Anxiety is a huge issue with youth right now in America. So much so, that the U.S. Preventative Services Task Force is officially recommending all kids eight to eighteen be screened for anxiety at their pediatricians’ office! While it’s bad news that anxiety is so prevalent in our kids, the good news is that there are very clear research-based interventions we can use to support them. This blog post is all about anxiety activities for kids that are rooted in evidence-based practice.
One of the coolest studies I found while doing research for a conference workshop was on mapping evidence-based treatments. The researchers examined 322 randomized control trials for children’s mental health. They broke them all down into the different “practice elements” included; what were the actual strategies implemented, what were the pieces of the intervention, etc. Then, they mapped which practice elements appeared the most frequently in effective interventions for each of the main areas (anxiety, school refusal ADHD, etc.).
How does this help us? Well, many counselors don’t have access to those evidence-based intervention programs, or they aren’t a great fit for our students’ needs. So what we can do, is focus on those practice elements and implement them in our work!
Below I’m sharing the four most frequently found practice elements for anxiety and giving examples of how to use them with kids in school.
If you’re a school counselor or child therapist, chances are you already have lots of practice teaching kids about different relaxation strategies. It’s something we include in all three tiers of services, and something lots of teachers and parents are teaching and modeling as well. I won’t dive very far into this since this is probably already something you do, I’ll just share a handful of examples.
- Deep Breathing – I’ve always been a fan of star breathing/five fingers breathing/finger breaths, but seeing how my youngest (6.5 as I’m writing this) has connected with it has made me appreciate it even more.
- Grounding – One of the most common grounding techniques is basically getting in touch with your five senses (and maybe doing it as a countdown with your five fingers). As popular as this is, though, I rarely have students that connect with it. What they’ve gotten into more are things like “BBB” – find something big, something blue, and something beautiful. This is one of the relaxation strategies I use in the relaxation BINGO session of this CBT-based emotional regulation group.
- Progressive Muscle Relaxation – This is another super common relaxation strategy taught to kids. You may have even seen the script that talks about squeezing a lemon, feet in the mud, fly on your nose, etc. I think this strategy is great when a kiddo is with an adult coaching them and just helping them to become more relaxed in general, but it’s not a coping skill I’ve had many students ever choose to use on their own.
- Imagery – The cool thing about imagery or guided visualizations as a relaxation strategy is that it can be tailored to the child’s interests. Really, the sky’s the limit! It can be a gratitude practice, it can be visualizing a favorite memory, or it can be imagining themselves in a made-up land like one of the relaxation prompts in this Escape the Worry Spell game.
Many of our kids’ worries stem from or include unhelpful thoughts, so it’s no surprise that this is part of research-based anxiety activities for kids. Most are some form of “something bad might happen” or even “something bad will happen and I won’t be able to handle it.” Cognitive restructuring is becoming aware of our thoughts, challenging them, and changing them.
Some verbiage I recommend when helping kids identify their thoughts: “What were you thinking in your brain? What were you saying to yourself in your head?” I also like going through different thought examples with kids and asking them to decide 1) are they helpful or unhelpful and 2) what thoughts they have. In my CBT-based emotional regulation group, I do a session where students identify where they stand between two opposing thoughts and then also sort additional example thoughts.
Once the child(ren) you’re working with recognizes their own thoughts, there are a lot of different strategies you can use for challenging worry thoughts!
- Play thought detective to gather evidence for and against the thought
- De-catastrophize them by examining the best/worst/most likely scenarios
- Challenge the thoughts with questions like “Will this problem matter in an hour, a day, a week?”, “What would I tell a friend with this worry?”, and “What is another possibility?”
Spinner from this CBT group
Sometimes the act of challenging thoughts naturally leads to restructuring them into more helpful thoughts. Other times, you’ll need to spend some time directly generating and practicing positive self-talk. This might look like going through different self-talk statements and the child deciding how helpful they think they are or using self-talk to “defeat” worry monsters.
Both activities pictured above from this Individual Counseling Curriculum for Anxiety
If a child hasn’t ever seen someone positively or helpfully handle worry before, it’s harder for them to know what to do (and actually do it) themselves. Modeling can help!
- Use figurines or puppets to act out experiencing worry and using coping strategies
- You participate in practice activities (you as the counselor read and respond to scenarios, too!)
- Give parents and caregivers scripting to model coping with worry (eg. “I was nervous about getting my flu shot this morning, so I took some slow breaths and started thinking about our family movie night,” “It can be scary when there’s a tornado warning. I remind myself that we have a very safe place to wait it out.” etc.)
- Reading books that model coping with anxiety! (Blog post on these coming soon, but for now here are affiliate links for a few favorites: The Whatifs, I’m Worried, Way Past Worried, and Worry Says What)
What exposure looks like depends a lot on the child’s worries and the setting you’re working in. For those of us in schools, exposure is mostly likely to be imaginal exposure. That means we’re not putting the students into actually anxiety triggering situations, but instead using visualizations and role plays. Exposure might not be imaginal and might be real/in vivo for worries like raising their hand to ask or answer a question, asking to join in on play, not asking (or being given answers) about things like “who is picking me up today” or “when is….?”
One example of imaginal exposure is, after the student identifies their triggers, going back through them. Ask the student to imagine that thing has happened. What would they do? How could they cope? What helpful self-talk could they use?
Cards from this CBT group
Imaginal exposure can also happen through puppets or figurines! Ask the kiddo to pick out one that represents them, and then to pick one that represents another person or object related to something that makes them anxious. Then you act out the triggering situation with your student coping through it! Depending on the student, you might choose to play the role of them first to model what this looks like.
Here are some examples of how this might look:
- Teacher giving feedback or redirection: you pretend to be the teacher saying something like “You need to add more detail to your writing.” or “Voice off, Juniper.”
- Having to take a turn in front of the class in PE: Set up figurines or stuffies to represent classmates, crumple up a piece of paper to be the “ball”, and tell your student to take their turn
- Taking a math test: Write “big important math test” at the top of a piece of paper, stand up, hand it to the student.
Sometimes (oftentimes!) our worries are “what ifs”, so you might also try using imaginal exposure for those actual “what if” situations. For example:
- Acting out how to cope if someone laughs at you in music
- Practicing self-talk if your mom is mad
- Problem solving next steps if you get a bad grade
What’s also important after exposure activities is processing them together. Ask:
- What was it like to imagine these worrisome things were happening?
- How big was your worry before you used deep breathing/self-talk/etc?
- How big was it after?
- How worried are you about that situation now, when you think about it happening in real life?