ACT for Anxious Children,
Adolescents, & Families
Lisa W. Coyne & Elizabeth Davis
Suffolk University
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.
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.
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
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
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
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 selfdirected/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
ACT Question
are you willing to
have that stuff, fully
and without defense
Contact with the
Present Moment
Acceptance
if the answer
is “yes” that’s
at this time, in this
situation?
Values
of your chosen
values
Psychological
Flexibility
AND do what takes
you in the direction
Defusion
as it is, and not as
what it says it is,
Committed
Action
Self as
Context
Given a distinction between you
and the stuff you are struggling
with and trying to change
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.
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
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
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
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
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
Values & Commitment:
Walking the Line
There Be Monsters!
Experiential Avoidance
Valued Direction
Whenever one moves in a valued direction,
avoided experiences show up!
Monsters on the Bus
• Role Play
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
Experiential Exercise
• Mindfulness Practice (5 minutes)
Defusion
• Exercise: Introductions!
Willingness & Commitment
• Behavior Change Processes
▫ Making life about living values
▫ Not about eliminating pain
▫ Pursuing values brings child into contact with
fears
Case Illustration
• 11 year old European American female
• Presenting Problems:
▫
▫
▫
▫
▫
Benign Rolandic seizures
“Anxiety”
Bullied at school
Social isolation
Inappropriate social behaviors
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?
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
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.
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?
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
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
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
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
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
Values & Commitment:
Walking the Line
There Be Monsters!
Experiential Avoidance
Valued Direction
Whenever one moves in a valued direction,
avoided experiences show up!
The Secret?
Experiential
Avoidance
Valued Direction
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!
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