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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
OPPOSITIONAL
PERCENT
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/
Impaired
13.7 %
Diagnosis/
Not Impaired
Impaired/
Not Diagnosed
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
23
27
Aggression
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
B. Psychological
Processes
Dorsal PFC-Based Circuits
Working Memory
PFC-Striatum-Based Circuits
Response Inhibition
Ventro-lateral PFCAmygdala-Based Circuits
Threat Influences on
Attention Orienting
C. Phenotype
Groups of…
Psychotic Disorders
Behavior Disorders
Anxiety Disorders
Environmental Influences
Evolving over the context of development
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.
Pine et al. 2008
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
Bodily
Reactions
Behavior -- AVOID
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*
7
6
SUDS
5
4
Anxiety
3
2
1
0
Base
5
10
TIME
SUDS, subjective units of distress
*This is a hypothetical clinical illustration.
15
How Feeling Better Can Make Anxiety
Worse
Two-Factor Theory of Acquisition/Maintenance

When an individual repeatedly confronts a fearproducing situation, the fear response is
strengthened through the process of classical
conditioning

Avoidance behavior is reinforced through the
process of operant conditioning (negative
reinforcement)
SUDS
Within Session Habituation*
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
SUDS
0
10
20
30
40
50
60
Time of Session
*This is a hypothetical clinical illustration.
70
80
90
Between Session Habituation*
Session #
*This is a hypothetical clinical illustration.
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

Fortune Telling

Over-generalizing
First report Card
Second Report Card
Math: B-

Mind Reading

Math: ?
“Should”ing
“I should this….
I should that…
I should this…
I should that…
I should this…”

Perfectionism
Third Report Card
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.