During initial sessions, the anxious child learns to distinguish between various bodily reactions to emotions as well as the somatic reactions that are specific to his or her anxiety. Coupled with this awareness, the child is taught relaxation exercises designed to help the child develop further awareness of and control over physiological and muscular reactions to anxiety (see King, Hamilton, & Ollendick, 1994). This segment may be especially beneficial for children whose worry is accompanied by more severe somatic symptoms (see also Eisen & Silverman, 1998). In this way, anxious children may develop an awareness of their physiological responses to anxiety and use this as an “early warning signal” to initiate relaxation procedures.

Next, children are taught how to identify and modify anxious cognition (their internal dialogue). Therapist and child then discuss such thoughts and the child is encouraged to ask himself or herself the various possibilities that may occur in a given situation. It is believed that helping children to challenge their distorted or unrealistic cognition will promote more constructive ways of thinking and less dysfunctional emotional and behavioral responses. For example, the “perfectionistic” nature of many anxious children can be challenged as these children become better able to examine, test out, and reduce their negative self-talk, modify unrealistic expectations, generate more realistic and less negative self-statements, and create a plan to cope with their concerns. Importantly, the idea here is not necessarily to fill the child with positive self-talk. Rather, the ameliorative power rests in the reduction of negative self-talk, or the “power of non-negative thinking” (Kendall, 1984). This phenomenon is supported by recent evidence indicating that changing children's anxiety-ridden and negative self-talk—but not positive self-talk—mediates the changes in anxiety that are associated with treatment-produced gains (Treadwell & Kendall, 1996). Children learn problem-solving skills that help them to devise a behavioral plan to cope with their anxiety. This includes learning to recognize the problem, brainstorming and generating alternatives to managing their anxiety, weighing the consequences of each possible alternative, and then choosing and following through with their plan (see D'Zurilla & Goldfried, 1971). The therapist serves as a model during each phase of problem solving by, for example, reminding the child that problems and challenges are part of life or by brainstorming ideas without judgment. With the acquisition of problem-solving skills, children develop confidence in their ability to handle anxiety-provoking situations as well as everyday challenges that arise. They learn to judge the effectiveness of their efforts and reward themselves for these efforts. They also learn to identify those things they liked about how they handled a situation and those things that they may want to do differently. Here, children are encouraged to reward both complete and partial successes. Children with anxiety may have exceedingly high standards for achievement and be unforgiving and critical of themselves if they fail to meet these standards. Therefore, it is important for the therapist to emphasize and encourage self-reward for effort and partial success.

The second phase of treatment focuses on exposure exercises in which children practice the newly acquired skills. In these sessions, participant youth are prepared for and exposed to various situations that induce anxiety. They are first exposed to imaginary and low-anxiety situations and gradually are exposed to moderate-and then high-anxiety situations. Through imaginal and in vivo exposures, the therapist assists the child in preparing for the exposure by, for example, discussing aspects of the situation that are likely to be troubling, working through the steps of the plan, and rehearsing. The in vivo exposures are extremely important, as these situations provide the child real opportunities to practice. Thus, they should be tailored to address the spe

cific worries (sources of anxious distress) of the child.

The therapist also facilitates children's postexperience processing of the exposures, helping them to evaluate their performances and think of a reward. In so doing, the therapist helps to frame the current exposure experience in terms of a pattern for future coping. When designing the graduated hierarchy of exposures, it is beneficial for the therapist and child to collaborate to create in vivo exposures that are meaningful and memorable for the child. Homework assignments are an important feature of this program. Throughout the treatment, children complete tasks in a personal notebook, which allow them to practice their steps and to use their skills outside of session. Rewards are provided upon completion of the assignments.

As the end of the time-limited treatment approaches (starting with 3 weeks left), the therapist and child begin to discuss how the child will create and produce a “commercial” about his or her experiences in the program to be presented and videotaped during the last session of the treatment. Children are encouraged to use their imagination and create a videotape, audiotape, or booklet describing their experiences to help in telling other children about strategies for coping with anxiety. This effort is designed to not only help children organize their experiences but also afford them the opportunity to “go public” with their newly acquired skills and recognize their accomplishments. The commercial also serves as a tangible reward that children can take home with them once the treatment is completed and, although it may not be described as such, it is an in vivo exposure task with emotional, social, creative, and organizational features.

The treatment manuals that have been written and evaluated in research (e.g., Kendall, Chu, Pimentel, & Choudhury, 2000) were designed for children between the ages of 8 and 13 years. Also designed for this age range, The Coping Cat Workbook (Kendall, 2000a) contains exercises that parallel treatment sessions in an effort to facilitate the child's involvement in the program and the acquisition of skills. Although some manual-based treatments have acquired the reputation of being somewhat rigid, the therapist working with this program is allowed flexibility, as life can be “breathed” into the manual to better fit the needs and functioning of the child (Kendall, Chu, Gifford, Hayes, & Nauta, 1998). Although adaptations can be made when working with older children, younger children may not have yet developed the cognitive skills necessary to participate fully in or benefit maximally from this intervention and children with an IQ below 80 may not have the prerequisite skills. Additionally, with developmental considerations, it is important to be cognizant of possible age-related increases in physiological functioning, emotional vulnerability, social and peer pressures, and comorbid conditions, as well as any other changes that these children may be experiencing. Accordingly, a CBT therapist manual and a related workbook for teenagers (Kendall, 2000a) are also available.