Michael A. Tompkins, Ph.D.
Co-Director of the San Francisco Bay Area Center for Cognitive Therapy
Exposure appears to be the key change-producing procedure in the cognitive-behavioral treatment of anxiety and phobic disorders in children. Successful exposures depend on the clinician’s ability to engage the child in anxiety-provoking tasks. Successful exposures are both developmentally appropriate and fun for the child. Developing exposures for anxious children can be fun for the clinician too and offer opportunities to be creative and playful. I present several exposure strategies that I have found helpful in treating anxious kids.
Toys and books. What child can resist a toy? Toys can be used as an exposure target or to facilitate exposure. For example, six-year old Jennie had a terrible fear of spiders that resulted in tantrums whenever she had to leave the house. Jennie and I put together an exposure hierarchy that began with her reading books about spiders. At first, she was only willing to stand near the book but gradually agreed to stand near the pictures of spiders and then to touch them. Later, Jennie agreed to write and illustrate her own book about spiders which she happily read aloud to me. She also agreed to wear black spider rings around the house and to wear other “spider jewelry” we made in the therapy session.
Kazoos are terrific toys for selectively mute children. The objective here is to create situations in which the child vocalizes. I encourage the child to play a kazoo or paper-and-comb and then gradually change the venue of these “little performances” to more anxiety-provoking situations. Mary, a selectively mute five-year old, was willing to play a kazoo in session with me. At first she hummed tunes but gradually was willing to speak words and phrases. Mary then agreed to play the kazoo when friends and strangers visited her home. When Mary graduated from therapy, Mary, I, her parents, and three siblings played kazoos to the tune, “Pomp-and-Circumstance.” What a performance!
Games and songs. I play lots of games with anxious kids. Games can take the edge off an exposure assignment because they are fun and build on the child’s innate wish to play. For example, Mary (the selectively mute five-year old) moved up to playing song games with me (e.g., “Who stole the cookie from the cookie jar?”). Later, we went for walks during which we played “Hi-on-the-Fly” in which we competed to who could first give a quick smile and a hello to strangers we meet on the walk. Playing cards on which the feared object is drawn is another fun exposure for kids. Jennie and I cut out pictures of spiders and pasted them on index cards. We used these cards to play “Go Fish.” A “Fast-Talking-Contest” is another fun game. Julian, a nine-year old with obsessive compulsive disorder, had an obsessive fear of growing young and avoided small children, diapers, and many objects in his home that were associated with toys once stored in a diaper box. When Julian and I started meeting, he would not permit me to say the word diaper in his presence, but he did agree to a “Fast-Talking-Contest.” In this game, I counted how many times Julian could say diaper in one minute. Then it was my turn. Julian was a competitive kid and loved to trounce his tongue-tied therapist.
“Get Dressed” is another great game for kids who fear wearing certain articles of clothing. First we sort the clothes into piles from lowest to highest discomfort. I bring a pile of sweaters and shirts from home and the child’s parent brings a bag of the child’s “contaminated” clothes. We then have a contest to see who can put on the most clothes in one minute. The child continues this game with parents at home until the child is comfortable wearing his or her clothes (but one shirt rather than six shirts, or one pair of pants rather than three). Board games can facilitate exposures too. I often play checkers using the feared objects (or checkers contaminated with a feared object) as game pieces. In the case of Julian, we used a set of “contaminated” toy soldiers as game pieces. Julian loved this and we played checkers contaminated with objects from his fear ladder until he no longer reported anxiety when he touched the game piece.
Sometimes changing the context of a fear makes it a bit more tolerable and songs can help do this. I often have the child with obsessive worry write songs, which include the child’s worry thoughts, that we then sing. For example, while Julian would not say the word diaper he was willing to write songs that repeated the word diaper over and over again. We wrote several that he sang with me and his parents until the word diaper no longer made him anxious.
Video and audio recordings. Children will often agree to watch videos containing situations or objects they fear. I have watch “Arachnophobia” many times with kids who feared spiders. Also, there are many nature videos that are great for kids who have animal phobias or who fear thunder and lighting. Videos are particularly useful for setting up exposures to objects or situations that are difficult or impossible to create in your office (i.e., lighting).
Videos and audios are also helpful in treating selectively mute children. Mary, the selectively mute five-year old agreed to being audio recorded while she spoke to her mother. We then set up an exposure hierarchy whereby we played the audio in situations that provoked more and more anxiety. First, Mary permitted me to listen to the audio with her and her parents in the room. Later, Mary and I listened to the audio alone, which was initially slightly more anxiety evoking. Gradually, Mary permitted other exposures (i.e., audio played for the teacher who listens with parents and Mary, audio played for teacher who listens with Mary only, audio played for one of Mary’s playmates who listens with Mary). Our last exposure involved showing a video of Mary singing to her classmates in school. The other kids were delighted to hear Mary sing. Thereafter, Mary began to speak spontaneously in class to her teachers and friends.
Mobile phones. I have found that mobile telephones are helpful in treating kids with separation anxiety. For example, Brad was an anxious ten-year old who could not tolerate being separated from his mother. When I first met him, he was being schooled at home and for the last seven years had slept on the floor next to his mother’s bed. Brad was willing to gradually extend the time away from his mom if he could reach her on her mobile telephone. However, mobile telephones are not helpful when they become safety signals for the child. Both Brad and his mother agreed ahead of time that the mobile telephone was just one step on his exposure ladder and we developed steps on the ladder that include Brad away from his mother for extended periods of time without a mobile telephone. Later, Brad spent more and more time away from his mom in situations where he could not reach her by phone until Brad was no longer anxious without his mother.