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 anxietyreducing 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 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.

In contrast to this sequential approach, the intense exposure approach involves exposing the
child to the most anxiety-provoking situation on the hierarchy first and maintaining exposure
until the child can tolerate the situation without distress. Graduated exposure tends to be
preferred over intense exposure, however, because intense exposure may intensify the child's
fear and subsequently cause the child to resist further treatment. The graduated approach also
allows the child to learn techniques to overcome his or her anxiety. These techniques may
involve muscle relaxation exercises and engaging in adaptive self-talk while learning to
tolerate the situation or object.
ERP is effective for treating OCD, specific phobias, separation anxiety, and PTSD. In some
cases, ERP has been more effective than pharmacological treatments for OCD. Treatment
gains may be more enduring with ERP because children learn adaptive coping skills in the
process. Children and adolescents diagnosed with a specific phobia show significant
improvement in as few as one or two sessions of exposure therapy, regardless of whether or
not their parents participate in treatment. ERP also reduces children's separation anxiety and
enhances their ability to function independently. Children and adolescents with PTSD also
respond well to ERP, which is currently considered a necessary component of treatment for
this disorder.
Developmental differences should be considered during the planning and implementation of
ERP. For example, it is important to assess the child's level of cognitive functioning, social
maturity, and his or her ability to maintain attention during treatment. Younger children may
require more directions to focus on the treatment task than adolescents. Older children and
adolescents may require more time discussing the impact that their symptoms have on their
social functioning. Parents should be included in their children's treatment so that they can
learn how to reinforce their children's successful treatment gains. Some argue that parental
involvement may actually be counterproductive because the parents inadvertently reinforce
the child's avoidant or unproductive ritualistic behaviors. Nevertheless, the parents need to be
educated about the reinforcing effects of their behavior on their children and how they can
reinforce their children's newly acquired adaptive coping skills.
Comorbid psychiatric disorders, especially externalizing disorders such as oppositional
defiant disorder, can interfere with treatment. However, recent research suggests that neither
externalizing behavior problems nor other anxiety disorders were related to treatment
outcome for children and adolescents treated for OCD. Comorbid depressive symptoms,
however, are associated with lower rates of success and interfere with the child's ability to
focus and learn that the anxiety-provoking situation is not threatening. It is recommended,
therefore, to treat the depressive symptoms to maximize the effect of ERP for anxietyrelated
disorders.
Laura Stoppelbein and Leilani Greening
Further Reading

Entry Citation:
Stoppelbein, Laura, and Leilani Greening. "Exposure and Response Prevention."
Encyclopedia of Behavior Modification and Cognitive Behavior Therapy. 2007. SAGE
Publications. 15 Apr. 2008. <http://sage-ereference.com/cbt/Article_n2048.html>.