Brennan J. Young, Thomas H. Ollendick, and Stephen P. Whiteside
Introduction
Working with anxious children through exposure therapy is at once inherently challenging and rewarding. Children by nature desire to learn, grow, and gain mastery over their world; but children with anxiety must work harder to approach and effectively interact with their world. For those of us who are called upon to help anxious children, our reward is to see them push through the fear to grow in both confidence and competence; our challenge is to enable them to do so.
Just as it is inherently difficult for a child to face his fears, it can be difficult for clinicians to effectively implement exposure therapy with children, and many clinicians choose not to adopt this approach (Addis and Krasnow 2000; Valderhaug, Gotestam, and Larsson 2004). For some, exposure does not fit their theoretical orientation or therapeutic style. Others may be reluctant to deliberately induce additional distress in children who are already fearful. Nevertheless, exposure therapy in anxiety has garnered both theoretical and empirical support. Avoidance of fearful stimuli is regarded as a core feature in the etiology and maintenance of anxiety disorders. According to Lang’s (1967) tripartite model, behavioral avoidance serves to negatively reinforce the anxiety response. Exposure, on the other hand, is incompatible with avoidance and, when performed competently and effectively, results in the extinction of the anxiety response through habituation. Indeed, empirical data support the efficacy of exposure in reducing fear and anxiety (see In-Albon and Schneider 2007; Kendall et al. 2005; Seligman and Ollendick 2011). For these reasons, exposure is considered the treatment of choice for childhood anxiety.
Our goal in the current chapter is to lay a clear road map for clinicians training to acquire competence in exposure therapy with children and adolescents. We begin by describing an evidence-based approach to conducting exposure therapy, highlighting key factors for successful implementation as well as key areas of competence for the successful clinician. We then discuss variations on this theme, describing the application of these central principles to treating specific types of anxiety. Next, we examine some developmental considerations that arise in work with children and adolescents and can further complicate the design and delivery of exposure therapy. Finally, we identify and suggest ways to overcome obstacles commonly encountered while delivering exposure therapy to children and adolescents.
Key Features of the Competencies: Behavioral Markers of Competently Delivering Exposure Therapy
Successfully delivering exposure therapy requires competence in several specific areas. Each area of competence will be discussed, but we begin with a general overview of the principal elements of exposure therapy. First, providing a strong rationale for engaging in exposure builds motivation for therapy, orients the child and her parent to their active role in therapy, and promotes tolerance for the distress that inevitably accompanies exposure. Next, the clinician conducts a functional analysis of the child’s anxiety, paying careful attention to the ways in which the child actively avoids facing her fears. The goal of this analysis is to build a graded fear hierarchy that specifies the steps by which the child will begin facing her fears. The clinician then guides the child through the appropriate form of exposure (e.g., in vivo, imaginal, narrative – see below), targeting her specific fears. In doing so, the clinician ensures that the child perseveres with each exposure until her subjective distress has decreased. During each exposure, the clinician is watchful for any safety behaviors the child engages in to avoid the situation or otherwise reduce her fear without directly facing it. The successful exposure session is then rewarded so as to reinforce the child’s new behavior, and the clinician ensures that the child learns the necessary lessons (e.g., the feared consequences do not occur; the distress can be tolerated). Finally, exposures within a particular step are repeated until the task no longer elicits significant fear or avoidance; when this is achieved, the child is ready to progress to the next step on her fear hierarchy. Ultimately, exposure therapy can be considered successful when an unplanned confrontation with the feared stimulus no longer produces a heightened anxiety response or significant behavioral avoidance.
Functional analysis
Each child will display a unique set of fears as well as unique behavioral reactions when confronted with his fears. Thus an idiographic (versus a nomothetic) approach should be taken to designing the exposure plan, and the careful diagnosis and detailed conceptualization of the child’s fear and behavioral avoidance should be considered an important area of clinical competence. A thorough functional analysis of the child’s fear will include a description of the context in which fear and anxiety are triggered. It is also important to build as good an understanding as possible of what the child anticipates will happen in these situations. Finally, it is important to identify current strategies the child employs to reduce his fear. These strategies may be ways in which he is able to avoid the situation altogether, to escape from the situation when it occurs, or to seek reassurance. It may also be necessary to elicit from parents their own reactions to the situation and to the child’s fears, looking for ways in which parents themselves reinforce the child’s anxious responses and avoidance.
It is important that the functional analysis of the child’s fear be as detailed and specific as possible. In fact a clinician may think of this assessment as “drilling down” or “peeling the layers of an onion” to find a core, underlying fear that lays at the heart of many of the child’s fears and avoidant behaviors (Beidel and Turner 2007). For example, consider the case of a 12-year-old boy who presented himself to an outpatient clinic with symptoms of social anxiety. This child became very anxious when interacting with strangers outside the home. Behaviorally, he withdrew from social interaction by hiding behind his parent, often had difficulty in making eye contact, and spoke in a whisper that was very difficult for others to hear. After the interview, the child and his parents were both in agreement about the range of situations that presented difficulties for the child, as well as about his behavioral reactions to those situations. The clinician continued to seek more information, asking why these situations were difficult for the child, what reactions the child feared he would receive from others, or what may happen as a result of interacting with others. The clinician also followed the matter up with questions such as: “And if that were to happen, what would be difficult about it?” Thus it is important to identify not only the negative outcome initially expected, but also the expected consequences of that outcome.
Over the course of interviewing and working with this child and his parent, it became clear that the child feared that he would say something incorrect or would make a mistake in front of a stranger, who would then form the impression that the boy was “dumb.” Understanding this core feature of the boy’s anxiety led to exposures in which he deliberately began making incorrect statements and other mistakes while interacting with strangers. Once his anxiety about making mistakes began to dissipate, his anxiety and behavioral avoidance began to improve across a variety of social situations that were not specifically targeted through exposure. Thus, when a specific fear can be identified through functional analysis, exposures can more directly target the child’s fear, and therapy can move more quickly and effectively. Often the process of getting to know a child’s anxiety continues to unfold over the course of treatment and, as the child’s trust in the clinician develops and rapport continues to be built, the child’s own insight and ability to identify thoughts and fears start to improve.
Fear hierarchy
Functional analysis will lead naturally to the next step in the therapy, which is to create the fear hierarchy – another area in which clinicians new to exposure therapy will need to achieve competence. The fear hierarchy delineates a series of exposures that target a specific type of anxiety or fear and progressively move the child closer to confronting his core fear; in the previous example, a hierarchy would have been created targeting the child’s fear of making mistakes in front of strangers. The clinician works with the child and his parent to identify a range of specific activities that center upon the identified fear and produce varying levels of anxiety or avoidance in the child. The child and his parent then provide a subjective rating of the level of the child’s anxiety for each activity (typically such a rating ranges from 0 to 10 and is referred to as the Subjective Units of Distress Scale – SUDS). Once each activity has been assigned a SUDS rating, the situations are in effect ordered from the least to the most distressing or impairing. Each step along the hierarchy progressively activates greater anxiety or fear in the child, since, with each exposure, he confronts his core fear more directly. It is important to bear in mind that the child’s level of distress for the later steps in the hierarchy may actually diminish as a result of his having progressed through the earlier steps. Thus a fear that originally was assigned a SUDS rating of “8” may actually be lower and more manageable by the time the child is ready to begin work on that step of the hierarchy.
A well-crafted hierarchy will include items that are easy enough for the child to engage with immediately; items that are more challenging than those encountered in a typical daily experience; and enough intermediate steps for the child to move from the former to the latter gradually. Taking good care to identify steps that produce lower levels of anxiety is very important for engaging the child and for starting to build confidence. By the same token, each step in the hierarchy should not be too far above the previous step in terms of the child’s anxiety. Finally, the last steps may include very challenging exposures, which directly target the child’s core fear and serve to dramatically disconfirm the consequences feared by the child. An example of this would be asking a child who is afraid of germs and contamination to put her hand in a toilet bowl – in the child’s mind possibly the dirtiest and most germ-laden place imaginable. This overlearning may enhance symptom improvement and maintain treatment gains.
Having stated the importance of a well-developed hierarchy, it is also true that the process of getting to know a child’s anxiety continues to unfold over the course of treatment, as rapport and trust continue to grow and the child’s own insight and ability to identify thoughts and fears begin to improve. Thus the initial fear hierarchy is also a work in progress, and, in training new clinicians, it will be important to encourage flexibility when they plan and deliver exposures. In addition, many anxious children show multiple fears, which often encompass several domains and thereby necessitate several fear hierarchies (Kendall, Brady, and Verduin 2001). Beginning with exposures that are easily controlled by the clinician and that present a high likelihood of success for the child will help build confidence and motivation early on in therapy. The clinician should also consider beginning with fears that, once reduced, can liberate the greatest potential for regaining daily functioning. Clinicians are encouraged to focus on one set of fears at a time, so that the child can achieve success in an identified area. However, due to practical constraints on conducting exposures, a child might work on several hierarchies at the same time in therapy.
The need for flexibility is often encountered when beginning exposures or moving from one step of the hierarchy to another. Children often underestimate the degree of situational anxiety they experience until they are actually experiencing it. Take, for example, a child who is afraid of heights, has rated looking down from a tenth-floor window as 3 on a scale from 0 to 10 (a good starting point for exposures), but experiences significantly higher anxiety when the time comes to actually approach the window on the tenth floor and is unable to do it. To change the exposure activity altogether would reinforce the child’s notion that he cannot cope with his anxiety and that avoidance is a solution. As a general rule, every step on the hierarchy can be further broken down into smaller, less anxiety-provoking steps. In the previous example, several intermediate steps are possible, such as allowing the child the first time round to hold onto a piece of office furniture or to the clinician’s hand. Alternatively, a subhierarchy could be quickly established by rating the child’s anxiety when he stands 5 feet from the window, then 4 feet, 3 feet, and so on; this method would allow the child to approach the window incrementally. Similarly each step of a hierarchy contains in itself a subhierarchy whose steps are small enough not to be overwhelming.
Psycho-education and building motivation
The anxiety experienced by both children and their parents may be a significant obstacle to promoting motivation and engagement in exposure therapy. Parents are asked to deliberately put their children in situations that cause distress, and children are asked to endure that distress. Thus both the children and the parents may need a strong motivation to engage in exposure therapy. A clinician’s ability to effectively deliver an explanation (or rationale) of exposure therapy that gives both children and parents this kind of motivation is another important area of competence.
Clinicians should be well versed in the theory underlying exposure therapy and should be able to explain it coherently both to parents and to children. As discussed more fully elsewhere, exposure is generally thought to work by modifying associations between fearful emotions, cognitions, and behavior that maintain anxiety reactions. Repeated and prolonged exposure modifies these associations by presenting information and experiences that are incompatible with the fear response. It can be helpful to introduce the cognitive behavioral conceptualization of anxiety and of its maintenance through a concrete example that does not provoke anxiety, such as fear of dogs (assuming the child does not have this fear). Using an illustration, the clinician begins by explaining that some people are afraid of dogs because they believe that dogs are likely to bite people. When they see a dog and become fearful, they naturally run away or avoid the dog. This reaction is quite successful in reducing anxiety for the moment. However, as these people still believe that dogs are likely to bite people, they remain scared of dogs and stuck in this cycle of fear and avoidance. The clinician emphasizes that (i) it is the thought (not the dog) that causes anxiety; (ii) avoiding dogs prevents people from learning through their own experience that dogs are relatively safe; and (iii) because avoidance is so effective at reducing unpleasant anxiety, people rely on this strategy more and more frequently. The majority of families, even those with fairly young children, can readily understand the self-perpetuating nature of the anxiety cycle as it applies to a fear of dogs.
