1. The programme at a glance
Indication. Anxiety disorders in children aged 7 to 12: separation anxiety, generalised anxiety, social anxiety, specific phobias, and the mixed presentations that are the rule. Selective mutism and anxious school refusal call for the adaptations described in section 33.
Reference model. Cognitive behavioural therapy with children, whose efficacy is solidly established. The reference is the multimodal trial of Walkup and colleagues (2008): therapy alone, medication alone and their combination all do better than placebo, and the combination does better than either taken alone. The evaluated protocols — Kendall's (1994; Kendall and Hedtke, 2006), that of Rapee and his team (Rapee et al., 2009), that of Wood and colleagues (2006), centred on the family — share the same frame, and it is the frame of this manual.
Format. Fourteen individual sessions of 45 minutes with the child, and six sessions with the parents, interleaved. About four months, plus two booster sessions. The evaluated range runs from ten to sixteen sessions in total, parents included; this format goes beyond it because the parent sessions are not an extra here: it is in them that family accommodation is reduced, that is, everything the parents do to spare the child the fear (section 12).
Target mechanism. Not the disappearance of fear, which is a normal emotion, but four changes: that the child faces what they avoid, that they discover their prediction is false, that they have tools when it rises, and that their parents stop helping them to avoid.
| Session |
Focus |
What the session produces |
| 1 |
Welcome, play, alliance, assessment |
What they say about it, in their own words |
| 2 |
Naming the anxiety, the thermometer, the diagram |
Thermometer calibrated, diagram drawn |
| 3 |
Where I feel it, and my tools |
Three tools tried in session |
| 4 |
What I tell myself: the detective |
Two thoughts examined |
| 5 |
The fear ladder |
Hierarchy built, rated |
| 6 |
The first challenge, in session |
Exposure done, prediction reviewed |
| 7 |
Challenges at home |
Three challenges planned and done |
| 8 |
Situations with other people |
Two social challenges, measures |
| 9 |
Separation |
Separation challenge kept to |
| 10 |
When a real problem comes up |
Five-step grid applied |
| 11 |
Hidden avoidance and the questions |
Inventory, and reassurance reduced |
| 12 |
School |
Plan written with the school |
| 13 |
What is left, and surprises |
Final inventory |
| 14 |
Stocktake, plan, what comes next |
Summary sheet made by the child |
| Parent session |
Placement |
Focus |
| P1 |
Before session 1 |
Assessment, information, frame |
| P2 |
After session 2 |
The model, and what the anxiety makes them do |
| P3 |
After session 4 |
Accommodation, reduced item by item |
| P4 |
After session 6 |
Supporting a challenge, rewarding courage, siblings |
| P5 |
After session 9 |
School, sleep, routines, their own anxiety |
| P6 |
After session 13 |
Stocktake, family plan, what comes next |
The programme's vocabulary. With the child, the manual uses simple words, which recur in every section. The thermometer is the 0 to 10 scale on which they rate their anxiety (section 17). The fear ladder is the exposure hierarchy: what they avoid, ordered from easiest to hardest, each rung being called a step (section 20). A challenge is an exposure exercise, chosen with them and prepared in advance (sections 21 and 32). The detective refers to the examination of their thoughts (section 19).
What the child takes away. Seven printable worksheets, listed in section 37 and downloadable from this page: my anxiety and where I feel it, my thermometer, my toolbox, my fear ladder, my challenges, the detective, my plan.
What sets this programme apart from reassuring support. The active component is exposure — facing, in small steps, what frightens them. Everything else prepares it and supports it. It is also the component most often skimped in practice: you explain, you reassure, you teach breathing, and the child goes on avoiding. A child who is very good at naming their emotions and who still does not sleep alone has not been treated.
2. Before you start
The prior question: is this a disorder?
That is the first decision, and it is taken in sessions 1 and P1.
Fears are normal and they have a calendar. Fear of strangers, of the dark, of monsters, of animals, of separation, then of other people's judgement: each has its age. Section 3 lists them, and you need to know it before diagnosing.
What makes a disorder is not the intensity of the fear, it is a fear that is excessive for the age and, above all, its impact. The child no longer goes to school, no longer sleeps alone, turns down invitations, does not speak in class, has stomach ache every morning, cries for an hour every evening, or the family has reorganised its life around their fears.
Do not treat an ordinary fear. An eight-year-old who is afraid of the dark and keeps a night light does not have a disorder. A shy child who takes ten minutes to settle at a party does not either. Saying so is an intervention in itself, and it often relieves alarmed parents.
Do not delay in the face of a real disorder. Childhood anxiety disorders are common, they persist when untreated, and they constitute a risk factor for depression and anxiety disorders in adulthood (Creswell et al., 2020). That is an argument to give hesitant parents, and it is well founded.
How to use it
Read the whole thing before session P1, and in particular sections 12 and 32: family accommodation and the conduct of exposure. Those are the two places where treatments fail.
Every session is described on the same frame: the objective, a step-by-step run-through, what to say, the common mistakes, and the criterion for moving on.
One warning specific to this treatment. It works because it asks a child to do what frightens them, and their parents to let them be frightened. Both are difficult, and the second is often harder. A therapist who has not the heart to conduct an exposure will run a pleasant programme with no effect.
3. What is normal, by age
This section serves your diagnosis as much as what you will say to the parents in session P1.
The fears and their calendar
Around 6 to 8 months: unfamiliar faces, separation.
From 1 to 3 years: separation, loud noises, animals, strangers.
From 3 to 6 years: the dark, monsters, imaginary creatures, being alone, storms, people in costume.
From 6 to 10 years: animals, injuries and blood, injections, natural disasters, burglars, death — their own and their parents' — illness. The appearance of the fear of death around seven or eight is normal and coincides with understanding that it is final.
From 10 to 13 years: other people's judgement, school, performance, appearance, rejection by peers. That is when social anxiety declares itself.
A child who has the fear of their age does not have a disorder.
What causes needless worry
A child who needs a night light. A child who cries on the first day of term. A shy child who watches before joining in. A child whose fears change every six months. A child who is afraid of a dog after being knocked over by one.
What should cause concern
The impact first, and the signs that go beyond what is expected at that age:
school, the child no longer goes or goes with great daily difficulty;
sleep, they no longer sleep alone, or no longer in their own bed at all, or not before two in the morning;
invitations, activities, birthday parties turned down;
the family reorganised: a parent sleeping with them, going everywhere with them, answering thirty questions a day, no longer going out;
daily physical complaints — stomach ache, headache — with no cause found;
major crying or rages at every separation or every dreaded situation;
a child who does not speak at school although they speak at home;
regression: toileting, language, wanting to be carried;
repeated questions about death, illness, disasters.
What distinguishes temperament from disorder
Many of these children have an inhibited temperament, identifiable very early (Kagan et al., 1988): cautious, watchful, slow to engage with the new. It is a constitution, not an illness, and it is neither treated nor cured.
What is treated is what that constitution becomes when avoidance sets in: a cautious child who has learnt that the only way of handling fear is not to go. Say it to the parents in these terms: "your daughter will probably always be cautious, and that is fine. What we are going to change is that she can do things in spite of the fear."
4. The clinical picture
What the child describes
Little, and rarely in terms of anxiety. They say they have stomach ache. That they do not like it. That they do not want to go. That it is rubbish. And often they say nothing at all, because they cannot name what is happening to them — that is the business of session 2.
Asked concrete questions, they describe two things very well: what happens in their body, and what they are afraid will happen. The second is almost always precise and often surprising: "Mummy is going to have an accident", "I am going to be sick in front of everyone", "the teacher is going to shout", "I am going to die in the night".
What the parents describe
The impossible mornings. The evenings that drag on. The endless questions. The tantrums at the moment of leaving. A child who never leaves their side. And considerable exhaustion, often with guilt and a disagreement between them about what to do.
Frequently too: a child described as "very mature", "who thinks of everything", "who worries about us". Those formulations are clues, not compliments.
The three components, explained to the child in session 2
The body. Stomach, head, heart, legs, throat, breath, needing the lavatory, nausea. In children the physical complaint is often the only expression, and it is real: their stomach genuinely hurts.
The thoughts. What they are afraid will happen. In children they are concrete and vivid, and they can be gathered very well with good questions.
What they do. Avoidance, in all its forms: not going, leaving, not speaking, not letting go of a hand, asking, checking, getting someone else to do it, crying until it stops.
What keeps the anxiety going
Avoidance. The central factor. Every avoidance relieves immediately and confirms that the situation really was dangerous. The child never learns that their prediction was false.
Family accommodation. This is the maintaining factor most characteristic of childhood, and it is the subject of section 12. Parents, out of love and out of exhaustion, help the child to avoid: they sleep with them, answer the questions, go with them, speak for them, forestall situations, cancel outings. Each of those acts relieves the child at the time and keeps the disorder going.
Predictions never checked. The child believes something specific will happen. They have never put it to the test, because they have never gone.
Reassurance. Answering "are you sure you are coming to get me?" relieves for five minutes and makes the question compulsory an hour later. Thirty times a day in some families.
The parental model. A parent who is anxious themselves passes on their avoidances and their warnings without meaning to. It is not a fault and it can be worked on: see session P5.
The physical complaints and their medical circuit. Repeated investigations, exemptions and trips home confirm to the child that there really is something seriously wrong with their body.
Epidemiology, in two useful figures
Anxiety disorders are the most frequent mental disorders of childhood (Cartwright-Hatton et al., 2006): estimates run around 5 to 10 % of children, depending on definitions and thresholds (Polanczyk et al., 2015).
They are lasting without treatment, and they predict depression and anxiety disorders in adolescence and adulthood. Treated, they respond well, even though relapses remain frequent in the long term: see section 13.
5. The forms, and what they change
Mixed presentations are the rule: most of these children have two or three anxiety disorders at once. Identify the dominant form; it determines the exposure hierarchy.
Separation anxiety
The most frequent before ten. The child dreads being separated from their parents, or fears something will happen to them. The manifestations: refusing to sleep alone, refusing to sleep at a friend's, refusing school, questions about accidents and death, phone calls, physical complaints on school mornings, tantrums at the moment of departure.
The exposure targets are concrete and progressive: sleeping in their own room, staying there all night, staying with a babysitter, going to a birthday party, sleeping at someone else's house.
It is the form in which accommodation is most massive, and where session P3 decides the result.
Generalised anxiety
The child worries about everything: school, marks, health, their parents' money, disasters, the climate, being on time, the rules. Often described as mature and perfectionist. They ask for a great deal of reassurance, redo their homework, want to be sure before acting.
The targets are reassurance, perfectionism and intolerance of uncertainty, that is, the difficulty of bearing not knowing what is going to happen, which can be approached from this age in simple terms (section 24). Added to these is a worry period: a short, fixed moment in the evening when worries are talked about, instead of answering them all through the day (section 25).
Social anxiety
Often declares itself around ten or eleven, sometimes earlier. Fear of judgement, of ridicule, of speaking in class, of eating in front of others, of joining a group. Not to be confused with shyness: it is the impact that settles it.
The targets: speaking in class, asking an adult a question, ordering for themselves, telephoning, joining a game, giving a presentation. Social exposure requires preparing the environment — see section 35 for school.
Specific phobias
Dogs, insects, injections and blood, vomiting, storms, lifts, flying, water, darkness. Often isolated, and often the quickest to treat: a single specific phobia can ease in very few sessions, sometimes a single long session of graded exposure. See section 33.
Phobia of vomiting and phobia of injections deserve a mention: the first leads to substantial dietary restriction, the second can compromise medical care and carries a risk of a vasovagal episode, a sudden drop in blood pressure that can go as far as fainting, which calls for a specific technique (section 32).
Selective mutism
The child speaks at home and not at school. It is an anxiety disorder, now classified as such (Muris and Ollendick, 2015). It requires substantial adaptations and close collaboration with the school: section 33.
Panic disorder
Rare before puberty, and not to be confused with separation panic. Where it exists, it is treated with the principles of the adult protocol adapted to the age: deliberate exposure to the dreaded physical sensations, and stopping safety behaviours, those discreet precautions that prevent the child from checking that what they fear does not happen (section 23).
Frequently asked questions
How do I know whether it is a normal fear or a disorder?
Do not look at the intensity of the fear, look at the impact. An eight-year-old who is afraid of the dark and keeps a night light does not have a disorder. A child who no longer sleeps in their own bed, who turns down invitations, who has stomach ache every morning, or whose family has reorganised its life around their fears, does. And check the calendar of fears in section 3: every age has its own, and the appearance of the fear of death around seven is normal.
Would it not be better to wait until he grows out of it?
No, and the answer is well founded: these disorders persist when untreated, and they predict depression and anxiety disorders in adolescence. Say it simply, and say the other half too: this is one of the disorders that responds best to treatment, and the programme lasts four months. The ratio between effort and result is favourable, even though relapses remain frequent in the long term.
The child refuses to do the exposure. What do I do?
Never force physically. In almost every case, a refusal means the step was too big: break it down, and break it down again. Looking at a photograph of the dog before seeing the dog, going into the room before getting into the lift. And negotiate a duration, not an exemption: you stop as soon as the number has fallen by half, and a short exposure taken that far is worth more than a quarter of an hour refused. Treat the refusal as information about your hierarchy, not as opposition.
Should a child be made to go to school when they cry and vomit in the morning?
Yes, they have to go — and no, not that way. What decides it is the stomach-ache protocol, settled in advance with the school and not negotiated at seven in the morning: the child goes to the school nurse, lies down for ten minutes, goes back to class; going home happens only in case of fever, repeated vomiting or another sign of illness agreed with the doctor. A child who vomits from anxiety should have been examined once; after that, a single bout of vomiting is not enough to keep them at home or send them home. Without that protocol, the child learns every morning that stomach ache puts an end to school. And always look for what makes school impossible: bullying, a teacher, a dyslexia.
The parents have slept with him for three years. Where do I start?
With very small steps, and never with "he sleeps alone tonight". The usual series: the parent sitting on the bed, then on a chair at a distance, then in the doorway, then in the corridor leaving after five minutes, then a simple goodnight. Each step kept to for three or four nights. And settle in advance what to do about a night-time return: he is taken back, every time, with the same sentence, with no room made for him. Warn them that on the first nights this may happen five times — and that a single evening of giving in wipes out a week.
How do I talk to parents about accommodation without inducing guilt?
By saying what is true: what they are doing is exactly what a good parent does with a child in distress — they relieve them. The problem is not their intention, it is that the immediate relief prevents the child from learning that they can manage. Then announce that it will be harder for them than for the child, which is almost always the case and which they hear with relief.
Should you reassure a child who asks thirty times a day whether everything is all right?
No — and the rule is simple: you never answer the same question twice. Instead, a single invariable sentence, said by the parents without irritation and without any added explanation: "I can see you are scared, and I know you can bear it." The invariance is essential, because an answer that changes contains information, and information reassures. And do not leave them with nothing: give them a tool, their courage sentence, or their notebook.
The rewards — is that not bribery?
No, provided you reward the right thing. You reward the attempt, immediately, with something small and frequent — never the result, never the absence of fear. A child who tried and failed gets the same reward as one who succeeded. And a reward once earned is never taken back. In a seven- or eight-year-old, it is a considerable lever, and its absence is a waste.
Is medication needed?
Begin with therapy in mild to moderate anxiety: comparable effects and fewer side effects. Discuss a child psychiatry opinion in four cases: anxiety so severe that the child cannot engage in the work, no response after eight to ten well conducted sessions, an associated depression, or prolonged absence from school. The reference trial showed that the combination does better than either treatment alone — so it is never an admission of failure.
What do I do when the child is better but a new fear appears?
That is frequent in children: the fear moves, and the mechanism stays the same. It is not a relapse and it is not a failure. Have them apply what they know themselves — a small ladder, a step, the repetition — and only check that they are doing it right. Two sessions of method are generally enough. Warn them about it in session 14: a child and parents who have been warned deal with the new fear themselves.
What do I do when one parent reassures and the other pushes?
That is very frequent in childhood anxiety, and it makes all rules fail — the child learns to go to the one who gives in. Deal with it in session P3, without them, before any reduction of the accommodation. You do not need them to agree about everything: you need them to apply the same thing on two or three precise points, written down.
What do I do when the parent is very anxious themselves?
Name it without reproach — many of the parents you see had the same thing as children, and that is also what makes them understand their child so well. Then work on what is concretely transmitted: the warnings, the stories of danger, the shared avoidances, the checking. And offer care of their own: it is one of the best things to do for the child, and it should be put that way.
What do I do when the child does not speak at school but speaks at home?
That is selective mutism, and it is an anxiety disorder — regularly taken for defiance or a language disorder, including by teachers, to whom it has to be explained. The protocol differs: you never ask them to speak in front of a witness as a first step, you progress in very fine stages along three dimensions at once — the person, the place, the form of communication — and collaboration with the school is indispensable. See section 33.
How long before a change is visible?
The first steps often produce a visible effect from the third or fourth week of exposure, that is, around session 8 or 9. What moves first is bedtime and the challenges themselves; school and relationships are slower. Announce that timetable in session P1: the first five sessions prepare, and the parents need to know that it is normal for nothing to happen before then.
Are fourteen sessions enough?
Yes for a majority of children, with the six parent sessions and the two boosters — the evaluated protocols have ten to sixteen sessions in total, parents included. If improvement is partial at the end, extend by four to six targeted sessions, naming what remains, rather than running the whole thing again. And in the particular case of an isolated specific phobia, with no other anxiety disorder, do not apply this programme: one long session of graded exposure is often enough.