is CBT the best therapy approach for my anxious tween?
February 24, 2016 8:49 AM   Subscribe

I want to get my girl some help. Help me figure out how to evaluate therapists for her? And if you were or had an anxious teen or tween who learned tools that helped, what were they?

In the last few months my 10 year old girl has been experiencing escalating anxiety issues that have escalated to physical panic attacks. It's been bewildering and traumatic to all of us -- while her dad and I do both experience mild anxiety occasionally, this is the first time any of us have seen the can't-stop-screaming, fighting-for-breath thing that my girl has had*. I need to get her some help. I've read that CBT is a good option; anyone here seen that work with a young person? Anything else I should consider? How should I evaluate the options and the professionals? There are so many acronyms and I don't know what they mean in practice.


*she is also alarmed and confused by what is happening; this is a classic older child who has always been even-tempered, high achieving and eager to please.
posted by fingersandtoes to Health & Fitness (26 answers total) 2 users marked this as a favorite
Best answer: You don't mention it, so I want to say that for other things you should consider: medication. It was a completely life changing godsend for my sister when she was in middle school (and for me when my anxiety did similar things when I was 30)
posted by brainmouse at 8:58 AM on February 24, 2016 [6 favorites]

Best answer: You should start with a referral from her paediatrician.
posted by DarlingBri at 9:13 AM on February 24, 2016 [2 favorites]

Best answer: CBT didn't help me because I was so anxious about the CBT itself, was afraid I was doing it wrong, was over-thinking it, etc. Once I had the right medication, I got a lot out of CBT. It's a great therapy and IF your daughter isn't helped by it, consider that she may be overwhelmed and need some meds.
posted by wryly at 9:43 AM on February 24, 2016 [1 favorite]

Best answer: Hi! Former anxious tween, now anxious adult with generalized anxiety disorder plus a bunch of other stuff. The thing that would have really helped me as a tween would have been CBT plus a psychiatrist to evaluate whether or not I needed medication (which in my case I did but never got). Having both someone to talk to and someone to look at my brain chemistry is the right mix for me since I also have panic attacks and was the eager to please, even tempered child that no one realized had a full on anxiety disorder plus bipolar and OCD. I don't bring this up to scare you, but rather to encourage you to not discount the value of having a psychiatrist on the team along with a CBT trained therapist and her existing primary care physician. Those three minds out together can help figure out a holistic health plan so your daughter can get the care she needs.
posted by Hermione Granger at 9:52 AM on February 24, 2016 [1 favorite]

Best answer: CBT is certainly a good thing for learning emotion management and processing, but yes do start with a medical doctor.

What you can do in the meantime while all that happens is poke around on the internet and see if you can identify if there's a counseling group/practice or individual counselor in your area that specializes in children or comes recommended by parents or resource groups.

My normal suggestion for adults, especially those who may need to feel a sense of familiarity to get over their fear of therapy/the unknown, is The Anxiety and Phobia Workbook. It looks like The Anxiety Workbook for Teens [many of the reviews complain it skews a little young for actual teens, so don't let the title scare you] is the preferred workbook for non-adults, and for 11 bucks might be a great way to let her kind of get some CBT 101 under her belt in private, to give her some reassurance and vocabulary and a sense of control. (And there are some other books in that series that are also highly rated and look really interesting.)
posted by Lyn Never at 9:53 AM on February 24, 2016

Best answer: Also -- sometimes anxiety has absolutely no cause. It just takes over and while certain things can exacerbate it (i.e. stress at home or school, pressures to be perfect and a high achiever) it can also just manifest and be omnipresent in a person's life. Don't tell your daughter she has nothing to be stressed about (which you might, because it's a natural first response to try and assuage her fears) because it may leave her feeling defective or guilty if her anxiety exists without cause. Thank you for seeking treatment for her; she is lucky to have parents who are willing to address this asap.
posted by Hermione Granger at 9:57 AM on February 24, 2016

Best answer: I'll preface my comments by saying this comes from someone who has experiencing parenting a child with a diagnosed anxiety disorder, but who does not suffer from anxiety herself. CBT for a long time has been the "gold standard" modality for depression, but for anxiety there appear to be several therapy modalities that work and for panic disorder specifically there are other tools that come into play. I would therefore focus on finding someone who has anxiety as a core focus of their practice and can bring a variety of therapeutic tools into practice rather than looking for a specific treatment modality such as CBT. If you look at their practice profile on Psychology Today, for example, they may use a term like "eclectic" to describe their approach. Obviously you also need to look for someone who works with children as a significant portion of their practice.

Finally, in my experiencing becoming an educated parent is as critical or more critical than the therapy relationship in the process of helping a child cope with anxiety. Look for someone who is able to work a lot with you as a parent so you can learn the most effective and supportive ways to respond to your child's challenges and triggers. I consider myself a fairly well educated person when it comes to mental health issues and a sympathetic, supportive parent, but because I don't have issues with anxiety myself I spent YEARS learning how to more effectively parent an anxious child--often times the right response runs counter to "standard" parenting advice and instincts.
posted by drlith at 10:31 AM on February 24, 2016 [3 favorites]

Best answer: My psychiatrist pointed me towards these workbooks to go through between sessions, and as someone with anxiety I found them to be helpful to work through on my own. They're focused at a general level and should be accessible to a teenager, specifically the books: Facing Your Feelings, Panic Stations, and What? Me Worry?
posted by the uncomplicated soups of my childhood at 10:33 AM on February 24, 2016 [1 favorite]

Best answer: CBT most certainly does work for young children/teenagers. I'm surprised by seeing so many here jump to medications for anxiety -- anti-anxiety medications may actually interfere with the learning processes that CBT depends on, so careful with that. Note that I'm not anti-meds in general, and meds+CBT for depression is a different story.
posted by Bebo at 10:50 AM on February 24, 2016

Best answer: If you go the CBT route, the most important advice that I have is that it takes time to work. Basically, CBT is an active process that modifies the subconscious process. To be quite forward about it, in my own CBT practice, the result has not been removal of the NATs (negative automatic thoughts) but rather the instant replacement of them. Perhaps a useful way of thinking about CBT can be as an immune system response. It doesn't prevent anxiety, what it does it to counter it. Through dedicated practice, one can nearly reduce the distance between a NAT and an RR (rational response) to infinitesimal, however he prompting thought may always be there. These days, it's a bit of a game -- to watch the NAT arise and then watch the RR come immediately. Like a macrophage.

The point for your daughter is that, inprovement comes from the practice, and it takes time. It takes months / years but it does work and it's an amazing life skill -- for you can take it beyond NATs to negotiation, interpersonal relationships, etc. She must do it, and the results will come. It's like piano.
posted by nickrussell at 12:49 PM on February 24, 2016 [1 favorite]

Best answer: Oh my gosh, as an anxious child I was punished for my feelings which made it so much worse, so I think you being amazing and helpful just by starting the process and being understanding and the trust you will build by not being negative about this will help.

CBT most certainly would be a good place to start, and I also suggest looking into DBT, which I have found more helpful for my anxiety. DBT focuses on self soothing, mindfulness, and meditation and helps when you are too far gone to think rationally (like with CBT).

Or maybe just a little relaxing yoga/meditation class, I have found those to be very helpful as well. When I was a kid I actually channeled my feelings into becoming a competitive runner, and exercise helped, with a mindfulness component it would have been even better.
posted by cakebatter at 12:49 PM on February 24, 2016 [1 favorite]

Aside from CBT, mindfulness, relaxing techniques and grounding will help your child get out of panic attacks. Counting breaths aloud with your child, practicing meditation and yoga, focusing intently on an object or objects, creating a mantra that is calming for her (mine is ptsd related. So it's I'm 30 years old live in Chicago and I'm safe), that she can repeat during attacks. Feelings are just feelings.

CBT will be helpful, DBT is focused on people with wide variations in intense emotions, which may or may not be helpful for your daughter.

One day at a time. Also remind her that you love get no matter what terrible things she might think will happen.
posted by AlexiaSky at 1:08 PM on February 24, 2016

Response by poster: I read that a typical CBT course is a limited term engagement, not open ended like psychotherapy. Nickrussell, your comment mentions months/years of practice - do you mean that one practices on one's own, or did it take you years of engagement with a CBT therapist to learn the skills?
posted by fingersandtoes at 1:11 PM on February 24, 2016

Best answer: Many psychotherapists use CBT in long term therapy. But true CBT is shot term and very structured. Most people use a mix.
posted by AlexiaSky at 1:14 PM on February 24, 2016

Best answer: DBT is definitely worth looking into! The mindfulness, distress tolerance, and emotion regulation units were super helpful for me. I also found having a very structured environment (workbook and homework included!) to be useful, although depending on your daughter's temperament, that might add more stress. Starting off with a practitioner who has a focus on anxiety issues and working with children is the way to go.

Also, I know you're not asking for specific tips, but as a stop gap measure, I just wanted to mention that when I used to experience panic attacks or some combination of hyperventilation and/or uncontrollable crying, the one thing that helped without fail was sticking my face in a bowl of ice water.

That may sound strange, but apparently it activates some sort of vasovagal response (or something like that). It was recommended to me by a psychologist, and I used it as a method of last resort, but when I really needed to rein things in, it worked even when nothing else did.

It's pretty self explanatory, but basically fill up a bowl with cold water and ice, and dunk your face in there for a few seconds. Repeat as necessary.

This isn't a long term coping strategy, and it doesn't really "fix" anything, but maybe it will help you daughter while you're working on getting more effective treatment.
posted by litera scripta manet at 1:16 PM on February 24, 2016 [2 favorites]

You need to know why she's doing it before you can decide how to fix it.

I think first things first, you need to take her to her pediatrician to ensure this isn't something physical. Once you get the all clear from them, then she should get some type of psychological evaluation so you can make an educated decision about the type of help she needs. Going from 0 to being unable to stop screaming is something you really need to have assessed.

I understand that you and her dad both have anxiety, but it's a mistake to automatically assume that she just has a bit of what the two of you have. It could be something entirely else. Again, before deciding what type of therapy she needs, you'd be better off getting a handle on what the issue actually is.

My credentials: special ed teacher specializing in teens with emotional disabilities and parent of kid with OCD (who did really well in a 12-week CBT program).
posted by yes I said yes I will Yes at 1:23 PM on February 24, 2016 [1 favorite]

*Sorry, forgot to mention a trick but again, I think you need to have her assessed to find out why she's doing this.

When she's escalating and losing the ability to calm herself, she needs to do something that forces her to pull herself out of the anxious part of her brain and FORCE her brain into the rational part. The trick is in FORCING her brain to actively do something rational.

She needs to have a deck of playing cards that she keeps with her. When a moment starts, she has to get out the cards and start naming them, i.e. "Red Queen, black two of clubs, red three of hearts," etc. for as long as she needs to.

If there's no deck of cards, then she needs to start counting whatever she can that she can see. Leaves on a tree, dishes in the pantry, anything. It's not enough to focus on the breath or pretend to blow out a candle; what she needs to do is to force her brain into doing something rational.

Seriously, try the playing cards. It is an amazing strategy.
posted by yes I said yes I will Yes at 1:31 PM on February 24, 2016

Response by poster: my assumption has been that assessment would be step 1 of any legit treatment; is that incorrect?
posted by fingersandtoes at 1:36 PM on February 24, 2016

my assumption has been that assessment would be step 1 of any legit treatment; is that incorrect?

Not entirely correct, no. A good therapist or CBT practitioner will do an intake to find out what's going on, but with the symptoms you're describing you'd be well-served to get a full neuropsychological assessment done. That takes several hours and it gives you a lot of answers.

I just wouldn't jump ahead into ways to solve a problem without knowing what the problem is. That's done by a full neuropsychological assessment.
posted by yes I said yes I will Yes at 1:50 PM on February 24, 2016

Best answer: A good LCSW can do an assessment just fine most of the time, and escalate to a neuropsycholgist if needed in my opinion. Neuropsycholgist testing is more expensive and usually not covered by insurance without a referral. It does provide some insight that an LCSW won't see. If she's looked pretty neurotypical until this point, and LCSW or equivalent is generally the appropriate first referal.

Ultimately this is going to require lots of communication from your daughter about what is happening in her head to get a full understanding.
posted by AlexiaSky at 2:02 PM on February 24, 2016 [1 favorite]

Best answer: Sorry for posting so much:

Some things to conccider when looking for an adolescent therapist is enviroment. It is more playful and childlike or serious, your daughter may do better in one enviroment over the other.

There are weekly appointments usually, so someone with good hours or works with her school would help logistically. Her school may offer services.

Your daughter will have preferences, she may like a younger more energetic therapist, over a matronly type. She may not want a female therapist. You will have to listen to get to see if it is working with her once she starts. A group practice that has a seperate family therapist in the same office be helpful if you want that in addition. A psychiatrist in the clinic is really useful as well, but pretty rare.

Most adolescent therapists are going to be competent in tween anxiety, it's common and very treatable. But there's are elements to therapy that are just 'a good fit'. Those things your child should tell you.
posted by AlexiaSky at 2:22 PM on February 24, 2016

Best answer: Please, please be aware that CBT is not for everyone. If your daughter does not want to do CBT, please don't make her do it. CBT does not work for me, and I had a hard enough time pushing back against it as an adult with agency. I am horrified to think about what might have happened if I had been a child with a CBT therapist.
posted by Violet Hour at 3:34 PM on February 24, 2016 [1 favorite]

Best answer: A cold wet washcloth on the face a physiological reflex and helps manage the attack. When I used to have panic attacks, I carried a washcloth in my bag.

It's the Mammalian Dive Reflex, and it also helps me manage tachycardia.
posted by theora55 at 4:53 PM on February 24, 2016 [1 favorite]

Anxiety sufferer here, popping in mostly to second the "don't discount medication" answers.

I'm in an online CBT program (Joyable, specifically for social anxiety, though I also suffer from generalized anxiety) right now, and getting some small, incremental benefit from it. I think it's worthwhile, but at least so far, it hasn't been night-and-day. The citalopram my doctor prescribed, however, has been night-and-day. It's what stopped me from having frequent panic attacks, and CBT is what I'm trying to use to prevent feeling needlessly anxious now.

Of course, that was my experience as a ~20-year-old male, which obviously might not translate well. The thing I'd convey to her is that there are a ton of options out there—myriad medications, therapies, and coping techniques. It might take a few tries to find what works for her, but there's something out there that will help. When I first left my doctor's office, prescription in hand, I started crying out of happiness. It was this huge relief to realize that what I'd been experiencing was a recognized medical condition, that there were treatments for it, and that nothing was "wrong with me."
posted by fogster at 10:26 PM on February 24, 2016

Best answer: Sometimes I find it helpful to think of therapy as a course in coping mechanisms. You find a practitioner who specializes in a set of coping mechanisms, you go to a few lessons to see if those work for you and if you like the "teacher", then you either keep going to lessons or you find someone else that clicks better. Your child will probably need to try a couple different "courses" (therapists/disciplines) over her lifetime and she will need to learn to manage these shifts so please don't be scared to switch if she is not getting what she needs.

The type of therapy your child needs will depend on her particular type of anxiety, her triggers, and what coping skills she is lacking (not in a checklist kind of way but in a "this coping skill actually helps but I do not know how to do it" way). I'm pretty sure CBT helps figure out some of these and with that information, you/she will be able to make more informed choices moving forward. Also, if your child has certain things that help her feel safer in therapy or open up more (fidgeting, not making eye contact, a specific toy, roleplaying etc) do consider asking the therapist to accommodate your child.

Anecdote: I was a very cerebral kid/teen and I found CBT to be moderately helpful with panic attacks but not so much help with more general anxiety (I was older than your daughter). So much of my anxiety was based on narrow definitions of acceptable/good so CBT just... gave me new definitions to stick to. It would have been helpful to have a space to get messy, have less rules, and not worry about what grade I was going to get at the end/whether I had done it Right, so I probably would have benefited a lot from art therapy in addition to the CBT.

tl;dr: CBT is a good enough starting point but if it's not resonating with your kid, do consider other approaches (also please don't be scared of medication, it exists for a reason and I found it necessary while I was in school all the way through grad school). In my experience, therapy only works if the patient is willing to be there. Good luck!
posted by buteo at 8:56 AM on February 25, 2016

Best answer: My 10 year old daughter is currently on Prozac for her anxiety and it has helped tremendously. In retrospect, she had always had issues with separation and General anxiety, but it began to spiral last summer. She would get sick to her stomach and vomit frequently, have trouble breathing, cry uncontrollably. There had been some changes to her regular routines that year, but nothing that we could point to and say “This traumatized her and we need to find a way to work through it.” After some work-ups with her Pediatrician to rule out medical issues, we began to see a therapist through our County Health Clinic. We live in a rural area, so shopping around for doctors isn’t an option. Over the next few months we tried many of the above suggestions recommended here on Metafilter or by her therapist or the school counselor. She resisted all of them. I tried to teach her breathing exercises to manage her panic attacks, and she just could not settle down to do it, she would get even more upset. She was often upset about the fact that she knew we were upset, and didn’t want to be making trouble for us!

Now that we’ve had the Prozac for a few weeks, I finding that I can finally try some of the methods again, because she is generally happier and more able to manage her emotions. We’ve gone a whole week without tears on the way to school! (I’ll just ignore the fact that the last two days were snow days.)
posted by saffry at 10:03 AM on February 26, 2016

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