Coping is an important part of successfully managing any problem because learning to make changes can be stressful and anxiety-producing. If we attempt to make change and it doesn't go well, it can be painful. This failure can trigger unhelpful thoughts or feelings about the experience. Instead of intentionally placing ourselves in situations where we might again experience similar pain, we will try to forget a painful experience, pretend it's never happened, or avoid it altogether. In fact, avoidance may be the most common coping strategy for dealing with painful experiences (Hayes, Strosahl, & Wilson, 2003).

When we think of avoidance and stuttering, we generally think about avoiding words, listeners, or speaking situations. In a cognitive-behavioral model, however, these behavioral avoidances are viewed as having origins in avoidance of thoughts and feelings. If we are avoiding unhelpful thoughts and feelings, it is almost impossible to make behavioral change. Thus, learning to cope involves learning to tolerate uncomfortable thoughts and feelings versus trying to avoid them.

In a cognitive-behavioral therapy approach, increasing the clients' repertoire of coping mechanisms is an integral part of the therapeutic process. Time is spent helping clients learn and implement various coping techniques such as relaxation, guided imagery, coping cards, and role-playing adaptive responses to stressful situations (Beck, 1995). Development of coping strategies helps decrease the likelihood that one will give up, which can contribute to unhelpful thoughts and the overall stress caused by change.

One strategy that can be used with children learning to cope with uncomfortable thoughts/feelings is the Worry Dial (Cook & Botterill, 2009). The Worry Dial is a visual representation of varying levels of worry a child might be feeling when thinking about an experience.

To introduce the concept of the Worry Dial, first brainstorm with the child some things that she knows about that she can adjust, like volume on a TV, temperature on the stove, or force of the water coming from a tap. Then, discuss reasons why it's helpful to be able to make adjustments, and when she might decide it's time to make an adjustment.

Next, introduce the idea that worry is just like the examples you've discussed. Sometimes it's really big and bothersome, sometimes it's barely there, but how worried we feel is a choice we can make. Just like a TV's loudness or temperature on the stove, we have a choice about where we want our worry dial to be set. If it feels like our worry is too high and we're really afraid or anxious, we can turn it down.

At this point, it's appropriate to introduce a visual representation of a Worry Dial. You can draw a worry dial together with the child, or use a visual from another source (Scott, 2010). Many different images can be found in a Google Image search using terms like "volume knobs" or "temperature knobs." It's also helpful to help the child identify where she feels worry in her body -- such as in the upper abdomen right below the sternum. Explain that this is a place where we can often feel our worry because our tummy gets upset or our heart beats a little bit faster, so that's where our worry dial is located (Cook & Botterill, 2009).

Once you've created a visual representation of the Worry Dial, brainstorm ways that worry can be turned down. Helpful strategies the child is currently using should be incorporated by asking what he or she does now when worried; this reinforces to the child that he already knows how to take care of himself. Then, add others that the child might not have previously considered and if necessary, explore them by trying them out. Broad categories of strategies for coping with worry include:

• positive self-talk statements, e.g., "It's ok to feel a little afraid right now. Other kids would feel scared too;" "I know the answers to these questions and I can take my time to give the answers"
• relaxation responses e.g., taking belly breaths, shaking muscles out
• distracting activities e.g., playing with a pet, listening to music
• asking others for support, e.g. telling another person that you're feeling worried.

The concrete nature of the Worry Dial is especially useful with children because once the clinician has worked through possible strategies for coping, they can be referred back to in later therapy sessions about different worrisome events. As children develop a repertoire of strategies for coping, these new strategies can be added to the Worry Dial. Using a dial with numbers also facilitates the discussion between the clinician and child across therapy sessions. If the child reports being especially stressed out or worried about a situation, the clinician can prompt for the child to assign a number to the situation and then the two can discuss ways to "turn the dial down."

Over time, the child learns that he has the ability to selectively choose which coping mechanism to apply to a given situation; this is known as developing psychological flexibility (Hayes et al., 2003). As children develop psychological flexibility, changes in thinking begin to occur, changing from unhelpful thoughts like "I'm too scared to do this," to more helpful thoughts such as "I know it's ok to feel a little afraid right now. I can do this even if I'm a little afraid."

Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: The Guilford Press.

Cook, F., & Botterill, W. (2009). Tools for success: Cognitive-Behavior Therapy taster (DVD). Memphis, TN: Stuttering Foundation of America.

Hayes, S.C., Strosahl, K. D., & Wilson, K. G. (2003). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: The Guilford Press.

Scott, L. A. (2010). Implementing Cognitive-Behavioral therapy with school-age children (DVD). Memphis, TN: Stuttering Foundation of America.

You can post Questions/comments about the above paper to the authors before October 22, 2012.