First Chapter

Parents' Concerns

"My Katie is a little chatterbox, but when you ask her to perform, even for the family, she gets so nervous that she freezes up. I wish I could help her relax more."

"Almost since he was a baby, Jose has been a 'clinger.' He hated starting kindergarten, and even now in the third grade, he misses me and can't wait to get home. I can't travel anywhere without him. We thought up a plan to help him be less frightened, but it just didn't work out."

"Our Damian is terrified of animals. He hates to walk down the street by himself. He thinks a squirrel is going to jump out at him! We took him to a psychologist, who helped him think about his fears differently, and for while he was a lot better. Then a dog barked at him, and he just gave up."

"I wouldn't say Felicia is a frightened child. She does most of the things the other kids do-it's just that she worries about doing everything. She's very capable, but she's always afraid she's going to screw up. She works hard to get over her fears, and we tell her that she is doing better. She just can't see it, though. She just doesn't realize the improvements she's made."

We're Never Going to Make It!

It was a cold, sunny day as my father and I set out on our drive to the San Bernardino Mountains for my Indian Princesses retreat. This was a father-daughter group, similar to Cub Scouts or Girl Scouts, but based on Native American stories, crafts, and values. We were going camping with the other members of our group. We would be staying in real wood cabins, sleeping in cozy sleeping bags, and cooking food over a campfire. I had been looking forward to this trip for weeks, imagining ghost stories and marshmallows and looking up at a million stars in the night sky.

THE NATURE OF ANXIETY

Young Lisa certainly experienced some highly anxious moments on her trip with her father. From her father's view, she was never in any danger, but she imagined that she was. Do these feelings indicate that Lisa had a serious problem? Before we can try to answer this question, we need to further explain the nature of anxiety.

WHEN ANXIETY BECOMES A PROBLEM

In the simplest sense, anxiety is the feeling that one's safety or well-being is threatened. Under some circumstances, a potential threat is readily resolved, such as the first time a child musters the courage to blow bubbles in the swimming pool. When she hears applause for joining the ranks of the ''minnows,'' the threatened feeling is replaced by a feeling of success.

MAJOR CAUSES OF ANXIETY

Social scientists used to try to explain human traits, including anxiety, from the standpoint of two causes: nature and nurture-that is, genes and environment. In recent years, social scientists have carried out numerous studies of the causes of anxiety. They have made much headway. Perhaps the most important conclusion they have reached is that anxiety always results from a combination of three factors: biological, psychological, and social. These researchers use what is referred to as the biopsychosocial model to explain the influence and interrelationships of the three factors. Understanding this model will help you take a more comprehensive approach to coping with your child's problems. Let's look at each of these factors more closely. Although we describe them separately, please remember that in reality they are always interacting and affecting each other.

Biological Factors

From the moment your child was conceived, she was subject to biological influences that affected her level of anxiety. Some of the indicators of a genetic tendency toward anxiety are obvious, such as a tense, irritable temperament or erratic sleep patterns. Other biological factors are less obvious but are equally influential, such as hormonal imbalances and abnormal brain activity. Whenever these biological abnormalities are present, they increase adrenaline in the bloodstream. As a result, a child will likely exhibit some physiological symptoms: shallow breathing, increased heart rate, sweaty palms, and tense muscles, for example. These symptoms are also typical when a child or adolescent is under stress and experiences the alarm reaction. The alarm reaction involves twenty-two physiological responses that usually result from heightened adrenaline levels (see the list that follows). Not all of these responses need to occur simultaneously for the alarm reaction to be present. Ironically, many people come to fear the uncomfortable and disabling symptoms of the alarm reaction more than the cause of the anxiety itself.

Physiological Responses of the Alarm Reaction

Physiological factors such as sleep, stimulation, and food affect the anxiety response to a degree and on an individual basis. For example, your child may be getting too much stimulation from her environment or not enough. Any child will be more easily agitated if she has not had enough sleep or has ingested too many candy bars or sugary, caffeinated soft drinks. Exercising judgment and control over a child's sleeping and eating habits is easier with young children than with adolescents, who make more decisions on their own. Nevertheless, by modeling desired eating habits and sleeping routines in the home, you can beneficially influence your child both directly and indirectly.

Psychological Factors

Psychological causes of anxiety result from an interaction between biological forces and disturbing experiences. An example would be what happens when a child takes a tumble off a tricycle. For most children it is upsetting, but they soon forget it. For a child who has a ''high-wired'' nervous system, however, such an accident can cause tricycles to become feared objects. Psychological factors affect the way your child perceives and thinks about the world.

Social Factors

Social factors typically involve your child's interactions with her family and friends and others in her life. These people may contribute to her anxiety in various ways, and their influences change as she matures. Parents, siblings, and other playmates can be constant sources of anxiety if she perceives them as a threat. For example, her big brother may be only kidding, but your child may think he is really going to hurt her. The intentions of these persons may be good, but if your child is predisposed toward feelings of anxiety, then everyday conflicts may seem especially threatening to her.

Anxiety Among Caribbean Children

Dr. Philips observes that after hurricane Luis, which brought about major destruction on St. Maarten in September 1995, the number of posttraumatic stress cases increased. She sees the source of her clients' anxiety as their anticipation of their surroundings, as well as the way they talk silently to themselves about their perceptions. Focusing on changing this "inner talk" toward more positive statements and anticipations is the core of her plan for treating these anxieties. If clients realize they can actively change their own perceptions and thoughts, then a sense of control develops that can result in reducing anxiety. The choice is whether to concentrate on and emphasize what could go wrong or what could go right. Dr. Philips finds that if her clients can focus more positively and constructively on developing healthier inner talk instead of fighting anxiety, they can make good progress.

ANXIETY AT DIFFERENT AGES AND STAGES

As you may well have noticed, age affects your child's anxiety patterns. For example, infants' fears revolve around sensory experiences, such as loud noises, falls, and their parents' absence. Toddlers will likely experience fear of strangers or distress upon their caregivers' departure (known as separation anxiety). Childhood brings with it fears of animals, the dark, and imaginary beasts and creatures. As children's circles of exploration and experience widen, the likelihood of exposure to anxiety-provoking stress increases. Children in middle childhood are often concerned with performance, and adolescents are more concerned with social and interpersonal anxieties as they begin to form intimate relationships. The list that follows shows the typical fears that child experts find at several age levels.

Typical Causes of Anxiety of Children at Several Age Levels

Ages 6 to 7

7 to 8

8 to 9

9 to 11

11 to 13

CURRENT THERAPEUTIC PERSPECTIVES ON ANXIETY

The science of psychology has taught us a great deal about the nature of anxiety. Unfortunately, but not surprisingly, there is still some disagreement about the best way to reduce it. There are several schools of thought that influence diagnosis and treatment of anxiety in children and adolescents: psychoanalytic, behaviorist, family systems, and cognitive. We think it is important to briefly describe these current psychotherapeutic viewpoints so that you can clearly see the orientation of this book. Many of the activities you will do later in the book are built on these perspectives, especially the behaviorist, family systems, and cognitive viewpoints. Also, knowing this information is helpful when you are choosing a therapist, should that be necessary.

The Psychoanalytic Perspective

Although Sigmund Freud was the father of psychoanalysis, his work has been largely superseded by the theory of Erik Erikson, another famous psychoanalyst. In his much-discussed book Childhood and Society, Erikson outlined eight universal stages of development. He stated that progressing from one stage to the next depends on the child's resolving the conflict present in each stage. At each stage, two personality traits conflict with each other. For example, at stage two the conflict is between whether the child develops a sense of autonomy or becomes filled with a sense of shame. For healthy development, the child needs to resolve the crisis in favor of the first trait in each pair. From the standpoint of the anxious child, the most relevant stage is stage four: industry versus inferiority. During this stage, which occurs at approximately five to eleven years of age, children are concerned with performance in school and at home. The anxious child may be overly concerned with "making the grade" both academically and socially. "Will I pass the test?" "Will I make new friends?" "Are people making fun of me behind my back?"

The Behaviorist Perspective

Anxious children naturally wish to avoid situations that scare them, even more than other children do. When your child avoids such situations, her behavior is reinforced because her frightened feelings are temporarily reduced. This only perpetuates the anxiety, according to behaviorist theorists, such as B. F. Skinner. Some parents feel that giving in to the child's reluctance is appropriate and caring, but doing so enables the child to avoid fearful situations, and she thus fails to deal with the problem.

The Family Systems Perspective

Family systems therapists, such as Virginia Satir, regard the anxiety symptoms of an individual as a family problem, and thus they find it necessary to treat the whole family rather than just the child or adolescent. There are many varieties of family treatments, which may be combined in different ways and with other types of therapy. Perhaps the most important feature of this perspective is the idea of bringing the whole family together for therapeutic sessions, as families are seen as self-sustaining systems that influence each member in a myriad of ways. The child is the "identified patient" whose symptoms bring the family to therapy. Once the family's rituals, rules, and routines have been determined, the therapist attempts to alter the patterns that affect the child. These changes then reverberate throughout the family system. For example, a family therapist will try to influence the interactions between a husband and wife in order to help the child. The personal story that follows illustrates how a mother's anxieties about separation from her husband can affect her children.

The Attack of the River Rats

Our house had a small front yard, surrounded by a low hedge. On the side of the hedge facing away from our house was a huge open field sloping down to the railroad tracks and the bank of the Delaware River. There was a narrow break in the hedge that opened onto a path, and that path led across the field to a train station about a quarter-mile away. It was exactly the kind of place that kids would want to explore and that any parent would declare off-limits.

The Cognitive Perspective

The cognitive perspective on anxiety focuses on the thoughts of the child. This view is the opposite of the psychoanalytic approach, which identifies repressed feelings as the culprits. Cognitivists, such as Aaron Beck, believe it is distorted thinking that causes disruptive feelings rather than the other way around. In the cognitive view, feelings are analogous to the level of the mercury in the thermometer when you have a fever. The heightened mercury in the thermometer is not itself important. It simply indicates that the body's internal temperature is above average, which is a sign of an invasion of germs. So it is with anxious feelings: they usually reflect thought patterns that have gone awry. Fix the thoughts, and the anxious feelings will subside.

The Perspective We Espouse

In our work with children and adolescents, we have employed each of these four perspectives. Although there are cases that respond well to the psychoanalytic, behaviorist, and family systems perspectives, in our experience most anxiety problems can best be helped by the cognitive orientation. Anxious children tend to be brighter than average and therefore are more likely to understand the mental skills the cognitive approach is trying to foster. In addition, as we argued earlier in this chapter, anxiety itself is most often a result of faulty perceptions and, even more important, faulty interpretations of the facts. Cognitive therapy is specifically designed to discover and correct mental misapprehensions. Therefore, the COPE program consists mainly of activities that were inspired by this orientation.

THE COPE METHOD

For the past fifteen years, John Dacey has been experimenting with techniques for helping children and adolescents increase their self-control over their study habits and their ability to avoid using drugs. In recent years he has adapted this method specifically to help children with anxiety problems. The method that has resulted from all this research is called COPE. The letters in this acronym stand for the four steps that make up the method:

What we have discovered through our teaching and our therapeutic and research studies is that most people, children and adults, have similar problems when they deal with situations that are anxiety provoking. These four problems (the same ones that are reflected in the four quotations with which we opened this chapter) fall into categories that are the focus of the four steps of COPE.

Calming the Nervous System

The first problem most of us confront when we enter a stressful situation is the stimulation of the fight-or-flight response, a physiological reaction to assault that is "hard-wired" into the human body. In prehistoric times this response, which prepares the body either to attack the antagonist or to run away, was most functional; life-or-death situations demanded immediate, unthinking action. In those days, if you were out hunting alone and saw an enemy tribe running toward you, pausing to consider your alternatives could mean disaster. Today, however, children in most scary situations cannot resolve their problems by simply attacking or running away. For example, as your child walks into a room full of children at a birthday party, she may feel angry with the people staring at her, or she may want to run and hide. However, what she needs to do is quell this neurological response to stress so that she can think clearly about what she wants to say and how she wants to say it. A calm nervous system, then, not a highly aroused one, is what she needs when dealing with most modern stressors.

Originating an Imaginative Plan

The second problem that anxious people often face is that, even when calm, they often have faulty understandings of their feelings and why they have them. Further, because they are under such pressure, they may be unable to think of really imaginative plans for dealing with their quandaries. Anxious children are less likely than others to have imaginative ideas about the best way to problem-solve, even though, with their vibrant imaginations, they often have greater creative potential. However, if they have calmed down their nervous systems, they can use the techniques that we teach to originate better insights about themselves and design an imaginative plan for dealing with their problem.

Persisting in the Face of Obstacles and Failure

We have found that many plans for dealing with anxiety start out well, but then the child loses faith. The temptation to quit blossoms, and soon the child gives up on her plan. A number of scholars have shown that those people who believe in God or some other higher power or supernatural force such as the Great Spirit are more likely to persevere when the going gets tough. Anxious children are especially prone to the problem of "throwing in the towel." We will offer a variety of paths your child can take to help her have faith in herself, her plan, and her "higher power." Among these paths is a new one about which we are very excited: techniques for designing your own family rituals, which, when faithfully attended to, are proving to be powerful anxiety fighters.

Evaluating and Adjusting the Plan

Having faith in her plan is important, but what is critical to your child's success is making sure the plan really works. We recommend evaluation techniques to use both while the plan is in operation and after the plan has been carried out, so that you and your child can construct improvements. We suggest a number of ways your child can get objective feedback on the efficacy of her plan.

We have devoted a chapter to each of these four strategies. In these chapters, we offer activities that will help you and your child practice the strategy and see precisely how to carry it out. Some of these activities are for five- to ten-year-olds, some are for ten- to seventeen-year-olds, and some are useful for this whole age range. Why have we chosen these ages? We start with five-year-olds because we believe that our cognitive approach is too difficult for children younger than that. Many of our activities would be helpful for persons older than seventeen, but we assume that most of them will no longer be under parental guidance in their efforts to quell their anxiety problems.