Helping an Anxious Child: Ideas from Cognitive Behavioural Research

Every child feels anxious sometimes. Fear of the dark, worry before a test and first-day nerves are part of growing up, and most pass with time. For some children, though, worry starts to shape daily life: refusing to go to parties, needing a parent in the room to fall asleep, stomach aches every Monday morning.

This article explains some ideas from cognitive behavioural research that can inform how adults respond. It is not therapy and cannot replace an assessment. If your child’s anxiety is persistent or getting in the way of daily life, the section at the end explains where to go.

The cognitive behavioural model

Cognitive behavioural therapy (CBT) grew largely from the work of the psychiatrist Aaron Beck, whose book Cognitive Therapy and the Emotional Disorders (1976) argued that the way people interpret situations shapes how they feel and what they do.

The model is often drawn as a triangle linking three things:

• Thoughts: “Everyone will laugh at me if I get it wrong.”
• Feelings, both emotional and physical: fear, a racing heart, a churning stomach.
• Behaviour: staying silent, asking to go to the toilet, refusing to go to school.

Each affects the others. An anxious thought produces anxious feelings, the feelings make the child want to escape, and escaping prevents the child from finding out that the feared outcome might not happen, or would be manageable if it did.

Why avoidance keeps anxiety going

Avoidance is the central idea for parents and teachers to understand.

When a child avoids something they fear, their anxiety drops immediately. That relief is real, and it teaches the brain a lesson: the situation was dangerous, and escaping made me safe. Next time, the urge to avoid is stronger.

Consider a child who is anxious about reading aloud. The teacher, seeing distress, stops asking. The child is relieved. Over the term, reading aloud becomes more frightening, not less, because the child never has the experience of doing it and being fine.

Family accommodation

Parents naturally try to protect an anxious child from distress. Eli Lebowitz and colleagues at Yale use the term family accommodation for the ways parents change their own behaviour to reduce a child’s anxiety: answering the same reassurance question many times a day, sleeping beside a child who fears being alone, ordering for a child in a café, or avoiding having visitors.

Each accommodation is loving and makes sense in the moment. Over time, though, it can maintain the anxiety, because the child learns they cannot cope without the parent stepping in.

In a randomised trial published in 2020, Lebowitz, Carla Marin, Alyssa Martino, Yaara Shimshoni and Wendy Silverman compared a parent-only programme called SPACE (Supportive Parenting for Anxious Childhood Emotions) with standard CBT delivered to the child. The study involved 124 children aged 7 to 14 with anxiety disorders. SPACE, which teaches parents to reduce accommodation while responding supportively, did as well as CBT on the main outcomes. The children never attended sessions themselves.

Gradual exposure

The opposite of avoidance is approach. In CBT this is often called graded exposure: facing feared situations in small, planned steps, starting with something only a little uncomfortable and building up.

A child afraid of dogs might move through steps like these:

1. Looking at pictures of dogs together.
2. Watching a dog from across a park.
3. Standing near a calm dog on a lead while the owner holds it.
4. Stroking a friend’s quiet, familiar dog.

Each step is repeated until it feels easier before moving on. The child stays in the situation long enough to learn that what they feared did not happen, or was bearable. The child should have a say in the steps, and should never be forced or surprised.

What the evidence shows

A Cochrane review by A. C. James and colleagues, including Cathy Creswell (2020), combined 87 randomised trials of CBT for anxiety disorders in children and adolescents. Among children receiving CBT, 49% no longer had their main anxiety diagnosis after treatment, compared with 18% of those on a waiting list or receiving no treatment. The authors rated this evidence as moderate certainty. They found less clear evidence that CBT outperforms other active treatments or usual care, and the clearest results concerned short-term outcomes.

Parents can play a large part. In a UK trial led by Cathy Creswell (2017), parents of 136 children aged 5 to 12 with anxiety disorders were taught to use CBT strategies with their own child, with about four hours of contact with a mental health worker. Outcomes did not differ significantly from those of a brief therapy delivered directly to the child. Creswell and Lucy Willetts have also written a self-help guide for parents, Helping Your Child with Fears and Worries.

Ideas for home

• Notice and name the feeling, then express confidence: “You’re feeling really worried about the party. I know it feels hard, and I think you can do it.”
• Reduce reassurance gradually. If your child asks the same question many times, answer once, then say kindly, “I think you know what I’m going to say.”
• Encourage small brave steps instead of removing the challenge. Plan them together.
• Praise the approach, not just the outcome: “You went into the classroom even though you felt nervous.”
• Be curious about thoughts. Ask “What do you think might happen?” and “What happened last time?” without arguing the child out of the worry.
• Look after your own anxiety. Children learn a great deal from watching how adults handle worry.

Ideas for school

• Plan gradual steps instead of removing all demands. A pupil anxious about speaking might start by answering on a mini whiteboard, then to a partner, then to a small group.
• Agree a consistent plan with home so the child gets the same message in both places.
• Give advance warning of changes and a predictable routine for difficult moments, such as arrival.
• Be cautious about long-term exemptions from activities. They may relieve distress today and make it harder next month.
• Share concerns with the SENCO or pastoral lead, and keep a record of patterns.

When to get professional help

Seek advice if anxiety is not improving or is getting worse, if self-help is not working, or if it is affecting school, family life or friendships. Your GP is the usual starting point and can refer to NHS Child and Adolescent Mental Health Services (CAMHS). Talk to your child’s school as well: the class teacher, SENCO or pastoral team may know of support in school or locally. If a child talks about harming themselves, or you are worried about their immediate safety, seek urgent help through your GP, NHS 111 or emergency services.

Further reading

• Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders. International Universities Press.
• Creswell, C. et al. (2017). Clinical outcomes and cost-effectiveness of brief guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. The Lancet Psychiatry, 4(7), 529-539.
• Creswell, C. and Willetts, L. (2019). Helping Your Child with Fears and Worries (2nd edn). Robinson.
• James, A. C., Reardon, T., Soler, A., James, G. and Creswell, C. (2020). Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews, CD013162.
• Lebowitz, E. R., Marin, C., Martino, A., Shimshoni, Y. and Silverman, W. K. (2020). Parent-based treatment as efficacious as cognitive-behavioral therapy for childhood anxiety: a randomized noninferiority study of Supportive Parenting for Anxious Childhood Emotions. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3), 362-372.