Helping children and youth cope with anxiety
Reprinted from "CBT" issue of Visions Journal, 2009, 6 (1), p. 29
Imagine: from therapist to junior knight trainer
In the early 1990s, Dr. Jane Garland imagined adapting cognitive-behavioural therapy (CBT) to better serve anxious children. CBT is known to be effective for anxiety, but it can be difficult to motivate children to practise the essential skills.
Inspired by one of her young patients, Dr. Garland developed a more playful model of CBT: training a junior knight in “taming worry dragons.” When the Mood and Anxiety Disorders Clinic was developed at BC Children’s Hospital in 1994, Dr. Garland teamed up with Dr. Sandra Clark, a child psychologist with expertise in CBT. Together, they developed these ideas into an engaging group program and training manual to help children and parents cope more effectively with anxiety.
With funding from a Children’s Hospital Foundation Telethon grant, the first Taming Worry Dragons manual was published in 1995.1 It became very popular with both professionals and families. A children’s workbook, therapist manuals and training videos followed.
The Taming Worry Dragons program is now used in schools and mental health programs for children throughout BC and across Canada, including at the Children’s Hospital of Eastern Ontario and London Health Sciences Centre. It includes Worry Taming for Teens, written for youth using language and analogies that appeal to this age group.2 The Kid’s Guide to Taming Worry Dragons is a pocket-sized book that was developed for classroom use,3 along with a classroom manual for teachers.
Training junior knights
Taming Worry Dragons is a creative approach to CBT and psychoeducation (teaching about mental health conditions) that is designed to help anxious children learn how to cope with their worries. The approach can be adapted by therapists and parents to match the developmental level and interests of the child involved.
We start by positively reframing anxiety problems. Anxiety is presented as a combination of a “talent for creative worrying” and an “oversensitive body alarm system” that work together to magnify worry and distress.
Anxious children may instinctively avoid their difficulties—the hardest part is actually facing their fears. In the worry dragon approach, the child externalizes the problem and views anxiety as separate from him or her self. A young dragon tamer in training shares in the process of naming anxiety—worry dragon, bully, worry virus or whatever appeals to the child’s imagination.
The child teams up with their parents and therapist to gradually face fearful situations. They start with the easier ones (playing at a friend’s home with their own mother present) and build up confidence to tackle more challenging ones (the sleepover birthday party). Verbal (praise) and concrete rewards (such as a star chart or Lego pieces) for brave behaviour can help this process move along.
The imaginative model helps children commit to making changes. It’s fun, interesting and they experience a sense of success as they move forward.
Children learn imaginative tools to trap the worries that are “bossing them around.” Typical tools include trapping the worries (putting them into a worry jar or confining them to a planned worry time) or imagining that you’re pressing the stop button on the worry machine.
They also learn tools to tame the worries so that their feelings and thoughts become helpful signals rather than things that make problems bigger. Taming the worries requires more sophisticated tools. Taming means investigating and challenging the self-critical messages or the bad predictions of the worry thoughts, and then developing more realistic thinking.
Children begin to understand that our minds constantly come up with new thoughts, but these thoughts are not reality. They learn to be curious about their own thinking process and learn how to evaluate the worrisome thoughts that arise.
Children also learn to befriend their own body reactions. They come to appreciate how a strong physical response like a fast heartbeat, muscle tightness or fast breathing can be a useful process in the body. They learn how these responses can be helpful for a crisis situation or playing sports. But they need to be able to calm and relax their bodies as well. They learn to use breathing strategies, visualization and/or progressive muscular relaxation to help them calm down.
Children can recognize that a dragon tamer in training needs to get enough sleep, eat well, exercise and have some fun and balance their lives. Kids also know that to face a challenge, you have to practise to build up the “coping muscles.” Popular fantasy books like the Harry Potter series or movies about the young King Arthur give children plenty of role models for the real work it takes to develop their dragon-taming skills.
Each week there are skills to practise and experiments or “detective” work to do (see example).
Taming Worry Dragons materials are available through the C&W Bookstore:
Contact information for AnxietyBC and local children’s mental health teams is available through the Kelty Resource Centre: www.keltymentalhealth.ca
‘Round tables’ of young knights and ‘orders’ of parents
Groups are an efficient, cost-effective way to teach children to understand and manage their anxiety, and for them to realize that they’re not alone in this problem. The controlled, encouraging peer setting can engage some of the more reluctant and socially anxious children in practising skills.
There is evidence that children with anxiety do better when their parents are supportive and can reinforce the coping skills and practice at home. Therefore, there is usually a parent group at the same time as the children’s group. This makes economic sense because parents need come to the clinic anyway to bring their children. We find that parents have often also been held hostage (i.e., are unable to go places, are afraid to have expectations for their child) by the child’s worry dragons and need encouragement to make changes to support their child.
Taming Worry Dragons groups are held at the BC Children’s Hospital outpatient clinic. They are also held in many BC communities through the children’s mental health teams and other agencies.
“Wow, you have an amazing imagination! I couldn’t even have thought of that many things that could go wrong! I wonder if you could use your amazing imagination to come up with some solutions.”
– Dr. Garland, in session with a young client
About the authors
Noel is a Social Worker and Therapist at the Mood and Anxiety Disorders Clinic at BC Children’s Hospital, where she does individual and family work with children and adolescents. Noel is involved in organizing and running the Taming Worry Dragons, as well as an interpersonal therapy group for older teens.
Dr. Garland is a Clinical Professor of Psychiatry at UBC and Clinical Head of the Mood and Anxiety Disorders Clinic at BC Children’s Hospital. She is actively engaged in research, teaching and consultation. Her focus is on psychopharmacological and cognitive-behavioural treatment of mood and anxiety disorders in young people.
Dr. Sandra Clark is the co-author of Taming Worry Dragons, a manual for helping anxious children, and Worry Taming for Teens. She has also developed additional tools to help children cope with anxiety for use by other professionals and in classrooms. Dr. Clark is a clinical psychologist who has been working in the Mood and Anxiety Disorders Clinic at B.C. Children’s Hospital for over 20 years. She also has a private practice in Vancouver.
Garland, E.J., Clark, S.L. & Earle, V. (2000). Taming worry dragons: A manual for children, parents, and other coaches (2nd ed.). Vancouver: BC Children’s Hospital. Note: a 2009 (4th) edition has just been completed.
Garland, E.J., Clark, S.L. & Earle, V. (2002). Worry taming for teens. Vancouver: BC Children’s Hospital.
Garland, E.J., Clark, S.L. & Earle, V. (2002). The kid’s guide to taming worry dragons. Vancouver: BC Children’s Hospital.