The A-Z Guide to Exposure: Creative ERP Activities for 75 Childhood Fears

This blog was written by Dawn Huebner, PhD, co-author with Dr. Erin Neely of The A-Z Guide to Exposure.

A child locked in the grip of fear wants nothing more than to escape. That makes sense. Anyone who thinks they are in danger is going to look for ways to stay safe. But that immediately puts the child in conflict with the adults around them, parents, teachers, even therapists who might be encouraging them to fight what they are feeling, breathe through it, or otherwise stick it out. It’s a puzzle, figuring out how to be an ally to an anxious child without discounting their feelings or overly accommodating the fear.

Therapists working with anxious children quickly learn that exposure is an important piece of the treatment puzzle. When implemented correctly, exposure teaches children to move towards rather than away from their fears. It corrects faulty wiring that perceives danger when none (or very little) exists. As a long-term solution, exposure works better than reassurance, logic, distraction, or bribery. It leads to happier, more competent functioning.

But exposure is hard. There’s an art to it, to getting children and their parents on board, then right-sizing challenges and persisting in the face of resistance and competing demands. And then there’s the part about creating hierarchies. How do you expose a child to dentists when they only go twice a year, or to intrusive thoughts when the thoughts freak everyone out? How do you, a busy therapist, treat a fear of pooping at 11am and a few of dogs at noon when you have neither a dachshund nor a bathroom in your office?

Dr. Erin Neely and I were in a peer consultation group together for years, and we noticed that a lot of our time was spent brainstorming about exposure. There were 4 therapists in the group, with over 70 years’ experience between us, and we were still, all of us, running into trouble figuring out relevant, creative, progressive challenges for child clients afraid of growing up, throwing up, losing games, making decisions, and more.

What we needed, we realized, was a set of lists, so each time we treated a child with a fear of dogs, or needles, or sleeping alone, we didn’t need to re-invent the wheel. Instead, we could pull out this handy-dandy list and immediately have at our disposal a set of exposures that were a) creative; b) do-able; and c) on-point. But a compilation of lists didn’t exist, we decided to write one.

The A-Z Guide to Exposure is a compilation of exposure lists, hierarchies of challenges meant to address 75 childhood fears, from Addiction to Zombies. Each entry has between 5 and 25 suggested activities ordered from easiest to hardest, with notes and explanations about how to customize activities to meet the needs of any particular child. Entries are cross-referenced, so when you look up Dolls, for example, you will also be directed to Baddies and Navigating Home Alone as these are frequently co-occurring issues.

There is also a section addressing questions such as What is exposure? How does it work? What are the contraindications? Is there a place for incentives? And, What can get in the way of effective treatment? Here is an excerpt from that section:

What can get in the way of effective treatment?

Insufficient preparation. Take the time to lay the groundwork for both the child and the parent. Exposure works best when everyone understands why it is being done. Be clear about what it means to “succeed” with an exposure. Success is not the absence of fear. It is finding challenges that trigger mild to moderate fear, and doing them.

Choosing challenges that are too hard, especially early on. Children who make their way into therapy often have low distress tolerance. Gradually build perseverance by choosing challenges that are just a fraction beyond what the child is already able to do. As success mounts, steps can be made larger.

Choosing challenges that are too easy. Parents and children may come to therapy with the mistaken notion that the child must always be comfortable. This idea causes them to shy away from even moderately challenging exposures. Initially, the therapist might allow small steps to build trust in the process, with the aim of encouraging larger leaps of faith over time.

Progressing too quickly, or too slowly. Unfortunately, there is not a set pace that works for all children. Motivation, distress tolerance, and frequency of practice all influence readiness to more to the next level of an exposure hierarchy. Some therapists dictate the pace, recommending moving up every fourth day, for example, or after a challenge has been done three times. Others use a Subjective Units of Distress Scale (SUDS) to keep the child in that sweet spot of just outside their comfort zone. Aim for a pace that is neither hurried nor languid, frequently referring to “next steps” so both the child and parent remember that exposure is dynamic.

The child is unwittingly undoing exposure with safety behaviors. It is not unusual for children to fall back on safety behaviors in an effort to reduce the anxiety stirred up by exposure. For example, a child may seek reassurance in the midst of an exposure, or they might throw themselves into an activity to distract from what they are doing. Keep in mind that self-regulation strategies can morph into safety behaviors as well. Getting rid of safety behaviors is the response prevention side of ERP, and an important thing to check if therapy is stalling.

Resistance on the part of the child. Children are more inclined to participate in exposure when they feel safe, seen, and heard by the therapist. Take the time to establish rapport. Give the child choices whenever possible. Start small, imparting early success. Focus on issues that matter to the child first, even if they differ from the parents’ priorities. Address resistance when you see it, and work to increase trust, confidence, and motivation.

Resistance on the part of the parent. As much as they genuinely want their child to feel better, some parents hold beliefs that get in the way of exposure. Thinking it’s their job to keep their child “comfortable” is one such belief. Seeing anxiety as dangerous is another. Not making time for exposure, or doing it in a rushed or punitive way, will also cause progress to falter. Parents might need additional support to be able to implement exposures at home and to coach their child effectively.

Underlying comorbidity. Comorbidity itself isn’t necessarily the problem; failure to take it into account is. Always begin with a comprehensive assessment so you know about underlying medical, learning, sensory, behavioral, and emotional issues as all impact the child’s experience of the world and their ability to be successful in treatment.

Exposure therapy is elegant, evidence-based, and effective. It is an essential part of treatment which, when done correctly, has the power to set an anxious child free.

The A-Z Guide to Exposure is available here.