improve child behavior

When the Worry Bug Makes You Mad: Understanding the Importance of Positive Behavior Plans for Anxious Kids

By | NESCA Notes 2021

By Renée Marchant, Psy.D.
Pediatric Neuropsychologist

“Don’t Feed the Worry Bug,” by Andi Green is a wonderful book for children who are anxious or experience a lot of worrisome thoughts. The story is about a monster who constantly feeds his WorryBug, only to find that as he worries more and more, the WorryBug continues to grow until the monster is totally overwhelmed by the emotion. Eventually, he learns to control it. In my practice, I evaluate a number of children with lots of worries…but they don’t actually look worried. Instead, children may appear defiant, hyperactive and aggressive. Why do children overwhelmed with anxiety sometimes become frustrated and angry or have poor behavioral control at home and in the classroom?

Children with anxiety “on the surface” may appear angry, oppositional and defiant to adults. However, these behaviors oftentimes reflect secondary responses to an underlying cause: anxiety. Responses to anxiety can be categorized as “fight, flight or freeze.” As a classic example, if you run into a grizzly bear on a hike, your body’s natural physiological response is to fight, flee or freeze. Your anxiety about the demands of a situation send your body and brain into a state of “threat alert.” Similarly, when a child is worrying about something, is socially anxious, or is feeling nervous about their ability to handle a task, this “threat alert” system is activated and the child’s ability to make well-thought out decisions is impaired. The child may be labeled a “behavior problem” because of the impulsivity, defiance, disruptiveness or aggression (fight mode). Or the child may appear distractible, silly and immature, or avoidant of challenging tasks (flight mode). An anxious child may also show difficulties shifting gears/transitioning, problems letting go of events, or seem unmotivated or apathetic (freeze mode). It is also not uncommon for children with anxiety to have challenges demonstrating appropriate social skills, such as problems with insight into how their behaviors may affect others. They may also experience challenges reading the nonverbal and verbal cues in their environment because their brain is “soaked” with high arousal, immobilizing their capacity to apply logic to everyday situations. How do we help children manage their anxiety and the resulting behavioral challenges from that anxiety?

A neuropsychological evaluation can provide insights into your child’s behavioral challenges to determine if there may be an “underlying cause,” such as anxiety, (or other causes such as learning disabilities, depression or poor information processing) which are driving weak emotional and behavior control. Once identified, a neuropsychologist can provide guidance on the most effective interventions for a child at school and at home.

In my experience, one of the most important interventions for a child who experiences anxiety and secondary behavioral challenges is the development of a Positive Behavior Plan at school, which can then be included in a child’s IEP. However, many children with anxiety do not respond well to traditional behavioral reward systems that solely focus on increasing or decreasing behaviors (e.g. follow directions, sit calmly, keep your body safe, etc.), as these systems do not teach the child the self-regulation skills necessary for controlling emotional and behavioral responses. Instead, an effective Positive Behavior Plan for a child with anxiety includes behavioral targets or “goals” that focus on the attempt at coping strategy application. Importantly, a child with anxiety should be rewarded for trying to use a coping strategy, as it will take time, practice and reinforcement before a child develops the capacity to apply coping strategies consistently and successfully.

Sample coping strategies that a child should be taught by a special educator, counselor or other specialist include “taking deep breaths, jumping jacks, taking a break, using words to say how I feel,” or other self-regulation tools. When the goals of a Positive Behavior Plan focus on using a coping strategy before or during moments of distress rather than a plan that is tied to increasing or decreasing specific behaviors after they occur, a child builds independent capacity to appraise and react appropriately to physical and emotional responses in the classroom and the community. Children learn the signs (e.g. in their body, mind and in their environment) that the WorryBug is approaching, and feel better equipped, confident and more in control of their emotions and behaviors. For more information on how to appropriately develop Positive Behavior Plans for children with anxiety, “The Behavior Code” by Jessica Minahan and Nancy Rappaport is an excellent resource for parents and educators.

When the “WorryBug” or anxiety makes kids mad, mean and aggressive, a comprehensive and thorough neuropsychological evaluation can determine how to best tackle the anxiety “beneath the surface” through therapeutic and educational interventions. A neuropsychological evaluation can also direct the development of strategic Positive Behavior Plans that are individualized and appropriate for the child’s home and school environment.

About the Author:

Dr. Renée Marchant provides neuropsychological and psychological (projective) assessments for youth who present with a variety of complex, inter-related needs, with a particular emphasis on identifying co-occurring neurodevelopmental and psychiatric challenges. She specializes in the evaluation of developmental disabilities including autism spectrum disorder and social-emotional difficulties stemming from mood, anxiety, attachment and trauma-related diagnoses. She often assesses children who have “unique learning styles” that can underlie deficits in problem-solving, emotion regulation, social skills and self-esteem.

Dr. Marchant’s assessments prioritize the “whole picture,” particularly how systemic factors, such as culture, family life, school climate and broader systems impact diagnoses and treatment needs. She frequently observes children at school and participates in IEP meetings.

Dr. Marchant brings a wealth of clinical experience to her evaluations. In addition to her expertise in assessment, she has extensive experience providing evidence-based therapy to children in individual (TF-CBT, insight-oriented), group (DBT) and family (solution-focused, structural) modalities. Her school, home and treatment recommendations integrate practice-informed interventions that are tailored to the child’s unique needs.

Dr. Marchant received her B.A. from Boston College with a major in Clinical Psychology and her Psy.D. from William James College in Massachusetts. She completed her internship at the University of Utah’s Neuropsychiatric Institute and her postdoctoral fellowship at Cambridge Health Alliance, a Harvard Medical School teaching hospital, where she deepened her expertise in providing therapy and conducting assessments for children with neurodevelopmental disorders as well as youth who present with high-risk behaviors (e.g. psychosis, self-injury, aggression, suicidal ideation).

Dr. Marchant provides workshops and consultations to parents, school personnel and treatment professionals on ways to cultivate resilience and self-efficacy in the face of adversity, trauma, interpersonal violence and bullying. She is an expert on the interpretation of the Rorschach Inkblot Test and provides teaching and supervision on the usefulness of projective/performance-based measures in assessment. Dr. Marchant is also a member of the American Family Therapy Academy (AFTA) and continues to conduct research on the effectiveness of family therapy for high-risk, hospitalized patients.


To book an evaluation with Dr. Marchant or one of our many other expert neuropsychologists, complete NESCA’s online intake form.


Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton and Plainville, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.


Dr. Ryan Conway on Parent-Child Interaction Therapy

By | NESCA Notes 2018


Ashlee Cooper
NESCA Marketing and Outreach Coordinator


PCIT was first developed in the 1970’s. How did you become interested in this treatment?  

My first exposure to PCIT was in graduate school, in a course through my doctoral program that covered evidence-based therapies for childhood externalizing disorders, including ADHD and disruptive behaviors. I was immediately intrigued by the methodology given my interest in providing behavior therapy to young children and supporting parents.

What training is involved for a therapist who wants to provide PCIT?

PCIT training for therapists is highly structured and time intensive. It includes in-person training and live practice with PCIT Master Trainers, as well as ongoing consultation to ensure treatment is being delivered effectively.

Who is the target audience for this treatment?

PCIT is for young children, ages 2-7, along with their caregivers. It is an empirically supported therapy for children who demonstrate emotional challenges and behavioral problems (e.g., noncompliance, aggression). Some children might have a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) and/or Oppositional Defiant Disorder (ODD), although it is not necessary to have a formal diagnosis in order to participate in treatment and get help!

How does PCIT work?

PCIT is a dyadic treatment, in which parents and children participate together. It is delivered in weekly 60-minute sessions that progress through two treatment phases. In PCIT, parents learn specialized techniques to improve interactions with their children and effectively manage their behaviors at home. What is unique about PCIT is that the therapist coaches parents in real time, where the therapist is able to observe certain behaviors and interactions while offering immediate feedback, which is then continuously practiced at home in between sessions.

Video Link: Dr. Conway explains PCIT


Can you speak more to the two phases of PCIT? Why is it important to complete the first phase before moving on to the second?

As mentioned in the video above, PCIT has two phases. The first phase is called Child Directed Interaction (CDI), in which caregivers learn and practice new parenting techniques in the context of playing with their child. However, even while playing, parents are practicing essential behavioral techniques for children who tend to have self-regulation challenges, such as giving lots of attention to positive behaviors and learning to ignore negative behaviors. CDI helps to promote positivity in parent-child interactions, which then sets the foundation for the second phase, called Parent Directed Interaction (PDI). The focus of PDI is teaching parents how to give effective commands and learning specific techniques to increase child compliance at home and in public settings.

What are some of the program goals? How long does it take to complete treatment?

Goals of PCIT include reducing challenging child behaviors, increasing child social skills and cooperation, improving the parent-child relationship and decreasing parental stress.

PCIT is time-unlimited, meaning that families remain in treatment until caregivers have mastered certain skills and child behaviors fall in the more typical range of development. While treatment length varies, given its structured, skill-based and targeted design, families typically graduate from treatment in about 12 to 20 sessions. Keep in mind that the length of treatment depends on each family’s specific needs, as well as other factors (e.g., regular attendance, completion of home practice in between sessions, and the intensity of the child’s behaviors at the onset of treatment).

When talking about PCIT, I have heard you say that parents are “not the problem, but part of the solution.” What do you mean by this?

Yes, I heard this once from a PCIT Master Trainer and it has stuck with me ever since! In PCIT, parents essentially are the agent of change in improving their child’s behavior. By promoting warmth in the parent-child relationship, learning new ways of relating to their child and employing both a consistent and predictable approach, parents are able to get back to enjoying their child again.

What advice do you have for families who may be considering this treatment?

There are many behavioral parent training programs out there, so it can be helpful to speak to a professional to determine which might be best for your family. While many parenting programs teach similar skills, PCIT is so effective because it emphasizes in session learning and practicing of skills through coaching, as opposed to separating learning in session and practicing at home. This process enables caregivers to feel increasingly equipped and confident in their parenting, after sometimes feeling defeated about ongoing behavioral challenges dealt with at home.

Are there any additional references to learn more about PCIT?

Yes, absolutely! Please check out my prior blog post about PCIT here: https://nesca-newton.com/pcit/ You can also visit PCIT International’s website (www.pcit.org) for additional information.

If parents or guardians would like to speak to you more about PCIT, how can they reach you?

I would be happy to speak with any caregivers who are interested in PCIT and/or wondering if the treatment would be a helpful next step. I can be reached at rconway@nesca-newton.com or (617) 658-9831.


Ryan Ruth Conway, PsyD
Clinical Psychologist

Ryan Ruth Conway, Psy.D., is a licensed clinical psychologist who specializes in Cognitive Behavioral Therapy (CBT), behavioral interventions, and other evidence-based treatments for children, adolescents and young adults who struggle with mood and anxiety disorders as well as behavioral challenges. She also has extensive experience conducting parent training with caregivers of children who present with disruptive behaviors and Attention-Deficit/Hyperactivity Disorder. Dr. Conway has been trained in a variety of evidence-based treatments, including Parent-Child Interaction Therapy (PCIT), Dialectical Behavior Therapy (DBT), and Exposure with Response Prevention (ERP). Dr. Conway conducts individual and group therapy at NESCA utilizing an individualized approach and tailoring treatments to meet each client’s unique needs and goals. Dr. Conway has a passion for working collaboratively with families and other professionals. She is available for school consultations and provides a collaborative approach for students who engage in school refusal.












Neuropsychology & Education Services for Children & Adolescents (NESCA) is a pediatric neuropsychology practice and integrative treatment center with offices in Newton, Massachusetts, and Londonderry, New Hampshire, serving clients from preschool through young adulthood and their families. For more information, please email info@nesca-newton.com or call 617-658-9800.