Exposure Therapy: Helping Children and Adolescents Overcome Fear
Anxiety is not always a bad thing. In fact, anxiety can be very helpful in preparing your body to fight or flee when there is danger nearby, such as seeing a bear in the wilderness. Anxiety works like an alarm system that alerts you to dangerous situations. Think about the fire alarms in your home – they need to be annoying enough to get your attention no matter what is going on in the home, and they need to be accurate, so they are only going off when there is actual fire or smoke. To be a good alarm system, anxiety also needs to be annoying and get our attention when danger is near, but just like your home fire alarms there can be “false alarms” when anxiety is happening in situations that are not dangerous, such as speaking with a group of friends. When an alarm goes off when it is supposed to, such as an actual fire in the house, we do not worry about the annoying sound of the alarm. We jump into action and do what we need to do to stay safe, and the same goes for anxiety. When there is an actual danger like a bear, we do not get distressed about feeling anxious, we do what we need to do to stay safe.
Everyone experiences false alarms with their anxiety from time to time. There are things that some of us tend to get anxious about while most others do not (e.g., heights, driving, germs). But when those false alarms become more frequent and lead to a lot of avoidance and disruption in your daily life, that is a sign that you may need the support of a mental health professional to help repair your alarm system, such that anxiety is only coming up when there is actual danger. There are interventions, like exposure therapy, that are well-studied and shown to be effective for correcting false alarms and reducing anxiety in children (and adults).
What is exposure therapy?
Generally speaking, exposure therapy calls for individuals to confront feared items or situations in a planned, gradual, and collaborative way. Children approach whatever it is they are afraid of (e.g., talking to peers), without using forms of avoidance (e.g., leaving the conversation), to learn that the situation might not be as bad as they predicted. During an exposure task, it is important that individuals stay in the situation long enough to gain new knowledge about that situation, either that it's safer than initially thought or that it's more tolerable than they thought. With that new knowledge, they can head into another feared situation feeling a little more confident and a little more able to tolerate those kinds of situations.
This approach can address a number of issues, such as social anxiety, panic concerns, separation concerns, school worries, and obsessive-compulsive disorder (OCD).
The first step in exposure therapy involves a discussion where anxiety comes from in general, how it is maintained by patterns of avoidance, and the ways in which exposure techniques can undo those patterns of avoidance to make you feel less anxious. Next, providers work collaboratively with children and their families to come up with a plan for gradually approaching feared situations, and they carry out that plan at whatever speed makes sense for the child.
The goal in exposure therapy is to identify the “Goldilocks” level of challenge—a provider wants to provide opportunities for the child to face their fears in a manner that is not too easy and not too difficult. If the exposure task is too easy the child, does not learn as much about their ability to face their fears. If it is too difficult, they might find the experience to be unpleasant and may be less willing to continue. Exposure therapists work collaboratively with the child and family to identify exposure tasks that offer the ideal level of challenge, and as that task gets easier with practice, they gradually move up to next ideal task.
The provider also assesses the scope of concern related to the avoidance behaviors. It could be riding out one big exposure. Other times it’s doing a lot of little ones. For instance, exposures to social situations might include one big social challenge like participating in a dance recital, or it might entail a series of little challenges like saying hello to people in a store. Exposure therapy works best when it is tailored to a child’s specific concerns. Coming up with exposure tasks that are a good fit for a child’s unique concerns can be a fun and creative process, and over time the child begins to see opportunities to complete additional exposures as they come up in their daily life.
How long does it take for exposure therapy to work?
Benefits can be seen early and throughout the course of exposure therapy. Exposure therapy works by providing children the opportunity to build their confidence and learn that they can handle feared situations. As their learning and confidence grows with each exposure task the benefits can start to emerge in parts of their daily lives. The duration of exposure therapy is different for each person. It is ideal to think about what functional goals you would like your child to work toward (e.g., regular school attendance, stopping avoidance of certain situations), and as they approach those goals you can discuss with their provider whether it is appropriate to discontinue services.
There will always be some level of anxiety in a person’s life. The good thing about exposure therapy is that once an individual learns the skills and possesses the confidence to face their fears, they are able to apply those skills to a variety of natural challenges that might come up in their daily life. The ultimate goal is for individuals to seek out opportunities to apply their exposure skills in their daily life by noticing when they are experiencing a false alarm and challenging themselves to face the situation – this is what we call “living the exposure lifestyle.”
Anxiety can be tricky, and avoidance can sometimes creep its way back into a person’s life, and it may be helpful in some instances to seek “booster” sessions after being out of treatment for a while to quickly shore up one’s exposure skills.
Considering exposure therapy for your child
When considering exposure therapy for your child it is important to speak with a trained exposure therapist. Together, you can discuss any concerns and get accurate information about what exposure therapy might look like for you and your family. Sometimes the word “exposure” can sound scary to both children and their caregivers, so you may hear some providers talk about exposure tasks as “bravery practice.” We prefer the term bravery practice because it’s a better representation of what is taking place during exposure – the child is building up their bravery and confidence in feared situations by taking many gradual steps toward facing their fears.
If other mental health concerns are present such as depression or inattention, it can help to add medication or do other behavioral strategies to help support those other concerns. Ultimately, the learning a person gets from exposure is tied to how well they're able to stay in a situation and attend to the exposure task.
Parents should reach out to a mental health professional if they think exposure therapy may be a solution for their child. You can learn more about exposure therapy and other helpful therapies for anxiety at the Pediatric Anxiety Research Center.
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