Cool Kids don’t worry!

The following article was published in the March 2014 edition of the UK  journal ‘Counselling Children & Young People’.

Narelle Smith uses the Cool Kids programme in Australia to address anxiety with groups of children and parents.

A few years ago, I spent time deputising as team leader of an early intervention programme for families. In every family I visited, there was at least one child suffering from anxiety. When I say suffering, I mean that every aspect of their development was severely limited by anxiety, in every environment. The parents also had a high level of anxiety that fed the children’s anxiety. I asked one of the caseworkers to investigate the availability of the Cool Kids programme (1) for the children we were working with. Apparently there was a waiting list, and the families would have to meet certain criteria. Not good enough – our kids needed help now. I decided to run Cool Kids myself.

CBT at its best

Cool Kids is an evidence-based anxiety treatment programme developed by the Centre for Emotional Health at Macquarie University, New South Wales, Australia. Many variations have been developed – for pre-schoolers, middle childhood, teens, outreach, autism spectrum, and for schools – and it has been translated into other languages. Cool Kids is cognitive behavioural therapy at its best. Prior to running Cool Kids, I wasn’t that keen on CBT, but this is a seriously good programme. The package provides a friendly workbook for the children, a workbook for the parent and a manual for the practitioner. The Cool Kids strategies involve naming the child’s worries and fears, the worry scale, detective thinking, approaching and challenging worries and fears by steps, social skills, being assertive, challenging negative attributions, and dealing with bullies. The programme is readily
accessible to practitioners and families due to being fairly low cost and available for purchase over the internet (2). Thankfully, there were no licensing loopholes requiring me to be trained in the programme before I could facilitate it. I purchased the manual and workbooks online and I was on my way.

As many of our children had a number of learning difficulties, I considered running the Cool Kids programme for children on the autism spectrum. I purchased the facilitator’s manual for that programme but it was all written in the third person and I preferred to speak to the children directly. The programme also used puppets to illustrate many of the points. Although I have used puppets with young children, it was out of my comfort zone with 10-year-olds. I decided to run the standard Cool Kids programme for children in middle childhood.

The structure of the group programme has four parts to the two-hour weekly sessions. These parts are:
1.  Family together (approximately 20 minutes)
2.  Children alone (approximately 50 minutes)
3.  Parents alone (approximately 40 minutes)
4.  Family together (approximately 10 minutes)

Due to the nature of the families we were working with – lower levels of literacy, high stress, low coping, high separation anxiety in the children – I decided to run the programme for one-and-a-half hours, eliminating the ‘children alone’ section and increasing the ‘family together’ section to one hour, and having the final ‘parents alone’ section for half an hour. I was going to present the information in the ‘children alone’ component to both the children and their parents. My aim was for the parents and children to be receiving the same messages, so that the parents could see how the programme worked for their children and hopefully take the concepts back into the home. The caseworkers of the early intervention service also sat in on the sessions so that they could refer to the lessons during their weekly home visits. Two parents with a total of four children attended the programme.

Parents and children together

Running the programme with the parents and children together turned out to be a blessing. In my work with children, they constantly surprise and delight me with what they know and how they figure things out. As the parents sat with the children during the programme, the parents were surprised by their children’s knowledge and wisdom. The children were so in tune with the programme that they frequently took the lead and pushed theprogramme along with their enthusiasm and questions. The programme helped to relieve some of the parents’ own anxieties, and I challenged them to differentiate between their own anxieties and their child’s anxieties. The parents were able to use the same language (for the concepts) that I used with the children and were able to talk about the examples that I used.

In one detective thinking activity, Emily (not her real name) said she couldn’t sleep because she was worried about an intruder breaking into her house and killing her. We did lots of brainstorming and she wouldn’t budge. One of the points I came up with was that no one had ever been seen or caught lurking around her house. But there was no movement from her. We had lots of evidence to challenge the thought but still it persisted. Then, light-heartedly, I challenged her about her beliefs by saying: ‘It hasn’t happened yet, and I know this because you’re not dead.’ Her parent caught her breath, but the girl laughed and said: ‘You’re right.’

In the ‘family together’ session, also, I was able to normalise child behaviour for the parents. When I presented something to the children that was a little bit out of their comfort zone, they sometimes reacted by misbehaving, as children do. I was able to point out to the parents that the reaction came from fear, not from naughtiness. I was able to role model different ways of dealing with the behaviour and demonstrate how to respond to a child’s anxiety. All of this was spoken about in the parents’ session, but there was so much greater value in being able to show them how it was done.

In the ‘parents alone’ section, I was able to attune the parents to their children’s anxious behaviours. In one session, a parent was talking about her son’s inability to complete his school work. She said that he was simply lazy. I put the comment up for reflection, asking: ‘Lazy or terrified?’ and the parent’s mouth dropped open. In that moment, her perception of her child was challenged and corrected. She replied: ‘Yes, terrified.’

The children and parents grew in confidence during the programme. Every week we heard of small changes that the families were making, and small acts of courage by the children. Emily made the greatest leaps, taking on challenges and activities that would not have been thought possible previously. The benefits were seen at school, at home and in the community.

The children in the programme formed strong friendships with each other. This boosted their confidence and their motivation to attend the programme. Whilst they were attending the Cool Kids programme, the families attended a weekend adventure camp organised by a local charity. The children supported each other in practising their anxiety-busting skills, as there were many activities at the holiday venue that tested their confidence.

I received a text from one of the caseworkers during the school holiday camp, saying a huge thank you and a ‘yay for Cool Kids’ and that I was magic! Emily had been on the flying fox, even though she was scared, and had made many friends. I replied: ‘It’s not me – I just create the space for other possibilities using evidence-based tools. All credit goes to the kids for taking up the challenge, to their parents for entertaining the possibility of change, and to their caseworkers for reminding the parents of what is needed for their children to grow!’ And this is true – it is crucial to provide an environment of challenge and support, and liaise with others.

Unfortunately, the families could not attend the last three sessions of Cool Kids due to illness. I worked really hard to try to reschedule those sessions but the momentum was lost, and I had long since returned to my regular job in another programme. This was a shame because the children missed out on the social skills and bullying aspects of the programme. Emily was teased at school and was given no support and lost touch with much of the confidence she had gained by attending Cool Kids. I resolved that in the future, if I were to run Cool Kids ever again, I would let nothing prevent me from the completing the programme.

 

Mark Two – Cool Kids in a school

Twelve months later, I found myself working in a public (government) school. The position was funded because 10 per cent of the children at the school were on the autism spectrum, and it was my job to focus on the students’ social and emotional wellbeing. Yes, there were lots of kids with autism, but I saw a whole lot more with anxiety (some had both autism and anxiety).

I rolled out Cool Kids again. The principal and teachers were incredibly supportive of me running a Cool Kids group during school time. The first group I ran at the school attracted three parents and four children. Two of the children were siblings, Lilly and Matthew (not their real names) and both were on the autism spectrum. This group had children aged five to 10 years of age. Again, I ran the standard programme for middle childhood.

The most remarkable transformation occurred with Lilly, and confirmed for me that the kids with chronic anxiety have the most to gain from Cool Kids. Lilly was eight years old. It was hard to separate her autism from her anxiety. She had trouble getting to school, and then completing certain tasks at school. She had no friends. She had a constant frown on her face, and behind the frown was a mixture of anger, sadness, and constant fear. She had trouble doing social activities that most other kids would consider normal. There was concern from the parents and teachers that Lilly’s behaviours were rubbing off on her younger brother, Matthew.

Lilly coped fairly well with the first few sessions, but as we progressed and started talking in depth about feelings and fears, she became increasingly agitated. She had an aversion to acknowledging her feelings or fears. Every time we mentioned either, she redirected the talk to her love of computers. Lilly could not tolerate the Worry Scale at all, a key part of the programme. I told her mother not to be concerned, but to do as much as she could, and to think of any small gain as a win.

From the beginning of the programme, I sent an email to the teachers and principal each week advising how each child was getting on and what we were learning. It was a small school, and with having so many children with a variety of challenges, team work was vital. Lilly’s teacher brought Cool Kids into the classroom. At the end of each day she had a talk with Lilly about how her day had gone, what she thought she had done well and what had worried her. The teacher was able to pick up when Lilly was starting to get anxious and did the Cool Kids activities with her. She did detective thinking with her for every new challenge. She communicated to Lilly that any failure was just another step towards success. She walked with her every step of the way, being curious, encouraging and supporting her, and never dismissing her fears and worries. This little school, a tiny dot on
the Australian landscape, has been blessed with some of the best teachers on the planet.

The sessions with the parents, after the children returned to class, went for up to two hours, talking with them about all of the struggles they had in raising their children. For Lilly and Matthew’s  parents, their children’s autism and anxiety had been very hard on everyone, and although they had received early intervention services, they didn’t know where to turn next and whether there was any light at the end of the tunnel.

Crisis time

In the third session, it all came to a head for Lilly. She ended up under a table screaming her guts out at me. She was angry and frustrated, I was pushing her limits to the maximum by talking about fears and feelings. I quickly and easily fell into emotion coaching, acknowledging all of her anger, frustration and fears. I reflected everything she said to me. This continued for a few minutes. When Lilly hit rock bottom and felt validated, she regained her composure and asked to go to the toilet. I said: ‘You do whatever you think you need to do to make yourself feel better.’ Her mother offered to go with her, and as they were leaving the room, Lilly’s mum said to her: ‘It’s OK, Lilly.’ Lilly turned around and snapped: ‘It’s not OK Mum. It’s never OK.’

Parents of anxious kids often seek to reassure their kids but it seldom works because the reassurance doesn’t match how the child is actually feeling, and it doesn’t feel real or genuine to the child. It can make the child feel unheard or annoyed, and they struggle with ‘I am feeling this way, but Mum/Dad is telling me that I should be feeling that way’. This small but intense interaction became a breakthrough for Lilly because in the previous weeks she had not been able to express any feelings at all. She had been blocking all of her overwhelming feelings. It demonstrated that Lilly was feeling safe enough within the group to express herself.

After Lilly went back to class, we did talk about whether she should continue with Cool Kids. Sometimes, we need to get the grumbles out of the way in order to get better. We didn’t want to distress her, but we didn’t want to rescue her either. Kids with anxiety are too frequently rescued. But that week, Lilly was more verbal than the previous weeks (even though it showed in screaming at me), and in that there was some hope. Nevertheless, I told the teachers and her mum that if she continued to not cope over the next few weeks, we’d reassess.

Moving on

After the third session, I let Lilly decide whether she wanted to come to Cool Kids or not, and how long she wanted to stay. I had done this since the start of the programme for Lilly’s brother, Matthew, who was only five years old and couldn’t focus for much longer than 20 minutes. Their mother was there for every session, even if her children weren’t in attendance. The other two children in the group attended every session, and we continued to work through the programme, regardless of absences. Lilly and Matthew’s mum took every element of the programme and applied it at home as much as she felt she could comfortably do without pressuring or stressing her children. She admitted that it was extremely hard for her at times to continue with the programme. She worried whether her children were getting any benefit from it, whether in fact it was doing them harm.

That third session proved to be a catalyst for Lilly’s healing. Her subsequent improvement astounded all of us – her parents, her teachers, and other parents at the school. It was her birthday soon after the third session and she asked her mum if she could go to aquagolf for her birthday. Surprised, her mum agreed. It was a huge first step, but Lilly couldn’t pluck up the courage to go into the venue. A few days later, she asked again, and her mum again agreed. This time she did it. Soon after that, there was a school excursion, which her mum would normally attend with her, but this time she said she would like to try it on her own, and did, with support. After that, she had play dates, roller skating, trampolining, and all the other activities that kids enjoy. She even started getting herself ready for school before the rest of the family got out of bed. Some days, she told her teacher that the Cool Kids group was the best part of her day.

However, as we saw Lilly grow and glow, we saw her brother develop a strong school anxiety, and become increasingly difficult at home. As Lilly changed, Matthew’s world did too, and it seemed that he had to fill the space that Lilly once occupied. He did not respond at all to emotion coaching. After the Cool Kids group completed, I continued to see Matthew, doing art with him even though he said he hated drawing (but beaming and revelling in every session). Working with his teacher, Matthew’s school anxiety slowly reduced.

I also continued to see the other two children individually, briefly each week for several weeks, as a transition period, helping them to integrate Cool Kids strategies into the ups and downs of daily life. Lilly was the only child from that group that I did not continue to see. She whizzed past me in the playground during break and lunch as she played happily with her friends, sometimes acknowledging me (mostly not). Of course, Lilly still has autism, but the anxiety is not exacerbating the autism and she is a completely different child.

When the children attend alone

Another parent approached me about running the programme for his child. I said that I could work with the child individually, but then another child was referred to me for school refusal and issues that the parent thought were related to bullying. After chatting with the child, I suggested to the parent that the child’s difficulties stemmed from anxiety. There did not appear to be any bullying.

Progress was much slower with these children, as the parents were not able to commit to attend the sessions. I kept them up to date by phone and email, but it was not as effective as them participating in the group with their children. They were not doing the work at home, and homework is an important aspect of the programme. Also, without the parents’ attendance, I was helping the children complete the workbooks, as they were not quite functionally literate. It was slow and steady with these young ones.

Despite all of this, the parents and teachers said they saw improvement in the children’s anxious behaviours, and, best of all, the children were able to provide tangible examples of when and where they used their Cool Kids skills. They approached me on a day when I was going to undergo a small surgical procedure in the afternoon. I played it up and said that I was scared. They spontaneously asked me where I was on the Worry Scale, and started talking me through detective thinking and brainstorming all of the reasons why I would be OK. One of them said: ‘They have good drugs, so you won’t be able to feel it.’

I have used Cool Kids in all manner of ways. I had been working with a boy who had a most difficult home life. I was working with him on his social skills and it dawned on me one day that he could have anxiety. I used Cool Kids as the basis for talking to him about the anxiety that stems from abuse and trauma. It made perfect sense to him. As he was bright, I was able to explain to him the brain processes involved in anxiety. He started to become attuned to his anxiety and began to understand that his negative attributions in social situations were due to the trauma and abuse lens through which he viewed the world.

By understanding how his anxiety impacted on his thoughts and actions, he was able, at times, to catch the negative thoughts before they impacted on his behaviour. It was a handy skill to have as he headed off into adolescence. I have also used the Cool Kids concepts to speak with parents about their anxiety.

Reflection on my methods

I have been queried about my change to the Cool Kids programme of allowing parents into the children’s session. It’s an evidence-based programme and I have changed it. Some people have said that it’s an invasion of the child’s privacy to include the parents in the session. Perhaps it is, but it’s also where I think the best work is done.

The families’ dynamics come into play, and of course you do need to be a somewhat competent group worker to manage all of that. But the programme’s activities provide enough tension and challenge to produce vulnerability, honesty and a glimpse into patterns of knowing, being and doing. These can be held up as a mirror to the parents, as a point for exploration and discussion. I get real-life examples and specific behaviours that I can talk with the parents about, rather than dryly presenting  information from the parents’ workbook.

On the other hand, there is an activity in the second session ofthe programme where the children have to name their fears. Some children have a lot of difficulty doing so in front of their parents. In the first group I ran, one parent realised what was happening for her child and left the room for five minutes. I now warn parents that I may have to ask them to leave the room briefly if I think there is an activity that a child is struggling with in their presence.

Having four children in a group is a magic number for me. It’s enough to keep up the momentum, but small enough to cater for individual needs and flexibility. The programme’s recommended number is eight, and Community Health run it with 12. Running the programme with children aged five to 10 years is tricky and requires a lot of flexibility. The therapist manual recommends dividing children into groups of ages six to eight, eight to 10 and 10 to 12, and this would be ideal if you had the numbers.

One practitioner asked me if I do any screening or surveys prior to accepting children and parents into the group. I do not, but I am fortunate to be already familiar with the families I accept into Cool Kids. I’ve seen them before and I have some history. Besides, I don’t have the time and volume pressures on me that services like Community Health have, so I can accommodate individual needs better. I can run more sessions if needed, I can see children individually after the group, I can extend and shorten sessions, and so on.

From what I have seen, I am fairly certain that anxiety is being overlooked. I’m surprised that early intervention services don’t regard anxiety treatment as a high priority for both children and their parents. Some of the children who are diagnosed with ADHD or autism seem to have greater social and emotional problems arising from anxiety than they do from their primary diagnosis. The Cool Kids therapist manual says that anxiety should be the primary diagnosis for children to be accepted onto the programme. I do wonder about the wiggle room on that one. My concern is that programmes like Cool Kids are not more readily available, and children aren’t getting the knowledge and support they require.

Working with Cool Kids has convinced me, however, that my work is just one leg of the stool. Without the other two support legs – the parents and the teachers – it’s a very wobbly stool for the child. The very best gains can be made by communication, connection and cooperation amongst all of the child’s significant others, to provide consistency for the child. Working in the school – with teachers, parents and children – is an extremely effective model for tackling child anxiety.

 

References
1.  http://centreforemotionalhealth.com.au/pages/cool-kids-program.aspx
2.  http://accessmq.com.au/catalog

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About Narelle Smith

Child & Family Worker

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