In the past years progress is made in the development of treatments based on cognitive behavioural therapy for anxiety disorders in youth. One of the important elements used in successful therapy is exposure in which the child is gradually exposed to the feared stimuli.

History and theory

There are different potential principles that could be responsible for the effectiveness of exposure. Based on principles of classical conditioning the exposure technique counterconditioning was developed by Wolpe. In counterconditioning the anxiety is reduced by presenting someone with both the feared stimulus and a pleasant stimulus. In systematic desensitization, an anxiety stimulus hierarchy is used. The client has to face the feared stimuli while engaging in reciprocal inhibition. At first stimuli that are rated low in anxiety but as soon as the stimuli does not elicit fear anymore a more difficult stimuli are presented. Simultaneously, the client has to engage in reciprocal inhibition to prevent serious fear attacks. Research has shown that it is not necessary to present the stimuli following a hierarchy and to use reciprocal inhibition. However, it can make the therapy session more pleasant for the client. Other behavioural explanations for the effectiveness of exposure are extinction and habituation. Extinction happens when the unconditioned response (e.g., fear reaction) no longer follows the conditioned stimulus (e.g. giving a speech) over repeated trials. In exposure exercises, operant extinction plays a role as the individual expects to be negatively reinforced through avoidance of the feared stimulus but, instead, experiences a decrease in anxiety while in the presence of the feared stimulus. In addition, habituation is decrease in anxiety that occurs when someone is presented with the feared stimuli for a period of time. It could be argued that the effectiveness of exposure therapy is due to an extinction generalization effect but it is also speculated that cognitive changes may be the reason .According to cognitive mediational models of anxiety reduction the effects are based on changes in maladaptive fear schema and reductions in negative self-talk. Clients also reported a change in their idea that unwanted anxiety would follow a conditioned stimulus. Also coping skills may be better developed during the therapy which also leads to increased self-efficacy. None of the described theories is significantly better than another and in every patient it has to be determined which is the most appropriate technique to use.

A sample CBT program for anxiety in youth

The described CBT program follows a gradual exposure model in which the child is progressively exposed to a hierarchy of feared stimuli. It is called ‘’coping cat program’’ and exists of 2 segments of each 8 sessions. The first segment focuses on skills training and the second on practicing these learned skills. In the first segment a FEAR plan is created as preparation of the exposure later on: the child learns about physiological/bodily reactions to anxiety. Then the child has to learn to attend to his/her self-talk (expectations and fears). The third step involves problem solving by starting the use coping thoughts or taking other actions to improve coping. Finally the child evaluates his/her effort that is made rewards this.

Features of the exposure task

It is important that the therapist does not make assumptions about the child’s fears but actively assess the fears. The therapist will create a fear hierarchy together with the child. The first step is to come up with anxiety-provoking situations that are rated on a Likert-type scale called The Subjective Units of Distress/Discomfort Scale (SUDS). When designing the first exposure task, the therapist starts with a minimally challenging situation. The ranking of the feared situations will probably change during the intervention. Also during an exposure exercise the SUDS ratings can be used to rate fear before and after the task. The ratings can be used to give the child feedback about the anxiety levels. The data that is produced by filling in the SUDS can be analysed and certain patterns might be found. In most exposure tasks the client is asked to remain in contact with the feared stimulus until anxiety is at least reduced by 50%. If the therapist thinks that the ratings of the child are inaccurate he/she can be choose to use own SUDS ratings to guide the exposure sessions.

Imaginal and in vivo exposure tasks

Two kinds of exposure tasks are possible, imaginal and in vivo. Imaginal exposure is more used with children who have abstract worries, such as found generalized anxiety disorder. The child can do a role-ply with the therapist how the situation will progress and end. Other tasks could be the child writing out a story about the feared ending and reading this out aloud to the therapist. In vivo exposure the child will remain in the feared situation while having to cope with the anxiety. The therapist should prepare the child for possible negative events during the exposure and should teach the child how to cope with this. The child will learn to challenge expectations and to cope with the situation, thereby feeling a sense of mastery. Therapy can exist of both in and out of session exposure tasks. The latter are performed at home, with the assistance of an adult who prevents avoidance behaviour and lets the child complete SUDS.

Rewards for effort

It is important that the exposure sessions are evaluated and that the effort made by the child is rewarded, also if the task was only partial successful. Rewards can be material goods but also self-rewards. Self-rewards are for example, a quiet reading time or playing with the family pet.

Posture of the Therapist

Therapists might be reluctant to give exposure therapy to children because they feel incompetent to manage the anxiety of the child or because they do not want to create such a distressing situation for the child. This view might also be held by parents and children. However, exposure tasks provide otherwise unavailable opportunities for youth to practice the newly learned coping strategies.

Developing and keeping rapport

The therapist and child have a collaborative relationship. Plans are made together and the exposure tasks are viewed as experiments in order to collect data. This will improve the success of the exposure task. Effort put in by the child should be emphasized instead of only specific outcomes.

Consulting with the child: but not in the negotiation trap

It is important to consult with the child and to create tasks together, however, the therapist has to prevent the negation trap. In the negation trap child tries to select exposure tasks that are too easy or that are in an area in which he/she feels more competent.

Shaping processes

Sometimes shaping might be helpful in achieving an ideal exposure session. Ideal means that tasks are prolonged, repeated and prevent the use of distraction and/or safety behaviour. Shaping is the use of a compromise on one of these standards.

Careful: do not reinforce avoidance

Failure to accomplish an exposure task may be the result of (a) real events, (b) pseudo-events (excuses reported by the child or parents), or (c) refusal to engage in exposure tasks. these events can lead to avoidance and the therapist has to address this immediately.

Modelling for parents

Some parents are overly protective and empathetic whereas others are overly critical and intolerant. The therapist can be a model for the parents and show how to behave in an appropriate way in for example showing enthusiasm for the treatment and tolerance for the child’s distress.

Dealing with less-than-successful exposure tasks

Less-than-successful exposure tasks can be caused by underestimations of the anxiety and the coping skills, parental interference and other unfortunate events. Because this information is now provided, the task is never totally unsuccessful.

Dealing with resistance

If the child really does not want to engage in the exposure task and is maybe crying the therapist still has to do the task but after the child has calmed down a bit. This can be done by some cooperative undertaking and adjustment or delay. For example, some questions, also funny ones, related to the task can be asked to give the child a feeling of control.

Youth characteristics

Developmental level is important. The chronological age is not always equal to the developmental age. The therapist has to adjust the intervention if necessary. By doing so, the therapeutic relation will be improved. In treating very young children it can useful to ask parents about the behaviour of their child. Development also plays a role in determining the role of the parents during the treatment. In addition, contextual factors, ethnicity, cultural background, religion and gender have to be taken into account.

Professional practice issues

Many therapists are questioning exposure out-of-office because of the question of liability. On the one hand, who is responsible for the child when the therapist goes to some place with the child to do an exposure exercise? On the other hand, is it responsible to withhold a child from exposure therapy even if there is evidence that exposure would be the best therapy? Therapists should be flexible and creative in designing an exposure task. The therapist also needs to be alert to avoidance behaviour in order to being protective and has to exude confidence in the child’s ability to compete the exposure task.