National Institute of Mental Health and Project # U45 MC00174 from the Office of Adolescent Health, Maternal, and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services

2. Practice Elements RelaxationCognitive/CopingModelingExposure

3. Treatment Manuals for Anxiety Coping Cat (Kendall & Hedtke, 2006) –Cognitive-Behavioral Therapy for Anxious Children The C.A.T. Project (Kendal, et al., 2002) –Cognitive Behavioral Treatment of Anxious Adolescents

4. What is Relaxation? Techniques or exercises designed to induce physiological calming, including muscle relaxation, breathing exercises, meditation, and similar activities. Guided imagery exclusively for the purpose of physical relaxation is considered relaxation.

5. Relaxation: Deep Breathing Breathe from the stomach rather than from the lungs Can be used in class without anyone noticing Can be used during stressful moments such as taking an exam or while trying to relax at home

6. Relaxation: Deep Breathing Tips Teach students to breathe in slowly through the nose, and out through the mouth Children should breathe in to the count of 5, and out to the count of 5 –“Breathe in, two, three, four, five, and out, two, three, four, five” (at a rate of about one count per second or two) Adolescents should breathe in and out to the count of 8 Have them take 3 normal breaths in between deep breaths Have them imagine a balloon filling with air, then totally emptying

7. Relaxation: Mental Imagery/Visualization Can enhance other relaxation techniques or be used on its own Provides relief from troubling thoughts, emotions, or feelings Evokes a pleasing, calming mental image (e.g., the beach, park, forest, playing with a favorite pet)

8. Relaxation: Mental Imagery/Visualization Tips Have the student close his/her eyes and imagine a relaxing place of their choosing While the imagine this, describe the place to them, including what they see, hear, feel, and smell Younger students may use a picture or drawing to help them

9. Relaxation: Progressive Muscle Relaxation Alternating between states of muscle tension and relaxation helps differentiate between the two states and helps habituate a process of relaxing muscles that are tensed Many good tapes/c.d.’s available on relaxation

10. Relaxation for Children Coping Cat, Session 5 Purpose: Review the cues that indicate that the child is tense and anxious. Introduce relaxation training and its use in controlling tension associated with anxiety.

11. Relaxation for Children - Steps Discuss how many feeling associated with anxiety involve muscle tension Introduce relaxation and practice techniques Discuss how/when relaxation might be useful Practice with student and parents

12. Relaxation for Children - Tips Gently point out muscle tightness that you notice Do the exercises along with the student Try different scripts/strategies Explain the procedure to parents

13. Relaxation for Adolescents The C.A.T. Project, Session 3 Purpose: For youth to learn about somatic responses to anxiety and identify own responses. Introduce relaxation training and its use in controlling tension associated with anxiety.

14. Relaxation for Adolescents - Steps Discuss somatic responses to anxiety Discuss the association between anxiety and muscle tension Introduce relaxation – discuss how it affects the body Practice relaxation Reinforce how/when relaxation might be helpful

15. Relaxation for Adolescents - Tips Point out muscle tightness that you notice Assure students that it might seem uncomfortable at first but will get easier with practice Do exercises along with student Encourage student to practice, practice, practice!

16. What is Cognitive/Coping? Any techniques designed to alter interpretations of events through examination of the student’s reported thoughts, typically through the generation and rehearsal of alternative counter-statements. Can include exercises designed to compare the “truth” of the original thoughts and the alternative thoughts through the gathering or review of relevant information. –“Which is more true?”

17. Cognitive/Coping with Children Coping Cat, Session 6 Purpose: Discuss how thoughts impact anxiety-provoking situations. Help child recognize his self-talk in anxious situations and develop coping self-talk.

18. Cognitive/Coping with Children - Steps Introduce concept of thoughts (self-talk) Discuss self-talk in anxiety-provoking situations Differentiate anxious self-talk from coping self-talk Help child answer the question “What do I expect to happen?” Practice coping self-talk

19. Cognitive/Coping with Children - Tips Ask the child to draw himself in an anxious situation Provide examples of TV shows in which the main character is the narrator (e.g., Everyone Hates Chris, Lizzie Maguire) Check with child to see if he believes his coping thoughts

20. Cognitive/Coping with Children - Tips Identify people whom the child admires as “good at coping” and use as model Don’t fall in the trap of trying to convince a child that the scary event is not likely to happen Make a list of thinking traps that the child typically uses

21. Cognitive/Coping with Adolescents The C.A.T. Project, Session 5 Purpose: Introduce function of personal thoughts and their impact on response in anxiety-provoking situations. Help teen recognize self-talk and learn to produce coping thoughts.

22. Cognitive/Coping with Adolescents Steps Introduce concept of thoughts (self-talk) Help teen answer the question “What do I expect to happen?” Discuss challenging self-talk and introduce concept of coping thoughts Have teen document anxious experiences throughout the week and pay attention to thoughts

23. Cognitive/Coping with Adolescents Tips Check with teen about whether s/he believes what s/he is saying to him/herself Have teen identify people whom they admire as good “copers” and use as model

24. What is Modeling? Demonstration of a desired behavior by a therapist, peer, or someone else to promote the imitation and subsequent performance of that behavior by the anxious student

25. What is Modeling? Learning from observing and imitating role models Learning about rewards and punishments that result from behavior Can be used to strengthen OR weaken behavior

26. Types of Modeling Participant modeling – Therapist acts out anxiety-provoking behaviors & prompts student to engage in behavior Covert modeling – Student uses imagination to visualize particular behavior Symbolic modeling – Using videotape, picture books, plays, etc. demonstrating target behavior

27. Modeling – Cuentos Therapy Storytelling/Folktales Taken from Puerto Rican culture; used historical heroic characters Used to foster imaginative behavior that youth are likely to imitate More effective when youth is attracted to and identifies w/the model

28. Modeling - Tips Clearly demonstrate target behavior without unnecessary details Start with the least difficult level of behavior and work up to difficult behaviors Incorporate a number of models to perform same target behavior

29. Modeling – Tips Use Role Playing Provide feedback – good and bad Encourage use of newly learned skills Coach student to move them closer to target behavior, one step at a time

30. Resources for Modeling Psychosocial Treatments for Child and Adolescent Disorders (Eds., E. D. Hibbs & P. S. Jensen), 1996 www.minddisoders.com/Kau-Nu/Modeling

31. What is Exposure? Exercises that involve direct or imagined experience with the feared stimulus, whether performed gradually or suddenly, and with or without the therapist’s elaboration or intensification of the stimulus

32. Systematic Desensitization Anxiety reducing strategy involving a graduated exposure of the phobic student to the feared object or situation. The student learns to tolerate the feared object by means of a series of steps beginning with the least anxiety producing aspect of the process and ending with the most difficult step. Begin with construction of the Anxiety Hierarchy

33. Exposure with Children Coping Cat, Sessions 10-15 Purpose: Practice 4-step coping plan under low and, eventually, high anxiety- provoking situations 1.Feeling frightened? 2.Expecting bad things to happen? 3.Attitudes and Actions that can help 4.Results and Rewards

34. Exposure with Children - Steps Review idea of progressing from learning to practicing new skill Practice using imagined exposure in anxiety-provoking situations Practice in-vivo (live) exposure task in anxiety-provoking situations Review relaxation exercises Decide on a situation where child will practice

35. Exposure with Children - Tips Be encouraging, supportive, and display confidence Note for the child how imagining situations is helpful Continue with imagined exposure until anxiety level is reduced Increase child’s involvement by soliciting suggestions

36. Exposure with Children - Tips Do not be drawn to “protect” the child from his negative emotions Be aware of “subtle avoidance” behavior Various in-vivo experiences can be arranged in the office Many natural-occurring exposure tasks can occur in public places

37. Exposure with Adolescents The C.A.T. Project, Sessions 10-16 Purpose: Practice the 4-step coping plan under low and, eventually, high anxiety- provoking conditions. 1. Feeling frightened? 2.Expecting bad things to happen? 3.Attitudes and Actions that can help 4.Results and Rewards

38. Exposure with Adolescents - Steps Shift focus from learning new skills to practicing them in real situations Imaginal practice with anxiety-provoking situations In-vivo practice with anxiety-provoking situations Decide on situation that will be practiced next Have teen record 1 anxious experience, including 4 steps

39. Exposure with Adolescents - Tips Continue to imaginal exposure until anxiety level is reduced Present a situation and ask teen to rate level of anxiety (0-8 scale) Various in-vivo experiences can be arranged in the office Many natural-occurring exposure tasks can occur in public places

40. Exposure with Adolescents - Tips Refrain from comforting the teen when they become anxious – allow them to develop independent coping skills Teens may enlist a friend as a support. Encourage the selection of a trustworthy peer Solicit suggestions from the teen in planning exposure tasks