Kenneth P. Sullivan, Ph.D.
The Anxious Child:
In many families there comes a time when a child develops a problem with anxiety and fear. The child cannot sleep alone, or cannot be alone in a room, or cannot make a purchase in a store alone. The parents' efforts to reassure or to be firm with the child do not put the problems to rest. Sometimes, the children are found to also have some obsessive symptoms, such as counting things or ruminating.
Fortunately, this type of problem can be remedied. A combination of treatment methods is applied to address the underlying concerns, build confidence of the child, focus the child on the task of fighting the fear, provide tools to accomplish the task, and finally, gradually expose the child to the fear in a manageable fashion. This sensible psychological treatment for the anxious child has remarkable results.
The course of therapy goes like this.
First, we convey confidence that this problem can readily be solved. Children derive some security from that assurance.
Second, we address the child's fears. Almost always, children go to their parents' bed in fear that they may die, or that their parents may die. This should be discussed in a matter of fact tone, and with an acknowledgement that it requires bravery to face that fear. We need to ask and answer the questions: What happens if I die? What happens if my parents die?
Sometimes this fear is brought by some frightening event, such as a fire, a car wreck, a death in the family, a death of a pet, a divorce, or an illness. I ask whether this type of event has occurred, and we discuss it if it has. I also ask whether the child has felt strong guilt recently, because guilt also commonly triggers fear and anxiety. If the child has, we discuss it.
If no particular frightening event is reported, we acknowledge that sometimes children fear the possibility of death because they are sensitive, prone toward anxiety, or have a strong imagination. This stage of therapy serves to build some confidence in the child that we understand fear and where it comes from.
Only after the possibility and uncertainty of death is addressed honestly, can the child get comfort from the explanation that imminent death is so unlikely. Then we spend a little time talking about chances and probability: likelihood and unlikelihood. We discuss fire alarms, emergency procedures, and other safety precautions as well.
We reach the conclusion that the death or whatever other event the child fears is extremely unlikely, and the family is prepared just in case. The child gets some comfort from this acknowledgement, at lease in the clear light of day, in the therapy room, with the support of the parents.
Next, we turn to the fact that it is the fear that is hurting and threatening the child, not the danger. The child starts to see the possibility of fighting the fear, instead of fighting or avoiding the danger.
We introduce the idea of fear being like a bully, trying to get the child to do something, such as going into the parents' room and bothering them. Just like any other bully, the "fear guy" has fun pushing the child around. The "fear guy" gets more confident that the child will do what he wants, the more the child gives in and acts afraid. Like a schoolyard bully who wants to take your lunch money, if you give in one day he will be back the next day with a stronger expectation that you will give in. On the other hand, if you stand up to the bully and not do what he wants, he gets frustrated. Even if he tries on you again, sooner or later he will get so frustrated with you that he goes away and picks on somebody else, somebody easier.
This concept of fighting the bully "fear guy" helps to bring the child's good oppositionalism to bear on the problem, fighting the fear, instead of fighting the parents' efforts.
We want the children to face their fears and to learn from experience that no real harm occurs. Then the fear dissolves. We make this plan clear to the child early in therapy, but we postpone the time of confrontation, assuring the child that we will not ask him or her to begin until they have the tools they need to be ready. We also explain to the child that we are teaching a method to face whatever fear they have in the future, as well as the particular fear they suffer at present.
This leads naturally to a discussion of bravery. and the acknowledgement that one can be brave only when afraid. A model of bravery will be developed further, and utilized throughout the therapy.
After discussing bravery in general, we turn to the concept of the hero, who, of course, is brave. We can use an image of a soldier, Luke Skywalker, the child in the movie Home Alone, or any other hero who comes to mind. It is helpful to ask the child who he or she thinks is a hero, and to use that individual as an example to emulate. We emphasize that the hero is afraid, but does the right thing, afraid.
Whatever other hero we use, we also talk about the Detective who bravely investigates. We teach the child to investigate whenever he or she is afraid. The child is to ask, Am I afraid of something that is likely to hurt me soon? If so, fight the danger by running, calling the fire department, or calling the parents. If instead I am afraid of something that is not likely to hurt me now, then fight the fear.
We coach the child in methods useful to fight fear. Fear makes the heart race, and slowing the heart will reduce the fear. We explain that the heart rate and breathing are directly linked, so we can slow our heart by slowing our breathing, with deep breaths. We practice breathing together in the therapy room. We also teach muscle relaxation as a helpful fear reduction method.
Next, we discuss the various uses of imagery in fighting fear. Imagining a safe and relaxing scene can work. Imagining the parents safe in bed, dreaming about the child, can also help. More helpful though, is for the child to take the feared image, (e.g. a bad guy sneaking up), and change it even just slightly, (e.g. he is wearing a dress, or he steps on a banana peel). This can tickle the child and break him or her out of fear rapidly, and the child usually takes to it with some enthusiasm. We are conspiring together against the "fear guy", and boy is he going to be surprised and frustrated when the child pulls this stuff on him.
After giving the tools needed to fight fear, we turn to discussion of the necessity for the child to do this alone. We acknowledge together that it is harder when you are alone, and then we use imagery of the child facing fear alone, while we are sitting together in the therapy room. We acknowledge again that we are giving the child tools and helping the child prepare for a fight alone.
Finally, we turn to the actual process of facing and fighting the child's fear. This stage is an application of the old fashioned Desensitization technique, long established as the treatment of choice for phobias and fears.
The point is to expose the child to the feared situation only gradually. For this example, let us say the child is afraid to sleep alone.
We let the child decide ahead which night this is to begin. The child will be alone in his or her bedroom for fifteen minutes the first night. After that time, the child can go to the parents' room if he or she feels the need. But within the time in the room, the child must stay there no matter how afraid, and preferably, fight the fear. We allow that maybe the child will choose to have the time be only ten minutes. It is up to the child, but once we start this process, each day the time gets that much longer than the night before. Fifteen minutes the first night, thirty minutes the second, forty-five minutes the third, night after night fifteen minutes more are spent alone in the bedroom, before the child can give in to the fear and go to the parents' room. The time limit each night is written clearly near the child's clock.
Potential setbacks are discussed ahead. The parents are firm that they will not allow the child into their room until the time is reached.
I predict that we will not know, and the child probably will not know consciously, which night he or she will decide to fall asleep and stay the whole night. In about a month the time spent alone in the room will have gradually extended over eight hours in any case.
I have never had a child lying awake in fear for hours. By the time we reach this stage of therapy, the child is confident and ready. We continue to schedule weekly therapy sessions throughout that time to provide further support and to determine together which methods of fighting fear are helping the most. Once the child is sleeping through the night, we declare a success, and we cheer the child.
In concluding the therapy, we anticipate how the same process can be reused against other fears in the future, even without a therapist
The key to the success of this treatment is the preparation, rather than the desensitization technique itself.
© 2003 Kenneth P. Sullivan, Ph.D.