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Supporting Children’s Mental Health with CBT — Unpacking the Thoughts, Feelings, and Behaviors of Kids



This is a guest blog post by: Alison McGrath, LMHC. Alison is the author of the new CBT picture book, Walter and the Worry Test. I love this book because it makes CBT concepts accessible to kids. Walter works with his school counselor and learns how to use the CBT Triangle. He learns how his thoughts, feelings, and actions are all connected, which is a concept we teach in Skills for Big Feelings too! When Walter learns how to  challenge or “test” his thoughts, it has a positive impact on his life.  Check out the book here.


Cognitive Behavioral Therapy (CBT) is one of the oldest and most researched forms of therapy. CBT has been proven effective for a variety of different disorders such as Anxiety, Obsessive-Compulsive Disorder, Depression, and Bipolar Disorder, and can be an extremely useful tool in improving individuals’ quality of life.


The basic science behind CBT is that all thoughts lead to feelings, which lead us to some sort of behavior or action. On paper, this makes perfect common sense. However, those who worry can have a very difficult time reframing the thoughts that occur in their minds. CBT treatment is proven to be very effective for a wide variety of diagnoses and a broad spectrum of ages beginning at three years of age.



Thinking about our Intrusive, Repetitive, or Distorted Thoughts


We all have thoughts. Some good, some bad, some repetitive. There are many different types of thoughts. Intrusive thoughts are ones that come into our head and despite everything we do, we can’t get rid of them. These are usually unpleasant thoughts and are often unwelcome. Intrusive thoughts can be a sign of something else occurring such as Depression, Obsessive-Compulsive Disorder, or Post Traumatic Stress Disorder. The most important message to give to children who have intrusive thoughts is that thoughts are just thoughts and can not actually cause harm. This way of thinking can help to reframe the unwanted messages. 


Repetitive thoughts can be a symptom of disorders like Obsessive-Compulsive

Disorder. These are recurring and uncontrollable thoughts, which usually lead to a person having to act on that thought (compulsion). A repetitive thought can often cause worry and increases stress. I like to visualize repetitive thoughts as a hamster on a wheel going around and around and I will often use that visualization when explaining this to children. 


Cognitive distortions can also occur which are also known as errors in our thinking. We need to ask ourselves what is the reality of this thought coming true? I teach children that worry thoughts usually start with a “What if….” Such as “What if this happens?….What if that happens?” However, in reality, the chances of the “what if” thought actually happening are small.  In fact, research shows that only about 8% of what we worry about actually occurs (LaFreniere & Newman, 2020).




Common Worry Thoughts at Different Ages


According to the Children's Hospital Association, common worry thoughts at different ages are as follows.


Common worrying thoughts in infants include:


  • Loud noises

  • Strangers 


Common worrying thoughts in primary school age kids:


  • Bad weather, such as tornadoes or loud noises from thunderstorms

  • Being home alone

  • Being kidnapped

  • Medical providers such as going to the doctor or to the dentist

  • The dark and noises at night



Common worrying thoughts in teenagers:


  • Being in a driving accident

  • Failure in school or work

  • Getting hurt or dying

  • Medical providers such as going to the doctor or to the dentist

  • Social fears such as embarrassment at school, public speaking, and performance





Understanding the Six Core Emotions, How to Identify and Name Your Feelings, and Coping Strategies to Feel Better


According to psychologist Paul Eckman, the six core emotions are: sadness, happiness, fear, anger, surprise, and disgust. All of our thoughts lead to certain feelings. I am a big believer in teaching children that all feelings are okay. Sometimes children will challenge me to say that’s not true or my grown-up tells me that boys shouldn’t cry.


Teaching our children that all feelings are okay is one of the most important messages we can send. When we identify and accept our feelings, we are then able to quickly identify a strategy to feel better. This is similar to the Feeling-Breath-Thought (FBTS) Strategy taught throughout Skills for Big Feelings. I often teach children to body scan (to identify how they are feeling), identify a coping skill, act on the strategy, or talk to an adult for help. While some feelings are less pleasant than others, it doesn’t make them right or wrong. Unpleasant feelings are ones that can cause us to be emotionally dysregulated or cause some form of discomfort. 


One's feelings may have a direct impact on body sensations, causing individuals to think something is physically wrong with them. This is where coping strategies and mindfulness can help. Mindfulness encourages individuals to focus on the present. We stay grounded in the here and now, and try to avoid thinking about things that happened yesterday, or what might happen in the future. 


Coping strategies are things that make our bodies feel better allowing us to change our behavior. I find brainstorming a list of strategies to create a toolbox for children can make accessing support easier. Helpful coping skills for children often include drawing or coloring, deep breathing and taking a break. 


The US Department of Health and Human Services recommends the following:


  • Name your own feelings.


  • Model how you have many different feelings during the day.


  • Help your child name their feelings through words or pictures.


  • Tell them that all feelings are OK if they are expressed safely.


  • Use books, songs, games, stories, and play to talk about many different feelings. Use words to help children name their feelings, such as happy, angry, disappointed, excited, frustrated, surprised, loved, scared, sad, peaceful, left out, delighted, quiet, or tired.


  • Make checking in about feelings part of the daily routine.



How to Support Children with Better Understanding and Control of Their Behavior 


Sometimes when we think of behavior, we think of it in a negative context. You might hear someone say “He is behaving badly”, or “I am so sick of this behavior.” However, behavior isn’t necessarily bad. In fact, the Merriam Webster definition of behavior is, “the way in which one acts or conducts oneself, especially toward others.” It is important to understand the definition as we take a closer look at how our behavior is impacted by our thoughts and feelings.


One's behavior is the observable action that others can see. This is how people will make inferences and determinations about the person or situation.  This is the only component that we have discussed which is observable to an outsider, since thoughts and feelings can not be seen. Behaviors are often how others analyze or make assumptions. It is also what is on display for others to see.


When we think and feel a certain way, it causes us to behave in a certain manner. An example I often use with children is this: if the recurring thought that “you won’t be good at something” makes you feel anxious, then you don’t perform as well as you could have.

When the emotional part of our brain has taken over, it makes it difficult for us to access the thinking part of our brain. When this happens, we often behave in a way that is not desirable and can become emotionally dysregulated, often creating even more negativity around anxiety.


When our amygdala is activated which can happen under emotional distress, the thinking part of our brains becomes impacted. When I teach this concept to children, I love to use Dr. Dan Siegel’s “Hand Brain Model”.  This is a concrete visual that helps children understand how their brain works when they become dysregulated.


To use this model, you will use one of your hands. Your wrist/lower arm is the spinal cord. The thumb is your amygdala, and if you close your hand tucking in your thumb the top fingers represent the prefrontal cortex. I explain the different jobs that your brain has, for example, the downstairs brain controls one's emotions and the upstairs brain controls one's thinking. However when we “flip our lid” the emotional part of the brain takes over.


When demonstrating with the hand model, you would lift the top fingers up, demonstrating the disconnection with both parts of the brain, and exposing the emotional part of the brain. It is definitely a helpful way to help kids understand the brain/ body connection. For another simple strategy to teach kids about the mind-body connection, check out this blog post.



How to Translate CBT in a Way that Children can Understand and Use 


There are a variety of ways we can help CBT make sense for children. One of the most effective ways to reach children is through literature. In my work as an elementary school counselor, I have found using picture books to be a powerful tool in guiding and supporting children's emotional regulation. This evidence-based support benefits include but are not limited to:


  • Increased relaxation

  • Stress reduction

  • Improving brain function

  • Increasing knowledge 


Psychology today describes bibliotherapy as "a therapeutic approach employing books and other forms of literature, typically alongside more traditional

therapy modalities, to support a patient’s

mental health.” In our post Covid-19 world, anxiety is something many of us are affected by. In my personal life with my own children, and in my professional practice with students at school, I gravitate towards teaching through reading. 


Throughout my career, I often wondered how I could use treatment that is effective, with a modality such as literature, to provide support for those who need it most. This is why I wrote the CBT picture book, Walter and the Worry Test and my goal is to get this book into as many hands of worried children as possible. 


In this story that makes CBT accessible to kids, Walter is impacted by his worries and experiences the feeling of butterflies in his belly causing him to feel sick, and not wanting to eat or go to school. Once at school, Walter is encouraged to see his school counselor when his teacher notices that something is wrong. 


Walter learns to “test” his worries with his school counselor. In order to do this, he draws a triangle and the counselor shows him how his thoughts, feelings, and behavior are all connected. The testing of his thought involves the counselor asking Walter specific questions in order to help him learn how to reframe his thinking. As a result of reframing his thinking, Walter’s feelings about the situation change, as does his behavior, which creates a more favorable outcome!


There are many books available on worry thoughts. Many good books! However, what Walter and the Worry Test provides is a simple and concrete tool that students can use to restructure their thoughts and mindset. This CBT story book also captures the powerful and transformative relationship between a counselor and student.




Finding the Just Right Book to Support Children with Anxiety: Teaching CBT to Children through Relatable Characters, Illustrations, and Text 



People often ask, who is Walter? My response is that there is a Walter in all of us. I truly believe whether your worries are big or small,  we all can work on reframing our thought patterns. Reframing our thoughts and asking ourselves the specific questions to “test” our thinking guide us to thinking more realistically about the “what if” thought.


Questions you may ask yourself or children, include:


  • Has this ever happened before?

  • What makes you think this will happen?

  • Do you have evidence to support this will happen?

  • Would you give the same message to a friend if there was one of their worries?


If the answer is no, there is a good chance you are wasting time, energy, and brain space on something that likely will not happen. 


There is a line in the book that is located on the dedication page. The text reads, “to all of the worried children I see you and you are not alone.” I sometimes wish I also included “I am you.” However, at the time I felt too vulnerable. Bearing this in mind,  we need to continue to remind children that all feelings are okay, empathize with how they feel, and provide accessible tools for them to utilize in order to feel better. 


To read more about helping kids with CBT, be sure to check out this blog post.


About the Author


Alison McGrath lives in Massachusetts with her husband, three children, and two dogs. Alison is a passionate School Adjustment Counselor who works with students from kindergarten through the fifth grade discussing worry-thoughts, coping strategies, and mindfulness. Alison loves to teach about growth mindset, self compassion, and reframing worry-thoughts. She has found the cognitive behavioral therapy (CBT) to be especially powerful with individuals who have anxiety. Her personal library of books is large, and she is a huge supporter of bibliotherapy. Alison’s hope is that this book will support educators and parents to help guide children on the journey to be as worry-free as possible! Learn more about Alison at www.authoralisonmcgrath.com.



References


Health, C. (n.d.). Childhood fears: What’s common and how can you help? Children’s Health. https://www.childrens.com/health-wellness/childhood-fears



Lucas S. LaFreniere, Michelle G. Newman, Exposing Worry’s Deceit: Percentage of Untrue Worries in Generalized Anxiety Disorder Treatment, Behavior Therapy, Volume 51, Issue 3,

2020.


Merriam-Webster. (n.d.). Behavior definition & meaning. Merriam-Webster. https://www.merriam-webster.com/dictionary/behavior?utm_campaign=sd&utm_medium=serp&utm_source=jsonld 


Posted May 17, 2019 by UWA. (2019, May 20). Our basic emotions infographic: List of human emotions. UWA Online. https://online.uwa.edu/infographics/basic-emotions/#:~:text=A%20widely%20accepted%20theory%20of,%2C%20anger%2C%20surprise%20and%20disgust



Teaching your child about feelings. ECLKC. (2022, April 5). https://eclkc.ohs.acf.hhs.gov/publication/teaching-your-child-about-feelings 



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