From Kazoos to Spider Rings: Prolonged Exposure with Kids
Exposure appears to be the key change-producing procedure in the cognitive-behavioral treatment of anxiety and phobic disorders in children. Successful exposures depend on the clinician’s ability to engage the child in anxiety-provoking tasks. Successful exposures are both developmentally appropriate and fun for the child. Developing exposures for anxious children can be fun for the clinician too and offer opportunities to be creative and playful. I present several exposure strategies that I have found helpful in treating anxious kids. Toys and books. What child can resist a toy? Toys can be used as an exposure target or to facilitate exposure. For example, six-year old Jennie had a terrible fear of spiders that resulted in tantrums whenever she had to leave the house. Jennie and I put together an exposure hierarchy that began with her reading books about spiders. At first, she was only willing to stand near the book but gradually agreed to stand near the pictures of spiders and then to touch them. Later, Jennie agreed to write and illustrate her own book about spiders which she happily read aloud to me. She also agreed to wear black spider rings around the house and to wear other “spider jewelry” we made in the therapy session. Kazoos are terrific toys for selectively mute children. The objective here is to create situations in which the child vocalizes. I encourage the child to play a kazoo or paper-and-comb and then gradually change the venue of these “little performances” to more anxiety-provoking situations. Mary, a selectively mute five-year old, was willing to play a kazoo in session with me. At first she hummed tunes but gradually was willing to speak words and phrases. Mary then agreed to play the kazoo when friends and strangers visited her home. When Mary graduated from therapy, Mary, I, her parents, and three siblings played kazoos to the tune, “Pomp-and-Circumstance.” What a performance! Games and songs. I play lots of games with anxious kids. Games can take the edge off an exposure assignment because they are fun and build on the child’s innate wish to play. For example, Mary (the selectively mute five-year old) moved up to playing song games with me (e.g., “Who stole the cookie from the cookie jar?”). Later, we went for walks during which we played “Hi-on-the-Fly” in which we competed to who could first give a quick smile and a hello to strangers we meet on the walk. Playing cards on which the feared object is drawn is another fun exposure for kids. Jennie and I cut out pictures of spiders and pasted them on index cards. We used these cards to play “Go Fish.” A “Fast-Talking-Contest” is another fun game. Julian, a nine-year old with obsessive compulsive disorder, had an obsessive fear of growing young and avoided small children, diapers, and many objects in his home that were associated with toys once stored in a diaper box. When Julian and I started meeting, he would not permit me to say the word diaper in his presence, but he did agree to a “Fast-Talking-Contest.” In this game, I counted how many times Julian could say diaper in one minute. Then it was my turn. Julian was a competitive kid and loved to trounce his tongue-tied therapist. “Get Dressed” is another great game for kids who fear wearing certain articles of clothing. First we sort the clothes into piles from lowest to highest discomfort. I bring a pile of sweaters and shirts from home and the child’s parent brings a bag of the child’s “contaminated” clothes. We then have a contest to see who can put on the most clothes in one minute. The child continues this game with parents at home until the child is comfortable wearing his or her clothes (but one shirt rather than six shirts, or one pair of pants rather than three). Board games can facilitate exposures too. I often play checkers using the feared objects (or checkers contaminated with a feared object) as game pieces. In the case of Julian, we used a set of “contaminated” toy soldiers as game pieces. Julian loved this and we played checkers contaminated with objects from his fear ladder until he no longer reported anxiety when he touched the game piece. Sometimes changing the context of a fear makes it a bit more tolerable and songs can help do this. I often have the child with obsessive worry write songs, which include the child’s worry thoughts, that we then sing. For example, while Julian would not say the word diaper he was willing to write songs that repeated the word diaper over and over again. We wrote several that he sang with me and his parents until the word diaper no longer made him anxious. Video and audio recordings. Children will often agree to watch videos containing situations or objects they fear. I have watch “Arachnophobia” many times with kids who feared spiders. Also, there are many nature videos that are great for kids who have animal phobias or who fear thunder and lighting. Videos are particularly useful for setting up exposures to objects or situations that are difficult or impossible to create in your office (i.e., lighting). Videos and audios are also helpful in treating selectively mute children. Mary, the selectively mute five-year old agreed to being audio recorded while she spoke to her mother. We then set up an exposure hierarchy whereby we played the audio in situations that provoked more and more anxiety. First, Mary permitted me to listen to the audio with her and her parents in the room. Later, Mary and I listened to the audio alone, which was initially slightly more anxiety evoking. Gradually, Mary permitted other exposures (i.e., audio played for the teacher who listens with parents and Mary, audio played for teacher who listens with Mary only, audio played for one of Mary’s playmates who listens with Mary). Our last exposure involved showing a video of Mary
What Does OCD Mean Anyway? A Quick Guide for Kids and Families
What Does the D in OCD Mean? Obsessions (the thoughts, images, and doubts that bother and scare you) and compulsions (the things you do and think to decrease your fear and discomfort) are upsetting enough but for some kids, the D in OCD can be pretty upsetting too. So what does the D in OCD mean anyway? The big D means there are four little d’s that are making your life hard. The first little d stands for disproportionate. This just means that what you think and what you do are a bit over the top. Washing your hands quickly after you use the toilet makes good sense. Washing your hands over and over after you use the toilet and then take a long shower because you still believe that you may have germs on your body doesn’t make good sense. In fact, it doesn’t make much sense at all but you still feel like you must do it, which makes the whole thing both scary and frustrating. The second little d stands for distressing. This means that the obsessions and compulsions are really bothering you. Obsessions are not little worries. In fact, there not worries at all but they’re very upsetting thoughts that don’t make much sense when you step back and look at them. Many kids have obsessions that are not very distressing for them. They’re just a little uncomfortable and can easily shrug off the thoughts and move on to more fun and important things. They might not have this little d. However, if your obsessions are really scary, you may have a lot of trouble resisting the compulsions, and the frustration of having to do these senseless compulsions can be distressing for you too. The third little d stands for disruptive. That means that the obsessions and compulsions are making it really hard for you to do the things you want to do in the way you want to do them. You may have trouble concentrating on your schoolwork because your mind is filled with all those scary obsessions. Even though you like school, you may hate going to school in the morning because of all the compulsions you have to do in order to start the day right. You may spend too much time washing, or checking, or counting, and this makes you late to the things you want to do and – it’s frustrating for you and for your parents and brothers and sisters. Although you don’t have to have obsessions that are both distressing and disruptive to have the big D – just one will do it — most kids who want help for their OCD have both. The fourth little d stands for duration. This just means that the other little d’s (disproportionate, distressing, disruptive) have been pushing you around for longer than just a few days or weeks. Usually, if you’ve been suffering for more than six months, you may have this last little d. So, that’s all the D means in OCD – something that you already know — the O and C are bigger than you can handle on your own. That’s where your family and the right therapist can help. Therapy helps get the D out of your life – even if a little O and C stick around — so that you can get back on track doing the things that are important to you. A little O and a little C never held back any kid. It’s the D that does that. You’re Not Alone No matter how scary the thought, how bad the thought, or how uncomfortable or guilty a thought makes you feel, other kids with OCD have had that thought too, in fact even kids without OCD have really strange and scary thoughts. One of the hardest things about having OCD is that you may believe that you’re all alone. You may think that you’re the only kid who has scary thoughts or does things that don’t make sense. But you’re not. One percent of kids have OCD. One percent may sound like a small number but it’s not. How many kids in your school? If you’re in elementary school, there are about 300-400 kids. Most middle schools have about 600-700 kids. Most high schools have about 700-800 kids. This means that if you’re in elementary school, there are two or three other kids in your school with OCD. If you’re in middle school, there may be six or seven, and if you’re in high school, there may be seven or eight kids with OCD. Now think about all the schools in your city. Now think about all the schools in your state and then think about all the schools in the United States. That’s a lot of schools and that’s a lot of kids with OCD. So, you might ask, “If there are so many other kids with OCD in my school, why don’t I know them. Well, you may not know them because they’re too embarrassed or too scared to tell you that they have OCD too. But just because you don’t know who they are doesn’t mean that they’re not there. Turn OCD on Its Head OCD has made your life hard by fooling you into thinking and acting in certain ways. So long as you continue to think and act in these ways, OCD is in charge. However, you can start to turn OCD on its head by trying a few simple things. These things might not help you completely overcome your OCD, but they’re a good place to start. Don’t try to Control Your Thoughts. Many kids (and adults too) believe that they can control their thoughts. They believe that they can think what they want to think and, more importantly, not think what they don’t want to think but this isn’t really true. Try this. Close your eyes and think about polka-dotted zebras. Let them swirl in your mind. Now, try to not think about polka-dotted