Since exposure or staying in a scary situation is difficult, children need to be taught skills they can use so they can face their fears. This involves teaching children cognitive or self-control strategies. Children should be taught to recognize when they are feeling scared and to recognize their scary thoughts or beliefs; to learn to think of other thoughts or beliefs when scary thoughts surface; and to praise themselves for successfully substituting better thoughts.
In teaching children self-control skills, the mnemonic STOP is often used: Scared, Thoughts, Other thoughts or Other things I can do to handle my fear, and Praise myself for successful handling of my fear and exposure (e.g., "I'm really proud of myself"; "I am a brave boy/girl").
Application. In the application phase, children (and parents, if they are involved) practice the principles and procedures taught in the beginning sessions. This application occurs in the therapy session and out-of-session as homework assignments. The therapist's role is similar to a coach in terms of providing feedback, support and encouragement as the child engages in increasingly difficult anxiety-provoking exposure tasks. Children begin with the lowest (easiest) steps on the fear/anxiety hierarchy. The importance of staying with the feeling of fear/anxiety for as long as they can until the fear/anxiety is reduced is emphasized. At the same time, it should be emphasized that the exposure can be stopped if the feeling of fear/anxiety is more than the child feels willing or able to handle. However, if children are willing, they should stay in the situation almost until the exposure situation seems boring to ensure that the fear reaction will be successfully reduced on each step on the hierarchy. To help determine whether the fear has been reduced during the exposure, it is useful for children to rate their fear/anxiety on a rating scale or thermometer (i.e., 0 to 8 rating scale) before and throughout the exposure. The exposure can be terminated upon a successful reduction in the fear ratings (e.g., initial rating of 6 and a final rating of 1 or 2).
If parents are involved, contingency management may be applied. The therapist helps the parent and child generate a contingency contract, which is a detailed written agreement about the specific exposure task that the child will try (e.g., what to do, when to do it, how long to do it), the specific reward the parent will provide for the child's successful attempt and/or completion of the task, and when the reward will be provided.
Whether or not parents are involved in the treatment, it is important for children to apply the self-control strategies. In this way, children can ultimately be responsible for managing their own therapeutic change efforts. For example, if a child has a social phobia and the exposure involves going to parties, the child might practice STOP as follows: Yes, I feel Scared at the party; My Thoughts are that the other kids will think I am an idiot because I will say something stupid; Other thoughts or other things I can do include telling some of the new jokes I learned for kids' parties; and Praise myself because I should be really proud of myself for being brave and going to the party.
As much as possible, children with separation anxiety disorder and GAD should engage in in vivo exposures for those situations that commonly trouble them. For separation anxiety disorder cases, parents may be asked to leave the child alone or with a baby-sitter for increasingly longer time intervals. It also may involve the child staying at another child's house for increasingly longer time intervals. Using the previous example of the child with GAD who worried about getting sick from eating in restaurants, the exposure might involve having the child gradually visit and eat in restaurants. For the child who worried about terrorist attacks in school, the exposure might involve having the child gradually attend school. Emphasis in the sessions is on helping children to realize that their worst fears do not happen during the exposures.
Although in vivo exposures are encouraged during the application phase, it may be difficult to devise an in vivo exposure for some patients with separation anxiety and GAD. In such cases, imaginal exposures can be used, where children imagine they are in a movie with anxiety-provoking scenes that involve a situation on their hierarchy. The details of the scene (e.g., clothes being worn, color of the room) should be elicited prior to having the exercise to help ensure a vivid image on the part of the child. The child should be asked to imagine the scene for as long as possible, but definitely until the anxiety decreases.
The child can use STOP as needed to help decrease the anxiety response. For example, part of the T (anxious thoughts) for the child worried about eating in restaurants is that the bad thing may happen-children can get food poisoning in restaurants. In such instances, it helps to generate the O (other thoughts or other things to do) that the children can do to decrease the probability of this occurring (e.g., only eat in clean and established restaurants; if your food tastes funny, stop and ask someone else to try it for you). Also part of the O is to help children figure out that the probability of these things happening is considerably less than the probability of not happening. It also may be helpful to ask, "What if it did happen?"