Coping Cat · Atlas

1. Introduction

Version followed: the standard individual Coping Cat programme for ages 7–13 (Kendall & Hedtke, 2006: therapist manual 3rd ed. and Coping Cat Workbook 2nd ed.; Parent Companion, Kendall, Podell & Gosch, 2010), 16 weekly sessions of about 50 minutes, as described by the CEBC profile, Kendall et al. (2023) and training sources. Named variants (C.A.T. Project for teens, Camp Cope-A-Lot computer version, group, brief and school formats) are covered where they differ. [source: CEBC; Kendall et al. 2023; NHS Scotland EIF] The therapist manual itself is not drawn on, so session numbering for sessions 1–8 is reconstructed from secondary descriptions and marked where uncertain. Later manual editions may exist; edition differences were not verified [uncertain].

Coping Cat is a manualised cognitive-behavioural treatment for children with problematic anxiety (separation, social and generalised anxiety, and related problems). The child learns to recognise anxious feelings and body reactions, notice anxious thinking, build a personal coping plan (the FEAR plan), and rate and reward their own efforts; then puts these skills to work in graded exposure to feared situations. [source: CEBC; Wikipedia] The core idea of change: anxiety is managed, not eliminated, by learning skills and, above all, by repeatedly approaching feared situations so that the child experiences mastery and learns that predicted catastrophes do not happen. Kendall et al. (2023) call exposure the most critical component and frame it as a set of behavioural experiments. [source: Kendall et al. 2023]

2. Framework

Format and dose. 16 sessions, weekly, about 50 minutes, mainly individual child sessions with a workbook; two parent-only sessions (sessions 4 and 9), and parents joined to other sessions when needed for exposures. One STIC ("Show That I Can") homework task per week. [source: CEBC; Wikipedia] Some descriptions give 16–20 weeks; school delivery uses sessions of about 30 minutes, up to twice weekly. [source: NHS Scotland EIF; Kendall et al. 2023]

Phase 1: Skills training (sessions 1–8). Goal: teach the child to recognise anxiety and to build and rehearse the four-step FEAR plan. Content: rapport and orientation, psychoeducation about feelings and anxiety, body clues, relaxation, anxious self-talk and coping thoughts, problem solving, self-evaluation and self-reward, then assembling and reviewing the FEAR plan (session 8). [source: CEBC; Henin slides; NHS Scotland EIF; Coping Cat DVD guide page]

Indicative session map (exact numbering in the 2006 manual not verified [uncertain]; order below follows a published study table that used Coping Cat and Henin's training slides):

Session 1: orientation to the programme, rapport, the child's anxious situations.
Session 2: recognising and naming different feelings; normalising anxiety.
Session 3: recognising the body's anxiety responses (body clues).
Session 4: parent-only session (programme information, parents' observations, enlisting cooperation).
Session 5: relaxation (managing the body's response). [uncertain: one source places relaxation in session 4 with parents met separately]
Sessions 5–6: recognising anxious self-talk and changing it to coping thoughts; problem solving.
Session 7: self-evaluation and self-reward.
Session 8: putting the FEAR plan together and reviewing it.
Session 9: parent-only session (review of skills, preparing parents for exposure, designing in vivo tasks).

[source: BMC Psychology 2024 Table 3; Henin slides; CEBC]

Phase 2: Exposure practice (sessions 9/10–16). Goal: use the FEAR plan in increasingly difficult real or imagined anxiety situations from the child's own hierarchy, from least to most feared, moving from role-play to in vivo practice. [source: Henin slides; CEBC; NHS Scotland EIF] Sessions 15–16: the child makes a "commercial" or ad teaching other children how to cope, reviews gains and celebrates. [source: Henin slides]

Criteria for moving on. The manual's split is by session number (8 skills sessions, then 8 exposure sessions), not by mastery test. Practical readiness markers [synthesis]: the child can name at least some body clues, catch an anxious thought and offer a coping alternative, and recite or use the FEAR steps with prompts. Do not delay exposure waiting for perfect skill use; Kendall et al. (2023) report that when services let exposure slip, many youth never got it (only 59% participated in exposures in one community study), so set a firm floor for in-session exposures. [source: Kendall et al. 2023] Ending: after session 16, or when hierarchy top items are achieved [synthesis].

Variants.

C.A.T. Project: adolescent version (ages 14–17 per CEBC; 13–18 per NHS Scotland), same structure with teen-appropriate format and language (Kendall, Choudhury, Hudson & Webb, 2002). [source: CEBC; Wikipedia; NHS Scotland EIF]
Camp Cope-A-Lot: computer-assisted version for ages 7–13; 12 sessions of about an hour, two blocks of six. Sessions 1–6 online (recognising anxious feelings and thoughts, coping strategies, self-reward); sessions 7–12 with a coach (any adult, including parent or therapist) doing role-plays and exposure tasks; materials are the Go-To-Gadget Workbook and Coach's Manual (Kendall & Khanna, 2022). Fewer than half the sessions need professional time. [source: ACF Prevention Services Clearinghouse; CEBC]
Group: about 4–6 children, one practitioner, 50–90-minute sessions; groups start after 3–4 individual sessions. [source: CEBC; NHS Scotland EIF]
Brief Coping Cat (8 sessions), family therapy manual (parents as co-clients), autism adaptation, telehealth delivery. [source: NHS Scotland EIF; Kendall et al. 2023] Content of these variants is [uncertain].

3. Guiding principles

Flexibility within fidelity. Deliver every core function (psychoeducation, coping skills, exposure, rewards), but tailor examples, pacing and activities to the child; rigid adherence is not linked to better outcomes. Practical meaning: keep the session goal, change the vehicle. [source: Kendall et al. 2023]
Exposure is the active ingredient. Practical meaning: protect the exposure half of treatment; if time is short, trim skills material, not exposure. [source: Kendall et al. 2023; synthesis]
Manage, not eliminate, anxiety. Anxiety is normal and adaptive; the target is anxiety that interferes. Practical meaning: success is approaching and coping while anxious, not feeling calm. [source: Kendall et al. 2023]
Collaborative coach. The therapist guides, models and cheers on; the child is put "in the driver's seat" (Kendall et al. 2023). Practical meaning: build hierarchies, plans and rewards with the child, not for them. [source: Kendall et al. 2023]
Youth agreement and control in exposure. Every exposure is agreed beforehand; the child is reassured they will not be forced into tasks they are not ready for. Practical meaning: negotiate the step size, never spring a task. [source: Kendall et al. 2023]
Reward effort, not outcome. Self-rating and rewards are for trying to cope. Practical meaning: praise the attempt even when the task was partly done. [source: Henin slides; Kendall et al. 2023]
Make it fun, or make it rewarding. Games, humour and a few minutes of play at session end build the alliance and serve as reinforcement. Practical meaning: plan a short fun activity into every session. [source: Kendall et al. 2023; Henin slides]
Alliance and motivation first. Alliance matters most early; ask the child's own reasons for coming and validate ambivalence, since a caregiver usually initiated care. Practical meaning: spend session 1 genuinely getting to know the child. [source: Kendall et al. 2023]
Practice outside the room (STIC). One weekly Show That I Can task. Practical meaning: every session ends with a concrete, doable task the child chose. [source: CEBC]
Developmentally pitched cognition. Younger children: concrete, playful tools (e.g., a "worry monster" character, body tracing); older youth: balanced, believable thoughts, not just positive opposites. Practical meaning: test whether a coping thought is credible to the child. [source: Kendall et al. 2023]
Parents as partners, not co-patients by default. Parents learn the model, support exposures and reduce accommodation; parental psychopathology triggers referral. Practical meaning: give parents specific jobs between sessions. [source: Kendall et al. 2023; CEBC]

4. Intervention inventory

Sources for this section: CEBC (components list, FEAR plan, STIC, parent sessions); Kendall et al. 2023 (rapport, psychoeducation, cognitive restructuring, exposure method, caregiver work); Henin slides (session sequence, thought bubbles, relaxation, ladder, parent guidance, commercial); NHS Scotland EIF (coping modelling, role-play, homework). Step-by-step detail beyond these descriptions is marked [synthesis]. All example language is illustrative unless quoted.

4.1 Rapport building and orientation (session 1)

Purpose / when: First session and the opening minutes of every session; alliance is most predictive early. [source: Kendall et al. 2023]
Steps: (1) Spend real time on the child's interests, games or casual chat. (2) Explain the programme: two parts, learning skills then practising them; weekly meetings; a workbook; STIC tasks; rewards. (3) Ask what the child would like to be different and why they think they are here; validate any reluctance, since a caregiver usually started treatment. (4) Begin a list of situations that make the child worried or nervous (seeds the later hierarchy). (5) Agree a simple reward system and set the first STIC task (e.g., note one time they felt good or bad this week) [synthesis on the specific task]. (6) End with a few minutes of a fun activity. [source: Kendall et al. 2023; CEBC; synthesis]
Example language (illustrative): "This is a programme where you learn some tricks for handling worries, and then we try them out together, a step at a time. You'll be the boss of how fast we go up the steps." / "Sounds like coming here was mostly your mum's idea. What would you want to get out of it, if anything?"
Watch for: one-word answers and compliance without engagement (slow down, play more); a child who believes they will be forced into feared situations (state clearly that each step will be agreed). Working: the child talks freely, returns next week willingly, completes the STIC task.

4.2 Psychoeducation about anxiety (child and family)

Purpose / when: Sessions 1–3 and both parent sessions; to explain how anxiety develops, persists and is treated. [source: CEBC]
Steps: (1) Describe anxiety as a normal, protective alarm that sometimes goes off when there is no real danger. (2) Explain that the goal is managing anxiety, not getting rid of it. (3) Draw the link between thoughts, feelings and actions (cognitive triangle) using an example from the child's life. (4) Explain how avoidance keeps fear going and why practice (exposure) is the main way it shrinks. (5) Check understanding by asking the child to explain it back with their own example. [source: Kendall et al. 2023; Henin slides; synthesis on steps 4–5]
Example language (illustrative): "Worry is like a smoke alarm. It's useful when there's a fire, but yours goes off when someone's just making toast. We're going to help you tell toast from fire."
Watch for: parents or child hearing "anxiety is bad and must go". Working: the child can describe their own anxiety cycle in plain words.

4.3 Feelings identification (affective education)

Purpose / when: Session 2; to build vocabulary for feelings and show that anxiety is one feeling among many with recognisable signs. [source: Henin slides; BMC Psychology 2024 Table 3]
Steps (synthesis built on the sourced aim): (1) Generate a list of feelings with the child, using pictures, magazine faces or acting games. (2) For each feeling, discuss how faces and bodies show it and what situations bring it on. (3) Normalise that everyone feels anxious sometimes; the therapist shares a brief, mild personal example. (4) Distinguish different intensities (a little nervous vs very scared). (5) STIC: notice and record one anxious and one non-anxious feeling during the week.
Example language (illustrative): "Let's play a guessing game: I'll make a face and you tell me what I'm feeling. Then you have a go."
Watch for: children who label every negative feeling "angry" or "bad"; work toward finer distinctions. Working: the child spontaneously names "nervous" or "worried" in a described situation.
Note: the workbook contains named feelings activities that were not seen [uncertain].

4.4 Somatic cue recognition: body clues (F of FEAR)

Purpose / when: Session 3, and before every exposure; so the child can use body sensations as an early signal to start coping. [source: CEBC; Henin slides]
Steps: (1) Ask what happens in the body when the child is scared (stomach, heart, breathing, sweating, shaking, face, muscles). (2) With younger children, trace their body outline on paper and mark where anxiety shows; with older youth, use a symptom checklist. [source: Kendall et al. 2023] (3) Link the sensations to specific situations from the child's list. (4) Teach the question "Am I feeling frightened?" as the first FEAR step: notice the clue. (5) STIC: record body clues during one anxious moment. [synthesis on 3–5]
Example language (illustrative): "When you walked into class on Monday, what did your tummy do? Where else did your body send you a clue?"
Watch for: health anxiety or a child who interprets sensations as illness; reframe them as the alarm's normal side effects. Working: the child reports clues in real situations, not only in the office.

4.5 Relaxation training (part of A of FEAR)

Purpose / when: Around session 5, for managing body arousal; used as one coping action, not as the main treatment. [source: CEBC (somatic management); Henin slides]
Steps: (1) Teach slow, deep breathing (e.g., breathe in slowly, hold briefly, breathe out slowly) and practise several rounds. (2) Teach progressive muscle relaxation: tense a muscle group for a few seconds, then release and notice the difference, working through the body. [source: Henin slides] (3) Use playful imagery for younger children (e.g., squeezing a lemon, a turtle in its shell) [synthesis; the workbook's own images were not seen]. (4) Record a short relaxation script for home practice [synthesis]. (5) Teach a brief version the child can do anywhere. (6) STIC: practise daily and rate tension before and after.
Example language (illustrative): "Make your hands into tight fists, as tight as you can... hold... now let go and feel them go floppy like spaghetti."
Watch for: relaxation used as an escape or safety behaviour during exposure (it should help the child stay, not leave); children who feel odd or more anxious during relaxation (switch method or shorten). Working: lower tension ratings after practice; the child chooses it unprompted.

4.6 Identifying anxious self-talk: thought bubbles (E of FEAR)

Purpose / when: Sessions 5–6; so the child can catch the expectations that drive anxiety. [source: Henin slides; CEBC]
Steps: (1) Introduce self-talk as the things we say to ourselves in our heads. (2) Use cartoons with empty thought bubbles; ask the child what each character might be thinking, from easy, neutral scenes to anxious ones. (3) Move to the child's own situations: "What is in my thought bubble?" (Henin slides). (4) Teach the E question: am I expecting bad things to happen? (5) STIC: write down the thought bubble in one anxious moment. [source: Henin slides; synthesis on 2 and 5]
Example language (illustrative): "If this boy is standing at the door of the party, what might be in his thought bubble? ... And when you stood at the door at Sam's party, what was in yours?"
Watch for: children who cannot report thoughts (use cartoons, multiple choice, or what a friend would think); images rather than words. Working: the child names specific predictions ("everyone will laugh").

4.7 Coping thoughts: Catch it, Check it, Change it (A of FEAR)

Purpose / when: Sessions 6–7 and before every exposure; to replace anxious expectations with coping self-talk. [source: Kendall et al. 2023; CEBC]
Steps: (1) Catch the anxious thought. (2) Check it with questions: How likely is this? What has happened before? What is the worst that could happen and could I cope? What would I tell a friend? (3) Change it into a coping thought the child believes. Kendall et al. (2023) summarise this as "Catch it, Check it, and Change it". (4) For younger children, externalise worry as a character (e.g., a "worry monster") who can be talked back to. (5) For adolescents, aim for balanced, believable thoughts rather than simple opposites. (6) Write the coping thoughts on a card for the FEAR plan. [source: Kendall et al. 2023; synthesis on the check questions]
Example language (illustrative): "Your worry says 'I'll mess up and everyone will laugh.' Let's check it like a detective: how many times have you read aloud this year? How many times did people laugh?" / "What could you say to yourself that's true and helps you keep going?"
Watch for: hollow positive thinking ("it'll be perfect") that collapses on contact; test believability 0–10 [synthesis]. Working: the child generates coping thoughts unprompted and uses them during exposures.

4.8 Problem solving (A of FEAR)

Purpose / when: Session 6–7 onward; to generate and evaluate coping actions for a difficult situation. [source: CEBC; Henin slides]
Steps (synthesis of standard problem-solving steps; manual wording not seen): (1) Define the problem in one sentence. (2) Brainstorm all possible actions, including silly ones, without judging. (3) Evaluate each: what might happen, would it help, can I do it? (4) Pick one or two and plan when and how. (5) Afterwards, review how it went. Start with low-anxiety, everyday problems before anxious ones.
Example language (illustrative): "Let's come up with as many ideas as we can for what you could do if you get lost at the shopping centre, even weird ones, and then we'll pick the best."
Watch for: avoidance disguised as a solution ("just don't go"); steer toward approach options. Working: the child generates several options and chooses an approach action.

4.9 Self-evaluation and self-reward (R of FEAR)

Purpose / when: Session 7 and after every exposure and STIC task; to teach the child to judge effort fairly and reward themselves. [source: CEBC; Henin slides; BMC Psychology 2024 Table 3]
Steps: (1) After a task, ask: how did I do; did I try to cope? (2) Rate effort on a simple scale, separating partial success from failure. (3) Choose a reward, tangible or activity-based, for trying, not only for succeeding (Henin slides). (4) Build a reward menu with the child and parents. (5) Model fair self-rating (e.g., the therapist rates a pretend effort and rewards the trying).
Example language (illustrative): "You said it went badly, but you stayed in the room for five minutes when last week you couldn't go in at all. On our effort scale, where would you put that?"
Watch for: perfectionism (only full success counts); reward menus the parents will not deliver. Working: the child rates partial successes as successes and asks for their reward.

4.10 Building the FEAR plan

Purpose / when: Session 8, then used before every exposure in phase 2; a four-step personal coping plan. [source: CEBC; Henin slides; NHS Scotland EIF]
Steps: (1) Review each step: F, Feeling frightened? (body clues); E, Expecting bad things to happen? (anxious thoughts); A, Attitudes and actions that can help (coping thoughts, problem solving, relaxation); R, Results and rewards (rate effort, reward). (2) Make a wallet card or poster with the child's own clues, thoughts, coping thoughts and actions, and reward ideas. (3) Rehearse the plan aloud on a mild situation. (4) Practise on a moderately anxious imagined situation. [source: CEBC; Henin slides; synthesis on 2–4]
Example language (illustrative): "Let's walk through FEAR for when you go to bed and Mum's downstairs. F: what does your body do? E: what are you expecting? A: what can you say and do? R: how will you know you did well, and what's your reward?"
Watch for: the plan recited by rote but not used; anchor every step in the child's own words. Working: the child can run through the plan with minimal prompting before an exposure.

4.11 Coping modelling and role-play

Purpose / when: Throughout both phases; the therapist demonstrates using a skill and the child rehearses it before trying it for real. [source: NHS Scotland EIF; Henin slides]
Steps: (1) Therapist models a situation aloud, showing some anxiety and then working through FEAR (a coping model who struggles and copes, rather than a calm expert) [synthesis on the coping-vs-mastery emphasis; not confirmed in sources, uncertain]. (2) Therapist and child do it together. (3) Child does it alone, with the therapist playing other roles (teacher, classmate, shop assistant). (4) Debrief with the R step. In the exposure phase, role-play precedes in vivo practice. [source: Henin slides; synthesis on 1–4]
Example language (illustrative): "I'll be the kid giving the talk first. 'Ugh, my heart's pounding, F, that's a body clue. E, I'm expecting to forget everything. A, I can look at my notes and take a slow breath...' Now you be the teacher and tell me how I did."
Watch for: the child watching but declining to try (shrink the step, swap roles). Working: the child rehearses with rising independence.

4.12 STIC tasks (Show That I Can)

Purpose / when: Every session, one task per week; to practise skills and exposures in daily life. [source: CEBC; Wikipedia]
Steps: (1) Agree one specific task linked to the session's skill (phase 1) or hierarchy step (phase 2). (2) Write it in the workbook with when and where. (3) Agree the reward. (4) Start the next session by reviewing it, praising effort and problem-solving obstacles. [synthesis on 2–4]
Example language (illustrative): "Your Show That I Can task this week: order your own drink at the café on Saturday and use your FEAR card before you go up. What will you earn for trying?"
Watch for: tasks too vague or too big; always review the STIC task, or it stops being done. Working: steady completion; the child brings back details.

4.13 Contingent rewards and session reinforcement

Purpose / when: Throughout; to reinforce attendance, effort and brave behaviour. [source: Kendall et al. 2023; Henin slides]
Steps: (1) Set up a points or sticker system for STIC tasks and exposures. (2) Reserve a few minutes at the end of each session for a fun activity as a reward. (3) Coach parents to reward approximations and brave attempts immediately and specifically. (4) Fade tangible rewards toward self-reward over time [synthesis]. Henin's slides put it as "When it can't be fun, make it rewarding."
Example language (illustrative): "You earned three points today for doing the phone call. Want to spend them now or save for the big reward?"
Watch for: rewards given non-contingently or withheld punitively. Working: willingness to take harder steps rises.

4.14 Building the fear hierarchy (ladder)

Purpose / when: Late phase 1 and session 9; a graded list of feared situations that guides exposures. [source: Henin slides; Kendall et al. 2023]
Steps: (1) Gather situations from the child, parents (session 9) and school. (2) Write each on a card; the child rates how scary each is on a 0–10 or 1–10 scale. (3) Arrange them from slightly feared to much feared, with a clearly stated end goal at the top. (4) Break big steps into smaller ones so there is a gentle gradient. (5) Treat it as a living document, adding, re-rating and splitting steps as you go. [source: Kendall et al. 2023; Henin slides; synthesis on 2 and 4]
Example language (illustrative): "On our worry thermometer, 1 is no worry and 10 is the most you've ever felt. Where would 'sleeping at Gran's without Mum' go? What about 'Mum goes to the shop for ten minutes'?"
Watch for: hierarchies that are all high or all low; items reflecting real danger (remove). Working: ratings cover the range and the child agrees the order.

4.15 Graded exposure tasks (phase 2, sessions 9/10–16)

Purpose / when: Every phase 2 session, plus STIC tasks; the most critical component. [source: Kendall et al. 2023; CEBC]
Consent and safety: Before phase 2, re-explain the rationale to child and parent, obtain parental consent and the child's agreement to the general plan, and agree each specific task in advance; the child is reassured they will not be forced into tasks they are not ready for. [source: Kendall et al. 2023] Exposure targets situations that are objectively safe; do not use it for real ongoing threats (bullying, abuse, unsafe home or neighbourhood) until safety is addressed; check medical issues before tasks involving strong physical arousal; for out-of-office tasks, arrange supervision, permissions (e.g., school, shop) and confidentiality [synthesis]. Expect short-term distress. [source: job codebook notes]
Steps: (1) Pick the next step on the ladder that produces moderate anxiety. (2) Have the child describe the situation and the expected thoughts, feelings and body reactions, then build a FEAR plan for it (Henin slides). (3) Ask for a specific prediction (what will happen) and set a specific, attainable goal (e.g., stay in the situation a set time). (4) Begin with imaginal or role-play versions, then in vivo; least to most threatening (Henin slides; imaginal stage as a distinct step not confirmed [uncertain]). (5) During the task, track distress on a 1–10 scale at intervals and coach briefly. (6) Afterwards, compare the outcome with the prediction, like a behavioural experiment. (7) Praise effort; the child self-rates and gets the reward. (8) Repeat until the step is easier, then move up. (9) Strengthen learning by varying content, contexts and people and by removing safety signals (e.g., parent's presence, a lucky object) as treatment progresses. [source: Kendall et al. 2023; Henin slides]
Adjustments: If the child anticipates escaping, ease the task so the goal stays reachable; if a task proves too hard mid-task, shorten the goal rather than abandon it. [source: Kendall et al. 2023]
Example language (illustrative): "Before we go into the hall, what's your prediction? ... You said people would stare and laugh. How many actually did?" / "Let's make the goal two minutes instead of five; staying for two is a real win."
Typical tasks by problem [synthesis, examples]: separation anxiety, parent waits outside, then leaves the building for set periods; social anxiety, asking strangers the time, giving a short talk to staff; generalised worry, making deliberate small mistakes, leaving homework imperfect.
Watch for: subtle avoidance (looking at phone, whispering, holding a parent's hand); relaxation or reassurance used to escape; tasks pitched too low to produce learning. Working: predictions are disconfirmed, ratings fall across repetitions, and the child volunteers the next step.

4.16 Exposures outside the office and by telehealth

Purpose / when: When feared situations occur at school, home or in the community. [source: Kendall et al. 2023]
Steps: (1) Conduct exposures in naturalistic settings (e.g., shops, school), or have the child do them at home or in the community with the therapist on the phone or video. (2) For telehealth, do a trial run, plan for technical failures and agree rules to limit distractions, including caregiver phone use. (3) In schools, give 5–10 minutes of a pleasant activity after an exposure before the child returns to class; book longer slots for exposures. [source: Kendall et al. 2023]
Example language (illustrative): "Keep me on the phone in your pocket while you ask the librarian. Afterwards tell me what happened and rate it."
Watch for: confidentiality in public; the phone becoming a safety signal (fade it). Working: gains generalise to real settings.

4.17 Parent session 1 (session 4)

Purpose / when: Parent-only, session 4; build parents' knowledge of the programme, gain cooperation and gather their observations. [source: CEBC; NHS Scotland EIF; BMC Psychology 2024 Table 3]
Steps: (1) Explain the CBT model, the adaptive function of anxiety and why skills come before exposure. (2) Gather information on when anxiety shows up, family responses and history. (3) Explain the parent's role: support STIC tasks, reward effort. (4) Prepare them for uneven, "saw-toothed" progress. (5) Introduce helpful responses: calm, low-key "ho-hum" reactions; acknowledge anxiety and reassure once, then prompt coping; avoid alarm, allowing avoidance, forcing, repeated reassurance and perfectionistic expectations. [source: Henin slides; Kendall et al. 2023]
Example language (illustrative): "When she asks for the fifth time whether you'll be back, try: 'I've already answered that. What's your coping thought?' then change the subject."
Watch for: parents' own anxiety (about half of parents of anxious children may have anxiety disorders, per older studies cited by Henin); refer if parental psychopathology interferes. [source: Henin slides; Kendall et al. 2023] Working: parents describe the model and commit to specific behaviours.

4.18 Parent session 2 (session 9) and reducing accommodation

Purpose / when: Parent-only, session 9, before exposures; plus parent involvement in exposure sessions as needed. [source: CEBC; NHS Scotland EIF]
Steps: (1) Update information and review the skills the child has learned. (2) Explain the exposure phase and enlist cooperation. (3) Work with parents to design in vivo tasks for the child's hierarchy. [source: BMC Psychology 2024 Table 3] (4) Identify accommodating behaviours (doing things for the child, changing family routines, excess reassurance) and have parents track them weekly while gradually reducing them. [source: Kendall et al. 2023] (5) Agree how parents will set up practice opportunities and reward approximations. [source: Henin slides]
Example language (illustrative): "Let's list what you currently do so he doesn't have to feel anxious, like ordering for him or staying until he's asleep, and pick one to step back from this week."
Watch for: parents who undermine exposures by rescuing; plan what they will say in advance. Working: weekly accommodation logs fall.

4.19 The commercial and ending (sessions 15–16)

Purpose / when: Final sessions; consolidate learning, build the child's identity as a coper, plan for the future. [source: Henin slides]
Steps: (1) Help the child make an ad (video, audio, poster or comic) teaching other children how to cope with anxiety using the FEAR plan and their own successes. (2) Review the hierarchy and exposure successes. (3) Plan continued practice and what to do if anxiety returns (lapse vs relapse) [synthesis]. (4) Celebrate with the child and family, showing the commercial if the child wishes. [source: Henin slides; synthesis]
Example language (illustrative): "You're the expert now. If you made a TV advert to teach another kid how to handle worry, what would you put in it?"
Watch for: fear of losing the therapist (taper or schedule a booster) [synthesis]. Working: the child explains the plan in their own words and owns the successes.

4.20 Camp Cope-A-Lot coach role

Purpose / when: In the computer-assisted version; the child completes sessions 1–6 online at their own pace, then sessions 7–12 with a coach doing role-plays and exposure tasks. [source: ACF Prevention Services Clearinghouse]
Steps: (1) Check the child has completed the online level and workbook pages. (2) Review the skill learned. (3) In coach sessions, plan and run the exposure or role-play with FEAR, as in 4.15. (4) Reward and set the next task. Coach procedures in the Coach's Manual were not seen [uncertain].
Example language (illustrative): "Show me what you learned on the computer this week. Now let's try it for real."
Watch for: children clicking through without learning; check understanding. Working: the child applies skills in coach sessions.

4.21 Adapting the delivery format: group, school and brief

Purpose / when: When delivering to groups or in schools, or when fewer sessions are available. [source: CEBC; NHS Scotland EIF; Kendall et al. 2023]
Steps: Group: 4–6 children, one practitioner, 50–90-minute sessions, starting after 3–4 individual sessions; individualise each child's hierarchy within the group [synthesis on individualising]. School: about 30-minute sessions up to twice weekly, a calming activity after exposures, longer slots for exposures, referral of severe cases to community services. Limited frequency: split a 50-minute session into two shorter ones, or cut to one activity per session. A brief 8-session version exists; its content was not seen [uncertain]. [source: NHS Scotland EIF; Kendall et al. 2023]
Example language (illustrative): "Today everybody picks one step from their own ladder, and we'll cheer each other on."
Watch for: group members comparing ladders or teasing; exposures dropped for lack of time. Working: each child still completes regular in-session exposures.

5. Handling problems

Sources: Kendall et al. 2023 and Henin slides where marked; everything else is [synthesis] from general CBT practice with anxious youth.

Low motivation or reluctance (child brought by parent). Ask what the child wants, validate ambivalence, use games and end-of-session fun, tie rewards to effort. [source: Kendall et al. 2023] Link goals to things the child values (sleepovers, sport). [synthesis]
Refusing an exposure. Never force. Confirm agreement beforehand, keep the child in control, ease the task so the goal is reachable, shorten the goal mid-task if needed, reward brave attempts. [source: Kendall et al. 2023] Offer a choice between two smaller steps, have the therapist model first, or do an imaginal or role-play version that session. [synthesis]
Overwhelm during exposure (crying, panic, wanting to leave). Stay calm; coach FEAR briefly; reduce the goal (e.g., one more minute) rather than ending at peak distress if possible; then debrief and praise effort. [source: Kendall et al. 2023 for shortening the goal; synthesis otherwise] Next time, take a smaller step. If distress includes dissociation, trauma memories or self-harm thoughts, stop, assess and adjust the plan. [synthesis]
Subtle avoidance and safety behaviours. Watch for distraction, reassurance seeking, parent presence, lucky objects, using relaxation to escape. Name them gently and fade them across repetitions. [source: Kendall et al. 2023 for removing safety signals; synthesis on examples]
Not doing STIC tasks (non-adherence). Check the task was specific and small enough, review it every session, problem-solve barriers, have the child do the first instance in session, involve parents as reminders and reward providers. [synthesis]
Parental accommodation and reassurance loops. Track accommodating behaviours weekly and reduce them gradually; coach one reassurance then a prompt to cope. [source: Kendall et al. 2023; Henin slides] Expect a short-term rise in the child's protest when accommodation drops; prepare parents for this. [synthesis]
Anxious or overprotective parent. Coach calm "ho-hum" modelling and use of anxiety as a "cue-to-cope" (Henin slides); refer the parent for their own treatment if their difficulties block progress. [source: Henin slides; Kendall et al. 2023] Consider the family-format manual. [source: NHS Scotland EIF]
Uneven progress. Warn families early that progress is "saw-toothed"; review the hierarchy and ratings to show trend over time. [source: Henin slides]
Perfectionism. Reward approximations; use deliberate-mistake exposures; separate effort from outcome in the R step. [source: Henin slides; synthesis on mistake exposures]
Child cannot report thoughts. Use cartoons, multiple-choice options, "what would a friend think", or move faster to exposure where learning is experiential. [synthesis]
Rote compliance (says the right things, avoids in life). Check real-world use via parents and school; rely on behavioural tasks rather than verbal answers. [synthesis]
Alliance ruptures (child angry or upset after an exposure, feels tricked). Acknowledge it, apologise for any surprise, restate that each step is agreed, give the child more control over the next step, and repair before resuming. [synthesis; agreement principle from Kendall et al. 2023]
Services letting exposure slip. Set minimums for sessions and in-session exposures; provide training, boosters and supervision. In one community study only 52% completed all sessions and 59% did exposures. [source: Kendall et al. 2023]
School refusal. Coordinate with school staff; build a graded return into the hierarchy; agree how staff respond to distress. [synthesis]
Comorbidity (ADHD, low mood, autism, OCD). Add transdiagnostic skills (behavioural activation, distress tolerance, sleep and activity guidance); an autism adaptation exists. [source: Kendall et al. 2023; NHS Scotland EIF] For ADHD, shorten activities and use more rewards; for low mood, screen for depression and suicide risk using standard assessment and safety planning, and treat depression first if it prevents engagement. [synthesis]
Adolescents. Use the C.A.T. Project; aim for balanced rather than positive thoughts; give more autonomy over goals and confidentiality. [source: CEBC; Kendall et al. 2023; synthesis on autonomy]
Telehealth problems. Trial run, backup plan for technical failures, distraction rules including caregiver phone use. [source: Kendall et al. 2023]
Real danger behind the fear. If the feared situation is genuinely unsafe (bullying, violence, abuse), exposure is not appropriate; address safety and follow safeguarding duties first. [synthesis]

Sources

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