Children with intellectual disabilities (ID) have high rates of mental health disorders, however there has been limited research evaluating effective treatments for them. The prevalence of mental illness for children with ID is estimated to be as high as 50% [11, 33], and children with ID show elevated rates of both internalizing and externalizing problem behaviours compared to typically developing children [10, 12]. Specifically, anxiety has been reported as the most prevalent mood disorder in young people with ID [13]. Furthermore, it is known that when left untreated, childhood mental health issues can result in elevated risks for the development of psychiatric disorders later in life [9, 13].

Historically, treatments for the mental health conditions of people with ID have involved medication and/or behavioural interventions [34]. It was argued that people with ID were unable to engage in cognitive-based therapies because of cognitive deficits [1, 3, 32]. Research has found however, that adults with mild to moderate ID are capable of engaging in the cognitive components of Cognitive Behavioural Therapy (CBT, see [7, 23, 27, 29, 30]), and when CBT is adapted for the needs of adults with ID, the therapy is effective in reducing anxiety, depression and anger [28, 34].

While CBT is considered the “gold standard” when treating mood disorders among typically developing adults and children (e.g. [4, 5]), and the need for adapting CBT for adults with ID has been addressed, the potential for children with ID to engage in and benefit from CBT has not been systematically evaluated. Considering this, the current paper aims to describes the steps involved in developing and evaluating a CBT intervention for children and adolescents with mild to moderate ID. The aim was to develop a program targeting clinical and subclinical anxiety issues given the high prevalence within this population. The development of the program, called Fearless Me ©, followed best practice guidelines to combine evidence and theory to systematically develop, pilot, evaluate and implement a program [6].

Development of the treatment intervention

The researchers first conducted a review of the literature to identify the cognitive deficits present for children with ID and identify adaptations to standard CBT to accommodate for such deficits [17]. Children with ID present with unique neuropsychological profiles and specific cognitive deficits, which are thought to have an impact on engagement in therapy [17]. The need to adapt CBT according to age as well as developmental level has been recognized for typically developing children [14, 16]. As children with ID have unique cognitive profiles, it is crucial that interventions are adapted according to their neuropsychological profile and developmental level, and not simply apply interventions developed for children of an equivalent mental age [17]. The review explored the deficits common in children with ID in the areas of attention, learning, memory, executive functioning, language and reading. For a full list of proposed therapy adaptations, see [17].

Following from this, the next phase of the development of the intervention was to understand the attitudes of clinicians when working with people with ID [19]. The Therapy Confidence Scale—Intellectual Disabilities (TCS-ID; [8]) was used to understand how confident clinicians felt with different components of therapy [19]. Clinicians were most confidence with the “counselling” components of therapy (i.e. being empathetic, listening carefully to client concerns, involving caregivers in therapy), but reported being least confidence using assessments, explaining the results of assessments, and identifying and implementing effective mental health interventions. Clinicians also endorsed that the use of treatment protocols as likely helpful in increasing confidence, particularly among those who reported lower confidence.

Parents of children with ID were also asked to provide their feedback on how they thought their child may be able to effectively engage in CBT [21]. Parents were provided with a summary explaining the components of CBT and how the therapy worked, along with a case vignette to illustrate how treatment could be applied. Following their reading this information, parents were asked about potential challenges their child may face engaging in therapy, any suggested adaptations parents may be able to provide to make the process easier, the role parents saw themselves playing in therapy, and factors which may encourage or discourage engagement in this type of therapy. Overall, it was found that most parents believed their child may be able to benefit from CBT, provided that therapy and the therapist adapted to meet the needs of the child, and potential challenges were considered and managed. Parents provided suggestions as to how CBT could be adapted for the specific needs of their child with ID, which were largely consistent with those in the proposed framework suggested in the literature review [17].

Fearless Me! ©: Cognitive Behaviour Therapy for children and adolescents with intellectual disabilities and anxiety

The Fearless Me! © treatment program was developed in the absence of a CBT intervention specifically designed for children with ID. The Fearless Me! © program is a multimodal CBT program, combining both face-to-face sessions and an online component. It has been designed for children and adolescents with mild to moderate ID with the aim of helping them learn to manage and overcome anxiety issues.

There are a number of ways in which the Fearless Me! © program has adapted CBT to meet the needs of children with ID. Firstly, the program aims to break down the elements of the CBT into their simplest form, as was found to be important when teaching children with ID from both parents and the literature. There are three modules which children work through (see Fig. 1): one module which focuses on cognitions and cognitive challenging, a second module which focuses on behavioural changes and exposure, and a third module which teaches relaxation techniques. There is a specific focus on breaking down the cognitive components into the simplest forms, as this is what was identified by parents as being a potential major obstacle. Children begin by identifying and distinguishing between thoughts, feelings and behaviours, and practice this using case vignettes involving other children. They then move onto identifying and distinguishing between helpful and unhelpful thoughts, followed by learning to challenge their thinking. This process is facilitated by the online program which was designed as a way to make therapy more fun and engaging for the children, as well as a way to provide them with the opportunity to practice skills in a structured manner outside of the therapy sessions. The use of technology and online programs in therapy has been found to be beneficial when working with people with ID, particularly to facilitate engagement, homework practice and the teaching of skills and techniques [2, 15, 35]. In addition to this, the website has engaging visuals and illustrations, along with videos to help children understand concepts and practice relaxation techniques.

Fig. 1
figure 1

The three modules on the Fearless Me! © website, teaching children relaxation strategies, providing cognitive challenging exercises and facilitating exposure tasks. From [19]. Copyright 2018, reproduced with permission

The program further incorporates adaptations such as using short, simple sentences, often containing a single concept, with a text-to-speech function on the website for all written text in order to accommodate for deficits in learning and reading. When completing tasks on the website, immediate feedback is provided to the child as to whether their response was correct or incorrect. It is recommended that these tasks be completed with a therapist, or parents when completing homework, in order to discuss any mistakes. The vignettes on the website allows for repeated practice with different scenarios to facilitate the consolidation of each step in the cognitive challenging module. Parents are encouraged to be actively involved in the process and to assist with homework where possible. Therapists are also able to run shorter therapy sessions than would be typical, or to include breaks in therapy to accommodate for possible deficits in attention. The program encourages that therapist implement adaptations to the therapy with flexibility, identifying what adaptations may be best suited to the individual child.

Evaluation of the Fearless Me! © program among adolescents with intellectual disability

The Fearless Me! © program was evaluated for feasibility and acceptability amongst a cohort of 21 female adolescents with mild ID, moderate ID, or intellectual functioning in the Borderline range, aged between 12 and 18 years [20]. A case series approach was adopted as this was deemed to be the most appropriate form of evaluation given that research in this area is still in its infancy. The intervention was delivered in a group format during school hours, and participants remained in their pre-assigned classes which were based on age and ability levels. Overall, the program appeared to be appropriate and feasible for adolescents with mild to moderate ID, with good uptake and engagement. The participants described actively using the skills they had learned, and reported thoroughly enjoying the videos and online activities. Additionally, it was found that many children with initially heightened levels of anxiety experienced significant reduction in anxiety, or reductions which placed them within the non-elevated range of anxiety on the School Anxiety Scale-Teacher Report (SAS-TR; [25]).

The Fearless Me © program has also been evaluated among children and adolescents with ID in an individual therapy context [22]. A case series evaluation was conducted of nine children aged between eight and seventeen who completed the program. Children has either a mild or moderate intellectual disability, or intellectual functioning within the borderline range. The results indicted that all children have a significant reduction on at least one measure of anxiety (as measured by the Spence Children’s Anxiety Scale—Parent Report or Child Report, [26, 31], or anxiety life interference (as measured by the Children’s Anxiety Life Interference Scale—Parent Report, [24].

Implications of the research

It is hoped that the Fearless Me © program will increase the access in which vulnerable children and adolescents with ID can have to therapy, and reduce barriers to treatment. The program has been evaluated, with future research aiming to conduct a full scale randomized controlled trial. While the program has only been evaluated for anxiety, the evidence suggests that CBT can be helpful for children and adolescents with ID, and it is therefore hoped that this could also be applied to the treatment of other clinical disorders for those with ID.

Fearless Me! ©: therapist treatment manual

The Fearless Me © therapist treatment manual is presented below. Note that the manual is designed to be used in conjunction with the online program available at

Fearless Me!

Cognitive Behaviour Therapy for children and adolescents with intellectual disability and anxiety

figure a

Table of contents

About the Authors:


About the Program:


Components of the Online Fearless Me! Program:


Working with Children with Intellectual Disability:


Program Outline:


Additional Resources:


1 About the authors

figure f

Dr Anastasia Hronis

BPsyc (Hons I), MClinPsych, AMusA, LMusA, PhD

Anastasia is a registered psychologist and clinical psychology registrar. The Fearless Me! program was developed as part of her Doctor of Philosophy (PhD) degree at the University of Technology Sydney. Anastasia's doctoral research looks specifically at how Cognitive Behaviour Therapy (CBT) can be adapted to suit the needs of children and adolescents with intellectual disabilities.

Anastasia also works clinically with children, adolescents and adults experiencing mental health concerns, and combines a strong interest and background for research into her clinical work. She is also passionate about working with adults with chronic mood disorders and interpersonal difficulties. In addition, Anastasia has published research in the area of problem gambling.

figure g

Associate Professor Rachel Roberts

BA(Hons), MPsych (Clinical), PhD

Rachel Roberts is an Associate Professor at the University of Adelaide and a clinical psychologist with extensive experience working with children with a range of developmental disabilities including intellectual disability, and their families. She teaches in the Master of Psychology (Clinical) and (Health) programs, and conducts research in the areas of clinical psychology, health psychology and neuropsychology. She has received grants and funding for much of her research, and has published numerous papers in high-ranking peer-reviewed journals.

figure h

Dr Lynette Roberts

BPsych (Hons), M. Clin.Psych, PhD

Dr Lynette Roberts is a practising Clinical Psychologist and was a Lecturer and Early Career Researcher at UTS from 2015-2017. She is passionate about her lab's work on improving mental health treatments for vulnerable populations, including children, adolescents and adults with intellectual disabilities, and their carers. Her lab’s focus on mental health included investigating novel treatments for depression, including the use of probiotics (good bacteria). She has a particular interest in women’s health, working clinically with women with perinatal anxiety and depression. She is currently an Honorary Associate in the Graduate School of Health, UTS.

The Fearless Me! website was funded by the following grant: L Roberts, "Unstoppable Me: An iPad anxiety program for children with intellectual disability", $20,581 from the James N Kirby Foundation 2016–2017.

figure i

Professor Ian Kneebone

BA, BA(Hons), MPsych (Clinical), PsychD

Professor Kneebone is currently Head of Discipline (Clinical Psychology) at the University of Technology Sydney. He has over 20 years’ experience in applied practice, teaching, training, policy and research in clinical psychology. He has worked as a Rehabilitation Counsellor for Bedford, SA and CRS Australia and as Programme Area Leader of a head injury service. He has also worked as a Clinical Psychologist in community mental health and with older people in a physical rehabilitation setting (Health Department of Western Australia). He worked at Consultant level, for the NHS (National Health Service of Great Britain and Northern Ireland) in physical rehabilitation and neuro rehabilitation settings in Surrey, UK for sixteen years. He has consistently achieved funding for his research in rehabilitation and has published numerous papers in peer-reviewed journals. These include journals with the highest ranking in this research area. Professor Kneebone is a Visiting Professor at the University of Surrey.

2 About the program

The Fearless Me! program is a Cognitive Behaviour Therapy (CBT) treatment program which has been specifically adapted for children with intellectual disabilities and anxiety. It was developed in recognition that children and adolescents with intellectual disabilities experience very high rates of mental illness, yet there are very few psychotherapy treatment programs available which cater for the unique needs of children with intellectual disabilities.

Children can sometimes fall into patterns of thinking which are unhelpful. They may think negative and unhelpful thoughts such as “I’m not good at this”, “this is too hard”, “my friends will laugh at me”, “I can’t do it” etc. These types of thoughts can lead children to feel sad, worried, scared or anxious. As a result, children may avoid particular tasks, situations and activities. In this case, the role of the clinician within a CBT framework is to help children link what they think, to how it makes them feel and to what actions they take. Therapists may help children learn ways to “catch” their thoughts, check whether their thoughts are helpful and realistic, and challenge unhelpful/unrealistic thoughts. Some adults will automatically challenge their own thoughts, but children with an intellectual disability may need to be taught these skills.

Fearless Me! is a multimodal treatment approach, in that it involves both face to face therapy sessions, as well as an online component. A multimodal approach is used as a means of breaking down the CBT skills in a way that can hopefully be engaging and fun for children with disabilities. This manual provides information on how to use and deliver the components of both the online program and the content for face-to-face sessions. It is recommended that before using the online program, clinicians access the material themselves and explore the various online modules.

It is important to keep in mind that this treatment manual has been developed as a guide for therapy. As with any intervention, it is crucial to adapt the treatment and therapy process to suit the needs of the individual. This is particularly important when working with children with developmental delays and unique needs. More on how to adapt therapy for children with developmental and intellectual disabilities can be found on page 11.

2.1 Who is the Fearless Me! program for?

The Fearless Me! program was designed to be used with children and adolescents who have mild to moderate intellectual disabilities, or intellectual abilities in the borderline range, aged from approximately eight years to eighteen years of age. It is designed to assist children with subclinical or clinical anxiety concerns.

2.2 How do sessions work?

Outlined in this manual is a ten session treatment program, to be delivered after a comprehensive assessment has been conducted. It is recommended that each session run for approximately 45–60 min, and involve both teaching and practicing skills. While the treatment manual has ten session plans provided, it is at the clinician’s discretion to adapt this however best appropriate for the client.

The aim of the program is to break down the skills of CBT in a way that can be understood and used by children with intellectual disabilities. In particular, there is additional focus on the cognitive components of CBT. It is recommended that both practical and online components be used in most sessions to help facilitate the child’s engagement in the therapy process. Therefore, it is important that the clinician have access to a computer or electronic device during the sessions, or that the child bring an electronic device with them to sessions (i.e. laptop, tablet or iPad. Using a mobile phone to access the online site is not recommended).

We highly recommend having a carer or parent present for all sessions. We have found that having a carer involved in the treatment is beneficial to the progress of therapy, as they are able to provide valuable clinical information as part of the assessment, can provide relevant examples of times when the child has felt anxious, and can learn the skills as part of the program to facilitate practice and generalisation of skills outside of therapy sessions.

As is typical within a CBT treatment program, sessions involve homework tasks for children to do between session. These involve a combination of exposure exercises, use of relaxation skills, and practice of cognitive skills. This is where parents/carers may be able to assist with a child’s progress outside of therapy sessions.

2.3 Group vs individual therapy

The Fearless Me! program has been designed to be an intervention which can either be delivered in an individual or group setting. Throughout the treatment manual you will note that there are options for adaptations, based on whether the program is being delivered in an individual or group setting.

For both individual therapy and groups, we recommend having a carer or parent present for all sessions. In addition, group therapy programs may benefit from having two group facilitators. Group sizes are likely to vary according to the level of disability of the children in the group and clinical judgement should be used to determine group size (i.e. groups of children with mild intellectual disabilities may be larger than groups predominately comprised of children with moderate intellectual disabilities).

2.4 Optional session 9

In the treatment manual, you will note that Session 9 had been identified as optional content to teach. This has been designed in this way as we recognise that some children may require additional teaching of previous steps and content, before being able to move onto the next steps. Thus the content of Session 9 does not need to be delivered if a child requires additional time to be spent on the other components of the program.

3 Components of the online Fearless Me! program

The Fearless Me! online program consists of three modules:

  1. 1.

    Keep Calm

  2. 2.

    Stop and Think

  3. 3.

    Facing Fears

figure b

3.1 Module 1—keep calm

Keep Calm teaches children relaxation strategies. Videos have been created which teach children paced breathing (Balloon Breathing) and progressive muscle relaxation (Squeeze and Relax).

Balloon breathing

Heightened anxiety often results in breathing become quick and shallow. Shallow over-breathing can prolong the symptoms of anxiety and make the experience worse. Balloon Breathing teaches children how to use a relaxed breathing pattern to help them feel calmer by breathing in through their nose and out through their mouth. The image of blowing up a balloon is used to help with the exercise.

Squeeze and relax

Squeeze and Relax is a variation of progressive muscle relaxation. The video takes children through the process of tensing and then relaxing particular muscles in their body while noticing the difference in the feeling.

3.2 Module 2—stop and think

This module focusses on the cognitive components of the CBT treatment. The aim of the module is to help children build the skills of identifying thoughts, recognising unhelpful thoughts and challenging unhelpful thoughts. There are three activities in this module: Think Feel Do, Thought Catching and Detective Thinking.

Think feel do

This activity first helps children learn the difference between their thoughts, their feelings and their actions. In this activity, they will read/hear brief scenarios about another child. They will have to identify what the person was thinking, what they were feeling, and what they were doing. Practicing this is the first step, as it is important children can tell the difference between their feelings, their thoughts and their actions.

See the example below:

figure c

In this example the answers are:

  • Thought→“Lucy thinks that she has always wanted a puppy”

  • Feeling→“Lucy is excited”

  • Doing→“Lucy picks up the puppy and hugs it.

Thought catching

This activity helps children to learn that unhelpful thoughts can lead to feeling stressed, worried, anxious or sad. The task requires them to read/listen to two different thoughts and choose, or “catch”, the worry thought.

See the example below:

figure d

In the example above, the “worry” thought is “I am going to have no one to sit with at lunch”. Thinking this would make a child feel more worried than thinking “I can go and sit with some of my other friends”. This exercise helps children build the ability to “catch” the worrisome or unhelpful thoughts they may think.

Detective thinking

Once children can identify their thoughts (by practicing Think Feel Do) and can catch their worry thoughts (by practicing Thought Catching) they can next move onto Detective Thinking.

Detective Thinking involves children challenging their unhelpful thoughts. They practice being a “detective” and finding more helpful thoughts. Children do this by asking “What else can it be?”, “What happened before?” and “What is a helpful thought?”. See the example below:

figure e

In the example above, children are encouraged to challenge the thought “Frank thinks if he asks a question the other students might make fun of him”.

Children are encouraged to question what else could happen (i.e. maybe the other children won’t laugh and make fun) and what happened before? (i.e. last time someone asked a question the other students did not laugh and make fun).

By doing this, children can come to choose a more helpful thought such as “If I ask the teacher a question she can help me and maybe other students too”.

3.3 Module 3—facing fears

This module focuses on the behavioural component of CBT. As is common with subclinical and clinical anxiety, avoidance of the feared stimuli is usually a key factor in maintaining the anxiety. This module therefore focuses on graded exposure, and working in small steps to achieve a goal.

This module includes a video called Brave Ben which explains how we can work step by step to reach a goal. Children can create their own steps and goals in the activity Facing Your Fears.

Facing your fears

In this activity, children choose something which they usually avoid or are scared of. Together with parents, a teacher or psychologist, they can develop a list of components which are related to their fear. These activities are then put in order from least anxiety provoking to most anxiety provoking. Children start with the least anxiety provoking task, and receive a reward when they complete it. By working through these steps children are able to eventually face the fear at the top of their list.

For example, a child who becomes anxious in social situations may avoid going to parties. To work up to being able to attend a party, they may start by having a conversation with a friend at school, then saying hello to a student they do not know, then inviting one friend over to their house, then going over to a friend’s house, and finally going to a party.

It is important that each step is repeated multiple times. It is also important that steps are gradual. The steps for one child will be different for another child.

4 Working with children with intellectual disability

As has been outlined in the previous sections, this program is an adapted Cognitive Behaviour Therapy (CBT) treatment. In the past, clinicians have placed greater emphasis on behavioural and pharmacological interventions for people with intellectual disabilities. This program aims to make use of both behavioural and cognitive strategies to help children and adolescents with anxiety.

Consideration of a child’s cognitive, social and emotional development is crucial prior to undertaking therapy and these factors should be examined during the initial assessment. Children with intellectual disabilities have cognitive deficits and as such, the therapy and therapist must adapt to meet the needs of the child. Neurocognitive deficits exist in the areas of attention, memory, learning, working memory, executive functions and language and reading. It is thus these factors which are likely to have an additional impact on the therapy process and needed to be accommodated and adapted for.

The authors of the Fearless Me! program have conducted a review into the research looking at the neurocognitive deficits of children with intellectual disabilities, the implications these may have for therapy, and suggested adaptations to therapy. The table below is taken from the review paper and is included to help clinicians and facilitators understand the ways in which they may consider additional adaptations to therapy to suit the needs of the individual child they are working with.

Table of adaptations to CBT for children with intellectual disabilities according to neurocognitive domain


Therapy adaptations


Shorter, more frequent sessions

Include breaks

Reduce task length by dividing into smaller units

Engage children with a variety of modalities, colours and pictures

Positively reinforce attention

Minimal distractions in therapy room

Begin with “person oriented” tasks before moving to “task oriented” exercises

Working memory

Use short, simple, subject-verb-object sentences

Present material verbally and visually

Use memory aids such as visual prompts

Present one task/activity at a time

Present information numerous times/ repeat tasks

Learning and memory

Engage in implicit learning processes (e.g. role play, hands-on activities)

Reality-based teaching; learn via “doing”

Teach via modelling, using “thinking out loud” when modelling

Frequently check understanding

Master skills before moving on

Practice and repeat skills

Provide immediate feedback

Record sessions or provide written summaries to the child and caregiver

Children encouraged to write events from the week to facilitate recall

Involve carers/parents to facilitate memory and recall

Executive functions

Therapist should plan and structure the sessions

Try to maintain a set structure to sessions

Use a visual schedule outlining session structure

Minimise switching between tasks

Target mental flexibility problem solving and decision making throughout therapy

Redirect uninhibited responses

Establish rules for therapy

Language and reading

Child should be facing therapist

Visual aids can assist communication

Use pictures/drawings to facilitate understanding, placed next to text with a clear link between text and image

Use ‘Easy Reading” format for text

High frequency connectives are more effective for ID (e.g. “and”)

Divide text into bullet points

Bold to emphasise main points

Avoid jargon

Define new terms where necessary

Sentences as short as possible (maximum 15 words)

Good contrast between colour of text and page

Sentences consisting a single concept

Words fewer than three syllables

5 Program outline

Session 1:

Introduction & psychoeducation

Session 2:

Balloon breathing & safe place

Session 3:

PMR and review relaxation

Session 4:

Facing fears: goals & hierarchy development

Session 5:

Identify thoughts, feelings and behaviours

Session 6:

Catching unhelpful thoughts

Session 7:

Check the facts

Session 8:

Check the facts

Session 9:

Linking helpful thoughts to exposure hierarchies (optional)

Session 10:

Review of skill

5.1 Session 1: introduction & psychoeducation

5.1.1 Introductions

  • Psychologist Introduces self and role

  • Name tags for everyone (if delivered in group setting)

5.1.2 Confidentiality

  • Explain confidentiality. Emphasise working as a team (child, psychologist, carer/parents, teacher etc.).

  • If delivered in group format, explain that we do not discuss about what other people say outside of group.

5.1.3 What this program is about

  • Psychoeducation around anxiety

  • Normalise anxiety experience

5.1.4 What are my fears?

Everyone has different fears and worries, and things that make them feel anxious.

  • Hand out—things that make me anxious. Circle what applies to you. Go through these one by one. Draw in the blank space any other fears/worries.

5.1.5 What does anxiety feel like?

Imagine that you have to do something that you circled. Imagine you have to give a speech, or go to the doctor, or spend the night away from mum and dad.

Close your eyes. Where can you feel the anxiety in your body?

  • Activity: colour/draw in where you feel anxiety in the body. What do these feel like? Butterflies, heart racing, tension etc.?

5.1.6 Thermometer

One way we can tell how anxious we feel is by using this thermometer to help us.

If we don’t feel a lot of anxiety, then we are low on the thermometer. If we feel a bit of anxiety, we are in the middle. If we feel a lot of anxiety, we are at the top!

5.1.7 Resources

  • Name Tag stickers (for group delivery)

  • Activity Sheet 1: what are my fears?

  • Activity Sheet 2: where do I feel anxiety in my body?

  • Activity Sheet 3: thermometer rating scale

5.2 Session 2: balloon breathing and safe place

Review anxiety psychoeducation from previous week.

5.2.1 Balloon breathing

Often when we feel anxious or scared, we start to breathe really fast. If we breathe fast, this makes our heart beat faster. This can make us feel even MORE anxious than we already are!

One way we can help ourselves feel more calm, is to do some balloon breathing.

Balloon breathing helps us to take slower and deeper breaths. When we do Balloon Breathing we imagine that we have a balloon inside of us. When we breathe in through our nose, we blow up the balloon. When we breathe out through our mouth, we let the air out of the balloon.

Practice Balloon Breathing with video first, then without.

5.2.2 Safe place

Another thing we can do when we feel scared or worried, is imagine a place that we call our Safe Place. When we imagine our safe place, nothing can hurt us or upset us. We are 100% safe. This is where we can go to feel calm. But it’s not a real place. We just go there in our mind.

Activity: Imagine the safe place.

Ask children to close their eyes and imagine the safe place.

Use prompts:

  • Where are you?

  • What can you see/hear/smell around you?

  • You can take anything you want to your safe place that you like. What will you take?

Activity: drawing the safe place and the things that are there with them.

5.2.3 Homework

Practice Balloon Breathing with the video. Practice imagining your safe place and describe it to carers/parents/siblings.

5.2.4 Resources

  • Fearless Me!: Balloon Breathing video

  • Blank paper for Safe Place

  • Materials to draw with

5.3 Session 3: progressive muscle relaxation and review relaxation

Review of Balloon Breathing and Safe Place exercises from last week.

Check in on homework practice and use of relaxation skills.

Practice Balloon Breathing and imagining Safe Place again.

5.3.1 Squeeze and relax—progressive muscle relaxation

Teach Progressive Muscle Relaxation using the “Squeeze and Relax” video.

Have children practice while watching the video (eyes open first time, eyes closed after repeated practices).

Activity: practice the squeeze and relax exercise with video.

Review times when children could use their relaxation strategies. Refer back to their initial activity where they indicated the situations that make them feel worried or anxious. Explain using relaxation strategies in these situations to help.

5.3.2 Homework

Practice Squeeze and Relax and teach a family member how to do it using the video.

Continued practice of the relaxation strategies.

5.3.3 Resources

  • Fearless Me!: Squeeze and Relax video

5.4 Session 4: facing fears—goals & hierarchy development

Review and practice relaxation strategies (balloon breathing; safe place; squeeze and relax).

Check in on homework practice and use of relaxation skills.

5.4.1 Facing fears

Sometimes when we have to do something which is seems scary or hard, it helps to break it down into small steps.

Activity: Watch the Brave Ben video

Q/ What did Ben learn from doing all those steps?

Q/ What can we learn from the video about Brave Ben?

Highlight how Brave Ben was able to conquer his fear of heights by going “step by step”.

5.4.2 Rewards

Q/ What did Brave Ben get after he did every step? (A: reward).

Develop a list of potential rewards.

5.4.3 Developing own hierarchy

Develop hierarchy/steps for something they are fearful of doing. Refer back to information from parents/carers and what they identified as anxiety provoking from session 1.

For each step on the hierarchy, add in rewards.

(If there is additional time, can work on developing a second hierarchy).

Use Fearless Me! online program to develop exposure hierarchy steps.

5.4.4 Homework

  • Watch Brave Ben video again at home.

  • Try to do the steps at the bottom of the exposure hierarchy and monitor progress using the website.

5.4.5 Resources

  • Fearless Me! Brave Ben video

  • Activity Sheet 4: Facing Fears Worksheet

5.5 Session 5: identify thoughts, feelings & behaviours

Review homework to take steps on exposure hierarchy.

5.5.1 Identifying thoughts, feelings and behaviours

Activity: using blank paper of a whiteboard, develop a list of all the emotions/feelings the children know. Once children are unable to identify additional emotions spontaneously, prompt them for more (e.g. What about anger? Have you ever felt angry?).

Practice making the link between feelings and situations as a group. Have children tell you a time they remember they felt the main emotions (anger, sadness, anxiety, happiness).

Activity: develop a list of behaviours i.e. “things that we can do”.

Start this with some examples.

e.g. Running is something I can do. Jumping is something I can do. Writing is something I can do.

5.5.2 Thoughts

Thinking is when we talk to ourselves in our mind/head. Everyone thinks. We can think about different things. Our thoughts are like an internal voice.

I can think all different things. I can think things which are true and I can think things which are not true. For example, I can think, that this table is brown and that is true. I can think that your hair is pink, but that is not true!

Can you tell me something you can think which is true?

Can you tell me something you can thinks which is not true?

Activity: Use the Fearless Me! website and orient parent and child to the Module titled “Stop and Think”. Practice together the activity titled “Think, Feel, Do”, which asks children to practice identifying thoughts, feelings and behaviours.

5.5.3 Homework

  • Practice Think, Feel, Do activity

5.5.4 Resources

  • Whiteboard/blank paper

  • Fearless Me! activity: Think, Feel, Do.

  • Continue with exposure hierarchy steps

5.6 Session 6: catching unhelpful thoughts

Review homework activity to practice Think, Feel, Do activity. Review progress on exposure hierarchy.

Practice “Think, Feel, Do” again in session to clarify child’s progress and in what areas they may be having difficulty and require further focused intervention. Consolidate this before moving onto next step of unhelpful thoughts.

5.6.1 Helpful vs unhelpful thoughts

Some of the things we think can be helpful. Our thoughts can help us. Our thoughts can help us do things that are important. Our thoughts can help us do things even if they are a bit scary or make us feel worried.

We might think “I can do this!” to help ourselves do something.

Some other thoughts are not so helpful. We might think things like “I can’t do this” or “this is too hard”. These thoughts don’t help us.

Some thoughts might make us feel even more worried!

Provide the following relevant examples:

  1. 1.

    Situation: school test.

    Unhelpful thoughts: I can’t do this it is too hard.

    Q/ How do you think someone would feel if they thought this?

    Helpful thoughts: I will try my best even if it is hard.

    Q/ How do you think someone would feel if they thought this?

  2. 2.

    Situation: starting a new school

    Unhelpful thought: no one will like me.

    Q/ How do you think someone would feel if they thought this?

    Helpful thoughts: I have made new friends before so I will be able to do it again.

    Q/ How do you think someone would feel if they thought this?

(Children can draw the above situations to help facilitate the discussion and examples).

5.6.2 Resources

  • Blank paper

  • Fearless Me! “Thought Catching” computer exercise

5.6.3 Homework

  • Fearless Me! “Thought Catching” computer exercise

  • Continue with exposure hierarchy steps

5.7 Session 7 & 8: check the facts

Review homework to practice “Thought Catching” and exposure hierarchy progress.

Practice “Thought Catching” again in session to clarify child’s progress and in what areas they may be having difficulty and require further focused intervention. Consolidate this before moving onto next step of unhelpful thoughts.

5.7.1 Check the facts

Explain what a fact is. Recap how thoughts can be true or untrue.

Explain detective thinking means looking for the facts of a situation.

After we check the facts, we can come up with a more helpful thought.

Go through examples as a group.

Jessica is going to a new school and thinks she won’t make any friends.

Jessica should stop and think. What are the facts? What happened before? Is thinking think way helpful?


A friend walks past and does not say hello. You think they do not like you.

Stop and think. What are the facts? What else could it be? Is thinking this way helpful?

You have a test to do. You think you will do badly.

Stop and think. What are the facts? What happened before? Is thinking this way helpful?

You catch a train and worry that you will get lost.

Stop and think. What are the facts? What happened before? Is thinking this way helpful?

You have the grand final netball game but are worried the team won’t win.

Stop and think. What are the facts? What happened before? Is thinking this way helpful?

You are learning to ride a bike but think you will never be able to do it.

Stop and think. What are the facts? What happened before? Is thinking this way helpful?

Activity: “Detective Thinking” computer exercise.

5.7.2 Resources

  • Fearless Me! “Detective Thinking” computer exercise

5.7.3 Homework

  • Fearless Me! “Detective Thinking” computer exercise

  • Continue with exposure hierarchy steps

5.8 Session 9: linking helpful thoughts to exposure hierarchies (optional)

(Note: this session can either be used to continue and consolidate the cognitive skills from sessions 5–8, or can be delivered according to the session plan below)

Review homework to practice “Detective Thinking” and exposure hierarchy progress.

5.8.1 Activity

Practice developing exposure hierarchies for a specific concern a friend may have, to help them face their fear.

  • Fear of making new friends

  • Fear of catching the train alone

  • Fear of spiders

  • Fear of the dark

  • Fear of hospitals

5.8.2 Positive self statements

Development of a list of helpful statements children can tell themselves and use to encourage themselves when feeling anxious or engaging in exposure hierarchies.

Children can draw/write these to facilitate the process.

5.8.3 Resources

  • Blank paper

5.8.4 Homework

  • Continue with exposure hierarchy steps

  • Fearless Me! “Detective Thinking” computer exercise

5.9 Session 10: review of skills

5.9.1 Review of skills

  • Balloon Breathing

  • Safe Place

  • Squeeze and Relax

  • Hierarchies—going step by step to face our fears

  • Helpful vs unhelpful thoughts

  • Check the facts

Practice each of the relaxation skills.

Practice applying “Thought Catching” and “Detective Thinking” to a personal situation.

Discussion with parents/caregivers around progress and provide referral options for further intervention where required.

Certificate for completion of the course.

5.9.2 Resources

  • Certificate for completion of the course

  • Fearless Me! activities on website

6 Additional resources

See Supplementary file1.