ACT for Anxious Children, Adolescents, & Families

1. ACT for Anxious Children, Adolescents, & Families Lisa W. Coyne & Elizabeth Davis Suffolk University

2. Why Pay So Much Attention to Anxiety? • 10-20% of school age children have anxiety symptoms. • Negative impact in multiple domains. • May not get noticed by adults. • High rate of comorbidity.

3. Course/Continuity • Retrospective studies: Half of adults with anxiety or depressive disorder report a history of anxiety disorder in childhood. • Prospective studies: Most childhood anxiety disorders remit by follow-up, but often replaced by other anxiety disorders or depression. • Significant, long-term impact.

4. Typical Developmental Fears • Transitory fears and anxieties are part of normal development. • 1st years of life  fears of loud noises, strangers, new places, heights • preschool age  fears of being alone, dark, animals, imaginary creatures • school age  fears of negative evaluation by others, illness/bodily injury, supernatural phenomena, natural disasters

5. What ACT wants to know about anxiety • Does it get in the way of stuff that matters to you? • Or, more specifically, does what you do about it stop you from doing stuff that you care about? • For young children, I ask this of parents • In cases of separation anxiety, and… • …selective mutism

6. Treatment Issues Unique to Children and Adolescents • Treatment can be taken out of children’s control – determined by parents/teachers • Involvement of parents in management/enabling of anxiety • Children are often embarrassed or defensive about symptoms • Children may appear oppositional instead of anxious • Children may be less skilled at using imagery/cognitive restructuring techniques that are typically used to increase motivation and treatment adherence

7. What ACT Might Offer Exposure • More fully elaborate the functions of anxiety in individual’s life through discussing workability/control strategies • Increase experiential participation in exposure/response prevention exercises through mindfulness exercises • Increase willingness to do more frequent/more self-directed/more “over-the-top” exposures through focusing on client values • Enhance generalization through encouraging more naturalistic exposure exercises outside of session and assist with relapse prevention through commitment exercises

8. Psychological Flexibility ACT Question at this time, in this situation? are you willing to have that stuff, fully and without defense of your chosen values if the answer is “yes” that’s AND do what takes you in the direction as it is, and not as what it says it is, Given a distinction between you and the stuff you are struggling with and trying to change

9. Special Process Issues with Children • Lack of control • Kids may not seek treatment willingly • Parents may want different things • Concrete goals vs. valuing behavior • Lack of generalization • Children think more literally than functionally • Show. Don’t tell. • Do. Don’t explain.

10. Setting the Context • The ACT therapeutic stance • Being present • Emotion is not the enemy • Client is capable of extraordinary things • Therapeutic contract • Therapeutic relationship/process • Useful metaphors • Mud in the glass • Mountain climbers

11. Establishing the Therapeutic Contract • Role Play: An example • Child vs. parent goals • Giving child choice • Practice (5 minutes) • Being present: Eyes on • Being vulnerable: State your value, and your limits • Being seen: Show up

12. Values: Making a Compass • Valuing: What do you want your life to be about? • I want to feel less worried… • Difference from goal-setting • Kids and material things • Identifying behaviors that take you in a valued direction • May only be able to identify • behaviors that DON’T • Learning the discrimination • Taught experientially • If something hurts, there’s a value there

13. Identifying Values • Role Play • Give us a client • Practice (5 minutes) • Shifting from symptom reduction to pursuing meaningful, valued “ways of being” • Exercise: Make your own compass

14. Identifying Obstacles • Functional Analysis • Identify “what shows up” • Painful/unpleasant content/private events • Thoughts, feelings, physiological sensations • Identify “what you do:” Way of Being • Current functions • Obstacles • Goal: Behavioral flexibility in presence of painful stimuli

15. Values & Commitment:Walking the Line There Be Monsters! Experiential Avoidance Valued Direction Whenever one moves in a valued direction, avoided experiences show up!

16. Monsters on the Bus • Role Play

17. Mindfulness & Acceptance • Mindfulness • Appreciation of experience without evaluation or defense • ANYTHING that involves interacting with the aversive event that is not avoidance • Contact with the Present Moment • “Showing up” • Acceptance • Allow self to have whole of experience when doing so fosters effective action • NOT simply tolerance

18. Experiential Exercise • Mindfulness Practice (5 minutes)

19. Defusion • Exercise: Introductions!

20. Willingness & Commitment • Behavior Change Processes • Making life about living values • Not about eliminating pain • Pursuing values brings child into contact with fears

21. Case Illustration • 11 year old European American female • Presenting Problems: • Benign Rolandic seizures • “Anxiety” • Bullied at school • Social isolation • Inappropriate social behaviors

22. Where do you start?

23. Assessment • Unstructured clinical interview, ADIS-PC, CBCL-TR • Functional Assessment of client behavior as reported at home and at school, as well as observed in session • Assessment of skills vs. performance deficit • AND…what is the stuff you care about? What gets in the way of that?

24. What questions do you ask? • I usually start with what they care most about • Whether or not they can tell me is important data • If they say, “to feel better”, I ask, “If you felt better, what would life look like for you?” “If I had a magic wand…” • Other ways to start • Say, “In order for me to help, I need your help first. I really want to know what it is like to be you, to walk around in your shoes. What’s it like to be in your skin?” • Be creative – trace their body on a large sheet of paper and label it • This helps identify thoughts, emotions, physical sensations • Outside body, can draw and label stuff they care about

25. What else do you ask? • If child is able to identify (or imagine) what it would be like to “feel better”, say, “What gets in the way of that?” • In academic, social, family domains • Ask, “When you are feeling badly, what do you do? How does that work for you – does it get you what you care about?” • At this point, don’t “explain” to the child – just restate what they have said • You are beginning to build a list of behaviors that belong to a functional class - they may look different, but have the same function • You are highlighting the child’s unworkable agenda and beginning the work of creative hopelessness.

26. Developing a Values-Based Therapeutic Contract • Core direction for treatment: What is it you care most about? • Things to listen for and “unpack” via functional analysis: • I want to switch schools • I want the bullies to like me/stop being bullied • I want kids to stop leaving me out • I want to feel less sad and lonely and worried and embarrassed • You need to fix me so I can have friends and feel less sad • There’s something wrong with my brain (seizures) • I know you can do it because you’re a great therapist • What value ties these all together?

27. Our Contract • I want to make and keep friendships where people see me and love me just as I am • I want to be a good friend to other kids • VERY IMPORTANT: Value is NOT to make friends to reduce loneliness/sadness/worry embarrassment/isolation • Such goals ALREADY organize client’s behavior in unhelpful ways • We “stand for” this contract with integrity

28. Acceptance/Mindfulness-Based Processes • Creative Hopelessness (Discrimination training about what is “workable” and “unworkable” – done as experientially as possible) • What have you been working on? How’s it going? • Control is the Problem (Helping client experience unworkability) • Monsters on the Bus

29. More Acceptance/Mindfulness-Based Processes • Defusion (Exposure to avoided internal experiences to “deliteralize” thoughts. Goal is change in psychological function of thoughts rather than content) • “This is the biggest loser I’ve ever met.” “This is my therapist who is an idiot and is not helpful at all • Self –as-Context* • Did not use • Same person as you were then/are now

30. Behavior Change Processes • Valuing (inherent in the therapeutic contract; discrimination training about when one acts values-consistent way vs. struggles) • Using Your Compass • Willingness (engendering an acceptant posture/openness/compassionate awareness of experience) • What if … • Committed Action (Identifying steps to take – experientially, didactically) • Going “North” • Skills training • Role-plays

31. Target Behaviors: Skills Training + Defusion • Responding to bullying: The “And?” exercise • Initiating conversations/peer entry skills • Being alone/being lonely • Socially appropriate behaviors • Asking for playdates, even after rejection • Discriminating between healthy vs. unhealthy friendships • Appreciating self in a non-evaluative, compassionate way

32. Values & Commitment:Walking the Line There Be Monsters! Experiential Avoidance Valued Direction Whenever one moves in a valued direction, avoided experiences show up!

33. The Secret? Experiential Avoidance Valued Direction

34. Assessment of Progress • Behavioral flexibility • “I feel powerful!” • Willingness to experience • “Can we do it again?” • Committed Action • Approaching feared situations in the service of one’s values • Symptom reduction/exacerbation • Congratulations – you are human!

35. Thank You! For slides or reprints please contact: Lisa W. Coyne Early Childhood Research Clinic (ECRC) Psychology Department Suffolk University 41 Temple Street Boston MA 02114 (617) 305-6363 Email: lcoyne@suffolk.edu Website: www.suffolk.edu