“No! No!” With a mad gleam in his eye, Thomas dashed forward for the glass. He snatched it out of his mother’s hand, and made it to the sink in three mighty strides, dumping the contents with a look of relief and triumph on his face. Then he quickly refilled the glass with juice and exactly five ice cubes.
Harry wailed as he screamed at the top of his lungs, “You just want to give me more work! This is using up my free time!” as Mom corrected his math homework.
Do you sometimes feel like you live in a nuthouse? That as soon as your child with autism and OCD (defined below under footnote ) gets over one compulsion, a new one (or two or three) springs up to take its place? That the “neurotypical” younger sibling with the low frustration threshhold explodes whenever you do homework together?
I put these cases together because they actually occurred in tandem one afternoon to a family I work closely with. It was a mess of a day, struggling with these disparate situations involving children having completely individual profiles and challenges, but afterwards upon reflection, Mom realized that she had used the same method called CBT, cognitive behavioral therapy, on both.
So what is CBT (see definition below under footnote  )? Is it something parents have to spend a lot of money to get from mental health professionals for their crazed children? Or can you try it yourself right at home in the trenches? The answer is definitely yes for latter, and possibly yes for the former. Parents can definitely learn to use CBT effectively on their own in the home. Professionals can add critical support in tougher cases, but the more a parent practices CBT on their own, the fewer consultations will be required, and the more fruitful those sessions will be.
The following steps were adapted from Dr. Anne Marie Albano’s excellent book, “You and Your Anxious Child,” (2013), Penguin Books. She’s the director of the Columbia University Clinic for Anxiety and Related Disorders.
Step One: Help your child learn the identify the negative feeling while it’s happening, with the goal of doing so early, before the emotion grows too intense to cope with.
Thomas’s case: Too late! Thomas went from 0 to 60 in seconds without warning- ice cubes triggered the OCD, and he was unbearably anxious immediately, acting on it (dumping the ice cubes) before there was any chance to engage those frontal lobes. But that’s ok. Mom was quite sure there would be a next time. So she talked about how wow! he must have felt pretty anxious when he saw there were too many ice cubes. She drew an emotional thermometer scaled 0 to 5, and he pointed to the 4.
Harry’s case: Also too late! At first Mom was puzzled- Harry got upset so suddenly, without warning, and in her opinion without any provocation- by fourth grade, surely he should expect having to correct his homework. But upon reflection, she realized that it was not her demeanor nor demand that had anything to do with the problem, but the situation combined with Harry’s temperament. He was proud of having done his homework on his own, and was looking forward to relaxing. He has a low frustration threshhold, so the thought of possibly having to start all over again when he was already tired was too much. Mom realized the importance of the two of them having a discussion about expectations (expecting his homework to be corrected), setting aside time for it, and limiting extracurriculars so that enough homework time could be set aside and scheduled early enough before he tired out. Especially for our kids with short fuses (so no warning time), setting up for success is critical. This kind of forethought and preparation may not only be your best but only option to avoid an explosion.
However in general, for the next time, how does one teach a child to recognize a negative emotion early, before it grows to overwhelming proportions? According to the book, during a calm time, you’re supposed to take the time to teach your child how to identify the physical feelings of anxiety, so he’ll be able to spot it in himself early. For example, you can draw a body map of your child on a big piece of butcher paper, and draw arrows to the chest labeling a tight, explosive feeling or racing heart, lungs for rapid breathing, wrist for rapid pulse, forehead for perspiration, hands for cold and clammy, abdomen for gurgling or tummy ache, etc.
For Harry, Mom also wrote on the pink side of an index card: “Homework Explosion Signs! Turning away. Raised voice volume and pitch. Fidgeting and throwing erasers. Blaming. Changing the subject.” Although I wouldn’t try this with every kid as it might make him madder, she also videotaped :Harry once during an explosion, so he could see what it looked like. Both of those “self-awareness” measures have reduced the explosions, even though Harry has never once viewed the videoclip, and Mom usually has only to mention and not even pull out the card.
Step Two: Address the Emotion
In a way, it was easier to address Thomas’s emotion because his anxiety resolved immediately upon performing his compulsion (easy only in the short run, BAD in the long run because the more times he performs a compulsion and feels relief, the stronger that connection between the compulsion=relief becomes in his mind, and the stronger the compulsion becomes).
But for Harry, dealing with the emotion was the hard part. All Mom could do is be silent and present until he stopped screaming and yelling, since he couldn’t hear her anyway even if she tried to talk. After a period of ranting about the “extra work,” he started ranting about why Mom was just sitting there instead of moving forward, “wasting more time.” Sigh! When she tried to quietly tell him he needed to calm down so he could hear her, and then she’d talk, he just yelled louder. When she suggested deep breaths and tried to demonstrate them, he just got madder. So finally she decided “being present” was actually providing an audience that wasn’t helping. Mom told Harry he could come get her when he was ready to work, and left. Lucky for her, Harry really did want to finish his homework, and did eventually calm down (barely) enough to finish going over the corrections. That was an accomplishment. In earlier days, she had had to send him to his room with a timer to make sure he didn’t just go and play and get out of his work. Several such time-outs were necessary for him to get the point that cooperation (fixing his homework mistakes) was required and inevitable.
If it were possible to catch these emotional “dysregulations” at an earlier, more manageable stage, perhaps they could have done deep breathing or PMR (progressive muscle relaxation) to put a halt to the growing anxiety. Deep breathing is “balloon breaths” where the child puts his hands on his abdomen and feels his fingers expand out (“blow up the balloon”) as he takes a deep breath on the count of 5, and slowly exhales (“blow out the birthday candles”) on a count of 5. You’re supposed to teach deep breathing exercises and “progressive muscle relaxation” (in which you teach your child to sequentially contract/tense up the various muscles groups and then relax them from head to toe) as exercises a couple times a day, as a fun family routine activity, so they’re automatic when you need to use them to cope with anxiety.
Often humor works the best. For Harry, if Mom thinks some homework item is going to be hard, she’ll say, “Now don’t panic, Harry, this’ll be okay!” before tackling the problem, and get a smile out of him. She used to say, “Oh dear- here comes the lion! I think he’s ready to roar!” when he was younger, and the imagery was fun and helpful. “I think I’ve got an angry cat!” still works to clear the air sometimes.
Step Three: Help the child identify the untrue, negative thought, in other words, the distorted thinking that does not match up with reality. Then come up with the true, positive replacement thought together. It is NOT advisable to try this until the child has calmed down!
In fact, usually this step can’t even happen at the first incident. You usually get through the incident as best you can- for example, Thomas had already performed his compulsion. Harry and I had already gone over his homework corrections. Once the child is relieved from the stress/demand, and has thoroughly calmed down, you can sit down and go over this step for the next time.
Mom drew a sad face (actually two eyes with upgoing eyebrows and a horizontal zigzag for the mouth) with a blank balloon thought bubble that they filled in with Thomas’s answer.
Mom: “So Thomas, what were you thinking when you saw the ice cubes before you dumped them?” Thomas: “I need five ice cubes or I won’t be okay.”
Then she drew a happy face with a blank balloon speech bubble that they filled in with Thomas’s next answer.
Mom: “So what’s the actual truth? What can you tell yourself and say back to the OCD?”
Thomas: “I’ll be okay with any number of ice cubes.”
Mom: (First we worked on getting down the negative thought on the pink side of an index card.) “So Harry, is this what you were thinking?”→Then they worked together on the true, positive thought which they wrote down on the back (white) side of each card.
1) “Mom is making more work for me.”→
“She is checking my understanding or giving me more needed practice.”
2) “This is too difficult and takes way too long. I’ll lose all my free time.”→
“Breaking it down like this will help me get it faster and save time in the long run.
Mom will set the timer and make sure we only work this long, so I’ll have plenty of free time.”
(Here are some other common ones, but I wouldn’t recommend presenting them all at once:)
3) “Making mistakes means I’m bad or stupid.”→
“Making mistakes is a normal part of learning. The faster I recognize a mistake and learn how to fix it, the faster I’ll learn.”
4) “Mom is correcting me because she thinks I’m stupid or don’t get it.”→
“Mom is correcting me because she knows I can understand and do this even better.”
5) “Mom is trying to punish or delay me by giving me a time out.”→
“I can’t learn when I’m too upset. I’ll learn better and faster if I give myself a little time to calm down.”
Step Four: Brainstorm management (“dealing with it”) strategies.
Mom: “So Thomas, next time you see a glass with something other than five ice cubes in it, how are you going to deal with the OCD?”
Thomas: “I can squish it by delaying it.”
Mom: “Great idea! Shall we set the timer for 5 minutes or 10 minutes?”
Thomas: “Five minutes.”
Mom: “While the timer is going, what can we do to help you with the anxiety? Balloon breaths?”
Thomas: :”Squeezes.” (He likes hand squeezes.)
Mom: “And what do you tell yourself?”
Thomas: “Any number of ice cubes is okay.”
Mom: “And remember the doctor told us we should also plan a way to get busy while the timer’s going. Should we do math facts? Lunch?”
Mom: “So Harry, next time you start panicking about homework, how can I help you?”
Harry: “I don’t know.”
Mom: “Do you feel it coming on or do you just suddenly explode?”
Harry: “What do you mean, ‘explode’?”
Mom: (Starting to show him the pink side of the card from step one) “You know, the homework explosion.”
Harry: (laughing) “Oh. I don’t know. I just get mad.”
Mom: “Maybe it just broadsides you. How about if I see signs of it coming (you know, the clenched fists and high voice), we try the deep breaths?”
Harry: “No! I don’t like doing those!”
Mom: “How about push-ups or jumping jacks?”
Harry: “No! I won’t do them!”
Mom: “Well, ok, but if I hear you make those negative thinking statements, I’m going to hand you a pink card.”
Harry: “What do I do with it?”
Mom: “Turn it over and try on the other way of thinking.”
Harry: “Ok, I’ll try it.”
Step Five: Set up contingent, controlled rewards, meaning positive consequences the child chooses and can look forward to. The reward should be simple, controlled: meaning not generally accessible (if the child has ready access to it anyway, it won’t mean anything), dependent on replacing the maladaptive with the adaptive behavior, and given as immediately as possible after the positive behavior.
Mom: “Thomas, I can see you working hard on this ice cube OCD. Ready to tackle it head-on?”
Thomas: “What do you mean?”
Mom: “The doctor says that you can stop OCD’s faster when you exercise your “stop muscle” in the brain.”
Thomas: “That’s her answer for everything. Practice.”
Mom: “True. So she suggests doing ‘exposure-response’ homework. Twice a day, we give you a glass of water or juice with some other number of ice cubes than five. You stop yourself from dumping the ice cubes for five minutes on the timer.”
Thomas: “Then what?”
Mom: “You do what you like with the drink. I’m hoping you just drink it, and find you don’t have to dump it after all. OCD is like a wave. If you wait it out, it passes over, and you won’t feel the need to dump anymore. We can gradually increase the timer to wait for longer lengths of time, till you get to that point.”
Mom: “Once you’re not dumping drinks anymore, we’ll celebrate, and go out and buy some of your favorites!”
Mom: “So Harry, next time we have a lot of homework to correct, how do you want to handle it?”
Harry: “Just let me do it, and don’t check it.”
Mom: “That sounds like a great goal. I’d love to do that once you’re ready.”
Harry: “What do you mean by ‘ready’?”
Mom: “When you’re checking your homework yourself, and correcting your own mistakes.”
Harry: “Mom! That’s too hard!”
Mom: “So we’ll get there step by step. The first step is checking the first three problems of your math homework yourself today. If you do, and they are correct when I look them over, you get three pennies in the homework jar. We can talk about what you want to use the pennies for- you can turn them in for a playdate or computer time.
In the meantime, what do you think a reasonable amount of time to spend on homework might be?”
Harry: “I don’t know.”
Mom: “Well, your teacher says 45 minutes a day is expected for 4th graders”.
Mom: “So let’s set a timer. Do your homework, and we’ll check it together. After 45 minutes you’re done, even if we’ve only corrected part of it. But if you start fussing and complaining, I turn off the timer during the fussing. It only counts, and the timer only restarts when you’re working.”
Harry: “Ok. Let’s try it.”
(Discussion with the teacher ahead of time to give her a heads up on this plan is advisable, so she isn’t caught off guard when some of the homework is turned in uncorrected or even incomplete.)
Step Six: Create a hierarchy of specific recurring problematic situations, and tackle them from easiest to hardest. Don’t get stuck- keep moving up the staircase, while you gradually hand over the responsibility of self-regulation to the child by getting him to query/say to himself what you have been saying to him.
Mom and Thomas might sit down and come up with four or five common OCD’s Thomas displays, rank them according to how anxious/how hard it would be to stop doing each one, and work on them one by one, easiest to hardest, with a celebration/reward after each success. For example, Mom could create a staircase with dumping ice cubes on the lowest step, then sitting on every bench they pass by on the next step, then pulling off sticks from our neighbor’s bush on the next, and finally on the top step cutting up yard-long pieces of tape into tiny pieces before doing each page of homework, as these are all problematic OCD’s for Thomas.
For strategies on dealing with OCD’s see my previous blog entitled, “A Contemplative Walk… Working with OCD,” from 2013. The basic exposure/response prevention “homework” is for the individual to intentionally and regularly expose himself to the OCD or anxiety trigger by gradually increasing degrees (for example, if one is afraid of dogs, one would not immediately expose oneself to a huge German shepherd, but start out with a small, very tame dog or possibly even a picture or movie about a dog), and make himself stop (not perform the compulsion or fight/flight response) for increasing amounts of time. Each time he successfully prevents himself from performing the compulsion, the “stop muscle” in his brain (in the basal ganglia) gets stronger, and the OCD gets weaker.
Mom: “Harry, how would you rank the things you have to do for school but make you feel anxious or overwhelmed, from 0 to 10?”
Harry: “Like what?”
Mom: “Like correcting your homework, reading a chapter from a chapter book daily, writing a report, or cleaning out your backpack?”
Harry: “Homework 6, chapter book reading 5, report 10!, backpack 4.”
Mom:” Ok, I put the four school tasks on four index cards in rank order of difficulty. I’ll give you all the support you need to get through them all, but we’ll work towards independence on the backpack first. Each time you master a card, we’ll do something really fun.”
Harry: “Can we go to Target for baseball cards?”
Mom: “That sounds good to me! And when you make it through all the cards, I’ll even get Dad to take you to a Angel’s game. So tell me what you know about keeping your backpack in order… ”
So there you are, CBT in a nutshell, or at least a flavor of it. CBT is a powerful, multipurpose tool, used successfully in a wide range of psychological disorders, including depression, anxiety, OCD, eating disorders, substance abuse, insomnia, posttraumatic stress disorder, personality disorders, trichotillomania (hair-pulling), tic disorders, and other repetitive behavior disorders. In Thomas’s case, we used CBT to work on OCD. In Harry’s case, we used it to develop a higher frustration threshhold. As parents, frontline and in the trenches, we need this tool.
A lot of CBT is commonsense. Teach your child to become more attuned to the body, recognize the physical symptoms of intense emotion and use deep breathing and muscle relaxation to ameliorate it. Address emotional dysregulation in its early stages while there’s still some frontal lobe control (ie ability to use his thinking brain). Teach him to become more self aware, both in monitoring his emotional state and identifying false, negative thinking. Help him learn how to replace it with true, positive thinking, and use a Socratic approach to develop the child’s multicausal thinking, giving him the freedom and support to brainstorm a variety of possible solutions and then to exercise judgment to decide upon a course of action. Show him how to harness motivation and reward to help execute those plans. Work systematically and persistently, from easier to harder, with the goal of transferring more and more control and responsibility to the child for his own emotional regulation. Set reasonable goals and expectations and make the steps as little as needs be for your child to experience success regularly with a reasonable, not heroic amount of effort.
CBT has got to be more effective than not knowing what to do, getting upset in reaction to our children’s crazed behavior, and acting out of frustration or trying to take over. So don’t be afraid to try it. Consider reading Dr. John March’s (2007) book “Talking Back to OCD,” or Dr. Anne Marie Albano’s book, referenced earlier. If you need more help, ask your pediatrician for a referral to a licenses psychologist or mental health provider experienced in CBT (you can ask if the therapist has any certification from the American Board of Professional Psychology or from the Academy of Cognitive Therapy). Things can only get better as you start moving your child in the right direction.
Disclaimer: CBT is only one tool in a parent’s toolbox. It is most appropriate to use on “crazed” behavior that may be primarily due to biologically-based.(meaning due to neurological wiring or temperament) negative emotion. But a lot goes into a parent’s decision that the emotion is irrational. Lots of times children get upset for very good, legitimate reasons, and those feelings need to be affirmed and their causes rectified, not extinguished with behavioral methods. Also some seemingly baseless negative emotions have deep roots in traumatic memories. You might need other tools to help you uncover and address the pain of these kinds of past experiences, such as psychodynamic or play therapy. Above all, there is no substitute for first and foremost listening to your child, and letting him know you care about all his feelings, rational or not.
 OCD stands for obsessive compulsive disorder. It is due to a brain glitch in which the individual has a recurrent false thought (like “there are always dangerous germs on doorknobs”) that compels him to perform a compulsion (like “I must wash my hands every time I touch a doorknob”).
 CBT stands for cognitive behavioral therapy. It is based on the assumption that thoughts lead to actions, and so if you repair the maladaptive cognitions or thinking, you can improve the behavior.
Read Full Post »