The model above illustrates how anxiety disorders are maintained through avoidance. For example, when the boy with a dog phobia sees a dog, he has thoughts related to the dangerousness of the dog (“It’s going to bite me”), which leads to fear. (Note that the anxious thoughts lead to fear, not the situation itself.) The body’s natural response to fear is escape. Once the boy successfully escapes the situation, he feels better. Therefore, his escape response is reinforced, making it more likely that he will respond similarly in the future.

The problem is, if feared situations are always avoided, it prevents one from having the chance to prove the anxious thoughts wrong, and worry continues.

Why not just teach the child to think differently? Well, I bet you can imagine how many times the boy has been told that most dogs are pretty safe, and it does not help. One problem is that the part of the brain responsible for fear is overriding the part of the brain responsible for logic—when emotions are high, logic tends to go out the window. Another problem is the strength of the belief in the anxious thoughts is too high. The most effective way to change one’s thoughts is to change one’s experiences. Therefore, only through slowly facing the fear of dogs, will the boy come to believe that dogs are safe and that he can handle anxiety-provoking situations. This model holds true for all anxiety disorders—phobias, obsessive-compulsive disorder, separation anxiety, social anxiety, post-traumatic stress disorder, and even more general worries. This is why exposure therapy is the most effective treatment for anxiety disorders.

Exposure therapy is a specific type of cognitive-behavioral therapy designed specifically for treating anxiety disorders. It takes approximately 12–16 sessions and involves identifying specific fears related to anxiety-provoking situations (e.g., overestimation of likelihood and severity of the threat, fears that anxiety will be unmanageable and never ending), as well techniques to challenge these fears, such as logical reasoning to evaluate the accuracy of predictions (How often does this happen to me and others? How bad would it really be if my fear came true?) and gradual exposure to a hierarchy of feared situations.

Fears are broken down to include several situations (about 10) that cause a range of fear levels. For example, for a fear of dogs, the child may talk about dogs, draw or look at pictures of dogs, view dogs in cages, sit in a room with a dog but not touch it, and pet various dogs deemed to be safe by the owner (of course, we will never be 100% sure that a dog will not bite, just as we cannot be certain that other feared outcomes will never happen, which is why it is important to gauge the relative risk of having the anxiety disorder versus the risk of a negative outcome; we never ask a child to do something that is dangerous).

The child must stay in the situation until the fear comes down on its own, without distractions or other subtle avoidance behaviors. Over time, the anxiety will come down (this may take a while at first). The exercise is repeated regularly until it no longer elicits fear, and then the child moves to the next higher step. The child begins to gather evidence about the actual vs. predicted risk, as well as the temporary nature of anxiety and his or her ability to manage it until it comes down. Confidence grows as children move up their fear hierarchy, and by the time they reach the most difficult exercises, they are fully prepared and usually do not fear them as intensely as when they first created the hierarchy.

It is recommended that you work with a mental health professional who has considerable experience with exposure therapy (particularly if the anxiety is more severe or complicated), as incorrectly implementing exposure exercises can lead to negative outcomes, such as increases in anxiety and unwillingness to make further attempts to face fears. If the anxiety is mild to moderate and parents wish to attempt exposure exercises, they can set up fear hierarchies by having the child rate his or her anxiety from 0–8 or 10 for various situations.

A list of about 10 situations is recommended, with a range of values beginning with 3 or 4. It is important that parents are positive and encouraging, not critical or punitive. Think of yourself as a coach or cheerleader. If you experience difficulty, are not seeing progress, or anxiety is getting worse, you should attempt to locate a trained professional in your area or look into options for intensive outpatient anxiety treatments in other areas that are designed to teach you the skills over a period of a few days, while providing initial relief from symptoms. Unfortunately, the latter may be the only option, as exposure therapy can be difficult to find.

Facing fears is hard work; it is important to reward children for their efforts. Earning points for each exposure that can be cashed in for certain rewards and privileges can be helpful. At times, when rewards are not enough, daily privileges may need to be made contingent on completion of exposure exercises.