Professor Jennifer Hudson Right, so now, I want  to focus on actually how to deliver exposure,   how to do it in a step-by-step way. So,  we talked about what the research says,   where we think we might be going wrong  in terms of delivering exposure. Now,   I’m going to focus on how to do it better. Alright, so I think some of the clear things  that we should include in exposure and how we   can execute a good exposure session, is making  sure that there is a clear rationale and a   clearly defined role for parents and children.  That’s really what they’ve been telling us,   is that even in the, you know, really structured  programmes, they’re not understanding how best   to support the child, if you’re a parent,  and also the child not knowing what it is   that they have to do. So, making sure that  there is – making sure there’s a really   clear rationale for both of them. Even when  it’s adolescents and, you know, you might be   focusing on seeing their teenager more, still  making sure that the parents know how they can   best support their child when they’re doing  their exposures or they’re facing their fears. Secondly, also providing the child with a  lot of autonomy. So, you know, when you’re   being forced to do something that makes you  scared, you know, it’s terrifying, you know,   it’s awful. If you think about if somebody was  making you do something that is – that scares you   and that you don’t really want to do, having some  control over it would help reduce the anxiety. So,   giving the child autonomy over what they  choose next, what they – what situations   they might select, how they can make it  harder, easier, what they’re ready for   to face, can be really helpful and encourage more  engagement with the child in the therapy session. Graded or random, I think I mentioned  this already, that graded, we think,   has better engagement. We need to  do some more research about that,   but this is our thoughts. It’s more likely to  – the child’s more likely to stick at it if   they’ve got control over how difficult each  situation is and you don’t throw them into   the deep end. But we do know that random –  just picking a random situation also works   really effectively. Some evidence that it  really does produce some good outcomes, but,   you know, if you, kind of, randomly pick  a situation that a child is terrified of,   then you’re much less likely to per – to get  engagement. But we’re looking at that in some   of the research that we’re doing at the moment  and how that might impact on engagement, but   what we think at the moment is that doing it in  a graded way might actually increase engagement. Repetition, I mentioned this too, that when  a child is doing an exposure it’s not really   good enough just to do it once. The child  might think, I’ve done that, it’s all good,   don’t need to do it again, but the more practice,  the more repetition, the stronger that new memory   will become and the weaker the old memory  becomes. So, repetition is really important,   and also just coming back to it, as well. Like,  if it’s an exposure that a child has practiced in   the past, doing it again, kind of, in the future,  particularly, you know, post difficult situations   or post transitions, that it might be good to just  – to practice that, doing it as much as possible. A really important part is setting  up rewards. Sometimes parents are   really concerned about using rewards. I think,   they have either some philosophical objection to  using rewards. It is really important to, kind of,   to work with what they’re – the way that the  parents think about things, but also, even giving   them the evidence around how rewards do improve  child engagement is really important, we think. For adults, yes, when you face – and perhaps  older adolescents, as well, when you face a   situation that you’re scared of, you know that  in the end it is going to make you feel better   and your life might be better, and you might be  able to go to work more effectively. But for kids,   say, and particularly younger kids,  they don’t have that intrinsic value   or understanding that “If I do this it’ll be  good for me,” and so, having that, kind of,   extrinsic reward can be really good at motivating  kids to do it. And I’ve got some tips we’ll talk   about later in terms of doing those rewards  and how to set them – those up effectively,   but we think exposure works better when you have  rewards and when you set those up consistently.  It might be for those parents who are not  concerned – that – who are concerned about it   and not wanting to use it, that perhaps you can  try it out for a bit. It’s the idea that, then,   you won’t be doing it all the time, that a child’s  not going to be getting rewards for forever,   but gradually, then, weaning them off it  and not actually using rewards all the   time in the future. So, it’s not meant  to be something that always happens,   but while they’re cha – doing difficult  things. It’s not a bribe, it is actually   giving them something, a reward, when they  face something that’s really challenging. Making it fun, too. As much as possible, trying  to make the first steps, in particular, fun,   being creative about that, trying to come  up with ways of making it silly or fun,   kind of, take the pressure off,  particularly in those early first   few steps. Making a treasure hunt out  of it or a game can, particularly for   younger kids in the, kind of, early stages  of school, more likely to get engagement. And just finally, making sure that the  feared situation is targeted, as well. So,   you know, if the child’s worried about making  a mistake, making sure that in the exposures,   there is practice of that feared situation  as much as possible. There are some fears   where that doesn’t work for. So, if the child’s  worried about something bad happening to mum,   you don’t really want to create that  situation, that’s not what we’re about. So,   those kind of fears you wouldn’t want to do that,  but where it is possible, where we really want a   child to be able to cope with that situation of  being able to make a mistake and be okay with it,   then making sure that they’re, kind of,  targeting what it is that they’re fearful of. Alright, I’ve got some examples  of some different goals that you   might want to use. We want to set, and  I’ll talk about this, too, in a minute,   set really clear goals that a child will  want to practice in their exposure. So,   I’ve got some examples here that we’re using in  the programme that we’re developing at the Black   Dog Institute here in Sydney. Kirra’s goal is she  wants to be able to go to her friend’s birthday   party and play some party games with other kids.  So, you can see that’s a really clear goal. At the moment, Kirra’s not able to go to birthday  parties, and not participate in the games. So,   she’s – this is her goal, she wants to be able  to go to a party and participate in two games.   That’s really clear, it’s not a game on  her own, it’s games with other kids. So,   it’s nice, clear, specific goals. It’s not, “I  want to feel less worried.” It’s really clear,   “I want to be able to go to a  birthday party and play games.” Rue has a – his goal is to be able to  have a sleepover at a friend’s house.   Simu is to visit his cousin’s house  and to pat the dog that they have,   and Melis is to be able to stop asking  questions about being late to school. So,   that’s a nice example of – Melis has some, kind  of, generalised anxiety and it’s a good example of   how you can set a goal for exposure therapy that  focuses on, kind of, more generalised worries.   And that is often a really common experience of  kids with generalised anxieties, this, kind of,   asking lots of repetitive questions, so that can  be a really key part of exposure and facing fears. Alright, so I mentioned this before, that the  rationale we use is that we want a child to be   able to face a situation or – whether it’s  a context or an object, so that the child   can learn – sorry, can develop a new memory and  learn that nothing bad is going to happen. So,   they, kind of, they have a threat expectancy. So,  here’s an example. We’ve got a child who’s setting   up a exposure set of tasks, to be – the goal is to  be able to pat the dog, and you can see they’re,   kind of, gradually increasing from a bit easier to  more difficult. And just on – if we look at that,   kind of, graded nature of this list here of  activities, it starts with the easy ones,   where the child’s only, kind of, a little bit  anxious about, moving up to more difficult. So, the easier one is just looking at pictures of  dogs, being able to go to the park and just look   at dogs from afar, being able to pat a friendly  dog, taking a neighbour’s dog for a walk, taking   a neighbour’s dog for a walk, as well. I think  there were some additional – it’s a different   neighbour’s dog that might be a little bit more  challenging, or perhaps doing it on their own,   but, kind of, grading it, making it more  difficult. So, the threat expectancy is, “If I pat   the dog, it’s going to bite.” What we want a child  to be able to learn is that if they do pat a dog,   they’re unlikely to get bitten. So, you can see in  particular the – this middle activity, patting a   friendly dog, really challenges that feared belief  and tries to violate that threat expectancy. We   talked about the fact that we want it to be  gradual, to get a lead to greater engagement. Alright, so setting an exposure activity.  We use this, kind of, worry rating,   a fear or worry rating scale. We use one  to eight, but it doesn’t really matter. If   you’ve got a child that’s a really young child,  perhaps eight scale – eight-point scale might   be too much. It doesn’t really matter; some  people use a ten-point scale. Just the idea   that we want to get some variation, and you want  to be able to show that the child’s anxiety comes   down a little bit after their practice.  Doesn’t really matter where they start,   some kids will only identify that, you know,  that they’re only a tiny little bit worried,   even though you know that they really should  be up here on the end of the scale. It doesn’t   really matter; it’s just we want them to be able  to see a slight difference before and after. So, as we mentioned, we want to start off with  writing a practical goal, “I’ll be staying with   a babysitter while mum goes out for the evening.”  We looked at quite a number of practical goals,   and it’s also helpful to identify the worried  thought because that helps you, you know,   work out what the threat expectancy is and how  you might want to target it. It’s not essential,   we don’t think, but it can be helpful in  you being able to target the right exposure. And the next step is, kind of, brainstorming  all the possible steps to build new memories,   so like in the previous list we looked  at, there was looking at pictures,   going to a park, patting the friendly dog, lots  of different activities. You’re just going to   want to brainstorm all the possible ideas.  It’s okay if kids come up with silly ones,   just put them all down, and the idea is  that you can come back and order the steps,   really. You want to give each step a rating,  so once they’ve come up with a big list of   activities or ways of approaching that situation,  then get the child to rate on that scale. And that   will just help you work out which ones to start  with, which ones are low, which ones are medium   and which ones are high. And that’s – I’ve kind of  broken them down there, low, medium and high, on   the basis of the fact that a child would use that  whole scale, but you can adjust it how you need. We also want to make sure we’re  negotiating rewards for each step,   and I’ll talk a little bit more about that  later. But each step they do, for instance,   in this, you know, every time that they  look at pictures of a dog, that there’s   a reward attached to it, every time they pat  a friendly dog, that there is some, sort of,   reward attached to it, and I’ll talk more about  that in a minute. Setting clear expectations,   what you want a child to do and what you want a  parent to do. Be really clear and open about it. Depending on where you’re at with – and  how difficult it is, you might want to   get the family more engaged at the beginning, the  parents more engaged in helping the child, either   modelling for them or getting them really involved  in helping. But then, as it gets more difficult,   you may want to ask the parents to step back and  let the child face the situation on their own. So, there are actually lots of different ways that  you can vary the activities in, kind of, their   difficulty, and I’ve got a diff – a list of  different activities here. It might be varying   the people present. So, whether it’s having mum  or dad there, or having siblings there or friends,   or going to a park where they’re definitely  not going to run into anybody they know,   and for different young people, that might,  you know, vary. A park where they know people   might be easier, a park where they don’t know  anyone might be easier. So, it's working out,   using that – the fear rating, that worry  scale, what it is that makes the situation more   difficult and how you can crank it up and make  it more difficult, how you can make it easier. That might be the number of people, their  age, I mean, different genders present   might make it easier or harder, depending  on the child, how familiar the location is,   how long they spend in a situation. It  may be that – if we’re thinking about   the dog situation, it may that they just  spend a minute at the park and moving up,   increasing the amount of time  they spend in the situation. One way, too, that you might not have thought  about is in terms of the preparation beforehand,   particularly for those more generalised worries  or social worries where young people might not   like to make a mistake, or they might like to  be really prepared for a situation. Actually   practicing what it’s like – how they can  handle it if they don’t do any preparation,   if they don’t know the answer, or if they haven’t  practiced their speech, and to see how they can   handle it with less preparation. ‘Cause often  young people with generalised anxiety will do   a lot of preparation, spend a lot of time on it,  so that can actually be something that you reduce,   starting off with letting them go with their  usual amount of preparation to start with,   and then gradually, reducing the  amount of preparation. And then,   they’ve got to give a completely impromptu  speech for instance, or answer a question   that they don’t know the answer to, in terms of  how much prep they have beforehand. And also,   another simple way of varying the activities,  there is varying the level of fear, so the   size of the dog, how dark it is, an easy way  of changing the difficulty of the situation. Right, I promised that I’d talk a little bit about  rewarding. So, this sometimes it is a challenging   thing for parents, but it is really important  that rewards are given consistently and as   soon as possible after an event. If you’ve ever  had to train a dog to do different activities,   if you forget to reward them immediately after,  it’s – the reward is no longer potent. So,   it’s really important that you encourage  those rewards to be attached to the event. Kids have much better brain capacity than puppies,  which is great. They do have capacity to hold it   for a little bit longer, that information,  but as close as possible to the event is   really great. We often have parents coming in  where they’ve forgotten to give the rewards,   life has got busy, which is really normal and  really common, but trying as much as possible   to make sure those rewards happen as close to the  event as possible and associated with it, “You’re   getting this reward because you did something that  was really hard for you, and I’m really pleased.” And reward size really should be proportionate  to how difficult the task is. Some parents are   over-generous with their rewards they give,  and some are perhaps less than generous. So,   we want to try and match it to the reward  size and, kind of, use your judgement on   that. We really find that potent rewards, the  best rewards, even though kids might say they   want the latest video game or more money or  clothes or whatever it is that they’re into,   that one of the things that is most potent that  we find actually is that the best reinforcer   is more time with parents and, kind of,  praise. That actually works really well.   And it might be we do, you know, activities  around getting – you know, choosing an activity   that the child gets to do, and they get to do with  their parent on their own, without any siblings,   or choosing the family meal, or things that they  don’t usually do that’s special, rather than   necessarily financial rewards, which we find that  works really well. Financial rewards and games,   clothes, work well as well. We try and encourage  more of that – that special time with parents   works really well. Even though they might say that  they want something else, actually what motivates   them is actually feeling valued by their parents  and having the time to do something one-on-one. Rewards. We also, particularly as kids are  getting older, we want to encourage them to   use rewards for themselves. So, it might be using  praise for themselves, “I did a really good job,   that was really tough and I did it.” And not  focusing – we know that kids with anxiety   might be more likely to focus on, “I didn’t  do that as well, I really wish I’d done it   this way,” but trying to focus on what it  is that they did well and rewarding them   for what they did positively and what they’re  proud of, and what they weren’t able to do. If you’re working in groups sometimes this  can also be really good, getting the group to   acknowledge what the cha – what the teenager has  done that’s difficult. ‘Cause kids often forget   how difficult it was the first time, so having  a record of how they rated the situation at the   start of the session or at the start of treatment,  can be a good reminder in getting them to work out   what it is that – how scary they thought it was  beforehand, and then after. And just reinforcing   that message, as often they forget how hard  or how scared they were at the beginning. But now, we want to make sure that exposures  are challenging. We talked about the fact   that the more challenging exposures you do,  the better outcomes your clients will have.   We want to make sure there’s exposure to  consequences when it’s appropriate. So,   including hierarchies of doing something, kind  of, risky, something that risks being laughed at,   perhaps, doing something silly, doing  something deliberately, making a mistake   deliberately. Where you’re actually getting  exposure to what they’re worried about,   that, kind of – that threat expectancy, and  being able to deliberately challenge that. Also, want to, kind of, look out for  safety behaviours or subtle avoidance. So,   sometimes, and this is a way to make  it even more challenging, initially,   a child might feel like they need to  have their phone with them as a way,   just in case something bad happens, they can call  their parents, or they may have something special   that they want to carry with them, there’s  some checking they want to do beforehand,   that initially, that’s okay. They want to ask a  lot of questions perhaps to their parent, but we   want a child to be able to face the situation  without those safety behaviours, without the   phone, without checking, without asking questions,  and being able to face the situation without it. Sometimes, you know, it’s – they can  be really subtle safety behaviours,   the things that a child’s doing to make them feel  safe. That might be really difficult to know,   they might keep it secretive. So, kind  of, keeping an eye out for those things   that might actually stop the young person  actually challenging a situation or making   it a really difficult exposure and just build  up to it gradually when the child’s ready. I talked about, you know, OCD before and that  idea of doing challenging exposures with response   prevention. So, the – that idea is, kind of,  gradually reducing participation in whatever it is   that they’re doing, so whatever the compulsion is.  So, if it’s washing their hands, asking questions,   if it’s repetitive checking, touching things  in a certain way, just gradually reducing the   amount of times that they’re allowed to do that  is a – that, kind of, response prevention part. We also like them to do some overlearning,  as well, exposure to extreme versions. So,   in OCD we might get them to – if they’re really  worried about getting dirty, we might get them   to actually not wash their hands after going to  the toilet, or even, you know, more dramatic,   sticking their hand in a toilet bowl to, you  know – not something we would usually do. We   wouldn’t be generally wanting to – kids to be  doing that, but the idea is that, actually,   “If I do, you know, how unli – how likely  is it that I’m going to get sick?” So, it’s,   kind of, a overlearning, deliberately making  a mistake, deliberately doing something silly,   to learn that, “Actually, I can handle it, even  if it, you know, is a – and what I – my – the   bad thing that I think is going to happen, like  people laughing at me.” Knowing that they can   handle it and create new memories about the  fact that, actually, they can cope with it. So, I just want to give you an example of a  more generalised anxiety worry, and this is   Melis’s goal to stop asking mum questions about  being late to school. She’s really worried about   being late and so, in the morning on the way  to school she would ask mum a lot of questions,   and that would get really repetitive and that was  a bit of a conflict in their relationship. So,   we set out this step-by-step set  of activities to actually target   this goal on how – what is it that she  can do that will help her to face this   goal and other activities that might  bring up that worry about being late? So, the first one is that she’s going to  ask two questions, that’s all she’s allowed,   about being late on the way. But she’s going  to a friend’s house, so it actually only   gives her a little bit of anxiety, you  can see that she’s starting with that,   and then it gradually gets more difficult.  She goes to netball training, grandparents,   and it just decreases the questions she’s allowed  to be asked and how late she’s – how late she is.   She’s practicing – we, you know, we don’t want  kids necessarily to be practicing being late. This is something that we’re – it, kind of,  goes against perhaps a lot of parents’ ideas   and Teachers’ ideas about how things should be,  but these are kids who worry unnecessarily about   being late. So, they’re usually the kids  that are very much on time and we want to   get them to learn that, actually it’s okay  and they don’t need to worry about it. So,   it’s practicing facing that situation  that they’re fearful of to develop this   new memory that it’s actually okay, and the  difficulty increases in those activities. Often, you find when you’re, kind of, setting up  these goals that you might set them up initially   and the child might give you their worry ratings  for each activity, but then, when you get to,   say, this second-last one, that actually is much  more difficult than what you thought and maybe you   need to add in a few more steps in between.  Or maybe on a day that’s more challenging,   they’ve had a stressful weekend, something hard  has happened at school, and a situation that   they’ve been able to do before is now actually  much more anxiety-provoking. That’s okay,   you might just want to go back and practice one  that’s a little bit easier that day. You know,   kind of, get that balance right between pushing  kids a little bit out of their comfort zone,   but not doing it in a way that it's going to  stop them from doing it and not feeling like   they’ve got control over it, and that – and, kind  of, wanting to develop their sense of mastery,   because we do also know that that sense of  mastery helps with reducing their anxiety. We also talked about the fact that the more  in-session exposure you do, the more you do   in therapy with the young person, the more  likely they are to have better outcomes. So,   there’s lots of different ways that you can  practice exposure sessions – practice the feared   situations. And obviously, you have to be a bit  creative in session ‘cause it is a bit limited,   you know, in the therapy session,  what you can do, but maybe practice   – maybe schedule a session outside of the  typical therapy session, go somewhere else. You can use imaginal exposure  sometimes if that’s not possible,   but lots of practice of doing speeches, if that’s  what they’re worried about, going to the shops,   making phone calls from your office, asking  for help around the clinic or your therapy   place. They can meet other children, perhaps,  at the practice. You can set up fake tests,   completing homework, and as I mentioned,  imaginal exposure as well. Using videos, also,   to facilitate attempts and analysis, having  phones or ways of recording it to help, can   be really useful in actually just making it more  gradual and setting up things within the session. And really important at the end, to be  asking kids what is it that they learnt   from the situation. We want to help, kind of,  reinforce that new memory about the situation   being okay and that they coped with it. So,  kind of, practicing that in the session,   and often those in-session exposures are really  good ways of helping the parent, as well, set   up how they can do it at home. They might want to  practice their homework sessions before they leave   the therapy session, so that parents are really  clear what they’ve got to do during the week. Scheduling the homework for particular times,  brainstorming what might get in the way. Just   doing exposure once a week for – in-session,  that’s going to be great, but it’s going   to be much better if they do more practice  during the week, and the more they practice,   the quicker the reduction in their anxiety  will be, the stronger that memory will be. So, trying to encourage kids to practice on  a daily basis, and keeping records of what   they achieve during the week so that when  they come back to the session with you,   you can see all the great things that they’ve  done. And it is a really rewarding experience   seeing kids face situations that they didn’t  think were possible and being able to praise   them for the challenging situations that they  faced, and it’s really great to see kids really   happy and proud of themselves for facing  situations that they hadn’t been able to do. So, that’s a bit of a brief overview of how to  perhaps do better exposures for children and   young people with anxiety. I encourage you to  practice those techniques that I talked about.   Think about in your therapy how you might  be delivering exposures in a way that may   be not ideal, what things do you need to  practice on, what things you’re avoiding   as a Therapist. And Therapist anxiety can  really impact on the delivery of exposures,   they’re worried about how the child’s going to  go. So, the more you practice doing silly things,   as well, and then practicing the exposure  sessions and modelling for the young person,   the better that will be in therapy and the more  comfortable you’ll be in using this technique. So, good luck and I hope you  enjoy using these strategies.