Exposure and Response Prevention

Exposure and response prevention (ERP) is a behavioral technique commonly used to treat anxiety disorders, including OCD, specific phobia, and PTSD among children and adolescents. In general, children with anxiety disorders have developed a fearful reaction to a nonthreatening situation or object, perhaps because of a chance association with a threatening or anxiety-provoking object. The lack of threat that the innocuous situation poses and the interference that the fear causes in the child's life makes the anxious response maladaptive. Over time, the child's anxiety may generalize to other situations or objects, further exacerbating the impact that the fear has on his or her life. To cope with this emotional distress, the child may develop unproductive behaviors, such as compulsive hand washing because of fears of germs and contamination, which the child associates with anxiety-reducing effects. Children also try to avoid the anxiety-provoking situation, further limiting their involvement in age-appropriate activities. With each episode of avoidance or escape, the child experiences a reduction in anxiety, which reinforces these avoidant responses. As long as the feared object is avoided, the child never has the opportunity to encounter the situation or object without anxiety.

The basic principle of exposure is to allow children to experience sustained contact with the feared object so that, over time, they learn that the object is not threatening and that they can successfully manage their emotional arousal in the future. With repeated and prolonged exposure, children learn that there are no negative consequences from exposure and that anxiety responses are reduced until they are eventually extinguished. In response prevention, children are prevented from avoiding the object or from engaging in any unproductive behaviors until the cycle of exposure-avoidance is broken and they can encounter the object without distress. While teaching children that the principles of ERP can assist with treatment, young children may not understand the theoretical underpinnings. Hence, treatment may be applied to younger children without explaining the principles.

ERP can be applied in different forms. For example, treatment can involve one long continuous exposure session or multiple shorter exposure sessions. Furthermore, there may be longer or shorter [Page 830]durations of time between each treatment session. It is unclear from the research literature what is the optimal number of exposure sessions. Other variations to treatment include the use of graduated versus intense exposure to the feared object. In the graduated exposure approach, the child ranks different anxiety-provoking situations in a hierarchical order from least to most anxiety provoking. Treatment begins with exposing the child to the least anxiety-provoking situation. Exposure to the feared object or situation may be in vivo or imagined by the child with the therapist's guidance. In vivo exposure produces more powerful effects because of the real-life applications. However, personal contact with the object or situation may be contraindicated in some situations, as in the case of abuse or where there is a risk of harm (e.g., petting a pit bull to overcome fear of the dog). Exposure to situations that the child imagines with the therapist's guidance may take longer to yield effects, but it is effective for situations in which live exposure is precluded. The therapist can help make the imagined scenes seem more realistic to the child by describing the scenes in vivid detail, perhaps including descriptions of the texture and sounds of objects. Guided imagery in which the therapist is actively involved in monitoring the child's level of anxiety in response to exposure and is also preventing the child from avoiding exposure helps to enhance treatment efficacy. The therapist may ask the child to describe in detail the scenes that are being imagined to ensure that the child is not avoiding anxiety-provoking scenes. As the child masters exposure to the situation without experiencing anxiety, then the child graduates to the next situation on the hierarchy until the child has been systematically desensitized to all the scenes.

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