Anxiety disorders, which include phobias, are among the most prevalent psychiatric disorders in children and adolescents (Albano, Chorpita, & Barlow, 2003; Costello, Mustillo, Erkanli, Keeler, & Angold, 2003).
Fear, as an emotion, is thought to be more biologically based as compared with anxiety (Davis & Ollendick, 2005). Fear involves a brain-based reaction that consists of the interplay of physiological responses, distorted cognitions, and behaviors designed to facilitate escape and avoidance of danger (Lang, 1979).
Although fear is a normal emotion, which is part of child development, phobias are evident in approximately 5% of the population (Davis & Ollendick, 2005). Some fears are considered developmentally appropriate and can occur transiently at various development stages. During the infant years, fears seem to be concrete and centered on the immediate environment, such as a loud noises or strangers. Among 4- to 6- year-olds, imaginary creatures such as monsters and ghosts, and the dark, are common themes. Between ages 7 and 12 years, fears are usually centered on realistic events such as natural disasters and physical health (Knell, Dasari, 2015).
According to DSM-5, phobia can be diagnosed when the fear is (1) persistent and becomes excessive, (2) leads to undue physiological arousal, and (3) triggers distress and avoidance.
The Cognitive-Behavioral Play Therapy intervention reported in this article is taken from the work of Susan Knell and Meena Dasari CBPT: Implementing and Integrating CBPT into Clinical Practice (2009), where is illustrated the use of CBPT for two comorbid concerns: animal phobia and parental separation.
The following case illustrates the use of CBPT with an eight-year-old female of Chinese descent who was adopted as an infant and brought to live in a large city in the United States. The little girl presented with a specific phobia for pigeons and feelings of sadness about her parents’ separation.
Specifically, she experiences intense fears about pigeons such as to compromise her daily life and safety (she ran quickly across the street without warning and her worries limited family outings because it was not possible to visit parks or open areas in the city).
In addition, although both parents reported that she seemed to be a happy child, she was sad when reminded about their separation, which happened two years earlier. She became tearful when transitioning from one home to another and when saying goodbye to either parent.
Assessment with parents
In the assessment phase, a combination of parent report, child self-report, and behavioral observation were used. During the clinical interview with parents, the history and background information of the child were collected, which indicated a specific phobia for pigeons with adjustment concerns.
Based on the reports, the girl enjoyed playing and had more than 100 stuffed animals in her room, with her favorites being Puppy, a very old dog, and Piglet, a furry pink pig.
Assessment with child
In the initial session, the therapist experienced the child as friendly and easily able to engage. Behavioral observations of child’s play suggested that she was comfortable playing with the therapist, but her level of emotional expression in play was low. In general, the little girl was considered a good player from unstructured assessment suggesting age-appropriate cognitive, emotional and social skills.
The child was seen for 11 sessions of Cognitive-Behavioral Play Therapy, over the course of 4 months.
Treatment goals were to build skills to manage her anxiety related to pigeons and to manage her emotions around parental separation. Addressing the anxiety about pigeons was chosen as the primary goal in collaboration with the parents. A skill-building approach would have increased the child’s ability for emotional expression in play, consequently these skills could have been generalized and also applied to feelings about the separation.
Throughout therapy, methods of delivering CBPT included modeling and structuring sessions, and techniques included psycho-education, relaxation, cognitive restructuring, exposure and systematic desensitization using her stuffed animals and worksheets.
The initial stages of treatment involved skill building. The child was provided psycho-education on emotions as a technique to develop labels for her different emotional experiences. She and the therapist read “How Are You Peeling?” (Freyman & Elffers, 1999) and built a feelings chart. The little girl and her mother agreed to select and describe a feeling on the chart each night.
Over the next few sessions, the child was asked to bring her favorite stuffed animals, Puppy and Piglet, who became part of the teaching of relaxation, cognitive restructuring and positive self-statements. First, the child was taught to do deep breathing as a technique to calm her body when sad or nervous. Both the therapist and the stuffed animals did the breathing with her. Then, cognitive restructuring was introduced as “helpful thinking,” a technique that helps kids to change their negative thoughts into positive thoughts. Worksheets with thought bubbles for animals and therapist modeling of the use of questions were implemented to develop positive self-statements. Also, the importance of positive self-statements was described by using worksheets that contrasted the emotional experiences between “helpful” and “unhelpful” thinking.
Then, an anxiety management plan (i.e., “Calm Down Plan”) was developed, with the purpose of implementing the plan for exposure tasks. Exposure was used to help the child be in contact with the anxiety-producing stimuli while coaching her to use her skills so that her anxiety could decrease over time. The “Calm Down Plan” included two steps: (a) Take a deep breath; (b) Say helpful things to myself like “Pigeons are gentle”; “I’ll be okay”; and “Mom and dad will scare them”. A fear hierarchy consisting of a low-level anxiety task to high-level anxiety tasks was developed, which was explained to the child as a “list of tasks to help you feel more comfortable around pigeons”. The girl listed a total of 10 tasks, which were determined by rating each task on a scale: 1 (low anxiety) to 10 (high anxiety). These tasks, from lowest (1) to highest (10) were:
– Reading facts about pigeons;
– Seeing a hand-drawn picture of pigeon;
– Touching a hand-drawn picture of pigeon;
– Seeing Internet picture of single cartoon-like pigeon;
– Seeing Internet picture of single pigeon that looked real;
– Touching Internet picture of single pigeon that looked real;
– Seeing Internet picture of a flock of pigeons that looked real;
– Touching Internet picture of a flock of pigeons that looked real;
– Standing across the street from a live pigeon;
– Standing 100 feet from a live pigeon while holding parent’s hand.
Each task was completed using concepts of modeling and exposure. Stuffed animals were used as the play medium and the child was an active participant by choosing tasks throughout.
Upon completing the exposure tasks, CBPT techniques were used to help the child better manage her feelings of sadness around parental separation. Initially, the little girl was comfortable with pretend play using her stuffed animals, but was reluctant to discuss her thoughts and feelings about her parents’ situation. She stated that she talks with her stuffed animals at night and friends at school but that what she told them was private. Psychoeducation of emotions and bibliotherapy were used to normalize her thoughts and feelings (e.g., “Not your fault”). Afterward the child was better able discuss her disappointment when first told about the parents divorcing and her ongoing desires for her parents to reconcile. The stuffed animals were used to challenge negative cognitions and to form positive self-statements.
Over time, both parents reported that the child was able to tolerate anxiety better when a pigeon was nearby or approached her, and that she also expressed neutral feelings when transitioning from one parent’s home to another. Thus, the conclusion was discussed and agreed upon. Despite a more gradual and planful end of therapy, the child’s termination was abrupt because the parents decided to take a break for the summer. At the final session, relapse prevention was used, which involved consolidating cognitive and behavioral techniques in a concrete way and as a summary for quick reference. This prepared the child and her parents to independently manage setbacks and decreased reliance on the therapist. Specifically, the little girl was asked to create a note card with the steps of the “Calm Down Plan” and a list of future anxiety-producing events for which the plan could be used. It was recommended to the parents that they “coach” the child to use the summary to manage anxiety in general and future triggers for anxiety.
Both parents reported improvements in the girl’s coping skills for anxiety for pigeons and sadness related to parental separation.
Three-month follow-up included a phone session and rating scale completed with Lisa’s father. In general, father reported that Lisa continues to use her ‘‘Calm Down Plan’’ when she sees pigeons. However, he noted that the anxiety management plan is more effective for one pigeon rather than flocks of pigeons. Father also described continued improvements in tran- sitioning from parents’ homes, in that the crying and reports of sadness are absent.
Anxiety disorders and phobias are among the most commonly occurring psychiatric disorders in childhood, with preschool children demonstrating similar prevalence rates as school-age children and adolescents.
With Cognitive-Behavioral Play Therapy, a significant component of overcoming anxiety appears to be the child’s gaining control and mastery over negative emotions. Developing this sense of control may mean that the child learns to deal with feared stimuli, to manage feelings associated with the fear, or to learn specific coping skills to deal with the fear. With Cognitive-Behavioral Play Therapy, the acquisition of these skills takes place within play, where the child has the opportunity to learn and practice the necessary skills to overcome the feared stimulus and anxiety-provoking situations.