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The Role of Parents in Treating Anxiety Disorder

An Excerpt from Anxiety Coach: A Parent’s Guide to Treating Childhood Anxiety and OCD
Stephen P. H. Whiteside, Ph.D.
Stephen P. H. Whiteside, Ph.D.

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As a parent, guardian, or caregiver, you play an essential role in the treatment of your child’s anxiety. According to the American Psychological Association, during exposure therapy, psychologists create a safe environment in which to “expose” individuals to the things they fear and avoid. The exposure to the feared objects, activities, or situations in a safe environment helps reduce fear and decrease avoidance. Exposure therapy is hard work, and central to our program is a belief that all children will be more successful if they have an exposure coach at home to support them. In this chapter of Anxiety Coach: A Parent’s Guide to Treating Childhood Anxiety and OCD, we’re going to outline what you can do to help your child successfully master anxiety and OCD.

Anxiety Coach cover

Parents’ roles certainly change as kids get older, and with different levels of child cooperation, but all parents will likely benefit from being aware of each of the concepts discussed in this chapter to help exposure therapy be successful.

Treatment in our clinic is based on the idea that parents are an essential part of the process. And this is true from the very start, when parents identify that something is going on with their child that might need to be addressed. I could probably count on one hand the number of times families have said that the child asked to see a therapist. The vast majority of the time, parents notice the problem and decide to seek help on their child’s behalf. To me, this illustrates how fundamental a parent’s perspective is to treatment.

This means that parents’ opinions and insight need to be included when deciding if a child’s symptoms are an anxiety disorder, applying the avoidance cycle to a child’s experience, or planning an exposure. Of course, we need to include and listen to the child’s perspective of their own experience too, but typically the parent’s perspective is just as important. This is not surprising with young children, since we would not expect a seven-year-old to have the ability to accurately recall their feelings and behavior and judge the degree to which it differs from their peers’.

The same can also be true of teenagers, who may feel embarrassed or overwhelmed by their anxiety and prefer to downplay its importance or impact on their lives. In those cases, even though parents may have limited opportunities to observe their teen in the moment, such as during social interactions, parents often recognize the signs of isolation, withdrawal, and avoidance of activities as well as their impact on their teen’s wellbeing.

The bottom line is this: Your perspective as a parent is important and you play an important role in gathering information about your child’s anxiety. If you think something is a problem or sets off your child’s anxiety, make sure it gets added to the exposure plan, even if your child disagrees.

BECOMING AN EXPOSURE COACH

An essential role for parents is to give their child warm support and encouragement. As parents, we know and embrace this, but we also know that parenting is hard, and we sometimes get stressed, irritated, and overwhelmed ourselves. This is especially true when our child’s anxiety makes daily life harder and causes us to worry about their future. It’s challenging to provide calm support when we are nervous that our child won’t be able to handle an exposure and have a nagging doubt that it might make things worse. And if you get frustrated doing exposures, your child may pick up on it and get frustrated too and the process can be quickly derailed. Our goal as parents is to do our best to remain calm, warm, supportive, and serve as our child’s cheerleader.

We opened this chapter reminding ourselves that exposure therapy is hard work. Most likely, kids, especially younger ones, are going to need parental help and guidance understanding what an anxiety disorder is, figuring out how it applies to them, and making a plan to fix things. Part of your job will involve helping them along. Even if you are working with a therapist, you will probably meet with that person at most one hour a week. That leaves a lot of time where you are the main source of support. At our clinic, we always work with kids and parents together for the entire session, all the time. So, if you are able to find a therapist to work with, I encourage you to ask to be involved in your child’s care.

Keeping in mind this commitment to being active, warm, and supportive, a parent’s new defined role in our anxiety treatment is as an exposure coach. On the first day of our treatment program, I explain to families that it is our responsibility as therapists to help them, kids and parents, do exposures during appointments, so they can learn first-hand how to do them. And then, it is the parents’ responsibility to help kids do exposures between appointments. Eventually, it’s the child’s responsibility to do exposures on their own, but parents actively coach their kids though exposures until kids can do them independently.

THE MOTIVATION PLAN

If you are going to be responsible for making sure exposures get done, then you are going to need some tools to do that. We already know that exposure therapy is hard work and mastering anxiety or OCD can take a lot of practice. Add on top of that, the prospect of feeling better in a couple months is lousy motivation for working hard right here, right now. We can pretty much guarantee there will be times when your child won’t want to cooperate. At our clinic, we follow four strategies we call the motivation plan, that parents can use to help kids stay motivated. As always, the way we do each of these looks different for a seven-year-old versus a 17-year-old, but the principles are the same.

Small steps.

If Michael’s mother were to hear the explanation of exposure therapy and say, I get it. Michael simply needs to face his fear. I’ll take him to the dog park, throw him in, and he can come out when he is no longer afraid of dogs, it would not go well. Michael would be terrified, argue with his mother, and not be open to any new learning. Instead, he and his mother need to make a plan to start easy and take small steps. Kids generally make the best progress when each exposure pushes them to do something a bit harder than the exposure before. When activities become too hard or move too quickly, kids are more likely to push back, get stuck, and stop making progress.

Ideally, parents and kids work together toward small steps. This can be done in two ways. First off, we make a treatment plan, often called a fear ladder, which is a list of ways to face a particular fear. It starts easy and gradually gets more challenging; in the next chapter, we’ll learn how to draw one up. Second, each exposure is planned together. This is usually somewhat of a compromise. Parents are often excited about their child overcoming anxiety and returning to normal life, so they want to progress as fast as possible. Kids on the other hand are often feeling nervous and want to take things slow. Our goal is to find a pace that parents can be patient with, and kids can accept.

When planning exposures, remember to balance being warm and accepting with being firm and active. Exposure therapy goes smoothly when we let kids take the lead making a list of activities to work on and choosing a next step that feels manageable. However, we are not helping our child if we sit passively by while they leave out important fears. Don’t make a decision, or choose the same activity over and over without progressing. So, in the end, parents are in charge of making sure a complete fear ladder has been drawn up and that it captures all the fears that need to be addressed. If kids can’t or won’t decide what to do for the next exposure, you as the parent must take the lead and decide for them.

Praise and ignoring

Our attention as parents is an important part of the avoidance cycle that keeps kids stuck in anxiety, and it is also a powerful tool for treatment. When kids are anxious or upset, they look to us for help. That’s a natural human response. When our kids are anxious, we as parents love to swoop in and fix things, which is also a natural human response. However, when a child’s fear has blown up into an anxiety disorder, then parents soothing and fixing things becomes a form of avoidance that maintains anxiety and distress. And if parents don’t respond quickly enough when kids are anxious, kids will typically ramp up their anxious reaction until they succeed in convincing us that they need our help. Over time, this can lead to kids acting more and more anxious as they understand it is the most effective way to receive our assistance.

As a rule of thumb, if you pay attention and help your child, whatever your child did to get that help, they will do it again. If your child gets help when they appear overwhelmed with anxiety, they will become overwhelmed with anxiety to signal that they need help. If your child gets your help when they are calmly trying to face their fears, then they will do so again in the future.

One of our jobs as a parent is to use attention and support to encourage calm cooperation. When your child is working with you, picking an activity for an exposure and cooperating with that exposure, give lots of warm support, affection, and encouragement. However, if your child is acting overwhelmed by anxiety and whining, complaining, being obstructive, or getting angry, it is best for you to walk away until your child is ready to cooperate.

Removing attention because your child is not cooperating when they are clearly anxious and upset is really hard to do. That’s why we start with small steps. If you feel confident that you have done your best to identify a small, manageable step, it makes it a little bit easier to walk away, especially if you remind yourself that as soon as your child is ready to work, you will give them your full warmth, support, and attention.

Set goals and reward progress

With the true pay off from exposure therapy often waiting months down the road, it helps if parents work with their children to create a plan of short-term goals and rewards for success. These goals should focus on things under the child’s control, primarily cooperating and completing exposures. Your child can’t control how they feel, and they can’t make themselves feel calm in a feared situation, so we should avoid goals such as we will go on a shopping trip when you are no longer afraid to order your own food. Rather, set goals such as doing five or 10 exposures. With younger kids this can be set up like a traditional reward system. Every time they do an exposure, they earn a point, and you can set levels of points to do fun things, like get ice cream, stay up later than normal bedtime, go to a basketball game, pick a prize, or take a trip to the zoo. With teenagers, it might go over better to approach it collaboratively like SMART goal setting. This is more self-driven and involves setting personal goals that are Specific, Measurable, Achievable, Relevant, and Time-Bound. In the end, the goal of either approach is to reward your child’s hard work and celebrate progress.

Consequences

The fourth component of the motivation plan is to bring in mild consequences when your child refuses to do an exposure. Exposures should be treated like schoolwork: If kids haven’t finished their homework, fun activities like TV, gaming, and friends are placed on hold until homework is done. Similarly, if your child hasn’t completed an exposure, then they lose access to electronics, seeing friends, or other fun activities until the exposure is done. If you remind your child it is time for an exposure and they angrily refuse, rather than engaging in arguing or negotiating, you should ignore them and remove your attention. However, if once you walk away they start playing video games, the exposure will never get done. So, in addition to not arguing you can remind them, It is your choice to not do the exposure, but remember there are no fun activities until it is done. Then you walk away, they get bored and figure out they should do the exposure to have their privileges returned; they do the exposure, and your day gets back on track. This is a lot easier said than done, and it is fair to say that we spend a good amount of our time in the clinic helping parents put a motivation plan in place.

Parents can also use what I like to call therapeutic consequences. These fit nicely when kids have advanced to doing on-the-fly exposures.

The Role of Parents

A therapeutic consequence means if a child refuses to do a reasonable exposure, they will be expected to complete two planned exposures at a later time. So, if Maria refuses to order her food at the restaurant for fear of making a mistake and insists on reverting to her parents doing it for her, she will be required to call restaurants and ask what time they close as a first exposure and then undertake a second exposure of asking directions in public.

Therapeutic consequences serve two purposes. If the situation is actually too hard, then the child can benefit from additional exposure practice to reduce anxiety and build confidence for the next time they are in that situation. And also, if kids are deciding to be resistant, the prospect of two rather than one exposure can help them make a better choice in the moment.

Your motivation plan will likely include each of these four aspects. Once the plan is in place, if your child is reluctant to complete the next small step of an exposure, you can remind them of their progress toward their next reward and that they will experience a consequence for refusal until the exposure is complete. This allows you to remove attention from resistant behavior and let the prospect of a consequence convince the child to cooperate, rather than resorting to arguing or pleading with your child.

About The Author
Stephen P. H. Whiteside, Ph.D.

Stephen P. H. Whiteside, Ph.D., is a board-certified clinical psychologist, professor of psychology at the Mayo Clinic College of Medicine and Science, and director of the Pediatric Anxiety Disorders Program at Mayo Clinic in Rochester, MN. His latest book is Mayo Clinic Anxiety Coach: A Parent’s Guide to Treating Childhood Anxiety and OCD.

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