Most professionals, or at least those trained in CBT approaches, are aware of the concept of exposure in treating children with anxiety. However, community studies suggest even those of us who are familiar with exposure, under-utilise it in practice. This article provides a quick review of the concepts, evidence and practical applications for using exposure when working with children with anxiety.
Key definitions and terms
Exposure is defined as a controlled therapeutic technique which involves a child being in the presence of an anxiety-provoking stimulus or situation (Marks 1973). There are a number of additional key terms related to exposure which are helpful to understand. I have outlined these below.
In-vivo exposure – when a child is exposed to the stimulus/situation in “real life” (eg a child with a fear of public toilets being taken to a public toilet with their therapist/parent).
Imaginal exposure – when a child is asked to deliberately bring a feared situation, memory or worry into their mind (eg a child with fears of being negatively evaluated by others at school vividly imagines doing a talk in front of the class).
Interoceptive exposure – when a child is helped/asked to deliberately create bodily sensations (eg a child with fear of panic symptoms assisted to hyperventilate in order to be exposed to symptoms of dizziness/breathlessness).
Graded exposure – In-vivo, imaginal or interoceptive exposure which is done gradually and systematically, usually from least to most feared (eg a child with a fear of spiders working up a hierarchy of getting closer and closer to a spider).
Flooding – exposure which happens all at once (eg a child with a fear of dogs spending a day in a dog kennel).
Virtual reality exposure- using virtual reality technology to assist a child to be virtually in the presence of feared stimuli (eg a child with a fear of flying using a VR headset to be in a plane).
Systematic desensitization – when exposure is combined with relaxation techniques (eg a child with a fear of the dark, being in a gradually dimmed room while practicing relaxing their body at the same time).
Exposure and Response Prevention – when we ask a child with OCD to use exposure techniques to their obsessions (distressing feared situations/images/ideas) while “preventing” them from using the compulsions they usually use to manage the anxiety they experience from those obsessions (eg a child touching a germy surface without washing hands, imagining a scary situation without immediately counting to 10).
Effectiveness of exposure treatments for anxiety disorders
Research suggests that more exposure included in a treatment for children (true for adults too) with anxiety disorders and symptoms, the more effective the treatment is. For example, two research studies which coded a number of treatments for children with anxiety disorders, according to how exposure was included, showed that the treatments using the most exposure based techniques were associated with better functioning at the end and larger effect sizes in symptom reduction. Another recent study compared relaxation based treatment to exposure based treatment without relaxation and found the latter more effective for children
Theories of exposure: why is it helpful?
The practice of exposure was initially developed from the behavioural learning principles of habituation. Theories about habituation state there will be a decrease in a response to a stimulus if that stimulus is repeatedly presented. In other words, if a child is in the presence of a feared stimulus for a long enough period of time, then their “fear response” will gradually lessen as they “get used to” – or habituate to – the feared stimulus.
Traditionally therefore, when psychologists conducted exposure with children they would asked them to rate their subjective units of distress (SUDS) during the exposure, and continue the exposure until it had reduced (a 50% reduction was an arbitrary, but accepted level of their starting fear level).
However, over the last 2 decades, researchers found that children often experienced reductions in fear AFTER the exposure session is over even if they didn’t report any reductions in fear during exposure. In other words, many children didn’t habituate to the fear during the exposure – but it seemed to work in reducing their fear later anyway! This suggests there is some other mechanism of change in explaining why exposure works which is separate from habituation.
It’s also been noted by some writers that the habituation theory of exposure is potentially unhelpful for clients given its focus on fear levels. This is because some children focus on and become anxious about their fear levels during exposure (possibly due to worries about whether it is “working” or not) – which can lead to additional anxiety. More contemporary forms of CBT often refer to “managing” or “coping with” anxiety rather than reducing anxiety, so emphasis on SUDS can be unhelpful in some situations
New theories of exposure
Alternative and newer theories for explaining why exposure is helpful in reducing anxiety have been referred to in many ways – including “Inhibitory learning models” or “Neo-conditioning”, “Information processing” or “Schematic and modal processing”.
The core idea in all of these models is that exposure is helpful not because the fear response is habituated via long/repeated exposure to feared stimulus, but instead because people “learn” different expectations about what will happen when they are in the presence of the feared stimulus.
In other words, exposure works because children learn that the feared stimulus is not necessarily as threatening as they previously thought. For example, they might learn that the feared situation doesn’t result in negative outcomes or that they may be able to cope with these outcomes. This new set of expectations then can “compete” with the old set of expectations.
For example, a child who is anxious about going to sleep outside of Mum’s bed and believes “I won’t be able to get to sleep anywhere else and this will be awful” and then has repeated experiences of falling asleep in other rooms, now has new expectations which can compete with old expectations, and this is the reason for their reduced anxiety.
Practical steps to using exposure with children with anxiety
It is important to understand the theory and evidence for exposure, but more important is working out how to implement this treatment component with children with anxiety symptoms. Here are a some ideas I have found helpful in doing this.
- Establish strong rapport
Evidence suggests that the therapeutic relationship between a therapist and child accounts for a significant portion of the outcomes in any therapy approach – and this may be even more true when using an approach such as exposure. We need to show high levels of warmth and empathy with both children/teens and parents/caregivers in the process of using exposure. This includes being empathic, showing positivity and interest in children, taking an interest and being genuine/authentic with them.
- Provide clear and comprehensive exposure psycho-education to children and families
We need to provide clear psycho-education to children and families about why exposure is important and what it will be like. This might include three psycho-education topics.
a) Psycho-education about the “anxiety/avoidance loop”
We first need to explain how avoidance leads to increased anxiety.
For example, for younger children we might say (and use accompanying visuals) something such as:
“When we stay away from or try not to think about things which seem a bit scary, our danger checker learns – that IS a dangerous thing! We get more and more scared”
For older children and teens, using a visual diagram is often still very helpful, but we might use more sophisticated language (ie refer to brain systems such as the amygdala and adrenalin/cortisol) and refer to the fact that scientists have studied this in laboratories.
b) Psycho-education about the “approach/lower anxiety loop”
It can be also helpful to explain the opposite loop, in other words that “approaching” or using exposure can reduce anxiety. For example, for younger children we might say (and use accompanying visuals) something such as:
“When we act in brave ways even when we are scared, our danger checker learns instead that we are safe.”
Again, for older children/teens, diagrams are still helpful, but we can use the same more sophisticated language (eg referring to “approach behaviours”, “exposure” or relevant brain structures) and scientific evidence.
c) Psycho-education about treatment practices
It is also very important to let children and their families know about what the treatment of exposure might look like, the fact that homework is required, and how long it might take to see reductions in anxiety during exposure.
It is also vital to discuss in advance of starting exposure the barriers to completing exposure exercises in session and at home (for both child and parents/caregivers), and have plans for managing these.
This includes the fact that children/teens may experience high levels of distress or very low motivation to complete the exercises, and that parents/caregivers will then have a choice about whether to take steps to assist and ensure the child completes the exercise – or whether to abandon the attempt.
Parents/caregivers should identify what will be hardest for them about a child’s low motivation/high distress and what specific plans they can put in place to assist them/ensure it is completed, or whether they want to follow these through.
- Identify avoidance and targets for exposure exercises
Designing an exposure exercise means firstly identifying appropriate feared situations or images which the child has typically avoided. This is easier said than done! Here are three ideas to help identify appropriate targets.
a) Identify specific situations or images the child is avoiding
In order to design exposure exercises, it is important to find the specific situations or images which a child avoids, rather than only identifying the general concepts that a child is anxious about. This means “digging” – asking many questions to get to some of the examples of the avoidance. These questions are often of the form:
- If you weren’t at all anxious in situation x/y/z, what would you be doing or saying?
- What types of situations are hardest?
- When is it worse/when is it better?
For example, a child who is afraid of public speaking might specifically be afraid of doing a presentation in English, rather than in History. A child who says they are afraid of being away from their parents, may be specifically most afraid of sleep overs with friends at night.
b) Don’t overlook avoidance labelled as “dislike/discomfort”
Sometimes children deny any avoidance despite there being apparent anxiety. One factor which can lead to this is due to children’s limited cognitive/introspection skills which means they only have “all” or “nothing” ways of describing anxiety: they can identify high levels of fear but find it hard to notice their “moderate” levels of anxiety. When this occurs, they label their moderate anxiety as “dislike/discomfort”
I don’t like being around dogs/I prefer to use my own toilet at home/I don’t like foods which are chewy/I just don’t like to think about that
We can provide psychoeducation about dislike/discomfort being anxiety and avoidance and if appropriate add these targets to the list of options for exposure.
c) Be aware that avoidance of some situations may be within a developmentally appropriate range OR not valued by families and therefore not an appropriate target
Some avoidance in children is either normal for their age, or even if not typically developmentally found, not valued. For example, avoiding being separated at bedtime is a normal behaviour for young children, and avoiding loud noises is typical for children with ASD and may not be a behaviour a family is concerned about. If an avoidance behaviour is either developmentally appropriate or not a prioritized problem by families then it may not be appropriate to target.
- Identify feared expectations which underlie the avoidance
If more contemporary theories of exposure are correct, it is particularly important to design exposure exercises which violate a child’s feared expectations (negative thoughts and beliefs about outcomes).
Therefore if possible we need to identify these feared expectations. For example, for a child with a fear of eating green foods, we want to elicit a feared expectation of what will happen if they eat green foods (which might be “I will vomit if I eat broccoli”). For a child with a fear of speaking in class, we want to elicit the feared expectation of what will happen if they do this (which might be “People will think I am stupid if I blush while I am doing my presentation”).
This is not always easy of course – and the younger the child, the more potentially difficult this is given their capacity for introspection is not developed. Questions to help elicit these expectations might be:
- And what will happen then?
- What might be one bad thing which happens if you do that?
- What does a part of your brain say could go wrong?
- What might people think if you do that?
- Is there anything not good which could happen to someone else if that happened?
- What is the thing you would most dislike if that situation occurred?
- Design exposure tasks to specifically challenge expectations – and highlight belief change
Once we have identified specific avoidance, and ideally feared beliefs and expectations, we should design a range of exposure tasks which target the specific fear and have the best chance of violating the feared beliefs and expectations.
For example, an exposure task for a child worried about peers thinking she/he is stupid for blushing should ideally be a task which generates blushing (even via make up perhaps if needed) and then elicits the thoughts of the peers in the class she/he is most fearful of (eg a survey or asking a friend to get another peers’ opinion), rather than a task which just requires the student to do a talk. This is not always easy, but the closer we can get to the expectation challenging situation, the better.
We then want to help children notice any changes in these expectations. This means asking them questions like:
- What is happening? What happened?
- What might happen next?
- Is it possible that (alternative, more positive expectation)?
- Eg did you have any times at school today where you were okay?
- Do you think people DID think you were stupid when you blushed? What did they say on their survey? What did X say about that?
- Did you vomit when you ate the broccoli?
- Did the spider hurt you?
These questions maybe more useful than “how anxious did you feel/are right now” which focus on the anxiety.
For younger children who were not able to identify a specific negative belief, we can “insert” positive expectancies as “calm thoughts”.
- You are/were safe and the spider isn’t /didn’t hurt you!
- You had some fun “big kid” time away from Mum/Dad
- Increase motivation/adherence
Exposure can be hard work or painful for children. It is important for us to think about how to increase motivation for or adherence to exposure tasks. The most important ways to increase motivation and adherence is having a close, connected therapeutic relationship and using a thorough and comprehensive psycho-education process prior to the exposure, as outlined above. However in addition to these two factors, here are two other options.
a) Consider the use of game like/enjoyable components of or distractions in the exposure task
Games, fun activities or enjoyable thinking tasks can help children be more likely to comply with or adhere to exposure tasks.
For example, during social anxiety exposure tasks we might use “social detective games” (secretly noticing eye/hair colour, using “bingo” sheets to tick off names of kids they are saying hello to) or we might have exposure tasks done on social media apps/websites if this is more enjoyable.
During separation anxiety exposure tasks, we might have children develop secret handshake goodbyes with parents/caregivers, have comforting or fun transitional objects they/their parents hold or have during separation, use “special activity” at beginning of day activities, or get children to have special time with friends while separated.
During performance anxiety avoidance exposure tasks, children might “play” “big and little mistakes games”, intentionally making funny mistakes or doing poor quality work with friends.
There are a multitude of ways we can make exposure tasks more enjoyable, and these can relate to a child’s personality, interests and preferences.
When discussing distraction like activities during avoidance, it is important to address the issue of “safety behaviours” versus “coping behaviours”.
A safety behaviour is something a child does during a feared situation which helps them believe a feared outcome will not occur. For example, they might drink water while eating broccoli to ensure they don’t vomit. There is some evidence that “safety” behaviours can reduce the effectiveness of exposure.
On the other hand, “coping behaviours” are something a child might do to help them manage the anxiety. For example, a child might watch TV while they are eating broccoli to help them cope with the anxiety about eating it. The use of coping behaviours are unlikely to interfere with the effectiveness of exposure, as they don’t impact on the challenging of the negative belief.
Unfortunately these often overlap and requires some discretion on behalf of the therapist.
A good question might be: if you did this behaviour/used this strategy while you were in this fearful situation, would it STOP (feared expectation). If the answer to this is “no” then it is likely to be a coping behaviour, rather than a safety behaviour, and is fine to use.
For example, if a child holding a photo of Mum/Dad while at school made them believe – this will stop Mum/Dad having a car accident and being harmed while I am not there – this would suggest this behaviour is a safety behaviour and therefore might interfere with the power of the exposure task. If they did NOT believe holding the photo would prevent that happening, and just made them feel better, then it is a coping behaviour and is probably okay.
b) Consider using rewards/reinforcement for completing exposure tasks
We can also increase children’s motivation/adherence to exposure tasks by considering the use of reinforcement and rewards. This doesn’t need to be seen as a “bribe” (ie potentially undermining internal motivation) but instead an appropriate appreciation for hard work.
This might include:
- External reinforcement – Stickers/prizes/points systems
- Building internal reinforcement – seeing own progress/charts
- Social/relational reinforcement – Praise, acknowledgement and thanks
- Use a variety of exposure situations and trials
Research shows that using a variety of different exposure situations may increase the generalisability of learning for children and increase reductions in anxiety. For example, for a child with a fear of eating green foods, we might set exposure tasks such as eating broccoli in 10 different places, eating 10 different green foods or with 10 different people around. For a child with separation anxiety, we might set exposure tasks where the child is separated from Mum/Dad in many different environments, places and with as many different other people as possible.
- Exposure exercises need to happen in session AND at home
It is important that exposure exercises happen both in session with therapists – so we can help guide families and in between sessions – so there are enough exposure exercises which happen quickly enough to consolidate new learning. Exposure completed for homework can be particularly challenging for families. Ideas for helping this to happen include the following:
- Provide psycho-education about the need for exposure exercises set as homework at the beginning and throughout therapy – including (as outlined above) anticipated barriers, identification of the most difficult outcomes and plans to manage these.
- Collaborate with the child/teen and family on their preferred exposure exercises to be done for homework (“what do you think you could do before next session which would teach your danger checker that X is safe/would help you put into practice what we have talked about today/”)
- Increase specificity and clarity about homework (dot point form with no ambiguity and put in writing)
- Increase accountability – will check on homework beginning of next session/email me before next session
- Problem solve homework non completion by again identifying barriers and plans
- Re-discuss evidence for exposure treatments over and above supportive counselling approaches
In conclusion: Exposure is an evidence based treatment component for anxiety disorders. Survey based research suggests that children, youth and families are more positive about exposure than some therapists expect. Of course, this doesn’t mean it is an easy treatment to complete – and of course it doesn’t apply to all families. All the best with your experiments with using this component with the families you work with.