Fighting fears by facing fears: towards improved exposure-based treatment for childhood anxiety disorders

Exposure-based cognitive behavioral therapy (CBT) has the most empirical evidence of any treatment for childhood anxiety disorders. However, there is a large proportion of children and adolescents that do not recover following treatment. Exposure is seen as the core component of CBT for anxiety disorders, but it is still unclear how to conduct exposure so that it is most effective in reducing fear and anxiety in youth. To answer this question, five studies were designed that showed that only one out of two children receive exposure in treatment for their anxiety disorder. Possibly due to their negative beliefs about exposure, therapists seem to prefer other CBT techniques like cognitive or relaxation exercises over exposure. This appears to be unnecessary, as exposure only treatment proved to be as effective as exposure in combination with cognitive or relaxation exercises. So, for a short but effective treatment, CBT can be restricted to exposure. For a better short-term treatment outcome, exposure might best be conducted with the help of a therapist within a therapy session, before it is conducted as homework outside the therapy session. Besides conducting the exposure exercises, therapists should monitor changes in fear and expectancy of the feared outcome, by discussing before and after each exercises what did (not) happen and why (not). To avoid that children or adolescents relapse after successful exposure-based CBT, exposure should be conducted in various settings. This helps the child after treatment to remember what it learned during treatment. It is now time to translate these findings to clinical care, so more children and adolescents get to face their fears to effectively overcome their anxiety.