by Michael D. Anestis, M.S.
There are several mental illnesses for which we have yet to develop particularly effective treatments. Anxiety disorders, however, do not fall within that unfortunate category. Empirically supported treatments (ESTs) with varying degrees of research support have been developed for every single anxiety disorder. We have exposure plus response prevention for obsessive-compulsive disorder, interoceptive exposure for panic disorder, cognitive processing therapy and prolonged exposure for post-traumatic stress disorder, cognitive behavioral therapy (CBT) for social anxiety disorder, and CBT for generalized anxiety disorder. One weakness in this area of relative strength, however, is that these treatments were all developed for adults.
Many clinical psychologists demonstrate a bizarre tendency to assume that children are simply miniature adults. They assume that mental illnesses in children mirror diagnoses in adults and, by extension, that the treatments that have been shown to work for adults will also work for children. In some cases, this assumption is backed up by empirical evidence. For others, this simply is not the case. Fortunately, there are many accomplished clinical psychologists who emphasize a developmental perspective of mental illness and treatment and who have devoted their careers to understanding the ways in which children differ from adults while developing treatments geared specifically towards the alleviation of childhood symptoms. Today, I would like to discuss one particular form of treatment that has emerged from this research - The Coping Cat 
- in hopes of providing readers with optimism regarding the potential positive outcomes for their anxious children.
The Coping Cat, developed by Philip Kendall of Temple University, is a treatment designed for children suffering from generalized anxiety disorder, separation anxiety disorder, or social anxiety disorder and is intended for individuals between the ages of 8 and 13. The program is based on a cognitive behavioral framework and typically lasts 16-20 sessions. The skills taught in the Coping Cat program are not fundamentally different from those taught in CBT for adults, but they are taught in a more developmentally appropriate manner that helps children relate to and understand the content.
Early sessions in the Coping Cat protocol center on teaching the child to identify situations that prompt anxiety and well as the manner in which he or she experiences that emotion. The therapist asks the child to describe a variety of situations in which she tends to become scared and then asks her to describe the different sensations she feels while afraid (e.g., stomach ache, sweating, dizzy). The therapist uses this as an opportunity to learn more about the types of things that frighten that particular child and to develop a rapport so that the child feels comfortable and confident in the therapeutic environment. Additionally, this is an opportunity for the child to begin learning how to identify anxiety at its earliest stages, increasing the likelihood that she can enact strategies to keep it under control.
The next step involves the construction of a fear hierarchy, which we have discussed in prior PBB articles. A fear hierarchy is a rank ordered list of situations that prompt anxiety, with less fear inducing situations listed at the bottom with a lower score and high fear inducing situations listed at the top with a high score. This list will be used later in treatment during behavioral exercises.
The child is next taught how to relax outside of session. Relaxation exercises, including focused breathing and progressive muscle relaxation, are taught in session and the child is given an audio tape to keep with a description of the exercises. The child can use the tape as a guide as he practices using relaxation when he first notices signs of increased anxiety.
Once the child has become adept at recognizing signs that she is becoming anxious and situations that tend to elicit anxiety and has practiced various relaxation exercises, the focus of the therapist shifts to teaching cognitive skills. Specifically, the child is taught to identify "anxious self talk." Anxious self talk is defined as automatic thoughts, prompted by physiological and environmental signs of anxiety, that cause increased severity and duration of anxiety. For instance, when a socially anxious child sees a stranger and feels his heart rate increase, he might think "this person thinks I am stupid." That thought, in turn, will increase the severity and duration of the child's anxiety. To counter this, the child is taught "coping self-talk."
If you have read our earlier articles on CBT in adults, you might recognize this as the basic structure of cognitive restructuring. In fact, this approach is absolutely based upon cognitive restructuring, but it is adapted in an ingenious manner that allows children to better understand the concept. Generally speaking, children have a difficult time naturally identifying their own thoughts and challenging them with evidence. The Coping Cat addresses this by presenting the child with a series of animated cartoons in which a cat encounters potentially anxiety provoking situations. In these cartoons, there are several blank thought bubbles. The therapist can thus teach the child to identify and challenge thoughts by first asking the child what she thinks the cat might say or think in a given situation.
The remaining portion of the Coping Cat treatment protocol revolves around exposure exercises. If you have read prior PBB articles on anxiety, you have likely learned that exposure exercises involve the client being presented with images or situations that induce fear and remaining in the presence of the feared stimulus until discomfort subsides, frequently challenging anxious thoughts as they arise. In the Coping Cat, as in any exposure protocol, situations are chosen from the lower end or middle of the child's fear hierarchy. As such, the clinician is never asking the child to confront something that will induce panic. The child repeats exposure exercises until the situation no longer induces fear. At that point, items that were previously higher up on the list generally sink towards the middle and become ideal targets for behavioral interventions.
Throughout treatment, the child is taught to acknowledge her own efforts towards treatment and to reward herself for engaging in practice and in exposure exercises. In this sense, the focus of treatment is on accomplishments rather than failures and the positive reinforcement increases the child's motivation to engage in the protocol and, as such, attain the maximum benefits of treatment.
The Coping Cat represents the clear benefits of child specific research. The basic structure of treatment - the various components of CBT - remain similar to those used in the effective treatment of adults, but the details are altered in a manner that increases the likelihood that a child will relate to, understand, and engage fully in treatment. The end result - empirically supported treatments for mental illness in children - is invaluable.
If you would like to learn more about the Coping Cat, we recommend browsing the Promising Practices Network website. I recently discovered this site, which summarizes research on treatments for children, and found that they have provided a strong summary of this particular treatment. Additionally, we recommend consulting our online store and the following resource:
- Coping Cat Workbook, Second Edition (Child Therapy Workbooks Series)
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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