Using exposure with young children

C H A P T E R

12 Using exposure with young children Amita D. Jassi and Z. Kindynis National Specialist Clinic for Young People with OCD, BDD and Related Disorders, South London and Maudsley NHS Foundation Trust, London, United Kingdom

Cognitive behavior therapy (CBT) is a well-established and evidencebased treatment for child and adolescent anxiety (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016). Within any CBT framework for anxiety, exposure therapy is an essential element (Kazdin & Weisz, 1998). Therapists implementing exposure techniques aim to support young people to approach anxiety-provoking situations, focus on the trigger and resist attempts to reduce anxiety (Benito & Walther, 2015). There are two frameworks for understanding the mechanisms behind how exposure works: one is inhibitory learning (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014; McGuire & Storch, 2019) and the other is habituation (Benito & Walther, 2015; Foa & Kozak, 1986). Ultimately, the goal of exposure is to promote distress tolerance (inhibitory learning) and allow reduction of anxiety over time (habituation). Despite strong evidence for the effectiveness of CBT with exposure for various anxiety disorders in young people (Freeman et al., 2014; Kendall et al., 2005), there is significantly less literature for children aged 7 years and below (Rudy, Zavrou, Johnco, Storch, & Lewin, 2017). Some evidence suggests that younger children may have difficulties accessing and engaging with CBT more generally (Grave & Blissett, 2004) and may not respond as well as their older counterparts (Durlak, Fuhrman, & Lampman, 1991; Weisz, Weisz, Han, Granger, & Morton, 1995). However, it has been argued that tailoring treatment to the developmental level of the child enables good outcomes (Freeman et al.,

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2014; Ollendick, Grills, & King, 2001). Considering the high prevalence rates of anxiety disorders in young children (Rudy et al., 2017), together with the identified need to provide early intervention for children with anxiety disorders (Hirshfeld-Becker & Biedermann, 2002; Stewart et al., 2004), it seems pertinent to explore how the well-established intervention of exposure-based therapy can best be provided for this age group. This chapter draws on the existing literature and clinical experience to explore the adaptations necessary to facilitate exposure therapy in young children. The chapter is for clinicians with limited experience of using exposure with this group but have a working knowledge of exposure therapy in general. We start the chapter by considering the broad modifications needed for younger children and then discuss how to incorporate these for different aspects of treatment. We use two case examples, Danny and Parveen, to illustrate exposure work with this age group. Danny is an 8-year-old boy who has obsessive-compulsive disorder (OCD). His compulsions included tapping, counting, and evening up owing to a “just right” obsession. Although he did not have to complete compulsions at school, he engaged in compulsions almost constantly when he was at home. He had started to notice his “evening up” compulsions interfered with his ability to play soccer, as he had to try to ensure both his feet touched the ball an equal number of times. These compulsions caused him significant distress, and as a result, he often became angry and shouted when he felt unable to perform a compulsion to completion. As Danny struggled to articulate why he is performed such routines, his parents suggested that he was in control of his routines and was tapping objects repeatedly to “annoy them”. They were worried about his recent angry outbursts and believed that this was a reflection of him becoming “naughty”. Parveen is a 6-year-old girl who was scared of dogs. Her fear started a year ago after her grandmother’s new dog chased her through a park and she thought he would bite her. Following this, she started to get upset and anxious when going to the park, her grandmother’s home and other places due to fear of seeing a dog. Parveen would cry and scream if she thought she would come into contact with one. Her mother, Zara, brought her to therapy as this fear was causing Parveen a great deal of distress and restricted where the family could go. They were unable to visit her grandmother who Zara, as a single parent, relied on for childcare. Zara felt very guilty about Parveen developing this fear; she was in the park when the dog chased Parveen and felt it was her fault for not recognizing she needed her help. She believed she was a bad mother and felt judged by Parveen’s grandmother as she said that Zara should stop accommodating Parveen’s phobia and make her come to her house. However, Zara did not want Parveen to be distressed as she believed this could “damage” and traumatize her further.

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Overview of modifications to exposure for young children Throughout the treatment components, clinicians will notice several overarching themes regarding the suggested modifications for working with younger children. These themes include: (1) developmental adaptations, (2) family work, (3) play-based approaches, and (4) contingency management techniques. First, a consideration of the child’s developmental level is necessary to ensure appropriate adaptations to all treatment components. Gauging the developmental level of the child will be essential to inform how best to establish rapport, plan sessions, and tailor the content of the therapy sessions. Therapists can do this when having a simple conversation with the child; this can help to gauge the child’s receptive and expressive language skills; how long they can stay engaged in the conversation can give an idea of their attention and concentration; and asking them questions such as what they did last week, can help assess their memory capacity. Younger children have limited attention span, memory capacity, and general mental organizational ability (Crick & Dodge, 1994; Russell & van den Broek, 1988). Therefore it may be pertinent to either plan shorter sessions, or to schedule breaks during sessions for optimal learning. Furthermore, the child may require more repetition and practice of skills during sessions in order to consolidate their learning. Guidance from parents can help inform decisions regarding which approaches may be best to optimize learning for their child (e.g., shorter sessions, scheduled breaks, etc.). Family involvement is an integral part of treatment with young children, and therapists have to engage and build rapport with the child and parent in equal measure to ensure success. There is emerging evidence to suggest that younger children benefit more than older children from the involvement of their families in treatment (Barrett, Dadds, & Rapee, 1996; Cobham, Dadds, & Spence, 1998). As a young child’s developmental level may limit their understanding of what is presented in therapy, parental understanding is critical for treatment success (Herren & Berryhill, 2018). Parents can be considered the experts on their child, and represent an invaluable asset both as an informant and co-therapist. Furthermore, anxiety disorders in younger children are likely to affect the whole family unit, whether this is observed in familial anxiety (e.g., parents with anxiety, worries about child behavior) and/or family accommodation (e.g., providing special accommodations and avoidance of feared stimuli; Zavrou, Rudy, Johnco, Storch, & Lewin, 2018). Given the importance of including families in treatment, therapists should evaluate and address beliefs that parents may bring into sessions (e.g. beliefs about anxiety, perceptions about the origins of a child’s behavior). These may be achieved by either tailoring session materials or conducting separate parent sessions at the start of treatment.

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When working with young children, it is important to remember that the more fun and interesting a therapy session, the more likely the child will engage and participate (Drewes, 2009). One approach might include integrating exposure tasks into a scavenger hunt or having 10 minutes of play directed by the child at the end of each successful session as a reward. Additionally, active learning in sessions is preferable (Bonwell & Eison, 1991) and results in greater learning (Woods, 2009). Active learning is experiential (e.g., scaring each other in session to identify symptoms of anxiety), whereas passive learning may entail information being shared with the child (e.g., showing the child a picture of a body with anxiety symptoms on it). Therefore to enhance engagement and learning in sessions with young children, treatment should incorporate play-based and behaviorally active learning, while tailoring content to the idiosyncratic interests of the child. Finally, many young children have limited insight into the necessity for change and/or the rationale for exposure work (Langley, Bergman, & Piacentini, 2002). Therefore contingency management can provide important motivation for engagement. Two approaches to contingency management for young children include praise and rewards. This chapter focuses on the different elements of exposure therapy, from psycho-education to facilitating exposure tasks, discussing how these components can be modified for younger children using the themes mentioned above.

Psycho-education and developing a formulation Psycho-education is a fundamental element of treatment that provides the child and family with an understanding of their difficulties, and a rationale for exposure work. Typically, this component of treatment covers psycho-education on anxiety including the physical anxiety symptoms, the fight or flight response, and habituation. In terms of a shared formulation, the child and family need to understand the cycle of thoughts, feelings, and behaviors and how this cycle can be broken with exposure therapy, in order to form a united team to fight fears together (see Chapter 12 for a more detailed discussion of psychoeducation for exposures). As a young child may not be able to access psycho-education fully, it is crucial that parents have a full and clear appreciation of these concepts. Indeed, a parent’s ability to understand the concept of exposure and to encourage their children to expose themselves to the feared situation is critical to treatment success (Herren & Berryhill, 2018). There is emerging evidence to support that treatment delivered via parents alone is effective for anxiety disorders in young children (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2010; Rudy et al., 2017), III. Developmental considerations

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which adds weight to the importance of parents being fully involved. It is useful to complete a separate psycho-education session with caregivers at the outset of treatment to establish rapport, ensure that caregivers accurately understand and “buy in” to the exposure model, address any unhelpful beliefs that could impact on treatment, and to allow the clinician to establish the caregiver’s role as an actively involved co-therapist. From the outset of treatment, it is helpful to externalize the anxiety disorder; a tool derived from Narrative Therapy (Freeman, Epston, & Lobovits, 1997). Giving the disorder a name and identity removes the blame from the child and allows a family to unite in fighting against the externalized condition. Moreover, it can help the child recognize the anxiety disorder as something separate from their own identity. For example, Danny considered names such as “Bully” or “Mr Worry” for his OCD before deciding on “Grumpalump.” Danny drew a picture of Grumpalump and every session this picture was put on the wall to remind his family to externalize Danny’s difficulties and use the name Grumpalump.

Danny’s picture of OCD called “Grumpalump”

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The family and the child are encouraged to use externalizing language wherever possible, and the clinician should aim to model this throughout sessions. Externalizing the condition in this way allows for a continued narrative that can help the child and family throughout treatment. For example, asking “What does the bully tell you will happen if you don’t do that?” can support children with accessing their worries, and continuing a narrative of aiming to “run OCD off my land” (March & Mulle, 1998), “squash Mr Worry,” “fight back against Grumpalump,” can be a helpful reminder of the rationale for conducting exposures. If a child does not want to name their disorder, it is encouraged that the clinician uses externalizing language by naming the disorder itself (e.g., “OCD,” or “anxiety”). In terms of delivering psycho-education to the child, therapists should be aware that the child’s cognitive capacities may result in limited understanding of some concepts. This may be particularly relevant if the concepts are abstract, hypothetical scenarios, or theoretical aspects of the exposure model (Drewes, 2009). Generally speaking, psychoeducation for a younger audience should aim to include less complex and verbally mediated techniques, and integrate more play-based, behaviorally active learning (DiGiuseppe, 1989) such as concrete picture and story-based tasks (Grave & Blissett, 2004). Puppets and cartoons can also be used to deliver didactic information in a more engaging, understandable way (Felix, Bond, & Shelby, 2006). For example, in Danny’s session the therapist explained how OCD is experienced in the following way:

Therapist

Danny, I would like you to pick two puppets out of this box, one is going to be you and one is Grumpalump. You can ask Mummy and Daddy to help you if you want.

Danny

OK

Therapist

Right, who is going to be you and who is going to be Grumpalump?

Danny

Mummy can be me and I will be Grumpalump

Therapist

Brilliant—well done. Now Danny is about to play soccer and he is getting ready to score a goal and look whose coming, its Grumpalump—show me what happens? What does he say?

Danny

Hello my name is Grumpalump and I am scary and you have to listen to me. Now tap your feet on the ball until I say it’s ok!

Therapist

Oh no, Grumpalump is so annoying, how does Danny feel Mummy?

Mum

Go away, I hate you Grumpalump, stop scaring me, I don’t want to listen

Therapist

Show me what Grumpalump does. What does he say?

Danny

I am not stopping until you listen to me Danny—now tap, tap, tap!

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Younger children are found to have a limited ability to recognize, understand, and differentiate emotional states (Izard, 1994). There is also evidence that capacity for introspection is not fully developed until adolescence (Harter, 1990); therefore young children are likely to have difficulties identifying and articulating their thoughts and emotions. This is exemplified by young children with OCD often displaying compulsions without identifying obsessions (Freeman et al., 2012). As such, it may be worth focusing on thought and emotion identification, with the focus being on anxiety. Again, this can be facilitated creatively using cartoon stories with blank thought bubbles, or by watching videos to help children recognize and report the emotion of anxiety. These can be selected according to the child’s interests; some nice examples of fear and anxiety can be found in various shows including Disney’s Inside Out, Monsters Inc., Harry Potter, and Mickey Mouse cartoons. Alternatively, physiological anxiety symptoms can be demonstrated by using a child’s toy (e.g., breathing quickly, shaking, etc.), or by playing games involving making each other jump and identifying anxiety symptoms. For example, Parveen and Zara were given homework to watch the Disney film Inside Out and were asked to focus on the character of “Fear” in the film. They were asked to focus on which situations Fear appeared in, and how he influenced the main character’s thoughts and behavior. Parveen drew the character and this was used in sessions to communicate when she felt scared. The other characters were used from the film to think about the differences between the emotions. Some young children may have limited emotion recognition and may struggle to identify or recognize anxiety. In such instances, therapists may feel they are unable to proceed with therapy; however, this is not necessarily the case. Even if the child struggles with this aspect of treatment, therapists must ensure parents understand what anxiety symptoms to look out for and what symptoms they recognize in their child. Therapists need to hold in mind when coming onto implementing exposure tasks later in therapy that they may not be able to gauge what task to do based on the child’s anxiety ratings but may have to reframe this into how easy or difficult a task or think about tasks being done based on ratings made by parents on how anxious they think the child will be based on their experience. If a child is able to recognize thoughts and emotions and once they feel more confident in doing so, it is helpful to map out the anxiety cycle and how thoughts, feelings, and behaviors are interlinked. This can be an abstract concept for young children to grasp, and so kinesthetic games, manipulative materials, or physical activities can assist with illustrating this cycle (Drewes, 2009). For Parveen and Zara, the therapist placed three large pieces of paper labeled thoughts, “feelings,” and

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“behaviors” on the floor and they each stood on one. They shouted out the word on their piece paper, and then threw a ball to the next person. This started with “thoughts,” then “feelings,” and then “behaviors,” and repeated until Parveen understood the cyclical nature of how these related. As the session progressed, they started to substitute words for an example of a thought, feeling or behavior focusing on the characters from a scene from Inside Out. They placed pictures of the different emotion characters (Joy, Anger, Sadness, Disgust, and Fear) on the feelings paper and discussed what a person may think and how they would behave if that character was in charge. When discussing Fear, the therapist used Parveen’s fear of dogs as an example, and also asked Zara to share something she was scared of to normalize anxiety. Parveen struggled to describe thoughts at times, but was able to understand the relationship between her feelings and behavior clearly. Zara became clear on this cycle and recognized that Parveen avoiding and running away from dogs was reinforcing her fear as she was not challenging the thought that they may bite her. Once a cycle has been mapped out, it is important to help the young person and parents understand that exposure work breaks this maintenance cycle, by preventing the behavioral response, and thereby allowing anxiety to habituate. This notion requires the understanding of advanced concepts, which may be beyond the cognitive capacity of young children. However, the key principles can still be considered creatively using a variety of metaphors, depending on the developmental level of the child. For example, using narrative techniques, the child may be able to articulate that when they do what “the bully” wants, the bully gets bigger and stronger. However, when the child ignores the bully, the bully gets angry for a little bit but then goes away. They may also be able to understand that if they keep ignoring the bully, he will get bored and stop bullying them. This illustrates that facing the fear (and ignoring “the bully”) repeatedly is the way to fight anxiety and get better in the long term. Danny was able to relate to the concept of soccer and so the therapist used an example of Team Danny and Team Grumpalump. Danny understood that every time Grumpalump succeeded in making Danny complete a compulsion, Team Grumpalump scored a goal against Team Danny, and got stronger. Danny was able to see that the way for Team Danny to score goals against Team Grumpalump was to not do what Grumpalump wanted him to. To support learning about habituation, you can use examples with the child and family such as swimming in a cold pool. Over time, the body gets used (or habituates) to the temperature. Another example might be going on a ride at a theme park, which may be scary the first time but it gets easier the more times they try the ride. Examples about how to practice with a sport or hobby help them get better, also illustrate the necessity for repetition and practice to facilitate improvement. If clinically indicated, and if parents have experience of facing anxietyprovoking situations, it can be helpful to ask parents to share examples

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of when they have faced their fears and their anxiety habituated. Not only can this bolster confidence in the child, who will trust what their parents say, but it helps the parent to relate their experiences to the exposure process, buy into the approach, and challenge some of their beliefs about anxiety being dangerous or something to be avoided. Young children are highly varied developmentally and will not all benefit from the exact same application of treatment strategies (Kendall et al., 2005). Therefore it will be important to idiosyncratically tailor psycho-education to the child’s developmental level and interests. Furthermore, it is not always necessary to cover every component in close detail for young children, and some aspects may be condensed while still achieving an understanding of the rationale for exposure work. It is, however, vital that the parents understand the key concepts in this part of the therapy, so they are prepared to take on the role of co-therapist. With this in mind, therapists may need to explain to parents the importance of them being involved in therapy. Below is a conversation that took place in separate parent session with Zara:

Therapist

Given what we have covered so far, how do you think Parveen will overcome her fear of dogs?

Zara

Well she needs to confront them, step by step, and she will get used to it

Therapist

Great! What do you think will happen to her anxiety when she faces a dog?

Zara

She will be petrified, but you said she will calm down, her anxiety will come down

Therapist

Great stuff. Zara, I was interested in what you think your role will be in the tasks?

Zara

I guess I will be in session with her, bring her here and maybe I can arrange for my mother to bring her dog in

Therapist

That would be super helpful. I know therapy is really hard work and we have spoken about some of your fears about what will happen if Parveen gets anxious. We encourage families to help set up tasks and do tasks alongside their child, what do you think about that?

Zara

I’m really not sure; I just don’t want to stress her out

Therapist

I understand. What do you think are the reasons for asking parents to take an active role in tasks?

Zara

So Parveen can see I am in charge, can support her, put boundaries in and that I am not scared

Therapist

All great reasons. We also know you have to do a lot of the hard work outside of sessions as an hour a week is not enough. We find that if we coach parents through setting up and seeing tasks through, that can help them to support their child outside of sessions (Continued)

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(Continued) Zara

That makes sense

Therapist

Zara, I have picked up on some of the worries you still have about the effect of anxiety on Parveen. I know it’s really hard to see your child anxious but what do you remember about what we have learnt about anxiety?

Zara

It’s not harmful, it’s normal and it does not last

Therapist

Great! I know when we do these tasks both you and Parveen will be feeling anxious, so we have to hold in what we have learnt. Do you think it would be helpful for us to have a check in after tasks to see how you have felt about setting them up and what you have learnt about anxiety—both yours and Parveen’s?

Zara

That would be great.

Anxiety rating scale An anxiety rating scale provides a ruler by which the child can communicate their level of distress during and beyond exposure tasks. Typically, a scale from 0 to 10 is used. As discussed, young children can struggle to identify their emotions and may also have difficulties identifying the strength of these emotions (e.g., often reporting an “all-ornothing” experience of anxiety; Herren & Berryhill, 2018). Therefore a smaller range may help to simplify this process (Kendall et al., 2005). However, young children may struggle to extrapolate feelings to number ratings and so this scale is likely to require modification to include visual cues such as pictures, emojis, colors, or symbols. This is also a nice opportunity to incorporate the child’s interests, and to use playbased methods to creatively develop a personalized scale together. For example, Parveen created a papier-maˆche´ volcano as her scale, which allowed for a creative and engaging activity while still developing an understanding of levels of anxiety (e.g., from grass at the bottom to the top with lava spewing out). Parveen printed pictures of Fear from Disney film Inside Out in progressively larger sizes and placed them onto her volcano to represent different levels of her anxiety. Younger children may require lots of practice of using this scale with scenarios unrelated to their anxiety disorder, to consolidate their understanding of how to utilize it. This can also be facilitated in a fun, and concrete way. For example, a clinician may ask everyone to watch a scary video and use the scale to measure their anxiety.

Building a hierarchy Once the anxiety scale is established and the child and family feel confident with its use, this framework can be used to develop a fear

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hierarchy. The fear hierarchy provides an exposure treatment plan that identifies specific feared situations that the patient will gradually face and ranks these according to their anxiety scale (Abramowitz, Deacon, & Whiteside, 2011). Building a fear hierarchy requires an accurate assessment of what triggers a child’s anxiety. However, young children may struggle to generate specific situations that they are fearful of, owing to difficulties identifying emotions, poor insight into the impairment (Langley et al., 2002), and difficulties articulating the nature of their fears (Kendall et al., 2005). Therefore collating information from multiple informants (parents/caregivers, siblings, teachers, and observations) can aid in identifying scenarios to add to the hierarchy. Again, ensuring that this process is facilitated collaboratively and creatively according to the child’s developmental needs and interests will assist with maintaining engagement. Examples of this include the child drawing out pictures of their feared scenarios, cutting these out, and then fixing them onto their anxiety scale. For example, Parveen and Zara used the internet to find pictures of different dogs which stuck onto her volcano.

Parveen’s hierarchy using her volcano anxiety scale.

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Designing exposure tasks The first stage of designing an exposure task is to review the hierarchy to decide which step to take. Knowing where to start on the hierarchy is often the challenging part. For younger children, it is important to choose a step on the hierarchy that will provoke mild distress, but will give them the best chance of successfully completing the task to build their confidence. It is best to start too low rather than with something that is challenging and could put them off further tasks. With younger children the pace of moving up the hierarchy is slow and therapists may need to break each task down into smaller steps as they go along. For instance, Parveen’s hierarchy initially focused on different types of dogs but subsequently included additional steps regarding how close she would get to these dogs and situations where she may encounter dogs. In choosing a task, therapists have to strike a balance between what the parents, child, and therapist think should be the task. The way the tasks are chosen by the family and child is likely to be different. Therapists may be more likely to be aligned with the parents whose goal will be their child overcoming their anxiety difficulties and reducing the impact this has on their functioning. However, therapists must be aware this goal may not be shared by the child and therefore the emphasis when choosing a task may need to be changed. An important part of engaging young children in choosing a task is to think about the reward system to put in place. At this point in treatment, therapists have a sense of the young person’s interests, likes, and dislikes, as well as what the family is able to offer in terms of rewards. When designing a task, it is the reward rather than overcoming the fear that often is the driver behind the child choosing and engaging in tasks. Therapists may focus on what reward the child can get and then explaining how they can get it, rather than focusing on the task in itself or reviewing the hierarchy to choose a step. It may be helpful to have a hierarchy of rewards to engage young people to continually challenge themselves, to earn better rewards as they go along. For example, Danny was rewarded with a different number of “goals” for tasks of increasing difficulty; for each task, he had to pick how many goals he wanted to win and the therapist explained how he could earn them. He made a scoreboard to record the “goals” he had “scored against Grumpalump” and there were pre-agreed prizes depending on how many goals Danny could score. When thinking about rewards, it is important the family and child are clear about what they have to do to get the reward. Young children should get a reward for making attempts at the task, rather than successfully completing it, so it should be clearly set out exactly what that would look like. For example, Danny received a reward of playing soccer in

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the garden with his father for trying a task of resisting tapping, whether he was successful or not, but earnt extra time for completing the task. Rewards for younger children may range from getting stickers to earning tangible goods or a privilege (e.g., more time on the computer or screen time). However, for some children, it may be attention from their parents or quality time with them that serves as a reward. It is important to spend time thinking about the details of this with the family and child. Parental attention is something we will come back to when we discuss implementing exposure tasks. Younger children may need more immediate rewards after attempting tasks, and may struggle with delayed gratification and so it is clearly paired with the approach behavior which is then positively reinforced (Mischel & Metzner, 1962). Once a step on the hierarchy and the corresponding reward has been chosen, it is important that the child and family have a clear and specific plan for the task. The details of planning the task include what the exposure will involve (e.g., what is the feared stimuli, how long the young person needs to be exposed for, what the young person and parents have to do during the exposure, and when the task is finished). The goal of exposure is for them to face the anxiety-provoking stimuli to learn they can tolerate anxiety and that it does eventually reduce, therefore this needs to be held in mind when designing the task. It is important when designing a task to again keep it visual and use play. Therapists may find it helpful to draw, show videos, or use puppets to show what a task would look like and help the child understand what is expected of them. There has to be a balance between setting up the task clearly so the young person and family know what to do and expect, while initiating the task as soon as possible in session so as to reduce anticipatory anxiety. The role of the therapist is to support the young person to engage in the exposure task, so as well as using rewards, making the tasks fun, and engaging is important. Therapists can come up with creative ways to do so, such as making it into a game or setting up an exposure competition. Families have a wealth of information they can draw on seeing their child outside of the therapy setting, which needs to be utilized when designing tasks. However, there may be issues that could come up in the process such as some parents struggling to push their child due to their own anxiety or their expectations being too high for their child. If this happens and it interferes in the design of tasks, therapists may consider having a separate session with parents to explore these issues. This may allow parents to share what their concerns may be and facilitate a way forward as well as giving an opportunity to revisit the psycho-education to remind them of why the tasks are being implemented. For example, Zara had strong beliefs that anxiety would damage or

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traumatize Parveen. Psycho-education on anxiety started to shift some of these beliefs; however, these were activated when exposure work began. The therapist arranged a separate session with Zara to consider this in more detail and to support her in relating her own experiences of overcoming fears.

Implementing exposure Once the exposure task has been set up, the task needs to be implemented with modifications for a younger child, to support them to engage in the tasks. Therapists need to strike a balance between the two exposure frameworks (habituation and distress tolerance). Younger children may struggle to tolerate distress; therefore there may be an increased risk that others, both parents and therapists, will engage in behaviors aimed at reducing...”? Therapists must assess these behaviors to ensure they do not undermine the anxiety habituation process (Benito & Walther, 2015). Incorporation of strategies, such as therapist and parent praise, positive encouraging self-talk, rewards, and modeling distress tolerance can help make this model more acceptable (Herren & Berryhill, 2018). For families who find it hard not to give reassurance, they may need to be given alternative statements so they can offer support such as “What would Harry Potter do?” “You are really brave, you can do it” or “Remember you will get a token after this task.” These are statements that provide encouragement and support without directly addressing anything about the feared stimuli. These statements can also be used by the young person themselves as positive self-talk. They can make posters of the statements and put them up at home as visual reminders and have pictures taken of them engaging in exposure tasks as a reminder of their bravery for encouragement during therapy. It is important that any techniques introduced into the exposure tasks have a neutral effect on anxiety so as not to undermine the principles underlying exposure work; that is the child learning they can tolerate distress and that anxiety habituates (Benito & Walther, 2015). Earlier we touched on parent attention being a potential reward when completing tasks. If a functional analysis is completed and it is deemed that the child is getting attention for negative or anxious behavior, which then reinforces it, then this needs to be addressed in sessions. Parents may need a separate session to discuss how they manage this where they are encouraged to try not to give attention to the child when they are trying to avoid the feared stimuli or resisting exposure and to attend to any approach behaviors. Other contingency management strategies may need to be considered if there are challenging behaviors during treatment; this will be discussed at the end of the chapter.

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Therapists have to be vigilant to behaviors the child is engaging in when undertaking exposure to ensure they are fully engaging with the tasks (e.g., not distracting themselves or engaging in mental rituals). It is helpful to draw on what was included in psycho-education, including externalizing the fears, as a way to support young children through the process as well as reminding them of the reward they will get after the task. Younger children may find it helpful if tasks are modeled before they do it so they can repeat the task after they have seen it or for someone to do the task alongside them. This can help them feel they are not alone when they undertake exposures, but also makes it clear to them as to what is expected for them to do. It is useful to get parents to do this as this can facilitate them in undertaking tasks with their child for homework. Therapists have to be careful that the child does not begin to rely on tasks being modeled or having someone to do it with them, as this will reduce the generalizability of exposure tasks to real-life situations and can undermine their sense of self-efficacy and may inadvertently provide reassurance. It is therefore helpful to introduce modeling when the child is struggling to engage in the task as opposed to it being done for every task. With younger children, therapists need to try to keep sessions light humored and fun to promote engagement in this challenging work and make the exposure tasks more tolerable. Therapists can utilize the creativity of younger children to help this process. For one of Danny’s exposure tasks around resisting evening up, Danny devised an “exposure obstacle course” where he and his father competed against each other to complete differing tasks. For example, one station involved wiggling his right arm and right leg for 10 seconds without moving his left side, and another station involved kicking a ball with only his right foot. This helped the task to be fun and active, while still ensuring a focus on exposure. However, something therapists need to be aware of when doing this is there is a risk this may provide a distraction from the exposure task. This may undermine the process of distress tolerance or bring anxiety down, which means the child will not learn that anxiety habituates naturally. It is important that the child focuses on the feared stimuli for as long as possible (Benito & Walther, 2015). Parents can be given the task to describe the feared stimuli, along with the child, and to take distress ratings, to keep their focus on the exposure. For example, while Danny and his father competed on the obstacle course, Danny’s mother asked him for his anxiety ratings, and interjected with “Does your left side feel funny?,” “Does Grumpalump want you to even up?” “Well done you are doing brilliantly to annoy Grumpalump.” These comments ensured that Danny remained focused on the anxiety. Younger children generally may struggle to stay focused on tasks and may discuss other topics, which provides a distraction. It is helpful to introduce time after the exposure task where they can talk

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about their favorite topics. This can be used as a reward for completing the task, but also does not deny them the opportunity to talk about other things! If sessions can be fun and rewarding without undermining the exposure process, this can facilitate the process of inhibitory learning (Craske et al., 2014) whereby the child gets a different experience of the feared stimuli. Children should be praised for the attempts they make to engage in exposure tasks, rather than the outcome of the task. For example, if therapists hold in mind the anxiety habituation model and say the task ends once the anxiety habituates, young children may give inaccurate ratings as a way to end the task as soon as possible. The therapist and parent should give praise for the child approaching their feared stimuli; praise needs to be specific and immediate. Young children should be congratulated on tolerating anxiety and their bravery, rather than the outcome of the task. It is also important to remember, parents require praise too when supporting their child implementing tasks. It is important to highlight to them that they are doing well supporting their child with the task. If the child is struggling to engage in the tasks, it may be a sign that the task set may be too difficult for them. The therapist may then have to break tasks down into smaller steps and move slowly up the steps with young children. For example, as you may recall, Parveen’s original hierarchy, which included approaching different types of dogs, had to be broken down into how close she would get to these dogs. They may also struggle to accurately identify their emotions and rate anxiety when doing a task. Therapists may find the child has underestimated their distress, so they may find tasks harder than expected. Therefore therapists should be prepared to adapt tasks with new information they attain in session and be ready to break tasks down. When engaging in exposure, it is important that the child is able to communicate their distress ratings regularly during the task using their anxiety rating scale. It is likely they may struggle with subtle changes in anxiety so you may consider taking ratings every 10 15 minutes rather than every 5 minutes, to allow them to recognize changes. The goal of the session is not that their anxiety should have completely habituated by the end, but rather they approached something they were scared of and could tolerate the anxiety. If the child is struggling to rate their anxiety, parents can give their ratings as they are likely to recognize signs of distress in their child. Additionally, therapists can make behavioral observations when setting up tasks to establish how difficult they may be based on how readily the child approaches their feared stimuli and their reports of being able to resist compulsions or safety behaviors. After completing an exposure task, it is important to review the hierarchy in each session to adjust steps with the new information gathered to set realistic goals for tasks. With Parveen, the pictures of the dogs were

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moveable on her volcano model; after each session, the pictures were moved to indicate how scary she found the task now it was complete and to see if other pictures needed to be repositioned with this in mind. This also gave her a chance to take the tokens she had earnt from the volcano. In addition, photographs were taken of her completing each task and these were stuck onto the volcano as a reminder of her bravery and success, which encouraged her to move up the hierarchy. It is important to monitor the pace at which the child is working through their hierarchy during treatment. One of the challenges is to agree a pace between the child, parents, and therapist. There will be a time frame for therapy and goals for treatment, so it is helpful to review these regularly. It is important to aim for the child and family to feel challenged and that they are making progress in each session. The ultimate goal is for the child and parents to build up their confidence in setting up and implementing exposure tasks so they are able to implement this outside of treatment; whether this is between sessions for homework or after treatment ends. As exposure sessions progress, it is helpful to ask parents to lead in designing and implementing the exposure of the tasks, in a graded fashion, to help build up their confidence to take a lead on this. For example, here is a session with Danny and his parents when they were setting up and doing a task:

Therapist

Right Danny, we are going to set up a challenge today! Let’s look at the Grumpalump challenge sheet—wow—look how much you have done so far! What is going to be the challenge for today?

Danny

I don’t know

Therapist

Shall we ask Mum and Dad to pick a challenge each and then you can decide between the two options?

Danny

I don’t know

Therapist

Hey, do you know what? I forgot to ask, what did you decide would be the prize for getting ten tokens this week?

Danny

Mummy and Daddy said I could get a soccer magazine

Therapist

Fantastic. So how many tokens do you have to get up to 10 tokens today?

Danny

I just need two more!

Therapist

Yay! Right, Mum, Dad—let’s have a look at Grumpalump list—where have we got to? Right, can you pick a task that is the next step which will earn Danny his final two tokens!

Dad

I think Danny should hop on one leg only for 2 minutes

Mum

I set Danny challenge of tapping the soccer ball only once (Continued)

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(Continued) Therapist

Great job! Danny, which one do you think you will be able to do to get your tokens so you can get your prize?

Danny

I will hop.

Therapist

Amazing! Now before we get started—let’s do a reminder of what the challenge is for Mum and Dad during the task

Danny

Dad—you hop with me and shout back at Grumpalump and Mummy you have to ask me what color I am on my chart before and after I hop

Therapist

Great team work! Does everyone know what they are doing? Great, ready, set, go!

Challenging issues Behavioral difficulties Younger children who have anxiety difficulties may also present with challenging behavior such as temper tantrums, aggressive behavior, and destruction of property. This is often a way they demonstrate their anxiety, therefore is secondary to the anxiety disorder. However, this behavior can interfere in the process of exposure therapy as the focus of sessions may shift to managing the behavior as opposed to the exposure tasks. If these behavioral outbursts are formulated as an indication of anxiety, it is important to continue with exposure therapy as planned, as evidence suggests they reduce as the anxiety disorder, such as OCD, gets better (Krebs et al., 2013). In order to facilitate the process of exposure therapy in such instances, as discussed earlier, it is important to continue to externalize the anxiety disorder and encourage parents to blame the anxiety disorder and not the child. Parents may find it helpful if therapists normalize temper outbursts, by framing them as the “fight” part of the anxiety “fight or flight” response. It is important to reassure parents that temper outbursts will subside as the anxiety disorder gets better and therefore joint efforts should be focused on challenging the anxiety problem. This is especially relevant for family accommodation as reducing this improves challenging behavior in the long term, following a short-term increase in such behavior (Lebowitz, Omer, & Leckman, 2011; Storch et al., 2015). It is, however, helpful to ensure that parents understand that although the anxiety disorder might be the reason for outbursts, it is not an excuse for unacceptable behavior and this should not prevent sensible parenting (e.g., putting boundaries in place for unacceptable behavior such as hitting). Parents should also be encouraged to praise their child when they manage their anxiety without an outburst.

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If the behavioral difficulties are not formulated as part of the anxiety disorder, it is important to consider if they are indicative of disruptive behavior disorder as it has been found in OCD that this can lead to poorer outcomes (Storch et al., 2008). In such cases, it may be helpful to consider if parents need specific parent management treatment, which has been found to augment CBT for young people with comorbid oppositional defiant disorder (Sukhodolsky, Gorman, Scahill, Findley, & McGuire, 2013).

Child refusing treatment In some cases, children may completely refuse to engage in sessions, despite the use of contingency management techniques and play to engage them. If this is the case, all is not lost as many CBT protocols for younger children have been developed to work just with parents (Rapee et al., 2010; Rudy et al., 2017) and have been found to be equally effective as those including children in sessions (Waters, Ford, Wharton, & Cobham, 2009). The components of treatment remain the same as mentioned previously, but parents would be encouraged to apply techniques with their child at home (e.g., having a discussion of fears and developing a hierarchy, exposing the child step by step to the feared stimulus). If the child refuses to engage in the work at home, parents may wish to take charge and implement exposure without the child necessarily being aware this is happening (e.g., exposing the child step by step to their fear and rewarding them for doing so). If the child is unable to approach the feared stimulus, parents may decide to start with reducing their accommodation of the difficulty (e.g., if they have to give reassurance). In such cases, it is important that parents say to the child they are planning to challenge their fears with them and what to expect, so the child is not shocked when this happens.

Parental factors and family dynamics As family involvement is vital to exposure work with younger children, unhelpful parental, and family factors can have a negative impact on the therapy. Children whose parents experience psychopathology or caregiver stress are at a higher risk to benefit less from CBT (Compton et al., 2014; Southam-Gerow, Kendall, & Weersing, 2001). Indeed, such parental factors may have more of an effect for younger children (Berman, Weems, Silverman, & Kurtines, 2000). Children are found to be at an increased risk of developing symptoms of anxiety if their parents have an anxiety disorder (Hirshfeld-Becker & Biedermann, 2002), or if they have been raised with parental-anxious rearing strategies (Muris &

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Merckelbach, 1998). This increased risk may be attributable to a parent modeling fear or avoidance Muris, Steerneman, Merckelbach, & Meesters, 1996), overprotecting the child (Hirshfeld, Biederman, Brody, Faraone, & Rosenbaum, 1997), attempting to control the child’s behavior in a way that limits psychological autonomy (Hudson & Rapee, 2001), or facilitating avoidant coping responses (Dadds, Barrett, Rapee, & Ryan, 1996). In addition, family accommodation, whereby family members alter their behavior to mitigate the anxiety their child experiences, is found to be commonplace in childhood anxiety disorders (e.g., Lebowitz et al., 2013). These behaviors often represent well-meaning attempts of parents to help their child cope with anxiety. However, therapists are therefore likely to work with parents who both experience anxiety, and have developed unhelpful beliefs or strategies around managing anxiety. The optimal approach for managing unhelpful family dynamics is likely to depend on the extent of associated impairment. Clinical experience suggests that lower level parental criticism and over-involvement can often be successfully addressed in the context of family-based CBT without deviating from standard, evidence-based protocols. For example, Danny’s parents blamed him and were critical of compulsive behaviors because they did not have a good understanding of OCD. In his case, the therapist highlighting that compulsions are anxiety-driven, externalizing OCD and framing it as a bully that Danny was struggling to stand up to, rather than him being naughty, helped his parents to develop empathy and reduce criticism. For Zara who was overprotective of Parveen, she learnt the importance of confronting fears and anxiety habituation in therapy, which helped her to move forward. However, if parental distress significantly interferes despite attempts to address it within therapy, or the therapist suspects a parent may have their own psychological difficulties that may warrant support, it is important to share this with the parent and support them in accessing their own help. In cases with higher levels of family dysfunction, therapists may wish to consider additional techniques or family therapy as an adjunct to exposure therapy to increase chances of treatment success. For example, positive family interaction therapy, which was designed as an adjunct to CBT for OCD in highly distressed and impaired families with difficult dynamics, improved treatment outcomes compared with CBT alone (Peris & Piacentini, 2013; Peris, Rozenman, Sugar, McCracken, & Piacentini, 2017).

Conclusion This chapter presents suggested modifications to ensure that exposure therapy is accessible, engaging and effective for young children. It is important to adapt material according to the child’s developmental

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level, include the family throughout treatment, incorporate play-based methods, and use contingency management techniques. It is hoped that this chapter provides therapists with inspiration for how to facilitate exposure therapy with young children and the potential adaptations necessary to enable good outcomes.

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