Considering CBT with anxious youth? Think exposures

Following a historical précis regarding exposure and a brief description of a representative cognitive-behavioral therapy (CBT) program for anxiety disorders in youth, we discuss several factors related to conducting exposure tasks in youth. Topics include assessing anxious situations, creating a hierarchy, and using imaginal, as well as in vivo and in- and out-of-session exposure tasks. We also describe and discuss the posture of the therapist with regard to the development and maintenance of rapport, the process of consulting with the child, the use of shaping and rewarding effort, the restraining from reinforcing avoidance, modeling for parents, and how to deal with the occasional less-than-successful exposure task. Developmental level of the child and contextual factors are examined as they might influence the design and implementation of exposure tasks. Last, we consider professional practice issues of liability, applications in private practice, and the challenges that face new therapists undertaking exposures. Examples and illustrations from actual clinical cases are included throughout.