Exposure therapy for generalized anxiety disorder in children and adolescents

C H A P T E R

10 Exposure therapy for generalized anxiety disorder in children and adolescents Jordan P. Davis, Sophie A. Palitz, Lesley A. Norris, Katherine E. Phillips, Margaret E. Crane and Philip C. Kendall* Temple University, Philadelphia, PA, United States

Generalized anxiety disorder (GAD) is characterized by persistent and uncontrollable worry about a variety of topics (e.g., health, family issues, school, safety, minor matters, the future; American Psychiatric Association, 2013), and it has historically been identified as one of the most poorly understood (Rowa, Hood, & Antony, 2013) and difficult to treat anxiety disorders (Salters-Pedneault, Roemer, Tull, Rucker, & Mennin, 2006). Ten to twenty percentage of youth meet diagnostic criteria for at least one anxiety disorder (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003), 2.2% of youth meet diagnostic criteria for GAD in particular (Merikangas et al., 2010), and a large majority of youth have comorbid anxiety diagnoses (e.g., Kendall et al., 2010). Despite its common occurrence, research has indicated that exposure-based cognitivebehavioral therapy (CBT) is efficacious in the treatment of GAD in youth (Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008; Ladouceur et al., 2000; Read, Puleo, Wei, Cummings, & Kendall, 2013; Walkup et al., 2008). Moreover, exposure is one of the critical features of gold-standard CBT programs for youth (e.g., Coping Cat; Kendall & * We would like to thank Drs. Jennifer Podell and Sandra Pimentel for their valuable suggestions for this chapter.

Exposure Therapy for Children with Anxiety and OCD DOI: https://doi.org/10.1016/B978-0-12-815915-6.00010-X

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Hedtke, 2006) and has been found to be a meaningful contributor to beneficial treatment gains (e.g., Kendall et al., 2005; Peris et al., 2015). Questions remain about the exact mechanism by which exposure is efficacious (e.g., behavioral experiments, habituation, coping skills development, extinction learning, cognitive change), but there is little disagreement that exposure is central. Developing and implementing exposure tasks for youth with GAD can be an arduous process, especially for therapists with clients whose worries cannot as easily be addressed with behavioral experiments (hypothesis testing) or in vivo exposure, but it is a necessary and worthwhile process. This chapter is designed as a how-to guide that therapists can reference during the planning and implementation of exposure tasks for youth with GAD. We provide detailed and illustrative outlines for the planning and implementation of exposures for school-related and future-oriented GAD worries. Sample feared situations and appropriate exposures are provided for several other common GAD worries. The detailed outlines for school-related and future-oriented worries can be generalized to assist in the planning and implementation of exposures for other GAD worries. We also outline steps for preparing youth, family, and others for exposure tasks, as well as problem-solving strategies for the management of challenging issues that may arise. Our work is based on experience treating anxious youth, primarily using Coping Cat (Kendall & Hedtke, 2006). The strategies align with a CBT framework, which can be seen in our emphasis on procedures that have been evaluated in research including changing self-talk, problem-solving, and exposure tasks, as well as preparing for exposures and processing the exposure experience after it is completed.

Before beginning exposures Therapists are encouraged to begin laying the groundwork for exposure tasks with youth prior to actually planning and implementing them. An important first step is building rapport with youth and with their parents. Many youth do not come to therapy of their own accord, which may contribute to difficulty gaining “buy-in” from them. Increasing youth engagement and involvement is a valuable first step to gaining “buy-in” for subsequent exposure tasks. Good therapist-client rapport and buy-in are likely to improve client’s compliance with exposures, thus leading to improved therapy outcomes (e.g., Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010). Therapists are encouraged to provide youth and their parents with psychoeducation about GAD. Through this process, therapists are encouraged to normalize the experience of GAD worries and explain

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Developing a fear hierarchy

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the different components of anxiety: the physical symptoms (e.g., racing heart, sweaty palms, stomachache), the cognitive elements (e.g., expecting bad things such as injury, death, or extreme embarrassment to occur), and the behavioral aspects (e.g., avoiding feared situations). The roles that avoidance and parental accommodation play in maintaining anxiety are discussed: avoiding anxiety-provoking situations might feel relieving in the moment, but it makes those situations feel more distressing in the future. Parents are taught how accommodation—changing their behavior or expectations to let the youth feel less anxious (i.e., “giving in” to the youth’s anxiety)—may offer short-term relief but bring long-term challenge. That is, accommodation lets the youth feel better in the moment, but enables avoidance and can send the message that the parent believes the situation was, in fact, too difficult for the youth to handle. Following psychoeducation but before beginning exposure tasks, it is helpful to teach youth and parents skills that they can use to reduce or cope with anxiety. These skills are taught over several weeks leading up to exposure (e.g., Kendall & Hedtke, 2006; Miller, Rathus, & Linehan, 2006). Briefly, they may include, identifying one’s signals for experiencing anxiety (anxious self-talk), which can serve as a cue for when to use strategies to reduce anxiety. Some children and adolescents find deep breathing helpful, and mindfulness practices have appeal for some adolescents. Changing one’s expectations and problem-solving can be helpful skills to bring to an exposure task. Additionally, distress tolerance can be helpful for managing anxious arousal during exposure tasks.

Developing a fear hierarchy Therapists are encouraged to collaborate with youth and their parents to create a fear hierarchy (see Tables 10.1A 10.9). A fear hierarchy is a ranked list of the youth’s fears and concerns, with the least feared at the bottom of the hierarchy and the most feared at the top. Be alert: do not fall prey to assumptions about the youth’s feared situations. Instead, collaborate with the youth to determine the nature of their fear (i.e., what the youth expects might happen). Therapists can prompt the youth to be specific. If the youth states that s/he is nervous about answering the phone at home, the therapist can collaborate with the youth to help him/her better understand the underlying fear or worry. For example, the youth may be nervous about the prospect of talking to a stranger. This added specificity facilitates a more targeted exposure for the youth. After a number of feared situations are identified (ideally 8 10), therapists and youth collaborate to assign anticipated subjective

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TABLE 10.1A School-related GAD worries. SUDs rating

Fear hierarchy

8

Getting a detention

7

Breaking an important rule in class

6

Breaking a small rule in class

5

My teacher getting mad at me in front of others

5

The teacher getting mad when I answer a question incorrectly

4

The teacher calling on me in class when I don’t know the answer to a question

4

Forgetting to read the directions to a homework assignment and doing something wrong.

3

Asking a question in class

2

Imagining what it would be like for my teacher to be really angry with me

1

Seeing my teacher get angry with another student and wondering “what if that was me?”

SUDs, Subjective units of distress. Scenario: Camila (9-years-old) has a lot of worries about her performance in school, particularly that she might do something wrong and get in trouble with the teacher. These worries are worse for her at the start of the school year, before she learns classroom rules and gets to know her teacher. As a result of her worries, she has a difficult time raising her hand in class and currently has a low participation grade.

units of distress (SUDs) ratings to each fear (see Tables 10.1A 10.9). SUDs ratings were originally developed using a scale from 0 (no distress) to 100 (highest level of situational distress; Wolpe, 1969). The Coping Cat program uses an SUDs rating scale of 0 8 (Kendall & Hedtke, 2006) in an effort to simplify the process, particularly for younger children. Providing anchors for the numbers can be helpful (e.g., cartoon faces ranging from smiling to extremely nervous; written or verbal descriptors ranging from “0 5 easy peasy” to “8 5 the scariest thing I could ever do”). Once anticipated, SUDs ratings are agreed upon and assigned, the therapist and youth arrange fears in descending order. The ordering of fears can be changed, and new fears can be added at any time. Keep in mind that fear hierarchies can be as simple (e.g., a plain list) or intricate (e.g., a colorful list with pictures written on a pyramid or a ladder) as the therapist and youth deem appropriate. Keep youth engaged in the process, including having them write or draw the list themselves. Once drafted, the therapist uses the youth’s hierarchy to develop the type

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Developing a fear hierarchy

TABLE 10.1B

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School-related GAD worries: exposure tasks.

SUDs rating

Fear hierarchy

Exposure

8

Possibly getting a detention

Run down the hallways in school

7

Breaking a rule in class

Keep talking to a friend after the teacher asks us to quiet down

6

Breaking a small rule in class

Break the no chewing gum rule in class

5

My teacher getting mad at me in front of others

Have my therapist to arrange for my teacher to get upset with me in class

5

The teacher getting mad when I answer a question incorrectly in class

Raise my hand and answer a question incorrectly on purpose

4

The teacher calling on me when I don’t know the answer to a question

Verbally run through the entire feared situation with my therapist, including as many details as possible and highlighting my feared outcome

4

Forgetting to read the directions to a homework and doing something wrong

Complete a practice worksheet without reading the directions

3

Asking a question in class

Raise my hand and ask a question in class

2

Imagining what it would be like for my teacher to be really angry with me

Have my therapist read the story I wrote out loud with me, pretending to be the teacher

1

Seeing my teacher get angry with another student and wondering “what if that was me?”

Write down a story of exactly what my teacher would say if she were angry, and read the story out loud to myself a few times a day for a week

SUDs, Subjective units of distress.

and order of exposures (see Tables 10.1A 10.9). Of note, children will vary in the ratings they assign and the extent to which they use the full range of the SUDs scale. Some hierarchies may contain feared situations with ratings from 0 to 8, whereas others may contain feared situations with ratings from four to eight. This variety is reflected in the sample hierarchies presented in this chapter. Prompting a client to generate feared situations that correspond to each rating level between 0 and 8 is unnecessary. Above all, fear hierarchies should be created collaboratively and should accurately reflect the experience of the youth.

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TABLE 10.2A Future-oriented GAD worries. Rating

Fear hierarchy

8

Going on an interview for a summer job

7

Messing up an interview for a summer job

6

Completing and submitting a summer job application

5

Getting a bad grade on a test

5

Getting a failing grade on a homework assignment (which will mean she will be a failure and will not get into college)

4

Never getting a good job, and thus being a failure

4

Not getting accepted to any college while all my friends are accepted to their top choice schools

4

Not knowing if something will go wrong in my future

Scenario: Alexis (15-years-old) spends a lot of time worrying about things that could go wrong in the future. Specifically, she worries about getting into a good university and getting a job after school. These worries become more intense when Alexis gets a bad grade on a homework assignment or thinks about having to apply for a summer job. If she does not get an A, Alexis “breaks down” and asks her mom for reassurance that she will be admitted into the college of her choice and will not be a failure. Though Alexis would like to work over the summer, the thought of going to an interview, messing it up, not obtaining a position, and thus beginning a life of failure is too upsetting for her to follow through with the application process. Additionally, Alexis worries that if she doesn’t get a summer job, she will never get a job in the future.

Planning exposures: school-related GAD worries This section outlines exposure tasks for one of the most common GAD concerns: school-related worries. We use Camila, a 9-year-old girl who worries that she might do something wrong at school and that she might get in trouble with her teacher, as an example (Table 10.1A). When planning exposures, consider using in vivo exposure and imaginal exposure both in-session and between sessions (i.e., homework; Table 10.1B). Therapists may opt to begin with imaginal exposures, but this is not required. One of Camila’s central worries is that her teacher will ask her a question in class and that she will not know the answer. An initial exposure could be to have Camila describe the classroom, and then imagine the situation in detail with the therapist. When planning such an imaginal exposure, the therapist strives to identify specific aspects of the situation that make Camila anxious and thus would be useful for Camila to imagine. For Camila, details could include the name of the teacher, the name of key classmates, where Camila is sitting, a question the teacher might ask, Camila’s internal and external reactions, the answer Camila would provide and,

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Planning exposures: school-related GAD worries

TABLE 10.2B

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Future-oriented GAD worries: exposure tasks.

Rating

Fear hierarchy

Exposure

8

Going on an interview for a summer job

Go on an interview for a summer job at a local ice cream parlor

7

Messing up an interview for a summer job

Role-play a “bad” interview with the therapist

6

Completing and submitting a summer job application

Submit several summer job applications

5

Getting a bad grade on a test

Purposefully answer three questions incorrectly on an Algebra test

5

Getting a failing grade on a homework assignment (which will mean she will be a failure and will not get into college)

Submit a homework assignment with half of the questions blank

4

Never getting a good job, and thus being a failure

Write out a story of what it would be like to not get a good job and to be failure; add as many details as possible; Read the story aloud every day for one week between sessions

4

Not getting accepted to any college while all my friends are accepted to their top choice schools

During the session, imagine (aloud with the therapist) being in this situation; Describe this scenario with as much detail as possible.

4

Not knowing if something will go wrong in my future

Ask Mom only three reassurance seeking questions

importantly, what Camila imagines the reactions of other students would be. Planning the imaginal exposure helps prepare the therapist to guide Camila through the exposure and enables the exposure to be maximally effective. If a youth does not identify and talk about the detailed aspects of the feared situation, the exposure is less likely to be successful. In-session in vivo exposures also require planning. The therapist considers which elements of Camila’s feared situations can be simulated effectively during a session. “Effectively” here refers to the ability of the situation to elicit anxious arousal in Camila. Of note, it is important to elicit anxious arousal so that the in-session situation can mimic the “real world” and so that youth can learn that they can survive their feared situations. When planning an in-session in vivo exposure for Camila for the fear of “asking her teacher a question in class,” the therapist could

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TABLE 10.3

Performance/perfectionism GAD worries.

Rating

Fear hierarchy

Exposure

8

Getting a failing grade on a drawing

Hand in a drawing half completed, earning me a failing grade

7

Having people not recognize what I drew

Draw an apple very abstractly

6

Forgetting to add shadow to a part of my drawing

Skip the shading on an object in a picture

5

Seeing an obvious stray line in a finished drawing

Make an intentional stray line in a drawing

4

Not being able to fix mistakes in my drawing

Do a drawing carefully once

3

Not checking my drawing several times to make sure there are no mistakes

Only double-check a drawing once

2

Only spending a short amount of time on my drawings

Limit time spent on drawings (e.g., to 20 min)

2

Not spending as much time as I want on my drawings

Limit time spent on drawings (e.g., to 1 hr)

Scenario: Aidan (13-years-old) has a passion for drawing, but he worries that his pictures are never perfect, which will cause him to get a bad grade in his art class. As a result, he stays up very late every evening drawing and redrawing sketches for his art class. Aidan sometimes refuses to turn in his pictures because of worries that there is a stray line and often gets distracted thinking about how he could improve his sketches. Sometimes, he even works on his drawings during other classes. This has negatively impacted his grades both in art class and in his other classes. Preparing for the exposure: Proper preparation for exposures would include discussing Aidan’s worries about imperfectly drawn artwork, discussing what makes Aidan’s favorite artists’ work good, and challenging the idea that any piece of artwork is “perfect.”

arrange for one or two confederates (e.g., a different clinician, staff member) to play Camila’s teacher during a session and role-play the anxiety-provoking situation. For the fear of forgetting to read the directions on her homework and doing something wrong, the therapist could create a worksheet to use in a session, instructing Camila to intentionally not read the directions before completing the worksheet. Between-session exposures are considered critical to treatment as these exposures typically involve the youth engaging in the very “reallife” situations that are on their fear hierarchies. Indeed, research indicates that treatment responders (i.e., youth who experience a meaningful decrease in interfering anxiety symptoms) are more likely to have completed between-session exposures than treatment nonresponders (Tiwari, Kendall, Hoff, Harrison, & Fizur, 2013). Between-session exposures vary in intensity. For example, an initial “real-life” in vivo exposure for Camila might involve her breaking a

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Planning exposures: school-related GAD worries

TABLE 10.4

229

Safety-related GAD worries.

SUDs rating

Fear hierarchy

Exposure

8

Having a burglar break into the house

Play “News Mad Libs” with my therapist: work with my therapist to select a news story about a burglary in my city, replacing the victims’ names with my name and my parents’ names

8

Being alone in the basement at night

Go downstairs in the basement at night for 10 min while Mom is upstairs

7

Going into the basement at night with my mom at the top of the stairs

Go downstairs in the basement at night for 5 min while Mom is at the top of the stairs

6

Having to sleep alone in my bedroom after hearing a strange noise

Use coping skills to stay in my bed when I wake up and feel nervous

5

Needing a glass of water at night and having to go downstairs to the kitchen alone to get it

Go to the kitchen alone on one night during the week to get a glass of water

4

Needing to go to the bathroom in the middle of the night

Go to the bathroom alone on two nights during the week

2

Hearing sounds outside my window at night

Wait 5 min to call out for Mom after hearing scary sounds at night; try to figure out the cause of the sound

SUDs, Subjective units of distress. Scenario: Ethan (9-years-old) experiences excessive safety worries. He worries that burglars might break into his house in the middle of the night through a window in the basement (he does not live in a high-crime neighborhood). He interprets any sound in the house as an indication that someone is entering. Ethan often calls his mother into his room at night and cannot be alone anywhere in the house after dark, which negatively affects his family, his sleep, and ability to function the next day. Preparing for the exposure: Proper preparation for exposures in this case would include sharing information about what causes scary noises (e.g., tree limbs brushing against windows, pipes knocking from temperature changes, equipment going on and off) and about how human vision adapts to the dark (i.e., when we turn off the lights, at first the dark hides things, but then your vision gets better as your eyes adapt to low levels of light).

school rule by chewing gum during her English class. Note also that imaginal exposures and simulated exposures can be completed between sessions. The therapist might ask Camila to write a one-page detailed description of what she imagines will happen if her teacher becomes very angry with her. After a review/discussion, Camila may be asked to read the story aloud to herself every day between sessions. For this type of imaginal exposure, the therapist and Camila collaborate on a guide for Camila to use when drafting the story (e.g., questions Camila may want to ask herself to elicit different levels of anxiety). The therapist may also arrange a simulated exposure in which Camila’s teacher

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TABLE 10.5

GAD worries about world affairs.

SUDs rating

Fear hierarchy

Exposure

8

Watching the news

Watch a full news program alone

7

Watching news coverage of a recent hurricane

1. Watch news coverage of a hurricane with Mom 2. Watch news coverage of a hurricane alone

5

Watching a news clip by myself

1. Watch a neutral news clip with Mom 2. Watch a neutral news clip alone

5

Hearing the news playing in a different room

Stay seated in the other room and listen to the news coverage for 10 min

4

Seeing the news on a public television (e.g., restaurant, electronics store)

Continue eating or walking in the store without trying to leave the location

3

Seeing a hurricane occur in a different city

Watch a video clip of a hurricane hitting a city

2

Reading an article about a hurricane

Read two news articles about a hurricane

1

Reading about a news event

Read two news articles about a neutral topic

SUDs, Subjective units of distress. Scenario: Jasmine (12-years-old) is overly concerned about world affairs and cannot be in the room if the television is on a news station. Jasmine reports that it is particularly distressing for her to hear news about recent weather events, especially hurricanes. She says that when she hears these stories, she worries for the rest of the day about the people who are affected, and she experiences concurrent muscle aches and irritability. Preparing for the exposure: Proper preparation for exposures in this case would include sharing an understanding of what constitutes news and how TV producers and directors intentionally select the uncommon/unusual storiesto try to lure viewers.

gets upset at Camila in front of the class. The therapist will speak to the teacher ahead of time to determine how upset the teacher will get. The aforementioned examples illustrate planning exposures based on the youth’s specific GAD worries. Exposures are best when they are individualized and targeted to the anticipated catastrophe, so as to maximally address the youth’s anxiety. For many youth, a GAD worry may need to be addressed with several imaginal and in vivo exposures, both in sessions and between sessions. Note that imaginal and in-session in vivo exposures may not always adequately trigger anxiety. In those

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Planning exposures: school-related GAD worries

TABLE 10.6 SUDs Rating

231

GAD worries about local affairs.

Fear hierarchy

Exposure

8

Going through “code blue” drills in school

Participate in a “code blue” drill in school without trying to avoid the situation

7

Watching a news report about school shootings that have occurred

Watch the news (clip) about a school shooting that occurred relatively nearby

5

Reading about an in-state school shooting

Check the newsto see if there is an instance of an in-state school shooting; Read the article each day for a week

4

Reading about a school shooting

Read a news article about a school shooting that occurred in a different state; read the article each day for a week

4

Not being able to text Dad during the day

Taper texts to Dad down gradually starting at 5 per day, ending in 0 per day

SUDs, Subjective units of distress. Scenario: Javier (14-years-old) heard about an upcoming “code blue” shelter-in-place drill at school and started to have daily worries about potential school shootings. In his effort to make it through the school day, he asks for constant reassurance from his father via text messages. In these texts, Javier asks repeated questions such as, “a school shooting won’t happen here, right?” He cannot see any reference to a school shooting on the news without experiencing severe anxiety and is starting to talk about wanting to be homeschooled. Preparing for the exposure: Proper preparation for exposures in this case would include role-plays for how the parent can react to continued need for reassurance.

cases, the focus would be placed on “real-life” between-session in vivo exposures. As part of a therapist’s exposure plan, we encourage having available several exposure options of varying intensities. These options will allow the therapist to make changes to planned exposures if a youth is reticent, or if the situation does not generate the intended level of anxiety. Take for example, Camila’s worry that there will be severe consequences if she completes her homework incorrectly after forgetting to read the instructions. An initial exposure may involve Camila engaging in an imaginal exposure in which she details the events of this feared situation for her therapist until doing so elicits less anxiety for her. Another exposure may involve completing a worksheet during a session without reading the instructions. This exposure may not be activating (i.e., it may not generate anxiety) for Camila because the worksheet is not “real” and will not be graded or shown to her teacher. Thus, a follow-up exposure might involve Camila intentionally not reading the instructions before completing her actual homework assignment. The therapist may specify that Camila is allowed to review the instructions

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TABLE 10.7 SUDs rating

GAD worries about changes in plans and new situations.

Fear hierarchy

Exposure

8

Not knowing the plan for an entire day

Spend an entire day with no set routine

7

Not having my planner for a full day

Leave my planner at home for one school day

6

Not writing everything in my planner

Write only the most important things in my planner, such as my homework assignments and upcoming test dates

6

Taking a new route

Drive to school taking a new route

5

Having my schedule be thrown off

Go to school 10 min late, thus throwing off the day’s schedule

4

Thinking about unexpected changes occurring during my day

Write a story describing what would happen if an unexpected change occurred in my schedule. Read the story aloud every day for one week.

3

Not knowing the plan for the day

Taper reassurance seeking questions from 5 to 0

SUDs, Subjective units of distress. Scenario: Jacob (10-years-old) has a very difficult time with changes to his routine and constantly writes out his schedule in a planner that he carries with him throughout the day. If he is not familiar with the route that his family is taking to get to a location or does not know what the schedule is for the day, he becomes very nervous and a bit oppositional. As a result, Jacob’s parents accommodate his distress by sticking to a strict schedule and never deviating from typical routes to each location. Preparing for the exposure: Proper preparation for exposures in this case would include working with parents to reduce the accommodation and increase Jacob’s ability to tolerate distress. The therapist might play the card game War with Jacob designating a card (e.g., seven of spades) to be the indicator that now a low card, rather than a high card, wins the war. Jacob has to tolerate the unknown timing of the change in the rules of the game.

for the homework before turning it in. A final, and most anxietyprovoking, exposure for this feared situation may be to have Camila complete and turn her homeworkassignment in without reviewing the instructions and editing her work. After planning a set of exposures, therapists are encouraged to consult with their clients. This process helps reduce the probability of having an unsuccessful exposure, as the youth will be able to provide information as to how activating a proposed exposure is likely to be. Therapists can avoid youths attempts at negotiating out of completing exposures by providing a forced choice. That is, instructing the youth to choose from three provided options for exposures. Exposure options may vary based on intensity or exposure type (i.e., imaginal or in vivo). Of note, some youth state that no provided exposure option will be

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Planning exposures: school-related GAD worries

TABLE 10.8 SUDs rating

233

GAD worries about health of self/others.

Fear hierarchy

Exposure

8

Hearing from my doctor that I need follow-up tests

Have my doctor tell me that I may be sick and will need to get some follow-up tests done

8

Going to the doctor

Go to the doctor for a physical

6

Not checking for symptoms when nervous

Taper body symptom checking from a total duration of 30 min per day to a duration of 0 min per day

5

Imagining having cancer

Write a detailed story of what it would be like to have cancer; Read the story aloud every day for one week

5

Not asking parents if I will be okay

Taper reassurance seeking from 10 questions per day to 0 questions

4

Not checking symptoms on WebMD

Taper WebMD checking from 15 times per day to 0 times per day

3

Seeing a story about people diagnosed with cancer

Read three stories about different people who have and have not been diagnosed with cancer

SUDs, Subjective units of distress. Scenario: Jayden (13-years-old) spends most of his day worrying that he might have cancer. He often asks his parents to confirm that he is not sick and spends several hours per day researching the symptoms of various diseases online. Jayden then worries about what he read online for the remainder of the day and repeatedly checks his body for new symptoms. He avoids going to the doctor’s office entirely because he is afraid to be told he is sick, even though he is long overdue for a check-up and needs to complete a physical to participate in school sports. Preparing for the exposure: Proper preparation for exposures in this case would include providing information about symptoms and their accuracy/inaccuracy in identifying disease as well asthe important topic of the tolerance of uncertainty. Under distress, one has to be able to tolerate not knowing what will happen. Additional exposures might include asking about several of the many things in life, in which the correct answer is “we don’t know.”

activating for them. In these cases, the therapist is encouraged to ask the youth to complete one of the exposures anyway. Youth often report that exposures are more activating than they thought they would be. This is often true of youth with poor insight into their experience of GAD worries. If the youth is truly not activated by an exposure, the therapist will learn that the youth can attempt a more advanced exposure in the future.

Preparing youth for specific exposure tasks After planning and consulting with the youth about exposures in general, the therapist prepares the youth for each exposure before implementation. The therapist helps the youth to identify which

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TABLE 10.9 SUDs rating

GAD worries about family issues.

Fear hierarchy

Exposure

8

Having my parents tell me they are going to get a divorce

Have my parents act out telling me they are getting divorced

7

Hearing my parents get into an argument

Watch my parents role-play two disagreements within earshot, one with a reconciliation and one without

6

Hearing my parents talk about disagreeing, agreeing, and the topic of divorce

Listen to my parents talking during a discussion about a potential divorce

5

Thinking about what would happen if my parents got divorced

Write down a story of exactly what would happen if my parents got divorced; read the story aloud every day for two weeks

4

Hearing other people talk about divorce

Watch a movie or read a storybook about a child whose parents got divorced

3

Not seeking reassurance when I worry about divorce

Taper reassurance seeking questions from 3 per day to 0 per day

SUDs, Subjective units of distress. Scenario: Mia (9-years-old) is very worried that her parents might get divorced. Any time she hears her parents become frustrated with one another, she assumes that they are going to separate, and she then spends the rest of the day worrying uncontrollably. When she has such worries, she asks her parents for constant reassurance that they will not separate and has difficulty concentrating. Preparing for the exposure: Proper preparation for exposures in this case would include some information about relationships and the fact that two people do not always agree (which does not necessarily indicate that a couple will separate). Parallels can be drawn between Mia’s parents and Mia and her own close friends (i.e., Have they ever disagreed? Are they still friends?). Exposure to the tolerance of uncertainty would be useful.

previously learned coping skills (e.g., coping thoughts, challenging negative/anxious thoughts, distress tolerance) might be most useful to him/her during the exposure. Within the Coping Cat program, this process includes discussing the physical symptoms of anxiety that the youth will likely recognize (e.g., racing heart) and identifying the anxious thoughts and feared outcomes s/he anticipates having (“My teacher will get mad at me,” “I’m going to be a failure.”) before brainstorming things that may help the youth to feel less anxious during the exposure. Distress tolerance strategies can be useful to youth with a wide variety of GAD worries. Common distress tolerance strategies include (1) progressive muscle relaxation (i.e., tensing and then relaxing different muscle groups directly before, during, or after an anxiety-provoking situation), (2) deep breathing, (3) attempting to derive meaning from the

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feared situation (e.g., “I am very nervous about getting a question wrong on purpose, but maybe doing so will help me learn how to deal with people being mad at me.”), (4) going on a run after completing an assignment without reading the instructions, (5) splashing your face with very cold water when you are feeling anxious about the prospect of not getting into college, (6) reminding yourself that your worries are just thoughts, and that you don’t have to listen to them, and (7) staying mindful in the present moment when you notice yourself worrying about any aspect of the future (therapists can help youth search for and rehearse relevant mindfulness practices). Distress tolerance strategies may also include coping thoughts such as “If I just jump into this situation, it will be over with as soon as I know it,” or “I don’t like feeling this anxious, but I can handle it.” Many of these skills are taught prior to the first exposure, during the psychoeducation portion of the Coping Cat program. An important step in preparing youth for exposure is defining a “successful outcome” and identifying the reward they will get when they complete the exposure. Recognizing that youth may be in therapy due to their parents’—and not their own—wishes, and that exposures are difficult, rewarding youth for their effort (not performance) in practicing brave behavior is an important motivator. Typically, a “successful outcome” would be that the youth completed the task, even if they were extremely nervous while doing so or changed the task a bit along the way. That is, even if Camila was red with embarrassment and shaky while answering a question incorrectly in class, it would still be considered a successful exposure—she made the effort! Youth are encouraged to discuss and arrange rewards with their parents, so that rewards can be meaningful. Youth and parents are also encouraged to consider nonmonetary rewards. For example, many youths enjoy rewards such as an extended curfew, extra time spent with Mom/Dad, creating the dinner menu, and even the feeling of being proud of themselves. Of note, parents can take care to ensure that rewards are commensurate with the intensity of the exposure. Therapists encourage and guide youth to develop a coping plan when completing exposures between sessions. Therapists highlight the importance of having ideas for how to cope with anxiety during a given situation (e.g., problem-solving a potentially anxiety-provoking situation before you become extremely anxious), as well as knowing what your reward will be ahead of time (i.e., you have something to look forward to). The therapist works with the youth to identify a “successful outcome” for each between-session exposure.

Preparing parents/family Prior to beginning exposure tasks, therapists are encouraged to discuss the exposure process with parents. Parents are warned that

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exposures may be difficult for youth, and that they may notice an increase in their child’s anxiety (or reluctance to come to sessions) at the start of the exposure process. Therapists are encouraged to describe the exposure process in detail (e.g., exposures will be gradually implemented and will occur in-session and between sessions) and to inform parents of their role during the exposure process. For example, therapists work with parents to help them notice and point out brave behavior. Parents are encouraged to remind their children to use coping skills and not to provide reassurance. Parents are encouraged not to accommodate their children’s anxious distress during the exposure, as doing so can lead to poor treatment outcomes (Hedtke, Kendall, & Tiwari, 2009). For example, Camila’s mother would be encouraged to avoid emailing Camila’s English teacher to check if Camila was too nervous to ask a question in class. Alexis’s father would be encouraged to not to repeat that “Everything will be fine. You could never be a failure (Table 10.2A).” Parents may be concerned about their own ability to stop accommodating their child’s distress. Role-play activities with parents may be useful. Here, the therapist will provide sample language that is supportive, but not reassuring (e.g., “I’m so sorry you are feeling anxious. I know that it’s hard to ask Mrs. Brown questions in class, but I also know you can do it!” rather than, “It’s okay, don’t worry about it. Mrs. Brown is not going to be mad at you. I’ll talk to her about it.”). Before finalizing and assigning between-session exposures, the therapist checks in with the parents to verify that the exposure is feasible. Planning multiple exposures can be helpful here so that a backup exposure is available if parents realize a particular exposure task is unfeasible. After exposure tasks have begun, the therapist meets with the parent(s) briefly after each session to define their role in the exposure and to clarify how they can be supportive at home. Some exposures may require direct parental instructions (e.g., “Camila is only allowed to ask you three reassurance seeking questions. For each additional question you can respond, ‘I’m sorry, honey; you already asked three questions.’”), while others may simply require reminders (e.g., “For this week’s exposure, I want you to not provide reassurance before school, but you can check in with Camila to see how her challenge went at the end of the day. Also, continue to praise her brave behavior whenever you notice it.”). As the exposure tasks progress, the therapist may begin to increase parent involvement. That is, the parents might begin to help the youth identify helpful coping skills and to reward bravery. Therapists can prepare parents by having them observe a therapist child role play.

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Preparing and coordinating with other individuals Some exposure tasks require coordination with individuals other than the youth or the youth’s parents ( e.g., teachers). This is particularly true of exposures for school-related GAD worries, but may also be true for other GAD concerns. Coordinating with a youth’s teacher can help facilitate exposures, such as having Camila’s English teacher get upset at her and having Alexis’s teacher tell her that she may never go to college. In some cases, communication with the teacher may also be necessary to ensure that exposures will not significantly hurt the youth’s grade. For example, when assigning Camila the exposure task of turning in homework without having read the instructions, speaking with her teacher beforehand is needed to confirm that the task will not be truly detrimental to her. It is helpful to talk with teachers about the aims and goals of exposure so that they are aware of the rationale for the youth’s behavior. Collaborate when possible: teachers may have helpful ideas for exposures. It may be useful to coordinate with other individuals that may increase the authenticity and success of an exposure. For example, Alexis’s therapist might find it useful to contact a local ice cream parlor to see if a staff member is willing to conduct an authentic mock job interview.

Planning exposures: future-oriented GAD worries This section outlines planning and implementing exposures for future-oriented GAD worries. As an example, we use Alexis, a 15-yearold female who is worried that something will go wrong in her future, that she won’t get into college, that she will be a failure, and that she won’t be able to obtain a summer job (Table 10.2A). All of the principles mentioned in the Planning Exposures: SchoolRelated GAD Worries section above can be applied to the planning of exposures for future-oriented GAD worries. As discussed in relation to school-related GAD worries, therapists should plan in vivo, imaginal, in-session, and between-session exposures (Table 10.2B). Many of the exposures highlighted for Camila’s school-related GAD worries were in vivo exposures that occurred both in and between sessions. However, therapists will often find that, due to the abstract nature of future-oriented GAD worries, as well as the fact that they are less amenable to problem-solving, imaginal exposures are often the preferred exposure type when treating youth with future-oriented GAD worries. One of Alexis’s main worries is that she will never get a good job and will end up being a failure. There is no way to prove that this will not happen, and there is no way to carry out an in vivo exposure in

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which Alexis is in the future with a good job. Imaginal exposures offer a viable method to address Alexis’s fear. When planning exposures for future-oriented worries, the therapist will attempt to identify both the specific and the global features of the youth’s fears. For example, Alexis worries about specific things such as getting a bad grade, not getting a summer job, and not getting into college. However, she also expresses some global concerns that these worries feed into, such as “being a failure.” Where possible, therapists are encouraged to address both specific and global worries. Specific concerns may be best addressed with in vivo exposures. For example, one exposure might involve Alexis interviewing people who she sees as “not a failure” and asking them if they ever got a bad grade on an Algebra test. Through this exposure, Alexis tests her anticipated catastrophe and is likely to learn that at one point or another, everyone—including people with good jobs—has done poorly on an examination. Another exposure might involve having Alexis apply for a summer job. Alexis demonstrates extreme anxiety at even thinking about applying for a summer job, so this exposure may need to be broken down. For example, the therapist could first have Alexis complete an in-session imaginal exposure focusing on a scenario in which she applies for a summer job. The therapist might then have Alexis complete an imaginal exposure in which she discusses the positions she is interested in applying for. Exposures could eventually progress to an in-session role-play of a job interview in which Alexis intentionally messes up the interview, and perhaps another in which she handles the interview very well. The therapist can arrange a higher intensity simulated exposure in which Alexis completes a prearranged, but realistic, interview with a local business owner. Of course, the highest level exposure for this feared situation would be for Alexis to apply for a job and complete a real interview. However, the therapist is not at liberty to make this situation occur. Thus, it is important to have multiple highintensity exposures planned. Global worries such as being a failure are harder to address using in vivo exposures; however, they can easily be addressed using imaginal exposures. For example, the therapist could have Alexis write out a story about being a failure, detailing what would happen to her at every step of the way. Once complete, the therapist could then have Alexis read the story aloud (in session and between session) until it elicits less anxiety. Simulated in vivo exposures may also be useful when addressing future-oriented GAD worries. For example, the therapist could have a confederate pose as a teacher handing back a failing homework assignment. The therapist could arrange for the confederate to have a serious conversation with Alexis informing her that she will never be accepted

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into college based on her performance on this one homework assignment. It is highly unlikely that such a scenario would ever occur; however, this role-play may activate Alexis’s anxiety and provide an opportunity for active coping. If possible, the therapist could arrange to have one of Alexis’s actual teachers conduct the same exposure with her at school. Another simulated exposure might involve having Alexis’s parents type up several realistic college rejection letters (and an acceptance letter) and mailing them to their home, so that Alexis can receive, read, and practice coping with them. Youth with both school-related and future-oriented GAD worries often seek reassurance from their parents. For example, Alexis frequently seeks reassurance from her father that everything will be okay and that nothing bad will happen in her future. A series of in vivo exposures in which Alexis slowly decreases the number of reassurance seeking questions she asks her father may be warranted here. The therapist could have Alexis start off with asking only five questions per day, followed by only two, and finally zero questions. As with all exposures, the starting point for allowable reassurance seeking is individualized.

Implementing exposure tasks Once therapists have planned several options for exposures; prepared the youth, family, and others; and verified that upcoming planned exposures are feasible, exposure implementation can begin. When implementing exposures, therapists verify that the youth and others are aware of what will take place, so that the exposure will go smoothly. Therapists collect SUDs ratings during the exposure. SUDs ratings help therapists identify how activating a given exposure is for the youth. The ratings also help youth to see how their experience of anxiety changes over time. In an ideal exposure, youth discover that their SUDs ratings decrease over the course of the exposure. As exposures are repeated, youth ideally find that their SUDs ratings decrease. In order to help to create this effect, it is recommended that therapists wait to end an exposure task until a time when youth experience a SUDs rating decrease (e.g., 50%). Exposure termination will be determined using the therapist’s judgment. For example, therapists make adjustments in instances of an extremely activated client. However, whenever possible, therapists do not discontinue exposures until the youth’s SUDs rating has decreased. If a client’s SUDs rating is not decreasing at all throughout an exposure, therapists may consider assigning exposures of lower intensity.

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It may be useful to create charts to help clients track their completion of between-session exposures. Charts remind youth of the assigned exposure and serve as a visual reminder of how close they are to getting their planned reward. Charts can be basic or intricate; they are individualized to each youth and include details specific to his or her practice. A quality chart will contain, at the minimum, the assigned exposures, areas to check off completion of the exposure, and a reminder of the planned reward. After an exposure is complete, the therapist and youth “process” the experience, as post-processing facilitates positive gains (Tiwari et al., 2013). Therapists may simply ask their client for an overview: “How do you think it went?” Therapists can also ask more specific questions: “Did what you feared would happen actually happen?” SUDs ratings provide a good tool to begin this discussion. Therapists may find it helpful to ask youth what thoughts they were having when their SUDs rating was highest and what thoughts they were having when their SUDs rating was lowest. Ask youth what skills helped them to cope during the exposure. If the exposure had been completed before, the therapist can compare the current exposure experience with the past one (e.g., which was easier, what made it easier, what was learned from one exposure to the next).

Problem-solving potential difficulties Exposures are challenging for youth, but they can also pose difficulties for therapists: be prepared to help manage potential difficulties. One difficulty emerges when an exposure that seemed to be at an appropriate difficulty level ended up being too difficult when the youth attempted to complete it. The therapist can “back up” but not “back down.” In this situation, work to make the exposure slightly less demanding, so the youth can be successful. That is, the goal is to have the youth still engage in the exposure, even if it has to be made easier. Over time, the therapist and youth collaborate and get to a point when the original exposure can be completed. As appropriate, the therapist works with the parents to help them modulate exposure intensity for between-session exposures. The markers for this decision are individualized. If youth become discouraged after a difficult exposure, remind them that valuable information is learned from every exposure. In the case of a less successful exposure, the therapist and youth learn that a feared situation is more anxiety-provoking than anticipated. This lesson is not a core failure on the part of the youth. The youth can also be reminded that now both the therapist and the youth know what the youth needs to practice.

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Another potentially difficult situation for therapists is when a youth refuses to do a previously agreed upon exposure. The therapist then determines the reason for the refusal. Is s/he nervous? Does s/he think the exposure process is silly? Is the anticipated catastrophe believed to be likely? Does s/he need a few minutes to prepare? Once the reason is identified, steps can be taken to re-engage the client. For example, if the client reports being too nervous to even try the exposure, the therapist can problem-solve with the youth to determine what might make the exposure more tenable. The therapist can remind the youth that they will be rewarded for making an effort to engage in brave behavior.The therapists may also find it useful to change features of the exposure (decrease the intensity) such that the client will likely succeed. Success in completing an exposure task typically leads to confidence boosts for the youth. If the youth thinks the exposure process is silly, this may be an instance of “verbal behavior as avoidance.” By saying it’s silly or unnecessary, the youth anticipates being able to avoid having to do it. In some instances, it is helpful for the therapist to discuss the rationale behind exposure, particularly as it relates to the youth’s specific GAD worries. They can increase buy-in by sharing a research article about exposure treatment or reminding the youth that they can earn rewards for completing exposures. When the youth simply needs time to calm down, the therapist can validate the distress, problem-solve, and then continue with the exposure.

Sample GAD fear hierarchies and suggested exposure tasks Seven cases involving GAD worries are provided (Table 10.3 10.9). Examples include the fear hierarchies, level of anticipated difficulty, and suggestions for exposure tasks.

Conclusion Although the development and implementation of exposures can seem like a daunting task, research has indicated that exposure-based therapy is efficacious for the treatment of GAD (e.g., Kendall et al., 2005, 2008; Ladouceur et al., 2000; Read et al., 2013; Walkup et al., 2008). When planning exposures for youth with GAD worries, therapists consider developing imaginal, in vivo, in-session, and between-session exposure tasks. Exposures are highly individualized, and although therapists plan exposures in advance of each session, they can change the details of a planned exposure during the exposure if doing so will be beneficial to treatment. Above all, therapists engage their clients

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throughout the therapeutic process to identify the specifics of the youth’s feared situations and feared/unwanted outcomes.1 Exposure tasks provide opportunities for youth to implement skills they have acquired, discover that some anticipated negative outcomes did not occur, and build confidence in their ability to manage and tolerate anxiety-provoking situations in the real world.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003). Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60, 837 844. Available from https://doi.org/10.1001/archpsyc.60.8.837. Hedtke, K., Kendall, P. C., & Tiwari, S. (2009). Safety-seeking and coping behavior during exposure tasks with anxious youth. Journal of Clinical Child and Adolescent Psychology, 38, 1 15. Available from https://doi.org/10.1080/15374410802581055. Kendall, P. C., Compton, S., Walkup, J., Birmaher, B., Albano, A. M., Sherrill, J., & Piacentini, J. (2010). Clinical characteristics of anxiety disordered youth. Journal of Anxiety Disorders, 24, 360 365. Available from https://doi.org/10.1016/j. janxdis.2010.01.009. Kendall, P. C., & Hedtke, K. (2006). Cognitive-behavioral therapy for anxious children: Therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing. Kendall, P. C., Hudson, J., Gosch, E., Flannery-Schroeder, E., & Suveg, C. (2008). Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities. Journal of Consulting and Clinical Psychology, 76, 282 297. Kendall, P. C., Robin, J. A., Hedtke, K. A., Suveg, C., Flannery-Schroeder, E., & Gosch, E. (2005). Considering CBT with anxious youth? Think exposures. Cognitive and Behavioral Practice, 12, 136 148. Ladouceur, R., Dugas, M. J., Freeston, M. H., Le´ger, E., Gagnon, F., & Thibodeau, N. (2000). Efficacy of a cognitive behavioral treatment for generalized anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957 964. Available from https://doi.org/10.1037/0022-006X.68.6.957. Mausbach, B. T., Moore, R., Roesch, S., Cardenas, V., & Patterson, T. L. (2010). The relationship between homework compliance and therapy outcomes: An updated metaanalysis. Cognitive Therapy and Research, 34, 429 438. Available from https://doi.org/ 10.1007/s10608-010-9297-z. Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49, 980 989. Available from https://doi.org/10.1016/j.jaac.2010.05.017. Miller, A. L., Rathus, J. H., & Linehan, M. M. (2006). Dialectical behavior therapy with suicidal adolescents. New York, NY: Guilford Press. 1 For additional information on implementing exposures for anxious youth see: Peterman, Read, Wei, and Kendall (2015). The art of exposure: Putting science into practice. Cognitive and Behavioral Practice, 22, 379 392.

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