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Worrywise Kids In Session:Case Conference on Putting Mr. Perfect in Perspective

Welcome to Worrywise Kids!

In this Case Conference, Dr. Lynne Siqueland presents treatment of a ten year old girl with worry that is significant enough to meet a diagnosis of Generalized Anxiety Disorder (GAD). Though all children worry from time to time, for children with GAD, worry is a constant companion and a full-time job. As if the brain is set up to "look for trouble", children with GAD can stress out and catastrophize about performance at school, breaking rules (though they never do), or social standing. In addition to these personal worries, they may also worry about family matters—financial stability or health status—even when these concerns are unwarranted. We will see here how learning to identify the worry voice helped this youngster begin to challenge the assumptions of the worry rather than assuming they were true. We also see how this youngster learned the important distinction between feeling scared about something and actually being in danger. Dr. Deborah Ledley offers her comments and reminds us that in order to make long-term change in a short-term treatment, we must prepare families with strategies for relapse prevention.
If you have questions about this case, please write to us: (contact here). If you are a therapist and would like to share a case or suggest a topic for future case conferences, please get in touch!

Tamar Chansky, Ph.D.
Children's Center for OCD and Anxiety

Putting Mr. Perfect in Perspective
Lynne Siqueland, Ph.D.
Children's Center for OCD and Anxiety

Sally was a ten year old girl who was delightful, impish, creative, bright and personable who was a pleasure to be around. Her parents brought her to the clinic because she was feeling "stressed out." Sally was a classic worrier and "what if" kid. Sally had always been shy and reserved but things had gotten more difficult since third grade. At school, she would cry often or yell out "Oh no!" and sometimes put her head in her hands during class. This behavior clearly showed how distressed she was but also had led to other kids beginning to shy away from her.

Red flags

  • Stating cannot do school work, don't know how to start despite competence
  • Perfectionist in her schoolwork and fun activities
  • Worried about getting into trouble at school - making sure kids followed rules
  • Avoiding eye contact and afraid to approach kids
  • Member of activities but did not talk with peers in groups
  • Rarely invited over to friends' houses
  • Multiple fears (e.g. bees, dark, firedrills)
  • Frequent headaches and stomachaches
Treatment approaches

Externalize the worry. I worked with Sally to draw a picture and give a name to her worry in order to separate herself from her worry. She decided to create 2 characters Mr. Perfect (all perfection) and Norry (no worry). Sally loved using puppets to act out these 2 characters and scripted elaborate shows over the course of therapy.

Teach about worry tricks the brain plays. We used these puppets to elicit her thoughts when anxious. For example, in regards to getting something wrong, she would think: "It's horrible. You are going to get suspended. You'll need to stay in for recess." Mr. Perfect would tell her how awful something would be, would go with her feelings and would tell her she was in danger. Sally was taught to recognize the kind of tricks worry plays and to begin to use Norry to boss back her fears. Norry would focus on how unlikely something is, would go with facts, and would tell her she was just feeling afraid.

The responses she drafted were: "It's alright to get some wrong, that is how you learn. I can talk to the teacher about fixing it. Did my teacher really say I would get in trouble or am I just thinking it." And finally, most important, "Norry will never be defeated."

Ways to self soothe and calm the body. I taught her to recognize her physical symptoms of anxiety: sweaty, heart racing, shaky, upset stomach, and headache. Sally was taught balloon breathing where she used diaphragmatic breathing and imagined with each exhale that she filled up a balloon that she watched float away. She also used a relaxation CD whose animal imagery appealed to her vivid imagination
Face fears step by step. We created a hierarchy of her fears which focused primarily on handling upset in school, being by herself in the dark and approaching peers. Norry challenged her thoughts about people not liking her ("They won't like me. I don't know what to say.") We role played how to talk with people and generated topics to talk about. Peer interactions were broken down into manageable steps, starting with make eye contact and smile at 5 people she knew each day and working up to approaching a child and starting a conversation. We worked our way through her hierarchy of fears.

Therapy course. Therapy continued for 14 sessions through the summer and into the next school year. Sally was able to control her outbursts by saying calm down and taking deep breaths. With her worry about getting in trouble and anger at peers for breaking the rules, she was able to think: "I'll just take care of myself. It's not my job to be the boss." Her new teacher reported that she was liked and included by peers unlike previous years.

Helping family focus on coping with anxiety. Sally had a very supportive family and a close relationship with her mother. However, her mother would try to save her from her distress by doing for her or withdrawing her request when she saw Sally was anxious. Instead we focused on helping Sally face the challenge. I worked with Mom to help in a different way by not letting Sally avoid or by rescuing her, but instead showing confidence in Sally's abilities, helping Sally to walk through her coping steps and promoting independence. Treatment ended when Sally was doing well through January of the school year but she was encouraged to return for booster sessions if needed.
Commentary: Dr. Deborah Ledley, Children's Center for OCD and Anxiety

Sally sounds like a delightful patient who fared very well with a brief course of cognitive-behavioral therapy (CBT) for her anxiety disorders. She presented as quite a complex case, with wide-reaching worries. Her principal diagnosis seems to be generalized anxiety disorder, which is characterized by excessive and unreasonable worry across a number of domains. Sally worried mostly about doing well in school, despite being intelligent enough to handle her work. She worried about completing her schoolwork correctly and feared that if she did not, she would get in trouble with her teacher and her mother. It also seems as if Sally's symptoms met diagnostic criteria for social phobia, a disorder characterized by fear of negative evaluation by others. In social situations, Sally preferred to stand on the sidelines looking in. While she went to activities that her mother enrolled her in, she seemed reluctant to socialize with the other children because she felt she did not know what to say. Finally, Sally also had a number of specific phobias including bees, the dark, and roller coasters.

When a child presents with a number of diagnoses, it can initially seem overwhelming. However, Dr. Siqueland seemed to focus less on diagnosis and more on clinical techniques that could target all of Sally's problems. This led to an integrated approach to treatment, where Sally was taught strategies for dealing with all of her current fears, as well as any others that might emerge in the future. This is a true strength of CBT. Even very young patients are essentially taught to be their own therapists so that they can manage anxiety on their own, should it continue to pop up from time to time in the future.

Dr. Siqueland got therapy off to a great start by helping Sally to name her anxiety. Therapy was framed as a battle against Mr. Perfect, aided by the character Norry. This type of framework for fighting anxiety was initially introduced by Dr. John March in his treatment for pediatric obsessive-compulsive disorder, but it clearly works well across the anxiety disorders. By naming the anxiety, and setting up the idea of waging a battle against it, children learn that anxiety is not their fault and that they have some control over it. Prior to treatment, anxiety often causes conflict between parents and children. When a therapist sets up treatment as a collective effort by child, parents and therapists to beat the anxiety, these conflicts are often diffused. Instead of parents getting mad at children for being anxious, or children getting mad at parents for not helping them enough with their anxiety, parents and children are taught to direct their anger at the anxiety and do whatever they can to beat it.

With this framework set, Dr. Siqueland then taught Sally a number of essential techniques for accomplishing her treatment goals. First, she was taught cognitive strategies. While this might sound like a difficult skill to teach children, when done correctly, it works beautifully. Children are taught to be tuned into what they are thinking. I like to have children think of capturing their thoughts in a net, like one would capture a butterfly. They can accomplish this by asking, "What am I thinking?" Once they know what they are thinking, they can be taught to boss back the thoughts. Dr. Siqueland explained that Norry bossed back Mr. Perfect by pointing out how unlikely her feared outcomes were and by focusing on the facts, rather than on feelings. These strategies can be used by children in many different situations after some careful in-session practice with the therapist. It is really useful to children to record their cognitive work in between sessions so that they can discuss it with the therapist in the next session. I try to make this fun for kids, so that they don't feel like it is just one more painful homework assignment! I encourage them to get some cool markers and a nice journal in which to record their thoughts, or to do it in some creative way on the computer. Kids often enjoy coming in and showing off their hard work…which they often adorn with drawings, cartoons and other creative touches.

Dr. Siqueland also taught Sally some exercises for dealing with the physiological symptoms of anxiety, including deep breathing and positive imagery. I often find when working with children that it can be helpful to teach them a number of different relaxation strategies and have them identify which works best for them. In addition to those mentioned by Dr. Siqueland, children can also benefit from progressive muscle relaxation or from less "traditional" activities like listening to their favorite music, drawing, or jumping on a trampoline. Finding effective relaxation strategies should be a collaborative effort between child and therapist. Once these have been established, I like to have kids make a list of their favorite strategies and put it in a prominent place in their bedrooms, since it is sometimes hard to remember which strategies to use in the throes of an anxious moment.

Dr. Siqueland also helped Sally to do exposures to her feared situations. The idea of exposure is two-fold. First, children learn that if they repeatedly practice going into a feared situation, their anxiety will decrease over time. Secondly, by repeatedly going into a feared situation, children learn that their feared outcomes are unlikely to occur. It is ideal to do at least some exposures in-session with the child. The therapist can use this opportunity to model good coping strategies, and also observe behaviors that a child is doing that might maintain their anxiety (e.g., watching a movie, but covering their eyes and ears during scary parts). While exposure often cannot be done to every situation a child fears, these learning experiences typically generalize to other situations. This was the case with Sally with respect to fire drills. While it would have been difficult to set up a fire drill during treatment, when one occurred naturalistically, Sally could use her new skills to deal with it effectively.

As an adjunct to exposure, Dr. Siqueland also did some social skills training with Sally. It is generally agreed that children with social phobia have some social skills deficits and can benefit from some targeted work in this area. Dr. Siqueland specifically focused on conversation skills with Sally. By practicing various topics in session, Dr. Siqueland not only helped Sally to feel more confident when she was sent off to do exposures with her peers, but also increased the likelihood that these exposures would be a success. Many adults with social phobia are also concerned about initiating conversations, and it is undoubtedly easier to teach children these skills (given that their non-anxious peers are also learning them as a normal part of development) than it is to teach adults! By going through CBT at an early age, it is likely that Sally would fare quite well during adolescence and adulthood. Even though she will likely always have to deal with some mild anxiety to various situations, she is now armed with the skills to manage it.

Finally, Dr. Siqueland did some great work with Sally's mom. It is essential to involve parents when working with anxious kids. Some can facilitate their children's avoidance because they don't want to see their children distressed. While this comes from good intentions, it keeps the anxiety disorder going. As Dr. Siqueland suggested, it is best to help parents learn how to cue their children to use the techniques they have learned in therapy to face their anxiety. Other parents can be very critical of their children's anxiety. In such cases, it is important to emphasize that treatment involves pitting parents, children and therapist against anxiety – rather than pitting parents against children. Rather than getting mad at their kids, parents should be taught to get mad at anxiety and to help children do the same with the techniques they have learned.

This case also highlights the importance of relapse prevention. Sally will likely always have some challenges where anxiety is concerned. An advantage of CBT is that she has left treatment with the skills that she needs to continue dealing with it. But, she might need help from time to time. I like to send patients home from their last day of therapy with an "Anxiety Tip Sheet," summarizing everything that they found helpful so that they can refer back to it in the future. Patients and their parents should always be reminded that they can also come in for booster sessions. They should be encouraged to call even for minor set-backs, rather than waiting for a full blown relapse. This should not be framed as a failure, but rather as a proactive step in the continuing battle against anxiety!

Brought to you by The Children's Center for OCD and Anxiety.