The following is a general description of cognitive behavioral treatment for the typical child or adolescent with separation anxiety, generalized anxiety, social anxiety or a specific phobia. However it should be noted that treatment plans require tailoring to address the individual characteristics of each child. Developmental level, age, gender are some example attributes that are considered when developing an optimally effective treatment plan. Cognitive behavioral therapy for anxiety disorders includes five essential components: education about anxiety and helpful treatment; relaxation training; restructuring of anxious beliefs into coping thoughts; gradual exposure to feared situations or objects; and relapse prevention strategies.

Education about Anxiety and Cognitive Behavioral Treatment

Anxiety education imparts an understanding of the nature and function of anxiety to the child, adolescent and family, the manner in which excessive anxiety is learned and maintained, and the rationale for cognitive behavioral treatment techniques. Anxiety is explained as an instinctive and beneficial emotion that functions to protect people from harm and motivate people to achieve their goals. For example, modest levels of anxiety help children and adolescents prepare and study for tests or remember to set their alarm clock to avoid being late. Families are taught that for various reasons, and by no means anyone's fault, children and adolescents learn to respond with fear and worry more readily than others and at higher levels than what is appropriate or necessary. The continuation of anxiety is explained to result from avoidance or escape from difficult situations and unhelpful thinking. Thus, treatment focuses on learning to confront feared situation with greater comfort and confidence. Anxiety is conceptualized as a three part system containing physical sensations within the body, cognitive components consisting of thoughts, beliefs, assumptions and images, and behavioral responses of escape or avoidance. Children are trained to become detectives that discover the "clues" or adolescents are trained to become scientists that discover the "evidence" or triggers to their anxiety. Children and adolescents are also taught to become aware of their unique physical, cognitive and behavioral reactions to feared situations or objects. Children and adolescents log in their information on structured, individualized monitoring forms and they are reminded that this treatment will teach them specific anxiety management skills to address each of the three anxiety components. Throughout treatment children, adolescents and their families are informed that the goal is never to eliminate anxiety completely as it is a helpful, necessary emotion. Therefore, cognitive behavioral therapy emphasizes learning skills and techniques to be proactive in coping with everyday stress, anxieties and negative life events.

Relaxation Training

Techniques to manage the physical symptoms of anxiety typically include training in slow, diaphragmatic breathing and progressive muscle relaxation. However, the application of relaxation procedures varies depending on the nature of the anxiety symptoms and the seriousness of the child's impairment. In other words, instead of concentrating on lessening the body's physical response to anxiety, treatment may focus on learning to develop a tolerance for the natural rise of anxiety and resultant physiological symptoms in challenging situations. Diaphragmatic breathing tends to be the simplest and most portable method for lessening physical symptoms of anxiety. Progressive muscle relaxation is generally added as an additional somatic management technique to ameliorate muscle tension. The use of imagery can be an additional useful relaxation method. Thus, relaxation training requires flexibility to adapt to the needs and developmental level of the child and adolescent as individuals differ in the types of relaxation procedures that are most effective. Children and adolescents routinely receive a personalized tape recorded relaxation procedure that is practiced daily until they become proficient in managing their physical responses to anxiety through utilizing these procedures in challenging, fear inducing situations.

Restructuring of Anxious Beliefs into Coping Thoughts

Restructuring children and adolescent's thoughts begins withidentifying anxiety provoking, unhelpful thoughts. Subsequently they are trained how to challenge these maladaptive thoughts and substitute them for adaptive, coping-focused thinking, problem solving and action plans that are based upon the reality of the situation. Children are taught to treat their anxious thoughts as "guesses" and adolescents learn to view their worried thoughts as "hypotheses" that need to be tested and challenged before being accepted as truth. For instance, in reaction to the thought "Why are mom and dad late coming home from dinner? Maybe they were mugged or in a car accident," the child is trained to generate alternative explanations for their parents lateness. Example alternatives include maybe mom and dad met up with friends for dessert or they decided to see a movie, or they could not immediately find a taxi outside the restaurant. An adolescent may have the thought "My best friend did not say hello to me in the hallway today at school, she must think I am a loser and does not want to hang out with me ever again." For this teen, example alternatives would be maybe your friend did not see you in the hallway or she was having a bad day or felt sick and her unfriendliness had nothing to do with you." These alternative explanations are harmless as they do not increase anxiety and train the child and adolescent in more adaptive, flexible thinking. Children and adolescents are additionally encouraged to concentrate on these realistic alternatives while practicing their relaxation methods to decrease their physical symptoms of anxiety. Parents of younger children are trained to reinforce their child's restructuring of anxious thoughts and use of active coping techniques rather than offering their usual responses of excessive reassurance, permitting avoidance or being overly directive in challenging situations.

Gradual Exposure to Feared Situations or Objects

Gradual, systematic, and controlled exposure to feared situations or objects is the hallmark of cognitive behavioral treatment of anxiety. Gradual, systematic, and controlled exposure of children and adolescents to their feared situations or objects is the hallmark of cognitive behavioral treatment of anxiety. There exists various forms of exposure that include using an individual's imagination, simulating situations through the use of role plays, or reality based experiences. The type and rate of the exposures are directed by the severity of the child's distress, impairment in functioning, age and developmental level, and child and family's commitment and motivation for treatment.

Thus, gradual exposure transpires over a series of weekly appointments or it may occur more rapidly in an extended session. The effectiveness and pace of treatment depends upon the child or adolescents willingness to engage in exposure situations in a slow, methodical manner in sessions and completing assignments outside of the office between appointments. Throughout the course of exposures, relaxation skills and cognitive restructuring are practiced to reduce anxiety and gain an increasing sense of control and competence. The overall objective of exposures is to provide the child or adolescent with new factual, reality based information about their feared situation and their ability to cope.

Relapse Prevention Strategies

Relapse prevention is a crucial component in a comprehensive treatment plan. Relapse prevention serves to consolidate the child or adolescent's coping skills and fosters continuation and generalization of their improvement.

The following methods are employed as preventative measures:
• Problem solving and role playing future challenging situations
• Tapering the frequency of final sessions to biweekly and monthly visits
• Scheduling booster sessions to reinforce gains and enhance progress
• Having the child create a story that explains their new coping skills
• Engage in a role reversal exercise of becoming the therapist to help other anxious children

As in the previous steps, parental involvement is encouraged as the parents can coach their child or adolescent through future difficulties by reinforcing and modeling the skills and techniques learned throughout treatment.

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