How Can Exposure Therapy Be Improved for Children and Teens with Anxiety?

What you need to know

• Exposure therapy is a key part of treating anxiety in young people, but many do not fully benefit from current approaches
• This review looked at ways to potentially improve exposure therapy for children and teens with anxiety disorders
• Some promising strategies were identified, like reducing safety behaviors and having parents/therapists discourage avoidance
• However, findings were mixed and inconsistent across studies, highlighting a need for more standardized research

Background on anxiety and exposure therapy

Anxiety disorders are very common in children and teenagers, affecting about 6.5% of young people worldwide. If left untreated, childhood anxiety can persist into adulthood and negatively impact many areas of life, including education, relationships, and future job prospects.

Cognitive behavioral therapy (CBT) that includes exposure is typically the recommended first-line treatment for anxiety disorders in young people. Exposure therapy involves gradually facing feared situations or stimuli in a controlled, therapeutic way. For example, a child with a fear of dogs might start by looking at pictures of dogs, then watching dogs from a distance, and eventually petting a calm dog.

While CBT with exposure is helpful for many, research shows that around 40% of anxious youth do not benefit enough. Even among those who do improve initially, almost half may relapse within a few years. Clearly, there is room to enhance the effectiveness of exposure therapy for young people with anxiety.

Reviewing ways to optimize exposure therapy

This paper reports on a systematic review that examined research on potential ways to improve exposure therapy outcomes for children and adolescents with anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

The researchers looked at 29 studies that investigated various strategies and factors that might impact how well exposure therapy works. These studies included over 2,000 young people aged 3-18 years old.

Some key areas they explored included:

• Using medications like D-cycloserine to enhance learning during exposure
• Having parents involved in exposure therapy sessions
• Reducing safety behaviors and avoidance during exposure
• Examining the impact of fear levels and emotional variability during exposure
• Looking at how therapists and parents can best support exposure

Promising strategies identified

While the overall findings were quite mixed, the review did identify some potentially helpful strategies for optimizing exposure therapy in youth:

Reducing safety behaviors: Safety behaviors are things people do to try to reduce anxiety in feared situations, like carrying “lucky” objects or excessively checking for danger. One study found that greater use of safety behaviors during exposure was associated with less improvement in anxiety. This suggests that therapists should work to reduce reliance on safety behaviors.

Discouraging avoidance: A couple studies found benefits when parents and therapists actively discouraged avoidance during exposure tasks. For example, a therapist saying “Keep looking at the dog” rather than allowing the child to look away. This appeared to lead to better long-term outcomes.

Promoting engagement and mastery: There was some evidence that children who were more engaged in exposure tasks and able to master the skills being taught had better outcomes. This highlights the importance of helping kids fully participate.

Encouraging “difficult” exposures: One study found that spending more time on exposures the child rated as difficult was linked to greater anxiety reduction. Pushing kids to face more challenging fears may be beneficial.

Using homework: Completing exposure homework between sessions was associated with better outcomes in one study of OCD treatment. Practice outside of therapy sessions seems important.

Processing the experience: Having kids discuss and process their thoughts/feelings after exposure tasks was linked to more anxiety improvement in one study.

Mixed findings and limitations

While the review identified some promising strategies, the overall results were quite mixed and inconsistent across studies. Many potential optimization approaches, like using D-cycloserine medication or having parents heavily involved in exposure, had conflicting findings or no clear benefit.

The researchers note several key limitations that make it difficult to draw firm conclusions:

• Most findings were only shown in one study and not replicated
• Studies used varying definitions, methods, and outcome measures, making comparisons difficult
• Many studies had small sample sizes and other quality limitations
• Few studies looked at long-term outcomes beyond 3 months
• Most research focused on short-term anxiety reduction rather than lasting learning

Additionally, while animal research suggests adolescents may respond differently to fear extinction compared to children or adults, only one study in this review examined age differences. More research on developmental factors is needed.

Implications for improving exposure therapy

Despite the limitations, this review provides some useful insights for clinicians on potentially helpful strategies when conducting exposure therapy with anxious youth:

• Work on reducing safety behaviors and discourage avoidance
• Ensure the child is engaged and able to master the information/skills
• Include some more difficult/challenging exposures
• Look for variable levels of anxiety (ups and downs) within exposure sessions
• Focus on quality over quantity - don’t try to pack in too many exposures per session
• Assign and encourage between-session exposure homework
• Have the child discuss and process the experience after exposure tasks

However, the authors emphasize that these are tentative suggestions. More research is still needed to determine the most effective ways to optimize exposure for children and teens.

Future research directions

To move the field forward, the researchers recommend:

• Developing standardized, validated measures of key exposure variables to allow better comparison across studies
• Conducting more experimental studies to test specific optimization strategies
• Examining age differences and other potential moderating factors
• Using “preclinical” studies (e.g. with subclinical samples) to efficiently test ideas before clinical trials
• Focusing more on long-term learning and generalization rather than just short-term fear reduction
• Exploring strategies from adult exposure research that haven’t yet been tested with youth

Conclusions

This comprehensive review highlights both the potential to enhance exposure therapy for anxious youth and the need for more rigorous, consistent research in this area. While some promising optimization strategies were identified, the mixed findings underscore that we still have much to learn about how to most effectively deliver exposure for children and adolescents.

As exposure appears to be a crucial ingredient in treating youth anxiety, continuing to refine and improve exposure methods could significantly benefit many young people struggling with these common disorders. However, care is needed to ensure new approaches are thoroughly tested before wide implementation.

Ultimately, this review sets the stage for a new wave of research aimed at helping more children and teens overcome anxiety through enhanced exposure therapy methods. With anxiety disorders affecting so many youth worldwide, optimizing this core treatment approach remains an important goal for the field of child and adolescent mental health.