Worried and fearful thoughts: Using cognitive strategies (CBT, MCT and ACT) to help children and teens with anxiety
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There is a significant body of research showing that children and teens with symptoms or diagnoses of anxiety disorders have been shown to “think in different ways” compared with children who do not have these challenges.
For instance, studies have found children with anxiety are more likely to remember negative or threatening information in their environment, interpret ambiguous situations as potentially dangerous, and be able to identify a greater number of threats in any given situation. Other studies have found that the degree or amount of “negative thinking” a young person regularly does/has (catastrophizing, black and white thinking, mind reading) is correlated with the severity of anxiety they experience. Finally, studies have also found that children with anxiety disorders spend significantly more time “worrying” (thinking repeatedly about fearful thoughts repeatedly) than children without anxiety disorders. A note for interest – although these effects have been found in children of all ages, they are more pronounced in older children/teens than in younger kids.
Given these differences in the way anxious children think compared to non-anxious children, it is not surprising that there is a long history of psychologists trying to help anxious young people to either think differently, or to think differently about their thinking.
There are at least three models of psychological treatment which outline strategies for how children/teens with anxiety might manage, respond to or view thoughts and beliefs - cognitive behaviour therapy, metacognitive therapy and acceptance commitment therapy. Each of these models of treatment have slightly different views about the way worried thoughts or beliefs contribute to anxiety. I have briefly summarized these below. Please note that each of these therapy models include other important components in their treatment protocols – in this summary however I have just focused on how these different treatment models view thoughts and beliefs.
Cognitive therapy (usually as part of cognitive behaviour therapy) aims to help anxious children to do the following with their fearful thoughts:
- Understand that it is not a situation or their environment which makes them afraid, but their fearful thoughts and beliefs about that situation or environment which leads to the fear.
- Understand that fearful thoughts and beliefs are not always true or helpful and that they make “thinking mistakes” (catastrophizing, mind reading etc).
- To notice, test out or question their own fearful thoughts and beliefs to see if their thoughts/beliefs are true or helpful
- To create and remember more helpful or accurate thoughts and beliefs
Metacognitive therapy similarly suggests that children’s fearful thoughts contribute to their increased anxiety– but only to the extent that children and young people spend a lot of time going over these thoughts (“worrying”). MCT aims to help children:
- Understand that spending lots of time going over fearful thoughts (worrying) is not helpful
- Understanding that they are able to stop or reduce this worrying behaviour
- To quickly notice when they start worrying, and to instead calmly move their attention to a different topic
Acceptance Commitment Therapy suggests that anxiety is exacerbated by children believing their fearful thoughts are more important than they really are - or by fighting or avoiding these thoughts/beliefs. ACT therapists aim to help children do the following:
- To understand and accept that having fearful thoughts and beliefs is a part of being a human being
- To practice “stepping back from” or seeing their thoughts and beliefs as not terribly important (“defusing” from their thoughts)
- To calmly switch their attention to other more important (valued) thoughts/ideas.
As you can see, these approaches have similarities - all three models state either that children’s fearful thoughts themselves or the way we think about fearful thoughts is likely to make children/young people’s anxiety worse. The models also have differences - whether we should help children try to change their thoughts/add in other thoughts or whether to accept/defuse from these thoughts, or whether to shift attention away from those thoughts when they happen repeatedly.
Which of these strategies are most helpful?
My reading of the literature suggests that we do not have enough evidence to know which of these approaches to fearful and worried thoughts is likely to be more effective for which children.
Actually, my reading of the literature is that we do not even have enough solid evidence to know for sure that any of these ways of thinking or approaching anxious thoughts is definitively helpful for most children. Some studies seem to suggest that none of these strategies for managing thoughts – by themselves - are any more helpful than placebo/attention control condition – and instead, what most helps children with anxiety is exposure (getting children to reduce avoidance).
However, given that firstly, CBT, MCT and ACT have all been reliably shown to be effective as “whole packages”, and secondly, there is reliable evidence that anxious children DO think differently than non-anxious children - it is still valid and potentially important for many anxious children/teens to try to use some of these cognitive strategies (or more simply: to help them think differently) in our work with them.
What should be our aims in helping children think differently?
Although CBT, MCT and ACT are sometimes presented as entirely different and contradictory approaches, I think it is possible to find common ground between all three.
Here are a list of aims we can have when helping children with their thoughts, which incorporates all three major therapeutic approaches.
1. Help children understand that having fearful thoughts and beliefs is a normal part of being a human being
2. Help children understand that fearful thoughts and beliefs are not always true or helpful (including understanding that humans make “thinking mistakes”)
3. To teach them to be able to notice, test out or question their own fearful thoughts and beliefs to see if they are true or helpful – and help them do this themselves at least sometimes (“catch what they can”)
4. To teach them to create more helpful or accurate thoughts and beliefs – and to regularly remind themselves of this (“add in what they can”)
5. To teach them to also be able to “step back” from worried or unhelpful thoughts – and to do this regularly, especially when they can’t easily test or question their worried thoughts.
6. To notice when they are spending lots of time going over their fearful thoughts, and to calmly move their attention to a different topic
Of course these aims will need to be achieved in a variety of different ways – depending on the child, their situation and our area of competence/the way we work with children. If you are a therapist/psychologist/working in a counsellor role, then you will be doing this in a more thorough and extensive way with young people. If you are a teacher/working in a non-counselling role, you may just be explaining the ideas in more general ways with the children you work with.
However I have outlined a few different ways of talking about or implementing each of these strategies below which might spark your own thinking about how you would like to do this with the children/young people you work with.
Aim 1: To help children understand that having fearful thoughts and beliefs are a normal part of being a human being and that they can exacerbate anxiety.
It can be helpful first to encourage young people to know that we all have thoughts and to notice their own (and others) thoughts and beliefs. Noticing thoughts and beliefs can then help children/young people to express these, and to go on to develop other ways of managing them. Secondly it can also be helpful to encourage children to notice how their thoughts and beliefs might contribute to further anxiety.
Possible explanatory sentences/ideas to explain these concepts:
The “threat detection systems” (OR – younger children: “a danger checker”) in our brain are on the lookout for what might go wrong or be a problem for us – and they create sentences/thoughts about these problems which sometimes go around and around in our mind.
A long time ago it was really important for us to think about problems or things which might go wrong – this helped us to be aware of dangers and to avoid them where possible (providing information about evolutionary theories of survival).
Sometimes our worried thoughts might lead to us feeling more anxious – here is a diagram which shows that this might look like (draw a flow through arrow diagram to show “situation –> thoughts –> feelings”)
For younger children we will of course want to add visual and concrete ways of learning these ideas – for example drawing pictures (sometimes using thought bubbles), making books, using puppets, videos or role plays to help them notice worried thinking in themselves and others.
Aim 2: Help children understand that fearful thoughts and beliefs are not always true or helpful (including understanding that humans make “thinking mistakes”)
It is often helpful to explain to young people that human beings –especially when they are worried – do not always think clearly or helpfully. If we have longer periods of time and the ability to work more intensively with young people, we can also explain particular types of thinking styles or thinking mistakes we make when we are worried.
Possible explanatory sentences/ideas to explain these concepts:
Research (younger children “scientists”) has found that when we are worried or stressed, we do not think in the same way as when we are feeling calm.
Our brain is designed to quickly tell us what can go wrong and remind us of problems. This is an important part of our brain but we can’t always trust it 100% as it makes mistakes.
When we are anxious or stressed we are more likely to make “thinking mistakes”. Thinking mistakes are particular types of thinking when we focus on what might go wrong without thinking accurately or helpfully.
For instance, catastrophizing is a type of sentence our brain says which tell us which is a sentence that says things are very terrible. Mind reading is a type of sentence our brain tells us which says that people are thinking negative things about us. Future predicting is a type of sentence our brain tells us which says bad things will happen in the future.
Aim 3: To teach young people to be able to notice, test out or question their own fearful thoughts and beliefs to see if they are true or helpful – and help them do this themselves at least sometimes (“catch what they can”)
This strategy is about helping children/teens to notice the errors in their own thinking – or to be able to at least “test out” their thinking.
This is a difficult task – even for adults – so usually we need to actively assist young people to do this. This means writing out/drawing worried thoughts and going through them to check: does this thought or belief contain any errors? Is it helpful?
We then need to help kids and teens to apply this skill at home. This might mean a short period of them recording thoughts (using paper, apps, diagrams, audio recordings), and using these to practice analyzing thoughts to find thinking mistakes during their daily/weekly life.
Possible explanatory sentences/ideas to explain these concepts:
Let’s come up with a list of the worried thoughts your brain tells you about X situation OR here are some examples of worried thoughts I know some kids have about X – let’s mark on a scale from 1-10 how often/much you have had these thoughts.
Let’s notice/make a record sheet of the scared thoughts you have this week – and see if we can use detective work to find any (catastrophizing/mind-reading/black and white thinking etc).
Let’s test out whether or not this thought/belief is true by doing an experiment. How can we test this out? Who could we ask (that you trust) to see what they think? What might tell us if it is true/not true?
This week/for this short period of time/over the next few days you can fill in this sheet/use this app to write your thoughts and tick a box in these columns to see if you think your worried thought has any thinking mistakes in it.
When you have a conversation with your friend/mum/teacher/other person, when/how could they help you to notice any thinking mistakes in a way which feels supportive for you?
Let’s imagine you are on a jury, and you have to weigh up all the evidence and judge whether someone is saying something true or false. Let’s put your belief on the “stand” and see what you think.
Let’s have a pretend debate – I will say all your thoughts/beliefs and you have to try to convince me why the things I am not saying might not be 100% true.
It is important to note that this strategy of being aware of and identifying thinking mistakes/unhelpful beliefs may not always be required when working with anxious kids/teens. Depending on the situation and age of the child I often skip this and move to the next strategy below of simply “adding in” more helpful/accurate thoughts and beliefs without specifically addressing the unhelpful/inaccurage thoughts and beliefs.
Aim 4: To teach young people to create more helpful or accurate thoughts and beliefs – and to have the ability to sometimes remind themselves of these more helpful thoughts (“add in what they can”)
It is often helpful to assist children and young people “add in” more positive, helpful or more accurate thoughts and beliefs. Again, given this is often a difficult task, this usually requires us to actively assist them to generate these thoughts and beliefs. For example, we might need to suggest “sentence starters” consisting of calm and helpful thoughts and beliefs and ask them to complete them.
It is important to know that it is usually not enough to identify these calm thoughts and helpful sentences – we also need to support young people to a) increase their belief in these thoughts and b) bring these thoughts and beliefs to mind during their daily life.
Possible explanatory sentences/ideas to explain these concepts:
(Older children/teens) We can’t stop ourselves from having anxious thoughts. However it is often helpful for us to identify helpful and more positive thoughts and beliefs to be able to reflect on when we are anxious. We might not always 100% believe these statements to start with, but knowing there is another way of viewing a situation can help a little over the long term.
(Younger children) Calm sentences are sentences we can use to help us when we feel worried. Calm sentences often start with these words: I can cope because….I don’t know for sure that….This is not terrible because….
How could we test out some of these positive/helpful thoughts and beliefs to see if they actually are true?
How can you remember or bring these thoughts or beliefs to mind when you are feeling anxious? Some kids/young people like to draw a picture to represent them, shortening them to be a word or two which “represents” the thoughts, taking a picture of calm sentences to put around home/on their phone etc.
Let’s visualize you saying these calm sentences to yourself in X situation? Could you practice imagining yourself saying these in situations in which you are normally anxious?
Can you say these calm sentences out loud and notice how they feel? Sometimes saying sentences out loud (in a confident and calm way) helps remind our brain that these sentences are true.
Aim 5: To teach children to be capable of “stepping back” from worried or unhelpful thoughts – and to use this strategy on some occasions (especially when they can’t easily test or question their worried thoughts).
It can be helpful to teach young people an alternative and additional strategy to deal with worried thoughts other than replacing them with positive/helpful ones. This alternative strategy is to practice activities which help them see their thoughts as not important, but as “just thoughts”. This strategy is the “accept/defusion” strategy and it can be particularly helpful for children/young people who have thoughts which are difficult to test or challenge.
Treatment manuals (depending on this therapeutic approach is being used) for anxiety generally use only either the test/replace approach OR the accept/defuse approach for dealing with thoughts.
However I have often found it useful to introduce young people to both ways of managing thoughts, and tell young people that they can choose which strategy they find most helpful. For example they can “catch what they can” in testing out their obviously unhelpful/negative thoughts, and also do activities to help them “step back” from these thoughts on other occasions.
Obviously we have to be careful not to confuse young people by giving totally mixed messages, but often they are more capable of being flexible with their thoughts and beliefs than we might suppose. Incidentally, I have found that teaching the strategy of defuse/accept to be more effective AFTER I have taught the strategy to be aware of thinking mistakes.
In any case, again helping young people effectively use this strategy usually requires an adult to practice and explain defusion strategies with them – and then helping them to remember and be able to do this themselves at home.
Possible explanatory sentences/ideas to explain these concepts:
Sometimes it can be helpful for us to remind ourselves that thoughts can’t hurt us, and that we don’t have to pay them much attention.
Our thoughts can be a bit like a toddler who is yelling at us trying to get our attention. The toddler is just doing what toddlers do, just like our primitive brain (danger checker) is just trying to say what it thinks is important. But that doesn’t mean the toddler or primitive brains knows everything.
There are some activities we can do to remind ourselves that our thoughts are just thoughts (introduce one of these activities, one at a time):
- We can say our thoughts out loud repeatedly in different accents/voices, this can remind us that this is just a thought we can play around with – not something which we have to pay attention to.
- We can label our thoughts as having a name “there is ‘Ms I am Terrible, Terrible Person’ coming to talk to me again”/Jane the Jumpy One/Sam Scared is telling me what might go wrong again
- We can label our thoughts as having a story/theme “there is my “I can’t do anything story”, “This is going to be bad movie/story”
Some kids/teens like to have labels or pictures on their phone/stuck on their pin up board at home/as a screensaver on their computer to remind them of the names of their “stories”.
Aim 6: To notice when they are spending lots of time going over their fearful thoughts, and to calmly move their attention to a different topic
It is important for us to teach children that it is helpful (and possible) for them to reduce the time they spend worrying and ruminating (going over and over anxious thoughts). In other words, we can explain to them that regardless of whether we might be noticing thoughts, testing, challenging or replacing or defusing from thoughts, we can and should avoid spending long periods of time actively focused on our worries.
This involves helping kids and teens identify triggers for worrying/rumination, to notice when they are worrying/ruminating, and to learn to switch attention to alternative activities/topics when this happens
Possible explanatory sentences/ideas to explain these concepts:
Spending a lot of time thinking our worried thoughts over and over again is called worrying. Worrying doesn’t help us feel better and often makes us feel worse. We might not be able to stop having worried thoughts sometime but we can avoid spending lots of time paying attention or thinking about them.
Let’s try to think about the times you spend time worrying about X. Often kids tell me that they worry when (provide example trigger events or situations) – do you think this is true for you
How can you notice when you are worrying? What happens to your body/mind/feelings?
What are some other activities you can do when you notice you start to do lots of worrying?
How can your family help you do something else when they notice you have started worrying?
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I hope this helps you think about some of the strategies we can use in helping children and young people respond to and manage their worried thoughts and beliefs. This is important work – we are helping young people build skills they can use throughout their lifetime.
Kirrilie
If you work with primary aged children, and would like some animated videos to help them understand the ideas of worried thoughts and calm sentences (as well as activity and record sheets), then you might be interested in Calm Kid Pro, click below to find out more.
